Vous êtes sur la page 1sur 87

Hypospadias

By Khaled Ashour John Radcliffe Hsopital

Hypospadias Definition
It

is a congenital anomaly characterized by a combination of 3 defects:


Abnormally located ventral meatus. Abnormal Ventral penile curvature (Chordee). Abnormal foreskin* (Deficient ventrally).

* Not always present

Hypospadias History
First

described by Galen in the second century. Antyl described the first surgical repair, by amputating the penis distal to the hypospaedic opening!! In the second half of 19th century, most of surgical procedures were first described. (Thiersch, Duplay, Bouisson,..)

Hypospadias Incidence
1

in 300 live male birth. This showed recent increase in incidence, which is believed to be related to increased referral of minor forms, for which parents would not previously seek medical advice. However, recent studies showed that the recent increase in incidence in US may ba attributed to (Oestrogenic pollution).

Hypospadias Pathophysiology
Developmentally,

the male urethra develops in the following way:


Androgenic stimulation genital tubercle male phallus. Starting 7th G. week urogenital sinus advances into the phallus as the urethral groove. Ingrowth of the urethral groove urethral plate formation, and 2 lateral urethral folds.

Hypospadias Pathophysiology
Fusion

of the urethral folds in the midline, in a proximal to distal fashion, results in the formation of proximal & penile urethra (endodermal lining). 2 theories are proposed to explain the development of the glanular urethra (ectodermal lining)

Hypospadias Pathophysiology

Ectodermal ingrowth theory:

States that the glanular urethra develops as ingrowth of the ectoderm (ectodermal pit) that grows proximally to join the penile urethra.

Hypospadias Pathophysiology
Endodermal

differentiation theory:

Recent researches done by Baskin et al., showed that the entire urethra develops in a proximal to distal fashion, with the endodermal cells capable of differentiating into stratified squamous epithelium as a result of mesenchymal/endodermal cell signalling.

Hypospadias Aetiology

The aetiology is not fully understood:

Deficient hormonal stimulation. Genetic disorder. Vascular abnormalities.

Familial tendency (common in monozygotic twin, and offspring of affected father)

Classification

Classification

Clinical picture & sequel

Diagnosis is essentially clinical

Abnormally located ventral meatus

Deficient ventral prepuce Ventral curvature (Chordee)

Clinical picture variants of Hypospadias

Megameatus intact prepuce variant MIP: In this uncommon variant, the patient presents with completely intact prepuce, and only hypospadias is detected on complete foreskin retraction.

Clinical picture variants of Hypospadias

Chordee without hypospadias: Complete degloving will mostly result in a hypospaedic meatus.

Associated anomalies
Undescended

testis (5-10%, rising to 50% in proximal hypospadias. Persistent Utricle (20%). Urinary tract anomalies (only 2%). Severe cases can be presented as ambiguous genitalia, with bilateral undescended testicles.

Associated anomalies
Up

to 50% of patients with severe hypospadias with cryptorchidism have underlying genetic, gonadal, or phenotypic sexual abnormalities. Therefore, we need to exclude:

CAH. Mixed gonadal dysgenesis Gonadal agenesis True and pseudohermaphrodite.

CAH

Complications of Hypospadias
Psychological

impacts. Difficult intercourse. Abnormal insemination & infertility.

Management of Hypospadias
Clinical

diagnosis and assessment of the type of hypospadias. When to operate. How to operate (selection of technique). Follow up & dealing with complications.

When to operate?
Elective

procedure, general guidelines, between 6 to 18 months. Size of the phallus and adequacy of tissue needed for repair. Associated anomalies.

General principles
Hypospadias

repair in general includes 3 main entities: 1. Orthoplasty (correction of chordee). 2. Urethroplasty. 3. +/- preputioplasty.

+ management of any associated anomalies.

General principles
Selection

of surgical technique. Magnification. Haemostasis.


Torniquet
Suture

Adrenaline

Diathermy

material.

6-7/0 PDS.

Urinary

diversion. Dressing.

General principles
Surgical

technique:

Urethroplasty is better done over a size 8F catheter. Multilayer repair is the rule. Interrupted rather than continuous sutures. Suture lines should not overly each other. Suture under tension = failure. Meatus should never be tight. Cosmetic appearance of the meatus.

Degloving, erection test, and correction of Chordee

There are many underlying cause for chordee. It may be, Skin, urethral plate, fibrosed tissue distal to meatus, or disproportionate corporal growth.

Specific Surgical procedures


I)

Anterior Hypospadias:
Meatal advancement. MAGPI. GAP procedure. Mathieu (meatal-based skin flip-flap). Urethral mobilization. TIPU.

Specific Surgical procedures


II)

Posterior Hypospadias:
TIPU. Onlay island flap. Ducketts urethroplasty. free flap techniques. 2-stage, 3-stage techniques.

Specific Surgical procedures


III)

Complicated Hypospadias:

TIPU. Free grafting.

