slides will Guide in management of Hypospadias

1. Dr. A.L. BhatDr. A.L. Bhat
DEPARTMENT OF UROLOGYDEPARTMENT OF UROLOGY
DR.S.N. MEDICAL COLLEGEDR.S.N. MEDICAL COLLEGE
JODHPUR RAJASTHANJODHPUR RAJASTHAN
INDIAINDIA
RATIONAL APPROACH IN
MANAGEMENT OF HYPOSPADIAS
Dr. A.L. BhatDr. A.L. Bhat
DEPARTMENT OF UROLOGYDEPARTMENT OF UROLOGY
JNU IMSRC Jaipur INDIAJNU IMSRC Jaipur INDIA

2. Hypospadias MafiaHypospadias Mafia

3. POINTS OF DISCUSSION INPOINTS OF DISCUSSION IN
MYMY TALKTALK
• CHORDEE CORRECTION
• TORSION CORRECTION
• MODIFIED TIPU
• SPONGIOPLASTY
• DOUBLE BREASTING SPONGIOPLASTY
• TIPU IN PROXIMAL HYPOSPADIAS
• BHAT’S MODIFICATION OF GLASSBERG DUCKETTE
REPAIR
• MANAGEMENT OF MIP

4. HYPOSPADIOLOGYHYPOSPADIOLOGY
The in depth study of the art andThe in depth study of the art and
science of the surgical correction ofscience of the surgical correction of
hypospadiashypospadias
Dr John W. Duckett 1981b,1995Dr John W. Duckett 1981b,1995

5. HYPOSPADIOLOGYHYPOSPADIOLOGY
John DuckettJohn Duckett
Many successful methodsMany successful methods
No single works ideally for all hypospadiasNo single works ideally for all hypospadias
Choose suitable technique for individual caseChoose suitable technique for individual case

6. • Basic Principle in management of any
congenital anomaly is to restore the
normal or near normal anatomy with the
existing tissue or with supplementation of
tissue.
• Bhat A
RATIONALE IN DECISION MAKING

7. • Ideal Urethral replacement is only the
urethra
Editorial comment Bhat A.L.Editorial comment Bhat A.L. J UrolJ Urol
October 2009October 2009
RATIONALE IN DECISION MAKING

8. RATIONALEIN DECISION MAKING
* Modern approach in repair of
hypospadias, attempts should be
made to preserve the urethral plate.
Upadhaya J et al UCNA 2002 29,299-310

9. POINTS OF DISCUSSION INPOINTS OF DISCUSSION IN
MYMY TALKTALK
• CHORDEE CORRECTION
• TORSION CORRECTION
• MODIFIED TIPU
• SPONGIOPLASTY
• DOUBLE BREASTING SPONGIOPLASTY
• TIPU IN PROXIMAL HYPOSPADIAS
• BHAT’S MODIFICATION OF GLASSBERG DUCKETTE
REPAIR
• MANAGEMENT OF MIP

10. VENTRAL PENILEVENTRAL PENILE
CURVATURECURVATURE
• Entrapment of corporeal body in the
coverings of the penis
• Skin
• Dartos fascia
• Bucks fascia
• Corpus spongiosum - Short / Bifurcation
• Corpus cavernosum Dorso-ventral
disproportion

11. METHODS OF CHORDEEMETHODS OF CHORDEE
CORRECTIONCORRECTION
Penile De-gloving
Tunica Albuginea Plication, Dorsal Midline Plication
MPP (Multiple Parallel Suture Plication), NESBIT’S
Mobilization of urethral plate and spongiosum
Mobilization of proximal urethra
Mobilization of urethral plate into glans
Midline dissection of corporeal bodies and
Lateral Dissection of Buck’s Fascia
Superficial corporotomy
Spongioplasty Glanuloplasty
Corporoplasty Tunica Vaginalis Free Graft, Dermal
Graft
Penile Disassembly/ Corporeal Rotation

12. Algorithm 2
Hypospadias with severe Curvature
TIP Penile Degloving
With spongioplasty
Curvature Persisted
Urethral mobilization with
diverting corpus spongiosum
Curvature corrected Curvature corrected
Curvature Persisted
Proximal urethral mobilization Urethral plate narrow
Curvature Persisted
Mobilization of urethral plate with Dorsal Onlay and TIP /OIF
Corpus spongiosum in to glans
Curvature Persisted
Single stitch dorsal plication
Curvature Persisted Curvature Persisted
Corporal disproportion Tethering of urethral plate
Corporoplasty Transaction of urethral plate
Inner prepucial flap urethroplasty
Inner prepucial flap--- Short
One tube from urethral plate + Inner prepucial Flap
Two stage urethroplasty Still short
Bhat A L et al IJU 2008

13. CORRECTION OF CURVATURECORRECTION OF CURVATURE
PRESERVING THE URETHRAL PLATEPRESERVING THE URETHRAL PLATE
Penile De-gloving
TAP ( Tunica Albuginea Plication)
Dorsal Midline Plication
MPP (Multiple Parallel Suture Plication)
NESBIT’S
Mobilization of urethral plate and spongiosum
Mobilization of proximal urethra
Mobilization of urethral plate into glans
Midline dissection of corporeal bodies and
Lateral Dissection of Buck’s Fascia
Resection of Chordee tissue
Tunica Vaginalis Free Graft
Dermal Graft

