1. Take down all adhesions, mark the penis for the procedure.

2. Place a 5-0 Prolene suture through the glans as a traction suture.
3. Insert and 8 French feeding tube, decompressed the bladder, and leave the catheter in place.
4. Inject Xylocaine with epinephrine 1:1000 (standard mixture) into the glans wings area with a 30 gauge needle.
5. Deglove the penis, preserving a vascularized pedicle of tissue from the ventral aspect.

6. Raise the glans wings, working your way up from the shaft.
7. Check for chordee if necessary, with an artificial erection test.
8. Incise the urethral plate sharply, to allow it to hinge.

9. Reapproximate the neourethra in the ventral midline with a running 7 0 Vicryl suture as the first layer of closure.
10. Do not bring the closure too far out to the tip, as this may result in a later stricture.
11. Swing up the vascularized pedicle to cover the suture line as a second layer of closure (use 7-0 Maxon).
12. Lay in three sutures of 6-0 PDS to reapproximate the glans wings in the ventral midline. Be certain to leave the 8 French feeding tube in place. The sutures are secured after all are in place. This is the third layer of closure.

13. A fourth layer of closure is provided by reapproximating the more superficial layers of the glans with horizontal mattress sutures of 7-0 Maxon.
14. The feeding tube is removed and replaced with a 6 French soft Silastic stent.
15. A three-way Tegaderm pressure dressing is applied.
16. A caudal block is performed by anesthesia.
17. The dressing is removed the following day at home by parents. At the same time, the drip stent is trimmed back to approximately one inch in length.
18. The patient is discharged on Bactrim (if no allergy) on a qhs suppressive dose, along with narcotic pain medication (Tylenol codeine).
19. A clinic visit in one week is scheduled. At that time, the stent is removed, and bathing or swimming may recommence.
20. Most common complications include leak (fistula). The risk of this depends on the location of the native urethral opening. For most TIPS repairs, the risk is a few out of 100. A stricture can occur, the risk is approximately 2 – 5%. Cosmetic results are usually quite good.