Hypospadias

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Hypospadias

  1. 1. Hypospadias Dr.Anil Haripriya
  2. 2. Introduction <ul><li>Congenital anomaly </li></ul><ul><li>Incidence is 1 in 125 live male birth </li></ul><ul><li>Defined as </li></ul><ul><li>“An arrest in normal development of the urethra ,foreskin & ventral aspect of penis which result in wide range of abnormalities” </li></ul>
  3. 3. Embryology <ul><li>Formation of male external genitalia </li></ul><ul><li>- Genetic programming </li></ul><ul><li>- Cell differentiation </li></ul><ul><li>- Hormonal signaling </li></ul><ul><li>- Enzymatic activity & tissue remodeling </li></ul>
  4. 4. Aetiology <ul><li>Aberrant signaling between epithelium & mesenchyma </li></ul><ul><li>Environmental factors </li></ul><ul><li>- Maternal vegetarian diet & estrogen progesterone exposure during pregnancy </li></ul>
  5. 5. Risk factors <ul><li>Maternal </li></ul><ul><li>- Maternal age </li></ul><ul><li>- Primiparity </li></ul><ul><li>Paternal </li></ul><ul><li>- Abnormality of testes & scrotum </li></ul><ul><li>- Low spermatozoa motility </li></ul><ul><li>- Abnormal sperm morphology </li></ul><ul><li>Fetal </li></ul><ul><li>- Low birth Wt baby </li></ul>
  6. 6. Hypospadiac penile anatomy <ul><li>Abnormal urethral spongiosum & glans </li></ul><ul><li>Spared of neuronal structures at 12 o’ clock </li></ul><ul><li>Vascularity </li></ul><ul><li>- Huge endothelium lined vascular channels filled with RBC </li></ul><ul><li>Urethral plate is well vascularized ,rich nerve supply & extensive muscular with connective tissue backup </li></ul>
  7. 7. Classification
  8. 8. Clinical Features <ul><li>Meatal dystopia </li></ul><ul><li>- Various configurations in terms of form, diameter, elasticity,rigidity,can be fissural in both direction </li></ul><ul><li>Dermal defects – frenulum is always –nt, dorsal hood </li></ul><ul><li>Penile curvature – due to deficient normal ventral penile structures </li></ul><ul><li>Penoscrotal transposition & bifid scrotum </li></ul>
  9. 9. Clinical Features <ul><li>Associated abnormalies- </li></ul><ul><li>- Undescended testis </li></ul><ul><li>- Inguinal hernia </li></ul><ul><li>- Utriculus masculinus </li></ul><ul><li>- Urinary tract anomalies – uretropelvic junction obstruction ,severe reflux,renal agenesis,wilms tumor,pelvic kidney,crossed renal ectopia & horse shoe kidney </li></ul>
  10. 10. Treatment <ul><li>Objects of therapy- </li></ul><ul><li>1- Orthoplasty </li></ul><ul><li>2- Urethroplasty </li></ul><ul><li>3- Meatoplasty & Glanuloplasty </li></ul><ul><li>4- Scrotoplasty </li></ul><ul><li>5- Skin cover </li></ul>
  11. 11. Treatment Plan Prevention of urethral plate , skin & dartos dissection Distal Proximal Glans configuration Meatal quality & location Urethral plate width Assess curvature Dorsal plication if necessary MAGPI GAP/Pyramid Tubularization Snodgrass Assess curvature Dorsal plication if necessary Rarely resect plate Onlay Two stage Bracka two-stage buccal graft
  12. 12. “MAGPI” <ul><li>Indication- </li></ul><ul><li>Glanular hypospadias with a flat or convex glans </li></ul><ul><li>Thick & healthy skin proximal to meatus without chordee </li></ul><ul><li>Contraindication- </li></ul><ul><li>Coronal hypospadias with or without chordee </li></ul><ul><li>Retrusive meatus after previous surgery </li></ul><ul><li>More proximal hypospadias & wide meatus, concave glans </li></ul>
