Two Stage Repair

A small group of patients with severe proximal hypospadias, chordee, and a small phallus as well as patients with recurrent hypospadias and fibrous unhealthy skin may benefit from a two-stage procedure (Fig. 12).

In the first stage, a circumferential incision is made proximal to the coronal sulcus, the chordee is excised, and the penile shaft is degloved. Penile straightening and removal of all chordee tissue must be confirmed by the use of the artificial erection test.

Fig. 12: Steps of two stage repair: identification of chordee, excision of ventral chordee and plication if needed. Coverage of raw surface with skin graft. Tubularisation in the second operation.

The glans is divided deeply in the midline to the tip. The dorsal foreskin is unfolded carefully and divided in the midline. A midline closure is performed, and the midline sutures catch a small portion of Buck’s fascia. The bladder is drained with an 8 French Silastic Foley catheter for approximately 5 to 7 days.

If there is inadequate genital skin available, buccal mucosa or rarely bladder mucosa may be used. The buccal mucosa is harvested from the inner surface of the cheek or the inner surface of the upper or lower lip. The parotid duct is identified opposite the upper molars, and cannulated with 3-0 nylon. The graft is outlined and the submucosa infiltrated with 1% lignocaine containing 1:2000 epinephrine. The graft is incised and the mucosa is dissected away by sharp dissection.

The second stage of the procedure is carried out 6 to 12 months later. The previously transferred skin or mucosa is used to reconstruct the glans and urethra. A 16-mm diameter strip is measured, extending to the tip of the glans. The strip is tubularized with a running subcuticular stitch of 6-0 Vicryl® all the way to the tip of the glans. Tension is reduced by generous mobilization and undermining of adjacent tissues. A protective intermediate layer (either tunica vaginalis or dartos) helps to reduce post-operative complications.

Artificial Erection Test and Chordee (Curvature) Correction

Ventral curvature (chordee) may be evaluated by the artificial erection test. There are two types of chordee associated with hypospadias:

1. Chordee associated with distal hypospadias (skin chordee), corrected by mobilization of the skin proximal to the meatus.
2. Chordee associated with proximal hypospadias, usually deep and fibrous, corrected by Heineke Mikulicz technique, dorsal placation, corporal rotation, or the “Split & Roll” technique.

Use of Protective Intermediate Layer

The use of an intermediate or interposition layer between the neourethra and the skin layer has greatly improved surgical outcomes and reduced complications. Types of protective layers include:

1. Durham Smith (1973): De-epithelialization
2. Snow (1986): Tunica vaginalis wrap
3. Retik (1988): Dorsal subcutaneous flap from the prepuce
4. Motiwala (1993): Dartos flap from the scrotum
5. Yamataka (1998): External spermatic fascia flap

Fig. 13: Types of protective intermediate layers

Some Technical Points

1. Stenting: May be associated with more complications.
2. Dressing: Dressing type significantly impacts surgical outcomes; some studies report better results without dressing.
3. Timing: Reoperation should not be attempted before 6 months post-surgery.
4. Fistula Management: Exclude distal obstruction and excise the fistula cornu to minimize recurrence.
5. Failed Distal Hypospadias Repair: Technique choice depends on the degree of fibrosis and available healthy tissue.
6. Failed Proximal Hypospadias Repair: Unhealthy tissue must be excised; a flap or graft may be used as needed.
7. Scrotal Transposition: Correct hypospadias first; address transposition later for better blood supply to flaps.
8. Tissue Culture: Research ongoing; indications in hypospadias surgery are still limited.