Reference book :Campbell-wals-wein UROLOGY

1. Hypospadias
DR. UMBREEN MINHAS
PLASTIC SURGERY
HOLYFAMILY HOSPITAL.

2. Introduction
Hypospadias is a congenital anomaly of the male external genitalia, in which the
urethral meatus opens on the ventral side of the penis, proximal to normal
granular location.

3. Characterize by :

5. Incidence
1:300 live male births (0.3 %)
Some genetic component
◦ 8% of patients have father with hypospadias
◦ 14% of patients have male siblings with hypospadias
More common in Caucasians

6. Etiology
 Mostly unknown
◦ Abnormal androgen production by the fetal testis
◦ Limited androgen sensitivity in target tissues
◦ Premature cessation of androgenic stimulation due to early atrophy of the Leydig cells of the
testes.
◦ Defect in testosterone biosynthetic pathway, specifically with impared 3beta-hydroxysteroid
dehydrogenase were reported in proximal hypospadias

7. Isolated versus Syndromic Hypospadias
Approximately 90 % cases are isolated penile defects
Syndromic hypospadias is suspected with development delay, dysmorphic facies, and/or
anorectal malformation
◦ Smith-Lemli-Opitz Syndrome
◦ WAGR syndrome
◦ G Syndrome
◦ 13q deletion syndrome
Associated anomalies include undescended testes, inguinal hernia and rarely upper tract
anomalies

8. Disorders of Sexual Development
 The coexistence of hypospadias with undescended testes may indicate a DSD
and may be an indication for karyotyping
◦ Most common diagnosis is mixed gonadal dysgenesis
◦ Ovotesticular DSD
◦ 5 alpha reductase deficiency
◦ Klinefelter syndrome

9. Classification

10. Chordee
Abnormal ventral curvature of penis
TYPES:
1 : skin tethering
2 : fibrotic dartos and bucks fascia
3: corporal disproportion
4: congenital short urethra

12. Differential diagnosis
 Chordee without hyposapadias : asymmetrical preputial development with normal meatus
 Hypospadias variant with normal foreskin concealing a granular to distal shaft mega meatus

13. Management
History
General physical examination
Local examination and examination of associated anomalies
Systemic examination

14. Diagnostic Evaluation
Diagnosis includes a description of the local findings:
◦ position, shape and width of the orifice
◦ Assessment of urethral plate width <1 or >1 cm
◦ appearance of the preputial hood and scrotum
◦ size of the penis
◦ curvature of the penis on erection
◦ Urogenital tract anomalies

15. Inguinoscrotal Examination
The diagnostic evaluation also includes an assessment of associated anomalies, which are:
◦ cryptorchidism (in up to 10% of cases of hypospadias);
◦ open processus vaginalis or inguinal hernia (in 9-15%).
◦ Severe hypospadias with unilaterally or bilaterally impalpable testis, or with ambiguous genitalia,
requires a complete genetic and endocrine work-up immediately after birth to exclude DSD, especially
congenital adrenal hyperplasia.

16. Correction is SURGICAL

17.  Urethroplasty
 Straightening of ventral penile curvature
 circumcision / perputioplasty
 scrotoplasty

18. Aims of Surgery
Functional penis with a normal cosmetic appearance
◦ Reconstruction of the missing portion of the urethra and extending it distally
◦ Widening of the meatus
◦ Correction of the curvature
◦ Restoration of the normal aspect of the external genitalia

19. Age of Surgery
 3-18 months of age to minimize psychosexual stress
 More quick healing with fewer scars and young infants overcome the stress of surgery more
easily
 The highest incidence of post operative emotional disturbance has been noted at the age of 1-
3 years

20. Anesthesia :
General anesthesia with adjuvant penile or caudal nerve blocks

21. Preoperative Androgen Stimulation
The role of supplemental hormonal therapy before hypospadias surgery is not clear.
Androgens are documented to increase penile length and glans circumference
Usually limited to patients with proximal hypospadias, a small appearing penis, reduced glans
circumference or reduced urethral plate.

22. Key Steps
Degloving the penis
Correction of associated ventral curvature
Urethroplasty
Interposition of a tissue barrier layer between the neourethra and overlying skin closure
Management of the prepuce by either circumcision or foreskin reconstruction.

