Management of Epispadia

1. Management of Epispadias
Regi Septian

2. Anatomy

3. Defenition
• Epispadia is an abnormality in which the
opening of the urethra is localized on the
dorsum (upper side) of the penis or clitoris.
• Seen in only 1:300.000 newborns.
• Occur in 1 in 117.000 newborns boys and 1 in
484.000 newborns girls.
• In females: Bifid Clitoris.

5. Embryology
• There is a disorder of the mesoderm cell
migration during the 4th developmental week.
• There is a defective migration of the paired
primordia of the genital tubercle that fuse on the
midline to form the genital tubercle at the fifth
week of embryologic development.
• The urethra does not develop into a full tube.
• Epispadia can occur with Exstrophy of the
bladder; in which the anterior wall of the
abdomen and bladder are absent.

7. Sign & Symptomps
• Males :
o usually have a short, wide penis with an
abnormal curve.
o Urethra usually opens on the top or side of the
penis instead on the tip, may open along the
whole length of the penis.
• Females:
o Abnormal clitoris and labia
o The opening is usually between the clitoris and
labia, but it may be in the belly area.

8. Sign & Symptomps
• Backward flow of urine into kidney (reflux
nephropathy).
• Urinary incontinence
• Urinary tract infections
• Widened pubic bones

9. Classification
• Glans → glanular
• Penile → Along the Shaft penis
• Penopubic → near the pubic bone

10. Complication
• Stress Incontinence → because the bladder neck can
not close completely, and the result is leakage of
urine.
• Urinary Tract Infections (UTIs)
• Infertile → the bladder neck may not close
completely during ejaculation → Retrograde
ejaculation.
• Difficult sexual intercourse → because of dorsal
chordae and a short, stubby penis.

11. Goal of Surgery
• Correction of dorsal chordae
• Creation of straight urethra to allow easy negotiation
during catheterization or cystoscopy.
• Satisfactory cosmetic
• Minimal complications, especially regarding
urethrocutaneous fistulas
• Maintenance of erectile function
• Creation of urinary continence

12. Management of Surgery
• Glandular epispadias → corrected with reposition of
the distal urethra and creation of a symmetric glans
(glanuloplasty) → for cosmetic or psychological
reasons.
• Penile epispadias → corrected with penile
straightening by resection of the chordae and creation
of a new urethra of adequat caliber and length
(urethroplasty).
• Penopubic epispadias → corrected to close the
abdominal wall and the bladder exstrophy.

13. Management of Surgery
• Surgical Technique in Male:
1. Modified Cantwell-Ransley Technique
o Involves partial disassembly of the penis
2. Mitchell Technique
o involves complete disassembly of the penis

14. Mitchell Technique
• Most recent evolution of the modern epispadias
repair.
• Complete disassembly of penis into its three
separate components:
o Two corpora cavernosa
o Single corpora spongiosum
• Has a lower complication rate.
• Facilitates bladder and bladder neck repair

15. Mitchell Technique
1. Initial Dissection

16. Mitchell Technique
2. Penile Disassembly

17. Mitchell Technique
2. Penile Disassembly

18. Mitchell Technique
2. Penile Disassembly

19. Mitchell Technique
3. Proximal Dissection

20. Mitchell Technique
4. Urethral Tubularization

21. Mitchell Technique

22. Mitchell Technique

23. Management of Surgery
Surgical Technique in Female:
• Genital reconstruction in girls with bladder exstrophy is
less complex compared to the reconstruction in boys.
• The urethra and vagina may be short and near the
front of the body and the clitoris is in two parts.
• If diagnosed at birth, the two parts of the clitoris can be
brought together and the urethra can be placed into
normal position.

24. Management of Surgery
Surgical Technique in Female:
• If repaired early enough: lack of urinary control
(incontinence) may not be a problem.
• If the vaginal opening is narrow in older girls or younger
women, reconstruction can be performed after
puberty.

25. Management of Surgery

26. Management of Surgery

27. Management of Surgery

28. Management of Surgery

29. Management of Surgery
• If surgery is performed within the first few months of
life, the child may have a better chance of having a
normal bladder.
• There is a reasonable increase in tha bladder capacity
after epispadias reconstruction

30. Terima Kasih