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  • Management of Hypospadias

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    Adebisi
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    This document outlines the key aspects of hypospadias, including the epidemiology, embryology, classification, clinical features, investigations, surgical principles, techniques, and complications. Hypospadias is a congenital anomaly involving an abnormal urethral opening on the ventral surface of the penis. The optimal timing for surgery is between 3-18 months of age. Surgery aims to reconstruct a straight penis with a slit-like meatus at the tip of the glans, allowing a forward urine stream and normal sexual function. Over 300 surgical techniques exist, and the procedure remains technically challenging.

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    Hypospadias

    Original Title

    MANAGEMENT OF HYPOSPADIAS

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    This document outlines the key aspects of hypospadias, including the epidemiology, embryology, classification, clinical features, investigations, surgical principles, techniques, and complications. Hypospadias is a congenital anomaly involving an abnormal urethral opening on the ventral surface of the penis. The optimal timing for surgery is between 3-18 months of age. Surgery aims to reconstruct a straight penis with a slit-like meatus at the tip of the glans, allowing a forward urine stream and normal sexual function. Over 300 surgical techniques exist, and the procedure remains technically challenging.

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    © All Rights Reserved
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    24 views34 pages

    Management of Hypospadias

    Uploaded by

    Adebisi
    This document outlines the key aspects of hypospadias, including the epidemiology, embryology, classification, clinical features, investigations, surgical principles, techniques, and complications. Hypospadias is a congenital anomaly involving an abnormal urethral opening on the ventral surface of the penis. The optimal timing for surgery is between 3-18 months of age. Surgery aims to reconstruct a straight penis with a slit-like meatus at the tip of the glans, allowing a forward urine stream and normal sexual function. Over 300 surgical techniques exist, and the procedure remains technically challenging.

    Copyright:

    © All Rights Reserved
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    of 34

    OUTLINE

    • INTRODUCTION
    • EPIDEMIOLOGY
    • EMBYROLOGY
    • AETIOLOGY
    • MORPHOLOGY
    • CLASSIFICATION
    • CLINICAL FEATURES
    • INVESTIGATIONS
    • PRINCIPLES OF SURGERY
    • TIMING OF SURGERY
    • TYPES OF SURGERY
    • COMPLICATIONS
    • CONCLUSION
    INTRODUCTION
    • A challenging and technically demanding
    congenital surgical condition worldwide
    • A widespread spectrum of congenital
    anomalies involving the inferior surface of the
    penis and having in common a urethral
    opening that lies on the inferior surface of the
    penis
    • hypo = under; spadias = opening or rent
    • Abnormalities include:
    – an abnormal urethral opening
    – chordee (ventral curvature of the penis)
    – an incomplete prepuce
    – rotation of the penis
    – abnormal raphe
    – disorganised corpus spongiosum and penile fascia.
    • Late presentation with already circumsiced phallus
    and suboptimal theatre conditions pose a threat in
    Africa
    EPIDEMIOLOGY
    • Most frequent congenital urological anomaly
    • Incidence of 1-3 in 1000 LBs
    EMBRYOLOGY
    • 3rd week: messenchymal cells migration around
    the cloacal membrane forming the cloacal folds
    • 4th week: cloacal folds cranially forming the
    genital tubercule while caudally the urethral
    folds forms anteriorly and anal folds posteriorly
    • Urethral folds gives rise to the scrotal swellings
    (male) and labia majora (female)
    • Rapid elongation of genital tubercle forms the
    phallus under androgen stimulation
    • Urethral fold pulls along forming the urethral
    plate
    • Male urethra forms by fusion of the urethral
    folds over the urethral groove
    • Canalization of a cord of ectodermal cells
    extending from the apex of the glans to the distal
    end of the developing urethra
    • 8th week: formation of a ridge just proximal to
    corona, carried distally forming the cone
    shaped prepuce
    • 12th week: labioscrotal folds fuse completely in
    the midline forming the scrotum
    AETIOLOGY
    • Endocrine:
    – Defective androgen production
    – Defective local androgen receptors
    – Subnormal testosterone response to hCG stimulation
    • Genetic:
    – Complex genetic background
    – 7% familial
    • Environmental:
    – increasing worldwide
    – probably due to environmental contaminants e.g. insecticides,
    pharmaceauticals
    MORPHOLOGY
    • Meatus:
    – transverse
    – longitudinal
    – pin-point
    – multiples
    GLANS

