DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Hypospadias, status post multiple repairs.
POSTOPERATIVE DIAGNOSES:
1. Hypospadias complications, status post multiple repairs.
2. Recurrent chordee.
OPERATIONS PERFORMED:
1. Redo second stage hypospadias repair following multiple prior operations.
2. Nesbit dorsal plication.
3. Artificial erection.
ANESTHESIA: General and caudal.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, general anesthesia administered and a caudal block placed. He was then positioned supine and prepped and draped in the usual sterile manner. Tourniquet was placed around the base of the penis and sterile injection with saline injected through a butterfly needle into the corporeal bodies. This revealed that there was still residual ventral chordee, most notably distally, over the ventral tilt of the glans. In light of this, we decided to perform plication to further straighten it. Incision was made transverse along the circumcising line dorsally, for less than 1 cm, and dissection proceeded to expose the corporeal bodies. Transverse parallel incisions were made into the corpora, in the proximal aspect and brought to the distal with interrupted 5-0 Vicryl sutures comparing the intervening bridge. The overlying Buck fascia was closed with a running 6-0 Vicryl. The skin on the surface was closed with several interrupted 5-0 chromic sutures. Artificial erection test was repeated which showed the penis was now completely straight with no residual ventral chordee.
Attention was then turned towards urethroplasty. Initially, a 10 French Foley catheter was placed into the bladder and some urine drained. The balloon was not inflated to allow the catheter to be changed later. With tourniquet in place, we then incised the dorsal midline of the urethra, where it was tight and narrowed. This allowed slight relaxation of the distal segment. Thus, we widened the markings in a couple of areas which included the narrowest. We made the transverse parallel incisions, then came around proximal to the meatus. The glans wings and penile shaft skin were then elevated to mobilize them. This was done just superficial to the corporal bodies. A flap of dartos tissue was then developed along the left lateral aspect to mobilize, to allow later coverage over the urethra. This was done by dissecting proximally, particularly on the left ventral aspect. Once that was completed and adequate glans wings had been developed, we then turned our attention towards the second-stage redo urethroplasty.
The graft was quite adherent and stuck down and thus we had to perform extensive sharp dissection to mobilize the lateral aspects of the medial urethra to allow to roll into a new urethra. This was pretty dense scar tissue, which required to be divided to mobilize these edges. Once that was accomplished, then the new urethra was formed using interrupted 7-0 Vicryl sutures, first with interrupted layer to approximate the edges and then a running inverting layer. The dartos flap was then brought overlying the urethra and tacked in place with interrupted 7-0 Vicryl sutures to avoid overlapping suture lines. Glansplasty was then performed by bringing the glans together with interrupted 6-0 Vicryl horizontal mattress sutures. The meatus was matured to the entrance of the glans with interrupted 7-0 Vicryl and redundant dog ears trimmed on either side. Once that was accomplished, then the ventral glans skin was closed with a running locking 7-0 Vicryl stitch. The skin was then reconfigured in the ventral area, incorporating it. We trimmed a couple of dog ears from the transverse closure along the proximal glans to bring the skin together and then the ventral midline skin of the remainder of the shaft. The dog ear was trimmed proximally along the penile shaft skin.
The tourniquet was then released and attention turned towards the dressing. The catheter had been changed to an 8 French Firlit-Kluge stent and this was secured to the glans with interrupted 7-0 Vicryl sutures. Next, a dressing was placed which consisted of Owens gauze soaked in benzoin, wrapped with Coban and taped to lower abdominal wall. This allowed drainage freely into double diapers. The patient was then awakened and brought to the recovery room. He tolerated the procedure without complications. All counts were correct.
