Should parents worry if the boy has hypospadias?
Ruslan Tagirovich Batrutdinov, urologist andrologist, candidate of medical sciences
What is hypospadias?
Hypospadias is a condition in which the external opening of the urethra is located on the lower surface of the penis, and not on its apex.
What characterizes hypospadias?
- The opening of the urethra (urethra) is below the top of the head of the penis
- Unusual view of the glans penis
- Incomplete foreskin (surrounds only half the circumference of the head of the penis) - the so-called "hood"
- Chorda (curvature of the penis during an erection)
- Hidden penis
- Unusual location of the scrotum in relation to the penis (sometimes)
Do all children with hypospadias have a foreskin in the form of a hood?
Due to the peculiarities of the embryological development of the penis and urethra, the skin of the foreskin in almost all boys with hypospadias remains not completely closed on the lower surface. In rare cases of hypospadias with a large external opening of the urethra (megameatal hypospadias) there is an unchanged foreskin, and the diagnosis is usually made during circumcision.
How common is hypospadias?
According to the frequency of occurrence, this is the second disease after cryptorchidism in boys. The incidence of hypospadias varies from 5.2-8.2 per 1000 newborn boys, or about 1 case per 200 newborns.
What causes hypospadias?
Hypospadias occurs due to incomplete development of the urethra. The exact cause is unknown. In some cases, the development of hypospadias is due to a genetic factor, but in most patients a hereditary history is not burdened. If the newborn has hypospadias, then the risk of having a second child with hypospadias is 12% with an uncomplicated family history. It rises to 19% if another family member has hypospadias, such as a cousin or uncle, and up to 26% if father and brother have hypospadias.
Do boys with hypospadias require a urological examination to identify other abnormalities?
Only boys with severe hypospadias and an unclear sex who have testicular malformations (e.g. cryptorchidism) need to be examined. Up to 25% of these patients have an enlarged prostatic uterus or other female formations. A routine examination with other forms of hypospadias is not required, since the frequency of malformations in them approximately corresponds to that in the entire population as a whole.
What problems can arise as a result of hypospadias?
- Hypospadias can cause urine to deviate when urinating your son, especially when standing, which causes some difficulties
- Cosmetic / psychological problems: the unusual appearance of the penis can have a negative effect, in particular on relationships with peers. In adulthood, there may be problems with the sex life.
- Penile curvature during erection can adversely affect or limit sexual function
Can hypospadias be cured?
Yes. In this situation, there is no medicine and your child will not outgrow hypospadias. Hypospadias correction is performed only surgically. Provided that the operation is performed by a urologist with experience in genital reconstruction, the result of the operation is usually successful. We prefer to perform these operations between the ages of 6 and 18 months of life. In most cases, the operation is performed in stage 1 and lasts from 1 to 4 hours (depending on the severity of hypospadias). In some severe cases, the operation is performed in 2 stages.
What age is considered optimal for performing hypospadias surgery?
When determining the optimal age for surgical treatment, it is necessary to take into account the emotional aspects, both in relation to the child and in relation to the family. It is believed that the ideal age falls between 6 and 15 months, when the factors of sexual awareness are clarified, caution is observed in determining sex, the technical aspects of the operation are determined, and it is easier to carry out activities in the postoperative period. The fact is that patient care at this age is greatly simplified compared to the age of 2-4 years. Secondly, the size of the penis from 1 year to 3 years is practically unchanged. Thirdly, the urine is removed from the baby by a tube (catheter) between 2 diapers, in connection with which, the child is not fixed, not attached, etc. And most importantly, a child under 15-18 months of age does not remember events related to the operation, etc.
How to perform hypospadias surgery for a small penis?
Sometimes testosterone is used to induce penile growth. Most often these are severe forms of hypospadias, where there is a small penis. Testosterone is prescribed 1.5-2 months before surgery in the form of a gel or injection. The hypospadias operation itself contributes to an increase in the length of the penis.
What is a hypospadias invalid?
"Hypospadias invalid" is an old term used to refer to a boy or man who has undergone numerous operations aimed at eliminating a hypospadias defect. Previously, such cases were quite common, but recently the number of such patients has significantly decreased, which is associated with an improvement in the technique of operations and a better understanding of the essence of the disease.
What is the principle of hypospadias surgery?
Reconstruction can conditionally be divided into 3 key stages:
- Create a direct penis (orthoplasty)
- Reconstruction of the missing part of the urethra (urethroplasty)
- Penile head and external urethral plastic surgery (meatoglanuloplasty)
The operation is performed under general anesthesia. After surgery, the penis will look like a normal penis (as after circumcision). In some cases (at the request of the parents), we recreate the foreskin (prepuceoplasty). After surgery, a catheter (tube made of 100% silicone) is usually inserted into the bladder, which removes urine for 7-10 days.
If hypospadias operations were performed several times and they were unsuccessful, what else can be done?
A failed operation for hypospadias is most often reproached to the surgeon, since all the difficulty in subsequent treatment consists in severe scarring of the penis and a lack of skin for plastics. Often, a skin transplant is required to create the urethra. Despite the fact that previously used skin flaps, at present they prefer to use other tissues, such as the mucous membrane of the cheek. This allows you to achieve better results, both in the near and distant periods.
List the most important technical factors for the success of hypospadias surgery.
- Use of well-circulated tissues
- Delicate tissue manipulation
- Anastomosis application (suturing tissue) without tension
- Suture avoidance of tissue during suturing
- Thorough hemostasis
- Thin, absorbable suture material
- Adequate urine diversion
What are the complications of hypospadias surgery?
A range of complications, ranging from cosmetic to the complete discrepancy of tissues in the area of surgery.These include the formation of urethral fistula, stricture of the urethra, stenosis of the external opening of the urethra, diverticulum of the urethra, excess or deficiency of the skin, persistent curvature and hypospadias.
Is urinalysis required during hypospadias surgery?
In most cases, urinary diversion is a desirable component of treatment. It allows tissue healing and reduces the risk of urethral-skin fistula formation. Despite the fact that some authors propose not to use urine diversion in operations for distal hypospadias, urine diversion provides advantages and, theoretically, contributes to a lower incidence of complications, especially in complex reconstructive operations. The use of a retaining urethral stent replaced the suprapubic cystostomy tube even in severe cases. Suprapubic urinary diversion in some cases may have some advantage (especially with repeated operations and in adolescents). The duration of urine diversion is approximately 1 to 12-14 days (an average of 5-7 days, depending on the form of hypospadias).
What is the best surgery for hypospadias?
There is not one single best method for surgical treatment of hypospadias. More than 150 types of operations are described. Currently, the most commonly used operations are Snodgrass (TIP), urethral advancement, onlay, Bracka, reconstructions using free grafts of the cheek mucosa.
After Hypospadias Surgery
- Usually, antibiotics are prescribed for the child while the urinary catheter is standing
- Analgesics are prescribed to prevent pain in the postoperative period.
- Sometimes, due to the standing of the catheter, your child may experience so-called bladder cramps (usually at night). In these cases, the drug Driptan (oxybutynin hydrochloride) is prescribed. These cramps are not as dangerous for the child as they are uncomfortable. After removal of the catheter, driptan is canceled
- During the operation, we carry out the so-called “penile blockade” (penile nerve block) with Markain (Bupivacaine) to prevent pain in the early postoperative period. This block lasts 4-6 hours
- After surgery, we apply a special bandage to the penis, which is removed 3-5 days after surgery
Today, in our clinic, hypospadias correction is performed according to the most modern standards and techniques adopted in Europe and North America (operations Snodgrass, Mathieu, Bracka (using the mucous membrane of the cheek), surgery to promote the urethra, etc., using grafts (grafts) with Extremely severe penile curvature We use suture material and instruments from leading manufacturers in the world, optical magnification (magnifiers, microscope).
Causes of Hypospadias
A similar developmental anomaly is congenital. It is formed at the stage of fetal development, approximately in the period from 7 to 14 weeks of pregnancy.
The external genitalia of female and male embryos until the eighth week are no different, then under the influence of testosterone in boys the genitals begin to develop in the male type. During penile growth, the urethral sulcus is displaced from the base of the trunk to the base of the head. The urethral leaf, which on the lower surface of the penis lines the groove between the cavernous (cavernous) bodies, closes along the midline, forming the urethral tube. The process of this closure occurs in the direction of the glans penis from its base.
The foreskin is in the form of a fold of skin that grows in the lateral directions in the area of the base of the head, covering it. With this pathology, the process of formation of the foreskin is disturbed and it is displaced in the back direction.Often together with hypospadias, strands (chords) are found that lead to the curvature of the penis due to an imbalance in the growth of tissues of its different departments.
Primary gonads form between the 4th and 5th weeks of fetal development. The presence of the Y chromosome provides the formation of testicles. It is believed that the Y chromosome encodes the synthesis of the Y antigen protein, which promotes the conversion of the primary gonad into testicular tissue. Embryogenic phenotypic differences develop in two directions: the internal ducts and external genitalia are differentiated. At the earliest stages of development, the embryo contains both female (paramesonephral) and male (mesonephral) ducts.
The internal genital organs are formed from the wolf and Muller ducts, which are located nearby at the early stages of embryonic development in both sexes. In male embryos, the Wolf ducts give rise to the appendages of the testicles, vas deferens and seminal vesicles, and the Müllerian ducts disappear. Female embryos from the Muller ducts develop the fallopian tubes, the uterus and the upper part of the vagina, and the Wolf ducts regress. The external genitalia and urethra in the fetuses of any gender develop from a common bookmark - the urogenital sinus and genital tubercle, genital folds and elevations.
Fetal testicles are able to synthesize a substance of protein nature - an anti-Muller factor that reduces paramesonephral ducts in a male fetus. In addition, starting from the 10th week of intrauterine development, the fetal testicle, first under the influence of chorionic gonadotropin (CG), and then its own luteinizing hormone (LH), synthesizes a large amount of testosterone, which affects the indifferent external genitalia, causing them to masculinize. The genital tubercle, increasing, turns into the penis, the urogenital sinus is transformed into the prostate and the prostatic part of the urethra, genital folds merge to form the male urethra. The meatus is formed by pulling the epithelial tissue into the head and merges with the distal end of the formed urethra in the scaphoid fossa. Thus, by the end of the first trimester, the final formation of genitals occurs.
It should be noted that for the formation of male internal genitalia (genital ducts), the direct action of testosterone is sufficient, while the development of external genitalia requires the influence of the active metabolite T-DHT (dihydrotestosterone), which is formed directly in the cell under the influence of a specific enzyme, 5 alpha reductase.
Currently, there are many classifications of hypospadias, but only the Barcat classification allows you to objectively assess the degree of hypospadias, since the evaluation of the shape of the defect is carried out only after surgical expansion of the penile shaft.
