TIP

The glans width is first measured and then a 5-0 polypropylene stay stitch is placed. The dorsal line for incision extends adjacent
to the corona approximately 3 mm proximally, preserving most of the inner prepuce for use as a graft should there be either VC
greater than 30 degrees or a urethral plate not suitable for TIP urethro- plasty. Ventrally the incision runs in a U shape alongside
the plate, avoiding visible hair follicles, and then continues down the midline of the scrotum. The ventral incision lines adjacent
to the urethral plate are injected with 1:100,000 epinephrine to minimize bleed- ing from underlying corpus spongiosum. The
penis is degloved to the penopubic and penoscrotal junctions. All ventral dartos and scrotal attachments are dissected off to
the base of the penis.

Next the glans wings are marked along their junction with the urethral plate and also injected with 1 : 100,000 epinephrine
before incision. The glans wings are dissected laterally along the surface of the corpora cavernosa to 3 and 9 o’clock. In patients
with a glans width less than 14 mm or with tension of glans wings approxima- tion, dissection is extended along the corporal
bodies distally for about 4 mm (see Fig. 147-11). The attachments of the corpus spon- giosum wings to the ipsilateral glans
wings on either side are divided. The spongiosum on either side of the urethral plate is further dis- sected off the corpora
cavernosa for subsequent spongioplasty.

Artificial erection is done and VC is addressed as discussed earlier. When the penis is straight and the urethral plate conserved,
the plate is incised dorsally from the meatus to its distal end extend- ing to near the underlying corporal bodies. A 6-Fr stent is
passed into the bladder and tubularization is done in two subepithelial layers, the first using an interrupted 7-0 polyglactin
stitch and the second a continuous 7-0 polydioxanone stitch.

Artificial Erection
Heparinized saline injected into the corpora was first described by Gittes and McLaughlin (1974) to create an erection
intraoperatively in men with Peyronie disease, and subsequently was adapted for use in boys with hypospadias.

We perform artificial erection during hypospadias repair after degloving, dissection of ventral dartos, and release of the corpus
spongiosum wings from the underlying corpora cavernosa and glans wings in proximal hypospadias because shortened ventral
shaft skin, dartos, and spongiosum can contribute to apparent VC. Normal saline is injected into a single corpora using a 23-
gauge butterfly needle until erection is achieved. We do not use a tourni- quet because occasionally it can mask curvature if
positioned at the point of bending. If compression is needed to slow fluid outflow and obtain erection, manual pressure is
applied below the base of the penis, pressing the corpora against the crura.

Criticisms of saline injection include supraphysiologic or sub- physiologic intracorporeal filling that would over- or
underestimate curvature. Vasoactive drugs have also been injected to induce erec- tion during hypospadias repair (Perovic et
al, 1997; Kogan, 2000), with the proposed advantage of being a more physiologic assess- ment in contrast to saline injection.
We have no experience with this method.

Spongioplasty approximates the corpus spongiosum wings over the neourethra. Then a hemiscrotum is entered and the testis
exposed. The tunica vaginalis is opened transversely and stay stitches are placed into its distal corners. A stay is also placed in
the adventitia near the inferior pole of the testis for countertraction. A tunica vaginalis flap is created by dissecting along the
spermatic cord to near the external ring. Fatty scrotal tissues are excluded

The testis is returned to its normal position and suture pexed into place, and then its compartment is closed. The flap is brought
over the neourethra, shiny surface down, and tacked with 7-0 polydioxanone.
Glansplasty is done in one layer using 6-0 interrupted subepi- thelial polyglactin, usually with three stitches from distal to the
corona. As described for distal TIP urethroplasty, the glans wings are not sutured to the neourethra.
Shaft skin attached to the inner prepuce ventrally is excised (see Fig. 147-10C) and the preputial collar is completed using inter-
rupted subepithelial 7-0 polyglactin and one epithelial 9-0 polygla- ctin suture at the corona. Then the dorsal prepuce is divided
in the midline to the level of the preputial collar and sutured there using 7-0 subepithelial polyglactin. Ventrally the penoscrotal
junction typically is incised to approximately 3 and 9 o’clock and then the scrotum near these points is sutured to the corpora
on either side of the true penoscrotal junction with 5-0 polydioxanone, moving the tunica vaginalis flap aside to do so. In nearly
all cases this maneuver corrects penoscrotal transposition without need for scrotal flaps and the visible scars those produce
(Fig. 147-16).
Excess preputial skin is excised to complete the circumcision and the ventral skin is closed, creating a median raphe. All skin
stitches are subepithelial. We use urinary diversion into diapers for 2 weeks.

