Mid Penile Hypospadias

Hypospadias

1. MID PENILE HYPOSPADIAS By :Dr. Amit Kumar Choudhary

2. Hypospadias is defined as hypoplasia of the tissues forming the ventral aspect of the penis beyond the division of the corpus spongiosum . Hypospadias is believed to result from arrested penile development, leaving a proximal urethral meatus .

3. Incidence- 1/250 male newborns . Association of 3 anomalies Abnormal ventral opening of urethral meatus Abnormal ventral curvature of the penis Abnormal distribution of foreskin with a dorsal hood

4. DIAGNOSIS Hypospadias is diagnosed by physical examination,first suspected by the ventrally deficient prepuce and confirmed by the proximal meatus . Other abnormal findings include : : downward glans tilt : deviation of the median penile raphe , :VC : scrotal encroachment onto the penile shaft midline : scrotal cleft : penoscrotal transposition

5. ETIOLOGY Genetic Factors – Familial aggregation is found in 4% to 10% of hypospadias cases, including first-, second-, and third degree relatives. Gene Mutations - Murine studies indicating androgen receptor activity regulates Fgf8, Fgf10, and Fgfr2 involved in urethral development have led to screening for defects in these candidate genes in patients with hypospadias .

6. In most cases, the cause of this congenital defect is not fully understood. Treatment with hormones such as progesterone during pregnancy may increase the risk of hypospadias . Certain hormonal fluctuations, such as failure of the fetal testes to produce enough testosterone or the failure of the body to respond to testosterone, increase the risk of hypospadias and other genetic problems.

7. ANATOMY

8. CLASSIFICATION

9. CLASSIFICATION Anatomic classification of hypospadias recognizes the level of the meatus without taking into account curvature. A more recent classification was described. This classification indicates the - site of urethral meatus (before and after chordee correction) - the prepuce (incomplete or complete) -the glans (cleft, incomplete cleft or flat) - the width of urethral plate, the degree of penile rotation if present and the presence of scrotal transposition

10. Indications for operation Functional indications : 1. Proximally located meatus 2. Ventrally deflected urinary stream 3. Meatal stenosis 4. Curved penis. The cosmetic indications which are strongly linked patient’s future psychology, are: 1. Abnormally located meatus 2. Cleft glans 3. Rotated penis with abnormal cutaneous raphe 4. Preputial hood 5. Penoscrotal transposition 6. Split scrotum.

11. Pre operative Consideration Timing of surgery: Recent studies showed that the ideal time for hypospadias correction is between 3 and 15 months as the penis grows less than 1 cm during the first 3 - 4 years

12. • Healing seems to occur more quickly and with fewer scars, and young infants overcome the stress of surgery more easily. • This age seems to insulate most children form the psychologic , physiologic, and anaesthetic trauma associated with hypospadias surgery .

13. Pre operative Consideration HCG 250-500 U sc twice a week for 3 weeks . Increase in penile size and length Decrease in hypospadias and chordee severity Increased vascularity and thickness of corpus spongiosum Allowance of more simple repairs IM testosterone enanthate – 2mg/kg/dose given for a total of 2 or 3 doses before hypospadias repair Testosterone propionate cream – 2% three times daily for 3 weeks cxxxa Preoperative Hormonal Stimulation

14. GENERAL PRINCIPLES OF HYPOSPADIAS REPAIR ORTHOPLASTY URETHROPLASTY MEATOPLASTY GLANULOPLASTY SKIN COVERAGE

15. ORTHOPLASTY Preoperative assessment cannot accurately predict either the extent of curvature or the means required for straightening Curvature up to 30 degrees can be corrected by midline dorsal plication into the tunica albuginea of the corpora cavernosa directly opposite the area of greatest bending

16. VC greater than 30 degrees -Multiple plications using 5-0 to 4-0 polypropylene, loss of penile length increase when more than one plication is performed . -Ventral lengthening traditionally involves transection of the urethral plate followed by transverse incision from the 3- to 9-o’clock position into the tunica albuginea to expose erectile tissues of the corpora in the region of greatest curvature.

