Hypospadias Surgery ,How To Avoid Complications

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Hypospadias Surgery ,How To Avoid Complications

  1. 1. HYPOSPADIAS SURGERY : How to avoid complications ? H S Asopa Asopa Hospital Agra India
  2. 2. OPERATOR <ul><li>WHO SHOULD OPERATE ? </li></ul><ul><li>Paediatric Urologist </li></ul><ul><li>Urologist </li></ul><ul><li>Plastic Surgeon </li></ul><ul><li>Paediatric Surgeon </li></ul><ul><li>Hypospadiologist </li></ul><ul><li>EXPERIENCE </li></ul><ul><li>4 – 5 Techniques </li></ul><ul><li>See many, assist many & do many </li></ul><ul><li>Then teach many </li></ul>
  3. 3. SELECTION OF PROPER TECHNIQUE <ul><li>4 – 5 Techniques and their evolution </li></ul><ul><li>Era of two stage repair </li></ul><ul><li>One stage transverse prepucial tube </li></ul><ul><li>MAGPI </li></ul><ul><li>Ventral prepucial patch </li></ul><ul><li>Tubularised incised urethral plate (Snodgrass) </li></ul>Pre operative decisions MIDWAY - after degloving <ul><ul><li>Location of meatus </li></ul></ul><ul><ul><li>Meatal Calibre </li></ul></ul><ul><ul><li>Glans configuration </li></ul></ul><ul><ul><li>Quality of ventral penile skin proximal to meatus </li></ul></ul><ul><ul><li>Presence of chordee after degloving </li></ul></ul><ul><ul><li>Prepuce </li></ul></ul><ul><ul><li>Preference/Experience of the surgeon </li></ul></ul>
  4. 4. MAGPI INDICATIONS <ul><li>Glanular or ? coronal meatus </li></ul><ul><li>Flat or convex glans </li></ul><ul><li>Narrow meatus </li></ul><ul><li>Skin and mucosa proximal to meatus thick </li></ul><ul><li>& healthy </li></ul><ul><li>No chordee or mild chordee to be corrected </li></ul><ul><li>by dorsal plication </li></ul>Less than 10% of all cases Special precautions <ul><li>Raising glans flap / Excision of glans margins </li></ul>Avoid <ul><li>Wide Meatus </li></ul><ul><li>Sub coronal / concave glans </li></ul>
  5. 5. PRESERVATION & UTILISATION OF URETHRAL PLATE <ul><li>T.I.P (Snodgrass) </li></ul><ul><li>Dorsal free graft </li></ul><ul><li>Onlay transverse prepucial patch </li></ul><ul><li>Perimeatal flap </li></ul>Considerations <ul><li>No chordee or mild chordee </li></ul><ul><li>Configuration of glans </li></ul><ul><li>Calibre of meatus and urethra </li></ul><ul><li>Skin proximal to meatus </li></ul><ul><li>Condition of urethral plate </li></ul><ul><li>Presence or absence of prepuce </li></ul>
  6. 6. INCISED URETHRAL PLATE TUBULARISATION - Snodgrass <ul><li>Concave glans </li></ul><ul><li>Wide Meatus </li></ul><ul><li>Skin & ventral mucosa proximal </li></ul><ul><li>to meatus healthy </li></ul><ul><li>No chordee or minimal chordee </li></ul><ul><li>Healthy thick urethral plate </li></ul>Best results in <ul><li>Distal penile meatus </li></ul>Precautions <ul><li>Lateral incisions only upto mid glans </li></ul>
  7. 7. DORSAL FREE GRAFT ON INCISED URETHRAL PLATE <ul><li>Flat glans </li></ul><ul><li>Narrow urethral plate </li></ul><ul><li>Meatus narrow or wide </li></ul><ul><li>No chordee or minimal chordee </li></ul>Indications
  8. 8. ONLAY TRANSEVERSE PREPUCIAL PATCH <ul><li>No chordee or minimal chordee </li></ul><ul><li>Narrow urethral plate </li></ul><ul><li>Narrow meatus </li></ul><ul><li>Glans flat or conical </li></ul><ul><li>Attenuated ventral mucosa or distal urethra </li></ul>
  9. 9. TRANSVERSE PREPUCIAL SKIN TUBE <ul><li>Considerable chordee </li></ul><ul><li>Conical glans – Glans tunnel </li></ul><ul><li>Flat or shallow glans - Glans wings </li></ul><ul><li>Good adequate prepuce </li></ul><ul><li>Young patients </li></ul><ul><li>Upto penoscrotal level </li></ul>Flap - Asopa Island flap - Duckett
