HYPOSPADIAS

LUMINA.S
M.Sc nursing (child health)
 DEFINITION

‘’Hypospadias is a developmental anomaly characterized by

a urethral meatus that opens on to the ventral surface of the
penis, proximal to the end of the glans’’
(ASHCRAFT)
 EMBRYOLOGY
Normal Phallic development occurs in weeks of 7-14 WOG
By 6 WOG ,genital tubercle is formed anterior to the
urogenital sinus
In the next week, two genital folds form caudal to the
tubercle & a urethral plate forms between them
The formation of the penile urethra is thus generally
completed by the end of 1st trimester
CONT….
This sequence probably accounts for the
predominance of glanular & coronal hypospadias
Mesenchymal tissues dorsal to the developing urethra
forms Buck’s fascia, Dartos fascia & Corpus
spongiosum
It is the tissue that normally surrounds the urethra &
communicates with erectile tissue of glans
CONT….
Buck’s fascia is the deep layer of fascia that surrounds
corpus bodies & invests spongiosum

Superficial to this layer is Dartos fascia which is loose

subcutaneous layer that combines superficial veins &
lymphatics

These structures form subsequent to completion to

urethra by medial fusion of outer genital folds,
proceeding from proximal to distal aspect of penis
CONT….
This development accounts for how a fully formed urethra
can have a poorly formed spongiosum with thin overlying
skin & ventral tethering , the meatus being located at the tip
of the glans
Finally ,the prepuce is formed originating at the coronal
sulcus
It gradually encloses the glans circumferentially
Arrested development of the urethra may leave the meatus
located anywhere along the ventral surface of penis
CONT….

Typically this would lead to foreshortening

of the ventral aspect of the penis distal to
meatus & failure of prepuce to form
circumferentially
 HISTORICAL
PERSPECTIVES
The first description of Hypospadias & its surgical
correction was reported in the 1st & 2nd centuries by
the Alexandrian surgeons, Heliodorus & Antyllus

In 1874,Theophile Anger reported the successful

repair of a Penoscrotal hypospadias using technique
of 1869 in which lateral skin flaps were tubularized to
form the neourethra
CONT….
Edmond in 1913 was the first to describe the transfer
of prepuital skin to the ventral aspect of penis

Improved techniques in preputial & meatal-based

vascularized flaps since the 1970s -1980s have greatly
advanced hypospadias repair
 1. INCIDENCE
Incidence estimated to be between 0.8 & 8.2 per
1000 live births

If minor hypospadias are included ,incidence is 1 in

125 live male births

Familial tendencies have been identified in 8% of pts.

CONT….
14% of male siblings of an index child have
hypospadias & if 2 members of family have
hypospadias ,the risk for the disorder is 21%

Cause is still unknown ,but most likely polygenic

because of higher familial incidence
2.CLASSIFICATION
1) ANTERIOR HYPOSPADIAS (71%)
 Glanular- Meatus situated on the inferior surface of
the glans
 Coronal
 Anterior Penile

2) MIDDLE HYPOSPADIAS (16%)

 Meatus situated in the middle third of the shaft
3)POSTERIOR HYPOSPADIAS (13%)

 Meatus situated in the posterior third of the shaft

 Penoscrotal - Meatus at base of the shaft in front of
the scrotum
 Scrotal- Meatus behind the scrotum
 Perineal- Meatus behind genital swellings
 3.Etiology
 A combination of Endocrine, Environmental &
Genetic factors determine risk for developing
HYPOSPADIAS
A defect in the androgen stimulation

It is the ultimate cause of hypospadias

Diminished response to HCG in some pt. with
hypospadias
CONT…
Higher incidence in winter conceptions
Weak association between maternal
ingestion of progestin like agents with
disease
No association between oral contraceptives
use before /in early pregnancy
 5.Associated anomalies
Inguinal Hernia & undescended testis ( common)
An enlarged prostatic utricle
Infection
Urinary tract anomalies
Associated myelomeningocele & Imperforate Anus
Upper/lower tract obstructions/ anomalies ,hematuria &
family history of urinary tract abnormalities
Inter sex state
 Elements of Hypospadias anomaly
Meatal Dystopia
o Urethral meatus may only be slightly displaced in a direction
immediately ventral, below a blind dimple at the normal
meatal opening on the glans
o On the other hand, urethra may be displaced so far back in
the perineum (Vaginal hypospadias)
o More distal locations are often associated with a stenotic
meatus
Dermal defects
o The skin of the penis is radically changed as a result of
disturbance in the formation of urethra
o Distal to meatus- skin shows a V-shaped defect(Van Der
Meulen)
o Lateral- 2 raphes obliquely extend from the edge of urethral
delta on the dorsum 1cm apart
o Proximal- thin skin
o Urethral plate is well developed
o Undeveloped act as a tethering fibrous band that bend the
penis ventrally in artificial erection
Penile Curvature
o Caused by deficiency of the normal structure on the ventral
side
o A strand of CT has been stretched like a cord between
meatus & glans giving rise to bowstringing
Penoscrotal Transposition & Bifid Scrotum
o Penis may be caught between the 2 scrotal halves & become
engulfed with fusion of the penoscrotal area
o Boundary between penis & scrotum may be formed by 2
oblique raphes that extend from the very proximal meatus to
dorsal side of the penis
Chordee Without Hypospadias
Defect in the course of urethra
(congenital urethral fistula) & as a
curvature of the penis without
Hypospadias
DIAGNOSIS
 Treatment
Repair done on Out Patient basis
Defect is not ‘’TOO MILD’’ & risk of complications are
not ‘’TOO HIGH’’
Chance to make the normal phallus as normal as
possible should be offered to all children regardless of
severity of the defects
 Age at repair
Most cases repair in 1st year of life
Most surgeons prefer to do in 6months-18months of
age
Anesthetic risk is low, post-operative care is easier
for parents than when child is at toddler age group
 Objectives of repair
1)Complete straightening of penis
2)Placing meatus at the tip of the glans
3)Forming a symmetrical conically shaped glans
4)Constructing a neo-urethra uniform in caliber
5)Completing a satisfactory cosmetic skin coverage
1) STRAIGHTENING