14. CONVENTIONAL METHODSCONVENTIONAL METHODS
DISADVANTAGESDISADVANTAGES
• Extensive procedure
• Bleeding due to resection of corpus
spongiosum
• Plication procedure - Against anatomical
Principles
• Shorten the penis
• Chances of Nerve Injury
• Impotence

15. OUR TECHNIQUE OFOUR TECHNIQUE OF
CHORDEE CORRECTIONCHORDEE CORRECTION
• Penile De-gloving
• Mobilization of urethral plate & corpus
spongiosum upto Corona
• Mobilization of urethral plate with
spongiosum in to glans
• Proximal extended urethral mobilization
• Spongioplasty and Glanuloplasty.

17. MOBILIZATION OF SPONGIOSUMMOBILIZATION OF SPONGIOSUM

18. LATERAL LIMIT OF SPONGIOSUMLATERAL LIMIT OF SPONGIOSUM

19. Penile De-glovingPenile De-gloving

20. Mobilization of Urethral plateMobilization of Urethral plate
with spongiosumwith spongiosum

21. Proximal urethral MobilizationProximal urethral Mobilization

22. Mobilization Urethral plate intoMobilization Urethral plate into
GlansGlans

23. A B C
D E F

24. Correction of curvature in severe
hypospadias
A. Bhat et al. http://dx.doi.org/10.1016
/j.afju.2014.12.003

25. Correction of severe CurvatureCorrection of severe Curvature
by Mobilization Techniqueby Mobilization Technique

26. PENILE DEGLOVING AND MOBILIZATION OFPENILE DEGLOVING AND MOBILIZATION OF
URETHRAL PLATE AND SPONGIOSUMURETHRAL PLATE AND SPONGIOSUM

27. GITTES TEST SHOWING CORRECTIONGITTES TEST SHOWING CORRECTION
OF CURVATUREOF CURVATURE

29. SPONGIOPLASTY AND GLANULOPLASTY
Dodat et al BJU I March 2003

30. GLANULOPLASTYGLANULOPLASTY
• Brings meatus at the tip of
glans
• Shape to glans as conical
• Adds length to glanular urethra
• Helps in correction of
glanular curvature

32. MANAGEMENT OF SEVERE HYPOSPADIAS
J Ped Urol 12, 2016

33. METHODS OF CHORDEEMETHODS OF CHORDEE
CORRECTIONCORRECTION
Penile De-gloving
Mobilization of urethral plate and spongiosum
Midline dissection of corporeal bodies and
Lateral Dissection of Buck’s Fascia
Superficial corporotomy
Corporoplasty Tunica Vaginalis Free Graft
Dermal Graft
Penile Disassembly/ Corporeal Rotation

34. A
BTransection of urethral plate

35. Penile de-gloving + Mobilization
of urethral plate with spongiosum

36. RESECTION OF HYPOPLASTIC TISSUE

37. A
B C D
E F G
Lateral dissection of Tunica Albuninea

38. Lateral dissection of Buck’s Fascia and Gittes
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

39. Lateral dissection of Buck’s fascia

40. A B
Midline dissection of corporal bodies

41. MIDLINE DISSECTION OF CORPORAL BODIES

44. POST-OPERATIVEPOST-OPERATIVE

45. POSTOPERATIVE RESULTSPOSTOPERATIVE RESULTS

46. POINTS OF DISCUSSION INPOINTS OF DISCUSSION IN
MYMY TALKTALK
• CHORDEE CORRECTION
• TORSION CORRECTION
• MODIFIED TIPU
• SPONGIOPLASTY
• DOUBLE BREASTING SPONGIOPLASTY
• TIPU IN PROXIMAL HYPOSPADIAS
• BHAT’S MODIFICATION OF GLASSBERG DUCKETTE
REPAIR
• MANAGEMENT OF MIP

47. COMPARATIVELY RARE CONDITION
LEAST DISCUSSED
TechniquesTechniques
PENILE DEGLOVING & REATTACHING THE SKINPENILE DEGLOVING & REATTACHING THE SKIN
INCISING THE BASE OF PENIS, EXCISION OFINCISING THE BASE OF PENIS, EXCISION OF
TUNICA & PLICATION extensive procedureTUNICA & PLICATION extensive procedure
DETORQUE BY DORSAL DARTOS FLAP--- Difficult toDETORQUE BY DORSAL DARTOS FLAP--- Difficult to
adjust exact degreeadjust exact degree
PLICATION PROCEDRE -- SHORTEN PENISPLICATION PROCEDRE -- SHORTEN PENIS
PENILE TORSION ASSOCIATED
WITH HYPOSPADIAS

48. PLICATION PROCEDURES
DISADVANTAGES
1.Against anatomical Principles
2. Shortens the penis
3. Recurrent torsion
4. Chances of Nerve Injury
5. Impotence
6. Numbness to glans and penile shaft
7. Penile pain
8. Applicable in mild to moderate torsion only
Bhat et al J. Ped Urol 2011

