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  • 1. Surgical Approach
  • 2. Incision
  • 3. Insert Catheter
  • 4. Dissection
  • 5. Prepare Island Flap for Urethra Formation
  • 6. Construction of Penile Urethra
  • 7. Mobilize Native Urethra for Length
  • 8. Excise Native Urethral Orifice
  • 9. Anastomosis of Native and Constructed Urethral Segments
  • 10. Alignment and Attachment of New Urethral Orifice
  • 11. Suture Corpus Around Penile Urethra
  • 12. Skin Closure
  • 13. Post-op Remarks
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Penoscrotal Hypospadias Repair


Domingo Alvear, MD1; Lissa Henson, MD2; Jaymie Ang Henry, MD, MPH3

1World Surgical Foundation
2Philippine Society of Pediatric Surgeons
3Florida Atlantic University, G4 Alliance



This patient has hypospadias and this is the worst- the most difficult hypospadias, it's called penoscrotal, and you can see that the penis is buried. The penis length is this much, but you can see that it's buried underneath. The opening where the urine comes out is here, there's the opening. Okay? So that's a problem, so, what we have to do is to release all the tissues that are keeping this penis curved like that. And then when that happens, you then have a length between this opening where the urine comes out to the tip of the penis. So we have to create a tube, and we're going to create a tube from here, from the shiny part of the skin right here. But we have to preserve the blood supply to that skin, so that we can move it, make a tube, and then move it in front. That's why he's so complicated. And that's called a transverse, island-flap procedure, so we're gonna- I'm gonna mark now where we're going to make the incision. So there's the first step, and then the next step is to mark where we are going to create the tube, and this is going to be the tube. So, that's going to be our tube. Two, three, four- four cm, so… Yeah, we'll see what happens. Okay, yeah, like that.


If you cut the skin gently on the top of the foreskin, it doesn't bleed that much. Hemostat. Now, when you're using this needle, make sure you're aware that there's a scissors in there. Otherwise you'd be cutting the… It's a nice needle holder. Yeah. Nice, but you be careful that you don't cut your suture, okay, like that. All right. One of the secrets of incisions is you know, you know the depth of the tissue you're cutting, so you don't go too far. Now, what I learned is that the curvature of the penis, which you call chordee, most of the- most of it is what we consider proximal, this is right around here. That causes the curvature, because during development, that's what happens. And then some of this curvature will be here, and I'll show you later as we go along with the procedure.


You get- we need a smaller catheter.


So, now we're going to dissect beneath the- this tissue. Go on, use the hook. First, press. Okay, hold on. Okay, here, cut the… Make sure you preserve the blood supply, so what I do is go close to the corpora. Stay close to the skin, okay? So what we're doing now is we're separating that, that island that we are trying to create. At the same time, preserving the blood supply, push hard, push hard. And move just a little, there you go, you got it. Stay close to the skin. Good, going to get bloody as we get close to this. You can see it's starting to develop. Flat. Go ahead, don't be afraid, just go. That's good. Now we're going to switch to a shears, because we're coming to the bloody part. All right.