Barcat Hypospadias Classification:
I. Anterior hypospadias:
II. Medium hypospadias:
III. Back hypospadias:
Despite its obvious advantage, the Barcat classification has one major drawback. It does not include a special form of pathology, such as “hypospadias without hypospadias” (sometimes called “chord-type hypospadias”). However, based on the pathogenesis of the disease, “hypospadias without hypospadias” is a more suitable term for this type of pathology, since in some cases the cause of ventral deviation of the trunk of the penis is exclusively dysplasia of the ventral surface without pronounced fibrous chord, and sometimes the fibrous chord is combined with deep dysplastic processes in the wall of the urethra.
In this regard, the Barcat classification is logical to expand, supplementing it with a separate nosological unit - “hypospadias without hypospadias”.
In turn, four types of “hypospadias without hypospadias” are distinguished: 1) in the first type, the ventral deviation of the trunk of the penis is caused solely by dysplasia of the skin of the ventral surface of the penis, 2) the curvature of the trunk of the second type is caused by the fibrous chord located between the skin of the ventral surface and urethra, 3) the fibrous chord, located between the urethra and the cavernous bodies of the penis, leads to the third type of curvature; 4) with the fourth type of curvature, the pronounced fibrous chord of the combination tsya sharp thinning actually urethra wall (dysplasia urethra) (B. Belman 1985. Fayzulin AK 2003.). Understanding the pathogenesis of this form of pathology of the development of the penis determines the correct tactics of the surgeon and contributes to the successful correction of the defect.
Hypospadias is treated exclusively by surgery. Before surgery, it is necessary to conduct a comprehensive examination of the patient, which allows to differentiate hypospadias with other disorders of sex formation. For this purpose, in addition to the general examination of the patient, karyotyping is performed (especially in cases where hypospadias is combined with cryptorchidism), ultrasound of the pelvic organs and urinary tract. In the case of a combination of hypospadias with kidney and urinary tract defects, the patient needs an in-depth clinical examination using urodynamic tests, X-ray urological, radioisotope and endoscopic diagnostic methods.
The goal of surgical treatment of patients with hypospadias is: 1) the complete straightening of the curved cavernous bodies, providing an erection sufficient for sexual intercourse, 2) the creation of an artifical urethra of sufficient diameter and length without fistulas and strictures from tissues lacking hair follicles, 3) urethroplasty using patient’s own tissue with adequate blood supply, ensuring the growth of the created urethra as the physiological growth of cavernous bodies, 4) the movement of the external opening of the urethra to the top head of the penis with a longitudinal location of the meatus, 5) the creation of free urination without deviation and spraying, 6) the maximum elimination of cosmetic defects of the penis with the aim of psycho-emotional adaptation of the patient in society, especially when entering into sexual relations.
Sometimes situations arise in the practice of a pediatric urologist when, due to diagnostic errors, a child with a karyotype 46XX, but with viril genitalia is registered in the male field, and a child with a karyotype 46XY, but with feminized genitalia, in the female. The most common cause of problems in this group of patients is erroneous karyotyping, or the lack of research at all. Changing the passport gender in children at any age is associated with severe psychoemotional trauma to the parents and the child, especially if the patient has already undergone psychosexual orientation. There are cases when girls with congenital hyperplasia of the adrenal cortex and clitoral hypertrophy were diagnosed with some form of hypospadias with all the ensuing consequences, and, on the contrary, a boy with testicular feminization syndrome was brought up in the female field before puberty. Often it is in puberty that the lack of timely menstruation attracts the attention of specialists, but by this time the child has already formed sexual self-awareness or, in other words, social gender. Therefore, any child with anomalies of the external genital organs should be examined in a specialized institution. In addition, even in children with unchanged genitals, it is necessary to conduct an ultrasound examination of the pelvic organs immediately after birth. Currently, more than 100 genetic syndromes accompanied by hypospadias are known.Already on the basis of this fact, it is advisable to consult a geneticist, which in some cases can help clarify the diagnosis and focus urologists on the features of the manifestation of a syndrome during treatment.
The endocrinological aspect is most important in solving this problem, since the causes of hypospadias are based on the pathology of the endocrine system, which, in turn, explains the combination of hypospadias with micropenia, scrotum hypoplasia, various forms of cryptorchidism, and violations of the obliteration of the vaginal process of the peritoneum (inguinal hernia and various forms of dropsy of the testis and spermatic cord).
In some cases, in children with hypospadias, congenital malformations of the urinary tract are detected, therefore, ultrasound of the urinary tract must be performed in patients with any form of hypospadias. More often, urologists meet with vesicoureteral reflux, as well as with hydronephrosis, ureterohydronephrosis and other abnormalities of the urinary tract. With a combination of hypospadias with hydronephrosis or ureterohydronephrosis, the affected segment of the ureter is initially plasticized and only 6 months later it is advisable to correct the hypospadias. In the case when the patient has a PMR, it is necessary to clarify the cause of reflux and eliminate it. In this group of patients, an in-depth clinical study is shown, including a full range of urodynamic tests, X-ray urological, radioisotope and endoscopic diagnostic methods that allow determining the tactics of further treatment of the patient.
Optimum age for surgical treatment
Since the introduction of the latest scientific advances in modern medicine, great opportunities have opened up to revise a number of concepts in penile plastic surgery. The presence of microsurgical instruments, optical augmentation, and the use of an inert suture material made it possible to minimize surgical trauma and perform successful operations in children from 6 months of age. Most modern urologists around the world prefer the simultaneous correction of hypospadias at an early age. Attempts by some urologists to perform simultaneous surgery in newborn boys or at the age of 2-4 months have not paid off (Belman, Kass 1985). Most often, hypospadias correction is performed at the age of 6 - 18 months, since at this age the ratio of the size of the corpora cavernosa and the supply of plastic material (actually the skin of the penis) is optimal for performing surgical manuals (Snyder 2000).
In addition, at this age, the implementation of corrective operations minimally affects the psyche of the child. As a rule, the child quickly forgets the negative aspects of postoperative treatment, which in the future does not affect his personal development. In patients who have undergone multiple surgical interventions for hypospadias, an inferiority complex is often formed.
All types of developed technologies can be divided into 3 groups:
hypospadias correction methods using own tissues of the penis,
surgical treatment of hypospadias using patient tissue located outside the penis,
defect correction using the achievements of tissue engineering.
The choice of method often depends on the technical equipment of the clinic, the experience of the surgeon, the age of the patient, the effectiveness of preoperative preparation and the anatomical features of the genitals.
Surgical treatment method selection algorithm
The choice of surgical treatment directly depends on the number of methods that the operating surgeon is fluent in, since with the same form of defect, with the same success, a number of previously proposed methods can be used.In some cases, to solve the problem, the production of a meatotomy is sufficient, and sometimes it becomes necessary to perform complex microsurgical operations, therefore, the determining moment for choosing a method is:
the location of the hypospadias meatus,
preputial bag size,
the ratio of the size of the corpora cavernosa and the skin of the penis,
dysplasia of the skin of the ventral surface of the penis,
degree of curvature of cavernous bodies,
penis head size,
furrow depth on the ventral surface of the glans penis,
penis rotation rate,
the presence of synechia of the foreskin and the degree of their severity,
topic of the trunk of the penis, etc.
Currently, more than 200 methods of surgical correction of hypospadias are known. However, in this chapter we tried to present operations that have a fundamentally new direction in plastic genital surgery.
The first attempt at surgical correction of hypospadias in 1837 was made by Dieffenbach. Despite the interesting idea of the operation itself, unfortunately, it was not successful.
The first successful attempt at urethroplasty was made by Bouisson in 1861 using rotated scrotum skin.
In 1874, Anger used an asymmetric displaced flap of the ventral surface of the penile shaft to create an artifact urethra.
In the same year, Duplay used a tubularized ventral skin flap according to the Thiersh principle for urethral repair, proposed for correction of stem epispadias in the 60s of that century. The operation was performed in stages 1 and 2. In the distal form of hypospadias, the operation was performed in stage 1, in cases with proximal forms of urethral plastic, it was performed several months after preliminary straightening of the trunk of the penis. This operation is widespread throughout the world, and now many surgeons who do not know the technique of one-stage hypospadias correction use this technology.
In 1897, Nove - Josserand described a method for creating an artifact urethra using an autologous free skin flap taken from the non-hairy part of the body surface (inner surface of the forearm, abdomen).
In 1911, Ombredanne attempted a one-stage correction of the distal hypospadias, in which the artifical urethra was created according to the “flip-flap” principle using the skin of the ventral surface of the penis. The resulting wound defect was closed with a displaced split preputial flap according to the principle developed by Thiersch.
In 1932, Mathieu, using the Bouisson principle, performed a successful correction of the distal form of hypospadias.
In 1941, Humby proposed using the cheek mucosa to create a new urethra.
In 1946, Cecil, using the principle of Duplay and Rosenberger in 1891, performed a three-stage plastic surgery of the urethra with a stem-scrotal form using a stem-scrotal anastomosis during the production of the second stage of the surgical guide.
Memmelaar in 1947 described a method for creating an artifact urethra using a free flap of the bladder mucosa.
In 1949 Browne described a method for distal urethroplasty without shorting the inner area of the artifical urethra, counting on self-epithelialization of the non-tubular surface of the artificial urethra.
The founder of a number of operations aimed at creating an artifact urethra using a vascular bundle was Broadbent, which in 1961 described several options for such operations.
In 1965, Mustarde developed and described an unusual method of urethroplasty using a tubularized rotated ventral skin flap with tunnelization of the glans penis.
In 1969 - 1971 N. Hodgson and Asopa developed the idea of Broadbent and created a number of original technologies that allow correcting severe forms of hypospadias in a single step.
In 1973, Durham Smith developed and implemented the principle of displaced de-epithelialized flap, which later became widespread throughout the world for the correction of hypospadias and excision of the urethral fistula.
In 1974Gittes and MacLaughlin first used and described the “artificial erection” test, in which, after applying the turnstile to the base of the penis, saline was injected intracavernously. This test allowed us to objectively assess the degree of curvature of the trunk of the penis.
In 1980, J. Duckett described a variant of a one-stage correction of hypospadias using the skin of an inner sheet of prepuce on a vascular pedicle.
In 1983, Koyanagi described the original method of one-stage correction of the proximal form of hypospadias with a double vertical urethral suture.
In 1987, Snyder developed the urethroplasty method using an inner sheet of prepuce on the vascular pedicle according to the principle of two flaps or “onlay” urethroplasty.
In 1987, Elder described an option to protect the urethral suture using a de-epithelialized, vascular flap.
In 1989, Rich applied the principle of longitudinal dissection of a ventral flap with distal hypospadias in combination with Mathieu technology, performing urethroplasty with less tissue tension, thereby reducing the likelihood of postoperative complications.
In 1994, Snodgrass developed the idea using the same method of dissecting the ventral surface in combination with the Duplay method.
Currently, in most cases, surgical treatment of hypospadias is carried out in one (maximum two) operations, however, the surgical treatment of hypospadias has been known since 1800, and at that time medicine was not so developed. As a result, the operations were not so successful and effective, but the operations could be up to 15-20 and they were carried out for several years.
