HYPOSPADIAS

HYPOSPADIAS
BY Dr SHIVRAJ SHARMA
2ND YEAR RESIDENT
DEPT OF PEDIATRIC SURGERY,NMCTH

• Definition : An abnormal ventral opening of urethral meatus located
anywhere from the ventral aspect of glans penis to perineum.
• Due to arrested penile development
• always associated with
 An abnormal ventral curvature of penis (chordee)
 An abnormal distribution of foreskin with a hood present dorsally and
deficient foreskin ventrally

Embryology
Two embryonic structures play an important part in the development of
urogenital system:
• Intermediate mesoderm
• Cloaca
Cloaca has two parts separated by urorectal septum:
• Dorsal: primitive rectum
• Ventral: primitive urogenital sinus (UGS)

Primitive urogenital sinus : 2 parts
 Cranial : vesico uretheral part
 Caudal : definative urogenital sinus
At the junction of these lies the opening of mesonephric duct
Definitive urogenital sinus : 2 parts
 Cranial : pelvic
 Caudal : phallic

Development of male external genitalia
• With formation of urorectal septum, coacal memb divides into urogenital
memb and caudal anal memb
• Urogenital memb elongates longitudinally
• On its both sides, mesoderm heaps up to form 2 longitudinal elevations
called primitive urethral folds, and 3 other elevations: genital tubercle, rt.
& lt. genital swellings
• Genital tubercle becomes cylindrical and enlarges greatly to form penis
• By epithelial ingrowth, glans is formed and then coronal sulcus appears
• Prepuce is formed by the reduplication of ectoderm, covering the distal
part of phallus

Development of urethra

• Proposed by Glenister in 1954
• Urogenital memb lies in a linear groove
• On its either sides are primitive urethral folds
• Groove elongates with the phallus and extends on its undersurface, lined
by ectoderm Called primitve urethral groove (PUG)
• At 10 mm stage, (4th week) thickening of anterior wall of endodermal
cloaca
• Solid mass of endodermal cells derived from the UGS extends into the
phallus Called urethral plate
• PUG is now fully formed . Urethral plate has now enlarged and extends
deeper in the phallus

• Urogenital memb has broken down so that endoderm of caudal part of
UGS is seen from outside
• Degeneration of core cells of urethral plate leads to deeper groove k/a
definitive urethral groove. Its margins are k/a definitive urethral folds
• At 11th week, 50 mm stage, Leydig cells of testis increase in no., size, and
function and under the effect of androgens the definitive urethral folds
grow towards each other and fuse to form a median raphe
• In this way DUG is converted into a tube which is urethra

• A pre-requisite of urethral fold fusion is the canalisation of the solid
urethral plate
• formation of urethral groove bounded on each sides by the urethral folds
• If any of the above is abnormal, urethral fold fusion is likely to be
impaired.
• The fusion starts caudally and progresses cranially
• This extends only upto glans penis.

• The elongating phallus is covered externally by the ectoderm that gives
rise to te penile skin
• Most of the penis is derived from the mesodermal cells forming the
corporal bodies,connnective tissue and dermis
• Corporal tissue is first recognised as distinct dense mesenchymal
condensations within the shaft of the developing penis.

• At 40 mm stage, preputial tissue did not uniformly surround the phallus in
the form of a circle but in the form of an oblique orientation, radiating out
on either side of phallus from the point of urethral opening
• The urethral opening is placed well back on the ventral surface of the
phallus
• Preputial tissue appears as a hood dorsally and gradually become less well
marked ventrally as it approaches the meatus
• Complete covering of the glans occurs at 130 mmm stage or 20th week of
development

Anatomy of penis
 Five layers of tissue cover the penis:
• Penile skin
• Superficial layer of penile fascia (Dartos fascia)
• Tela subfascialis
• Deep layer of penile fascia (BUCK’S fascia)
• Tunica albuginea
 Two Ligaments
• Superficial fundiform ligament
• Suspensary ligament proper