49. PLICATION PROCEDURES
DISADVANTAGES
It is difficult to achieve an exact correction, they are
ineffective in severe torsion of more than 90
degrees.There is a risk of recurrence if sutures dissolve or
give way early, and they are against the anatomical
principles of surgery as they produce counter torque.
•Hsieh JT, Wong WY, Chen J, et al.. Urology 2002;59:438e40.
•Ami Lal Bhat et al., J Pediatr Urol (2009), oi:10.1016/j.jpurol.2009.05.013

50. DE TORQUE BY DORSALDE TORQUE BY DORSAL
DARTOS WRAPDARTOS WRAP
Commonly done
Good technique
Can be done with hypospadias repair
Fisher PC and Mark JM: Penile torsion repair using dorsal dartos flap rotation. J Urol
2004; 109: 1903-4

51. DE TORQUE BY DORSALDE TORQUE BY DORSAL
DARTOS WRAPDARTOS WRAP
Limitation - ineffective in severe torsion
Chances of recurrence - sutures may give way
Difficult to adjust the exact correction of torsion
Counter torque rather than correcting the cause
Ami Lal Bhat et al., J Pediatr Urol (2009), doi:10.1016/j.jpurol.2009.05.013

52. Penile torsion
Amilal Bhat et al
J Ped Urol 2009

53. OUR TECHNIQUE OFOUR TECHNIQUE OF
CORRECTION OF TORSIONCORRECTION OF TORSION
• Penile De-gloving
• Mobilization of urethral plate & corpus
spongiosum up-to Corona
• Proximal urethral mobilization
• Mobilization of urethral plate with
spongiosum in to glans

54. Penile torsion

55. CORRECTION OF TORSION BY
MOBILIZATION OF URETHRA AND
SPONGOSUM IN TO GLANS
Amilal Bhat et al
J Ped Urol 2009

56. SEVERE TORSION (180 DEGREE ) URETHRAL DIVERICULA

57. COMPARATIVELY RARE CONDITION
LEAST DISCUSSED
TechniquesTechniques
PENILE DEGLOVING & REATTACHING THE SKINPENILE DEGLOVING & REATTACHING THE SKIN
INCISING THE BASE OF PENIS, EXCISION OFINCISING THE BASE OF PENIS, EXCISION OF
TUNICA & PLICATION extensive procedureTUNICA & PLICATION extensive procedure
DETORQUE BY DORSAL DARTOS FLAP--- Difficult toDETORQUE BY DORSAL DARTOS FLAP--- Difficult to
adjust exact degreeadjust exact degree
PLICATION PROCEDRE -- SHORTEN PENISPLICATION PROCEDRE -- SHORTEN PENIS
Penile torsion associated with hypospadias
Amilal Bhat et al
J Ped Urol 2009
Amilal Bhat et al
J Ped Urol 2009

58. Correction of torsion by mobilization ofCorrection of torsion by mobilization of
urethral plate and urethraurethral plate and urethra

59. TORSION -TAKE HOME MESSAGETORSION -TAKE HOME MESSAGE
1- Torsion is more common and more severe distal
hypospadias
2- Mobilization of divergent corpus spongiosum with
urethral plate/ hypoplastic urethra , in to glans
urethra corrects the torsion in almost all cases
3 The technique is as per anatomical principals of
Surgery , simple, safe and effective .

60. OUR TECHNIQUE OF CHORDEEOUR TECHNIQUE OF CHORDEE
CORRECTION IN CHORDEECORRECTION IN CHORDEE
WITHOUT HYPOSPADIASWITHOUT HYPOSPADIAS
• Mobilization of Hypoplastic urethra &
corpus spongiosum into glans and
proximal extended urethral mobilization
• Spongioplasty and Glanuloplasty.
Bhat et al J . PAEDIATRIC UROLOGY Feb 2008

61. TECHNIQUETECHNIQUE
STEPSFOR CHORDEE CORRECTIONSTEPSFOR CHORDEE CORRECTION
Gitte’s Test at complete correctionGitte’s Test at complete correction
Step1- Penile skin de-gloving
Step2- Mobilization of divergent corpus
spongiosum
Step3- Mobilization of hypoplastic urethra
Step4- Mobilization of proximal urethra up
to bulbar urethra
Step4- Mobilization of hypoplastic urethra
into glans
Step5- Dorsal plication
Step6- Division/ resection of hypoplastic
urethra
Step7- Penile Dis-assembly.

62. A B C D
E
F G H
Steps of chordee correction in type III chordee without hypospadias

63. A B C D
F
G
H I
E
Steps of chordee correction in type II chordee without hypospadias

64. B C D
J K
L
M N
F
G
E
Steps of chordee correction in type II chordee without hypospadias with plication
N
O P
A F
J K
I
H

65. COMPLICATIONCOMPLICATION

66. CO-RELATION OF CHORDEECO-RELATION OF CHORDEE
WITH TORSIONWITH TORSION
Conclusions: Penile torque is more common and severe in distal hypospadias,
while ventral curvature is seen more often in proximal hypospadias.
The degree of torsion is inversely proportional to the severity of
ventral curvature.
Techniques for the repair of penile torque and ventral curvature include penile
Degloving and mobilization of the urethral plate with the corpus spongiosum
and the urethra.