Artificial erection by injection physiologic Saline in

the corpora at the time of operation allows
determination of exact degree of curvature
Curvature secondary to true fibrous chordee requires
division of urethral plate & excision of fibrous tissue
down to the tunica albugenia
CONT…
True deficiency of ventral corporal development can
be treated by making a releasing incision in the
ventral tunica albugenia

Axial rotation of the penis /penile torsion is managed

by releasing the dartos layer as far as proximal as
possible on the penile shaft
2) PLACING THE MEATUS

 Placing the meatus at the tip of the glans has not

always been standard in hypospadias repair
 Risk of complications to be too great
 Surgical techniques- glans channeling & glans
splitting technique are used to reduce complications
 Meatoplasty with or without dorsal advancement
distal urethral mobilization & tubularization /meatal
based flaps are most selected methods
CONT…
 Proximal – creating neourethra with local vascularized
skin flaps/free grafts allows placement of urethra at the
end of penis
 In glanular channeling/glans splitting accomplishes
placement of meatus at the tip of glans
3) Glans Shape
 Conically shaped glans is the objective of the
glansplasty component of repair
 Approximation of well-developed glans wings to the
midline over a neourethra ,in a split glans restores the
glans to its normal conical shape
4) Urethral Construction

Formation of neourethra can be accomplished with local skin

flaps, various types of free grafts /vascularized pedicle flaps
Avoid flaps too thin to avoid risk of less blood supply

Mobilized vascularized flaps of preputium have more relate

blood supply than do free grafts

A water tight closure of the well vascularized neourethra is

formed with care being taken to make it uniform in caliber &
of appropriate size for the age of child
Skin flaps in proximal hypospadias
 Surgical procedures
Because of wide variations in anatomic
presentations of hypospadias, NO SINGLE
URETHROPLASTY is applicable to every case

The versatility & experience to deal with all

variants & options of surgical treatment are KEY
successful management
 Specific techniques
1) ANTERIOR VARIANTS
Some glanular variants are amenable to MEATAL
ADVANCEMENT & GLANULOPLASTY(MAGPI)
A stenotic meatus with good mobility of urethra & a fairly
shallow ventral groove –best suited

Meatal based flap repair may be used if chordee is not

present & if mobile well vascularized skin exists proximal to
the meatus
CONT…
Glans approximation procedure is useful when a wide
mouthed proximal glanular meatus exists with a very deep
groove
Pyramid procedure is well suited for the fish mouth type of
meatus & gives a good cosmetic result

Tubularized Incised Plate Urethroplasty (TIP) involves a

deep longitudinal incision of the urethral plate in the meatus
It allows the lateral skin flaps to be mobilized & closed in
midline without tension
Tubularized Incised Plate Urethroplasty
(TIP)
2) MIDDLE VARIANTS

When no significant chordee is present, TIP repair / Meatal

based flap can sometimes be done
Onlay Island Flap Repair- mobilizing an inner preputial flap on
its pedicle & rotating it ventrally to lay it on the well,developed
ventral urethral plate to complete the tubularization of
neourethra
lateral to the urethral plate
It can be used instead of tubularization pedicle flap which has
higher incidence of complications
3) PROXIMAL VARIANTS

1) Staged procedure in which coverage of the ventrile penile

shaft is attained by rotation of dorsal flap to the ventrum
with later tubularization to form the neourethra
 technical perspectives
Optical magnification : 2.5power-4.5power is
standard
Sutures & instruments: 6.0-7.0 size sutures, small
single toothed forceps & delicate instruments are
preferred
a)Bleeding
complications
b)Infection
c) Devitalized skin flaps
d)Fistula
e)Strictures
f) Diverticulum/ureterocele
g)Persistent Chordee
h)Recurrent multiple complications
i) Sexual function
THANK
YOU