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Hypospadias.ppt

methes
hadidi paper
oxford plastic surg

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Hypospadias.ppt

  1. 1. HYPOSPADIAS BY: DR AKASHA AMBAR PGR P& R S UNIT BVH BWP
  2. 2. Anatomy: penile anatomy
  3. 3. Urethral anatomy:  3 segments: prostatic,membranous,spongy  Posterior urethra:prostatic + membranous  Anterior urethra: bulbous : pendolous(penile)  Transitional epithelium (except navicular fossa)
  4. 4. Undifferentiated gonads ovaries testes Y- chromosome Leydig cells Sertoli cells Anti-mullerian hormone Inhibits mullerian ducts Tubes, uterus, vagina Testosterone 5a-reductase Dihydrotestosterone Genital tubercle Penis Penile growth Maintain wolffian ducts Epididymis, Vas deferens clitoris
  5. 5. Embryology: Genital tubercle at caudal end of cloaca Develops a groove on its ventral surface Corpus spongiosum 8 weeks 9 weeks Urogenital membrane Coronal meatus 6 weeks Urethral mucosa Definitive urethral groove Genital folds fuse progressively over urethral groove posterior to anterior, thus advancing meatus to coronal position Elongates Urethral plate Followed by mesodermal cuff Penoscrotal meatus Swellings on either side, Genital folds 12 weeks Penile fascia Glans forms around distal urethra, ectodermal ingrowth forms glanular urethra
  6. 6. Hypospadias  abnormality of anterior urethral and penile development in which the urethral opening is ectopically located along the ventral aspect of the penis proximal to the tip of the glans.
  7. 7. Clinical features  Abnormal meatal opening along ventral aspect of penoscrotal tissue or even on peineum  Abnormal ventral curvature and developmental anomaly of ventral penile tissue (skin upto urethral plate)  Hooded prepuce (“feminization of male genitalia”)  Praurethral sinuses
  8. 8. Associated conditions:  Cryptorchidism  Bifid scrotum  Inguinal hernia  Renal tract malformations
  9. 9. Association with syndromes  approximately 200 recognized syndromes  Hand-foot-genital syndrome  OPITZ syndrome  WAGR syndrome  (Wilm’s tumor, Aniridia,Genital anomalies,mental Retardation)
  10. 10. Incidence & etiology:  1 in 100 to 1-400 live male births  Etiology; unknown  Believed as multifactorial process  GENETIC FACTORS:  Gene mutations  ENVIRONMENTAL FACTORS:  Increasing maternal age  Fertility drugs  Antiepileptic drugs  Low birth weight  Pre-eclampsia
  11. 11. Chordee  Abnormal ventral curvature of penis  Hypoplasia and longitudinal shortening of ventral tissue(skin,urethra,fascia,corpora)  Mesenchymal tissue(C.S and fascias) ; fibrous tissue  Chordee without hypospadias  Rare,late in children as downward curved erection  Normal meatus position and hypoplastic shortened ventral tissues
  12. 12. Types of chordee  Devine and Horton classified chordee into  type I (skin tethering)  type II (fibrotic dartos and buck’s fascia)  type III (corporal disproportion)  type IV (congenital short urethra)
  13. 13. Approach towards management:  preoperative assessment :  History  general physical examination  local examination and examination of associated deformities  Systemic examination
  14. 14. Local examination:  Measure:  the size of the phallus  glans cleft (flat, incomplete, or complete)  location and size of the meatus (type of hypospadias and meatal stenosis or mega-meatus)  urethral plate width (<1 cm or ≥1 cm)  type of chordee  prepuce (complete, incomplete, circumcised)  penile torsion (clockwise, anticlockwise)  shape of the scrotum (normal, penoscrotal transposition)  associated anomalies (cryptorchidism, inguinal hernia, persistent Mullerian structures)  urogenital tract anomalies such as pelviureteric junction (PUJ) obstruction, vesicoureteric reflux and renal agenesis which should be excluded by ultrasonographic scan in every hypospadias patient.  Proximal hypospadias with cryptorchidism, enlarged utricle, or penile size <2.5 cm should be investigated for intersex disorders by ultrasonography, hormonal profile, and karyotyping
  15. 15. Timing of surgery
  16. 16.  ANESTHESIA:  G/A and pidural/caudal block or penile block
  17. 17. ■ normal micturition while standing ■ natural appearance ■ normal sexual function
  18. 18. Principals of repair  Surgical expertise  Minimal tissue trauma  minimal/pin-point use of cautery  well-vascularised tension free repair of all layers with epithelial inversion(water proofing)
  19. 19. Successful hypospadias repair
  20. 20. Surgical techniques  3 categories  Historical procedures:  Known by author’s names,  high complication  poor aesthetic results  Textbook operations:  Meatoplasty and glanuloplasty(MAGPI) for coronal & glanular hypospadias  Flip-flap for distal shaft hypospadias  Inner preputial island flaps for more proximal hypospadias  High complication rate,couldn’t achieve slit like meatus  Modern techniques:  Tubularization of remaining plate or it’s replacement with a graft in two stage procedure