    A. Cleft glans (Rx


    Tubularisation of
    the urethral plate
    repair gives good
    results)
    B. Incomplete cleft
    glans (inverted-Y
    tubularised plate
    or inverted-Y
    meatoglanuloplast
    y usually gives
    good results)
    C. Flat glans
    MORPHOLOGY CONTD
    • Chordee: widespectrum with disproportionate
    growth of one of the fascial coverings or skin
    – Chordee with hypospadias: skin, dartos fascia,
    Buck’s fascia or corpus spongiosum. Urethra is
    normal though maybe very thin & lies directly
    under the skin
    – Hypospadias with superficial chordee
    – Hypospadias with deep chordee
    – Hypospadias with corporeal disproportion
    • Prepuce:
    – in majority, longer than normal dorsally but absent
    ventrally
    – <5% MIP, (Mega-meatus Intact Prepuce
    Hypospadias. “Hidden Hypospadias”). This may
    result in late diagnosis and wrongly excision of the
    prepuce in routine circumcisions
    CLASSIFICATION
    • Kaufmann’s classification, 1886:
    – 1st degree (glanular)
    – 2nd degree (penile)
    – 3rd degree (proximal)
    • Duckett’s classification: glanular, coronal,
    subcoronal, distal penile, mid-penile, proximal
    penile, penoscrotal, and perineal
    • Glanular and penile hypospadias constitute
    about 85% of patients with hypospadias
    CLINICAL FEATURES
    • Usually diagnosed in early life
    • Peculiar appearance of hooded prepuce
    deficient ventrally in 95% of patients
    • Ventral splaying of urine from undersurface of
    penis
    • Usually asymptomatic, unless in patients with
    very narrow urethral meatus
    CLINICAL EVALUATION
    • Detailed clinical examination is needed with
    recording of:
    • meatus site and size
    • presence of chordee and severity
    • glans configuration
    • complete or incomplete prepuce
    • width of the urethral plate
    • presence of torsion
    • presence of bifid scrotum or penoscrotal transposition
    • any associated anomalies e.g., undescended testis
    INVESTIGATIONS
    • Usually not required in healthy asymptomatic
    patients
    • Abd USS and urinalysis for those with urinary
    symptoms or proximal hypospadias
    • Micturating cystourethrogram indicated in
    dilated bladder, ureters, or kidneys
    • Routine usual work-up for surgery e.g. PCV,
    E/U/Cr, Screening for other congenital
    abnormalities
    MANAGEMENT
    • Objectives:
    – Reconstruct a straight penis with a slit-like meatus on
    the ventrum of the terminal aspect of the glans
    – Allow a forward –directed urinary stream
    – Allow for normal coitus
    • Onset Parents counselling
    • Timing of surgery: optimal window 3-18months.
    • Should not be attempted by a non-specialized
    surgeon!!!
    GENERAL PRINCIPLES OF SURGERY
    • Preoperative hormonal therapy:
    – Local testosterone cream
    – IM testosterone 1-2mg/kg monthly for 3months
    – Aims at ↑sing phallus size & vascularity
    – Limited to severe cases of intersex with very small penis
    – Side-effects are edematous tissues, & bleeding
    • Visual aids
    – 2.5 or 3.5 magnifying loups
    – Simple reading glasses
    CONTD
    • Fine instruments
    – 6-12 fine mosquito forceps
    – 2 fine tooth dissecting forceps
    – Fine sharp scissors
    – Sharp scapel
    – Fine needle holder
    • Adequate haemostasis
    – Tourniquet, released every 40minutes
    – Swabs soaked in adrenaline (1:100,000)
    – Bipolar diathermy
    CONTD
    • Choice of suture materials & technique
    – Fine 6/0 & 7/0 vicryl
    – Interrupted stitches in glans
    • Stents & catheters
    • Choice of dressings
    • Postoperative analgesia/antibiotics
    TYPES OF SURGERY
    • Over 300 different techniques
    • MAGPI
    • DOUBLE-Y GLANULOPASTY
    • INVERTED-Y MODIFIED MATHIEU REPAIR
    • INVERTED-Y MODIFIED THIERSCH TECHNIQUE
    • LATERAL-BASED FLAP TECHNIQUE
    • TIP URETHROPLASTY
    • TUBULARISED PREPUTIAL ISLAND FLAP
    • ONLAY ISLAND FLAP PROCEDURE
    • URETHRAL RECONSTRUCTION USING BUCCAL MUCOSA
    MAGPI
    Suitable in
    glandular
    hypospadias with
    mobile urethral
    meatus
    DOUBLE-Y
    GLANULOPASTY

    Suitable for
    selected patients
    with glanular
    hypospadias
    with mobile
    meatus in
    the absence of
    deep chordee
    INVERTED-Y MODIFIED MATHIEU REPAIR

    Suitable also for distal hypospadias


    INVERTED-Y
    MODIFIED THIERSCH
    TECHNIQUE
    It is suitable in
    hypospadias
    patients
    without deep
    chordee
    THE LATERAL-BASED FLAP
    (LB FLAP) TECHNIQUE FOR
    PROXIMAL HYPOSPADIAS
    A. Y-shaped deep incision
    of the glans;
    B. three flaps are
    elevated and
    orthoplasty;
    C. new urethral plate;
    D. design of the LB flap;
    E. urethroplasty;
    F. mobilisation of
    dartos/tunica vaginalis
    fascia;
    G. Protective
    intermediate layer;
    H. skin closure
    TUBULARISED INCISED PLATE (TIP).
    Described by Snodgrass
    ONLAY ISLAND FLAP
    PROCEDURE
    DUCKETT TUBULARISED
    PREPUTIAL ISLAND FLAP
    COMPLICATIONS OF HYPOSPADIAS SURGERY

    • Not common
    • Depends on the surgical experience and
    technique of the surgeon
    • Meatal & urethral stenosis
    • Fistula:
    – Distal stenosis
    – Poor technique
    – Poor skin cover
    – Tension on sutures
    • Diverticulum
    • Recurrency of chordee/residual curvature
    • Cosmetic abnormalities
    CONCLUSION
    • Hypospadias is a wide spectrum of anomalies
    involving all the ventral structures of the penis and not
    just the urethra
    • Hypospadias reconstruction remains one of the most
    challenging fields of surgery.
    • Surgeons need to master several techniques to suit
    the wide range of anomalies encountered
    • A second protective layer to cover and protect the
    new urethra is an essential part of hypospadias
    surgery

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