The ultimate aims of surgical correction of hypospadias are normal urination, normal sexual function and a natural appearance. In order to achieve this, any chordee is corrected. A slit-shaped urethral meatus is then constructed at the tip of the glans. This shape provides the most natural appearance and prevents spraying of urine. Finally, where possible and desired, reconstruction of the prepuce may follow.
Surgery is usually undertaken before the patient can remember it, avoiding the period between 1 and 3 years when patients are deemed to be particularly uncooperative. This provides two windows, the first 12 months of life or after age 3, with individual surgeons having their own preference.
Since the term hypospadias covers an array of abnormalities ranging from minimal sub-coronal hypospadias to severe perineal hypospadias with significant chordee, over 300 surgical techniques have been described. These can be loosely categorised as either one or two stage procedures.
One Stage Procedure
The majority of hypospadias can be managed with one of the many single stage procedures. Typically, this includes distal or mid-shaft hypospadias with little or no chordee.
The most common techniques create a neo-urethra using the remaining urethral plate. This is a strip of urethral mucosa which extends from the ectopic, abnormal meatus to the glans groove and is essentially the unfused section of urethra. The urethral plate is incised along its lateral borders and lifted off the ventral corpora. A catheter is then inserted into the current meatus and the free urethral plate, if wide enough, can then be rolled over the catheter and sutured in the ventral aspect creating a neo-urethra. Reconstruction of the glans and shaft is then completed using a prepucial graft.
In cases where the urethral plate itself is not wide enough, tissue flaps or full thickness skin grafts are used to form a neo-urethra. Buccal mucosa is commonly harvested and used as a graft.
|ONE STAGE PROCEDURE|
Two Stage Procedure
Two stage procedures are thought of as more versatile as they can repair both distal and proximal hypospadias. They may also be preferred by surgeons as only one procedure needs to be mastered. However they are commonly reserved for more proximal hypospadias or where there is significant chordee.
The first procedure begins with a Horton’s test to measure chordee. Full-thickness prepucial graft is then harvested and the area of the new meatus is marked on the glans. A vertical midline incision is made between the current meatus and the proposed site of the new meatus. Chordee are then dissected and a repeat Horton’s test is performed to check for a straight erection. The prepucial graft is then grafted over the split and the wound dressed.
The second stage takes place six months later to allow the prepucial graft to take. The lateral margins of this graft are incised and then rolled over a catheter, as in one stage reconstruction, and sutured to form a neo-urethra. The procedure is then completed with skin reconstruction.