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1. Updates in the management of Hypospadias Moderator:- Dr. Fisseha (Consultant Pediatric & General Surgeon ) By:- Dr. Mekdelawit M(PSR5) July 28,2021G.C

2. Outline Introduction Embryology Classification Managements Paper review 28-Jul-21 Hypospedia Management Updates 2

3. Introduction Urethral meatus that opens on the ventral surface of the penis proximal to the end of the glans. second most common congenital GUT abnormality in males next to cryptorchidism. 1 in 250 newborns.  1 in 125 live male births. 28-Jul-21 Hypospedia Management Updates 3

4. Embryology Indiferrent Stage (Hormone independent) Genital tubercle Labioscrotal swellings Urogenital fold 28-Jul-21 Hypospedia Management Updates 4

5. Differentiation (Hormon Dependent ) Phallus enlarges and elongates The urethral folds fuse :- Endodermal edges  Penile urethera Ectodermal edges  median raphe 28-Jul-21 Hypospedia Management Updates 5

6. Theories of Glanular Urethral development 16th wks  the glanular urethra appears. Two possible explanations Endodermal cellular differentiation Intrusion of ectodermal tissue from the glans 28-Jul-21 Hypospedia Management Updates 6

7. Preputal skin development 28-Jul-21 Hypospedia Management Updates 8

8. Ethiology 28-Jul-21 Hypospedia Management Updates 9

9. Familial associations of Hypospadias Twin boys  9% to 27% A first-degree relative hx  9% to 15% Index child+ father  second sibling 26%. Index child + a second-degree relative  second sibling 19 %. Index child  second sibling 12% 28-Jul-21 Hypospedia Management Updates 10

10. Associated Anomalies & Syndromes   28-Jul-21 Hypospedia Management Updates 11

11. Classification Hypospedia Management Updates 28-Jul-21 12

12. Diagnosis and Preop assessment Classic Triads Dorsally hooded foreskin Proximal urethral meatus, Ventral penile curvature midline scrotal cleft, penoscrotal transposition. Chordee without hypospedia 28-Jul-21 Hypospedia Management Updates 13

13. What to look for Degree of penile curvature, Location of the urethral meatus Quality of the urethral plate Glans size Quality of urethral plate Perpetual skin Testicular locations Family counseling about the stages of repair 28-Jul-21 Hypospedia Management Updates 14

14. The goals of Surgery 1. Complete straightening of the penis 2. Meatus at the tip of the glans 3 . A symmetric , conically shaped glans 4. Uniform caliber neo urethera 5. Cosmetically satisfactory skin coverage skin coverage 28-Jul-21 Hypospedia Management Updates 15

15. 1. Chordee Abnormal curvature of the penis occurs in the presence or absence of hypospadias. The degree of curvature is a major determinant in the selection of a one stage versus a two-stage repair. 28-Jul-21 Hypospedia Management Updates 16

16. Classifications Cause Type I skin Tethering Type II Fibrotic Bucks and dartos facia Type III corporal disproportion Type Iv short urethral palte Degree Mild (<30 degrees) Moderate (30–45 degrees) Severe (≥45 degrees). 28-Jul-21 Hypospedia Management Updates 17

17. Options of Chordee realize/ Orthoplasty Penile Skin degloving Release urethra from fibrous tissue Dorsal plication Corporal lengthening procedures Uretheral plate division 28-Jul-21 Hypospedia Management Updates 18

18. corporal lengthening procedures 28-Jul-21 Hypospedia Management Updates 19 Multiple superficial incisions ( Fairy cuts) Full thickness incisions iwithout grafting A single full-thickness corporotomy with grafting Graft options include :- dermal graft , tunica vaginal flap or graft, small intestinal sub mucosa

19. Algorithm for Orthoplasty 28-Jul-21 Hypospedia Management Updates 20 Dorsal plication Corporal lengthening procedures 2 staged repair Corporal lengethening procedures 2 staged repair Proceed with uretheroplasty

20. Distal Hypospadias Repairs No functional defect, no significant penile curvature, able to stand and void with a straight stream The most common procedures Meatal advancement with glansplasty incorporated (MAGPI), Glans approximation procedure (GAP) Primary tubularization Mathieu or flip-flap TIP . 28-Jul-21 Hypospedia Management Updates 21

21. MAGPI A stenotic meatus Good mobility of the urethra shallow ventral glanular groove 28-Jul-21 Hypospedia Management Updates 22

22. GAP (The glans approximation procedure) a wide-mouthed proximal glanular meatus very deep groove 28-Jul-21 Hypospedia Management Updates 23

23. Pyramid Procedure Intact prepuce Mega meatus Wide glanular defect No penile curvature 28-Jul-21 Hypospedia Management Updates 24