TWO STAGE

First Stage. The initial skin incision is the same as described earlier for proximal TIP urethroplasty, maintaining most of the
inner prepuce for a graft if needed. The operation proceeds as described for proximal TIP urethroplasty to the point that
artificial erection demonstrates VC greater than 30 degrees.
Urethral plate transection is done distally at the coronal level, and then the plate is excised from the corpora, moving
proximally to the meatus and beyond toward the membranous portion. The native urethra is then gently stretched distally and
anchored at intervals to the corpora using 6-0 polydioxanone. This maneuver moves the urethrostomy distally, reducing the
length of graft needed. The native urethral mucosa is sutured to the corpora using 7-0 polyglactin at 10, 12, and 2 o’clock.
Proximal urethrostomy is completed by suturing the native urethra to penile skin or scrotum at 4, 6, and 8 o’clock with 7-0
polyglactin.

Stay stitches are placed into the corners of the dorsal prepuce and the underlying dartos is excised. Typically the graft is mostly
inner prepuce with less outer preputial skin, with the width deter- mined by the lower edge of the subcoronal collar (Fig. 147-
18).

The dorsal shaft skin is sutured to the preputial collar using interrupted subepithelial 7-0 polyglactin. Then the graft is placed
into the ventral defect and first stitched to the glans, which has been opened widely, at the level of the corona with 7-0
polyglactin. Additional stitches secure the graft to the distal end of the glans, placed subepithelially to avoid marks where the
neomeatus will be created during the second procedure. The graft is gently stretched proximally and sewn to the shaft skin on
either side using inter- rupted 7-0 polyglactin. The proximal end is split in the midline to extend graft to either side of the
urethrostomy, which is sutured at the 2, 10, and 12 o’clock positions medially and to the shaft skin or scrotum laterally. A
preputial graft harvested as described in Figure 147-28 (see later) will fill the defect from the glans tip to deep within the
scrotum.

Next the graft is quilted onto the corpora at 1-cm intervals using 6-0 polyglactin on an RB-1 needle, which easily penetrates the
graft and adheres it to the underlying tunica albuginea (Fig. 147-19). A catheter is placed in the bladder. Then a rolled Vaseline
gauze (Conopco, Englewood Cliffs, NJ) is laid onto the graft and held firmly, but not tightly, by 5-0 polypropylene stay stitches
tied over the gauze. This tie-over bandage further immobilizes the graft and helps prevent seroma or hematoma accumulation
beneath it. The catheter and tie-over bandage are maintained for 7 days. Physical activity is not limited in infants and young
children. No special care is needed for the graft after the bandage is removed during the interval before the second stage. We
always wait 6 months before second-stage repair.

Second Stage. An incision is marked along the glans wings and shaft skin adjacent to the now revascularized graft, moving into
the urethrostomy ventrally to remove the penile or scrotal skin that was sutured there from 4 to 8 o’clock. The glans wings are
injected with 1 : 100,000 epinephrine and incised and dissected laterally, as is the remainder of the marked incision. If the glans
width is less than 14 mm, extended dissection is done as described earlier to reduce tension on the subsequent approximation
of its wings.

A 6-Fr stent is passed into the bladder and secured to the glans traction stitch. Preputial grafts are very thin and can be tubu-
larized in two layers similarly to the urethral plate in proximal TIP repair using 7-0 polyglactin and polydioxanone. Then a tunica
vaginalis flap is created and placed over the entire neourethra. Glansplasty is completed as described earlier for proximal TIP
urethroplasty.
A subepithelial 5-0 polydioxanone suture secures the scrotum to the corpora on either side of the neourethra to establish the
penoscrotal junction, and then penile and scrotal skin are closed in the midline using subepithelial sutures. Urine is diverted for
2 weeks.

PREPUTIAL FLAP

Onlay Flap. The technique for onlay preputial flaps is illustrated in Figure 147-20. The initial lines of incision, degloving and
release of dartos and scrotal attachments, and development of glans wings are the same as described earlier for proximal TIP
urethroplasty. Artificial erection demonstrates 30 degrees or greater VC, straight- ened by dorsal plication when present.
The corners of the dorsal prepuce are held with stay stitches and a 10-mm-wide strip of its inner surface is harvested,
preserving the underlying dartos vascular supply. Dissection of the pedicle extends to the penopubic junction to prevent
tension when the flap is moved ventrally either around the side of the penis or via a but- tonhole incision over the glans.
A 6-Fr stent is passed into the bladder. The flap is then sewn to the urethral plate using subepithelial 7-0 polyglactin, gently
stretch- ing it distally and trimming it as needed to maintain uniform dimensions. The dartos pedicle is used to cover the suture
lines. Next, glansplasty first secures the glans wings to the flap edges using interrupted subepithelial 7-0 polyglactin. Proximally
the wings are approximated together with interrupted subepithelial 6-0 polygla- ctin. Circumcision and skin closures are done
as described for proxi- mal TIP urethroplasty.