67. A B C D E
F G H I J
Correction of Chordee without hypospadias with torsion

68. A B C D
E F
G
H
I

69. CORRECTION OF CHORDEECORRECTION OF CHORDEE
AND TORSIONAND TORSION

70. POINTS OF DISCUSSION INPOINTS OF DISCUSSION IN
MYMY TALKTALK
• GENERAL CONSIDERATIONS
• CHORDEE CORRECTION
• TORSION CORRECTION
• MODIFIED TIPU
• SPONGIOPLASTY
• DOUBLE BREASTING SPONGIOPLASTY
• TIPU IN PROXIMAL HYPOSPADIAS
• BHAT’S MODIFICATION OF GLASSBERG DUCKETTE
REPAIR
• MANAGEMENT OF MIP

71. MODIFICATION IN TIPUMODIFICATION IN TIPU
• Partial penile Degloving
• Mobilization of urethral plate with
spongiosum
• Spongioplasty
• Ventral Dartos Cover
• Frenuloplasty
• Preputioplasty

72. MODIFIED TIPUMODIFIED TIPU
• Partial penile de-loving

73. Mobilization of spongiosumMobilization of spongiosum

74. Mobilization of spongiosum in toMobilization of spongiosum in to
GlansGlans

75. Tubularization of urethral plateTubularization of urethral plate
& Spongioplasty& Spongioplasty

76. FrenuloplastyFrenuloplasty

77. Ventral Dartos closureVentral Dartos closure

78. PrepucioplastyPrepucioplasty

79. PrepucioplastyPrepucioplasty

80. POINTS OF DISCUSSION INPOINTS OF DISCUSSION IN
MYMY TALKTALK
• GENERAL CONSIDERATIONS
• CHORDEE CORRECTION
• TORSION CORRECTION
• MODIFIED TIPU
• SPONGIOPLASTY
• DOUBLE BREASTING SPONGIOPLASTY
• TIPU IN PROXIMAL HYPOSPADIAS
• BHAT’S MODIFICATION OF GLASSBERG DUCKETTE
REPAIR
• MANAGEMENT OF MIP

81. HEALTHY TISSUES INTERPOSITIONHEALTHY TISSUES INTERPOSITION
•Dorsal subcutaneous flapDorsal subcutaneous flap
•Lateral dartos flapLateral dartos flap
•De-epithelialized skin flapsDe-epithelialized skin flaps
•Double breasted de-epithelialized penileDouble breasted de-epithelialized penile
skin flapskin flap
• Tunica vaginalisTunica vaginalis
•Corpus spongiosumCorpus spongiosum

82. DISADVANTAGE OFDISADVANTAGE OF
ADITIONAL TISSUE LAYERADITIONAL TISSUE LAYER
• Torsion
• Skin necrosis
• Buried skin dermoid cyst
• Tunica vaginalis need opening of
scrotal sac

83. ADVANTAGE OFADVANTAGE OF
SPONGIOPLASTYSPONGIOPLASTY
• Y TO I spongioplasty adds length to
urethra
• Helps in correction of Curvature
• Reconstructs near normal urethra
• Healthy tissue cover prevents fistula

84. Yerkes SpongioplastyYerkes Spongioplasty

85. DIS-ADVANTAGESDIS-ADVANTAGES
• Incising the spongiosum medially and mobilization on both
sides of spongiosum,
• Laterally spongiosum is neither sutured to neo-urethra nor
to corpora
• Partial coverage of urethra at the bifurcation of spongiosal
pillar
• All these factors increase the chances of fistula.

86. SPONGIOPLASTYSPONGIOPLASTY

87. POORLY DEVELOPED SPONGIOSUM
Bhat et al IJU Oct-Dec 2014, Vol 30, Issue 4

88. MODERATELY DEVELOPED SPONGIOSUM
Bhat et al IJU Oct-Dec 2014, Vol 30, Issue 4

89. Bhat et al IJU Oct-Dec 2014, Vol 30, Issue 4
WELL DEVELOPED SPONGIOSUM

90. MOBILIZATION OF CORPUSMOBILIZATION OF CORPUS
SPONGIOSUM INTO GLANSSPONGIOSUM INTO GLANS

91. Conventional spongioplasty

92. SECONDARYSECONDARY
SPONGIOPLASTYSPONGIOPLASTY

94. DIS-ADVANTAGESDIS-ADVANTAGES
• Superimposing of suture lines, of urethral plate ,
spongiosum and skin closure
• Conical shape of urethra,
• These factors increase the chances of fistula and is
question of cosmesis

95. POINTS OF DISCUSSION INPOINTS OF DISCUSSION IN
MYMY TALKTALK
• GENERAL CONSIDERATIONS
• CHORDEE CORRECTION
• TORSION CORRECTION
• MODIFIED TIPU
• SPONGIOPLASTY
• DOUBLE BREASTING SPONGIOPLASTY
• TIPU IN PROXIMAL HYPOSPADIAS
• BHAT’S MODIFICATION OF GLASSBERG DUCKETTE
REPAIR
• MANAGEMENT OF MIP

