Fig. 6 a–d: Use of ventral skin distal to the meatus to reconstruct a partially epithelialized neourethra

[A] Combined Use of Prepuce and Skin Distal to the Meatus

• Lateral based flap (LAB) by Hadidi (2003, modified 2009)
• Lateral oblique flap by Hook (1896)
• One stage repair for proximal hypospadias by Broadbent (1961)
• Parameatal foreskin flap by Koyanagi (1983)
• Yoke repair by Snow (1994)

[B] Scrotal Skin (Not Recommended)

• Bouisson (1861)
• Rosenberger (1891)
• Rochet (1899)
• Lowsley and Begg (1938)
• Beck (1897)
• Cecil (1946)

[C] Dorsal Penile Skin

Davis (1940) tubed the dorsal penile skin proximally directed. Penile gymnastics required for this procedure were considered too demanding.

[D] Different Grafts

• Nove-Josserand (1897) – split-thickness skin graft
• Devine and Horton (1961) – preputial full-thickness graft
• Bracka (1995) – full-thickness skin graft (two-stage)
• Mommelaar (1947) – bladder mucosa
• Humby (1941) – buccal mucosa

General Principles

The ideal surgery time is between 3 and 18 months. Fine instruments and magnification are preferred. Haemostasis using a tourniquet or epinephrine is critical. Urethroplasty is performed around a 10 Fr catheter.

Choice of Operative Technique

More than 300 surgical techniques are described. Surgeries vary by tissue used. The author recommends:

• Inverted Y technique for glanular hypospadias
• Y-V Glanuloplasty modified Mathieu for distal hypospadias
• Lateral based flap for proximal hypospadias
• Two-stage repair for perineal hypospadias

Fig. 7: Recommendations for primary hypospadias repair

Grade I or Glanular Hypospadias: The Double Y Glanuloplasty (DYG)

Ideal for patients with glanular hypospadias and mobile meatus. Contra-indicated if the meatus is not mobile.

Operative Steps:

• Inverted Y incision outlined on the glans
• Two diverging limbs incised along upper edge of meatus
• Longitudinal midline limb to tip of the glans
• Space created for new urethra
• Inverted Y sutured as inverted V
• Glans mobilized to wrap around urethra
• 24 hours urinary diversion and dressing

Fig. 8: The Double Y Glanuloplasty (DYG) Technique