Tubularized Flap. The technique for tubularized preputial flaps is illustrated in Figure 147-21. When artificial erection finds VC
greater than 30 degrees, the urethral plate is transected and additional straightening maneuvers as described earlier are
performed as needed.
The corners of the dorsal prepuce are held with stay stitches and a flap 12 to 15 mm wide is outlined horizontally on its inner
portion. The flap is released and its pedicle dissected to the peno- pubic junction. The flap can then be tubularized over a 6-Fr
stent in two layers, the first using a running subepithelial 7-0 polyglactin followed by several more interrupted stitches. This
tube is moved ventrally, sewn to the spatulated native urethral meatus, and then stretched distally with the suture line down
against the corpora. The flap is sewn to the glans wings using interrupted subepithelial 7-0 polyglactin. Remaining glans wings
are approximated using subepi- thelial interrupted 6-0 polyglactin.
Alternatively, the flap can be brought ventrally before its tubu- larization and sewn to the native urethra dorsally. Then it is
stretched distally and one edge is sewn to the underlying corpora to create a pseudoplate. Excess flap skin is excised and the
remaining free end is sewn to the lateral edge to complete a tube.
Results. Urethroplasty complications after proximal preputial flap repairs have been reported in 27% to 45% of onlay flaps and
in 14% to 33% of tubularized flaps. Two articles suggested that complications are fewer with tubularized flaps when they are
first secured to the corpora along one edge to create a pseudoplate and then fashioned into a tube.
Onlay flap repair for proximal hypospadias was reported in 126 patients with mean follow-up to 22 months. Urethroplasty
compli- cations developed in 27%, with 18 fistulas, 13 glans dehiscences, 2 strictures, 1 diverticulum, and 4 flap prolapses
through the meatus (de Mattos e Silva et al, 2009). Another retrospective review described outcomes for penoscrotal onlay
flaps in 75 cases with postoperative follow-up to a mean of 39 months. Complications were encountered in 45%: eight fistulas,
two dehiscences, two stric- tures, one meatal stenosis, and five patients with recurrent VC after dorsal plication (Braga et al,
2007).
Tubularized preputial flap outcomes for penoscrotal or more proximal hypospadias were described for 27 cases with median 9
months of follow-up. Of these, 33% developed urethroplasty com- plications, including seven fistulas, one stricture, and one
meatal stenosis (Powell et al, 2000).

Byars Flaps
Byars flap refers to a two-stage operation in which the urethral plate is excised during penile straightening in the initial
operation. The dorsal prepuce is split down its midline and the two parts are trans- ferred ventrally with their dartos vascular
pedicles and sutured into the defect from the meatus to the glans. At the second operation the previously transferred prepuce
is tubularized (Byars, 1955).
This technique has been used following corporotomy with grafting by those who prefer a two- stage urethroplasty rather than a
single-stage tubularized preputial flap. However, there are few reported outcomes. The largest, with 58 patients, only
mentioned postoperative fistulas among all the possible urethroplasty compli- cations (Retik et al, 1994). Another three studies
had fewer patients. Shukla and colleagues (2004) reported results in only 10 patients with an average 43 months of follow-up,
noting urethroplasty com- plications in 70%, including seven fistulas, three meatal stenoses, and one diverticulum. Gershbaum
and colleagues (2002) had 11 patients with follow-up of “5 to 15” years, with complications in 18% (one fistula and one
diverticulum), although the authors stated that 2 more patients had a “subterminal meatus or skin irregularities” that
potentially increased the rate to 36%. In addi- tion, they stated that 37% had abnormal voiding and spraying.
I (W.S.) used the operation in 9 patients with a 100% complica- tion rate, with two fistulas, five diverticula, one stricture, and
two glans dehiscences. Although fistulas and glans dehiscence are common in proximal hypospadias repair, it was diverticula,
and the stricture that resulted when a less wide skin strip was tubularized to try to prevent a diverticulum, that prompted me to
abandon this technique. We no longer perform Byars flaps or recommend their use.