24. Mathieu No chordee is present Mobile, well-vascularized skin proximal to the meatus Moderately deep ventral groove, The length-to-width ratio of the skin flap should not exceed 2:1. 28-Jul-21 Hypospedia Management Updates 25

25. TIP Hypospedia Management Updates 28-Jul-21 26

26. MIDSHAFT VARIANTS Degree ofventral curvature dictates the type of repair No significant chordee  TIP  Onlay island flap 27 Mid shaft Hypospadias Repairs

27. Posterior Hypospedia 28-Jul-21 Hypospedia Management Updates 28

28. Transverse Tubularized Island Flap 28-Jul-21 Hypospedia Management Updates 29

29. Two-stage preputal graft

30. Two-stage Bracka buccal hypospadias repair

31. Recap from previous seminar discussion Who should do the Surgery ? The surgeon of whichever speciality having an annual volume of at least 40-50 cases Preop Testosterone injection More post OP complications No significant difference Surgery after 3 months 28-Jul-21 Hypospedia Management Updates 32

32. Exogenous testosterone administration? Bush and colleagues (2013) analyzed urethroplasty complications in patients who received adjuvant testosterone injections versus those with glans 14 mm or greater who did not . Mean glans width before stimulation was 12 mm, increasing to a mean of 16.5 mm with testosterone injections. Untreated patients had a mean glans width of 15.4 mm. Urethroplasty complications occurred in 34% with versus 11% without adjuvant androgens ( P < .0001). Because the goal of therapy was to reduce complications, we stopped preoperative testosterone stimulation.

33. Androgen cont.… J Pediatr Urol.  2011 Apr;7(2):158-61. doi : 10.1016/j.jpurol.2010.05.003. Epub 2010 Jun 8. Does androgen stimulation prior to hypospadias surgery increase the rate of healing complications? - A preliminary report. Thirty-five patients presented with a complication (27.7%) of whom 26 (20.6%) had a fistula or dehiscence. Among patients on androgen stimulation there was a 30% healing complication rate (9/30) whereas for those without this was 17.7% (17/96). When androgenic treatment was given > 3 months prior to surgery the healing complication rate was 21.7% (5/23), and when < 3 months prior to surgery the rate reached 57% (4/7). Mean follow up was 41 months (10-97).

34. The role of preoperative intra muscular testosterone in improving functional and cosmetic outcomes following hypospadias repair: A prospective randomized study Sibi Chakravarthi , Indian Journal of Urology, Feb, 2018. Department of Pediatric Urology, Sri Ramachandra Medical College and Research Institute, Porur , Chennai, India Only patients with distal hypospadias eligible for a tubularized incised plate (TIP) repair were included. Group 1 did not receive any intervention, and group 2 received three doses of intramuscular testosterone enanthate 2 mg/kg at the age of 9, 10, and 11 months. Within group 2, those who failed to have more than a 2 mm increase in size were considered non-responders (group 2a), and the remaining were taken to be responders (group 2b). Total complications were significantly less in group 2b (17.9%) than in group 2a (50%). The reoperation rate was significantly less in group 2b (11.5%) than in group 1 (23.1%). A significantly higher number of parents ( p  = 0.03) were satisfied with cosmesis of the glans/meatus in group 2b (71/78; 91%) compared with group 2a (11/16; 69%) or group 1 (72/92; 78%). The overall PPPS was significantly higher ( p  = 0.003) in group 2b (8.88 ± 2.20) than in group 1 (8.03 ± 1.55).

35. Timing of surgery 6 month to 18 months has better outcome Post Op complication Anesthesia complications Psycosocial complications 28-Jul-21 Hypospedia Management Updates 37

36. Technical aspects Instruments Fine and  delicate instruments Small, single-toothed forceps or fine skin hooks  minimal trauma.  Suture 6-0 or 7-0 polyglycolic for buried sutures With the microscope, 8-0 or 9-0 suture can be used. 28-Jul-21 Hypospedia Management Updates 39

37. Magnification Standard operating loupes 2.5× to 4.5× magnification, Hemostasis Tourniquet Lidocaine with epinephrine Low current Bovie, bipolar sticks to tissue 28-Jul-21 Hypospedia Management Updates 40

38. Drainage and dressing Dressing enough gentle pressure to help with hemostasis and to decrease edema without compromising the vascularity of the repair . Diversions Urethral diversions are used for 3 to 10 days. 28-Jul-21 Hypospedia Management Updates 42

39. Follow up 28-Jul-21 Hypospedia Management Updates 43

40. Paper Review 28-Jul-21 Hypospedia Management Updates 44

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