Do you also use harmonic sir with pediatric hypospadias? Yeah, you can use it, but you have to be careful, because it's- obviously, it's very powerful, you know? You have to take the skin first. Bleeds. Because the adults, they get bigger blood vessels. Okay. I'm going to go ahead and divide this. So we're just dividing the chordee, sir? Yeah, part of the chordee. See, see what's happening? The penis is now straight, look. Now I need to stop all this bleeding. Okay, now we can go around here. I said underneath here, like that. Use the scissors, and then you divide this, this tissue. Yes, okay. Use this like... scissors. Okay, good. Now you divide that. Push down, push down, there we go. There you go. Okay, let me hold that. Go ahead and divide the chordee. You see now the- dissect more here, all around the distal. Just alongside, midline. Let's go midline now, let's go. Yes. I think you need to go put another… Deeper bite sir? Yeah, another spot. Good, that should do it. You can lap it like that, that's fine. But we got- corrected half of the- the buried penis is no longer buried, see? You still have- see how it's straighter now? Now, what we do, is release all this, and you have a nice long penis, it's already in good shape. Okay, now, we can divide some more of this. Yes, go ahead. Perfect. And you have to use the harmonic- this would be bloody like hell if you're, using without the harmonic. Push hard, push, there you go, you got it. Yes, you can get around the skin, it's okay, we'll take them out anyway, eventually. We're just doing… Yes, stay away from those- the corpora. Yes, just release all of that, close to the midline, good. Preserve the urethra. Hold on a second. That's the urethra, right? Yeah, here's the urethra right here, so stay away from it. Urethra is here, I got it in my finger, so, that's what you're going to the corpora. It's spongiosum, that's why it's bleeding. Yes, you go ahead and divide that. Okay, good. Go ahead, use the harmonic, I'll tell you when to… You have to preserve the blood supply to that, remember. I think we have enough... Have enough to mobilize? Yes. You have to go all the way up to the, to the glans penis, you see? And there's a bleeder in there, so you can get that. Now we got- we got good length already, so we don't have to do much more. A little curve here, but you can- he can live with that. So, there's the flap that we are going to be bringing. We can mobilize it a little bit more A little bit more sir? Mobilize more, but… A little more laterally than in the middle. Go more. See the nerve, see? Now look at all those big vessels. Yes, just that fascia. ...blood vessel in there, yeah. Good. These are the testicles already, so, we're okay. You got the testicle here. If you can divide some of this tissue, that will mobilize the proximal penis more. You can see the penis length is increasing. So, this is called the penile lengthening procedure, so if anybody wants length, I could make- i could create one. If length is a problem, I could make one. Girth, I might have a little problem with that, but, but length- Yes, that blood vessels- that's good enough. See, it's got a little curvature, but I don't think- I think he can accept a little bit of that. Some people have a little curvature anyway. See? See how much length he has now? Compared to what it was? It started out like this. And now we got it like this. Now we have to make a- we have to- Yes. Figure out how... urethra. So there's- we have some bleeding, but, if you notice, this is not excessively bloody, because, if you didn't have the harmonic scalpel, this is a bloody procedure. You see, I have a little blood on my hands, but not that bad. Hemostat? Now sometimes when he has a curvature like this, I make- I suture some of the glans- the corpora to- to correct the curvature from the top, but I don't think I'm going to do that. But I think we can probably release the curvature more from here. There, see? That seems like- looks like you did something. See the main- the most important part of this procedure is you preserve all the tissue here in the back. There's the nerve and the blood vessels. They're the ones that supply the penis. Wow, that did it. Look at that, it's got enough lenghth now we're- now we might have a problem trying to get the urethra. Okay, now we'll figure out how we're going to make him a urethra.


We have to use- that's six- and eight. At least eight cm.

It'll stretch. The skin will stretch, so it's not a problem. Put a silk here, put a hemostat in there.

Six, but that will stretch. Okay. It's bleeding, so it's good. Okay.

And get a skin hook to lift this flap. It's bleeding, that's good. Oh, look at that big blood vessel in there. I'm not going to cut that one. Yes, that supplies for that one, yeah. You're going to cut it right here. Okay, let's see. Look, that's our flap, okay? Then we going to rotate it like this, close to the skin. So, the bleeding will stop, they're sluggish- bleeding, so they'll stop. Right here. Perfect. All right.


Yes, it'll fit. Tightly, yes, it'll fit. It'll fit, we'll excise all those skin later. Go ahead, push it in. Silk, saline? okay, good- quickly, how many? Good, okay. So now you are going to create a tube around this catheter.

Let's see where this skin wants to go. Yes, like that. Okay. So- you… You may create a tube around it. It's the enlay island-flap technique? No, this is a transverse island-flap, enlay is when you, when just lay it into the tissue. That's an enlay, like you, you have half a tissue and then you lay skin over, that's enlay. This is transverse island-flap because it's coming from transverse area, then you create a new flap. Perfect. Perfect. Good. Okay, hemostat? On the one end, okay, you got it. Okay, now you... Are you going to do continuous sir? Continuous? Make small bites, okay? I'm holding to this. Small bites on the edge. No, no you, I'm talking about- yeah, take a big- yes, that's good, I like that. Good, perfect, that's the bite I want. Okay, saline? Put some- pour some saline, pour some saline? Good. Perfect. We're creating a tube, out of the skin that we harvested from the top, and we harvested the skin with the blood supply, and that's what makes it work because you can do a free graft where you can just take skin out and just make a tube out of it, but it's not as, viable, obviously, you need the surrounding blood supply to make blood vessels. This one, you have blood vessels already, so the chances of making it is pretty high. I think we can gain enough length, sir. I think so, it'll lengthen. Because he can still stretch. Yes. You might have to trim that one. kind of crooked. Except we'll see if we can use that. Yes. I think that's an anomaly, so you might trim it. Trim that anomaly. Yes. Yes. Okay, good. Get the skin, the other side of the skin. See, there's the other side. Make sure to stretch it when you tie.


