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![Age for Surgery
• Healthy full term baby ≥ 3mon – daycare procedure
• Preterm baby >56 gestational weeks
• AAP – surgery to be done by 18mon – ↓ psychosexual stress
• Usual age at primary repair – 6-18mon
• Age at surgery in pre-pubertal 1° TIP repair is not a risk for
complications [LE:2b]
• 1° TIP repair complication rate – 2.5 times higher in adults [LE:2a]
• Younger the child, lesser the discomfort following repair](https://image.slidesharecdn.com/hypospadias-approach-210622035424/75/Hypospadias-clinical-approach-12-2048.jpg)
![Pre-operative Hormonal
Treatment
• Androgens (testosterone / DHT / β-hCG) increase penile
length & glans circumference [LE:1b]
• Weak evidence for local / parenteral use in –
– proximal hypospadias
– small appearing penis
– reduced glans circumference
– reduced urethral plate
• s/e – genital pigmentation, pubic hairs, ↑ erections](https://image.slidesharecdn.com/hypospadias-approach-210622035424/75/Hypospadias-clinical-approach-13-2048.jpg)
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Hypospadias - clinical approach
- 1. Approach to acase of Hypospadias Dr. Abhishek Pandey
- 2. Introduction • Greek –“hypo” – under, “spadon” – rent / fissure • Urethral opening proximal to the normal glanular location • Occurs in 1 in 300 males (0.3%) • Increase in incidence over last 25 yrs • 90% are isolated penile defects • Considered arrested development of prepuce & glans • Correction is surgical
- 3. History • Proximally locatedmeatus • Ventrally deflected or spraying urine stream • Curved penis • Split scrotum • Urine trickling & ballooning of urethra – meatal stenosis • Assessment of risk factors • Presentation at circumcision – concealed variants
- 4. Risk Factors • Genetic– – Family history – positive in 7% families (RR-13 in 1° relatives) – Endocrine disorders • Placental – – Birth weight – associated with low birth weight • Environmental – – Use of OCP after conception (a/w middle & posterior forms) – Endocrine disruptors - DES, PCBs, DDT
- 5. Examination • Asymmetrical prepucialdevelopment – dorsal hood & ventral deficiency exposing glans & proximal meatus. • Downward glans tilt • Deviation of the median penile raphe • Ventral curvature (VC) • Scrotal encroachment onto penile shaft • Midline scrotal cleft • Peno-scrotal transposition – scrotum anterior & superior
- 6. Associated abnormalities • Cryptorchidism– 10% case • Open processus vaginalis or inguinal hernia – 9-15% case • Meatal stenosis • No relation between the severity of the hypospadias and associated anomalies of the upper- or lower urinary tract • Isolated hypospadias regardless of severity – NOT an indication for Upper tract imaging
- 7. Isolated vs Syndromic Hypospadias •Syndromic Hypospadias – – WAGR syndrome – del 11p13 – Smith-Lemli-Opitz syndrome – Wolf-Hirschhorn syndrome • Suspected in patients with – – Developmental delay – Dysmorphic facies – Anorectal malformations
- 8. Isolated vs DSDwith Hypospadias • DSD suspected in Phenotypic boys with both – – Hypospadias – Undescended testis • It is an indication for Karyotyping – DSD in 25% • Most common associated DSDs – Mixed Gonadal Dysgenesis – Ovotesticular DSD • More likely if – Proximal hypospadias + Nonpalpable testes
- 9. Concealed Hypospadias • Normalprepuce concealing glanular to distal shaft meatus • Detected at circumcision • Circumcision should NOT be stopped • Megameatus with intact prepuce – deeply grooved urethral plate extending laterally under skin edge
- 10. Chordee without Hypospadias •Asymmetrical prepucial development with a normal glanular meatus • Congenital Ventral Penile Curvature • Classified as hypospadias if distal urethra is thin with deficient corpus spongiosum
- 11. Classification Distal Anterior Glanular,Subcoronal 50% Intermediate Middle Penile 30% Proximal Posterior Penoscrotal, Scrotal, Perineal 20%
- 12. Age for Surgery •Healthy full term baby ≥ 3mon – daycare procedure • Preterm baby >56 gestational weeks • AAP – surgery to be done by 18mon – ↓ psychosexual stress • Usual age at primary repair – 6-18mon • Age at surgery in pre-pubertal 1° TIP repair is not a risk for complications [LE:2b] • 1° TIP repair complication rate – 2.5 times higher in adults [LE:2a] • Younger the child, lesser the discomfort following repair
- 13. Pre-operative Hormonal Treatment • Androgens(testosterone / DHT / β-hCG) increase penile length & glans circumference [LE:1b] • Weak evidence for local / parenteral use in – – proximal hypospadias – small appearing penis – reduced glans circumference – reduced urethral plate • s/e – genital pigmentation, pubic hairs, ↑ erections
- 15. Functional indications for surgery •Proximally located (ectopic) meatus • Ventrally deflected or spraying urinary stream • Meatal stenosis • Curved penis
- 16. Cosmetic indications forsurgery • Abnormally located meatus • Cleft glans • Rotated penis with abnormal cutaneous raphe • Preputial hood • Penoscrotal transposition • Split scrotum
- 17. Ventral Curvature • Distalhypospadias – VC in 10% – <30° after degloving • Proximal hypospadias – – 50% have no or <30° VC after degloving – 50% have >30° after degloving • VC corrected in 70% by degloving & excision of chordee • Artificial erection – intra-operative corporeal hep-saline inj. • VC correction – – <30° - Dorsal plication – >30° - Ventral corporotomies with or without grafting
- 18.
- 19. Assessment of UrethralPlate • Mainstay of repair – preservation of vascularised urethral plate & its use for urethral reconstruction • Wide urethral plate – Tubularized • Narrow urethral plate – TIP • Urethral plate incision deep – inlay graft • If transected / excised for chordee correction – 2-stage repair • Urethral plate elevation / mobilization not to be combined with TIP – focal devascularisation
- 20. Postoperative Management • Anticholinergicsfor bladder spasms • No difference in outcome with / without bandages • No consensus on duration of dressing & stenting • No data indicating benefit of SPC in addition / substitute for PUC • No recommendation on medical prevention of NPTs – Ketoconazole, phenobarbitone, diazepam • Post-op antibiotics - controversial
- 21. Risk factors forcomplications • Proximal meatus • Redo repair • Glans width <14mm • Complication rate – – 10% in distal & 25% in proximal one-stage repairs – Higher and variable rates (30-70%) in two-stage repairs. Tunica vaginalis barrier flap reduces risk of Fistulas
- 22. Follow-up • Long termfollow-up recommended till adolescence – Urethral stricture & Meatal stenosis – Voiding dysfunctions – Recurrent penile curvature – Diverticula – Glanular dehiscence – Ejaculatory disorder • 50% complications requiring re-operation present >1yr after surgery
- 23. Outcome Assessment • Validatedobjective scoring systems recommended to evaluate functional and cosmetic outcome • Hypospadias Objective Scoring Evaluation – HOSE • Hypospadias Objective Penile Evaluation (HOPE) Score • Pediatric Penile Perception Score (PPPS)
- 24. Hypospadias Objective ScoringEvaluation – HOSE >= 14 Acceptable outcome May be used for initial severity assessment LE – 2b
- 25. Hypospadias Objective PenileEvaluation (HOPE) Score 1. Meatus position 2. Meatus shape 3. Glans shape 4. Penile skin shape 5. Penile Axis 1. Torsion 2. Curvature on erection
- 27.