There are many surgical techniques available for hypospadias repair. If we had to choose a classification system for these techniques, we would describe them simply as flap-based techniques and graft-based techniques. At The Caribbean Hypospadias Center, we subscribe to graft based surgical techniques primarily even though we have had tremendous successes with both types of techniques. We utilize the Snodgrass – Bush doctrine for hypospadias repairs. Dr. Snodgrass of the Hypospadias Specialty Center in Dallas, Texas, pioneered these techniques along with Dr. Nichol Corbin Bush, both world-renowned hypospadiologists.

TIP repair (Tubularized Incision Plate) refers to incising the urethral plate which is a remnant structure of abnormal urethral development inside the uterus. The urethral plate can vary in length, width, shape and degree of flatness. The TIP surgical technique involves incising the native urethral plate then tubularizing the edges so created. This surgical technique is indicated for distal hypospadias cases with less than 30 degrees of penile curvature and those infrequent cases of midshaft hypospadias also with less than 30 degrees of penile curvature. It is unusual to encounter midshaft and more severe forms of the disorder with less than 30 degrees of penile curvature.

It is important that the parent consenting to hypospadias surgery for their child be aware that all hypospadias surgeons have complications no matter how expert they may be.

In a meta-analysis study of TIP repairs worldwide by Pfistermuller et al 2015, TIP repairs had a success rate greater than 90%. The following were the complication rates documented in that study:
Mean % incidence – meatal stenosis – 3.6% // Mean % incidence fistulae – 5.7% // Mean % incidence urethral strictures – 1.3% // Mean % incidence re-operations – 4.5%

STAC REPAIR: STRAIGHTEN AND CLOSE

STAG REPAIR: STRAIGHTEN AND GRAFT

STAC REPAIR refers to a surgical technique that is utilized in the staged correction of penile curvature. The primary objective of a STAC repair is to straighten a penis with more than 30 degrees of penile curvature at birth. The other important objective is to redistribute the penile skin so that it stretches with normal erectile activity thereby having enough foreskin tissue if still present for subsequent grafting at the second operation.

What happens during hypospadias repair?

It is impossible for the surgeon to know before surgery if the straightening maneuvers on your child will require a STAC vs a STAG approach. The STAG REPAIR refers to straightening and simultaneously applying foreskin or oral mucosa graft tissue (using a segment of the superficial lining of the inner lower lip if previously circumcised) to an opened, flat inner glans surface (the urologist opens the head of the penis until it is flat). The key event inside the operating room as your child is under anesthesia is the following. To straighten the penis, some boys will become straight with dissection of penile skin tissue and dissection of the urethra (pee channel) off the erectile tissues of the penis. Other boys require an additional maneuver called ventral corporotomy which is essentially making thin cuts in the fascia that surrounds the penile cylinders responsible for erection. These cuts do not affect future sexual function. If all the cuts can be covered back again with the urethra previously dissected off, then a STAG is performed. If some of the cuts to straighten the penis cannot be covered, then a STAC is performed and the glans (head of the penis) is left untouched for 6 months until the second operation /stage is performed. At the second stage, a circumcision is performed and the foreskin is applied to the head of the penis which is dissected until it is perfectly flat and open. This allows the foreskin to be applied as a graft that will take another 6 months to heal before the final and third stage of tubularizing the penis occurs to result in a normal looking penis.

The bottom line is the following. If your child’s anatomy requires a STAC then a minimum of three operations will be required to obtain a normal looking penis. If his anatomy allows for a STAG initially, then only two operations are necessary.

The above is a child with distal hypospadias that is associated with severe curvature or chordee. The significant curvature renders this a more complex case requiring more than one surgical procedure for a durable satisfactory outcome.

This staged approach to obtain an optimum result is also seen in the management of breast cancer and subsequent breast reconstruction by plastic surgeons. It takes time to allow the tissues to heal to obtain successful results. If this process is not respected and ambitious one surgery techniques are applied to complex hypospadias problems, there will be high complication rates and less than satisfactory functional or aesthetic outcomes.

Fixing Penile Birth Defects

A focus on hypospadias & fixing complications of surgical intervention