1. Introduction

a. Divide at Frenulum

b. Circumferential Incision

c. Release Curvature

2. Chordee Release

a. Midline Division

b. Dorsal and Ventral Sutures

c. Excise Excess Skin on Right

d. Right Midline Suture

e. Excise Excess Skin on Left

f. Left Midline Suture

3. Remove Excess Foreskin

4. Closure for Chordee Release

a. Cauterize Native Meatal Mucosa

b. Excise Mucosa

c. Meatal Advancement

5. Glanular Hypospadias Repair

6. Post-op Remarks

Hypospadias is a congenital malformation that affects the urethra and foreskin of the penis. The urethral opening is ectopically located on the underside of the penis in any place from the glans penis to the scrotum, and the penis is more likely to have associated ventral shortening and curvature called chordee. Hypospadias is common, occurring in 1 out of every 250 to 300 newborn males and has been related to certain factors in the mother such as obesity, age over 35 years, use of fertility and hormonal treatment, and smoking. Hypospadias is characterized as glanular, distal, midshaft, penoscrotal, or proximal, with glanular being the most common. Diagnosis is usually made during physical examination after birth. Hypospadias can be repaired with surgery and is done at 6 to 24 months old when penile growth is minimal. If it is not treated, hypospadias can lead to problems such as having to sit down to urinate or difficulties with sexual intercourse and fertility. The goals of the surgery are to correct the curvature of the penis and to relocate the urethral meatus to its correct position. Here, we present the case of a 13-year-old male with glanular hypospadias and chordee. Release of the chordee was performed to straighten the penis, and repair of the glanular hypospadias was performed using the meatal-advancement technique.

<h4>CHAPTER 1</h4>

<p>Okay, this child is 13 years old. He was never been circumcised. But if you look here, his foreskin is not completely covering the glans penis. So it’s a, I call this a natural circumcision. So if you were a normal child, nothing wrong with you and you have a foreskin like this, you don't need to circumcise, you don't have to. Now what he has is, he has a curvature. You can see the penis is curved, and we call that chordee, curvature, because there are adhesions causing that to curve. But also there's another one that causes this to curve, and that is the frenulum is tight. You can see how tight. This structure is tight. You can release that and that will take care of some of the chordee. The other problem he has is that the opening where he pees is right here. The entire meatus where the urine should come out is through this little hole. But instead, he has it through here, which is not so bad because he can still direct- he can live with this without any disability, whatsoever, but he has to be careful when he pees because with the curvature, and he’s peeing, then he can pee on himself. Yes, directed to the commode or to the urinal. So, that can be a problem. So…</p>

<h4>CHAPTER 2</h4>

<p>So what we are going to do first is we’re going to release the chordee, part of the chordee by going underneath here. Go ahead and divide that, that scar tissue like so. See, part of the chordee is released just by doing that. But that's not enough. You see, there's more of that there.</p>

<p>So- what we're going to do now is we’re going to do- we're going to make an incision like that with a knife. Okay? We're going to make an incision- on the top. Hold this one. Keep it steady. Make an incision. Okay. Scissors? It'll bleed a little, but it's not going to be that bad. And you always leave a cuff of foreskin close to the glans- away from the glans. See? This cuff has to be preserved. Can you do the same thing? Go underneath. Just the skin mainly. Go deeper. That's good. And then you divide. Okay, cut. Excellent. Okay. Keep going. And you keep going and make sure you leave a 1-1.5 cm cuff. So his main problem is the curvature, not the- not the opening that's abnormal. We'll address that later. Most of the curvature is in the front. So we will try to divide all the tissue that's causing him to curve. Perfect.</p>

<p>So now- what we’re going to do now is we're going to release the curvature, the tissue that causes the curvature. As we divide those tissue, the penis will straighten out. It’s a very mild chordee he got. Yeah, Mild. See, it's starting to release itself.</p>

