Hypospadias

Hypospadias

1. Hypospadias Dr Mujtuba Pervez Khan Plastic and Reconstructive Surgery DUHS/CHK

2. Congenital condition characterized by 1. Abnormal proximal urethra meatus on the ventral aspect of the penis 2. Ventrally deficient prepuce (hooded foreskin) 3. Chordee

3. Classification

4. embryology Internal organs differentiate during 6 th gestational week Y chromosome Sertoli cells M.I.F Leydig cells Testosterone During the 11 th gestational week, external organs develop Urethral groove grows down the genital tubercle, distal glanular urethra is formed by ingrowth from the glans penis Urethral folds Tubed urethra Labioscrotal swellings Scortum G

5. etiology Mostly unknown Following factors lead to the developmental arrest 1. Defects of testosterone synthesis 2. Androgen receptor deficiency 3. Mutations in FGF8 and FGFR2 genes 4. High levels of exogenous estrogens Risk factors Family history G enetics Maternal age +35 Exposure to pesticides, industrial chemicals during pregnancy

6. epidemiology 1 in 300 live births have some degree of hypospadias Abnormalities are associated more with proximal hypospadias 10% ∞ inguinal hernias Most common G.U tract abnormality is cryptorchidism. 3% with distal hypospadias, 10% with proximal hypospadias Others: Paraurethral sinuses, urethral valves, enlarged prostatic utricle 4-10% have a family history 5 times more common in In vitro fertilization

7. Anatomy

8. history Ask parents If they have witnessed erections and if they were straight or curved If the child has been operated before Direction of the urinary stream Flow of the urinary stream If the child is circumcised or not

9. examination Site of abnormal opening Degree of Chordee (Mild: 10-20°, Moderate: 30-40°, Severe: >50°) Assess penis size Check both testes in the scrotum Exclude inguinal hernia Check for prepuce (weather circumcised or not) Urethral plate width (<1cm, >1cm) Watch the child pass urine to assess the direction and flow of urine

10. investigation No need in most cases To exclude disorders of sex development mostly in proximal hypospadias Pelvic ultrasound Karyotype analysis Serum electrolytes for Congenital Adrenal Hyperplasia

11. Complications, if not treated Abnormal appearance of the penis Abnormal curvature of the penis Problems with impaired ejaculation Problems with normal urinary flow

12. Aims of surgery Normal aesthetic looking penis Slit like terminal meatus Normal erection and sexual function Normal urinary stream timing of surgery Between 6-18 months Testosterone surge at 4-6 months Counsel parents to not get their child circumcised

13. Surgery - Chordee correction True chordee VS False chordee Horton’s Test < 30°: Dorsal plication of Tunica Albuginea (Nesbit dorsal tunical tuck) >30°: Transverse incision through the urethral plate… Covering the defect with skin graft or flap Corporotomy and graft Urethral plate division

14. Surgical techniques Tubularisation of the urethral plate (TIP) Replacement of the urethral plate with skin flaps Replacement of the urethral plate with grafts No technique is universally accepted

15. Single stage For distal and mid shaft hypospadias Tubularised incised plate snodgrass

16. Snodgrass – post op care Antibiotics and Sponge bathing till the catheter/stent is removed Removal of stent/ catheter after a week

17. Snod -graft repair Modification of Snodgrass, where urethral plate is narrow or shallow Use of inner preputial skin graft, buccal mucosa to deepen and widen the urethral plate

18. Braca (two stage) repair Indications Proximal hypospadias with severe chordee Inadequate urethral plate Distal hypospadias with conical glans Previously operated cases Two stage Excellent cosmetic results Low complication rates

19. Braca 1

20. Braca 1 – post op care After 1 st stage, catheter is removed within 2 days. Child can take a bath Removal of bolster on 7 th P.O.D Apply moisturizing ointment over the graft and suture line 2 nd stage 5-6 months later

21. Braca 2

22. Braca 2 – post op care After 2 nd stage, remove dressing after 2 days. Catheter removal on 6-7 th day Catheter can be left for 2 weeks in cases of swelling

23. Mathieu perimeatal based flap Also called flip flap For distal hypospadias

24. Urethral advancement Circumferential dissection and advancement of the distal urethra Gain of 2.5cm of urethra in children Urethra is advanced till it reaches the level of normal meatus

25. complications Early Bladder spasm Hematoma Wound dehiscence Edema Erections can cause comlications Late Fistula (most common) Urethral Stenosis Diverticulum Persistent UTI

26. Thanks .