Hypospadias.ppt
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This document provides information about hypospadias, including: - The embryology of normal penile development and how hypospadias occurs due to abnormal anterior urethral and penile development. - The clinical features of hypospadias such as an abnormal urethral opening along the ventral penis and abnormal ventral curvature. It can be associated with other genital anomalies. - The various surgical techniques used to repair hypospadias depending on its location, from distal techniques like MAGPI to techniques for more proximal hypospadias like tubularized island flaps or multistage repairs. - Post-operative considerations like catheters, dressings and potential
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Hypospadias.ppt
- 1. HYPOSPADIAS BY: DR AKASHA AMBAR PGR P& R S UNIT BVH BWP
- 3. Urethral anatomy: 3 segments: prostatic,membranous,spongy Posterior urethra:prostatic + membranous Anterior urethra: bulbous : pendolous(penile) Transitional epithelium (except navicular fossa)
- 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. 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. 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. 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. Associated conditions: Cryptorchidism Bifid scrotum Inguinal hernia Renal tract malformations
- 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. 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
- 12. 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
- 13. 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)
- 14. Approach towards management: preoperative assessment : History general physical examination local examination and examination of associated deformities Systemic examination
- 15. 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
- 18. ANESTHESIA: G/A and pidural/caudal block or penile block
- 19. ■ normal micturition while standing ■ natural appearance ■ normal sexual function
- 20. 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)
- 23. 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
- 25. 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
- 26. 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)
- 27. 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
- 29. 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
- 30. Tubularization techniques: Thiersch (1869) and Duplay (1880) initial descriptors of the simple urethral plate tubularization technique; known as the Thiersch-Duplay urethroplasty.
- 31. 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.
- 35. Flip-Flap procedure (Mathieu’s Meatal Based Flap)
- 36. 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
- 37. 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
- 38. 2 stage Glans Splitting Bracka Technique
- 39. Inner Preputial Island Flap Inner preputial skin islanded and used as: A complete tub Onlay flap Sutured to urethral plate to augment another technique
- 40. Onlay Island Flap Proximal with deep chordee
- 41. 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)
- 44. Complications: Early: Bleeding/ hematoma Infections Late: Fistula Meatal stenosis stricture Urethral diverticulum Persistent chordee Skin assymetries BXO
- 46. 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
- 47. Complications: Striture: At junction of neourethra and original urethra Entire urethral repair Minor and early menifestation: dilatations Severe or late occurrence : urethroplasty/redo
- 48. 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)
- 51. 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
- 52. THANK YOU
Notes de l'éditeur
- 5 layers: skin: expandable,pliable,high vascular network, separate blood supply than the deep fascias and tissues Superficial fascia(dartos fascia);continuation of membranous layer of groin and perineum(colles fascia),abundant vascular supply(superficial dorsal penile vein and arteries) 3rd: loose connective tissue( tela subfascialis of eberth) 4th: deep buck’s fascia enclosing deep dorsal penile arteries and vein and corpora spongiosa and corpora cavernosa 5th: tnica albuginea; double layer,covers corpora cavernosa only
- SRY Gene; Sex-determining zone of y chromosome Testicular cells(lydig cells; FSH,LH/ sertoli cells: testosterone) Failure of Dihydrotestosterone stimulation of genital tubercle; hypospadius
- Urethral plate endodermal growth from cloaca into ventral aspect of gential tubercle Corpora and penile fascia mesenchymal tissue grows along urethral plate Genital folds fuse ventrally; advance meatal opening from proximal to distal An ectodermal ingrowth meets tubularized urethral plate at coronal level prepuce skin fuses ventrally
- Based on meatal opening location ( more specifically) after release of chordee ANTERIOR,MIDDLE AND POSTERIOR ,classification is most acceptable –OXFORD plastic surgery
- Tolerance to anesthesia: 6 months Uncooperative after 18 months to 3 years so never do surgery during this period Difference in penile size between 1 year and preschool age: 8 mm only 6–18 months; most suitable age next window of surgery is preschool age (3-4 years)
- Medical or hormonal management : HCG, testosterone topical or injectible
- 1. Meatal advancement techniques (MAGPI) 2. Onlay tchniques (Mathieu;s flip flap, inner preputial island onlay) 3. Inlay technique: a vascularized flap tubed as a neourethra (MUSTARDE’S REPAIR which is similar to Mathieu’s, duckett’s inner preputial island tubularised flap, harris technique using inner preputial skin for tube flap as neourethra and outer preputial flap for skin cover.)