Today, such treatment includes four main stages and is carried out in one day:
- Penis straightening,
- Creation of the urethra,
- Positioning the external opening of the urethra on the head of the penis.
The whole process takes from one and a half to three hours, but at some points (depending on the form of hypospadias and its severity), doctors may decide to carry out the operation in stages.
Even an adult patient can undergo surgery, however, until adulthood, leaving hypospadias without attention is at least impractical and not always possible, therefore, in most cases, treatment is carried out at the age of one and a half to two years.
Hypospadias operation in boys
Most specialists are currently inclined to conduct hypospadias in boys as early as possible, optimally between the ages of 8 and 16 months. This is due to the fact that modern children quite early realize their inferiority in connection with this disease and may receive psychological trauma.
Despite the complexity of the operation, in 95% of cases a favorable cosmetic and functional effect is guaranteed.
The main causes of hypospadias
- Genetic factors. The risk of hypospadias is significantly higher in the presence of a similar anomaly in the child's father or grandfather.
- Endocrine Disorders A violation of the development of the external genitalia, including hypospadias, can be caused by a decrease in the level of androgens. Also associated with the development of congenital defects of the scrotum and penis are mutations in the hormone 5-alpha reductase, which converts testosterone to dihydrotestosterone, which has a more powerful effect. The frequency of development of this pathology in children conceived in the winter is higher, which is associated with a change at this time in response to a change in the length of daylight hours of the hypothalamic-pituitary system.
- Adverse environmental factors can provoke the development of hormonal imbalance and abnormalities in the formation of the urethral canal. The effect of pesticides and the use of contraceptives after conception on the increased likelihood of hypospadias has also been proven.
- The combined effect of several of the following factors:
- drinking alcohol during gestation,
- toxicosis in early pregnancy,
- endocrine diseases in the mother,
- toxic substances
- chromosomal diseases,
- the presence of hypospadias in the family,
- mother too young or too late
- low birth weight.
A similar anomaly is often observed in boys conceived by in vitro fertilization (IVF). Hypospadias is often combined with such disorders as inguinal hernia, hydronephrosis, cryptorchidism (undescended testes in the scrotum).
Depending on the degree of underdevelopment of the urethra, hypospadias is classified into the following forms:
- coronary hypospadias - the opening of the urethra is located in the area of the coronary sulcus,
- capitate - the exit of the urethra is located on the base of the head,
- stem - the hole goes to the trunk of the penis,
- perineal - the exit of the urethra is located in the perineum,
- scrotal - the hole is located on the scrotum.
Given the degree of displacement of the external opening of the urethra, the front, middle and posterior hypospadias are distinguished.
The anterior includes capitate and coronary forms. They occur in about half of all cases of the disease. The scrotal stem, scrotal and perineal forms of the pathology belong to the back (approximately 30% of cases). The average hypospadias (stem) is found in 20%.
The operation of the stem form of hypospadias
With stem hypospadias, it is recommended that an operation be performed under the age of three years, which allows for the psychological comfort of the patient and to achieve maximum results.
With this type of hypospadias, an abnormal location of the urethra is observed, and its external opening is shifted to the trunk of the penis. As a rule, with stem hypospadias, there is also a curvature of the penis, and depending on how far the hole is from its normal position, the curvature can be more or less.
Urethral stricture may also be observed. (narrowing of the urethra).
All these problems are easily resolved by surgerywhich is preceded by a thorough diagnosis.
In the process of such studies, the possibility of surgery is identified, concomitant diseases are determined - these measures contribute to increasing the safety of the operation itself and minimizing complications. The operation is performed in one step under general anesthesia..
Symptoms of Hypospadias
The symptom of the disease is directly affected by the peculiarity of the location of the urethra and the nature of the curvature of the penis.
Capitate form hypospadias is the most frequent and mild. The urethral opening is narrowed, which complicates the process of urination. There may be an increase in the curvature of the penis in the puberty period, as well as after the onset of sexual activity.
At crown shape pathology, urination is difficult, urine due to a narrowed hole flows in a thin stream, the curvature is quite pronounced. In order not to get liquid on his feet, the child in the toilet is forced to lift his penis up.
Stem shape manifested in the fact that children have to lift the penis up, and sometimes it is even easier to urinate while sitting. Deformation of the penis is very noticeable, an erection can be painful. During intercourse, depending on the location of the urethra, sperm may not enter the vagina.
Scrotum form considered the hardest. With this arrangement of the urethra, the penis is often curved and underdeveloped. The urethral opening divides the scrotum into two parts, making it somewhat similar to the female labia majora. Sexual life is not possible with this form of hypospadias, and urination is only possible while sitting. Urine almost always enters the skin, causing irritation and even inflammation.
In patients with perineal form pathology noted underdevelopment of the penis and its small size. It is often difficult at birth to determine the sex of the child, since a similar anomaly is confused with adrenogenital syndrome in girls. In some cases of the disease, a birth defect lies only in the shorter length of the urethra, and its external opening is normally located. This form is called "hypospadias without hypospadias."
The operation of the coronary form of hypospadias
Like capitate hypospadias, the coronary form is considered simple from the point of view of the operation, however, in this case, surgical intervention is justified not only in terms of the difficulty of urination, but also by the need to correct the appearance of the penis.
With coronary hypospadias, distensional methods of therapy and ureaplasty are used., and if after the second method of operation, complications in the form of fistulas often appear, then the diffusion methods have several advantages:
- Distraction methods are not so complicated from a technical point of view,
- This type of intervention causes fewer complications (no more than 10% of patients).
Capitate hypospadias operation
The optimal age for the operation of capitate hypospadias is from two to five years. The operation is performed in one or two stages.
This is the easiest form of hypospadias, in most cases of capitate hypospadias, surgery is not required. The exception is narrowing of the urethra, as well as severe curvature of the penis.
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What it is?
This is the physiological condition of the penis, in which the urethral opening is not located in the upper part of the head. This causes a violation of the urination process.
With a slight displacement of the hole, pathology practically no worries. If the hole is located noticeably below the head, then it is impossible to urinate while standing, since the jet is directed downward. The child has to perform the procedure while sitting.
In addition, curvature of the penis develops, since the mucous membrane is absent above the urethral opening, and the organ develops incorrectly. There is a significant thickening of the foreskin on the head, which because of this does not close completely.
As the boy grows and develops deformations become more noticeable. Psychological problems are added to physiological problems. A boy cannot urinate while standing, like his peers. He has to do this only while sitting, as a result, complexes and a tendency to depression arise.
At an older age, problems will arise in sexual terms, since deformation of the organ can interfere with sexual intercourse or cause pain during an erection. Atrophy of head tissue can cause impotence or inability to eject sperm, that is, cause complete infertility.
Forms of pathology
Distinguish several forms diseases (see photo below):
- Capitate - the hole is located in the lower part of the head. The most common form. Penile curvature is rare. Problems only with the direction of the jet during urination.
- Coronary - the hole is located on the border of the head and trunk of the penis. The jet is directed downward when urinating. Pathology is often accompanied by curvature of the penis.
- Stem - the hole is located on the lower part of the trunk of the genital organ. Curvature is often observed, and, in any direction. Urination is only possible in a sitting position.
- Scrotum - the hole is located in the scrotum.In this case, the penis is underdeveloped and has a small size. Urination is only possible in a sitting position.
- Crotch - the hole is located in the perineum (as in girls). It has the shape of a funnel of considerable size. Member of small size, practically undeveloped and significantly curved.
- Chordate - the hole is located in the right place, but the urethra is short and underdeveloped. This causes head tissue atrophy and penile curvature. As puberty, deformation of the organ increases.
(Image is clickable, click to enlarge)
What kind of treatment?
The only effective treatment for pathology is surgery.
Surgical intervention for newborns is not performed. The operation is done for boys aged 1 to 3 years. In rare cases, in adolescents, since it all depends on the degree of complexity of the violation. The optimal age is 2 years. In this case, the chances of a normal organ development increase.
The operation allows you to normalize the process of urination and to ensure the full formation of the organ in the future. All functions of the penis will be preserved, and external defects will be eliminated.
During the operation, the surgeon shifts the urethral opening to its normal position and corrects the shape of the urethra. If the foreskin is enlarged, then its excess will be removed, and the penis will take on a natural look.
The operation is performed under general anesthesia and lasts a maximum of 3 hours. There will be no threat to the life and health of the boy if there are no other serious diseases.
The recovery period is more difficult. The child will experience pain and discomfort when urinating for the first time until the wounds heal completely. The penis is inserted special catheterto relieve suffering and not irritate the unhealed urethra.
How do catheterization of the bladder read in our article.
Additionally, painkillers and antibiotics can be prescribed to prevent the occurrence of infectious processes. During recovery, bed rest is shown with minimal mobility. The timing of full recovery depends on the age and condition of the child. In young children, this period is much shorter.
The presence of hypospadias in a child is diagnosed immediately after his birth. The neonatologist examines the newborn and determines the form of the pathology. If the anomaly in the development of the genital organs does not allow you to determine the baby’s gender accurately, then an ultrasound examination of the pelvic organs is performed, and sometimes even the determination of the chromosome set.
After identifying the disease, the child is sent for consultation with a doctor of genetics, since such a violation can be accompanied by other congenital pathologies.
An additional ultrasound of the bladder and kidneys is performed in order to assess their structural condition. Quite often, any problems are also found there.
Further observation is carried out by several narrow specialists: urologist, endocrinologist, etc.
A thorough examination of the baby is carried out with the determination of the localization of the pathology, urination disorders, as well as the degree of curvature of the penis. Before the examination, the parents find out the presence of a similar pathology in close relatives, the information on possible risk factors is clarified.
Upon examination, the doctor pays attention to the location and diameter of the external opening of the urethra, the size of the penis, the appearance of the foreskin, the presence of separation of cavernous bodies and bends of the trunk during an erection. He then checks the scrotum to rule out cryptorchidism, as well as the presence or absence of a congenital inguinal hernia.
Severe hypospadias in combination with other pathologies of the genital organs requires a full endocrinological and genetic examination immediately after the birth of the child in order to exclude disorders of sexual development.
Of the additional instrumental methods for diagnosing hypospadias, magnetic resonance imaging (MRI) of the pelvic organs, urethroscopy, and urethrography can be used.
Hypospadias is the most common malformation of the diuretic channel, which is observed in many boys. According to information obtained as a result of studies conducted over the past 40 years, a noticeable increase in the number of newborns with this pathology occurs over the years.
Hypospadias in boys is called a congenital anomaly in the formation of the external genitalia. This disease affects only males. Patients have a lack of posterior wall in the distal urethra. As a rule, this is possible for different periods of time.
Pathology is characterized by the fact that in the urethra there is an external opening, which is not located in the upper zone of the glans penis, but proximal in the trunk region, at approximately the same level as the coronary groove, which is much closer to the body itself compared to the normal development of the genital organs . In addition, the external opening can be located in other places: on the perineum, near the scrotum.
