Hypospadias

1. INTRODUCTION
 1st credited to Galenus
 Derived from 2 greek word: hypo – “under” & spadon –
“rent”.
 DEFINITION: opening of urethral on the ventral surface
of the penis proximal to the normal site of external
urethral meatus (at the tip of glans) ± ventral curvature of
penile shaft (ventral chordee)

2. Characteristic
 Usually 3 features
 ventral meatus
 ventral curvature (chordee)
 Dorsal "hood“; deficient
foreskin ventrally

3. Incidence
 1:300 live male births
 6000 boys each year in the US
 Some genetic component
 8% of patients have father with hypospadias
 14% of patients have male siblings with
hypospadias
 If child with hypospadias, risk to next child
 12% risk with negative family history
 19% if cousin or uncle with hypospadias
 26% if father or sibling
 More common in Caucasians (Jews and
Italians)

4. Associated anomalies
 Undescended testes- in 7–9% generally, and 22% of patients with
severe hypospadias
 Inguinal hernia-in 9–16%
 Prostatic utricle
 Upper urinary tract abnormalities
 Disorder of sexual differentiation (DSD)-
 about30% of patients with severe hypospadias
 50% of patients with severe hypospadias and bilateral UDT
 Malformation syndrome:
 Opitz synd.: X-linked, AD
hypertelorism, hypospadia, mild to moderate mental
retardation, swallowing problem

5. HISTORY
 Galen (130–199 AD) used the term hypospadias
 . Matthieu 1932 – meatal based flap.
 John Duckett
 Tubularized transverse preputial island flap – 1980
 Meatal advancement and glansplasty inco-operated(MAGPI) -
1981
 Onlay preputial flap
 Warren Snodgras – Tubularized Incised Plate in 1994
 Bracka A – staged repair using preputial graft – 1995

6. EMBRYOLOGY
 Differentiation of the undifferentiated external genitalia
into the male pattern starts at 8 weeks
 Urethralization starts proximal and advances distally (9-16
weeks)
 At 12 weeks, coronal sulcus is seen
 At 16 weeks, glanular urethra via endodermal cellular
differentiation

7. Embryology
 Prepuce forms as ridge of skin
from corona
 Hypospadias
 Failure of ventral aspect to form
 Dorsal hood
 Chordee
 Differential growth between
normally developed dorsal tissue
and underdeveloped ventral
corporal tissue
 Fibrous tissue distal to
hypospadiac meatus

8. AETIOLOGICAL FACTORS
 Cause is yet unknown in the vast majority of patients
 GENETIC MUTATIONS
 Testosterone-dependent sonic hegdehog
 Homeobox A (A9, A10, A11 and A13– hand-foot-genital syndrome)
and D
 FGF 10
 ATF3
 and MAMLD1 (Cxorf6)
 ENZYME DEFICIENCIES
 5α- reductase
 3a-hydroxysteroid dehydrogenase, 17a-hydroxylase, and 17,20-
lyase

9.  HORMONES
 Extrinsic: preconceptual oestrogens and progesterones in
pills, artificial reproductive techniques(ART)
 Intrinsic: steroid secreting tumours, obesity
 ENVIRONMENTAL
 Endocrine disruptors: Biphenol A, polyesters,vinyl
 Canned foods, plastics, herbicides and pesticides
 BPAs better transported in microwaved foods, hand
washes…
 Vegetarian mothers
 Phytoestrogens especially from soya
 Herbicides and pesticides
 Birth weight: noticed more in small for gestational age babies

10. Classification

12. Hypospadia

13. PRE-OPERATIVE CARE
Investigations
 FBC
 Serum electrolyes, urea and creatinine
 Urine MCS
 Children with proximal hypospadias and UDT should be
evaluated for DSD
 Serum biochemistry
 Karyotype
 Gonadal biopsy
 Urethrocystoscopy/laparoscopy

14.  PARENTAL COUNSELING AND CONSENT
 DO NOT CIRCUMCISE
 To operate or not (cosmesis)
 To circumcise or not to (preputial flaps,
grafts)
 Operative technique is subject to
intraoperative findings
 May need staged repair
 Diversion or not- SPC

15. Algorithm proposed by EAU

16. Goals
 good calibre urethra with a slit-like urethral
meatus at the tip of the glans and a straight
penis
 Boys with hypospadias should grow up as self-
confident young men with a normal body image.
 Voiding and sexual activity should not be
impaired by hypospadias or its corrective
procedure

17. PRINCIPLES
 Timing
 Good illumination
 Magnification – loupes/microscopes
 Atraumatic fine sutures
 Hemostasis: Tourniquets, diathermy and adrenalin
 Fine/microsurgical instruments
 Tissue handling with minimal trauma

18. COMPONENTS OF REPAIR
 Orthoplasty
 Urethroplasty
 Glanoplasty
 Meatoplasty
 Skin cover

19. Urethroplasty
Urethral advancement
Tubularizing the urethral plate
Vascularized pedicled flap
Two stage free flap repair

20. SNODGRASS’ TIP
-Tubularised incised Plate

21. MATHIEU’S –Flip flap

22. Island
Onlay

23. Staged repair using graft
•Buccal mucosal graft
•Post-auricular graft
•Buccal mucosal graft

24. Technical Aspects/Postoperative
care
 Magnification
 Dressing
 Immobilzation and prevention of hematoma
and edema
 Bladder spasms
 Oxybutinin
 Analgesia
 Local penile block
 Caudal block
 Diversions

25. Factors for Technical Success
 Use of vascularized tissues
 Careful tissue handling
 Tension-free anastomosis
 Non-overlapping suture lines
 Meticulous hemostasis
 Fine suture material
 Adequate urinary diversion

26. OUTCOME
 IMMEDIATE
 Complication rates below 10%
 haematoma, dehiscence, fistula, meatal
stenosis, recurrent chordee
 Depend of degree /location of meatus

27. Complication
 Fistula
 Wound dehiscence
 Urethrocutaneous fistula
 Meatal stenosis
 Urethral diverticulum
 Residual chordee

28. Conclusions
 Common
 Genetic component exists
 Evaluation for associated anomolies with
severe proximal hypospadias
 Rule out intersex, especially with
cryptorchidism
 Multiple repairs exist, tailor to the patient,
anatomy, and previous repairs