2. Hypospadias is defined as hypoplasia of the tissues forming
the ventral aspect of the penis beyond the division of the
corpus spongiosum.
Hypospadias is believed to result from arrested penile
development, leaving a proximal urethral meatus.
3. Incidence- 1/250 male newborns .
Association of 3 anomalies
Abnormal ventral opening of urethral meatus
Abnormal ventral curvature of the penis
Abnormal distribution of foreskin with a dorsal hood
4. Hypospadias is diagnosed by physical examination,first
suspected by the ventrally deficient prepuce and confirmed
by the proximal meatus .
Other abnormal findings include :
:downward glans tilt : deviation of the median penile raphe,
:VC : scrotal encroachment onto the penile shaft midline
: scrotal cleft : penoscrotal transposition
5. Genetic Factors –
Familial aggregation is found in 4% to 10% of hypospadias
cases, including first-, second-, and third degree relatives.
Gene Mutations - Murine studies indicating androgen
receptor activity regulates Fgf8, Fgf10, and Fgfr2 involved in
urethral development have led to screening for defects in
these candidate genes in patients with hypospadias.
6. In most cases, the cause of this congenital defect is not fully understood.
Treatment with hormones such as progesterone during pregnancy may
increase the risk of hypospadias.
Certain hormonal fluctuations, such as failure of the fetal testes to produce
enough testosterone or the failure of the body to respond to testosterone,
increase the risk of hypospadias and other genetic problems.
10. Anatomic classification of hypospadias recognizes the level of the meatus
without taking into account curvature.
A more recent classification was described.This classification indicates the
-siteof urethral meatus (before and afterchordee correction)
- the prepuce(incompleteor complete)
-theglans(cleft, incomplete cleft or flat)
- the widthof urethral plate, the degreeof penile rotationif present
and the presenceof scrotal transposition
11.
12. Functional indications:
1. Proximally located meatus
2.Ventrally deflected urinary stream
3. Meatal stenosis
4. Curved penis.
The cosmetic indications
which are strongly linked patient’s future psychology, are:
1. Abnormally located meatus
2. Cleft glans
3. Rotated penis with abnormal cutaneous raphe
4. Preputial hood 5. Penoscrotal transposition 6. Split scrotum.
13. Timing of surgery:
Recent studies showed that the ideal time for hypospadias correction is between 3 and 15
months as the penis grows less than 1 cm during the first 3 - 4 years
14. • Healing seems to occur more quickly and with fewer scars,
and young infants overcome the stress of surgery more
easily.
•This age seems to insulate most children form the
psychologic, physiologic, and anaesthetic trauma associated
with hypospadias surgery.
15. HCG 250-500 U sc twice a week for 3 weeks.
Increase in penile size and length
Decrease in hypospadias and chordee severity
Increased vascularity and thickness of corpus spongiosum
Allowance of more simple repairs
IM testosterone enanthate – 2mg/kg/dose given for a total
of 2
or 3 doses before hypospadias repair
Testosterone propionate cream – 2% three times daily for 3
weeks
c
x
x
x
a
Preoperative Hormonal Stimulation
18. Preoperative assessment cannot accurately predict either the extent of curvature or the means
required for straightening
Curvature up to 30 degrees can be corrected by midline dorsal plication into the tunica
albuginea of the corpora cavernosa directly opposite the area of greatest bending
19. VC greater than 30 degrees
-Multiple plications using 5-0 to 4-0 polypropylene, loss of penile
length increase when more than one plication is performed .
-Ventral lengthening traditionally involves transection of the
urethral plate followed by transverse incision from the 3- to 9-
o’clock position into the tunica albuginea to expose erectile tissues
of the corpora in the region of greatest curvature.
20. -The resultant defect has been closed using
dermal grafts, small intestine submucosa, or
tunica vaginalis flaps or grafts.
21. - VC that persists despite mobilization of the
urethral plate and urethra requires urethral
plate transection for straightening.
22.
23.
24. Although the penile repairs can be grouped into 8 major principles,
depending on the tissues used
Basic principles or tissues:
1) mobilisation of the urethra
2) skin distal to the meatus
3) skin proximal to the meatus
4) preputial skin
5) combined prepuce and skin proximal the meatus
6) scrotal skin
7) dorsal penile skin
8) different grafts.
25. In a consecutive series of boys with midshaft hypospadias
none hadVC greater than 30 degrees, indicating the urethral
plate can be maintained for urethroplasty in most cases
(Snodgrass andYucel, 2007).
Accordingly, options for repair include:-
TIP repair
preputial
flap
26. TheTubularized Incised Plate repair (Snodgrass 1994) is based on the assumption that
midline incision into the urethral plate may widen it sufficiently for urethroplasty
without stricture
There are two important criteria to achieve good results:
-the urethral plate should not be less than 1 cm wide .
- there should be no distal deep chordee.
The technique has gained popularity because it is easily performed, with few
complications and results in a slit like meatus.
27. A 5–0 polypropylene suture is place into the glans for traction and to
later secure the urethral stent.
When circumcision is the desired result care is taken to preserve
sufficient inner prepuce
Then the penis is degloved to near the penoscrotal junction.
If the foreskin is to be reconstructed the skin incision extends from the
corners of the dorsal preputial hood to 2 mm proximal to the meatus.
Ventral shaft skin is released until normal dartos tissues are encountered.
An artificial erection confirms the absence of ventral curvature, but if
there is significant bending a midline dorsal plication is done using a
single 6–0 polydioxanone suture placed in the tunica albuginea of the
corpora cavernosa directly opposite the point of maximum curvature
28. Next, longitudinal incisions are made along the
visible junction of the glans wings to the urethral
plate.