96. CAN WE PREVENT SUPERCAN WE PREVENT SUPER
IMPOSITIONIMPOSITION
“Double-breasting spongioplasty” in
TIPU.

97. DOUBLE BREATINGDOUBLE BREATING
SPONGIOPLASTYSPONGIOPLASTY

98. DOUBLE BREATINGDOUBLE BREATING
SPONGIOPLASTYSPONGIOPLASTY

99. DOUBLE BREATINGDOUBLE BREATING
SPONGIOPLASTYSPONGIOPLASTY

100. DOUBLE BREATINGDOUBLE BREATING
SPONGIOPLASTYSPONGIOPLASTY

101. RESULTSRESULTS
• A total of 3 patients had developed
complications (seroma, fistula and
meatal stenosis 1each) and overall
complication rate was 5% and fistula
rate was 1.66%.

102. DISCUSSIONDISCUSSION

103. CONCLUSSIONSCONCLUSSIONS
• Double breasting spongioplasty avoids
superimposition of suture line and adds two
layers of spongiosum over neourethra, thus
decreases the chances of urethral fistula and
gives cylindrical shape to neourethra.
• The technique is simple, easy to understand,
can be done even by a beginner and is
reproducible.
• Incidence of fistula was significantly low
clinically. It is our initial experience with very
good results, and needs further studies at
different centers for its validation.

104. MANAGEMENT OF SEVERE HYPOSPADIAS

105. • It is like trying to decide whether an apple or an orange is
the best tasting fruit. Clearly personal taste, upbringing
and situational preference are all important variables in
making a decision, just as training, experience and
personal success are all factors when deciding what type
of hypospadias technique to use.
Laurence Baskin
Vol. 184, 1469-1475, October 2010
Surgical Management of Primary
Severe Hypospadias in Children:
Systematic 20-Year Review
One stage Vs two stage

106. Variables in Decision
• Age of patients
• Type of hypospadias
• Quality of spongiosum
• Width of Urethral Plate
• Penile Torsion
• Degree of Penile curvature
• Size of penis
• Size of glans
• Length of hypoplastic urethra
Bhat A et al IBIMA Publishing
Vol. 2014 , Article ID 547185, 12 pages
DOI: 10.5171/2014.547185

107. Technique using urethral tissueTechnique using urethral tissue
Total-Total- TIPUTIPU
Partial –SNODGRAFTPartial –SNODGRAFT
On lay Flap UrethroplastyOn lay Flap Urethroplasty
Replacement urethroplastyReplacement urethroplasty
DUCKET’S REPAIR ,DUCKET’S REPAIR ,HODGSON’S X,HODGSON’S X,
HODGSON’S XX ,ASOPA’SHODGSON’S XX ,ASOPA’S
DOUBLE ISLAND URETHROPLASTYDOUBLE ISLAND URETHROPLASTY
KOYONAGIKOYONAGI
Bhat’s modification of Glassberg –DucketteBhat’s modification of Glassberg –Duckette
techniquetechnique
CHOICE OF SINGLE STAGE ROCEDURESCHOICE OF SINGLE STAGE ROCEDURES
IN PROXIMAL HYPOSPADIAS WITHIN PROXIMAL HYPOSPADIAS WITH
CURVATURECURVATURE
Bhat A L et al IJU 2008

108. Single- vs. multi-stage repair of proximal
hypospadias: The dilemma continues
• The reported complications in both techniques were
similar, including mostly minor complications in the form
of fistula, meatal stenosis, partial glans dehiscence, and
urethral diverticulum, with their easy surgical repair.
• The outcomes of single- and multistage repairs of
proximal hypospadias are comparable
Haytham Badawy *, Ahmed Fahmy
Arab Journal of Urology (2013) 11, 174–181

109. The contemporary role of 1 vs. 2-stage
repair for proximal hypospadias
• One stage repairs are an attractive option in that they may
reduce cost, hospital stay, anesthetic risks, and time to the
final result.
• The 2-stage repair is versatile and has satisfactory
outcomes, but necessitates a second procedure.
• Given the lack of clear high-quality evidence supporting the
superiority of one approach over the others,
hypospadiologists should develop their own algorithm,
which gives them the best outcomes.
•
Shawn Dason, Nathan Wong, Luis H.
Braga Transl Androl Urol 2014;3(4):347-
358

110. Algorithm 2
Hypospadias with severe Curvature
TIP Penile Degloving
With spongioplasty
Curvature Persisted
Urethral mobilization with
diverting corpus spongiosum
Curvature corrected Curvature corrected
Curvature Persisted
Proximal urethral mobilization Urethral plate narrow
Curvature Persisted
Mobilization of urethral plate with Dorsal Onlay and TIP /OIF
Corpus spongiosum in to glans
Curvature Persisted
Single stitch dorsal plication
Curvature Persisted Curvature Persisted
Corporal disproportion Tethering of urethral plate
Corporoplasty Transaction of urethral plate
Inner prepucial flap urethroplasty
Inner prepucial flap--- Short
One tube from urethral plate + Inner prepucial Flap
Two stage urethroplasty Still short
Bhat A L et al IJU 2008

