Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Hypospadias

27,081 views

Published on

Published in: Health & Medicine

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>

×