<h4>CHAPTER 3</h4>

<p>Okay, that should be good now. Okay. So what did we have to do is remove the excess foreskin, that's all. We can divide it in the middle, and then we can do a Byar's flap, like we do a flap. You can use the cautery to divide it. Hemostat? Yeah, cut some more of this adhesion here. Yeah. Yeah, good. Yeah, here. Okay, now you divide it here, in the middle. Okay, divide it. Perfect. Okay, then cut some more.</p>

<p>Hemostat? Yeah, we can use all of his skin. You go ahead and put together, then we'll just excise that excess.</p>

<p>Okay, then you excise this excess skin. Excise that, here. Just move it slowly, like that. Then to cut… Just move slowly. Yeah. Yeah, yeah. Activate. Yeah, cut here. Cut the skin now. Good. Perfect. See? You are doing good. Sub-q is where the blood supply is, so you have to- that's where you activate. Yeah, then the skin, sub-q. Good. Okay. Let's see how that looks like. That's pretty even. We can trim some later. Go ahead, put your suture in the middle.</p>

<p>Hemostat.</p>

<p>We'll probably have to trim that excess skin. This one here. Stretch it.</p>

<p>You're going to need another one of these 5-0. TF, 5-0 TF. Okay.</p>

<h4>CHAPTER 4</h4>

<p>Two sutures in between, sir? Yeah, two, yeah. Good. Nice bites, 2 mm bites. Like that- like take a triangle. Yeah, like that, see? Yeah. Okay. Yeah, nice, 2 mm. Good.</p>

<h4>CHAPTER 5</h4>

<p>So what you're going to do now is we're going to just- what you do is cauterize this mucosa, and then leave the bridge intact. That's what we going to bring over, Okay, so just- just like you're excising it, except you're cauterizing it. I'm going to go in this direction. Yeah. Yeah, and then leave the bridge intact. Yeah, you take- excise that. Yeah, make a mark. Yeah, go ahead. Make a mark with the cautery. Like that. Yup. Exactly, like that. There. And if you can hold the mucosa, you can pick it up and excise it.</p>

<p>Yeah, if you can- yeah, that's good. If you can excise it- yeah, there you go, you've got tissue. I'm just going to excise the mucosa. Yeah, excise the mucosa. You’re doing fine. You're getting some tissue. Yeah. Yeah, yeah. You're good. You're good. You're good. Yep. Yeah, push that. That's what the most difficult part is, pushing it and working at the same time. Just let the- yeah, that's good. Yep. Yeah, you're doing fine, You have tissue now, you just pull that tissue and excise it. Yeah, you're almost there, you almost got it. Yeah, that's… If you can excise that down there, you'll be fine. I think you're done. You just burn that mucosa there. And burn the deep one. Okay, now you can put your stitch in the middle with a 5-0, from here to there.</p>

<p>Yeah, big bite. Nice, that's good. Same thing. Right in the middle. Okay, good. Perfect. You see that? This is called a meatal advancement- meatal-advancement technique. You see how the meatus looks like now? Hemostat. All you need now is about 2 stitches, then you're done. That's called the meatal-advancement. Yep. Beautiful. Very simple technique. Not Bloody and no pain. The patient won't have too much pain. Yeah. Good. Good bite. See? That's it. You're done. Then we put a dressing on. See, the penis is straight now. Cut.</p>

<h4>CHAPTER 6</h4>

<p>So what we did was we took care of the chordee, the curvature, by cutting the tight frenulum, and then we released the adhesions all around. And then we divided the skin on the back, and then we just used the- we didn't take too much skin, just enough to make a nice rim. And then we did an advance- the opening where the urine comes out was in the bottom, we advanced it to the top. And that's called the  meatal-advancement technique. Meatal-advancement. Okay. All right, so you put the dressing on, and we're all set.</p>

Watch this full-length, narrated procedure of a pediatric chordee release, circumcision, and glanular hypospadias repair. This surgery was performed with the World Surgical Foundation in the Philippines.

Romblon Provincial Hospital