Another classification
Common operative techniques

One-stage

Multi-stage

Without flaps

With flaps

With flaps

Without flaps

GAP, MAGPI, TIPU, Urethral mobilization

Mathieu, Onlay I. F., Duckett.

Free flaps

2 & 3 stage Old techniques

MAGPI
Meatal Advancement with Glanuloplasty Incorporated.

In 1981, Duckett published a simple technique in the management of AH, namely the MAGPI operation.

MAGPI, Surgical Technique

Patient selection

MAGPI, Surgical Technique

Making sure that the urethra is not tethered proximally.

MAGPI, Surgical techniques

Tension sutures application.

MAGPI, Surgical techniques

Application of tourniquet.

MAGPI, Surgical techniques

The midline glanular cleft incision is made, involving the posterior urethral wall.

MAGPI, Surgical techniques

The posterior urethral wall is now ready to be advanced.

MAGPI, Surgical techniques

Three sutures are applied, anchoring the urethra to the incised glans.

MAGPI, Surgical techniques

The meatal pedicled flap is now mobilized.

MAGPI, Surgical techniques

MAGPI, Surgical techniques

Complete freeing of the flap, and the glanular wings are being prepared.

MAGPI, Surgical techniques

The glanular wings can be brought easily in front of the urethra.

Mathieu repair
In

1932, Mathieu described his Meatalbased flap technique in the management of anterior hypospadias.

Mathieu, Surgical techniques

Patient selection.

Mathieu, Surgical technique

Tension sutures application.

Mathieu, Surgical technique

Designing the flap area on the shaft proximally.

Mathieu, Surgical technique

Starting the flap dissection, the glanular incision is not deepened before the tourniquet is applied.

Mathieu, Surgical techniques

The flap is dissected distally till its pedicle at the meatus.

Mathieu, Surgical technique

Now, the glanular incision is deepened after application of the tourniquet. Note the depth is marked by the corporal body.

Mathieu, Surgical technique

The flap is now rotated to form the urethral tube.

Mathieu, Surgical technique

The flap is sutured using the continuous extracuticular fashion.

Mathieu, Surgical technique

The flap is sutured using the continuous extracuticular fashion.

Mathieu, Surgical technique

The glans is closed in 2 layers in front of the urethroplasty.

Mathieu, Surgical technique

Completion of the operation.

TIPU, Snodgrass technique

In the early ninties, W Snodgrass accidently invented the technique of urethral plate incision to accomplish the Duplays principle

TIPU

The idea is to relax the urethral plate using a mid-line incision, so that tubularization of the plate could be achieved without tension.

TIPU

Initially, Design the Ushape incision around the meatus.

TIPU

Urethral plate incision, balanced so that the depth of incision does not exceed the urethral plate thickness. Again, it should not extend distally till the tip of the glans.

Onlay Island flap

Using the dorsla flap technique, however, with less suture lines, and avoids the circular anastomosis at the base.

Ducketts repair

Involves tubularization of dorsal preputial flap around a catheter, then transferring it ventrally to be anastomosed to the hypospaedic meatus. High rate of complications, many suture lines.

Ducketts repair

Multi-stage techniques

Usually done for proximal or complicated hypospadias. Initially, degloving and correction of Chordee will send the meatus more proximal. Free grafts can be then used ventrally, e.g. buccal mucosal, post-auricular, bladder mucosa Six months later, tubularization of the graft is to be accomplished.

Buccal mucosal free graft

Protection of urethroplasty.
Almost

invariably all Paediatric urologist will use a second, or even third vascular protective layer to protect the initial urethroplasty. The easiest, and richly vascular flap can be obtained from local tissue (dartos fascia flaps).

Pedicled flap
Dorsal Dartos flap

Another example of distant flap

TIPU

FLAP

Urethral plate

Parameatal flap

Use of Spongiosus tissue


Distal

to the hypospaedic meatus, the corpus spongiosus (CS) tissue fans out till the base of the glans. Careful dissection of tissue can easily demonstrate CS, which then can be utilized as a covering layer above urethroplasty. Spongioplasty

Complications of Hypospadias repair

Despite the great advances in hypospadias reconstructive surgeries, many frustrating complications are still met with: Urethrocutaneous fistula Meatal stenosis Disruption Hairy Urethra Urethrocele flap complications (BXO) Recurrent chordee!

Urethro-cutaneous fistula

Disrupted repair

Hairy urethra

Can complicate repairs that include the use of skin lining of the urethra (e.g, Mathieu with long flap, or the classical Cecil Culp operation)

Complicated hypospadias repair


What

is The problem of complicated hypospadias? 1. Scar tissue rather than healthy one. 2. Loss of tissue (Circumcision). 3. Affected urethral plate.

Management of complicated Hypospadias


Multi-stage

rather than one stage in severe cases. Use of multilayer repair. Warn the parents about the increased incidence of recurrence.

Hypospadias-like situations

Traumatic urethral injury can happen to children, and can result in severe urethral complications (Hair strangulation)

God Bess is always happy after any successful hypospadias repair!!

Vous aimerez peut-être aussi