The foundation of surgery is always anatomy, including forgotten or overlooked anatomical knowledge. Despite the development of hundreds of surgical techniques for hypospadias surgery, the ongoing prevalence of complications raises questions about whether these techniques are compatible with normal anatomy.
The fallacy of appealing to tradition (the tradition fallacy) is common in medicine; it arises when a medical or surgical treatment method is maintained without question and without reliance on scientific evidence, solely on the grounds that “we have always done it this way” or “this is correct because everyone does it.” The mere fact that an established practice has been in use for a long time does not inherently demonstrate its anatomical or scientific validity. In fact, traditional treatments, even when taught and practiced by “professionals,” may cause complications that are accepted as normal, and these same professionals may also teach how to treat these complications. The unquestioned transmission of treatment methods as a tradition to subsequent generations for decades or even centuries can cause delays in the emergence of superior treatment modalities.
Today, modern evidence-based medical practices are frequently driven by clinical or experimental studies (such as randomized controlled trials or animal experiments) or systematic reviews (the analysis of thousands of studies). The transition from a tradition-based approach to an evidence-based approach in medicine has led to significant breakthroughs and advancements in healthcare. The most crucial way to break free from traditional fallacies is to question them. Scientific inquiry begins first with observation, followed by asking “why” and “how,” and proceeds with formulating and testing a hypothesis. The obtained results may support, reject, or necessitate modifications to the hypothesis. The earliest historical example of the transition from “traditional medicine” to “evidence-based medicine” is the controlled clinical trial conducted by James Lind on sailors with scurvy in 1747 (https://www.bbc.com/news/uk-england-37320399).
However, the same principle applies to innovations. Being new, technological, or high-profile does not inherently render a treatment scientific. Implementing a surgical treatment method on humans without prior clinical or experimental studies can lead to catastrophic outcomes. The most recent example of such a practice is the “artificial airway” applied by thoracic surgeon Dr. Macchiarini to his patients. A scandal at a leading research hospital in Sweden revealed that Dr. Macchiarini implanted 3D-printed plastic tracheas into his patients without any experimental studies or evidence-based data. Following an evaluation by a scientific committee and a court of law, Dr. Macchiarini was dismissed from his position and sentenced to prison for this practice, which led to the death of all patients (https://news.ki.se/news-archive/the-macchiarini-case-timeline). The synthetic trachea surgeries performed by Dr. Macchiarini on patients without sufficient scientific substantiation have demonstrated that unproven innovation can be just as dangerous as tradition.
On the other hand, alongside dogmas and the fallacy of appealing to tradition, professional jealousy and ego conflicts have historically made the acceptance of new discoveries highly difficult, resulting in numerous instances where discoverers were marginalized. This phenomenon has even escalated to the point where scientists resisted empirical evidence solely to protect their own status. The most striking example of this is the discovery by two Australian scientists, Dr. Marshall and Dr. Warren, that gastric ulcers are caused by a bacterium named Helicobacter pylori, rather than by stress or spicy foods. Authorities in the field of gastroenterology rejected this theory due to professional envy and the fear of losing the diet and antacid treatment market they had established for decades. To prove the truth, Dr. Marshall personally ingested the bacterial culture broth, subsequently developed gastritis, and cured himself with antibiotics. Years later, in 2005, they were awarded the Nobel Prize (https://pmc.ncbi.nlm.nih.gov/articles/PMC4124396/).
HYPOSPADIAS AND FUNDAMENTAL PROBLEMS IN HYPOSPADIAS SURGERY
The foundation of surgery is always anatomy, including forgotten or overlooked anatomical knowledge. If the same complication is observed for years after an operation, this outcome may, over time, cease to be viewed as a flaw of the method and instead be accepted as the natural course of the disease. However, the high prevalence of a complication does not imply that it is inevitable. Sometimes, the core issue is the anatomical model upon which the utilized surgical technique is based.
Hypospadias is a severe congenital structural anomaly of the penis and the external urethra in male children. Following birth, it is observed that the male infant’s urethra does not open at the tip of the penis, and the infant urinates from a point on the ventral surface of the penis or from between the scrotal sacs. This condition, colloquially known as “prophet’s circumcision” or “being born circumcised,” is also frequently accompanied by penile curvature (chordee). Hypospadias adversely affects the ability to urinate while standing during childhood, as well as psychosocial development; in adulthood, it negatively impacts sexual functions and reproductive capacity. It is highly remarkable that there are more than 300 surgical techniques for hypospadias treatment, yet satisfactory results cannot be achieved even in the hands of experienced surgeons, and complications along with multiple surgeries are accepted as normal. There are traditional assumptions used in hypospadias surgeries for centuries and included in treatment guidelines. These are, in summary:
- The male urethra is reconstructed as a straight tube around a urinary catheter/sound,
- The spongy tissue surrounding the male urethra (corpus spongiosum) extends uninterrupted to the glans penis and forms the glans,
- The glans penis completely (1800) surrounds the urethra.
