What are the steps for hypospadias repair?

Surgical Steps for Hypospadias Repair

Hypospadias repair involves five sequential steps: orthoplasty (penile straightening), urethroplasty, meatoplasty and glanuloplasty, scrotoplasty, and skin coverage. These steps must be performed in a systematic manner to achieve optimal functional and cosmetic outcomes.

Preoperative Considerations

• Optimal timing: Surgery recommended between 6-18 months of age 1
• Endocrinological evaluation for proximal hypospadias (30% of cases) to exclude disorders of sexual differentiation, especially with undescended testes 1
• Anesthesia considerations: Regional anesthesia with long-acting local anesthetics (penile block, bilateral pudendal nerve block, or ultrasound-guided caudal block) combined with general anesthesia 2

Step 1: Orthoplasty (Penile Straightening)

• Artificial erection test to assess degree of chordee
• Degloving of penile shaft skin to expose the urethral plate and corpora
• Dorsal midline plication for correction of ventral curvature 3
• Release of fibrous tissue causing chordee
• Reassessment with artificial erection to confirm adequate straightening

Step 2: Urethroplasty

Based on severity of hypospadias:

For Distal Hypospadias (70% of cases):

• Preservation of the urethral plate when possible 3
• Tubularization of the urethral plate (Snodgrass technique)
• Incision of the urethral plate to widen it if necessary 3

For Proximal/Severe Hypospadias:

• One-stage repair when urethral plate can be preserved
• Two-stage repair when urethral plate requires transection 4
• First stage: placement of graft (often buccal mucosa) or flap
• Second stage (performed 6 months later): tubularization of the neo-urethral plate

Step 3: Meatoplasty and Glanuloplasty

• Creation of a slit-like meatus at the tip of the glans
• Reconstruction of the glans to create a conical shape
• Securing the neo-urethra to the glans with absorbable sutures
• Ensuring adequate meatal caliber to prevent stenosis

Step 4: Scrotoplasty (if needed)

• Correction of penoscrotal transposition when present
• Reconstruction of scrotal anatomy
• Fixation of scrotal skin to maintain appropriate penoscrotal junction

Step 5: Skin Coverage

• Deepithelized dartos flap coverage over the neo-urethra to provide vascularized barrier layer 3
• Closure of penile skin with fine absorbable sutures
• Reconstruction of ventral prepuce when possible or circumcision based on parental preference and tissue availability

Postoperative Management

• Pain control: Combination of NSAID and paracetamol as baseline therapy 2
• Consider methylprednisolone or dexamethasone to reduce postoperative swelling 2
• Urinary drainage: Urethral stent or suprapubic catheter depending on repair complexity
• Dressing: Non-adherent compression dressing for 3-5 days
• Antibiotic prophylaxis while catheter is in place

Potential Complications and Management

• Urethral fistula (5-50% depending on severity): Most common complication, requires surgical repair after 6 months 5
• Meatal stenosis: May require meatoplasty
• Urethral stricture: May require dilation or urethroplasty 6
• Persistent chordee: May require reoperation
• Wound infection or dehiscence: Requires prompt antibiotic therapy and wound care

Long-term Follow-up

• Regular follow-up until puberty to assess for late complications
• Evaluation of urinary function, cosmetic appearance, and sexual function in adolescence
• Monitoring for lower urinary tract symptoms which occur twice as often in patients after hypospadias repair 1

The success of hypospadias repair depends on meticulous surgical technique, appropriate selection of repair method based on defect severity, and careful postoperative management. Surgeons performing these procedures should have dedicated experience with at least 40-50 cases annually to maintain expertise 4.