This document provides information about hypospadias, including: - The embryology of normal penile development and how hypospadias occurs due to abnormal anterior urethral and penile development. - The clinical features of hypospadias such as an abnormal urethral opening along the ventral penis and abnormal ventral curvature. It can be associated with other genital anomalies. - The various surgical techniques used to repair hypospadias depending on its location, from distal techniques like MAGPI to techniques for more proximal hypospadias like tubularized island flaps or multistage repairs. - Post-operative considerations like catheters, dressings and potential

1. HYPOSPADIAS
BY: DR AKASHA AMBAR
PGR P& R S UNIT BVH BWP

2. Anatomy:
penile anatomy

3. Urethral anatomy:
 3 segments: prostatic,membranous,spongy
 Posterior urethra:prostatic + membranous
 Anterior urethra: bulbous :
pendolous(penile)
 Transitional epithelium (except navicular
fossa)

4. Undifferentiated
gonads
ovaries
testes
Y- chromosome
Leydig cells Sertoli cells
Anti-mullerian hormone
Inhibits mullerian ducts
Tubes, uterus, vagina
Testosterone
5a-reductase
Dihydrotestosterone
Genital tubercle
Penis
Penile growth
Maintain wolffian ducts
Epididymis, Vas deferens
clitoris

5. Embryology:
Genital tubercle at caudal end of cloaca
Develops a groove on its ventral surface
Corpus spongiosum
8 weeks
9 weeks
Urogenital membrane
Coronal meatus
6 weeks
Urethral mucosa
Definitive urethral groove
Genital folds fuse progressively over urethral groove posterior to anterior, thus advancing meatus to
coronal position
Elongates
Urethral plate
Followed by mesodermal cuff
Penoscrotal meatus
Swellings on either side, Genital folds
12 weeks
Penile fascia
Glans forms around distal urethra, ectodermal ingrowth forms glanular urethra

6. Hypospadias
 abnormality of anterior urethral and penile development in which the
urethral opening is ectopically located along the ventral aspect of the
penis proximal to the tip of the glans.

7. Clinical features
 Abnormal meatal opening along ventral aspect of penoscrotal tissue or
even on peineum
 Abnormal ventral curvature and developmental anomaly of ventral penile
tissue (skin upto urethral plate)
 Hooded prepuce (“feminization of male genitalia”)
 Praurethral sinuses

8. Associated conditions:
 Cryptorchidism
 Bifid scrotum
 Inguinal hernia
 Renal tract malformations

9. Association with syndromes
 approximately 200 recognized syndromes
 Hand-foot-genital syndrome
 OPITZ syndrome
 WAGR syndrome
 (Wilm’s tumor, Aniridia,Genital anomalies,mental Retardation)

10. Incidence & etiology:
 1 in 100 to 1-400 live male births
 Etiology; unknown
 Believed as multifactorial process
 GENETIC FACTORS:
 Gene mutations
 ENVIRONMENTAL FACTORS:
 Increasing maternal age
 Fertility drugs
 Antiepileptic drugs
 Low birth weight
 Pre-eclampsia

12. Chordee
 Abnormal ventral curvature of penis
 Hypoplasia and longitudinal shortening of ventral
tissue(skin,urethra,fascia,corpora)
 Mesenchymal tissue(C.S and fascias) ; fibrous tissue
 Chordee without hypospadias
 Rare,late in children as downward curved erection
 Normal meatus position and hypoplastic shortened ventral tissues

13. Types of chordee
 Devine and Horton classified chordee into
 type I (skin tethering)
 type II (fibrotic dartos and buck’s fascia)
 type III (corporal disproportion)
 type IV (congenital short urethra)

14. Approach towards management:
 preoperative assessment :
 History
 general physical examination
 local examination and examination of associated deformities
 Systemic examination

15. Local examination:
 Measure:
 the size of the phallus
 glans cleft (flat, incomplete, or complete)
 location and size of the meatus (type of hypospadias and meatal stenosis or mega-meatus)
 urethral plate width (<1 cm or ≥1 cm)
 type of chordee
 prepuce (complete, incomplete, circumcised)
 penile torsion (clockwise, anticlockwise)
 shape of the scrotum (normal, penoscrotal transposition)
 associated anomalies (cryptorchidism, inguinal hernia, persistent Mullerian structures)
 urogenital tract anomalies such as pelviureteric junction (PUJ) obstruction, vesicoureteric reflux
and renal agenesis which should be excluded by ultrasonographic scan in every hypospadias
patient.
 Proximal hypospadias with cryptorchidism, enlarged utricle, or penile size <2.5 cm should be
investigated for intersex disorders by ultrasonography, hormonal profile, and karyotyping

17. Timing of surgery

18.  ANESTHESIA:
 G/A and pidural/caudal block or penile block

19. ■ normal micturition while standing
■ natural appearance
■ normal sexual function

20. Principals of repair
 Surgical expertise
 Minimal tissue trauma
 minimal/pin-point use of cautery
 well-vascularised tension free repair of all layers with epithelial
inversion(water proofing)

21. Successful hypospadias repair

23. Surgical techniques
 3 categories
 Historical procedures:
 Known by author’s names,
 high complication
 poor aesthetic results
 Textbook operations:
 Meatoplasty and glanuloplasty(MAGPI) for coronal & glanular hypospadias
 Flip-flap for distal shaft hypospadias
 Inner preputial island flaps for more proximal hypospadias
 High complication rate,couldn’t achieve slit like meatus
 Modern techniques:
 Tubularization of remaining plate or it’s replacement with a graft in two stage procedure