  13. 13. “MAGPI”
  14. 14. “GAP” Procedure <ul><li>Indication- </li></ul><ul><li>Wide and deep glanular grooves </li></ul><ul><li>Patulous fish mouth meatus with out curvature </li></ul><ul><li>Procedure- </li></ul>
  15. 15. Pyramid procedure <ul><li>Indication- </li></ul><ul><li>Megameatus with wide glanular defect without curvature </li></ul><ul><li>Procedure- </li></ul>
  16. 16. “ Mathieu” or Perimeatal-based procedure <ul><li>Indication- </li></ul><ul><li>Too proximal meatus to perform MAGPI </li></ul><ul><li>No deep glanular groove </li></ul><ul><li>Procedure - </li></ul>
  17. 17. “ Snodgrass” Tubularized incised plate urethroplasty <ul><li>Indication- </li></ul><ul><li>Urethral groove is not wide enough for tubularization in situ </li></ul><ul><li>Contraindication- </li></ul><ul><li>Pt with significant curvature </li></ul><ul><li>Flat glans ,narrow urethral plate,narrow meatus </li></ul><ul><li>Moderate chordee </li></ul><ul><li>Skin proximal to meatus is thin & attenuated </li></ul>
  18. 18. “ Snodgrass” Tubularized incised plate urethroplasty <ul><li>Procedure- </li></ul>
  19. 19. Posterior hypospadias <ul><li>Onlay island flap </li></ul><ul><li>Transverse tubularized island flap </li></ul><ul><li>Two-stage hypospadias repair </li></ul><ul><li>Bracka two-stage buccal graft repair </li></ul>
  20. 20. Onlay island flap Indication-pt with narrow urethral plate,thin ventral skin, no chordee
  21. 21. Transverse tubularized island flap
  22. 22. Two-stage hypospadias repair <ul><li>Indication- </li></ul><ul><li>Proximal Hypospadias with marked chordee </li></ul><ul><li>Inadequate prepucel skin </li></ul><ul><li>Re do surgery </li></ul><ul><li>Procedure- </li></ul><ul><li>-First stage - correction of chordee with or with glanuloplasty </li></ul><ul><li>-Second stage – done after 6 mth by tubularization of neourethra & skin cover </li></ul>
  23. 23. Bracka two-stage buccal graft repair
  24. 24. Different tissues used for correction of hypospadias
  25. 25. Complications <ul><li>Meatal stenosis </li></ul><ul><li>Fistula </li></ul><ul><li>Infection </li></ul><ul><li>Diverticulum </li></ul><ul><li>Stricture </li></ul><ul><li>Penile torsion </li></ul><ul><li>Procedure failure </li></ul>
  26. 26. General considerations <ul><li>Testosterone stimulation- im 2mg/kg 3 dose /3wks </li></ul><ul><li>Vascularity </li></ul><ul><li>Minimal tissue damage & correct tissue planes </li></ul><ul><li>Suture material & suture technique </li></ul><ul><li>Antibiotics </li></ul><ul><li>Analgesia – Caudal block </li></ul><ul><li>Haemorrhage – 1:100000 epinephrine in 1% xylocaine </li></ul><ul><li>Catheter </li></ul><ul><li>Magnification </li></ul>
  27. 27. Summary <ul><li>Selection of patient & appropriate procedure </li></ul><ul><li>Appropriate time 6 to 18 mth of life </li></ul><ul><li>A terminal slit like meatus should be the goal with or without preservation of foreskin depending on parental preference </li></ul><ul><li>Mid line dorsal plication is safe for correction of curvature </li></ul><ul><li>Deepithelialized vascular flap should be use as a second layer for all urethroplasties </li></ul><ul><li>Follow up at 6mth,1year,after toilet training & after puberty </li></ul>

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