Hypospadias

1. HYPOSPADIAS
Dr Mujtuba Pervez Khan
Plastic and Reconstructive Surgery
DUHS/CHK

2. • Congenital condition characterized by
1. Abnormal proximal urethra meatus on
the ventral aspect of the penis
2. Ventrally deficient prepuce
(hooded foreskin)
3. Chordee

3. CLASSIFICATION

4. EMBRYOLOGY
• Internal organs differentiate during 6th gestational
week
• Y chromosome Sertoli cells M.I.F
• Leydig cells Testosterone
• During the 11th gestational week, external organs
develop
• Urethral groove grows down the genital
tubercle, distal glanular urethra is formed by ingrowth
from the glans penis
• Urethral folds Tubed urethra
• Labioscrotal swellings Scortum
G

5. ETIOLOGY
• Mostly unknown
• Following factors lead to the developmental arrest
1. Defects of testosterone synthesis
2. Androgen receptor deficiency
3. Mutations in FGF8 and FGFR2 genes
4. High levels of exogenous estrogens
RISK FACTORS
• Family history
• Genetics
• Maternal age +35
• Exposure to pesticides, industrial chemicals
during pregnancy

6. EPIDEMIOLOGY
• 1 in 300 live births have some degree of hypospadias
• Abnormalities are associated more with proximal hypospadias
• 10% ∞ inguinal hernias
• Most common G.U tract abnormality is cryptorchidism. 3% with distal hypospadias,
10% with proximal hypospadias
• Others: Paraurethral sinuses, urethral valves, enlarged prostatic utricle
• 4-10% have a family history
• 5 times more common in In vitro fertilization

7. ANATOMY

8. HISTORY
• Ask parents
1. If they have witnessed erections and if they were straight or
curved
2. If the child has been operated before
3. Direction of the urinary stream
4. Flow of the urinary stream
5. If the child is circumcised or not

9. EXAMINATION
1. Site of abnormal opening
2. Degree of Chordee (Mild: 10-20°, Moderate: 30-40°, Severe: >50°)
3. Assess penis size
4. Check both testes in the scrotum
5. Exclude inguinal hernia
6. Check for prepuce (weather circumcised or not)
7. Urethral plate width (<1cm, >1cm)
8. Watch the child pass urine to assess the direction and flow of urine

10. INVESTIGATION
• No need in most cases
• To exclude disorders of sex
development mostly in proximal
hypospadias
1. Pelvic ultrasound
2. Karyotype analysis
3. Serum electrolytes for Congenital
Adrenal Hyperplasia

11. COMPLICATIONS, IF NOT TREATED
• Abnormal appearance of the penis
• Abnormal curvature of the penis
• Problems with impaired ejaculation
• Problems with normal urinary flow

12. AIMS OF SURGERY
1. Normal aesthetic looking penis
2. Slit like terminal meatus
3. Normal erection and sexual function
4. Normal urinary stream
TIMING OF SURGERY
• Between 6-18 months
• Testosterone surge at 4-6 months
• Counsel parents to not get their child circumcised

13. SURGERY - CHORDEE CORRECTION
• True chordee VS False chordee
• Horton’s Test
• < 30°: Dorsal plication of Tunica
Albuginea (Nesbit dorsal tunical tuck)
• >30°: Transverse incision through the
urethral plate… Covering the defect with
skin graft or flap
• Corporotomy and graft
• Urethral plate division

14. SURGICAL TECHNIQUES
1. Tubularisation of the urethral plate (TIP)
2. Replacement of the urethral plate with skin flaps
3. Replacement of the urethral plate with grafts
• No technique is universally accepted

15. • Single stage
• For distal and mid shaft hypospadias
TUBULARISED INCISED PLATE
SNODGRASS

16. SNODGRASS – POST OP CARE
• Antibiotics and Sponge bathing till the catheter/stent is
removed
• Removal of stent/ catheter after a week

17. SNOD-GRAFT REPAIR
• Modification of Snodgrass, where
urethral plate is narrow or shallow
• Use of inner preputial skin graft, buccal
mucosa to deepen and widen the
urethral plate

18. BRACA (TWO STAGE) REPAIR
• Indications
1. Proximal hypospadias with severe chordee
2. Inadequate urethral plate
3. Distal hypospadias with conical glans
4. Previously operated cases
• Two stage
• Excellent cosmetic results
• Low complication rates

19. BRACA 1

20. BRACA 1 – POST OP CARE
• After 1st stage, catheter is removed within 2 days. Child can take a bath
• Removal of bolster on 7th P.O.D
• Apply moisturizing ointment over the graft and suture line
• 2nd stage 5-6 months later

21. BRACA 2

22. BRACA 2 – POST OP CARE
• After 2nd stage, remove dressing after 2 days.
• Catheter removal on 6-7th day
• Catheter can be left for 2 weeks in cases of swelling

23. MATHIEU PERIMEATAL BASED FLAP
• Also called flip flap
• For distal hypospadias

24. URETHRAL ADVANCEMENT
• Circumferential dissection and
advancement of the distal urethra
• Gain of 2.5cm of urethra in children
• Urethra is advanced till it reaches the
level of normal meatus

25. COMPLICATIONS
• Early
1. Bladder spasm
2. Hematoma
3. Wound dehiscence
4. Edema
5. Erections can cause
comlications
• Late
1. Fistula (most common)
2. Urethral Stenosis
3. Diverticulum
4. Persistent UTI

26. Thanks.