  21. 21. Options or chordee release/orthoplasty  Simple degloving of penile skin  Nesbit operation  Heineke mikulicz operation  Dorsal midline plication  Tunica albuginea plication  Corporal rotation  Split & roll technique  Total peile disassembly- perovic
  22. 22. Distal hypospadias  Glanular & subcoronal  Minimal hypospadias;  Meatus position normal  Shape abnormality  Foreskin abnormality  Surgical techniques  GAP/GRAP  MAGPI (Meatal Advancement and GlanuloPlasty Incorporated)  Tubularized Incised Plate Repair (TIP Repair)
  23. 23. GAP/GRAP (Glanular Approximation Procedure/Glanular Reconstruction And Preputioplasty)  Uses: distal hypospadias with glanular groove  Anesthesia: both G/A and caudal anesthesia  Glans groove tubuarized  Distal suture is critical in determining location of meatus  2 layered closure of neourethra with water proof closure  Results in slit like meatus  Preputital reconstruction with independent inner & outer layer closure
  24. 24. Double-Y Glanuloplasty
  25. 25. MAGPI (Meatal Advancement and GlanuloPlasty Incorporated)  glanular and coronal hypospadias  Duckett  Meatal regression if used in immobile urethral meatus.  Complications: meatal retraction,stenosis and fishmouth meatal opening  No slit like meatus achieved
  26. 26. Tubularization techniques:  Thiersch (1869) and Duplay (1880)  initial descriptors of the simple urethral plate tubularization technique; known as the Thiersch-Duplay urethroplasty.
  27. 27. Tubularized Incised Plate (TIP Urethroplasty)/ Snodgrass Repair  Initially used for distal, but used equally for midshaft and proximal  easily performed, with few complications and results in a slit like meatus  Complications: meatal stenosis, persistent fistula, functional urethral obstruction and persistent chordee  5-35 % in distal hypospadias and upto 65 % in proximal hypospadias.
  28. 28. Snod-Graft Repair
  29. 29. Flip-Flap procedure (Mathieu’s Meatal Based Flap)
  30. 30. MIDDLE HYPOSPADIAS PROCEDURES:  a. Tubularization Techniques:  TIP Urethropasty (Snodgrass)  Mathieu fip-flap technique  Duckett’s Tubularized Preputial Island Flap (TPIF).  b. Onlay Techniques:  Onlay Island Flap (OIF) technique  Double-Onlay Preputial Flap
  31. 31. Proximal Hypospadias  I. One-Stage Repair.  a. Tubularization Techniques  TIP Urethropasty (Snodgrass repair)  Tubularized inner Preputial Island Flap (TPIF)  b. Onlay Techniques:  Onlay Island Flap (OIF) technique  Double-Onlay Preputial Flap  Onlay-Tube/Onlay Urethroplasty.  II. Two-Stage Repair.  Glans-Splitting Bracka Technique
  32. 32. 2 stage Glans Splitting Bracka Technique
  33. 33. Inner Preputial Island Flap  Inner preputial skin islanded and used as:  A complete tub  Onlay flap  Sutured to urethral plate to augment another technique
  34. 34. Onlay Island Flap  Proximal with deep chordee
  35. 35. Sutures, Dressings, Urinary Diversion, Catheters  Absorbable sutures: 6-0 or 7-0  vicryl(polyglactin)  PDS(poly Dioxanone)  Monocryl(poliglecaprone)  Usually no dressing; various forms of dressings (tegaderm/foam)  Stent must be placed; sutured to glans( leaves marks); a balloon catheter taped with abdomen (preferrable)  8FrG silicon catheter used in paediatric age group  Rubber catheter avoided  Fine bore tubing working on siphon action can be used  Postoperatively:  ketoconazole( prevent androgen production from testes and adrenals, prevents erection) or CYPROTERONE ACETATE  Oxybutynin (DITROPAN)(prevents bladder spasm)
  36. 36. Complications:  Early:  Bleeding/ hematoma  Infections  Late:  Fistula  Meatal stenosis  stricture  Urethral diverticulum  Persistent chordee  Skin assymetries  BXO
  37. 37. Complications:  Urethrocutaneous fistula
  38. 38. Complications:  Meatal problems:  Stenosis  Techniques:  cicumferential suture line at meatus  Urethral plate midline incisions extends onto glans  Minor: dilatation  Severe: meatoplasty or redo with two stage procedure
  39. 39. Complications:  Striture:  At junction of neourethra and original urethra  Entire urethral repair  Minor and early menifestation: dilatations  Severe or late occurrence : urethroplasty/redo
  40. 40. Complications:  Skin problems:  Minor skin assymetries (correction with surgery)  Lichen sclerosus et atrophicus( balanitis xerotica obliterans)  Pre-malignant for SCC  Results in phimosis, involving repair,it may cause meatal stenosis, strictures  Minor: topical steroids  Severe: excise all skin and redo in two stage with buccal graft (no skin graft as recurrence of LSEA is high)
  41. 41. Treatment Algorithm If deep sulcus on glans? Yes If significant chordee Yes Can curvature be corrected by dorsal plication Yes No No If a dense bar distal to meatus Yes TIP urethroplasty No GAP No Two staged Repair If foreskin repairable? Yes preputioplasty No Circumcision
  42. 42. THANK YOU
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