CPT® Code 54336

1. Indications

The procedure described by CPT® Code 54336 is indicated for the surgical correction of perineal hypospadias in males, particularly when accompanied by chordee. The following conditions warrant this surgical intervention:

• Perineal Hypospadias - A condition where the urethral opening is located on the perineum instead of the tip of the penis.
• Chordee - A curvature of the penis that may accompany hypospadias, necessitating correction to ensure proper function and appearance.
• Cleft Deformity of the Scrotum - Associated deformities that may require surgical intervention to restore normal anatomy.

2. Procedure

The surgical procedure for CPT® Code 54336 involves several detailed steps to achieve the correction of perineal hypospadias and chordee:

• Step 1: Catheter Placement - A catheter is placed transurethrally into the bladder to facilitate urine drainage during the procedure.
• Step 2: Incision - A circumferential incision is made just proximal to the coronal sulcus, extending down between the dartos and Buck's fascia on the dorsal side of the penis.
• Step 3: Exposure and Dissection - The urethral plate is exposed, and fibrous bands on the ventral aspect proximal to the hypospadias meatus are excised down to the corpus spongiosum within the scrotum to correct the chordee.
• Step 4: U-Shaped Incision - A U-shaped incision is made around the hypospadias meatus, with extensions laterally and dorsally into the prepuce, which is then joined at the 12 o'clock position.
• Step 5: Dissection of Prepuce - The portion between the prepuce and dartos is dissected free on the dorsal side, allowing for mobilization of the prepuce.
• Step 6: Fixation of Prepuce - The prepuce is fixed to the dartos to form the neo-urethra, ensuring that there is no vascular compromise.
• Step 7: Buttonhole Incision - A buttonhole incision is made through the pedicle of the dartos, allowing the glans penis to be passed through the hole.
• Step 8: Mobilization of Flap - The parameatal skin flap and vascular pedicle are mobilized to the ventral side, maintaining a loop shape for the neo-urethra.
• Step 9: Closure of Loop - The internal side of the loop is closed over the catheter with a running stitch, incorporating full thickness, while the external side is closed with a running subcuticular stitch.
• Step 10: Creation of Neo-Meatus - A slit-like midline incision is made in the glans penis, extending from the tip to the coronal sulcus, and dissecting bilaterally to create a groove for the neo-urethra.
• Step 11: Adjustment and Suturing - The length of the neo-urethra is adjusted, and it is sutured to the tip of the glans to complete the neo-meatus.
• Step 12: Flap Mobilization and Closure - The wings of the created flap are mobilized over the neo-urethra and sutured in the midline, while Byer's flaps from the dorsal foreskin are divided and sutured to cover any remaining ventral skin defects.
• Step 13: Final Closure - The circumferential incision is closed around the corona, creating the appearance of a circumcision, and the catheter is left in place for postoperative care.

3. Post-Procedure

After the completion of the procedure, the patient will require careful monitoring and postoperative care. The catheter remains in place to allow for proper drainage of urine while the surgical site heals. Patients may experience swelling and discomfort in the area, which can be managed with appropriate pain relief measures. Follow-up appointments are essential to assess healing, ensure the proper function of the neo-urethra, and address any complications that may arise. It is important to provide instructions regarding activity restrictions and signs of potential complications, such as infection or catheter blockage, to ensure a smooth recovery process.