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Maher et al. Hypospadias: an algorithm for repair

a thin Dartos fascia flap is dissected starting at the sufficient to tubularise around the catheter chosen.
distal end of the inner layer of preputal skin. Care is This varies according to patient age, penis size, and
taken to carry the dissection proximally with adequate the native urethral plate width; this is left to the clinical
length in a manner that will allow tension free ventral judgement of the senior author, hence the steep
transposition after neo-urethral reconstruction. This learning curve associated with hypospadias surgery.
avoids rotation of the penis.
A second layer from the soft tissue surrounding the
At this stage, a silastic size 6 Fr catheter is passed in neourethra is used to reinforce the reconstruction,
the urethra and 1.5 mL of distilled water is used inflate and help create the deficient corpus spongiosum. It is
the balloon. The penis is retracted cephalad to allow repaired using the same suture material in a running
for the reconstruction of the neourethra. The first step fashion from proximal to distal. The competency of
of the reconstruction is to form the distal most part of the neourethra reconstruction is tested with an intra-
the neourethra with a single interrupted polyglactin 7-0 urethral injection of normal saline via a 22G intra-
suture (Vicryl-Ethicon) around the inserted catheter. venous cannula (BD Venflon), to delineate possible
This produces a natural slit like urethral opening. The leakage sites, which if found, are repaired using
neourethra is then created starting at the edge of the interrupted sutures. Care is taken to introduce the
anomalous ventral meatus and is carried distally with cannula dorsal to the urethral catheter to avoid injury
a running submucosal polyglactin 7-0 suture (Vicryl- of the neo-urethra. The previously dissected Dartos
Ethicon) using the native urethral plate. In contrast with flap is transposed ventrally to create a waterproof
the tabularized incised plate (TIP) procedure described layer with its distal extent at the level of the coronal
by Snodgrass, the urethral plate was not incised in all sulcus. The Dartos flap is secured with interrupted
of the patients but one. The width of the urethral plate polyglactin 7-0 sutures (Vicryl-Ethicon). The flap is not
used in the distal (glandular and coronal) subset of
is not routinely measured, but in general, it has to be
metal openings, as it would create an unwanted and
unnatural bulk under the glans flaps. The glans flaps
are brought together with an undyed polyglactin 6-0
suture (Vicryl-Ethicon).
The tourniquet is released at this stage and bleeding
vessels are cauterized with bipolar diathermy. After
haemostasis is secured the tourniquet is reapplied.
The ventral skin is closed in a “V-Y” manner starting
distally, where the ventral skin is sutured to the glans
flap with a four corner rapidly dissolving polyglactin 7-0
suture (Vicryl Rapide-Ethicon) at the frenulum. The
remainder of the ventral vertical limb is closed with
an interrupted suture using the same material. The
excess preputal skin is marked for excision. A number
15 Beaver blade (Beaver-Visitec) is used to make the
initial incision and the rest of the excision is carried
out with the bipolar diathermy to facilitate a bloodless
wound edge, which can be a source of postoperative
bleeding in circumcision. Care is taken when closing
the subcoronal incision to avoid a rotational deformity.
The average time taken for the one stage is between
60-75 min.

Two stage Bracka repair
The penis is examined under magnification and
the morphological findings are processed through
the algorithm, at which stage it will indicate that a
single stage repair is not suitable. With the two stage
approach, there is generally a deficiency of tissues to
form a neourethra and coverage.
Figure 2: Utilization of a urethral dilator while degloving the ventral
skin The glans cleft in the centre of the narrow urethral
66 Plastic and Aesthetic Research ¦ Volume 4 ¦ April 27, 2017