25. Options or chordee
release/orthoplasty
 Simple degloving of penile skin
 Nesbit operation
 Heineke mikulicz operation
 Dorsal midline plication
 Tunica albuginea plication
 Corporal rotation
 Split & roll technique
 Total peile disassembly- perovic

26. Distal hypospadias
 Glanular & subcoronal
 Minimal hypospadias;
 Meatus position normal
 Shape abnormality
 Foreskin abnormality
 Surgical techniques
 GAP/GRAP
 MAGPI (Meatal Advancement and GlanuloPlasty Incorporated)
 Tubularized Incised Plate Repair (TIP Repair)

27. GAP/GRAP
(Glanular Approximation Procedure/Glanular
Reconstruction And Preputioplasty)
 Uses: distal hypospadias with glanular
groove
 Anesthesia: both G/A and caudal
anesthesia
 Glans groove tubuarized
 Distal suture is critical in determining
location of meatus
 2 layered closure of neourethra with
water proof closure
 Results in slit like meatus
 Preputital reconstruction with
independent inner & outer layer
closure

28. Double-Y
Glanuloplasty

29. MAGPI (Meatal Advancement and GlanuloPlasty
Incorporated)
 glanular and coronal hypospadias
 Duckett
 Meatal regression if used in immobile
urethral meatus.
 Complications: meatal retraction,stenosis
and fishmouth meatal opening
 No slit like meatus achieved

30. Tubularization techniques:
 Thiersch (1869) and Duplay (1880)
 initial descriptors of the simple urethral plate tubularization technique;
known as the Thiersch-Duplay urethroplasty.

31. Tubularized Incised Plate (TIP
Urethroplasty)/ Snodgrass Repair
 Initially used for distal, but used
equally for midshaft and
proximal
 easily performed, with few
complications and results in a slit
like meatus
 Complications: meatal stenosis,
persistent fistula, functional
urethral obstruction and
persistent chordee
 5-35 % in distal hypospadias and
upto 65 % in proximal
hypospadias.

34. Snod-Graft Repair

35. Flip-Flap procedure (Mathieu’s Meatal
Based Flap)

36. MIDDLE HYPOSPADIAS PROCEDURES:
 a. Tubularization Techniques:
 TIP Urethropasty (Snodgrass)
 Mathieu fip-flap technique
 Duckett’s Tubularized Preputial Island Flap (TPIF).
 b. Onlay Techniques:
 Onlay Island Flap (OIF) technique
 Double-Onlay Preputial Flap

37. Proximal Hypospadias
 I. One-Stage Repair.
 a. Tubularization Techniques
 TIP Urethropasty (Snodgrass repair)
 Tubularized inner Preputial Island Flap (TPIF)
 b. Onlay Techniques:
 Onlay Island Flap (OIF) technique
 Double-Onlay Preputial Flap
 Onlay-Tube/Onlay Urethroplasty.
 II. Two-Stage Repair.
 Glans-Splitting Bracka Technique

38. 2 stage Glans Splitting Bracka Technique

39. Inner Preputial Island Flap
 Inner preputial skin
islanded and used as:
 A complete tub
 Onlay flap
 Sutured to urethral
plate to augment
another technique

40. Onlay Island Flap
 Proximal with deep chordee

41. Sutures, Dressings, Urinary Diversion,
Catheters
 Absorbable sutures: 6-0 or 7-0
 vicryl(polyglactin)
 PDS(poly Dioxanone)
 Monocryl(poliglecaprone)
 Usually no dressing; various forms of dressings (tegaderm/foam)
 Stent must be placed; sutured to glans( leaves marks); a balloon catheter taped with
abdomen (preferrable)
 8FrG silicon catheter used in paediatric age group
 Rubber catheter avoided
 Fine bore tubing working on siphon action can be used
 Postoperatively:
 ketoconazole( prevent androgen production from testes and adrenals, prevents erection) or
CYPROTERONE ACETATE
 Oxybutynin (DITROPAN)(prevents bladder spasm)

44. Complications:
 Early:
 Bleeding/ hematoma
 Infections
 Late:
 Fistula
 Meatal stenosis
 stricture
 Urethral diverticulum
 Persistent chordee
 Skin assymetries
 BXO

45. Complications:
 Urethrocutaneous
fistula

46. Complications:
 Meatal problems:
 Stenosis
 Techniques:
 cicumferential suture line at meatus
 Urethral plate midline incisions extends onto glans
 Minor: dilatation
 Severe: meatoplasty or redo with two stage procedure

47. Complications:
 Striture:
 At junction of neourethra and original urethra
 Entire urethral repair
 Minor and early menifestation: dilatations
 Severe or late occurrence : urethroplasty/redo

48. Complications:
 Skin problems:
 Minor skin assymetries (correction with surgery)
 Lichen sclerosus et atrophicus( balanitis xerotica obliterans)
 Pre-malignant for SCC
 Results in phimosis, involving repair,it may cause meatal stenosis, strictures
 Minor: topical steroids
 Severe: excise all skin and redo in two stage with buccal graft (no skin graft as
recurrence of LSEA is high)

51. Treatment Algorithm
If deep sulcus on
glans?
Yes
If significant
chordee
Yes
Can curvature be
corrected by dorsal
plication
Yes
No
No
If a dense bar distal
to meatus
Yes
TIP urethroplasty
No
GAP
No
Two staged Repair
If foreskin
repairable?
Yes
preputioplasty
No
Circumcision

52. THANK YOU