The common steps in surgery for Posterior hypospadias include

Placing the holding stitch on glans:     using 50 or 40 Prolene

Marking :  Mark the landmarks on glans. Outline the urethral plate. Mark the level of healthy ventral skin. Check for the length of dysplastic urethra proximal to the meatus. Mark circumferential incision to save a good mucosal collar at corona.

Degloving:     Start on the ventrum by incising along the margins of both side of urethral plate. Use scissors instead of the knife for better control. Incise the skin proximally to reach the level of healthy spongy tissue. 

Raising glans wings and mobilization of corpus spongiosum:               Incise Buck’s fascia lateral to the spongy tissue near the glans. Develop a plain just superficial to the tunica albuginea. Raise glans flaps off the tunica albuginea till the apex of the glansplasty. Mobilise laterally to allow medial and inward rotation without tension. 

Artificial erection test:            Tie a tourniquet at the base, if not done earlier. Using a 26 needle inject saline into the corpora cavernosum. Observe for chordee. Mark the site of maximum bend. Loosen the tourniquet. Remove the needle. Press the shaft to decompress the corpora.

Nesbit procedure:      If chordee persists after erection test- proceed for excision of fibrotic tissue along the urethral plate till bulging corpora is seen, leaving a small length of urethral plate in midline. This leads to correction of chordee in majority of mid penile hypospadias. If it fails, then proceed for Nesbit. Do dorsal degloving. At the site of maximum bend incise Buck’s fascia on each side of the neurovascular bundles on the dorsum. Lift the neurovascular bundles off the tunica albuginea. Excise a diamond shaped area of tunica albuginea from the dorsum. Close the defect by PDS/Prolene. Close the incision in Buck’s fascia. Check for correction by artificial erection.

Even after this chordee is not corrected and urethral plate is thought to be the culprit, transect the urethral plate in middle and check for chordee correction.

Urethroplasty: If Urethral plate is not transected and is of adequate width(> 8mm) ( rare in posterior hypospadias),Tubularize the plate using vicryl or monocryl fine sutures. Ensure adequate caliber. If urethral plate is preserved and not of adequate caliber, then augment either by lateral based onlay flap. In most of the posterior hypospadias, Urethral plate is narrow and some form of augmentation is needed. Author preference in Lateral based onlay flap( LABO) flap or dorsal longitudinal onlay flap.  If urethral plate is transected, then either dorsal longitudinal tubularized  flap or staged repair is preferred. Staged repair includes  either  Bayers flap or Braka free preputial graft.

Glansplasty:  Close glans with Vicryl in a horizontal mattress fashion. Check meatal caliber. Include refashioning of coronal collar with glans closure. If glans not favourable: use glans substitution and frenuloplasty.

Skin cover:   Skin  rearrangement is needed amd these children get a circumcised look.

Dressing:     Should provide gentle uniform compression all around. The author uses a gauge dressing impregnated with Neosporin ointment , kept in place by elastic tape.