17. - The resultant defect has been closed using dermal grafts, small intestine submucosa , or tunica vaginalis flaps or grafts.

18. - VC that persists despite mobilization of the urethral plate and urethra requires urethral plate transection for straightening.

19. Urethroplasty

20. Different tissues used for correction of hypospadias Although the penile repairs can be grouped into 8 major principles, depending on the tissues used Basic principles or tissues: mobilisation of the urethra skin distal to the meatus skin proximal to the meatus preputial skin combined prepuce and skin proximal the meatus scrotal skin dorsal penile skin different grafts .

21. Choice of operative technique for Midshaft Hypospadias In a consecutive series of boys with midshaft hypospadias none had VC greater than 30 degrees, indicating the urethral plate can be maintained for urethroplasty in most cases (Snodgrass andYucel , 2007). Accordingly, options for repair include:- TIP repair preputial flap

22. TIP REPAIR The Tubularized Incised Plate repair (Snodgrass 1994) is based on the assumption that midline incision into the urethral plate may widen it sufficiently for urethroplasty without stricture There are two important criteria to achieve good results: -the urethral plate should not be less than 1 cm wide . - there should be no distal deep chordee . The technique has gained popularity because it is easily performed, with few complications and results in a slit like meatus .

23. STEPS A 5–0 polypropylene suture is place into the glans for traction and to later secure the urethral stent. When circumcision is the desired result care is taken to preserve sufficient inner prepuce Then the penis is degloved to near the penoscrotal junction. If the foreskin is to be reconstructed the skin incision extends from the corners of the dorsal preputial hood to 2 mm proximal to the meatus . Ventral shaft skin is released until normal dartos tissues are encountered. An artificial erection confirms the absence of ventral curvature, but if there is significant bending a midline dorsal plication is done using a single 6–0 polydioxanone suture placed in the tunica albuginea of the corpora cavernosa directly opposite the point of maximum curvature

24. Next, longitudinal incisions are made along the visible junction of the glans wings to the urethral plate. Proposed lines for incision are first infiltrated with 1 : 100 000 noradrenaline or a tourniquet is used around the base of the penis for haemostasis . After making the skin incision, complete the dissection and glans wings mobilization using tenotomy scissors,.

25. The key step in the procedure is midline incision of the urethral plate . The relaxing incision is made from within the meatus to the tip of the urethral plate. It should not be carried further distally into the glans . The depth of incision depends upon whether the plate is grooved or relatively flat, but in all cases extends down to near the corpora cavernosa . Figure c: A 6 F Silastic stent is passed into the bladder and secured to the glans traction suture. Then the urethral plate is tubularized beginning at the neomeatus , using 7–0 polyglactin suture. The first suture is placed through the epithelium at a point just distal to the mid glans so that the meatus has an oval, not rounded, configuration. Tubularization is completed with a running two-layer subepithelial closure, turning all epithelium into the neourethral lumen.

26. A dartos pedicle flap is dissected from the preputial hood and dorsal shaft skin in patients undergoing circumcision. Then button-holed and transposed ventrally to cover the entire neourethra . When the foreskin is reconstructed this layer is not accessible.

27. Glansplasty is a key determinant of the final cosmetic outcome. Begins with a 7–0 polyglactin suture through the epithelium at the desired point for the ventral lip of the meatus . A second 7–0 suture is placed subepithelially in this same location to further buttress the neomeatus No attempt is made to secure the glans to the underlying neourethra . The remainder of glans approximation is then done using interrupted 6–0 polyglactin subepithelial sutures proximally to the corona.

28. Skin closures also use subepithelial 7–0 polyglactin sutures to minimize the risk of suture tracks. During circumcision the dorsal hood is incised down the midline to the level of the subcoronal collar of the inner prepuce. ventral shaft skin is approximated up the midline, simulating the normal median raphe . When the foreskin is reconstructed the inner prepuce is first closed with interrupted sutures, then dartos is approximated, and finally the outer shaft skin is sewn, giving a three-layer closure.