See, so we need to mobilize this tissue to try to get some length, so just go underneath, close to the skin. Yes. Don't go in there, right here, close to the skin. Yes, use the harmonic for that one. I got the urethra. Yes, like that. Don't go in on the skin, that's good. Yes, stay away from the urethra. Okay… Now, here's the- oh good, I got that. Okay, good, go in that tissue. Okay, that looks like we gained something.


So what you have to do now is excise this- leave a little bit of skin, but excise all this tissue. I would like you to remove this, that one comes out, this one is kind of knobby. So if you could excise this skin, and then we'll try to anastomose this to that. Yes, sir. Okay? Yeah. It's all right, don't worry about the bleeding, it's going to bleed. Yes, just the skin, there you go, you got it. Excise that. Good, excise that skin. Good, excise it. Yes, take that out, get the harmonic. Yes, good.


Perfect, okay anastomose these two guys, start from the- start posteriorly. Good. Yes, you got it. Nice bites. You can do it twice. Good. Continuous? Hemostat. You can actually maybe put the skin together, I don't know. You might use this to Increase length. So you can cut- put the stitch here. Yeah. Is there a hole in there or… No, there's no hole, okay. I think we can use that skin to increase the length, yes. Yes, go ahead. You mean like obliquely? Yes, yes, yes. To make length of- to increase length. And you can actually start another stitch later there. You're doing fine. Tie this and see what happens. Yes, go ahead. I'm holding it, more 6-0. Okay, now let's see, you could anastomose that. That's good. Use that as skin. Yes, a little more length sir? That's good. Okay, tie it. You can cut them. Good, long, cut. Cut this one.


Okay, what we're going to do now is we're going to split the penis, so we can bring the, the distal end to the tip, silk? Push. Silk?

Okay, so what we do is we cut through here, and then we'll put the- this urethra in there, okay? Or I can just go- I think I'm just going to go straight. Here, yes. Okay, we'll just split this in half, and then we're going to bring this to the top. So you anastomose this- I'm going to split this like so, you split that in the middle. Yes, spit it, right in the middle. Yes, yes, that's good. Yes, yes, not too deep. Just keep going, a little bit more.

Put this guy over. Anastomose the tail end of that to the apex, okay? Suture? Big bites, yes, that's good. To the very tail end of the skin. Yes, that's good. Skin. Perfect. Actually you might make more length, see, there's plenty more length. Hemostat. Yes, good Hemostat? So what we can do instead of running we'll just do interrupted so we create more, and then and then we can use that as a urethra, the other part of the skin, see? Hemostat? Yes. Nice thick bite. Good. Saline. Suture, cut the suture long. Now you create another tube, running. See, we have- gain another cm and a half. Just make sure we are able to take the catheter out, don't make it too tight. Yes, one more, then you tie it. You're doing good. So now we'll create a meatus, next step.

So you'll just keep sewing all the skin to the distal, the meatus, so we can surround it with glans penis, see? The whole idea. So you have enough, okay. So keep sewing it up, small bites. Yes, and then we can surround it with glans penis. Like that. Okay, see, that's good. You can have another single stitch on the, on the distal urethra, one more stitch, interrupted. Yeah, to make a- Yes, that's good. You can still take- See, the catheter will still be taken out. You can take out, it's enough of an opening, yes, that's good. So that'll be a good meatus. We are creating the distal opening of the urethra now, by surrounding it with this head of the penis. We started out from the bottom where he pees through the bottom, close to the scrotum. He has the pee- to be able to pee- he has to sit down to pee. Okay, go to the other side. Big bite, nice, good. I like that bite. Really nice big bite on that. Closer to the glans, yeah. See the flap looks good, the blood supply is excellent, what we've created is as a nice vascular flap. Perfect. Yes, good. Get a bigger bite there, so you can have it- yeah, that's it. More tissue to surround the distal- surround the meatus. So now we're going to try to put the- part of the glans around it. Okay, what you need to do is get a stitch from here, to the other side, to complete the process. Get that over it, yes. Even that- I think- I yes, I would do that. Pick up the other side. Perfect. Good. Now you put two more. Big bite, nice big bite, and you can catch the suture line, which is right there. That's that, big bite. That should be- That should be good. I think that's good enough for him. I don't want to be too ambitious because he didn't have enough length on the urethra. All right, so now we've got to- our next challenge is to figure out how to cover this whole thing.