111. WHY ONESTAGE
DISADVATAGES OFTWO STAGE
TWO OPERATIVE PROCDURE
COMPLICATIONS 10 TO 32 % REQUIRING THIRD SURGERY
HIGH COST
PARENTS/ SURGEON TIME LOSS TWICE/ THRICE
STRESS AND MENTAL TRAUMA TO CHILD , PARENTS
TWICE /THRICE
QUALITY OF URETHRA – POOR -NO SPONGIOSUM
SIGNIFICAT LEARING CURVE-

112. ADVATAGEOF ONESTAGE
Healthy unscarred skin for primary repair
Decreased cost, anesthesia risk &
psychological impact
Decreased separation anxiety
Greater convenience to Patient ,Parent and
Surgeon
Kajbafzadeh AB et alKajbafzadeh AB et al
J Urol 2007 178 ;1036-42J Urol 2007 178 ;1036-42

113. COMPLICATIONS OFTWO STAGE
A study of 34 cases
Glans disruption 11.7 %
Fistula 05. 8%
Metal stenosis 02.9 %
Urethral diverticula 02.9 %
Over all complication 23.5 %
Zaccara et al Two stage repair
J Urol 168 ,1730- 33; 2002

114. COMPLICATIONS OFTWO STAGE
A study of 47 cases
Over all complication ( 13) 32 %
Graft contracture and slough ( 06)
Meatal stenosis and fistula (07 )
First 3 years complications 60 %
Last 7 years complications 19 %
Hensle et al Buccal mucosa graft
J Urol 168 ,1734- 37; 2002

115. WHY ONESTAGE
Long term complication two stage
A study of 44 cases
Spraying of stream 40 %
Milking of urethra after voiding 40 %
Milking of the ejaculate 42.9 %
Painful ejaculation 7.7 %
Lam et al Two stage repair
J Urol 174 ,1565- 72; 2005

116. WHY ONE STAGE
Long term complication two stage
Urine dribbling 40 %
Dribbling ejaculate 33%
Retained ejaculate ejaculation 40 %
Bracka A long term review
Brit J Plast Surg 42 ,251-4; 1989

117. WHYTIP ?WHYTIP ?
*NO TISSUE AS GOOD AS URETHRA AND TIP
WITH SPONGIOPLATY RECONSTRUCTS NEAR
NORMAL URETHRA
*RESULTS GOOD
*REPRODUCIBLE
*CAN BE DONE BY BEGINNER
*LOW COMPLICATION RATE 2-5%
*BEST SUITED FOR ANTERIOR HYPOSPADIAS
*CAN BE DONE IN SEVERE HYPOSPADIAS
*CAN BE DONE IN REOPERATIVE CASES

118. Prior Reports of Proximal TIP
Authors Date Patients Ventral
curvature
(%)
Mean
follow up
months
Total patient
complications
(%)
1. Snodgrass et al
(multicenter)
1998 NS 3 (11)
11 proximal 10 (91)
2. Chen et al 2000 9 (23) 12.5
27 proximal 5 (19)
3. Borer et al 2001 NS 6-38
9 proximal 2(22)
4. Cheng et al
(multicenter)
2002
100
penoscrotal”
NS 4-66 4 (4)
5. Samuels and Wilcox 2003 18 proximal 4 (22) 4 4 (22)
6. Mustafa 2005 NS 4 (31)
12 proximal 1 (8)
Totals 177 22 (14%)
NS – not stated
* denotes 1 patient with more than 1 complication Snodgrass WT IJU 2007

119. TIPU IN PERINEAL HYPOPSPADIAS
A. Bhat et al.
Af. J. Urol 2014.12.003

120. TIPU IN PERINEAL HYPOPSPADIAS
A.Bhat et al. http://dx.doi.org/10.1016
/j.afju.2014.12.003.

121. TIPU IN PERINEAL HYPOPSPADIAS
• The excellent functional and cosmetic results
achieved with a single-stage procedure in 85.8%
of our patients compare favorably with the
results of two-stage procedures reported in the
literature. Repairing severe hypospadias in a
single stage using TIP urethroplasty seems to be
preferable from an anesthetic, safety and
economic perspective, especially in this era
where cost reduction is getting more and more
important A.Bhat et al. http://dx.doi.org/10.1016
/j.afju.2014.12.003.

122. Preputial reconstruction and tubularized incised
plate urethroplasty in proximal hypospadias with
ventral penile curvature
• Twenty four (88.88%) patients and/or their parents were fully
satisfied with the outcome of surgery and cosmesis.
• Urethroplasty-related complications were noticed in 7.40 %
cases only.
• Preputioplasty with TIP is feasible in proximal hypospadias
with curvature without increasing the complication
rate.
Bhat A L et al IJU Oct-Dec 2010,

123. POST-OPERATIVEPOST-OPERATIVE

125. Algorithm 2
Hypospadias with severe Curvature
TIP Penile Degloving
With spongioplasty
Curvature Persisted
Urethral mobilization with
diverting corpus spongiosum
Curvature corrected Curvature corrected
Curvature Persisted
Proximal urethral mobilization Urethral plate narrow
Curvature Persisted
Mobilization of urethral plate with Dorsal Onlay and TIP /OIF
Corpus spongiosum in to glans
Curvature Persisted
Single stitch dorsal plication
Curvature Persisted Curvature Persisted
Corporal disproportion Tethering of urethral plate
Corporoplasty Transaction of urethral plate
Inner prepucial flap urethroplasty
Inner prepucial flap--- Short
One tube from urethral plate + Inner prepucial Flap
Two stage urethroplasty Still short
Bhat A L et al IJU 2008