In the zone of the missing part of the urethra, a specific connective tissue cord is formed, which is usually called the chord. Thus, from the outside it seems that this part of the organ is sort of flattened and divided into several separate parts.
How common is pathology?
About 60-70 years ago, most researchers suggested that such a disease is relatively rare - only one case per 400 newborn boys.
Symptoms attract parental attention in the very early childhood of the baby. Usually, at the same age, pathology is corrected. This explains the fact that older males with an anomaly of the penis can be met extremely rarely.
Varieties. Capitate hypospadias
Tarasova Inna Valentinovna Doctor of the highest category, Candidate of Medical Sciences
Work experience 28 years.
There are various forms of hypospadias in which the abnormal location of the urethra is characteristic and which determine the severity of the disease and, as a consequence, the consequences:
- capitate hypospadias (as shown in the photo, placement is slightly lower than usual, penile curvature is extremely rare),
- stem hypospadias (placement in the lower part of the head of the penis with a curvature of the penis and narrowing of the urethra, which makes urination difficult)
- scrotal hypospadias (located in the scrotum, which makes it difficult to determine the sex of the child due to the anatomical similarity of the abnormally small penis to the clitoris, and the scrotum to large labia, urination only when sitting, in a standing position is impossible),
- coronary hypospadias (placement in the area of the coronary sulcus with difficulty urinating and curving the penis),
- perineal hypospadias (placement near the neck of the head of the penis),
- perineal hypospadias (one of the most difficult varieties of the disease, the location in the perineal region with the same difficulties as with scrotal hypospadias - sex determination is difficult, you may need to consult a geneticist),
- hypospadias without hypospadias or chordal type hypospadias (correct anatomical location of the external opening of the urethra, but with a strong curvature of the penis).
All about the form of the disease and methods of treatment
Men's diseases 0
Among all kinds of pathologies of the development of the genital organs in children, hypospadias is considered the most common, especially when it comes to male newborns. In this case, for 200-300 children there are 1-2 with such a diagnosis.Hypospadias is an anomaly in the development of the urethra, as a result of which the urethral opening is not in the place where the nature and anatomy of the structure of the human body is conceived.
Hypospadias differs into several forms depending on the location of the urethral canal, capitate form occurs in 70% of cases among children with this diagnosis. In order to make such a verdict, a visual examination is sufficient, in the future, the patient’s diagnosis is carried out in order to establish the causes of the anomaly, its shape and degree of development, as well as the presence of concomitant deviations and diseases.
Despite the fact that in most cases hypospadias surgery ends successfully, there is always a risk of certain complications. In particular, a violation of the blood supply to the artificial urethra is possible, and in these cases up to twenty surgical interventions can be performed.
Other major complications include:
- Bleeding for a long time after surgery,
- Inflammation of postoperative wounds
- Pain syndrome,
The last problem is the most common.. The development of the fistula is the canal connecting the urethra and the skin, and scars may also form in the external opening of the urethra.
Usually, most complications appear soon after surgeryHowever, there are cases when postoperative consequences made themselves felt years after surgery.
Despite the fact that in most cases the results after surgery for the treatment of hypospadias in children are favorable, after the child’s surgery, it is recommended to periodically show it to specialists. Often, after the operation, latent deformities can also be detected that need to be quickly corrected, especially often such deformations can occur in children during puberty.
Modern methods in about 80% of cases allow achieving positive results. At the same time, it is possible to restore the desired appearance of the organ and functional abilities.
Early correction of the pathology ensures the normal development of the penis, as well as the exclusion of psychological trauma in the boy. After the operation, until the completion of growth and formation of the penis, such patients continue to be observed by a urologist.
It should be remembered that early discharge of the child from the hospital contributes to his early forgetting about the presence of pathology and the operation completed. In the absence of complications, a urologist should be visited after 1, 3 and 6 months, as well as 2 years after the operation.
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To provide technical assistance in the surgical correction of hypospadias, the urologist must have a deep knowledge of the anatomy of the penis. This knowledge allows optimal distribution of cavernous bodies, cutting out a skin flap, which is supposed to create an artifact urethra with preservation of the vascular bundle and close the wound surface without damaging important anatomical structures. Underestimating this problem can lead to serious complications, up to disability. In many respects, the successful treatment of hypospadias depends on the technical equipment. As a rule, for surgical correction of hypospadias, urologists use a binocular magnifier with a 2.5-3.5-fold increase or a microscope, as well as microsurgical instruments. Most often they use a bellied scalpel No. 15, anatomical and surgical tweezers with a minimum tissue capture area, an atraumatic needle holder, hummingbird tweezers, small-sized single-toothed and two-toothed hooks,as well as absorbable monofilament atraumatic suture material 6/0 - 8/0. Crush tissue used to create the artifact urethra should be avoided during surgery. For this purpose, it is more logical to use small hooks or microsurgical retractors.
For long-term fixation of tissues in a certain position, it is advisable to use thread-holders that do not cause damage to the skin flap.
When correcting any form of hypospadias, it is advisable to complete the mobilization of the corpora cavernosa in the space between the superficial fascia of the penis and the fascia of Buck. This manipulation allows you to perform a complete audit of the cavernous bodies and carefully excise the fibrous chord, which even with distal forms of hypospadias can be located from the head to the penoscrotal angle, limiting further growth of the penis. Mobilized skin of the penis allows you to more freely perform the stage of closure of the corpora cavernosa, eliminating the possibility of tissue tension. One of the main principles of genital plastic surgery, contributing to the achievement of a successful result, remains the principle of freely laid flaps without tensioning the tissues.
Sometimes, after mobilization of the skin of the penis, signs of microcirculation disturbance in the flap are noted. In these cases, you should postpone the stage of urethral plastic surgery for the next time, or by performing plastic surgery of the urethra, move the area of ischemic tissue away from the vascular pedicle that feeds the urethra, in order to avoid contact thrombosis of blood vessels.
At the end of the urethral plastic surgery, it is advisable to shift the line of subsequent sutures to prevent the formation of urethral fistulas in the postoperative period. Thiersch used this technique more than 100 years ago to correct the stem form of epispadias.
Most urologists agree that in the process of performing an operative manual, it is necessary to minimize the use of an electrocoagulator, or use minimal coagulation modes. Some surgeons use an adrenaline solution (1: 100,000) to reduce bleeding. From our point of view, spasm of peripheral vessels prevents in some cases an objective assessment of the condition of skin flaps and can lead to erroneous tactics during the operation. Significantly more effective is the use of a tourniquet placed on the base of the corpora cavernosa in order to achieve the same effect. However, it should be noted that it is necessary to remove the tourniquet from cavernous bodies every 10-15 minutes for a while. During the operation, irrigation of the wound with antiseptic solutions is recommended. Sometimes urologists use the single dose of a daily dose of a broad-spectrum antibiotic at an age-related dosage for prophylactic purposes.
At the end of the surgical allowance, an aseptic dressing is applied to the penis. Most surgeons tend to use a glycerin dressing in combination with a porous elastic bandage. An important point is the application of a loose gauze bandage soaked in sterile glycerin in one layer in a spiral from the head to the base of the penis. Then, a thin porous elastic bandage (for example, 3M Coban bandage) is applied over the gauze bandage. A band 20-25 mm wide is cut out of the bandage. Then, according to the same principle, one layer of the bandage is applied in a spiral from the head to the base of the penis. There should be no bandage tension during dressing. The bandage should only follow the contours of the trunk of the penis. This technique allows you to maintain adequate blood supply in the postoperative period, while limiting the increasing swelling of the penis. By the 5-7th day of the postoperative period, edema of the penis is gradually reduced, and the dressing is reduced due to its elastic properties. The first change of dressing is usually done on the 7th day if it is not saturated with blood and retains its elasticity.The condition of the dressing is assessed visually and by palpation. A bandage soaked with blood or lymph dries quickly and does not fulfill its function. In this case, it should be changed after moistening with an antiseptic solution and keeping it for 5-7 minutes.
Postoperative urinary diversion
An important aspect in genital plastic surgery remains the derivation of urine in the postoperative period. Over the long history of genital surgery, this issue has undergone many changes from the most complex drainage systems to the banal transurethral abduction. Today, most urologists consider it necessary to drain the bladder for a period of 7 to 12 days.
In the 70s, the famous urologist V.I.Rusakov developed and introduced the method of urine diversion.
In turn, many urologists use cystostomy drainage in the postoperative period, sometimes in combination with transurethral derivation. Some authors consider puncture urethrostomy, which allows adequate urine drainage, to be the best way to solve this problem.
The vast majority of urologists consider effective urine diversion a mandatory item in the overall package of measures aimed at preventing possible complications, allowing you to keep the dressing on the penis without contact with urine for a long time.
Years of experience in the surgical correction of hypospadias objectively prove the rationality of the use of transurethral derivation of urine in patients with any form of malformation.
An exception may be made to patients in whom the achievements of tissue engineering were used to create the artifact urethra. In this group of patients, it is logical to use combined urinary diversion - puncture cystostomy in combination with transurethral diversion for up to 10 days.
As an optimal catheter for drainage of the bladder, the use of a urethral catheter with end and side openings No. 8 CH is recommended. A catheter should be inserted into the bladder no deeper than 3 cm in order to prevent involuntary detrusor contractions and urine leakage in addition to the drainage tube.
The use of a catheter with a balloon that causes irritation of the neck of the bladder and a constant contraction of the detrusor is not recommended. In addition, removal of a Foley balloon catheter increases the risk of damage to the artifact urethra. The reason lies in the fact that the balloon, inflated within 7-10 days, in the postoperative period is not able to fall to its original state. The overstretched wall of the balloon leads to an increase in the diameter of the retrieved catheter, which can contribute to a partial or complete rupture of the artifact urethra.
In some cases, leakage of urine in addition to the urethral catheter persists, despite the seemingly optimal location of the drainage. This fact is usually associated with the posterior position of the neck of the bladder, as a result of which there is constant irritation of the wall of the bladder with a catheter. In these cases, it is more efficient to leave a stent proximal to the hypospadias in the urethra, in combination with drainage of the bladder by means of puncture cystostomy (Faizulin A.K. 2003).
The urethral catheter is fixed to the glans penis, leaving a “mesentery” for easier ligature crossing when the catheter is removed. It is advisable to apply a duplicate nodal suture beyond the edge of the dressing and tie it with an additional node to the urethral catheter. Thus, the urethral catheter will not pull on the glans penis, causing pain to the patient. The outer end of the catheter is connected to the urinary receiver, or diverted to a diaper.
Usually, the urethral catheter is removed in the range of 7 to 14 days, paying attention to the nature of the stream. In some cases, it becomes necessary to bougie artifact urethra.Since this manipulation is extremely painful, anesthesia must be performed. After the patient is discharged from the hospital, it is necessary to conduct a follow-up examination after 1, 2 weeks, after 1, 3 and 6 months, and then once a year until the penis growth is complete, focusing the attention of parents on the nature of the jet and erection.