Okay, what we need to do is to stabilize this urethra that we created by suturing it with the- with the corpora. Okay? With interrupted stitches. Okay, go ahead. Catch the suture line. And then- nice tissue right there. Good, okay, tie it. Got it. Use corpora- no, right here. That's good. Yeah, good. It's to there. The suture line. Good, that and then catch the other one. The corpora, go ahead, come through. Corpora, over there. Good, perfect. What I've seen is a penoscrotal hypospadias done in two stages. Really? I haven't seen... First, one stage? One stage. Well, you've seen it now. Look at that, see? So now you can put this- yes, you can put this tissue over like that to give them blood supply, yes, Put this to there- to here. Yes, right there. Good, that's a good bite, nice bite. Wonderful! That was a good bite. I can't believe it either. Right here, now you had- covered- you put this over there to give blood supply. Yes, to the urethra. Yes, just like that. And then just stabilize it. Perfect. Are we going to put a drain, sir? No. No drain? No drain. He'll be fine. But all that bleeding will stop, soon, low flow.


Okay, now, you have the cover it with skin. Cutting the skin and a little bit of tissue, deep tissue, okay? Start closing, interrupted, Yeah, okay, thanks. Cuts deep, cuts deep. Take some deep tissue- right here, get some deep tissue, like that. Just catch it, good. And then get the skin again and the hemostat. That's a little bit of the sub-q. Don't worry, it'll stop. Okay, this one you catch a little bit of that sub-q. That's a good- don't stop the bleeding, don't worry about that. Good, perfect. Now, you can go with skin. Make it even, so...

I think you keep working on it. We'll eventually cover. Just keep… The problem is splitting is- yes, we could split it. And then make a z-plasty. Yes, we could split it. Just slightly because we don't want to cut off the blood supply, make sure you have that vessel, see, there's the vessel right there in the middle. So you split it right here. Yes, you can split it, right here, the vessel is here. Yes, split right there. Yes. Okay. That's it. One more, a little bit more, not too much more.

Okay, all right, that's perfect. Now you go ahead. Put your stitch. Put the stitch here? Yes. Okay, just keep working on it. Yes sir. We're almost done anyway, we're doing good. It's supposed to be a three hour operation. I hope it's still three hours- within three hours. This one takes 12 hours for some people. This procedure. And in stages, yes. They can't do it in one stage.

You might have to work… Yes, you might have to start putting them together again from here, from the, from the bottom. Yes. You then- What's the recovery time? Six weeks. But I told him not to do anything for three months to six months. He asked me that, I said, how long? I said Three to six months. Yes, you'll be fine, you can keep working at it. Get plenty of skin now. Good, perfect. Because if you put it on the glans, it hurts when he has an erection. Yes, that's good. Then you have to go- if you want to do that, you have to go back there, Yes, go back the other way. It's a good idea, but that's better like that. And go back, and that's okay, that's better, he's not going to- he's not going to feel it when the time comes. Cut that lip that- that's better, he likes that. In which they- on the other side sir? Okay, work on that side. Yes. Want more, 4-0? You might have to trim some of this excess. Yes sir. Like that, and then just go like so, see? That might be an excess. That, maybe here, there. No, maybe here. Yes, that's better. Good, hemostat? Good, perfect, that's what you want, take this one too. Put that there, yes, good. All complete, and you put them together. Okay, good. This one, excess. You can cut this- you can trim that. Yes, like that.

Good, That's good. A bit, yes, that's good. Okay This is the last row of stitches, and then we'll put the dressing, Tegaderm, medium, and then we'll put a gauze around it, with pressure. Let's remember how we started, from way down the bottom here, and now we're up at the very end. Okay.

Cut this one too, and that one. Shall we continue the antibiotics? Yes, three doses.


Now, you notice, if you remember, we started from here, and the penis was buried inside, and we were able to bring the penis out, replace the urethra with a skin from the, from the top of the penis. See, the whole idea was you, you straighten out the penis- the penis was buried by the tissues here and we made it- we got him unburied. And then we straightened out the penis, and because we straightened out the penis, there was a length of- urethra we have to replace, and we used the skin from the top. That's what we did.