Purpose of review <p>Severe hypospadias, defined as proximal meatal ectopy with significant ventral curvature, represents a complex reconstructive challenge for pediatric urologists. This review synthesizes contemporary evidence on techniques and considerations for severe hypospadias management.</p> Recent Findings <p>This review covers high-yield topics including but not limited to: preoperative hormonal stimulation, intraoperative curvature assessment to minimize erroneous operative decisions, globally favored staged reconstruction approaches, a general framework outlining management strategies, and more.</p> Summary <p>While mild phenotypes predominate prevalence, severe cases of hypospadias contribute disproportionately to surgical complexity, complication risk, and long-term morbidity. Numerous techniques have been used to address severe hypospadias, each with their own respective indications and limitations. Despite technical advances, long-term outcomes data remain limited by poor follow-up adherence, inconsistent phenotypic nomenclature, and underutilization of patient-reported outcome measures. Multi-center collaboration and standardized reporting frameworks are essential to advance evidence-based care and meaningfully counsel families on long-term functional and psychosocial outcomes.</p>