Definition:
- Any condition in which the meatus occurs on the undersurface of the
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penis.Usual y 3 features
ventral meatus
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ventral curvature (chordee)Dorsal "hood"; deficient foreskin ventral y
TYPES/ CLASSIFICATION
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EMBRYOLOGY:
Genital tubercle fuses in midline
Mesodermal folds create the
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urethral and genital folds
coalesce in midline as phal us
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elongatesDistal glans channel tunnels to
proximal urethra as solid core then
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undergoes canalization.
EMBRYOLOGY:
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Prepuce forms as ridge of skin from
corona.
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HypospadiasFailure of ventral aspect to form
Dorsal hood.
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ChordeeDifferential growth between normal y
developed dorsal tissue and
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underdeveloped ventral corporal tissue
Fibrous tissue distal to hypospadiac meatus.
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INCIDENCE:1:300 live male births
Some genetic component
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8% of patients have father with hypospadias14% of patients have male siblings with hypospadias
If child with hypospadias, risk to next child
12% risk with negative family history
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19% if cousin or uncle with hypospadias26% if father or sibling
More common in Caucasians (Jews and Italians)
Higher incidence in monozygotic twins (8.5x)
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ASSOCIATED ANOMALIES:Undescended testes 9%
Inguinal hernia 9%
Upper tract anomalies rare (1-3%)
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Utriculus masculinus
10 to 15% in perineal or penoscrotal hypospadias
Incomplete mul erian duct regression
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hypospadias and cryptorchidism
high index of suspicion for an intersex state
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Walsh reported the incidence of intersexuality in children with cryptorchidism,
hypospadias, and otherwise nonambiguous genitalia to be 27%.
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Only with severe hypospadias and sexual ambiguity
Includes testicular abnormalities
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Up to 25% of these patients have enlarged utricles or other female structuresIntersex, especial y with cryptorchidism
Adrenogenital syndrome
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Mixed gonadal dysgenesisIncomplete pseudohermaphroditism
True hermaphrotidism
TREATMENT TECHNIQUES:
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Meatoplasty and glanuloplastyMultiple techniques
Orthoplasty
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Utilize artificial erection-Gitte's test
Release urethra from fibrous tissue
Plicate dorsal tunica albuguinea
Ventral graft if needed
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Urethroplasty
Onlay vascularized flap
Tubularized flap
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Free graftSkin cover/Rearrangement
Mobilized dorsal prepuce and penile skin
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Double faced island flapScrotoplasty
FACTORS FOR TECHNICAL SUCCESS
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Use of vascularized tissuesCareful tissue handling
Tension-free anastomosis
Non-overlapping suture lines
Meticulous hemostasis
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Fine suture materialAdequate urinary diversion
HYPOSPADIAS SURGERIES
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Distal hypospadiasTubulization of the incised urethral plate (Snodgrass)
Meatal advancement (MAGPI)
Meatal-based flaps (Mathieu)
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Proximal hypospadias
Onlay grafts
Vascularized inner preputial transfer flaps (Duckett)
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Free grafts (skin, buccal mucosa)MAGPI
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MATHIEU PROCEDUREREDMAN and
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BARCATPROCEDURE
ISLAND ONLAY
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BUCCAL MUCOSAL
GRAFT
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ACUTE COMPLICATIONS:
Wound infection
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Poor wound healing 2 to ischemia of flapsEdema
CHRONIC COMPLICATIONS:
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Urethrocutaneous fistulaUrethral diverticulum
Residual chordee
Persistent hypospadias
Urethral stricture
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Hair bearing skinMeatal stenosis
Excess skin
Balanitis xerotica obliterans
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HYPOSPDIAS- CONCLUSIONSCommon
Genetic component exists
Evaluation for associated anomalies with severe proximal hypospadias
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Rule out intersex, especial y with cryptorchidismMultiple repairs exist, tailor to the patient, anatomy, and previous repairs
THANK YOU
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