Postoperative wound drainage is performed only in cases when it is not possible to apply a compression dressing to the entire area of surgical intervention, for example, if the urethral anastomosis is applied proximal to the foam-scrotal angle.
For this purpose, use a thin tube No. 8CH with multiple side openings or a rubber graduate, which is brought out to the side of the skin suture line. Drainage is usually removed the day after surgery.
MAGPI Method Characterization (1981 Duckett)
An indication for the use of this technique is the location of the hypospadias meatus in the region of the coronary sulcus or glans penis without ventral deformity of the latter.
The operation begins with a bordering incision around the glans penis, 4-5 mm from the coronal sulcus, and on the ventral surface, the incision is 8 mm proximal to the hypospadias.
When performing an incision, maximum caution must be exercised in connection with the thinning of the distal urethral tissue over which the incision is made, in connection with the threat of the formation of the urethral fistula in the postoperative period.
The skin incision is made to the full thickness to the fascia Buck. After this, the skin of the penis is mobilized, allowing you to save the vessels that nourish the skin. After dissection of the skin of the penis with the help of tweezers, the superficial fascia rises and is dissected by vascular scissors. The tissues are bluntly bred between the surface fascia and the fascia Buck. With the correct dissection of the fascia, skin mobilization occurs almost bloodlessly.
Then, using soft vascular scissors, soft tissue of the penis is diluted along the skin incision, gradually moving from the dorsal surface to the lateral sides of the penis in interfascial space. Particular attention should be paid to manipulations in the area of the ventral surface, since it is here that the skin of the penis, the superficial fascia and the white membrane (fascia Buck) are soldered intimately, which, in turn, can lead to injury to the walls of the urethra.
The skin is removed from the trunk of the penis to the base as a “stocking”, which eliminates the skin torsion that sometimes accompanies the distal forms of hypospadias, and also creates a mobile skin flap ().
The next step is a longitudinal incision along the scaphoid fossa of the penis, including the dorsal wall of the hypospadias meatus for the purpose of meatotomy, since distal forms of hypospadias are often accompanied by meatal stenosis.
The incision is performed deep enough to cross the connective tissue jumper located between the hypospadias meatus and the distal edge of the scaphoid fossa. Thus, the surgeon achieves smoothing of the ventral surface of the head, eliminating the ventral deviation of the stream during urination.
The wound on the dorsal wall of the meatus takes a rhomboid shape, and thus any meatal narrowing is eliminated. The ventral wound is sutured with two or three transverse sutures using a monofilament suture (PDS 7/0).
For the production of glanuloplasty, a single-tooth hook or microsurgical forceps are used, with which the skin edge proximal to the hypospadias meatus rises towards the head so that the ventral edge of the surgical wound resembles an inverted letter V.
The lateral edges of the wound on the head are sutured with two or three U-shaped or interrupted sutures without tension on an age-related urethral catheter.
When closing a wound defect with the remains of mobilized skin, there is no single method that is universal for all cases of skin plasty, since the degree of ventral skin dysplasia, the amount of plastic material on the penile shaft and the dimensions of the prepuce sac vary significantly. Most often, the skin defect closure method proposed by Smith is used, which splits the prepuce sac with a longitudinal section of the latter along the dorsal surface. Then, the formed skin flaps are wrapped around the trunk of the penis and stitched together on the ventral surface, or one below the other.
In most cases, the remaining skin is sufficient for free closure of the defect without any movement of the tissue, and a mandatory point, from a cosmetic point of view, is the excision of the remains of prepuce.
By the time a wound defect is closed, as a rule, a mobilized skin flap has characteristic signs of marginal ischemia. More often, ischemic areas are located in the region of the lateral edges of the prepuce and are characterized by a certain blueness of the tissue, therefore, when resecting excess skin at the stage of closure of a wound defect, it is necessary to first resect the affected areas. When unchanged skin is resected, thorough preparation of the prepuce mesentery is performed, excising only the skin proper and, thus, preserving the vasculature, which contributes to the rapid healing of tissues in the postoperative period.
In some cases, the Tiersh-Nesbit principle is used to close the ventral wound defect, in which a “window” is created in the avascular zone of the dorsal skin flap, through which the glans penis is moved dorsally, and the defect on the ventral surface is covered with foamed prepuce tissue. In conclusion, the coronal skin edge of the wound is sutured with the edge of the skin "window", and the wound on the ventral surface of the shaft of the penis is sutured in the longitudinal direction with a continuous suture.
Hypospadias can be capitate, coronal, scrotal, scrotal, stem, and crotch - its shape depends on the location of the urethral opening. Each form implies an individual approach to treatment: some do not require treatment, others need to be treated. Consider what you need to do depending on what form of hypospadias is defined.
With capitate hypospadias, the external opening of the urethra is displaced from the apex of the penis slightly down to the coronal groove. There is no curvature of the penis with this form, urination is not impaired, and there will be no problems in the adult's sexual life - capitate hypospadias is more likely to have a cosmetic defect.
Crown, it’s coronary hypospadias is the location of the urethral opening in the area of the coronary groove of the penis. In this form, there is an obvious defect in the appearance of the penis, up to the lowering of the head down, and possible functional deviations. With coronary hypospadias, surgery is usually required. The operation includes the alignment of the head of the penis, the displacement of the urethral opening to the top of the head of the penis and the foreskin plastic.
With stem hypospadias, the external opening of the urethra is located on the trunk of the penis, which makes it impossible or extremely difficult to urinate while standing, and also complicates the sexual life of a man - there is a curvature of the penis during an erection. Surgical treatment in this case is already absolute. During the operation, the penis straightens and the urethral opening moves closer to the head.
And the last forms of hypospadias - scrotal and perineal, are the most serious congenital pathologies that can even cast doubt on the gender of the child.In such cases, the operation is absolutely indicated, since starting from childhood, the boy will not be able to urinate while standing, and his sexual life in adulthood will be impossible due to severe deformation of the penis.
Examination and preparation for surgery
A visual examination will allow not only to diagnose hypospadias, but also to determine its shape, the state of the urethra and the degree of deformation of the penis. All these characteristics are necessary to solve the main issue - the type of hypospadias and the method of reconstructive surgery. With complex forms of this disease, genetic, ultrasound, and other studies may also be required.
When indications for surgery, it is necessary to take blood and urine tests, consult other specialists, including the anesthetist. The operation is performed under general anesthesia and lasts from one to several hours, depending on the degree of correction.
Hypospadias Surgery in EMC
At present, there are about 200 types of hypospadias correction operations, but none of these types can be called universal, each case requires an individual approach. It is very important to note that the success and safety of hypospadias treatment completely depends on the technical and theoretical training of the surgeon, the urologist must know and improve the methods of modern surgical interventions, possess the elements of microsurgery and working skills under optical magnification.
Another factor affecting the success of surgical treatment of hypospadias is the modern equipment of the operating room, the use of special tools, including consumables and suture materials. Anesthetic management is also important - this allows for long-term operations in children of the first years of life.
Surgical treatment of hypospadias in all forms sets such important goals as:
reconstruction of the missing segment of the urethra
straightening the penis
moving the urethral opening to the place of its normal location - the top of the glans penis.
achievement of aesthetic appearance and full functions of the penis
Doctors at the EMC clinic perform both primary and repeated operations during hypospadias, striving for the complete elimination of this problem and the absolute restoration of the functions and appearance of the penis.
Urethroplasty with megalomeatus without prepuce (MIP) (Duckett - Keating 1989)
An indication for the use of this technology is the coronary form of hypospadias without ventral deformation of the trunk of the penis, confirmed by the test of "artificial erection".
The principle of operation is based on Tiersch - Duplay technology without using prepuce tissue. The operation begins with a U-shaped incision along the ventral surface of the glans penis with bordering the megameatus along the proximal edge. With sharp scissors, the lateral walls of the future urethra are accurately distinguished without crossing the split spongy body of the urethra. Most often, there is no need for a deep separation of the walls, since a deep scaphoid fossa allows you to form a "new" urethra without the slightest tension.
The urethra is formed on the urethral catheter. The transurethral catheter should move freely in the lumen of the created channel. As a suture material, it is optimal to use monofilament absorbable suture 6/0 - 7/0.
In order to prevent paraurethral urinary flow in the postoperative period, a continuous precision urethral suture is used. Similarly, a skin suture is applied.
Movement of the urethra with glanuloplasty and plastic prepuce in distal forms of hypospadias (Keram> Indications for use of this method are capitate and coronary forms of hypospadias without signs of dysplasia of the distal urethra.
At the beginning of the operation, the bladder is catheterized.The operation begins with a submeatal sickle-shaped skin incision, which is produced 2-3 mm below the meatus. This incision is extended vertically, bordering the meatus on both sides, and continues upward until they merge at the top of the glans penis. The meatus is isolated in an acute and blunt manner, then the distal urethra is mobilized. Behind the urethra is the fibrous layer. It is very important not to lose the layer during the allocation of the urethra, without damaging the wall of the urethra and cavernous bodies. At this stage of the operation, special attention is paid to maintaining the integrity of the urethra and thin skin of the penis, which reduces the risk of postoperative fistula formation. Urethral mobilization is considered complete when the urethral meatus reaches the top of the glans penis without tension. To excise the remaining chord near the coronal groove, 2 incisions are made, each of which is about ¼ of its circumference. After the complete mobilization of the urethra, its reconstruction begins. The meatus is sewn to the top of the glans penis with an intermittent suture. The head closes above the displaced urethra with interrupted sutures. The skin of the prepuce is given a natural look by transverse dissection of its ventral part on both sides and a vertical connection. Thus, the head is closed with the restored foreskin. After the operation is completed, the penis acquires its normal appearance, the meatus is located at the top of the head, and the prepuce skin borders the head. The transurethral catheter is removed on the seventh day after surgery.
An indication for the use of this technology is the capitate form of hypospadias without deformation of the trunk of the penis and a well-developed navicular fossa, in which the urethral defect is 5-8 mm in combination with full-fledged skin of the ventral surface that does not have signs of dysplasia.
The operation is performed in one step. Two parallel longitudinal cuts are made along the lateral edges of the scaphoid fossa laterally to the hypospadias and the proximal to the length of the urethral tube deficit. The width of the skin flap is half the circumference of the created urethra. The proximal ends of the sections are interconnected.
In order to reliably cover the created urethra, the erectile tissue of the glans penis is mobilized. This very delicate task is performed by carefully dissecting along the connective tissue jumper between the cavernous body of the head and the cavernous bodies until the rotated flap is placed in the newly created niche and the edges of the head are freely closed over the formed urethra.
The proximal end of the skin flap is mobilized to the hypospadias and rotates distally, superimposed on the base flap, so that the angles of the apex of the selected flap coincide with the tops of the cut flap-flap sections. The flaps are stitched together with a lateral continuous intradermal precision suture from the top of the head to the base of the flap on the urethral catheter.
The next stage, the mobilized edges of the glans penis are sutured together with interrupted sutures above the formed urethra. Excess preputial tissue is resected at the level of the coronary sulcus. The operation ends with the application of a compression dressing with glycerin. The catheter is removed 10-12 days after surgery.
