Proximal Hypospadias

• Prevalence of hypospadias in Europe is 18.6 new cases per 10,000 births

• Disruption in the urethral development (8 – 15 weeks of gestation)
• Classification: Distal, Penile, Proximal
• The age at surgery for primary hypospadias repair is usually 6-18 (24)
months

RADMAYR, C., et al. EAU guidelines on paediatric Urology. In: EAU Guidelines, edition presented at the annual EAU Congress Barcelona. 2019.
Woodhouse, Christopher. (2004). Hypospadias Surgery: an Illustrated Guide. European Journal of Plastic Surgery. 27. 10.1007/s00238-004-0627-9.
RADMAYR, C., et al. EAU guidelines on paediatric Urology. In: EAU Guidelines, edition
presented at the annual EAU Congress Barcelona. 2019.
 Proximal Hypospadias

• 1 stage repair
• TIP (Snodgrass), Island Onlay Preputial Flap & Tubularised Preputial Island Flap,
Koyanagi Repair

• 2 stages repair
• Thiersch-Duplay, Bracka
Tubularized Incised Plate Urethroplasty (TIP)

• First described in 1994 by Warren Snodgrass “Midline incision into the urethral
plate widens it sufficiently for urethroplasty and heals without stricture”
• Chordee < 30’, greater curvature prompts urethral plate transection and so
precludes TIP repair.
• Urethral plate must be supple and not grossly scarred.
• Reported outcomes of TIP reoperations are encouraging, with complications
noted in 15-24% of patients.
• The most common probem has been fistulas, especially when barrier layers
were not used between the neourethra and skin.
HADIDI, Ahmed, et al. (ed.). Hypospadias surgery: an illustrated guide. Springer Science & Business Media, 2013.
 Island Onlay Preputial Flap
&
Tubularised Preputial lsland Flap

• The concept of a vascularized preputial island flap was introduced by Hook

in 1896  refined by Asopa in 1971, who developed the first very effective
use of inner preputial skin for a substitution  Duckett developed this by
describing a transverse island tube repair in 1980.
• This was an era when it was presumed that if there was a need for a
substitution urethroplasty, the urethral plate would be abnormal and
require division  since the plate was of elastic tissue, it would retract.
• Cumulative complication rates ranged from 15% to 46%.
SNODGRASS, Warren; BUSH, Nicol. Primary hypospadias repair techniques: A review of the evidence. Urology annals, 2016, 8.4: 403.
HADIDI, Ahmed, et al. (ed.). Hypospadias surgery: an illustrated guide. Springer Science & Business Media, 2013.
Island Onlay Preputial Flap
Tubularised Preputial lsland Flap
 Koyanagi-Nonomura One-Stage Repair

• The first reported the technique was Koyanagi in 1984, then refined by
Nonomura in 1992.
• Used to deal with severest case of hypospadias.
• Only few dared to perform such case in one stage.
• Experts considered staged repair preferable in this group of children.
• Primary success was obtained in 53%  secondary repair, satisfactory result
was 90%
• Complication rate of 40% is certainly higher than that of distal hypospadias,
where less than 5%
 Thiersch-Duplay

• The first to publish the technique was professor Thiersch in 1869, he

tubularized the urethral plate to form the urethral canal
• In 1874 Duplay tubularized the urethral plate distal to the urethral orifice
• Low complication rate compared with one stage repair (5%)
 Bracka’s Technique

• Humby in 1941 is the first person to use skin grafts and that of buccal
mucosa.
• Turner-Warwick used the technique for adult surgery.
• Bracka in 1995 popularised this technique for primary hypospadias, the
complication was fistula (5.7%) and stricture (7%)