23. Degloving
The corners of the dorsal prepuce are held and the line for incision is marked. Ventrally the
incision is approximately 2 mm below the meatus,

24. Degloving is done in different planes: dorsally along the Buck fascia and ventrally just under the
shaft skin, preserving available dartos.
Dissection continues to the penopubic and penoscrotal junctions.

25. Artificial Erection
Normal saline is injected into a single corpora using a 23 gauge butterfly needle until an erection
is achieved

26. Ventral Curvature
10 % of distal hypospadias have VC after degloving (<30)
50 % of proximal hypospadias have no VC or VC < 30 degrees
50 % of proximal hypospadias have VC > 30 after degloving

27. VC < 30 after degloving – Dorsal plication

31. VC > 30 after degloving and extended dissection
◦ ventral corporotomies with or without grafting
Ventral corporotomy
◦ Single incision and graft
◦ Three incisions without graft

34. Urethroplasty
Anatomical Location – distal vs proximal
Assessment of urethral plate – can it be tubularized or not
Degree of ventral curvature - < 30 or > 30

35. Distal Hypospadias
Tubularized Incised Plate Urethroplasty (TIP/Snodgrass)
Meatal advancement and glanuloplasty incorporation (MAGPI)
Meatal based flap (Mathieu)
Double Y glanuloplasty

36. TIP

38. MAGPI
 Circumferential incision is made proximal to corona and meatus
Skin is dissected down to the penoscortal junction
Meatoplasty : Vertical incision b/w meatus and distal glans groove
Diamond like defect is created which is closed transversely ,advancing
dorsal meatus lip into glans groove
Next ventral lip is pulled distally and the glans closed beneath it.

40. Mathieu

43. Proximal Hypospadias
VC < 30
◦ TIP
◦ Onlay preputial flap
VC > 30
◦ Single stage preputial flap
◦ Two stage preputial flap
◦ Two stage graft

44. TIP

45. Onlay preputial flap

49. There are two situations in which the urethral plate cannot be tubularized:
◦ most common is penile curvature greater than 30°, which leads to plate transection
◦ less often encountered is an ‘unhealthy’ incised plate
Options for repair include :
Tubularized preputial flaps (single stage ).
staged urethroplasty ( Bracka two stage repair)

50. Tubularized preputial flap

57. Factors for Technical Success
Use of vascularized tissues
Careful tissue handling
Tension-free anastomosis
Non-overlapping suture lines
Meticulous hemostasis
Fine suture material
Adequate urinary diversion

58. Post op Management
 Urinary Diversion :
Several studies proposed Distal TIP in pre-toilet trained boys can be
done without diversion expecting <5% to need catheterization early
post-operatively without increase in urethroplasty complications.
Stent must be placed ; sutured to glans or a balloon catheter taped
with abdomen
6-Fr bladder stent in pediatric age group
12-14 Fr post pubertal age group

59.  Dressing : remove at 3 day and use of petroleum jelly for week
 Antibiotics and analgesia
Follow up – no defined protocol
◦ Distal: 6 weeks and 8 months post op
◦ Proximal: annually
 Post op penile erection and bladder spams

60. Complications
1. Bleeding and hematoma (most common )
2. Meatal stenosis (Tight granuloplasty )

67. Neourethral stricture :
Treatment options :
<1cm : Direct vision internal urethrotomy (DVIU) or
inlay or two stage oral mucosal grafting
Meatal prolpaspe (mostly ass with bladder mucosal grafts)
Hairy urethra

71. Outcomes
Urinary function:
◦ Symptoms - Patients reported significantly more obstructive symptoms, spraying and deviated stream
than did controls. Those with proximal hypospadias had more spraying than did patients with distal
repairs
◦ Uroflowmetry - Qmax was significantly less in patients than controls. Patients with proximal
hypospadias had significantly lower Qmax than did those with distal hypospadias.

72. Sexual function:
◦ Ejaculation - problems, including milking semen and poor force, were significantly more common in
patients than controls
◦ Sexual Satisfaction - Patients were less satisfied with sexual function than controls
Cosmesis
◦ Patients were more likely to be dissatisfied with penile appearance than were controls. Those with
proximal hypospadias were more dissatisfied with penile appearance than those with distal hypospadias

73. THANK YOU !