Timely detected hypospadias of the capitate form allows specialists to start treatment at the right time, and also to determine all the prerequisites for the development of the problem. This anomaly of development is laid in the embryonic period in the first trimester of pregnancy. The capitate form in newborns manifests itself in the form of the location of the urethral outlet not in the center of the head, as it should be, but with a shift in different directions.
Symptoms of the capitate form in children are as follows:
- in the place where a healthy person has a urethral opening, a thin leather plate is observed in the form of a deepening of a longitudinal shape to the coronal groove of the penis head,
- the urethral outlet is offset a certain distance from the center of the head,
- in addition to the pathology of the placement of the urethra, narrowing of the urethra is observed, which is manifested by urination with a weak thin stream.
In addition to external manifestations, pathology can negatively affect future sexual functions, so it is very important to start treatment in a timely manner. In this case, most often doctors use surgery to correct the location of the urethra and its size and shape.
The pathology of the development of the urethra (hypospadias) is observed in rare cases in girls. In addition, the most severe forms of hypospadias can confuse doctors in determining the sex of the child, since the genitals are significantly deformed.
You can learn more about other forms of hypospadias from selected materials:
- Scrotal hypospadias,
- Coronary hypospadias,
- Stem hypospadias.
Description of the method of urethroplasty type Tiersch - Duplay (1874)
An indication for this operation is considered a coronary or capitate form of hypospadias in the presence of a well-developed glans penis with a pronounced navicular groove.
The principle of operation is based on the creation of a tubularized flap on the ventral surface of the penis and therefore has quite reasonable contraindications. This operation is undesirable in patients with stem and all proximal forms of hypospadias, since the urethra, created on the basis of the Tiersch-Duplay principle, is practically devoid of main supply vessels and, accordingly, has no growth prospects. Children with proximal forms of hypospadias operated by this technology in the distant postoperative period (puberty) suffer from the syndrome of "short urethra". In addition, the percentage of postoperative complications after the use of this technique is the highest.
The operation begins with a U-shaped incision along the ventral surface of the penis with bordering the hypospadias meatus along the proximal edge. Then the wound edges are mobilized on the head, penetrating the connective tissue septum between the erectile tissue of the head and the cavernous bodies. Then the central flap is sutured into the tube on catheter No. 8-10 CH with a continuous precision suture, and the edges of the head are sutured with interrupted sutures above the formed urethra. The operation ends with the application of a compression dressing with glycerin.
Characterization of the method of urethroplasty using the mucous membrane of the cheek (Humby, 1941)
In 1941 G.A. Humby first proposed using the cheek mucosa as a plastic material for surgical correction of hypospadias. Many surgeons used this method, however, it was J. Duckett who actively promoted the use of the mucous membrane of the cheek to reconstruct the urethra. Many surgeons avoid using this technology due to the high percentage of postoperative complications, which varies from 20 to 40% (Ransley, 1999, Hadidi, 2003, Manzoni, 1999).
Distinguish between one-stage and two-stage operations during reconstruction of the urethra using the mucous membrane of the cheek. In turn, one-step operations should be divided into three groups: 1) urethral plastic with a tubularized flap of the cheek mucosa, 2) urethral plastic according to the onlay or patch principle, and 3) the combined method.
In any case, the cheek mucosa is initially taken. Even in an adult, it is possible to get a flap of 60-55mm by 12-15mm in size as much as possible. It is more convenient to take a flap from the left cheek, if the surgeon is right-handed, standing to the left of the patient.It must be remembered that the flap should be taken strictly in the middle third of the lateral surface of the cheek in order to avoid injury to the salivary ducts. An important condition should be considered remoteness from the angle of the mouth, since the postoperative scar can lead to deformation of the line of the mouth. Ransley (2000) does not recommend using the lower lip mucosa for the same reason. In his opinion, the postoperative scar leads to deformation of the lower lip and impaired diction.
Before the flap is taken, 1% lidocaine solution or 0.5% novocaine solution is injected under the cheek mucosa. The flap is sharpened and the wound defect is sutured with interrupted sutures using 5/0 chromed catgut sutures. Then, the acute tissue residues are removed from the inner surface of the mucous membrane. Next, use the treated flap as intended.
In those cases when the urethra is formed according to the principle of a tubular flap, the latter is formed on the catheter by a continuous or knotted suture. Then, the formed urethra is sutured with the hypospadias meatus according to the “end to end” principle and a meatus is created, closing the edges of the dissected head over the artifical urethra.
When creating the urethra onlay principle, it should be remembered that the size of the implanted mucous flap directly depends on the size of the base skin flap. In total, they should correspond to the age diameter of the formed urethra. The flaps are stitched together with a lateral continuous suture using absorbable sutures 6 / 0-7 / 0 on the urethral catheter. The wound is closed with the remains of the skin of the trunk of the penis.
Less often use the mucous membrane of the cheek with the resulting deficit of plastic material. In such situations, part of the artificial urethra is formed according to one of the methods described, and a deficiency of the urethral tube is created using a free flap of the mucous membrane of the cheek.
The production of similar operations in patients with completed growth of cavernous bodies is certainly of practical interest, however, with regard to pediatric urological practice, the question remains open, since it is impossible to exclude a lag in the development of the articular urethra from the growth of the cavernous bodies of the penis. In patients with hypospadias operated on at an early age using this technology, the syndrome of “mild urethra” and secondary ventral deformation of the trunk of the penis may develop.
Characterization of the method of urethroplasty using a tubularized inner sheet of prepuce on a vascular pedicle (Duckett 1980)
The Duckett technique is used for one-stage correction of the posterior and middle forms of hypospadias depending on the supply of plastic material (the size of the foreskin). The technology is also used in severe forms of hypospadias with severe skin deficiency in order to create an artifact urethra in the scrotal and scrotum sections. An important aspect is the creation of a proximal fragment of the urethral tube from skin devoid of hair follicles (in this case, from the inner leaf of the foreskin), with the prospect of distal urethroplasty by local tissues. The defining moment is the size of the preputial sac, limiting the possibilities of plastic surgery of the artificial urethra.
The operation begins with a bordering incision around the glans penis 5-7 mm from the coronal sulcus. The skin is mobilized to the base of the penis according to the principle described above (p.). After mobilization of the skin of the penis and excision of the fibrous chorda, a true assessment of urethral deficiency is performed. Then a transverse skin flap is cut out from the inner leaf of the foreskin. The incision on the inner surface of the prepuce is made to the depth of the actual skin of the inner leaf of the foreskin. The length of the flap depends on the size of the defect of the urethral tube and is limited by the width of the prepuce bag.The flap is sutured into the tube on the catheter with a continuous precision intradermal suture using atraumatic monofilament absorbable sutures. The remains of the inner and outer sheets of the foreskin are stratified in the avascular zone and are used later to close the wound defect of the ventral surface of the penis. An important step in this operation is the careful mobilization of the artifact urethra from the external epithelial plate without damaging the vascular pedicle. Then, the mobilized urethral tube rotates on the ventral surface to the right or left of the shaft of the penis, depending on the location of the vascular pedicle in order to minimize the kink of the supply vessels. The "new urethra" anastomoses with a hypospadias meatus of the type "end to end" nodal or continuous suture.
Anastomosis between the artifact urethra and the glans penis is performed according to the Hendren method. To do this, the epithelial layer is dissected to the cavernous bodies, after which the distal end of the created urethra is laid in the formed hollow and sutured to the edges of the scaphoid fossa with interrupted sutures over the formed urethra. Sometimes in children with a small penis, it is not possible to close the edges of the head. In these cases, the Browne technology described in 1985 by B. Belman is used. In the classic version, in order to create an anastomosis of the distal artifact urethra (J. Duckett 1980), tunneling of the glans penis was used. According to the author, urethral stenosis occurred with a frequency of more than 20%. Using the principle of Hendren and Browne allows to reduce the percentage of this type of postoperative complications by 2 - 3 times. To close the cavernous bodies of the penis, previously mobilized skin of the outer sheet of the prepuce is used, dissected along the dorsal surface and rotated on the ventral surface according to the Culp principle.
Characterization of the method of islet urethroplasty on the vascular pedicle according to the “onlay” Snyder-III principle (Snyder 1987)
Indications for the use of this technology are patients with coronary and stem forms of hypospadias (anterior and middle forms according to Barcat) without curvature of the trunk of the penis, or with minimal curvature. Patients with severe curvature of the trunk of the penis often need to cross the ventral skin path to completely straighten the corpora cavernosa. An attempt to straighten the penis with pronounced fibrous chord by dorsal plication leads to a significant shortening of the length of the trunk of the penis.
The operation is not indicated in patients with hypoplastic foreskin. Before the operation, it is necessary to evaluate the correspondence between the sizes of the inner prepuce leaf and the distance from the hypospadias meatus to the top of the head.
The operation begins with a U - shaped incision along the ventral surface of the penis with the bordering of the hypospadias meatus along the proximal edge. The width of the ventral flap is formed by at least half of the age length of the circumference of the urethra. Then the incision is extended to the sides, bordering the head of the penis, retreating 5-7 mm from the coronal groove. Skin mobilization is performed according to the method described above. The fibrous chord is excised on the sides of the ventral flap. In the case of persistent curvature of the trunk of the penis, plication is performed along the dorsal surface.
The next step is to cut out a transverse skin flap corresponding to the size of the ventral flap from the inner leaf of the prepuce. The incision is made to the depth of the actual skin of the inner leaf of the foreskin. Then produce the mobilization of the prepuce flap in the avascular zone, exfoliating the sheets of prepuce. The skin islet is mobilized until it moves to the ventral surface without tension. The flaps are stitched together with a continuous subcutaneous suture on the urethral catheter.Initially, the mesenteric margin is sutured, then the opposite. The mobilized edges of the head are sutured with interrupted sutures over the formed urethra. Naked cavernous bodies are covered with the remains of mobilized skin.
Perinatal form of hypospadias (coronary, parietal, coronal) - the urinary canal is displaced slightly below the head into the region of the bridle that the head forms. This is one of the most common forms of hypospadias.
The site of the frenum of the penis during fetal development is most susceptible to the influence of negative factorssuch as alcohol, nicotine and medications. The penis with this type is curved in the ventral direction.
Patients with this form of anomaly complain that the urine stream is directed at an angle toward the penis. Capitate and coronary hypospadias are classified as anterior forms of this anomaly.
Why does hypospadias occur?
According to various sources, this anomaly is recorded from 0.5 to 5% in newborn boys and has a tendency to increase. Experts attribute this phenomenon to an increase in the number of pregnancies using assisted reproductive technologies, the use of hormonal drugs to preserve pregnancy, toxicological effects, adverse effects of external conditions, heredity, etc.
There is evidence that with in vitro fertilization, the incidence of hypospadias increases by 5 times (a study by Silver RI et al. 1999).
What are the consequences of hypospadias?