126. INDICATIONSINDICATIONS
Urethral plate poorly andUrethral plate poorly and NarrowNarrow
Flat glansFlat glans
Meatus narrow or wide,Meatus narrow or wide,
Chordee corrected preserving theChordee corrected preserving the
urethral plateurethral plate
DORSAL INLAY

127. DORSAL INLAYDORSAL INLAY
GRAFTGRAFT
• INNER PREPUCIAL FREE
GRAFT
• BUCCAL MUCOSAL GRAFT
• FREE SKIN GRAFT

128. PENILE DEGLOVING AND MOBILIZATION OFPENILE DEGLOVING AND MOBILIZATION OF
URETHRAL PLATE AND SPONGIOSUMURETHRAL PLATE AND SPONGIOSUM

130. Tubularization of urethral plate,spongioplastyTubularization of urethral plate,spongioplasty
glanuloplastyglanuloplasty

131. Dartos and skin closureDartos and skin closure

132. DORSAL INLAY (SNODGRAFT)
Results
Authors Year No. of
patients
Complications Mean Follow up
Hayes &
Malone
1999 3 Nil NS
Snodgrass 2007 12 Fistula 1
Glans dehiscence 1
NS
Schwenter
et al
2007 31 Stricture 4
Fistula 1
Over all 16 %
30.71 Months
Baccala et
al
2005 Proximal 8
Midshaft 8
Distal 85
Over all 5 % 6 Months

133. Algorithm 2
Hypospadias with severe Curvature
TIP Penile Degloving
With spongioplasty
Curvature Persisted
Urethral mobilization with
diverting corpus spongiosum
Curvature corrected Curvature corrected
Curvature Persisted
Proximal urethral mobilization Urethral plate narrow
Curvature Persisted
Mobilization of urethral plate with Dorsal Onlay and TIP /OIF
Corpus spongiosum in to glans
Curvature Persisted
Single stitch dorsal plication
Curvature Persisted Curvature Persisted
Corporal disproportion Tethering of urethral plate
Corporoplasty Transaction of urethral plate
Inner prepucial flap urethroplasty
Inner prepucial flap--- Short
One tube from urethral plate + Inner prepucial Flap
Two stage urethroplasty Still short
Bhat A L et al IJU 2008

134. A
B C

135. SUBSTITUTION URETHROPLASTY SUBSTITUTION URETHROPLASTY
• Inner prepucial tube

136. Graft VS Flap
• Although flaps are better than the graft as
per plastic surgical principles of surgery
but still the flap based procedures lost its
shine.
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

137. Round table discussion
Hypospadias dilemmas
• Recent roundtable discussion by expert
Hypospadiologists, the tubularized Duckett
tube is considered to be history.
Snodgrass W, Journal of Pediatric Urology
2011; 7: 145-157.

138. Complications in flap procedures
• Residual curvature
• Diverticula, fistula,
• Stricture and meatal stenosis
• Splaying of stream,
• Dribbling of urine or ejaculate
• Milking of ejaculate because of poor quality
urethra (devoid of support),
• Penile torsion
• Ugly meatus due to protruding skin
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

139. Penile de-gloving

140. Curvature correction and Gittes
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

141. Complications at proximal Complications at proximal
anastomosisanastomosis
• Stricture
• Fistula

142. Elliptical Anastomosis proximal to
the edge urethral plate
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

143. Distal anastomosis proximal glans
margin
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

144. Urethral Diverticula
• Laxity of dartos based flap,
• Larger width of length of un-stretched of
the dartos based flap,
• Not fixing the flap to corpora
• No support to the skin tube
• Meatal stenosis due to circular
anastomosis at the meatus
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

145. Measuring the length and breadth
of stretched inner prepucial flap
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

146. Difference in width
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

147. PREVENTION OF TORQUE PREVENTION OF TORQUE

148. Covering the neo urethra with
spongiosum and dartos
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

149. Prevention of Diverticulae
Measuring the width by stretching the flap
Stretched length of penis
Wide skin to skin anastomosis
Skin tube fixed to ventrum – Prevents
mobility
Covering skin tube with dartos pedicle and
proximal with spongiosum .
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

150. Curvature correction and
preservation of urethral plate
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

151. Prevention of Retained Ejaculate
• The spongiosum with urethral plate is
mobilized and preserved with the objective
reconstructing neourethra with
spongiosum beyond the penoscrotal
junction which helps in propulsion of
semen as well urine.
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