Anatomical findings we obtained through magnetic resonance imaging (MRI) of the penis have revealed that all techniques used in hypospadias surgery and the aforementioned assumptions are incorrect, uncovering the overlooked anatomical structures:
- The male urethra is not a uniform tube with the same diameter from beginning to end. In the terminal segment of the urethra within the glans, there is the fossa navicularis,
- The spongy tissue surrounding the urethra terminates within the glans, and the glans is a distinct tissue with a different structure,
- Surrounding the fossa navicularis, there is a fibroelastic tissue called the septum glandis; this tissue separates the glans wings from each other inferiorly, and the frenulum is located on it. Consequently, the glans wings do not fuse with each other, and the glans does not encircle the urethra (4,5).
The septum glandis is a structure that has almost completely disappeared from anatomy textbooks and has never been mentioned in hypospadias surgeries. As a result of my research lasting approximately one year, I discovered in the library of the Heidelberg University Faculty of Medicine that this tissue, which we detected via magnetic resonance imaging, was described by the famous German pathologist Prof. Jacob Henle in 1877. Intriguedly, both the septum glandis and the wider segment of the urethra, termed the fossa navicularis, have been consistently overlooked in hypospadias surgeries. The wide configuration of the fossa navicularis and the structural characteristics of the septum glandis can influence urinary flow rate, pressure, and the stream pattern. With this consideration, our evaluations utilizing fluid dynamics have demonstrated that the fossa navicularis and the septum glandis collectively function as a “flow control chamber.” In light of these studies, the Glanular-Frenular Collar (GFC) technique, which I developed, aims not only to advance the urethra to the tip of the penis but also to reconstruct the functional relationship among the glans, septum glandis, frenulum, and fossa navicularis. The GFC technique, which permits the formation of the fossa navicularis without incising the glans wings, yields superior outcomes compared to techniques that have been applied for centuries by incising and suturing the glans wings together (glans fusion), and is preferentially practiced in numerous countries (6-10).
The power of science lies not in never being mistaken, but in its capacity to modify its own knowledge upon recognizing an error. If the model on which a method relies is anatomically deficient or incorrect, it cannot be defended solely on the grounds of its widespread implementation. I understand my colleagues’ difficulty and resistance in accepting that surgical and anatomical assumptions practiced for centuries—especially a technique globally prevalent for the last 30 years—are flawed (just as it was during the eras of Dr. Marshall and Dr. Warren, or Dr. Semmelweis). I would like to conclude my article with a quote from our late anatomy professor, Prof. Sami Zan: “The fact that something is performed by everyone does not demonstrate its correctness.”
REFERENCES
- https://www.bbc.com/news/uk-england-37320399
- https://news.ki.se/news-archive/the-macchiarini-case-timeline
- Hellstrom PM. This year’s Nobel Prize to gastroenterology: Robin Warren and Barry Marshall awarded for their discovery of Helicobacter pylori as pathogen in the gastrointestinal tract. World J Gastroenterol. 2006 May 21;12(19):3126-7. https://pmc.ncbi.nlm.nih.gov/articles/PMC4124396/
- Özbey H, Kumbasar A. Glans wings are separated ventrally by the septum glandis and frenulum penis. Turk J Urol 2017;43:525–529 · DOI · PDF
- Özbey H. The mystery of Jacob Henle’s “septum glandis”. Journal of Anatomy 2019;234:728–729 · DOI · PDF
- Özbey H, Arlı T. Fossa navicularis and septum glandis: a flow-control chamber for the male urethra? Medical Hypotheses 2020;140:109642 · DOI · PDF
- Özbey H. Traditional misconceptions in hypospadias surgery. J Pediatr Surg 2026 · DOI · PDF
- Özbey H. The glans and its connection to the penis shaft. Pediatr Surg Int 2026 · DOI · PDF
- Özbey H, Etker Ş. Hypospadias repair with the Glanular-Frenular Collar (GFC) Technique. J Pediatr Urol 2017;13:34.e1–34.e6 · DOI · PDF
- Özbey H. The Glanular-Frenular Collar (GFC) technique: dual approach to hypospadias reconstruction. J Pediatr Urol 2024;20:539–540 · DOI · PDF
