This document discusses hypospadias, a congenital anomaly where the urethra opens on the underside of the penis instead of at the tip. It covers the embryology, risk factors, classifications, clinical features, and various surgical treatment options for hypospadias repair. The goals of treatment are to position the urethral meatus at the tip of the penis, correct any penile curvature, and provide adequate skin coverage. Complications can include meatal stenosis, fistula formation, infection, and procedure failure. Careful patient selection and appropriate surgical technique are emphasized to achieve the best outcomes.

1. Hypospadias Dr.Anil Haripriya

2. Introduction Congenital anomaly Incidence is 1 in 125 live male birth Defined as “An arrest in normal development of the urethra ,foreskin & ventral aspect of penis which result in wide range of abnormalities”

3. Embryology Formation of male external genitalia - Genetic programming - Cell differentiation - Hormonal signaling - Enzymatic activity & tissue remodeling

4. Aetiology Aberrant signaling between epithelium & mesenchyma Environmental factors - Maternal vegetarian diet & estrogen progesterone exposure during pregnancy

5. Risk factors Maternal - Maternal age - Primiparity Paternal - Abnormality of testes & scrotum - Low spermatozoa motility - Abnormal sperm morphology Fetal - Low birth Wt baby

6. Hypospadiac penile anatomy Abnormal urethral spongiosum & glans Spared of neuronal structures at 12 o’ clock Vascularity - Huge endothelium lined vascular channels filled with RBC Urethral plate is well vascularized ,rich nerve supply & extensive muscular with connective tissue backup

7. Classification

8. Clinical Features Meatal dystopia - Various configurations in terms of form, diameter, elasticity,rigidity,can be fissural in both direction Dermal defects – frenulum is always –nt, dorsal hood Penile curvature – due to deficient normal ventral penile structures Penoscrotal transposition & bifid scrotum

9. Clinical Features Associated abnormalies- - Undescended testis - Inguinal hernia - Utriculus masculinus - Urinary tract anomalies – uretropelvic junction obstruction ,severe reflux,renal agenesis,wilms tumor,pelvic kidney,crossed renal ectopia & horse shoe kidney

10. Treatment Objects of therapy- 1- Orthoplasty 2- Urethroplasty 3- Meatoplasty & Glanuloplasty 4- Scrotoplasty 5- Skin cover

11. Treatment Plan Prevention of urethral plate , skin & dartos dissection Distal Proximal Glans configuration Meatal quality & location Urethral plate width Assess curvature Dorsal plication if necessary MAGPI GAP/Pyramid Tubularization Snodgrass Assess curvature Dorsal plication if necessary Rarely resect plate Onlay Two stage Bracka two-stage buccal graft

12. “MAGPI” Indication- Glanular hypospadias with a flat or convex glans Thick & healthy skin proximal to meatus without chordee Contraindication- Coronal hypospadias with or without chordee Retrusive meatus after previous surgery More proximal hypospadias & wide meatus, concave glans

13. “MAGPI”

14. “GAP” Procedure Indication- Wide and deep glanular grooves Patulous fish mouth meatus with out curvature Procedure-

15. Pyramid procedure Indication- Megameatus with wide glanular defect without curvature Procedure-

16. “ Mathieu” or Perimeatal-based procedure Indication- Too proximal meatus to perform MAGPI No deep glanular groove Procedure -

17. “ Snodgrass” Tubularized incised plate urethroplasty Indication- Urethral groove is not wide enough for tubularization in situ Contraindication- Pt with significant curvature Flat glans ,narrow urethral plate,narrow meatus Moderate chordee Skin proximal to meatus is thin & attenuated

18. “ Snodgrass” Tubularized incised plate urethroplasty Procedure-

19. Posterior hypospadias Onlay island flap Transverse tubularized island flap Two-stage hypospadias repair Bracka two-stage buccal graft repair

20. Onlay island flap Indication-pt with narrow urethral plate,thin ventral skin, no chordee

21. Transverse tubularized island flap

22. Two-stage hypospadias repair Indication- Proximal Hypospadias with marked chordee Inadequate prepucel skin Re do surgery Procedure- -First stage - correction of chordee with or with glanuloplasty -Second stage – done after 6 mth by tubularization of neourethra & skin cover

23. Bracka two-stage buccal graft repair

24. Different tissues used for correction of hypospadias

25. Complications Meatal stenosis Fistula Infection Diverticulum Stricture Penile torsion Procedure failure

26. General considerations Testosterone stimulation- im 2mg/kg 3 dose /3wks Vascularity Minimal tissue damage & correct tissue planes Suture material & suture technique Antibiotics Analgesia – Caudal block Haemorrhage – 1:100000 epinephrine in 1% xylocaine Catheter Magnification

27. Summary Selection of patient & appropriate procedure Appropriate time 6 to 18 mth of life A terminal slit like meatus should be the goal with or without preservation of foreskin depending on parental preference Mid line dorsal plication is safe for correction of curvature Deepithelialized vascular flap should be use as a second layer for all urethroplasties Follow up at 6mth,1year,after toilet training & after puberty