94. Hypospadias - Global HELP

552 Hypospadias
Epithelium
to be excised
Onlay island flap
Pedicle
The four important steps for the correction of urethral fistula are:
1. exclusion and correction of distal stenosis;
2. wide excision of the fistula tract;
3. use of healthy, well-vascularised tissue; and
4. protection of fistula repair with a healthy vascular second protective
layer.
Diverticulum
Diverticulum may occur after surgery for distal hypospadias and is
probably due to a narrow new urethra. Diverticulum may also occur
after proximal hypospadias, however, and is believed to be due to a
lack of the supportive corpus spongiosum in patients with proximal
hypospadias. This is supported by the finding that diverticulum is often
encountered without distal obstruction in proximal hypospadias and
may even recur after excision of the redundant urethra. 56
Persistent or Recurrent Chordee
Persistent or recurrent chordee may occur due to inadequate orthoplasty
during hypospadias correction or due to healing by scarring and fibrous
tissue formation. In cases of scarring, the urethra is usually healthy,
and excision of the fibrous tissue superficial to the urethra is sufficient
to correct chordee. Correction of persistent chordee due to inadequate
orthoplasty in the first operation is difficult and technically demanding.
Some surgeons may opt for repeated tunica albuginea plication. Others,
including the authors, would prefer to incise the urethra and correct the
curvature from the ventral aspect to avoid shortening the penis.
Epithelium
to be excised
Subcutaneous
tissue (pedicle)
Corpus
Spongiosum
Source: Hadidi AT, Azmy AF, eds. Hypospadias Surgery: An Illustrated Guide, 1st ed. Springer
Verlag, 2004. Reproduced with kind permission of Springer Verlag.
Figure 94.21: Onlay island flap procedure.
Key Summary Points
1. Hypospadias is a wide spectrum of anomalies involving all the
ventral structures of the penis and not just the urethra.
2. The ideal time to correct hypospadias is before 18 months of
age. In fact, many surgeons correct hypospadias starting at age
3 months.
3. Surgeons need to master several techniques to suit the wide
range of anomalies encountered.
4. The surgeon should use the technique that is suitable for the
patient and not make the patient suitable for the technique he
or she prefers.
5. Neourethra should be reconstructed around catheters of size
10 Fr or larger, depending on the age of the patient.
6. Tubularisation of the urethral plate without incision is suitable
for more than 60% of hypospadias patients.
7. A second protective layer to cover and protect the new urethra
is an essential part of hypospadias surgery.
8. With experience, the success rate in glanular and distal
hypospadias has reached more than 95%. In proximal
hypospadias, the complication rate is 10–20%.
References
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