29. PREPUTIAL FLAP Onlay Island Flap The Onlay Island Flap is ideal for patients with proximal hypospadias without deep Chordee .

30. OPERATIVE STEPS - Onlay Island Flap The tip of the neo- meatus is identified. A midline vertical incision is made in the glans until the width of the glanular groove is adequate for the meatus . The vertical incision is left open without closure for secondary epithelialisation . A subcoronal incision is made around the glans . The incision continues on either side of the urethral plate at the junction with the normal ventral skin, then up on either side of the glanular groove to the apex of the glansplasty . The skin is degloved from distal to proximal close to the Buck's fascia preserving the arteries that constitute the pedicle to the preputial flap.

31. The pedicle is then separated from the outer preputial skin in a plane just below the intrinsic blood supply of the outer prepuce. A 1-cm wide onlay flap is prepared from the inner prepuce. The onlay flap is sutured into place beginning with the suture line underneath the pedicle utilizing running 7-0 polyglactin suture. The glans should be drawn together setting up the first stitch of the glansplasty ventrally at its apex. The mobilized glans wings are rotated medially around the neo-urethra. Three transverse mattress sutures maintain firm approximation of the glanular wings in the midline.

32. Tubularized preputial flap.

33. Koyanagi flap

34. ASSESSING SURGICAL OUTCOMES The goal of hypospadias repair is to improve function and appearance as near to normal as possible. Therefore, success requires more than straightening curvature and extending the urethra to the glans . cosmetic results are as important as functional outcomes

35. COMPLICATIONS 1. Fistulas Urethrocutaneous fistulas are the most common complication. -overlapping suture lines from urethroplasty and skin closure potentially increase likelihood for fistulas -other factors such as larger suture size (4-0) and different suture materials (catgut, horsehair)

36. Technical steps thought to reduce fistula risk include two-layer subepithelial closure of the neourethra and subsequent coverage with a barrier flap, usually dartos . Fistulas occasionally close spontaneously, and there are anecdotal reports that fibrin glue can promote closure. The majority require reoperation

37. 2.Meatal Stenosis Obstructive narrowing at the neomeatus can result from technical error, ischemia, or balanitis xerotica obliterans (BXO). Tubularization of the urethral plate too far distally is most likely the main cause for meatal stenosis after TIP repair. plate should not be tubularized beyond approximately the mid- glans point, leaving an oval terminal opening. Mistaken belief that the glans wings must be sutured to the neourethra probably has caused some to extend plate tubularization too far distally to approximate the wings without leaving a glanular hypospadias .

38. 3. Neourethra Stricture Strictures of the neourethra , like meatal stenosis , may indicate technical error, ischemia, or BXO. The most common site for neourethral strictures is at the proximal anastomosis of the neourethra to native urethra inflap and graft repairs. Circumferential anastomoses have been considered at greater risk for stricture.

39. 4.Dehiscence Partial or complete wound separation results in recurrent hypospadias . Causes potentially include technical factors (suture materials and/or technique during glansplasty ), glans size, traumatic catheter displacement, or wound infection.

40. 5.Diverticulum Ballooning of the neourethra during voiding with subsequent postvoid dribbling indicates diverticulum formation. Contributing factors include distal obstruction, turbulent urinary flow, and ability of tissues used for urethroplasty to expand. Accordingly, diverticula are most often noted after tubularized preputial flap repairs and are rarely encountered after tubularization of the urethral plate or buccal grafts.

41. 6. Balanitis Xerotica Obliterans Late development of meatal stenosis or neourethral stricture can indicate BXO. A characteristic white appearance to involved tissues. Development of obstruction several years after apparently successful urethroplasty . The importance of recognizing BXO is that repair requires excision of all involved tissues and their replacement with nonskin tissues, usually buccal mucosa,because reoperation using skin results in high recurrence rates.

42. REOPERATIONS

43. THANK YOU