CPT® Code 54328

1. Indications

The 1-stage distal hypospadias repair is indicated for the treatment of distal hypospadias in males, particularly when the urethral meatus is located near the glans. This procedure is performed to correct the abnormal positioning of the urethral opening and to address associated conditions such as chordee, which is the curvature of the penis that can occur during erection. The surgery is typically indicated when the patient presents with functional issues related to urination or when there are concerns regarding the aesthetic appearance of the penis.

• Distal Hypospadias The procedure is indicated for males with distal hypospadias, where the urethral opening is located on the underside of the penis, near the glans.
• Chordee It is also indicated for patients who exhibit chordee, a condition characterized by the curvature of the penis, which may require correction during the repair.
• Functional Issues The surgery is performed to resolve any functional problems associated with urination that may arise from the abnormal urethral placement.
• Aesthetic Concerns The procedure is indicated for patients or families concerned about the cosmetic appearance of the penis due to hypospadias.

2. Procedure

The 1-stage distal hypospadias repair involves several detailed procedural steps to ensure the successful reconstruction of the urethra and correction of any associated chordee. The procedure begins with the placement of a stent or catheter in the urethra to maintain its patency during the surgical process.

• Step 1: Incision A Y-shaped incision is made in the glans of the penis. The short limbs of the incision are approximately 0.5 cm long, while the vertical limb extends to the coronal sulcus, allowing access to the underlying structures.
• Step 2: Dissection The surgeon identifies and excises fibrotic tissue from the midline and laterally, elevating the glans flaps to enlarge the meatus and create a core space for the neo-urethra.
• Step 3: Circumferential Incision A circumferential incision is made in the subcoronal tissue below the glans, extending laterally to the area of excised fibrous tissue, facilitating further dissection.
• Step 4: Degloving The penile and preputial skin is degloved, exposing Buck's fascia while preserving the vascular connection to the preputial flap, which is crucial for healing.
• Step 5: Evaluation of Chordee An erection is induced to evaluate the degree of curvature caused by chordee. Extensive dissection of the tissues is performed to correct the curvature as needed.
• Step 6: Neo-Urethra Construction The neo-urethra is constructed using a rectangular flap, which may be extended with a horseshoe incision incorporating penile skin on either side. The flap is tubularized around the catheter with interrupted sutures, starting at the meatus under the vascular pedicle.
• Step 7: Anchoring the Flap The small upper median flap formed by the Y incision is anchored with sutures to the upper dorsal aspect of the tube, ensuring stability.
• Step 8: Aesthetic Meatus Creation To achieve an aesthetically pleasing meatus, a small V-shaped wedge of tissue is excised from the tip of the glans, and the mobilized glans wings are rotated medially around the neo-urethra.
• Step 9: Final Suturing The glans wings are anchored with three mattress sutures placed transversely to approximate the wings in the midline, completing the construction of the neo-urethra.
• Step 10: Alternative Techniques Alternatively, a local skin flap or skin patch graft may be utilized to construct the neo-urethra, depending on the specific surgical plan and patient anatomy.

3. Post-Procedure

Following the completion of the 1-stage distal hypospadias repair, the urethral stent or catheter remains in place to ensure that the newly constructed urethra maintains its patency during the initial healing phase. Post-operative care includes monitoring for any signs of complications, such as infection or bleeding, and ensuring that the patient is comfortable. Patients may be advised on activity restrictions to promote healing and prevent stress on the surgical site. Follow-up appointments are essential to assess the healing process and the functional outcome of the procedure, including the position of the urethral meatus and the correction of any chordee.