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CURRENT TREND IN THE MANAGEMENT OF PRIMARY HYPOSPADIAS INDICATION FOR SURGERY AND SURGICAL GOAL


Semir A. S. Al Samarrai

 


Background:

Hypospadia can be defined as hypoplasia of the tissues forming the ventral aspect of the penis beyond the division of the corpus spongiosum.

Clasiffication:
1. Distal
2. Intermediate
3. Proximal

Risk Factors: Risk factor associated with hypospadia
  • Are likely to be genetic, placental and/or environmental (1).
  • Endocrine disorders can be detected in a very few cases.
  • An additional member with hypospadia is found in 7% of families (2).
  • Babies of young or old mothers and babies with a low birth weight have a higher risk of hypospadias (2).
  • A significant increase in the incidence of hypospadias over the last 20 years suggests a role for environment factors (hormonal disruptors and pesticides) (3-6). This information has been questioned recently (7).
  • The use of oral contraceptives prior to pregnancy has not been associated with increased risk of hypospadia in the offspring (8).
Diagnosis:

Patient with hypospadia should be diagnosed at birth (except for the megamentous intact prepuce variant).

Diagnosis includes a description of the local findings:
  • Position, shape and width of the orifice
  • Presence of atretic urethra and division of corpus spongiosum
  • Appearance of the preputial hood and scrotum
  • Size of the penis
  • Curvature of the penis on erection.
The diagnosis evaluation also includes an assessment of associated anomalies which are:
  • Cryptorchidism (in up to 10% of cases of hypospadia)
  • Open processus vaginalis or inguinal hernia (in 9-15%).
Severe hypospadias with unilaterally or bilaterally impalpable testis, or with ambiguous genitalia, requires a complete genetic and endocrine work-up immediately after birth to exclude intersexuality, especially congenital adrenal hyperplasia. Urine tickling and ballooning of the urethra require exclusion of meatal stenosis.

Treatment:

Differentiation between functionally necessary and aesthetically feasible operative procedures is important for therapeutic decision-making. Hypospadias still represents an ongoing challenge for the pediatric urologist and requires a dedicated surgeon who needs appropriate judgment and experience to correct each variant surgically. Over the past thirty years the approach to the patient with a hypospadia has consistently changed and developed due to the utilization of newer surgical techniques and a better understanding of the embryology of the penile anatomy, awareness of the physiological implications and, finally, increased safety of anesthesia.

It is the pediatric urologist’s goal to use all the elements available and to try to create “the perfect penis” which is cosmetically ideal, has normal sensation and functionally allows unimpeded voiding, associated with straight erections. The modern “hypospadiology” has started with recognition of the crucial role of the urethral plate for the reconstruction of the neo-urethra. For primary cases the urethral plate can be simply tubularized, with or without hinging, or augmented. In more severe proximal forms, the urethral plate may be discarded, since it contributes to a pathological penile curvature, and the urethral reconstruction accomplished by a substitution either with single stage or a multi-staged procedure. The much more complex issue of re-operation surgery still represents one of the greatest challenges for the pediatric urologist. The use of free grafts of buccal mucosa (harvested from either the lip or the cheek) represents, currently, the best solution.

Age at Surgery:

The age at surgery for primary hypospadia repair is usually 6-18 (24) months (3). However, earlier repair between 4 and 6 months of age has been reported recently (9).

Adolescence and Adult hypospadia:

As a matter of fact, many of the complications arise in the long term follow-up when the boys reach puberty and adulthood.

The fate of many reconstructive techniques has become evident only after the boys has passed through puberty and has become sexually active. This is the case of scrotal skin or hair-bearing skin, some skin flaps which showed tendency to retract and stenose or to produce diverticula and “ballooning” of the neo-urethra related to the lack of spongiosum tissue around the neo-urethra in sexually active young adults.

Last but not least, the physiology of the urinary stream has been recently and closely examined revealing that bio-mechanical properties of the neo-urethra can lead to a “functional obstruction” in absence of true mechanical obstruction.

The therapeutic objectives are to correct the penile curvature, to form a neo-urethra of an adequate size, to bring the neomeatus to the tip of the glans, if possible, and to achieve an overall acceptable cosmetic appearance of the boy’s genitalia (3, 4). The current trend is to time the operation around the first birthday of the boy, and to preserve and tubularize the urethra plate and to stage the procedure in proximal hypospadia with severe chordee.

The perioperative management includes modern paediatric anesthesia methods in combination with regional anesthesia, urinary drainage into a double diaper and to waive the fixation of the baby at the bed.




References:

1. Morera A, Valmalle A, Asensio M, et al. A study of risk factors for hypospadias in the RhÔne-Alpes region (France). J Ped Urol 2006 Jun;2(3):169-77. http://www.ncbi.nlm.nih.gov/pubmed/18947603
2. Fredell L, Kockum I, Hansson E, et al. Heredity of hypospadias and the significance of low birth weight. J Urol 2002 Mar;167(3):1423-7. http://www.ncbi.nlm.nih.gov/pubmed/11832761
3. Belman AB. Hypospadias and chordee. In: Belman AB, King LR, Kramer SA, eds. Clinical Pediatric Urology. 4th edn. London, Martin Dunitz, 2002, pp. 1061-1092.
4. Mouriquand OD, Mure PY. Hypospadias, In: Gearhart J, Rink R, Mouriquand PDE, eds. Pediatric Urology, Philadelphia, WB Saunders, 2001, pp. 713-728.
5. Lund L, Engebjer MC, Pedersen L, et al. Prevalence of hypospadias in Danish boys: a longitudinal study, 1977-2005. Eur Urol 2009 May;55(50:1022-6. http://www.ncbi.nlm.nih.gov/pubmed/19155122
6. Weidner IS, Møller H, Jensen TK, et al. Risk factors for chryptorchidism and hypospadias. J Urol 1999 May;161(5):1606-9. http://www.ncbi.nlm.nih.gov/pubmed/10210427
7. Fisch H, Hyun G, Hensle TW. Rising hypospadias rates: disproving a myth. J Pediatr Urol 2010 Feb;6(1):37-9. http://www.ncbi.nlm.nih.gov/pubmed/20022563
8. Nørgaard M, Wogelius P, Pedersen L, et al. Maternal use of oral contraceptives during early pregnancy and risk of hypospadias in male offspring. Urology 2009 Sept;74(3):583-7. http://www.ncbi.nlm.nih.gov/pubmed/19592074
9. Perlmutter AE, Morabito R, Tarry WF. Impact of patient age on distal hypospadias repair: a surgical perspective. Urology 2006 Sep;68(3):648-51. http://www.ncbi.nlm.nih.gov/pubmed/16979730 

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae