Hypospadias repair (TIP urethroplasty)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• urethrocutaneous fistula
• meatal stenosis or urethral stricture
• breakdown of the glans closure and return of the hypospadias
• urethral diverticulum
• residual or recurrent curvature
• bleeding and haematoma under the dressing
• infection
• bladder spasms and catheter problems
• need for further surgery, usually not before 6 months
• late problems in 5-10%, so review after toilet training and at puberty

Pre-operative details for this operation

1. Age and weightage in months, weight in kg
2. Meatus position (clinical)GlanularCoronalSubcoronalDistal penileMidpenileProximal penilePenoscrotalScrotalPerineal
3. Curvature on examinationestimated degrees
4. TestesBoth in scrotumUndescended: DSD work-up done
5. ForeskinHooded, not circumcisedPreviously circumcised
6. Previous hypospadias surgeryNone (primary)Redo: details
7. Hormone treatment before surgeryNoneTestosterone / hCG: details
8. Consentgiven by parent or guardian: name, relation, language; foreskin preservation discussed

Anaesthesia and position

1. AnaesthesiaGeneralSpinal (infant, distal repair)
2. Regional blockCaudalDorsal penile nerve blockNonedrug, strength, volume
3. PositionSupine
4. MagnificationLoupes (power)Operating microscope
5. Tourniquet at base of penistimes on and off

Operative findings

1. Meatus position after deglovingmay be more proximal than it looked
2. Urethral platewidth in mm, depth of glans groove, healthy / thin
3. Glanswidth, size of glans wings
4. Ventral urethra and skinnormal / thin and dysplastic up to what level
5. Curvature on artificial erectiondegrees before and after correction
6. Penile torsionNonePresent: direction and degrees

Procedure (steps)

1. Glans traction stitchsuture size
2. Markings and incisionurethral plate 8-10 mm wide outlined; subcoronal incision, ventral limb just below the meatus
3. Deglovinglevel reached (penoscrotal junction / base)
4. Artificial erection testsaline, needle size, tourniquet at base; degrees of curvature
5. Curvature correctionNot needed after deglovingDorsal plication: suture, number of stitchesVentral corporotomy / graft (not a TIP case)repeat artificial erection result
6. Glans wings raisedadrenaline infiltration or tourniquet
7. Plate tension testplate edges wrapped around an 8 Fr (10 Fr in older children) tube
8. Midline relaxing incision of the platefrom just inside the meatus to the end of the plate, down to the corpora, not into the glans
9. Neourethra tubularisedover what stent size; suture material, size, subepithelial, interrupted or running; stopped short of the neomeatus
10. Second layerDorsal dartos flap (button-holed)Ventral dartosSpongiosumTunica vaginalis
11. Glansplastycoronal stitch size, tied over a sound (size); glans mucosa sutures
12. Meatus calibre checkedFr size that passes easily (8 Fr infant, 10 Fr over 3 years)
13. Mucosal collar and skin coverMidline ventral closureByars flapsForeskin reconstructed

Closure, drains and dressing

1. Skin suturesmaterial and size
2. Urethral stent or catheterSilicone stent, dripping into double nappyFoley to bagNoneFr size, length inserted, how fixed to the glans
3. Dressingtype; compressive but not tight

Specimens and implants

1. SpecimenNoneExcess foreskin discarded
2. Stent / cathetertype, Fr size, planned removal day

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Stent or catheter caredouble nappy, no bag pulling on the penis, check it is draining
2. Stent removalplanned day (many keep 7-10 days)
3. Dressingremove on day 2-3 or earlier if it rolls down and constricts
4. Analgesiaparacetamol and ibuprofen alternately, weight-based doses
5. Bladder spasm and bowelsanticholinergic if needed, stool softener
6. Antibiotic while catheter is inif used: drug and dose
7. Meatus carepetroleum ointment to the meatus for several weeks
8. Bathingavoid until the stent is out
9. Warning signs for parentsbleeding through the dressing, no urine, fever, dressing too tight
10. Follow-upstream check after stent removal; review after toilet training and at puberty

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery