HYPOSPADIA

Definitions

Hypospadias, in boys, is defined as an association of three

anomalies of the penis:
1.
An abnormal ventral opening of the urethral meatus
2.
An abnormal ventral curvature of the penis (chordee).
3.
An abnormal distribution of foreskin with a redundant
hoodlike foreskin in the dorsum while deficient in the ventral
aspect. 1,2

Epidemiology

Prevalence : 3-8 in 1000 live male birth1,2

Incidence : 1: 4000 live birth. 1:300 live male births3

Genetic factors

4% to 10% familial cases. 3

o Endocrinopathies Disturbed androgen activity
Gene Mutations 3
Endocrine Disruptors eg phytoestrogens by vegetarian
mother.3

Anatomy
Normal Anatomy of the Penis

Figure 1. Normal Anatomy of the Penis

Figure
2.
Anatomy of
the Penis 2.
3

Figure 3:

Anatomy of Hypospadia

Classification

Figure 4: Classification1,5

Classification of Glans Configuration 5

Figure 5. Glans Configuration5

Embryology Development
Hypospadias results from a failure of tubularization of
the horizontal segment of the urogenital sinus: 4
during the 11th week of gestation for the penile
urethra
during the 4th month of gestation for the
glanular urethra

Figure 6: Embryology4

Associated Conditions

Cryptorchidism 7% 3
Prostatic Utricle1 : 27.5%6
Disorders of Sex Development :
50% of patients with a nonpalpable testis and
hypospadias.3
Intersex conditions occur in approximately 15%.7
Malformation Syndromes 3
Micropenis

Clinical Findings
A. SYMPTOMS AND SIGNS8
Newborn and young children: seldom
Older children and adults difficulty directing the urinary
stream and stream spraying
Chordee
Voiding in the sitting positionPerineal or penoscrotal
hypospadias.
Abnormal (hooded) appearance of the penis
The hypospadiac meatus may e stenotic
B. LABORATORY, X-RAY, & ENDOSCOPIC FINDINGS8
A buccal smear and karyotyping
o indicated to help establish the genetic sex.
Urethroscopy and cystoscopy

o determine internal male sexual organs normal or

abnormal
Excretory urography
o to detect additional congenital anomalies of the kidneys
and ureters.

Treatment

Should be repaired before the patient reaches school age; in

most cases, this can be done before age 2. 9
150 methods of corrective surgery for hypospadias have been
described 9

SURGICAL PRINCIPLES2,4
1. Straightening of the penis (i.e., correction of chordee)
2. Reconstruction of the missing urethra (i.e., urethroplasty)
3. Reconstruction of the tissues forming the ventral radius of the
penis (i.e., glans, corpus spongiosum, and skin).
5 Sequential Steps for the Successful Repair of
Hypospadias2,9
1. Orthoplasty or penile straightening
2. Urethroplasty
3. Meatoplasty and Glanuloplasty
4. Scrotoplasty
5. Skin Coverage.
ORTHOPLASTY

Figure 7. Straightening Maneuvers3

Figure 8. Algorithm for straightening ventral curvature (VC) with

hypospadias.3

Tissues Used for Correction of Hypospadias

Figure 9. Tissue Used for Hypospadias Correction5

Choice of Operative Technique

Figure 10. Recommendation of Primary Hypospadia Repair 5

I. The Y-V modified Mathieu procedure (for

glanular type)

The most popular technique for distal hypospadias repair

Contraindication: severe chordee distal to the hypospadiac
meatus.
Complications : fistula occurs in 2 - 5 % of patients

Figure 11. Y-V modified Mathieu procedure

II. Mathieu flip-flap procedure

Figure 12. Mathieu Flip Flap Procedure

III. Tubularized Incised Plate Urethroplasty

(TIP)5
Two important criteria to achieve good results:
the urethral plate not less than 1 cm wide
no distal deep chordee
Complications :
Fistula :2 - 15 % of patients.
Meatal stenosis 5 - 20 %

Figure 13. Tubularized Incised Plate Urethroplasty (TIP)5

IV. Onlay Island Flap

Ideal for patients with proximal hypospadias without deep

Chordee.
Complications
Fistula, wound disruption, rotation, recurrent curvature occurs
in 10 - 20 % of patients.

Figure 14. Onlay Island Flap5

V. Thiersch-Duplay Procedure

Can be used to correct an urethral plate which is wide enough

and healthy

Figure 15. Thiersch-Duplay Procedure

COMPLICATION10
1. Fistulas Urethrocutaneus Fistulas
Steps to decrease risk for fistula
a. subepithelial sutures to turn epithelial edges into the
neourethra
b. 2-layer urethroplasty
c. Interposition of tissue flaps, including dartos, corpus
spongiosum, and/or tunica vaginalis, between the
neourethra and shaft skin closures.
2. Meatal Stenosis
o Result from technical errorstubularizing the neourethra
too far distally
o vascular compromise.

3. Urethral Stricture
Recurrent or longer strictures best be repaired using
single stage dorsal inlay grafts.
4. Urethral Diverticulum Excision of the excessive skin.
5. Wound Dehiscence
Reoperation is performed 6 months later

Figure 14. Inlay Graft.

10

Plastic Surgery Division RSCM

Two Stage operation Sidik-Chaula urethroplasty
One Stage Tubularized incised plate urethroplasty adapted
from Snodgrass Bracka modification

Sidik-Chaula Urethroplasty

Stage One

Stage Two

The Manset Flap

Bracka-Snodgrass Urethroplasty

References
1. Hipospadia. Modul Bedah Plastik FKUI. Modul no : 36
2. Sukasah CL, Supit L, Mukarramah DA, Ramadan R. Illustrated
Guideline of Hypospadia Surgery. Lingkar Studi Bedah Plastik.
2013
3. Wein AJ, Kavoussi LR, Partin AW, Novick AC. Hypospadias. In:
Campbell-Walsh Urology 10th edition. Elsevier 2012;130
pg;3504
4. Mouriquand PDE, Demede D, Gorduza D, Mure PY.
Hypospadias. In: Pediatric Urology 2nd Ed. Saunders. 2001
5. Hadidi AT. Hypospadia Surger. In:International Workshop on
Hypospadias Surgery, Medical University Vienna, 2006
6. Ikoma F, et al. Classification of enlarged prostatic utricle in
patients with hypospadias. Br J Urol. 1985 Jun;57(3):334-7.
7. Kaefer, M., Diamond, D., Hendren, W. H. et al. The incidence of
intersexuality
in
children
with
cryptorchidism
and
hypospadias: stratification based on gonadal palpability and
meatal position. J Urol. 1999 162: 1003
8. McAninch JW. Hypospadias. In: Smiths General Urology 17 th Ed.
Lange. 2008. Pg;629.
9. Baskin LS, Ebbers MB. Hypospadias:anatomy,etiology,and
technique. J Pediatr Surg 2006;41(3):463472
10.
Snodgrass WT. Hypospadias. In: Pediatric Urology a
General Urologists Guide. Springers. USA 2011