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