Proposed lines for incision are first infiltrated with
1 : 100 000 noradrenaline or a tourniquet is used
around the base of the penis for haemostasis.
After making the skin incision, complete the
dissection and glans wings mobilization using
tenotomy scissors,.
29. The key step in the procedure is midline incision of the urethral
plate.
The relaxing incision is made from within the meatus to the tip of the
urethral plate. It should not be carried further distally into the glans.
The depth of incision depends upon whether the plate is grooved or
relatively flat, but in all cases extends down to near the corpora
cavernosa.
Figure c: A 6 F Silastic stent is passed into the bladder and secured to
the glans traction suture. Then the urethral plate is tubularized
beginning at the neomeatus, using 7–0 polyglactin suture.
The first suture is placed through the epithelium at a point just distal to
the mid glans so that the meatus has an oval, not rounded,
configuration.
Tubularization is completed with a running two-layer subepithelial
closure, turning all epithelium into the neourethral lumen.
30. A dartos pedicle flap is dissected from the
preputial hood and dorsal shaft skin in patients
undergoing circumcision.
Then button-holed and transposed ventrally to
cover the entire neourethra.
When the foreskin is reconstructed this layer is
not accessible.
31. Glansplasty is a key determinant of the final
cosmetic outcome.
Begins with a 7–0 polyglactin suture through
the epithelium at the desired point for the
ventral lip of the meatus. A second 7–0 suture
is placed subepithelially in this same location to
further buttress the neomeatus
No attempt is made to secure the glans to the
underlying neourethra.
The remainder of glans approximation is then
done using interrupted 6–0 polyglactin
subepithelial sutures proximally to the corona.
32. Skin closures also use subepithelial 7–0 polyglactin
sutures to minimize the risk of suture tracks.
During circumcision the dorsal hood is incised down
the midline to the level of the subcoronal collar of the
inner prepuce.
ventral shaft skin is approximated up the midline,
simulating the normal median raphe.
When the foreskin is reconstructed the inner prepuce
is first closed with interrupted sutures, then dartos is
approximated, and finally the outer shaft skin is sewn,
giving a three-layer closure.
33. Onlay Island Flap
The Onlay Island Flap is ideal for patients with
proximal hypospadias without deep Chordee.
34. The tip of the neo-meatus is identified.
A midline vertical incision is made in the glans until the width of the glanular
groove is adequate for the meatus.
The vertical incision is left open without closure for secondary
epithelialisation.
A subcoronal incision is made around the glans.The incision continues on
either side of the urethral plate at the junction with the normal ventral skin,
then up on either side of the glanular groove to the apex of the glansplasty.
The skin is degloved from distal to proximal close to the Buck's fascia
preserving the arteries that constitute the pedicle to the preputial flap.
35. The pedicle is then separated from the outer
preputial skin in a plane just below the intrinsic
blood supply of the outer prepuce.
A 1-cm wide onlay flap is prepared from the
inner prepuce.The onlay flap is sutured into
place beginning with the suture line
underneath the pedicle utilizing running 7-0
polyglactin suture.
The glans should be drawn together setting up
the first stitch of the glansplasty ventrally at
its apex.The mobilized glans wings are
rotated medially around the neo-urethra.
Three transverse mattress sutures maintain
firm approximation of the glanular wings in
the midline.
36.
37.
38. The goal of hypospadias repair is to improve function and
appearance as near to normal as possible.
Therefore, success requires more than straightening
curvature and extending the urethra to the glans.
cosmetic results are as important as functional outcomes
39. Urethrocutaneous fistulas are the most common complication.
-overlapping suture lines from urethroplasty and skin closure
potentially increase likelihood for fistulas
-other factors such as larger suture size (4-0) and different
suture materials (catgut, horsehair)
40. Technical steps thought to reduce fistula risk include two-layer
subepithelial closure of the neourethra and subsequent coverage
with a barrier flap, usually dartos.
Fistulas occasionally close spontaneously, and there are anecdotal
reports that fibrin glue can promote closure.
The majority require reoperation
41. Obstructive narrowing at the neomeatus can result from technical error, ischemia, or balanitis
xerotica obliterans (BXO).
Tubularization of the urethral plate too far distally is most likely the main cause for meatal
stenosis afterTIP repair.
plate should not be tubularized beyond approximately the mid-glans point, leaving an oval
terminal opening. Mistaken belief that the glans wings must be sutured to the neourethra
probably has caused some to extend plate tubularization too far distally to approximate the
wings without leaving a glanular hypospadias.
42. Strictures of the neourethra, like meatal stenosis, may indicate technical
error, ischemia, or BXO.
The most common site for neourethral strictures is at the proximal
anastomosis of the neourethra to native urethra inflap and graft repairs.
Circumferential anastomoses have been considered at greater risk for
stricture.
43. Partial or complete wound separation results
in recurrent hypospadias.
Causes potentially include technical factors
(suture materials and/or technique during
glansplasty), glans size, traumatic catheter
displacement, or wound infection.
44. Ballooning of the neourethra during voiding with subsequent
postvoid dribbling indicates diverticulum formation.
Contributing factors include distal obstruction, turbulent urinary
flow, and ability of tissues used for urethroplasty to expand.
Accordingly, diverticula are most often noted after tubularized
preputial flap repairs and are rarely encountered after
tubularization of the urethral plate or buccal grafts.
45. Late development of meatal stenosis or neourethral stricture can indicate BXO.
A characteristic white appearance to involved tissues.
Development of obstruction several years after apparently successful
urethroplasty.
The importance of recognizing BXO is that repair requires excision of all involved
tissues and their replacement with nonskin tissues, usually buccal
mucosa,because reoperation using skin results in high recurrence rates.
