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Figure 7
I recommend initially maintaining the urethral plate in all proximal hypospadias repairs, as even apparently severe ventral curvature sometimes can be straightened without transecting the plate. The skin incision should be made immediately next to the plate to minimize the risk of incorporating hair follicles into the neourethra. Similarly, the foreskin also can be preserved at the beginning of surgery as curvature is assessed, although in many patients it will be necessary to completely deglove the penis and ultimately circumcise it. My experience with foreskin reconstruction in boys with proximal defects is limited, and a desire to avoid circumcision should not outweigh the need to correct significant ventral curvature that might later impair sexual function. After degloving, the corpus spongiosum alongside the urethral plate is dissected off the underlying corpora cavernosa. This tissue later will be approximated over the neourethra as a barrier layer against fistula, and its mobilization sometimes also lessens the extent of ventral penile bending. Then an artificial erection is created; persistent mild curvature is corrected by midline dorsal plication, as described above. More severe bending next leads to dissection under the entire urethral plate, and if it still persists, to transection of the plate and, in my hands, a staged urethroplasty.
 

Figure 8
A midline incision of the penile aspect of the urethral plate is made to assess the ‘health’ of this tissue. In a very few cases the incised plate has appeared less supple and poorly developed, and this finding has led to excision of the unhealthy plate and a staged repair. Note that the glans is left undisturbed until this point, as even when the penile urethral plate has seemed undesirable for urethroplasty, the glandular aspect has been supple and could still be incorporated into the neourethra. When the incised plate is satisfactory, glans wings are next dissected from the urethral plate as described for distal repairs. This aspect of the plate is then incised in the midline in preparation for tubularization.

 Figure 9
A 6 F stent is passed into the bladder; occasionally there may be difficulty negotiating the catheter past an enlarged utricle, and in this situation a cystoscope is introduced under vision into the bladder and a wire placed over which the stent can be manoeuvred. To create the longer neourethra in proximal repairs, I prefer a two-layer, 7–0 polyglactin subepithelial closure, the first using interrupted sutures and the second a running suture. Care is taken to turn all visible epithelium into the neourethral lumen. Then the previously mobilized corpus spongiosum is closed, followed by coverage of the repair by a dartos pedicle flap. Glansplasty follows and then skin closure. Significant penoscrotal transposition is also corrected at this point. Next a Tegoderm dressing is applied. After proximal repairs I further immobilise the penis with a mild compression dressing consisting of a small gauze square placed onto the ventral aspect of the penis that is held in place by a second, larger Tegoderm dressing against the lower abdomen.

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