Hypospadias repair: tubularised incised plate

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Assessment Three findings define the operation and each is recorded before incision: the meatal position on the ventral shaft, the degree of chordee demonstrated on artificial erection, and the quality of the hooded prepuce. The meatus marks where the urethral plate begins and sets distal versus proximal disease, which sets single-stage repair against staged reconstruction. The hooded prepuce is examined as the skin bank it is, deficient ventrally and redundant dorsally, and its adequacy for ventral cover is judged on the table. No circumcision and no discard of the hood happens before repair, because skin removed at the start is cover missing at the end.
   where it bites: never circumcise or discard the hood before repair: without it there is no ventral skin cover.
2. Chordee correction The penis is degloved to the root through a circumferential subcoronal incision, releasing the tethering skin and fascial layers, and the artificial erection test is repeated before anything further is decided. Skin release alone straightens a proportion of penises, and the re-test is what identifies them. Where bend persists, the dorsal tunica is plicated at 12 o'clock with small bites strictly in the midline, shortening the longer side to match the ventral. The erection test is repeated until the penis is straight, and the midline discipline is absolute because the dorsal neurovascular bundle runs immediately either side of that line.
   where it bites: plication is strictly midline at 12: the dorsal neurovascular bundle lies just either side of that line.
3. Glans wing elevation The glans wings are dissected off the lateral edges of the urethral plate with fine scissors, in the plane immediately lateral to the strip, until they will mobilise later without tension. The plate itself is left as a bare midline strip running from the ectopic meatus onto the glans tip, untouched by the dissection. The depth of the wing dissection decides whether the wings will meet over the neourethra: wings left under-elevated will not meet, and wings closed under tension strangle the meatus. The unforgivable error is cutting into the strip itself, because the plate is the repair's only building material and a devascularised strip breaks down.
   where it bites: the dissection plane is lateral to the plate: cutting into the strip devascularises the repair's only building material.
4. Midline plate incision A single incision is made along the midline of the plate from meatus to glans tip, deep through the full thickness of the strip, and the strip is seen to relax and widen as the incision opens. The widened edges become mobile enough to roll into a tube without being stretched across the gap. The cut is decisive and strictly midline: a hesitant, shallow or wandering incision neither relaxes the plate properly nor preserves its blood supply, and a lateral cut devascularises the strip entirely. Bleeding from the incised edges is controlled with fine precision, because over-cautery here is a burn delivered to the future neourethra.
   where it bites: strictly midline and decisively deep: hesitant lateral cuts both narrow and devascularise the plate.
5. Tubularisation over a stent A silastic stent is laid along the strip and the lateral plate edges are brought together over it with a fine running absorbable suture, starting distally where the meatus will be and working proximally. The suture line is checked for watertightness before moving on, because a leak found now is a stitch and a leak found later is a fistula. The tube must sit tension-free around the stent: closed tight over it, the tube strangles its own blood supply and parts. The stent stays to drain the neourethra while it heals, secured so that neither dressing nor movement can pull on it.
   where it bites: tension is the enemy: a tube closed tight over the stent strangles its own blood supply and parts.
6. Glansplasty + skin cover The elevated glans wings are folded back over the neourethra and closed in front of it with interrupted sutures, coned to a meatus at the tip rather than cinched tight over it. The hooded prepuce is then rotated ventrally, often as two flaps, so the dorsal skin the child was born with becomes the ventral cover the repair needs. The design principle is layering: a second well-vascularised layer over the neourethral suture line is the barrier that stands between urine and a fistula. Skin closed under tension is not cover but a tourniquet, and the flaps are re-planned rather than pulled.
   where it bites: a second well-vascularised layer over the neourethral line is the barrier to fistula.
7. Dressing + stent care A firm dressing supports the repair without constricting it, and the stent is checked to drain freely before the child leaves theatre, with the dressing secured around it so nothing can pull on the tube. The ward instructions are specific: the stent stays patent and draining, the dressing stays dry, and the team is called if either fails. The stent is removed on the planned day, and the first void afterwards is watched for split stream or spraying before the family goes home. A blocked stent or a traction injury in the first days is how a well-sewn repair fails, which is why the plan for both is written before theatre ends.
   where it bites: a blocked stent or a traction injury in the first days is how a good repair fails.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance