A 2-years-old boy was brought to Dr A.K.Singal for repair of severe penoscrotal hypospadias (hypospadia) with chordee- the penis was bent at almost right angle- op degrees angle.
The hypopadias repair surgery in such cases involves chordee correction (straightening of the penis) and then urethroplasty to bring the urinary opening to the tip of the penis. The first step in chordee correction surgery is to deglove the penis which means all th skin is taken down and almost 50% of the cases chordee correction happens with this step alone. Some cases may need a stitch on the top side of penis called Tunica Albuginea plication to correct the curvature. But in this case the chordee was very severe and even after degloving the penis was very bent. In such cases, stitch on the top side of the penis may not work.
First Stage:
As a first step, we degloved the penis but still there was significant chordee.
This was due to shortage of tissue on the underside of penis. We made a horzintal incision at the site of maximum curvature first dividing the urethral plate and then on tunica albuginea to straighten the penis. As soon as this was done the penis became straight.
There was a large oval defect in the tunica albuginea on the underside of penis. This was covered using a “dermal graft” from nearby inguinal region. Dermal Graft refers to a strip of skin without the top layer and hair follicles.
The graft was sewn into place using PDS sutures and leak checked.
After that the foreskin (prepuce) was divided in midline and rotated onto the underside to cover the whole penile area completely. At the end of it, the boy had a straight penis without any chordee and enough of skin n the underside for the second stage repaur of hypospadias (urethroplasty)
Second stage hypospadias repair surgery was done after 6 months. To begin with the strip of skin on underside of penis was rolled into a tube with thick dartos cover.
Second Stage:
Then a second layer of tunica vaginalis s placed and finally the mobilized skin on underside of penis was closed with interrupted sutures to finish the repair.