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Hypospadias

Preoperative considerations

• Indications: allow for normal urination, erection (fix chordee), and ejaculation
• Consider repair timing, usually 6-18mo to prevent patient anxiety regarding genitals and complications
• Preoperative testosterone: consider if small glans, give IM testosterone 5 and 2 weeks prior to surgery

Repair tips/techniques

• Goals: create normal meatus/glans, straighten penis, normal urethra, adequate skin covering, normalize scrotum position
• Urethromeatoplasty: use Heineke–Mikulicz technique for stenotic distal meatus
• Primary tubularization (GAP, Thiersch-Duplay): use glans wings to tubularize without incising urethral plate
• Meatal advancement glanuloplasty (MAGPI): advances the distal glans without tubularizing
• M inverted V glansplasty (MIV): parameatal skin is compliant for glanuloplasty
• Tubular incision (TIP): incise plate and tubularize using glans wings to increase diameter
• Proximal repairs usually require staging and urethral flaps/grafts

Postoperative management

• Leave a urethral stent in place for 3-21 days, SPT occasionally used
• Antibiotic prophylaxis and anticholergics used depending on circumstances
• Follow-up: 4-6 weeks after surgery, then 1yr postop, after toilet training, and after puberty to assess for complications and discuss concerns

Hypospadias complications

• Fistula: 4-28%, may present with double stream, management depends on specific situation
• Glans dehiscence: 0-8%, separation of glans wings, repair depends on presence of symptoms
• Meatal stenosis: 0-14%, obstructive voiding symptoms, warrant repair or dilation
• Urethral stricture: 6-12%, usually form at junction of urethra and neourethra, warrants repair
• Urethral diverticulum: urethral ballooning with voiding, warrants repair
• Recurrent curvature: 9-32%, > 30 degrees demonstrated on erection
• Secondary phimosis: 2-20%, treat with circumcision
• Urethral stones: 5-15%, due to flap with hair-bearing skin, can ablate hair or perform substitution urethroplasty

Penile curvature (chordee)

• Assess intraoperatively after degloving, use goniometer while injecting saline
• 30 degree cutoff used for dorsal plication vs dividing urethra (corporal lengthening)
• Usually plicate at 12 o'clock, avoiding neurovascular bundles
• Important to repair curvature, otherwise will worsen during puberty

Penile torsion

• Seen in 2-27% males, > 90% torsion seen in 0.7%
• Can observe (usually asymptomatic), consider treating if affecting urination or intercourse (uncommon)

Tubularized incision of plate (TIP) technique

1. Can perform penile block or caudal block (some concern that caudal block increases risk for fistula formation)
2. Position supine, prep/drape, can give cefazolin or other antibiotic due to urethral manipulation
3. Take down preputial adhesions to assess foreskin length and location, assess degree and direction of curvature
4. Place ethibond traction stitch into glans, place 8Fr feeding tue
5. Perform dorsal circumcision incision, extend laterally to create Firlit wings (inner preputial wings), then extend ventraly taking care over urethra
6. Deglove the penis, create an artificial erection to assess curvature
7. Can perform plication stitches dorsally if necessary due to curvature (will worsen during puberty)
8. Apply tourniquet with umbilical tape when performing glansplasty to minimize bleeding
9. Incise urethral place at midline from glans down to meatus, use wescott scissors or small scalpel
10. Create glans wing incisions on either side of urethra, then close with running 7-0 PDS in two layers
11. Using excess dorsal dartos, create dartos flap (remove overlying skin), create buttonhole and place over penis so that flap lies ventrally, then secure over urethroplasty with 7-0 interrupted PDS
12. Complete glansplasty with 5-0 PDS horizontal mattress sutures and epithelial 7-0 vicryl
13. Exchange 8Fr feeding tube for 7Fr stent, stitch to glans to ensure it stays in place
14. Assess and adjust skin for coverage, and place fixation stitches at penopubic and penoscrotal junctions at 12, 5, and 7 o'clock
15. Complete circumcision, bring flaps around for adequate coverage, close with interrupted 5-0 plain gut (can perform simple or subcuticular interrupted)
16. Apply circumferential telfa dressing, then tegaderms to hold in place
17. Remove dressing POD#4, remove catheter POD#7, prophylactic antibiotics until POD#9