Abnormal Urethral opening - Hypospadias & Epispadias.pptx

This lecture will discuss an approach to a child / neonate with Abnormal Urethral opening - Hypospadias & Epispadia:-

Hypospadias
Definition and embryology
Calssifiaction and types
Clinical features
Sequlaes
Age of surgical correction
Treatment
Surgical complications
Epispadias

1. Abnormal Urethral opening Hypospadias and Epispadias By:- Jwan Ali Ahmed AlSofi

2. Contents:- Hypospadias Definition and embryology Calssifiaction and types Clinical features Sequlaes Age of surgical correction Treatment Surgical complications Epispadias 2

3. Hypospadias 3

4. Definition:- Hypospadias is caused by failure of development of the tissues forming the urethra, on the shaft of the penis . The urethral orifice opens on the ventral surface of the penis and does not reach the end of the glans. In severe cases, the urinary meatus may open in the scrotum or perineum, where a disorder of sexual development should be considered. There is deficiency of the ventral foreskin and the skin on the ventral penile shaft ( dorsal hooded foreskin ). The lack of tissue on the ventral surface of the penis leads to a tight bow-string effect, causing a ventral bending of the penis known as chordee . This chordee deformity is more marked during erection and will cause difficulty with intercourse in later life if not corrected. 4

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7. Classification of Hypospadias:- 7

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9. The malposition of the urinary orifice and the chordee deformity are usually present together, but in some cases, severe chordee may be present with an orifice at the end of the penis . Hypospadias affects 1 in 150–200 boys. Severe hypospadias with a bifid scrotum and undescended testes is actually a presentation of a disorder of  sexual development with ambiguous genitalia 9

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11. The clinical findings in hypospadias are :- Downward deflection of the urinary stream from the ventrally placed meatus . The penis is bent ventrally with chordee , which causes difficulty with intercourse . The foreskin forms a dorsal hood and is deficient ventrally , The dorsal hooded prepuce , which gives an abnormal appearance to the penis. 11

12. Sequelae of hypospadias are :- These disabilities are primarily functional . the boy may find it difficult to direct his urinary stream, in later life, intercourse may be difficult if there is significant chordee . The disabilities are also psychological . severe anomalies of the penis or a poor cosmetic result following operative repair may interfere with the development of his normal male body image. 13

13. The age for correction of hypospadias has been made younger, and now, the recommended age for repair is 6–12 months . 14

14. Associated anomalies with hypospadias :- Some increase in other anomalies of the genito -urinary system :- 9 % incidence of cryptorchidism, 9 % inguinal hernia 3 % renal anomalies More severe penoscrotal hypospadias is associated with a utriculus masculinus , a remnant of the vaginal anlagen that may predispose to:- recurrent UTI epididymo-orchitis stone formation. 15

15. Investigation:- Investigation with renal ultrasonography is recommended. Severe hypospadias with bifid scrotum and/or undescended testes (ambiguous genitalia) requires full investigation for disorders of sexual development . 16

16. Treatment:- The four aims of treatment of hypospadias are: To correct the chordee To bring the urinary meatus to the tip of the penis To provide a good cosmetic appearance To achieve the above aims with the minimum complications 17

17. Treatment:- Hypospadias surgery is one of the most difficult areas of surgery in children. As the primary defect is failure of tissue development , there is tissue missing from the ventral surface of the penis and any simple attempt at closing the defect has a high failure rate . There are over 250 different operations described for hypospadias, most of which are no longer performed having been superseded by procedures with better cosmetic and functional outcomes. 18

18. The principles of surgery are as follows: Correct the chordee by releasing the ventral skin that tethers the penis. Relocate the meatus to the tip of the penis using locally based skin flaps. Achieve a cosmetic outcome with either a circumcised or uncircumcised appearance by reconstructing the prepuce. Post-operative urinary drainage is usually aided by a urinary catheter or a urethral stent. In most cases of hypospadias, surgery is performed in a single stage ; however, in severe cases, the chordee may be corrected first and then the urethra is repositioned at the tip of the penis at a later operation to reduce the complication rate. 19

19. Post-operative Complications:- Failure of healing with complete breakdown, or a partial breakdown with urinary fistula formation, is a distressing problem. Strictures may occur in the neourethra , and poorly corrected chordee will lead to troubles in adult life. These complications used to be common, but the standards of surgery for hypospadias are now quite high, and one should expect good results. 20

20. Epispadias 21

21. In this condition, the urethra opens at the base of the penis on its dorsal aspect. It is part of the spectrum of lower abdominal wall defects in which ectopia vesicae (bladder exstrophy ) is a more severe form. Most boys with epispadias are incontinent of urine because the bladder neck is deficient. Epispadias as an isolated abnormality in a continent child is exceptionally rare, even rarer than ectopia vesicae itself. Apart from the problem of the repair of the urethra, using the same type of urethral reconstruction as in hypospadias, there are many of the same major difficulties that arise in ectopia vesicae . 22

22. A newborn baby presents with hypospadias. Q 4.1 At what age is corrective surgery best performed? Q 4.2 What are the aims of surgery for hypospadias? Q 4.3 What are the principles of hypospadias surgery ? 4.1 6–12 months. 4.2 Fix chordee and put urethra on top of glans ; satisfactory cosmetic appearance and minimum complications. 4.3 Extensive mobilisation to fix chordee , foreskin advanced to ventral surface, neourethra constructed, ± post-operative stenting/urinary diversion, one or two stages. 23

23. THANKS