The Cock-up Splint: A Novel Malleable, Rigid, and Durable Dressing Construct for the Post-hypospadias Repair.

One of the most innovative yet controversial areas of modern hypospadias surgery is the postoperative dressing. In our center, a 2-stage buccal mucosal graft is the technique of choice for proximal penoscrotal hypospadias. The number of dressing methods and materials used for this repair exceeds the surgical techniques described for this deformity.[1] The difficulties lie not only in stabilizing a graft on a soft, mobile, and boneless organ subject to dynamic changes in all dimensions during erection but also in keeping the graft clean from constant fecal and urinary soilage. The definite apprehension of these pediatric patients also precludes ease of dressing change or reinforcement.[2] Authors have tried to wrap, layer, glue, bolster, crepe, and suture anchor the wound to construct a sturdy dressing both occlusive and compressive to barricade against infection and reduce postoperative edema and hematoma.[3] Materials ranging from Allevyn to Silastic foam, glove finger, Coban (3M, St Paul, MN, USA) self-adhesives, and even cyanoacrylate have been described.[4,5] Some have concluded that no dressing may be the best dressing for these wounds.[2,4]

Our original dressing technique utilizes the Denver Splint (Summit Medical, St Paul MN, USA) to create a malleable but rigid construct that maintains a supportive ventral trough for the repair and allows for expansion during erection without compromising the dressing’s structural integrity. The aluminium shield is hand-moulded to the penile girth to retain the graft in position. It can be easily readjusted at any time to patient comfort. The splint’s layered foam not only enhances patient comfort but also applies cushioned pressure on the graft to reduce postoperative edema and hematoma. The splint’s keystone is that it maintains the phallus upright in a “cocked-up” position keeping the penile shaft straight for stabilization of the graft analogous to a back slab for splinting split-thickness skin grafts in the extremities to reduce shear.[1,3,5] The urinary catheter is compartmentalized from the wound to obviate graft to urine contact. Although this dressing requires adhesive Hypafix (BSN Medical, Hamburg, Germany) tape for securement, it is easily removed during changes with minimal discomfort due to the rigidity and centrality of the Denver splint.

The size of the Denver splint is matched to the base to proximal glans shaft length. The longer base of the trapezoidal-shaped splint is applied toward the glans. The longer transverse length provides more support for the penis, like the leading edge of a baseball mitt (Fig. 1). The shield is bent to shape to accommodate the resting girth of the penis to that of the expected expansion in the erect state. The entire construct is secured down with Hypafix from groin crease to crease in a hammock maneuver (Fig. 2).

Fig. 1.

Denver splint application: height of the splint is matched to base to glans length. The splint is oriented so that the longer base of the trapezoid supports and “catches” the glans.

Fig. 2.

The Denver splint dressing construct is secured with Hypafix Adhesive tape from groin to groin via a hammock maneuver producing a cocked-up position of the penis.

This method has demonstrated to be steadfast with dressings pristine at postoperative day 7. This cock-up splint is fast, easy to apply, adjustable, and cheap because it may be reused during subsequent dressing changes for the same patient. In our series, there have been zero graft losses. The rigidity of this construct splints the graft reducing secondary contracture and minimizing downstream chordee deformity during the second stage tubularization process.