Hypospadia

INTRODUCTION

1.What is hypospadia?
2.Incidence of Hypospadia
3.Kind of hypospadia
4.Why treat hypospadia surgically?
5.Advisable age for the surgical treatment of hypospadia
6.Surgical techniques for hypospadia
7.Hypospadia complications
8.Most-operative assistance for hypospadia
9.Catheter
10.Penis medication
11.Remarks about hypospadia

1.What is hypospadia?

It is a congenital penile pathology characterized by an insufficient urethral development, the external urethral meatus is not at the apex of the glans, but on the ventral penile surface, or in the scrotum or in the perineum. [Fig .S1]

 

ipospadia      
Figura S 1
 
     

It is often associated with congenital ventral penile curvature due to an insufficient development of the ventral side of the penis.
The meatus can be sub-stenotic, causing obstruction to urination.
The penile skin ( prepuce) is absent on its ventral side, and in excess on its dorsal side. [Fig. R].

 

     
Figura R 1
 
     

Hypospadia is often an isolated pathology, but sometimes (10% of the cases), especially in its severe form (scrotal hypospadia) it can be associated with other malformations such as hydrocele, inguinal hernia, kidney malformations, undescended testicles.

Severe cases of scrotal hypospadia or perineal hypospadia can hide asexual ambiguity: in these cases we must perform a cromosomic map to establish the real sex before treat the hypospadia.

 

2.Incidence of Hypospadia

This is a rare pathology (8 out of 1000).
It is genetic that is there are 20% possibilities that the same pathology affects another member of the family (father, brother, son , etc.)

 

3.Kind of hypospadia

There are 3 different types of hypospadia depending on the distance of the urethral opening (meatus) from the apex of the penis: [Fig. S 1]

 

  • ANTERIOR HYPOSPADIA(70% of the cases) the meatus is located near the apex of the penis [Fif. S 2]
     
  • MEDIUM HYPOSPADIA(10% of the cases) the meatus is located on the medium part of the penis, which often has a slight curvature.
     
  • POSTERIOR HYPOSPADIA(20% of the cases) these are the most severe types : the meatus is located at the base of the penis or in the scrotum of in the perineal scrotum. The penile curvature is considerable [Fig. S 3].

     
    Figura S 1 Figura S 2 Figura S 3  

 

4.Why treat hypospadia surgically?

There are three reasons:

 

  • Functional reason:
    • the anomalous location of the meatus prevents urination from a standing position.
    • if the meatus is sub-stenotic , this causes impediment to urination
       
  • Sexual reason:
    • lthe penis curvature will obstacle in the future the penetration of the penis into the vagina
    • the anomalous location of the meatus in the severe cases, prevents ejaculation in the vagina and the possibility of fertilizing the woman.
  • Aesthetical reason:
    • the anomalous appearance of the penis causes severe psychological problems.



This surgical treatment is the anwer to all three reasons ( functional, sexual and aesthetical):

  • Bring the urethral meatus to the apex of the penis and reconstructing the missing urethra
  • Correcting the penis curvature
  • Creating an aesthetical appearance of the penis, the glans and the meatus similar to normal.

 

5.Advisable age for the surgical treatment of hypospadia.

In order to minimize the psychological impact, the surgical operation should take place during the first 18 months of life (the child will not remember the operation) or when he is 5-6 years old, before he starts attending school- It is advisable to avoid the period between 2 and 4 years of age, since it is difficult to manage the child during the post-operative period : moreover the psychological trauma caused by the operation leaves vivid memories.

 

6.Surgical techniques for hypospadia

More than 200 techniques have been described.
The choice of the operation depends on the type of hypospadia, the structure of the penis and the experience of the surgeon.
At present the most frequently used techniques are:

 

  • Mathieu's technique
  • Duckett's technique
  • Snodgrass's technique
  • Bracka's two-stage technique

 

Mathieu's technique:

A strip of skin on the ventral side of the penis is cut an overturned forward in order to cover the meatus until the apex of the glans [Fig. T]

   
Figura T 1 Figura T 2    

 

Duckett'stechnique:

A rectangle of skin is cut from the dorsal prepuce. This rectangle is then transferred to the ventral side of the penis and is involved in the reconstruction of the new urethra.

 

Snodgrass's technique:

The new urethra is created after the tissue of the ventral surface of the penis has been incised and tubularized [Fig. U]

 

Figura U 1 Figura U 2 Figura U 3
Figura U 4 Figura U 5 Figura U 6
Figura U 7 Figura U 8 Figura U 9
   
Figura U 10    


Bracka's two-stage technique: During the first operation the ventral surface of the glans is enlarged bu means of a skin graft taken from the prepuce of a buccal mucosa graft. In such a way a platform it will be used and tubularized to construct the urethra [Fig. V].

7.Hypospadia complications

Hypospadia surgery is characterised by a 10-30 % rate of complications, expecially fistulae and urethral strictures, which can require a further repairing operation at least 3 months after the first one.
A urethral fistula is the communication between the reconstructed meo-urethral and outside: urine flows , as well as from the meatus, from a hole along the ventral surface of the penis.
A stricture is the marrowing of the neo-urethra which causes an obstacle to the flow of the urine.
The rate of complications is reduced by:
  • a meticulous surgical accuracy.
  • an adequate surgical equipment.
  • the right age of the patient.
  • the experience of the surgeon who performs this kind of surgery on a routine basis.

 

8.Most-operative assistance for hypospadia

The child is discharged on the day following the operation, so as to limit the stay in hospital and the psychological trauma.

 

In order to help the parents with the post-operative assistance information on the following matters is very useful.

  • Catheter
  • Penis medication

 

9.Catheter

Small and soft (silicon) catheters are used which drain unin from the bladder to outside.
The catheter is kept for 6-10 days.
In young children the catheter is left open with a continuous trickling in the mappy.
In older patients the catheter is connected to a bag which collects urine.
It is kept in place by means of a stitch on the glans or a ballon inflated in the bladder.

 

10.Penis medication

The dressing covers the wound and immobilizes the penis for a few days.
During the first few days after the operation a small loss of blood and urine when straining during defecation is frequent and normal.
After the removal of the dressing it is possible to have a slught bleeding and an increased swelling of the penis.
The signs of wound infection are skin rash, pus and temperature: in this case it is advisable to contact the doctor.
Suture stitches (disappear by themselves are reabsorbed).
It is advisable to avoid any compression of the perineal and scrotal area for 2 months:; avoid cycling.

 

11.Remarks about hypospadia

Nowadays this type of surgery tends to pay more attention in reducing the psychological trauma by choosing the right age for the operation and by reducing the stay in hospital (2-3 days). Moreover grater good results not only from a functional point of view but also from an aesthetical point of view.