HYPOSPADIAS

1. Hypospadias
Raghu Nath Karmaker , MBBS , MS ( Paediatric surgery )
Defination : External urethral meatus on ventral surface of penis or perineum rather than
its normal position at tip of glans .
Classify as -
Distal variety (Mild 65-70% ) – Glanular , coronal/subcoronal , Distal penile shaft .
Midshaft (moderate 10-15%) –Middle third of penile shaft
Proximal ( severe 20% cases ) – Proximal third of penile shaft to perineum .
Penoscrotal , scrotal , perineal .
Associated anomalies – UDT
HERNIA
Upper urinary tract anomalies
Imperforate anus
Myelomeningocele , Club foot
Ebryology :
Prostatic urethra above ejaculatory duct – Vesicourethral canal
Prostatic urethra below ejaculatory duct, membranous urethra , bulbar urethra -
pelvic part of definitive urogenital sinus.
Penile urethra – phallic part of definitive urogenital sinus
Terminal part - ectoderm of surface epithelium of glans penis .( ectodermal and
endodermal component unit known as navicular fossa )
Connective tissue and smooth muscle – splanchnic mesoderm .

2. Embryological background of hypospadias – 6th
week of gestation genital
tubercle formed anterior to urogenital sinus and next week two genital folds form
and urethral plate ( ectopic rest of urethra ) develops between them under the
influence of testosterone from fetal testes at 8th
week . while failure of fusion of
two genital fold( urethral fold ) develop hypospadias . failure of canalization of
ectodermal cord cells in glans develop glandular hypospadias . (germ layer theory
,failure of fusion theory )
Cause : unknown etiology
Defect in androgen stimulation
Failure of testosterone convert dihydrotestosterone
Diminished response to HCG
Environmental and genetic cause
Incidence : 1 in 125 live male birth
Anatomical defects :
External urethral meatus on ventral surface of penis(1)
Meatus is adequate or stenosed [4]
Urethral plate is fibrosed or normal or thin
Glans is splayed out /flattened
Perimeatal skin normal / excoriated
Proximal urethra is well developed or not .
Prepucial skin is deficit on ventral surface redundant on dorsal surface (2)
Dorsal hooding
Chordae present ( mild /moderate / severe )[ 3]
Scrotum , testes , hernia orifice

3. Rotational deformity [5]
Importance of urethral plate :
More than 8mm - BMG inlay graft , less than 8 mm – TIP
Treatment : there are 5 basic phase for a successful hypospadias correction
1. Orthoplasty ( straightening ) chordae correction .
2. Urethroplasty
3. Glanduloplasty
4. Meatoplasty
5. Scrotoplasty and skin coverage
Timing of operation - ( 6- 12/15/18 month )
Objective of repair :
1. Complete straightening of the penis
2. Meatus at the tip of glans
3. Forming a symmetric conical shaped glans
4. Constructing neourethra uniform in caliber
5. Completing a satisfactory cosmetic skin coverage( cosmesis )
Aim : functionally and cosmetically as normal as possible
Requirement of hypospadias operation correction / Technical perspectives :
1. Use magnifying glass ( loop )
2. No use of tourniquet ( at a time not more than 30 minutes )
3. No use of adrenaline
4. Use of bipolar diathermy
5. Suture and instruments
6. Urinary diversion
7. Dressing
8. Analgesia

4. Investigation :
urine R/M/E , C/S
USG KUB – Other anomaly
Preoperative – CBC , Createnine , CXR
BT , PT , APTT
MCU , IVU
Operative approaches :
Distal variants –
MAGPI
GAP ( Glans approximation procedure )
PRIMARY TUBULIRAZATION
The Mathieu or Flip Flap
Duplay or primary tubulirazation with the incision of urethral plate when the
plate is too small for primary closure ( Snodgrass modification )
TIP – tubular incised plate
ASOPA Technique
Middle hypospadias : Matheiu , Horton devine , mastarde
Proximal variants :
Onlay island , ASOPA, Duckett
Two stage ( foreskin amount ) Byars techniques
Bracka two stage buccal graft
Multi stage – Denis brown

5. Complications :
1. Bleeding
2. Infection
3. Devitalized skin flaps
4. Urethrocutaneous fistula , failed urethroplasty
5. Stricture
6. Diverticulum
7. Retrusive meatus ( retraction of meatus from its normal position )
8. Persistent chordae
9. Multiple failed repair
10.Sexual function – erectile , ejaculation , fertility function
Chordee is related to –
1]The tethering of the ventral hypoplastic skin onto the underlying structure
[urethra]
2]The fan shaped lateral and upward extension of the devided corpus
spongiosum
3]Tethering of urethral plate and hypoplastic distal urethra on to corporeal
surface
4]Asymmetric development of the corpora cavernosa .
Hypospadias sans hypospadias :
External urethral meatus is situated at or near glans but there is marked chordee
it may be due to following reasons :
1]Deficiency of corpora spongiosum distal urethra
2]Abnormality of the bucks or dartos layer of penis
3]Tethering of the skin on the ventral surface of the penis.

6. Chordee correction : called orthoplasty
1] Heineke – mikulicz technique : several transverse incision in the tunica
(degloving )
2] Tunica albuginea plication ( baskin and duckett)/nestbit procedure by prolene
suture(nest bit procedure) .
3] Dermal graft ( Devine and Horton ) : corporal defect .(urethral transection )
DR. RAGHU NATH KARMAKER , MBBS , MS PHASE B RESIDENT , MMCH.