Firstly, it is difficulty in urinating, the lower the opening of the urethra, the more need to urinate in the “female type” while sitting.
Often the urine stream is curved or splattered.
A curved penis with an abnormally opening urethra leads to the impossibility of a full sexual life.
An inferiority complex, depression, apathy - these are the companions of a man who was not operated on in a timely manner, in childhood.
When is it best to perform hypospadias surgery?
Currently, the optimal period is considered the age of the child from 8 months to 3 years. There are experts who are of the opinion that it is better to perform surgery earlier: from 6 to 9 months. This is due to the absence of trauma to the psyche of the child during early surgical intervention, the creation of opportunities for the full development of cavernous bodies and normal growth of the penis.
To correct a mild form, one operation is enough, with complex forms of hypospadias several surgical interventions can be performed.
The first stage involves the closure of a skin defect and the formation of a flap of the missing urethra from the skin flap of the foreskin or scrotum.
Reoperation is performed at 4-6 years of age, the intervention is aimed at completing the formation of a new urethra with an adequate diameter for normal passage of urine.
With combined pathology, abnormalities of the upper and lower urinary tract are corrected, which allows you to preserve the functional abilities of the kidneys, and only then proceed with the correction of the urethral malformation.
The stem form of hypospadias or hypospadias of the distal third of the penis (translated from the English. penile hypospadias) - the cavernous body of the urinary canal is poorly developed or even absent.
Its outer opening may be located throughout the cavernous body.
The severity and direction of the curvature of the penis depends on where the hole opens.
What are the indications for surgery?
Indications that are expressed in functional disorders and indications associated with a cosmetic defect are distinguished. Functional:
- posterior hypospadias,
- penis curvature,
- spraying urine stream, its deviation,
- narrowing of the external opening of the urethra.
Cosmetic indications for surgery are as follows:
- anomaly in the location of the urethral opening,
- penis rotation
- malformations of the foreskin,
- splitting of the scrotum.
Surgery for hypospadias in a child implies the following aspects: restoration of the normal form of the penis, the formation of a "new" urethra, excretion of the external opening of the head of the penis.
In modern urology, there are more than 200 modifications of surgical treatment used for hypospadias of the urethra.
Earlier, plastic surgery was performed using a skin flap; at present, urologists mainly use the operation of notching and tubularization of the urethral plate (TIP). This method is applicable to correct both distal and proximal hypospadias. Compared to previous operations, the advantages of TIP are as follows:
- less trauma to surrounding tissues,
- fast rehabilitation
- fewer complications
- technical availability
- shorter duration of anesthesia sleep.
Why is it important to perform an operation with early urethral hypospadias?
About 40 years ago, hypospadias correction was performed for boys older than 3 years. It was believed that it was technically easier to perform surgical correction on the larger penis.
But later drew attention to the fact that boys operated on in a conscious age, develop significant physiological and psychological disorders.
Sometimes, before surgery, they resort to adjuvant hormone therapy, for which hormonal drugs are used. But this is done according to strict indications, after consultation with an endocrinologist. The goal is to increase the size of the penis while using testosterone and human chorionic gonadotropin.
According to current standards, a boy with hypospadias should be operated on no later than 1.5 years.
Advantages of early surgery for hypospadias:
- the smaller the age, the better the regenerative ability of tissues,
- easier care of the penis after surgery: it’s easier for the baby to put on a diaper so as not to draw attention to the urinary catheter installed after the operation,
- at this age, boys do not have spontaneous erections that increase the likelihood of postoperative divergence of sutures,
- the psyche of the child does not suffer, since at this age the baby remembers little.
The duration of surgery depends on the type of hypospadias and abnormalities that need to be adjusted.
On average, it takes 2 to 3 hours, but hypospadias surgery can last even longer.
Note that all interventions are performed under general anesthesia, which facilitates the surgical correction of defects in a small child.
Rehabilitation after surgery for hypospadias
After discharge from the hospital for at least 24 months, the surgeon observes, since it is during this period of time that complications are often recorded.
After surgery, the bandage is removed on the 5-7th day.
For the prevention of secondary infection, antibiotic therapy with penicillin drugs is prescribed. For local therapy, an ointment with an anti-inflammatory effect is used, which is applied 4 to 5 times a day.
Pampers need to be changed often, every 1.5 - 2 hours. Be sure to “ventilate” the postoperative scar, but make sure that the child does not pull out the urethral catheter, which has been in the bladder for at least 2 weeks.
Causes and consequences of hypospadias in newborn boys
When hypospadias in a boy is observed urinary displacement, which normally should be located on the glans penis, and in the presence of pathology is located closer to its middle, or, near the scrotum.
This phenomenon is considered very common, but also quite dangerous.The disease requires special treatment, the main method of therapy is surgical intervention.
The disease may subsequently seriously affect on the quality of the intimate life of a man, his ability to conceive.
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Hypospadias in boys - photo:
Hypospadias - a disease that has congenital character. It manifests itself in the form of an atypical location of the urinary opening, when the urethral opening is in the area of the trunk of the penis, or closer to the scrotum.
This pathology does not occur as an independent deviation, it is often accompanied by other abnormalities of the development of the genital organs (curvature of the penis, deformation of the foreskin, the presence of diseases of the genitourinary system).
What complications and troubles can there be after surgery for hypospadias?
The pain syndrome is stopped by the appointment of drugs from the NSAID group in the form of syrups, which have anti-inflammatory and analgesic effects.
The origin of the pain is understandable: firstly, the surgical intervention performed, and secondly, the urinary catheter acts on the neck of the bladder, which has many nerve endings, which cause cramping. Putting a warm diaper on the lower abdomen somewhat eases the condition.
The allocation of blood in the first days after surgery should not bother, provided there is no pronounced bleeding. A few drops of spotting on the diaper are allowed.
The most unfavorable complication is infection of the postoperative wound, which can lead to zero result of all the efforts of surgeons. therefore it is important not to give up the antibiotic, not to reduce the dosage on your own and not to miss the dose.
The formation of the fistulous course develops against a background of divergence of sutures and leakage of urine into nearby tissues. If there is no concomitant urethral stricture, there is a chance that a small fistula will pass on its own.
The stricture of the newly formed urethra requires bougienage; if unsuccessful, they resort to laser excision of the defect.
Reasons for development
Among the negative factors that provoke the development of anomalies, it is customary to include:
- Genetic predispositiontransmitted from generation to generation on the male line.
- Hormonal abnormalities in the body of a future mother, when an excessive content of the hormone estrogen is observed in her body. This situation arises in cases where there has been IVF (artificial insemination), taking hormonal medications in the early stages of bearing a child, taking hormonal contraceptives shortly before conception.
- Bad habits of a pregnant women (smoking, drinking alcohol, genetically modified foods).
- Unfavorable ecological situation in the region where the expectant mother lives.
- Intrauterine fetal infection across the placenta.
- Multiple pregnancy.
- Gene mutations during fetal development.
These causes especially strongly affect the formation of the urogenital system of the fetus in the first trimester of pregnancy (8-12 weeks), when its formation occurs.
Is it necessary for a child to have an operation with a “mild” form of hypospadias
“Light” forms include capitate, perinosal, and coronary hypospadias. The operation must be done, since all the same psychological aspects in adulthood can lead to adverse consequences. According to statistics, these boys are still operated on, but only at a later age.
Stem, scrotal, perineal hypospadias becomes a significant psychological trauma for parents. It is necessary to realize that only surgery can correct the pathology, which should be the main task.
Accusing each other of bad heredity, the hope of a “miracle” and self-resolution of the situation, is at least unconstructive.
In the most severe form of hypospadias, the penis is so small that it resembles a clitoris, the scrotum is similar to the labia due to splitting, and the urethra is similar to the vagina. Testicles in the scrotum may be absent due to cryptorchidism.
In this case, a blood test is performed on a karyotype to determine the sex of the child, since the girl can actually be a boy. But even such severe cases lend themselves to surgical correction.
Scarlet form of hypospadias (translated from the English sсrotal hypospadias) - with this anomaly, the urinary canal opens on the scrotum. Patients can produce urination only sitting.
The penis is severely underdeveloped, curved in the ventral direction.
In some cases, the external genitalia may take the form of the female labia and hypertrophic clitoris.
Before starting treatment for scrotal hypospadias, it is recommended to consult an endocrinologist.
What can be done to prevent hypospadias?
According to experts, anomalies in the development of the urethra are laid in the early stages of pregnancy, and the sooner the harder the pathology.
Therefore, pregnancy should be planned in order to exclude, for example, the harmful effects of alcohol, nicotine, drugs, etc. on embryogenesis. Prophylactic administration of folic acid and vitamin E reduces the likelihood of fetal malformations.
You should not plan a pregnancy immediately after taking oral contraceptives. It is better to wait for the year when the hormonal background of the mother recovers.
Misha Victoria, urologist, medical observer
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Types and forms of the disease
Depending on the degree of development of the urinary canal and the place of its localization, the following forms of pathology are distinguished:
- Capitate. It is considered the most common form of the disease, in which the hole is located on the glans penis, but is located just below the normal location. In this case, the penis is not bent, any other concomitant anomalies, as a rule, are not detected.
- Coronet. The hole is located in the area of the coronal groove. This anomaly contributes to the development of disorders of the urination process.
- Stem. The hole is on the trunk of the penis. At the same time, a narrowing of the lumen of the urinary opening is noted, a significant violation of the urination process is observed, when it is already not possible to empty the bladder in a standing position.
- Scrotum. The hole is located in the scrotum. The penis is curved, has a small size. The process of urination is possible only from a sitting position.
- Crotch. The external opening of the urethra is greatly expanded, the penis is curved and has small dimensions.
- Chord. The urinary canal is deformed, shortened. Its opening is in a standard place, but the penis is deformed.
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Symptoms and signs
The disease has a characteristic clinical picture, in the presence of which this pathology can be recognized. Depending on the form of the disease, such signs as:
- incorrect location of the urethral opening,
- the irregular shape of this hole (its narrowing, or, conversely, expansion),
- penile deformity,
- small size of the penis.
Complications and consequences
In addition to the psychological problems that arise during hypospadias, the development and physiological complicationsthat significantly impair the patient’s quality of life. Among them are:
- narrowing of the lumen of the urethra,
- violation of the urination process, when urine is delayed in the kidney area, which can lead to the development of inflammatory processes,
- the inability to conceive a child,
- inflammation of the skin located near the opening, the formation of suppuration in the affected areas of the skin,
- the appearance of fistulas in the affected area,
- violation of sexual function, the development of severe depression on this background.
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Perineal and perineal scrotal hypospadias
Perineal hypospadias - the urinary canal opens in the perineum. In this case, the penis has a clearly noticeable curvature, the scrotum is split (dysplasia).
The act of urinating is squatting. The structure of the external genitalia is mixed.
Such patients need the advice of a geneticist and endocrinologist.
Perineal hypospadias, along with scrotal and penile-scrotal, refers to the posterior forms of pathology.