Penile skin
 Properties
• Movable
• Expandable
• Adaptable to urinary contact
 Advantageous for urethral tube reconstruction b/c it is:
• Available
• Vascular
• Distensible

Penis : arterial and venous supply

• Incidence: 1: 300 males
• Risk is 13 fold in 1st degree relatives
• 8% patients have father with hypospadias, 14% have male siblings with
hypospadias
• Risk of hypospadias in next child, when one child is affected with
hypospadias:
• 12% with negative family history
• 19% if cousin or uncle has hypospadias
• 26% if father or sibling has hypospadias
• 8.5 times more risk in monozygotic twins

Other risk factors:
• Placental dysfunction
• Low birth weight
• Preterm birth
• Pre-pregnancy maternal obesity
• Extremes of maternal age ( <24 and >40)
• Assistive Reproductive techniques

ASSOCIATED ANOMALIES
• Undescended testes- 9%
• Inguinal hernias- 9%
• Upper urinary tract anomalies 1-3%
• Utriculus masculinus- Incomplete mullerian duct regression
• Cryptorchidism- intersexuality needs to be ruled out especially in cases of
non palpable testis

Clinical findings
• c/o difficulty directing the urinary stream and stream spraying
• Chordee
• Perineal or penoscrotal hypospadiasis necessitates voiding in sitting
position
• Proximal forms of hypospadiasis results in infertility in adults
• Abnormal hooded apperance of penis
• Associated undescended testicles

Investigations
• Diagnosis is clinical .
• Imaging is not required in cases of isolated hypospasdias, regardless of
surgery
• In penoscrotal and perneal hypospadias , pt often present with bifid scrotum
and ambiguous genitalia : buccal smear and karyotyping are indicated to
help establish genetic sex.
• urethroscopy and cystoscopy will aid in evaluating development of internal
reproductive organs.

Treatment
HISTORICAL DESCRIPTION
• Carl thiersch,1869 and Duplay 1880 described use of
buried skin tube as neo urethra
• Sir Denis Browne 1950, popularised this procedure
,still used as two stage procedure
BURIED
SKIN TUBE
• Ombredanne 1932,suggested making
circular flap with hypospadic meatus at its
centre
Perimeata
l flaps
• Nove Josserand 1897 and later Mcindoe : produce
urethra by an inlay free graft of penile tunnel
• Devine and Hortan elaborated technique
Inlay free
graft

• Bucknall , formation of tube fom penile and scrotal skin and
burying the penis1907
• Broadbent 1951 used full thickness oblique strip of skin
from prepuce and penile skin
Single
stage
operation
• Byars ; first successful two stage repair
• First stage : chordee correction and redistribution of dorsal penile skin onto
ventrum
• Second stage : neourethra formed using ventral penile skin
Two stage
repair

Present day concept of hypospadias repair
Goal :
 to produce a straight penis and the external urinary meatus at the tip of
conicl glans
 To provide symmetrical skin cover with minimal ,short and long term
compication
The procedure is preferably performed in one stage as a day case and at the
young age.
Earlier till 60s, it was generally argued that cosmetic considerations are
secondary and are more concern of the parents of child and chordee
corrected by staged procedure
18 months onwards before school going is ideal time
•

Common operative techniques
 MAGPI ( Meatal Advancement and Glanuloplasty)
 Tubularised incised urethral plate
 Dorsal free graft Inlay
 Onlay transverse preputial skin patch
 Two stage repair

Meatal Advancement And Glanuloplasty (MAGPI)
• IDEAL patient : glanular hupospadias with a flat or convex glans and thick
and healthy skin proximal to meatus without chordee
• It can be contemplated in pts with coronal hypospadias without or with
very mild chordee which can be corrected by dorsal plication or in pts who
have retrussive meatus after previous surgery.
• Should be avoided in pts with subcoronal or more proximal hypospadias
with wide meatus or concave or grooved glans with considerable chordee

• A circumcoronal icision is given and chordee is excluded by artificial
erection.
• A vertical incision is given in dorsal plate of glans distal to meatus and the
glanular plate is mobilised starting from the meatus to the proposed site at
tip.
• Vertical incision closed by two or three transverse sutures of 6/0
absorbable.
• Glans is carefully undermined on both sides of distal urethra between
tunica and glans tissue after dividing fanned out spongiosa to expose the
tunica underneath.