- If groove is not deep: TIP is used Always check for chordee, can use artificial erection test
- (a) A circumferential incision 0.5cm below the corona. (b) The transverse bridge of the tissue distal to the meatus is sharply incised. (c) A Heineke-Mikulics closure opens and advances the meatus. (d) The ventral meatal edge is pulled distally and the exposed glans edges are trimmed and approximated. (e) Glanuloplasty is performed with subepithelial sutures to leave a rounded, conical glans. (f) The dorsal skin is transferred ventrally, excess skin is excised.
- based on the assumption that midline incision into the urethral plate may widen it sufficiently for urethroplasty without stricture. two important criteria to achieve good results: the urethral plate should not be less than 1 cm wide and there should be no distal deep chordee After torniquet placement,traction suture is placed in the glans just beyond the anticipated neomeatus, circumscribing skin incision proximal to the meatus,shaft skin degloved to penoscrotal junction. "U" shaped incision, urethral plate separated from glans wings, relaxing incision using scissors in midline from within meatus to end of the plate, stent secured into the bladder, Tubularization of urethral plate completed with 2 layer closure. adjacent dartos tissues used to cover the neourethra,then a dartos pedicle is developed from the dorsal shaft skin, button-holed, and transposed to the ventrum to additionally cover the repair.coronal skin approximated after glanuloplasty. Byars' flaps are created from the preputial skin to mimic the median raphe The stent is removed approximately 1 week later.
- Very effective Sagitally slit meatus Least complication rates
- Progression of snod grass repair If urethral plate;poorly developed, single stage snod grass is converted into staged procedure 1st stage,incision is given in midline, it is grafted 2nd stage, 3-6 months later; without midline incision, urethral plate is tubularized
- for coronal, subcoronal and distal penile defects measure the length of the defect from the urethral native meatus to the glans tip, After a straight penis is either appreciated or achieved with an orthoplasty technique, the premeasured segment of penile skin proximal to the meatus is mobilized off of the urethra in a proximal to distal direction Patulous meatus
- Proximal/distal variety with flat glans or severe chordee: two staged techniques
- Midline incision given from proposed meatus to downward ectopic meatal opening, lateral incisions given,midline incision through glans is deepened enough so corpora become separated,chordee released and all scarred tissue and urethral plate excised,defect covered with a graft(preputial skin or buccal mucosal graft..it is held in place by tie over dressing. After 6 months,2nd stage; preliminary erection test to check for any chordee,then u shaped incion and tubularization performed,glansplasty
- high complications as too much dissection, risk of hemorrhage and flap necrosis Cicumferential suture line at meatus tip & junction of native and neourethra
- tip of the neo-meatus is identified midline vertical incision in the glans,left open for secondary epithelialisation subcoronal incision around the glans, incision continues on either side of the urethral plate, then up on either side of the glanular groove to the apex of the glans skin is degloved 1-cm wide onlay flap is prepared from the inner prepuce. The onlay flap is sutured into place. 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.
- 1.More proximal the original meatus,greater the risk,it can be repaired if distal to leak,urethral caliber is adequate,otherwise redo it. 2.
- Balanitis: inflammation of glans Phimosis: tight foreskin around glans that can not be pulled back
- Dorsal plication has shortening effect on phallus, not advised for severe chordee Asses relation of glans sulcus to meatus, if both adjacent, do GAP, f some dense tissue inbetween two do TIP If hypospadiac meatus opens directly into glans groove: MEGAMEATUS After GAP,TIP or two stage repair: assess foreskin condition