HYPOSPADIAS Dr.GOVINDRAJAN Department of Urology and Renal Transplantation SRMC & RI NORMAL PENILE ANATOMY 2 Corpora Cavernosa, Corpus Spongiosum Enclosed In A Fascial Sheath- T.Albuginea Bucks Fascia, Thick Fibrous Envelope Connective Tissue, Dartos Fascia HYPOSPADIAS Hypo- below, Spadon- orifice Urethral meatus opens on ventral side of the penis, proximal to the tip of glans penis Incidence ……..1/125 to 1/250 EMBRYOLOGY Cloacal membrane, genital tubercle, labioscrotal swellings Androgen stimulation…phallus elongation 3 phases of urethral formation Posterior urethra formation Anterior urethra formation Glandular segment formation Prepuce formation CLASSIFICATION Smith …….. Able …….. I , II, III degree Browne …….. Coronal - distal penile, proximal penile, penoscrotal, scrotal penile Basrat …….. (post chordee release) CLASSIFICATION (LOCATION) DISTAL Glandular, Coronal, Distal penile MIDPENILE Midshaft PROXIMAL Proximal penile, Penoscrotal, Scrotal, Perineal ASSOSIATION WITH OTHER DEFECTS Renal agenesis, dysplasia, reflux Prostatic utricle Hernia : 9% Cryptorchidism : 9% Father : 9% Siblings : 14% PARTS OF HYPOSPADIAS Meatus … usually non-stenotic Stenosis more common in distal hypospadias Megalomeatus intact prepuce SKIN….. Ventral defect & dorsal hood Urethral delta Hood of monk….Cobra eyes Defects of spongiosum Defects of cavernosa Defective urethral plate CURVATURE Skin attachments Bucks defect Urethral plate Cavernosa defects Problems of unhealthy urethra CHORDEE WITHOUT HYPOSPADIAS Primary penile curvature Types Without defects With defects Penile torsion Deviation to left Concealed hypospadias (2/3) (1/3) DEVINE HORTON CLASSIFICATION TYPE I : SPONGIOSUM DEFECT TYPE II : BUCKS & DARTOS DEFECT TYPE III : DARTOS & SKIN DEFECT HYPOSPADIAS & INTERSEX ? Form of androgen insufficiency Mixed gonadal dysgenesis Androgen insensitivity Testosterone synthesis defects 5 alpha reductase defects FEATURES OF REPAIR Artificial erection ( Gittes & McLaughlin) Meatal correction Neourethral formation Orthoplasty Skin cover…. Neourethral cover Dorsal prepuce : Tunica Vaginalis Time of repair : 6months - 12months CORRECTION OF CHORDEE AFTER ORTHOPLASTY Nesbitt plication T.A.P Dermal graft T.Vaginalis graft Corporal resection HCG BEFORE SURGERY Increase in penile length Meatal advancement by 5-20mm Decrease in hypospadias Decrease in chordee Increased vascularity Increased corporal thickness both proximal & distal TREATMENT OPTIONS GLANDULAR & SUBCORONAL MAGPI GAP MIP DISTAL PENILE MATHEIU SNODGRASS DEVINE HORTAN MUSTARDEE TREATMENT OPTIONS… MIDPENILE SNODGRASS ONLAY ISLAND PREPUTIAL FLAP KING HODGSON II PROXIMAL PENILE TRANSVERSE PREPUTIAL FLAP HODGSON I HODGSON III TREATMENT OPTIONS… POSTERIOR URETHRA TRANSVERSE PREPUTIAL FLAP TWO STAGED BUCCAL….TUBULAR….GLANS CHANNEL BAYRS… CECIL SMITH COMPLICATIONS BLEEDING & HEMATOMA MEATAL STENOSIS URETHROCUTANEOUS INFECTION URETHRAL DIVERTICULA RECURRENT CURVATURE / STRICTURE BREAK DOWN
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