HIPOSPADIA

HYPOSPADIAS

abnormal meatus
abnormal prepuce
abnormal ventral aspect
ventral curvature
 Classification

Hypoplasia
Glans
Penile skin / foreskin
AND Corpus spongiosum
Corpus cavernosum
Testicles
 Timing of surgery
• Ideal age 6 – 24 months
• No added risk of anesthesia after 6 months
• Sufficient development
• Sexual orientation and parental bonding is
less affected
• Easy to manage post-op
• 3-6 years → least satisfied with penile
appearance. Miller & Grant, Br J Urol, 1997
• Adolescent → wound healing, erections
 Steps of Successful
Hypospadia Repair
(treatment principles)
• Penile Straightening / correct chordee / ventral
curvature (orthoplasty)
• Urethroplasty
• Glansplasty
• Scrotoplasty
• Skin Coverage

COMPLEX SURGERY !!
Objectives
What is a good outcome?
A functional and cosmetic satisfying results:
• Good glandular cosmesis
• A slitlike urethra
• A straight penis
• No torsion on the penis
• A good caliber of urine
• Little scar tissue
• One stage when possible
• Happy parents
• Define anatomy well
• Choose the technique for the
anatomy

Individual Phenotype needs individual repair

 Treatment of proximal hypospadias

• Tubularized Incised Plate (TIP)

• Onlay island flap repair
• Transverse Tubularized Island Flap
• Onlay urethroplasty with parameatal
foreskin flap (Koyanagi)
• Two stage
Intraoperative algorithm for hypospadias repair
 Complications
Intra operative early late

Bleeding Blocked tube Persistent chordee

Inadvertent urethrotomy Hematoma Fistula
Infection Meatal stenosis
Spasm Urethral stricture
Erection diverticulum

Persistent chordee
“ most common problem after hypospadias repair “
Etiology: - hematom post op
- graft contraction / flap ischemia
- incomplete removal disgenetic tissue
- corporal disproportion
Proximal hypospadias,which technique and why?
Complications and results

Complications

fistula cosmesis Stitch

marks

prolaps
 Conclusions
• Hypospadias repair is a complex surgery
• First surgery most critical
• Long term follow-up essential
Thank you
 TIP
- surgical technique
(Snodgrass 1994)

1. Circumscribing incision made

2mm proximal to the meatus.
2. The urethral plate is separated
from the glans by parallel
incisions and the glans wings
are mobilized.
3. Midline relaxing incision of the
plate (down to the corpora
cavernosa)
4. Tubularization of the plate
over 6 F stent

Retik and Borer,World J.Urol. 1998

 TIP
- surgical technique
(Snodgrass 1994)

4. Tubularization of the plate

over 6 F stent
5. Meatus -generous oval
opening to prevent stenosis
(the first stitch to place at the

midglans level)
6. The neourethra is covered by
a thin dartos pedicle
7. Postoperative stenting
- distal 5-7 days
- proximal 10-14 days

Retik and Borer,World J.Urol. 1998

 TIP- indications
(according to Snodgrass)

Indicated in most hypospadias, even after failed

repairs

Not indicated
• when urethral plate does not appear healthy
• in a short plate which has to be divided
• in a flat or conic glans (Jayanthi 2003)
T.I.P. N Distal hyp. Proximal hyp. All compl.
(compl.) (compl.)
Complications
Snodgrass et al. 148 7% 7%
1996
Snodgrass 2002 33 33 % 33 %
Sugarman et al 32 4% 14 % 6%
1999
Decter and 197 3% 3%
Franzoni 1999

Chen et al. 2000 40 18 % 18 %

Dajanc et al. 2000 25 10 % 20 % 12 %

Riccabona et al. 228 4.1 % 9.6 % 7.8 %

2003
RSCM (2002-2008) 42 10.6 %
 The
flap

The The flap becomes an

‘Plate’ ‘Island’

ONLAY ISLAND FLAP

Onlay Island Flap Urethroplasty

Courtesy of Prof. Nijman

Transverse Preputial Island Flap Repair
Transverse Preputial Island Flap Repair
 Duckett: single island flap
Tube from foreskin
Neo-urethra

Tunnel in Glans
 Duckett:
Double Island Flap

Courtesy of Prof. Konrad

Onlay urethroplasty with parameatal foreskin flap
(Koyanagi)
 The
Modified
Koyanagi
Repair

2 or 3
stage in
1 operation
Thank You