• The dissection in the midline must be careful and fairly superficial so as to
avoid injury to underlying urethra
• Glans wings are approximated by two or three vicryl 6/0 sutures after
excising redundant free margin with compromising the lumen of urethra
• Skin cover is provided after excising the redundant skin andgiving oblique
cut dorsally if required
• Skin sutures by 6/0 chromic catgut,preferably subcuticular
• 6fr catheter is introduced and light pressure dressing applied.

Tubularised Incised Urethral Plate (TIP) :SNODGRASS
• Best suited for pts of distal penile hypospadias with a wide concave (wide
groove) ,wide meatus, healthy thick urethral plate ,healthy skin/mucosa
ventrally proximal to meatus and without chordee.
• Can be done in pts having minimal chordee , corrected by dorsal plication
• Avoided in those with more proximal hypospadias with flat glans ,narrow
urethral plate , moderate chordee and when skin proximal to thin and
attenuated.

• Penis is degloved by a circumcoronal incision incorporating meatus.
• Absence of chordee assesed by artificial eerection
• Urethral plate is incised dorsally in midline from meatus to tip of glans
penis
• Glans wings are raised on either side of urethral plate upto midglans level
only
• Tubularisation on a catheter is performed by a continous suture of 6/0
chroic catgut
• Redundant and thinned out margins of penile skin are excised and dorsal
oblique cut is given on outer preputial skin
• Skin closure ad catheter is secured.

A DORSAL FREE GRAFT ON INCISED URETHRAL
PLATE
• Pts with distal penile hypospadias with a flat glans and a narow but healthy
urethral plate
• Meatus narrow or wide ,with no chordee
• Also performed for those with proximal hypospadias with above criteria
and minimal chordee.
• Procedure similar to Snodgrass except that after incising the urethral plate ,
two half of the plate are mobilised partially from underneath the tunica and
anchored to tunica.
• The raw are between two halves of urethral plate is coered with an inlay
dorsal free graft.

Onlay transverse preputial skin patch
• Can be applied to pts who have narrow urethral plate from distal penile
meatus to proximal penile meatus and with attenuated ventral skin.
• Glans may be flat or convex and there is no chordee

The two stage repair of hypospadias
• The two stage repair is suitable for patients with marked chordee and
meatus suited far proximally.
• Also suitable if there is no or adequate prepuce or if there is preference of
the surgeon.
• FIRST STAGE
 A circumcoronal incision ,circumscribing the external urethral opening is
applied leaving 5 to 6mm corona
 Degloving is done and chordee correction is done.
 Glans is laid open and glans wings are raised.
 The dorsal penile skin is incised in the midline upto an appropriate level o
as to cover the degloved penis with care while not injuring the superficial
dorsal vessels.

• Suturing is started from the tip of the laid open glans to the meatus
proximally proximally by 6/0 chromic catgut and the two edges of the
covering skin lying in midline.
 SECOND STAGE
 usually done after 6 months
 Assessment is made for width of laid open glans ,the quality of the ventral
penile skin, the meatal area for stenosis or for any hair bearing area.
 After assesment ,a 14f catheter is passed.
 Two parrallel incisions are given on ventral penile skin, circumscribing the
meatus upto midglans .
 The width of ventral penile skin should ideally be equal to the calibre of
14F catheter.

 Leaving ventral penile skin strip intact ,the rest of the covering penile skin
is mobilised after leaving a cuff of 4 to 5 mm corona and degloving is
done.
 Byars cut is now given on dorsal penile skin in such a way that the covering
skin suture line will fall eccentrically.
 a tube is made of the ventral penile strip by 6/0 subcuticular chromic
catgut sutures.
 Skin suturing is provided in two layers ,inner subcuticular by 5/0 chromic
and outer skin to skin 5/0 chromic .

HYPOSPADIAS

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Editor's Notes