152. BHAT’S MODIFICATIONS IN
FLAP PROCEDURE
1) Not excising the spongiosum but mobilizing the urethral
plate and spongiosum with the objective of doing a TIP with
spongioplasty beyond the penoscrotal junction.
2) Cosmesis achieved by : a) Ugly skin outside external
urethral meatus prevented by anastomosis done 5-7 mm
proximal to meatus with creation of wide meatus.
b) Symmetrical shaft of penis due to splitting of dartos
and cover from both sides.
3 ) Torsion of shaft of penis prevented by mobilizing dorsal
dartos upto root of penis, slitting in midline and dividing it
into two equal parts brought ventrally on each side.
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

153. BHAT’S MODIFICATIONS IN
FLAP PROCEDURE
4) Commonest complication of such repairs is
anastomotic fistula – prevented by
spongiosum cover of proximal TIP with burying
of the anastomosis under the spongiosal
wrap and dartos cover for the distal flap tube.
5) Wide elliptical anastomosis of proximal and
distal segments prevents stricture at this site.
6) Overall a success rate of 81% was
achieved with only 9.5 % patients
requiring a second surgery.
A Bhat et al AFJU 2016
10.1016/j.afju.2016.04.007

155. POST-OPERATIVEPOST-OPERATIVE

156. POSTOPERATIVE RESULTS POSTOPERATIVE RESULTS

157. POSTOPERATIVE RESULTS POSTOPERATIVE RESULTS

158. Take home message
1) Choice of technique will depend
upon various variables, surgeons
experience and training.
2) Most of the proximal hypospadias
can be managed in single stage only.

159. TAKE HOME MESSAGETAKE HOME MESSAGE
3)Urethral plate is adequate and the corpus
spongiosum is moderate to well
developed, TIP is feasible in proximal
including perineal hypospadias with
acceptable results
4) Urethral plate narrow, spongiosum poor–
Onlay flap urethroplasty / inlay
5) Poor urethral plate/ transaction of urethral
plate for curvature correction Flap
procedures

160. TAKE HOME MESSAGETAKE HOME MESSAGE
6) Duckett’s tube anastomosed with proximal
incised plate urethra covered with
spongiosum to give functional proximal
urethra
7) Fistula – prevented by spongiosum cover
of proximal TIP urethra & Dartos over
distal flap tube
8) Stricture- joining the two segments with an
ellipitical anastomosis, wide meatal
anastomosis

161. TAKE HOME MESSAGETAKE HOME MESSAGE
9) Torsion of shaft of penis prevented by
slitting dorsal dartos in midline and dividing
into two equal parts brought ventrally on
each side
10)Ugly skin outside external urethral
meatus prevented by anastomosis done 5
mm proximal to meatus with creation of
wide meatus

162. TAKE HOME MESSAGETAKE HOME MESSAGE
11) Diverticulae formation prevention –
- Measured equal width of flap
- Prevention of meatal stenosis
- Skin tube fixed to ventrum
- Covering skin tube with dartos pedicle
12) Prevention of retained can be prevented
proximal urethra with spongiosum up to
penoscrotal junction.

163. MEGAMEATUS INTACT PREPUCEMEGAMEATUS INTACT PREPUCE
MEGAMEATUS INTACT PREPUCE is an unusual,
anterior hypospadias variant characterized by :
widely splayed meatus,
 deep glanular groove,
 normally conformed prepuce that completely
covers the glans.
Hypospadias is usually identified at birth due to
the deficient ventral prepuce but when the prepuce
is intact the hypospadias remains concealed.

164. MATERIALS & METHODSMATERIALS & METHODS
Glanular MIP Coronal MIP Distal penile

165. TUP with SpongioplastyTUP with Spongioplasty

167. POSTOPERATIVE RESULTS

168. CONCLUSSIONS CONCLUSSIONS

169. THANKSTHANKS

170. METHODS OF TORSION
CORRECTION
Johnson’s technique (circular incision at the base of
the penis)
Easy technique
Effective only in mild torsion
May lead to under correction or recurrence of torque.
Reported keloid in 25 %, lymphoedema in 50% and ugly
scar at the base of the penis in 50 % cases with
Johnson’s technique
Tryfonas G I et al Paedtr surg Int 1995; 10:359-61

171. METHODS OF TORSION
CORRECTION
Penile de-gloving and reattaching the skin
•Azmy A, Eckstein HB.. Br J Urol 1981;53:378- 9.

172. PENILE DEGLOVING AND
RE-ATTACHING SKIN
Advantages:
Simple technique, can easily be done even by beginner
Disadvantages: Effective only in mild torsion
In moderate and severe torsion, these sutures would not be
strong enough to hold the expanding and rotating force of
erection
May lead to under correction or recurrence of torque.
Fisher PC and Mark JM: J Urol 2004; 109: 1903-
4
Corriere JN Jr. . J Urol 1981; 6: 410-11
Baskin L S: . J Urol 2000; 163:951-56

173. METHODS OF TORSION
CORRECTION
Resection of Buck’s fascia and plication
procedures
Plication procedures
•Slawin KM, Nagler HM. Treatment of congenital penile curvature
•with penile torsion: a new twist. J Urol 1992;147:152- 4.

174. METHODS OF TORSION
CORRECTION
Resection of Buck’s fascia and plication
procedures
Plication procedures
•Slawin KM, Nagler HM. Treatment of congenital penile curvature
•with penile torsion: a new twist. J Urol 1992;147:152- 4.