  10. 10. TWO STAGE <ul><li>Byars </li></ul><ul><li>Free graft - Prepuce </li></ul><ul><li>- Buccal mucosa </li></ul>Indications Special considerations <ul><li>Chordee ++ </li></ul><ul><li>Meatus scrotal or perineal </li></ul><ul><li>Inadequate prepuce </li></ul><ul><li>Preference of surgeon </li></ul><ul><li>Lay open glans </li></ul><ul><li>Start suture line from glans to </li></ul><ul><li>meatus </li></ul><ul><li>Smooth ventral skin </li></ul><ul><li>Excise hair bearing skin around </li></ul><ul><li>meatus </li></ul>
  11. 11. GENERAL CONSIDERATIONS <ul><li>Vascularity </li></ul><ul><li>Flap - Island </li></ul><ul><li>- Skin based dorsal flaps </li></ul><ul><li>- flaps </li></ul><ul><li>Free Grafts - Dorsal Lateral </li></ul><ul><li>- Ventral </li></ul><ul><li>- Tube - Unreliable </li></ul><ul><li>Minimal tissue damage </li></ul><ul><ul><ul><ul><li>- Thumb and forefinger </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- Skin hooks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- Stay sutures </li></ul></ul></ul></ul>Correct tissue planes - start proximally
  12. 12. GENERAL CONSIDERATIONS Contd… <ul><li>Cover ventral suture line </li></ul><ul><li>- Dartos </li></ul><ul><li>- Tunica </li></ul><ul><li>- Spongiosa </li></ul><ul><li>Eccentric suture line of skin cover </li></ul>
  13. 13. GENERAL CONSIDERATIONS Contd… <ul><li>Sutures </li></ul><ul><ul><ul><li>- Fine ( 6/0, 7/0 ) absorbable </li></ul></ul></ul><ul><ul><ul><li>- Chromic catgut - through mucosa and skin </li></ul></ul></ul><ul><ul><ul><li>- Vicryl - for glans and spongiosa </li></ul></ul></ul><ul><li>Inversion of mucosa & skin </li></ul><ul><li>Subcuticular whenever possible </li></ul><ul><li>Avoid tension - Scrotal flaps </li></ul><ul><li>Two layers </li></ul><ul><li>Distance between sutures </li></ul>
  14. 14. GENERAL CONSIDERATIONS Contd… <ul><li>Local antibiotics </li></ul><ul><li>Systemic antibiotics </li></ul><ul><li>Haemostasis </li></ul><ul><ul><li>- Minimal and precise cautery </li></ul></ul><ul><ul><li>- Adrenaline </li></ul></ul><ul><ul><li>- Tourniquet </li></ul></ul><ul><ul><li>- Circular dressings </li></ul></ul><ul><li>Catheter </li></ul><ul><ul><ul><li>- 6 Fr Protex or Poly vinyl chloride (PVC) </li></ul></ul></ul><ul><ul><ul><li>- Polyurethane </li></ul></ul></ul><ul><ul><ul><li>- Silastic </li></ul></ul></ul><ul><li>Diversion </li></ul>
  15. 15. GENERAL CONSIDERATIONS Contd… <ul><li>Magnification </li></ul><ul><li>- Operating microscope </li></ul><ul><li>- Loupes </li></ul><ul><li>Pre operative hormones </li></ul><ul><li>Scrotal bury </li></ul>
  16. 16. CHECKLIST <ul><ul><li>Meatus Calibre </li></ul></ul><ul><ul><li>Site </li></ul></ul><ul><ul><li>After chordee correction </li></ul></ul><ul><ul><li>Proximal skin mucosa </li></ul></ul><ul><ul><li>Glans Conical </li></ul></ul><ul><ul><li>Flat </li></ul></ul><ul><ul><li>Concave </li></ul></ul><ul><ul><li>Size </li></ul></ul><ul><ul><li>Urethral plate Wide / Narrow </li></ul></ul><ul><ul><li>Thick / Thin </li></ul></ul>Patients considerations
  17. 17. CHECKLIST Contd… <ul><li>Chordee - Pre Op </li></ul><ul><li>- After degloving </li></ul><ul><li>- After correction </li></ul><ul><li>Prepuce </li></ul><ul><li>Technique </li></ul><ul><li>Suture material </li></ul><ul><li>Catheter </li></ul>

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