Introduction <p>Hypospadias repair is challenging due to complications like urethrocutaneous fistula and flap necrosis, often linked to preputial vascular anatomy. While macrovascular and microvascular patterns are studied, findings are inconsistent. The impact of preoperative hormonal therapy (PHT) on vascularity and outcomes is unclear. This review and meta-analysis evaluates preputial vascular anatomy in hypospadias and its surgical implications.</p> Methods <p>A systematic review (2000–2024) was conducted in PubMed, MEDLINE, and Cochrane following PRISMA guidelines. The inclusion criteria used the PICOS framework. The bias was assessed using Robvis and microvessel density (MVD) differences were analyzed via meta-analysis with heterogeneity quantified (<i>I</i>²). Effects of PHT on vascularity were also reviewed.</p> Results <p>Fourteen studies (707 hypospadias, 106 controls) revealed predominant net-like vascular patterns in severe cases. MVD was significantly lower in hypospadias (pooled Mean, 28.85/HPF) versus controls (pooled Mean, 45.46/HPF), correlating with severity of hypospadias, the MVD varied a lot across different population worldwide. The meta-analysis showed high heterogeneity (<i>I</i>² = 98%). PHT increased MVD and vessel diameter, improving outcomes in three studies.</p> Conclusion <p>Hypospadias alters preputial vascular anatomy, show varied patterns, with reduced MVD linked to surgical challenges. A lot of variation exist in MVD across various population. PHT enhances vascularity but requires further validation. Standardized vascular assessments and advanced imaging are essential for optimizing surgical outcomes.</p> <p><i>PROSPERO registration number</i> CRD42025640297.</p>