Flaps versus Grafts

There are no trials randomizing patients with proximal hypospadias and VC greater than 30 degrees to tubularized flap versus
two-stage graft repair. Proponents of flaps state that their vascularity is assured from the pedicle, whereas that of grafts is less
reliable because they must revascularize. However, Duckett once commented that fluo- rescein showed devascularized edges
to his flaps that had to be excised, although he never published these observations in a clinical series (Duckett, unpublished
comment to Hodgson, 1981).
Graft take was successful in all 43 cases reported by Ferro and colleagues (2002) using prepuce. We encountered contracture
resulting in an additional procedure to partially or totally regraft in 4 of 65 (6%) patients, without a difference between prepuce
and oral mucosa (Snodgrass and Bush, 2015). Our series differs from that of Ferro and colleagues in that we straightened VC in
26 (90%) of these cases using transverse corporotomies, which was done in 3 of the 4 patients with contracture. No patient has
required more than one regrafting.
Urethroplasty complications that potentially indicate impaired vascularity include meatal stenosis and strictures. Tubularized
flap outcomes described earlier reported meatal stenosis and/or stricture in approximately 8% (Powell et al, 2000; Shukla et al,
2004; Aoki et al, 2008), whereas 3% of two-stage grafts developed a stricture (Ferro et al, 2002). None of our patients has had
either meatal stenosis or stricture.
There are also few data regarding cosmetic results. Patients we have evaluated who were operated elsewhere with flaps, an
admit- tedly potentially biased group, most often have had glans dehis- cence and a less cylindrical shape to the penis (Fig. 147-
22). This glans dehiscence may be protective against diverticulum, but at the potential cost of urinary spraying.
Currently there are insufficient functional or cosmetic data to establish the best practice and determine if benefits of a two-
stage repair outweigh the need for two operations.
Prepucioplasty
Prepucioplasty can be done in nearly all patients, with both distal and proximal hypospadias, whose caregivers request it (Fig.
147- 23). In 1% of cases a patient has a large glans and small dorsal hood that prevent prepucioplasty. When prepucioplasty is
done for proxi- mal hypospadias in which urethral plate transection is needed for VC straightening, two-stage repair uses an
oral labial mucosa graft. Indications. Foreskin reconstruction is indicated in any primary hypospadias repair when caregivers
prefer it to circumcision. We simply ask if newborn circumcision was anticipated and, if not, offer prepucioplasty.
Surgical Technique. Stay sutures are placed into the corners of the dorsal prepuce (see Fig. 147-23A). Initial incision extends
from these points, lateral to the glans, and then to a point approximately 2 mm below the meatus. The penis is not degloved,
and ventrally
dissection is done immediately under the skin to preserve dartos for a barrier flap until normal tissues are encountered,
generally near the penoscrotal junction.
Urethroplasty and glansplasty are done as already described for distal or proximal TIP or two-stage graft repairs.
After glansplasty the foreskin stays are pulled down below the glans and the inner prepuce is approximated using subepithelial
7-0 polyglactin. Then the stays are pulled distal to the glans. These corners are approximated together also using subepithelial
7-0 polyglactin. Previously we adjusted the position of this initial stitch to allow the foreskin to readily retract back and forth
over the glans. However, this sometimes leaves the prepuce visibly deficient ven- trally, and so today we suture it to achieve
the best appearance and are not concerned about its retractability, given that normal boys the same age as those undergoing
hypospadias repair often have similarly nonretractable foreskin. The remainder of the incision is closed using interrupted 7-0
polyglactin. Caregivers are instructed not to retract the foreskin.
Results. Urethroplasty and skin complications are the same after distal or proximal TIP or two-stage graft repairs, whether
circumcision or prepucioplasty is done.
Suoub and coworkers (2008) compared 25 distal TIP repairs with prepucioplasty to an age- and time-matched cohort of 49
distal TIP repairs with circumcision, reporting no difference in either urethroplasty or skin complications. The only urethroplasty
com- plications were fistulas, occurring in 12% and 8%, respectively. One patient with “recalcitrant” phimosis had secondary
circumcision after prepucioplasty versus two with “redundant skin” after circum- cision who had circumcision revision (Suoub et
al, 2008).
Snodgrass and colleagues (2013) also reported a case-cohort study of 428 consecutive distal TIP urethroplasties of which 85 had
prepucioplasty. There were no intraoperative conversions to circum- cision. Urethroplasty complications developed in 8% after
prepu- cioplasty and 9% after circumcision. Two percent of each group had subsequent skin revision, which included one
circumcision for BXO 5 years later and one excision of an unsightly dorsal whorl without circumcision following prepucioplasty.
Snodgrass and Bush (2011) did prepucioplasty during proximal TIP urethroplasty in 21% of cases (all who requested it), with
none having postoperative urethroplasty or skin complications. Prepucio- plasty was also done in 25% of those undergoing two-
stage graft repair (all who requested it), with none having recurrent curvature or urethroplasty or skin complications
(unpublished data).
Because prepucioplasty does not increase either urethroplasty or skin complications, the choice between it and circumcision
should be mentioned to all caregivers, allowing them to determine the final cosmetic appearance.

SCROTOPLASTY

In the last edition of this textbook “major” scrotoplasty using rota- tional skin flaps to correct penoscrotal transposition was
illustrated. Today we no longer perform this maneuver, having found that we can correct transposition with ventral penoscrotal
incisions leaving no visible scars. Instead, shaft skin adjoining the scrotum is incised ventrally to 3 and 9 o’clock, and then the
scrotum is rotated down to create a new penoscrotal junction and sutured to the corpora on either side of the neourethra with
5-0 polydioxanone as shown in Figure 147-16.