HYPOSPADIAS SURGERY :How to avoid

complications ?

H S AsopaAsopa Hospital

Agra India

OPERATORWHO SHOULD OPERATE ? Paediatric Urologist Urologist Plastic Surgeon Paediatric Surgeon Hypospadiologist

EXPERIENCE

4 – 5 Techniques See many, assist many & do many Then teach many

SELECTION OF PROPER TECHNIQUE 4 – 5 Techniques and their evolution Era of two stage repair One stage transverse prepucial tube MAGPI Ventral prepucial patch Tubularised incised urethral plate (Snodgrass)

Pre operative decisionsMIDWAY - after degloving Location of meatus Meatal Calibre Glans configuration Quality of ventral penile skin proximal to meatus Presence of chordee after degloving Prepuce Preference/Experience of the surgeon

MAGPI INDICATIONS Glanular or ? coronal meatus Flat or convex glans Narrow meatus Skin and mucosa proximal to meatus thick & healthy No chordee or mild chordee to be corrected by dorsal plication

Less than 10% of all cases

Special precautions Raising glans flap / Excision of glans margins

Avoid Wide Meatus Sub coronal / concave glans

PRESERVATION & UTILISATION OFURETHRAL PLATE

T.I.P (Snodgrass) Dorsal free graft Onlay transverse prepucial patch Perimeatal flap

Considerations No chordee or mild chordee Configuration of glans Calibre of meatus and urethra Skin proximal to meatus Condition of urethral plate Presence or absence of prepuce

INCISED URETHRAL PLATE TUBULARISATION - Snodgrass

Concave glans Wide Meatus Skin & ventral mucosa proximal to meatus healthy No chordee or minimal chordee Healthy thick urethral plate

Best results in Distal penile meatus

Precautions Lateral incisions only upto mid glans

DORSAL FREE GRAFT ON INCISED URETHRAL PLATE

Flat glans Narrow urethral plate Meatus narrow or wide No chordee or minimal chordee

Indications

ONLAY TRANSEVERSE PREPUCIAL PATCH

No chordee or minimal chordee

Narrow urethral plate Narrow meatus Glans flat or conical Attenuated ventral

mucosa or distal urethra

TRANSVERSE PREPUCIAL SKIN TUBE

Considerable chordee Conical glans – Glans tunnel Flat or shallow glans - Glans

wings Good adequate prepuce Young patients Upto penoscrotal level

Flap - AsopaIsland flap - Duckett

TWO STAGE Byars Free graft - Prepuce - Buccal mucosa

Indications

Special considerations

Chordee ++ Meatus scrotal or perineal Inadequate prepuce Preference of surgeon

Lay open glans Start suture line from glans to meatus Smooth ventral skin Excise hair bearing skin around meatus

GENERAL CONSIDERATIONS

Vascularity

Flap - Island - Skin based dorsal flaps - flaps

Free Grafts - Dorsal Lateral - Ventral - Tube - Unreliable

Minimal tissue damage - Thumb and forefinger- Skin hooks- Stay sutures

Correct tissue planes - start proximally

GENERAL CONSIDERATIONS Contd…

Cover ventral suture line - Dartos - Tunica - Spongiosa Eccentric suture line of skin

cover

GENERAL CONSIDERATIONS Contd…

Sutures- Fine ( 6/0, 7/0 ) absorbable- Chromic catgut - through

mucosa and skin- Vicryl - for glans and

spongiosa Inversion of mucosa & skin Subcuticular whenever

possible Avoid tension - Scrotal

flaps Two layers Distance between sutures

GENERAL CONSIDERATIONS Contd…

Local antibiotics Systemic antibiotics Haemostasis

- Minimal and precise cautery - Adrenaline - Tourniquet - Circular dressings

Catheter - 6 Fr Protex or Poly vinyl chloride (PVC) - Polyurethane - Silastic

Diversion

GENERAL CONSIDERATIONS Contd…

Magnification - Operating microscope - Loupes Pre operative hormones

Scrotal bury

CHECKLIST

Meatus Calibre

Site After chordee correction Proximal skin mucosa Glans Conical Flat Concave Size

Urethral plate Wide / Narrow Thick / Thin

Patients considerations

CHECKLIST Contd…

Chordee - Pre Op

- After degloving - After correction Prepuce

Technique

Suture material

Catheter