Hypospadias without hypospadias
Hypospadias without hypospadias (as a chord) - the urinary canal is located at the top of the head of the penis, but at the same time there is a different degree of deformation of the penis.
This may be due to dysplasia of the skin of the ventral surface, a complex of dysplasia of the skin and the presence of strands of connective tissue along the urethra or the underdevelopment of the urethra itself.
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How to treat?
The only way to treat hypospadias is surgery. Such operations belong to the class of reconstructive plastic. The main task of surgical intervention in hypospadias is the plastic surgery of the missing section of the urethra, the creation of a normal size of the lumen of the urinary canal, correction of the deformation of the penis and the complete removal of cosmetic defects.
The optimal age for the treatment of hypospadias is considered to be a period from 6 to 18 months, since during this period the child is easier to tolerate both the operation itself and the course of the postoperative period. As a rule, children operated on before the age of three do not remember the operation.
What is hypospadias and causes
Hypospadias refers to a strong or moderate displacement of the anatomical tube of the urethra relative to the body of the penis. Moreover, the urethra can be displaced even in the perineum or scrotum, which is even worse for a small patient.
With such an abnormal structure, the patient disrupts the urination process. As a result, in the absence of treatment of pathology, a boy or already a man will have kidney problems. There is no question about the sex life and normal functioning of the reproductive system in an adult male with such a pathology. Especially if the patient has a complex form of hypospadias, since the displaced urethra over time leads to the curvature (deformation) of the penis.
Hypospadias of the penis is formed in boys during intrauterine development. Provoking factors and causes of the abnormal structure of the penis can be such processes and conditions in a future mother:
- Taking certain medications without the recommendation and approval of a gynecologist or other specialized specialist (especially hormonal treatment),
- Alcohol and tobacco use,
- Adverse environmental factor,
- Gene or chromosomal mutations,
- Food poisoning during pregnancy,
- Male lineage
- Artificial insemination.
Important: before surgical treatment of a newborn boy, a pediatric urologist should constantly observe.Since the abnormal structure of the penis can provoke an inguinal hernia, hydronephrosis, the absence of normal prolapse of the testicles into the cavity of the scrotum, etc.
Symptoms and forms of the disease
After we found out what hypospadias in a boy is, various forms of the disease should be studied. They are classified by the degree and depth of displacement of the urethral lumen relative to the entire length of the penis, as well as by the zone of location of the meatus (external urethral lumen) on the head of the penis. Therefore, for any form of hypospadias, this is considered the main signs. That is, such symptoms of the abnormal structure of the penis are distinguished:
Penis erosion: causes, symptoms and treatment
- The displacement of the external lumen of the urethra from the center of the glans penis down to the coronary groove or lower along the shaft of the penis towards the scrotum. This displacement is called proximal.
- The curvature (dysplasia) of the foreskin of the penis. In most cases, it hangs on the head like a hood or has splitting.
- Deformation of the cavernous bodies of the penis and its curvature to one degree or another. The degree of deformation is detected during an erection in a man or during an operation by a test method called “artificial erection”.
In general, such various forms of the abnormal structure of the penis are revealed in boys and men.
Capitate hypospadias is characterized by minimal displacement of the urethra. That is, the lumen of the urethra is shifted down to the furrow, but not below it. The penis is slightly curved, and the foreskin has obvious signs of deformation. When urinating, the stream is clearly weak, thin, and can come out in portions. Hypospadias capitate form in children is visible as well as other forms of anomalies.
With this form of abnormal structure, the external lumen of the urethra can be located at one of the points of the length of the trunk of the penis from its coronal groove to the base. That is why when emitting urine, the jet goes down. The patient has to constantly tighten his penis to his stomach to provide a more or less normal direction of urine flow. The penis with this form of hypospadias is deformed significantly.
Hypospadias scrotal is one of the most complex forms. With such an anomaly, the outer lumen of the urethra is located either on the scrotum itself, or on the border of the penis with the scrotum. A man with this pathology cannot urinate while standing. Urination occurs only according to the female type, while sitting. With scrotal hypospadias, the penis is curved so much that it resembles the female large labia and clitoris. With this form of pathology, an endocrinologist's consultation is mandatory.
Reception at the urologist: preparation for the examination, diagnosis and treatment measures
Among all types of hypospadias, the coronary form is considered as simple as capitate. Refers to the anterior anomaly, as well as capitate hypospadias. Here the lumen of the urethra is located on the coronary groove. At the same time, the urethral lumen is narrowed. During urination, a stream of urine is directed at an angle to the stem of the penis.
Characterization of the combined method of urethroplasty according to the method of Hodgson III-Duplay
The indication for surgery is the scrotal or perineal form of hypospadias (posterior according to Barcat classification), in which the meatus is initially located on the scrotum or perineum at a distance of at least 15 mm from the hypospadias to the foam-scrotal angle.
The operation begins with a bordering incision around the glans penis, backing 5-7 mm from the coronal groove. On the ventral surface, the incision is extended longitudinally to the foam-scrotal angle. Then, the skin of the penis is mobilized before moving to the scrotum along the ventral surface.On the dorsal and lateral surfaces, the skin is mobilized to the foam-symphysar space with a lig dissection. suspensorium penis.
The next step is the production of urethroplasty using the Hodgson-III technology (see above), and the interval from the hypospadias to the foam scrotal angle is performed according to the Duplay method. N. Hodgson suggests stapling artifact urethral fragments on an end-to-end basis on an urethral catheter No. 8 CH. It is known that the number of postoperative complications when using terminal anastomoses reaches 15 - 35%. In order to minimize complications, the principle of “onlay-tube” or “onlay-tube-onlay” is currently used, described below. The wound defect is sutured with a continuous twisting seam. The operation is traditionally completed by applying dressings with glycerin.
The combined principle of urethroplasty for proximal hypospadias can also consist of an islet tubularized skin flap from the inner sheet of the foreskin (Duckett principle) and the Duplay method, as well as Asopa technology in combination with the Duplay method.
Characterization of the method of urethroplasty (F - II) (Fayzulin 1993.)
This method of surgical correction of hypospadias is based on the principle developed by N. Hodgson (1969-1971), and is essentially a modification of the known method. This method is used for anterior and secondary forms of hypospadias.
In 50% of patients with distal hypospadias, congenital stenosis of the meatal opening is diagnosed. Surgery begins with bilateral lateral meatatomy according to Duckett. The length of the incisions varies from 1 to 3 mm, depending on the age of the patient and the severity of meat stenosis. The incision line is preliminarily crushed with a mosquito-type hemostatic clamp, and after dissecting the meatus, a nodal suture is applied to the incision region, but only if blood leakage from the edges of the wound is noted. After eliminating the meatal stenosis, they proceed to the main stage of the surgical aid.
On the ventral surface of the penis, a U-shaped incision is made with the meatus bordered along the proximal edge. In the classic version, the width of the base flap is created equal to half the circumference of the urethra. We modified the incision on the ventral surface, performing it along the edge of the scaphoid fossa, which does not always correspond to half the circumference of the urethra. Most often, the shape of this section resembles a “vase” with an expanded neck, a narrowed neck and an expanded base.
In these cases, the opposite flap (“flap”) is formed in such a way that when the flaps are applied, a perfectly smooth tube is obtained. In those places where expansion was formed on the base flap, narrowing is created on the donor flap, and vice versa.
A shaped incision on the ventral surface is created in order to maximize the preservation of head tissue for the final stage - glanuloplasty and more convenient access to the connective tissue intercavernous groove separating the erectile tissue of the glans penis and cavernous bodies.
The mobilization of the skin of the penis is carried out according to standard technology to the foam-scrotal angle. In cases where the deep dorsal vein of the penis has a perforating vessel associated with a skin flap, surgeons try not to cross it. The maximum preservation of venous angioarchitectonics of the penis can reduce venous stasis and, accordingly, reduce the degree of edema of the penis in the postoperative period. For this purpose, the perforating vessel is mobilized to the level until the dorsal flap is laid freely, without the slightest tension after moving the skin flap to the ventral surface. In cases where mobilization of the flap is not possible due to the tension of the vessel, the vein is ligated and cut between the ligatures without coagulation.Coagulation of a perforating vessel can lead to thrombosis of the main venous trunks.
A prepucial flap for the formation of the urethra is cut to the thickness of the skin of the outer sheet of the foreskin. Only the skin is dissected without damage to the subcutaneous tissue rich in vessels feeding the prepuce flap.
The shaft of the penis is moved using the Tiersch-Nesbit technique. Given the presence of meatotomy incisions, it became necessary to modify the principle of stitching of skin flaps. At the same time, a “base” nodal suture is applied at three hours from the right edge of the meatus, and then, during suturing of the urethral flaps, the dorsal flap is sutured to the albumen in the immediate vicinity of the ventral edge. This technique allows you to create a tight line of the urethral suture without technical difficulties and to avoid urinary leakage.
According to the method proposed by N. Hodgson, the ventral surface of the glans penis remains prepuce skin, which creates a clear cosmetic defect with a good functional result. Later, when a patient enters into sexual life, this type of head raises tactless questions and even criticism from sexual partners, which in turn sometimes leads to nervous breakdowns and the development of an inferiority complex in a patient who underwent surgery.
In the modification of the final stage of this operation (F-II), a solution to this problem is proposed. The bottom line is de-epidermisation of the distal artifact urethra using microsurgical scissors and stitching the edges of the glans penis over the formed urethra. This technique allows you to simulate the natural look of the head.
To do this, curved along the plane with microsurgical scissors, the epidermis is excised without grabbing the underlying tissues, in order to preserve the vessels of the skin flap, 1-2 mm away from the artifact meatus. De-epithelialization is carried out to the projection level of the coronal groove. Then, the lateral edges of the wound on the glans penis are sutured together above the created urethra by interrupted sutures without tension of the skin tissue.
Thus, it is possible to close the ventral surface of the glans penis, which allows you to maximize the appearance of the glans penis to the physiological state. The final stage of the operation did not differ from the standard method described above.
Signs of Violation
Each form of the disease has a number of characteristic features:
- The capitate form of the anomaly is noted in 75% of clinical situations, it is considered a common variant of this disease - the urethral opening is lower, it is narrowed, as a result of which urination is difficult. It can be combined with penile deformity, intensified with the start of sexual relations,
- Crown type of disease - urination is impaired, organ deformation is noticeable. Urine excretion occurs as a thin stream, requires effort,
- Hypospadias stem - has a variability of its development depending on the location of the meatus (different levels of the posterior surface of the penis). It is also difficult to urinate, organ deformation is observed, painful sensations in the erectile process are noted. Hypospadias stem does not interfere with sexual intercourse, but in the process of ejaculation the sperm does not penetrate the vaginal area,
- Hypospadias scrotal - recognized as a serious variant of this anomaly. The opening of the urethral opening occurs in the scrotum, dividing it into two halves. An underdeveloped state of the organ is noted - the penis is deformed, similar to a hypertrophic clitoris, the scrotum itself is like the labia. Male newborns with this pathology are often mistaken for girls with adrenogenital impairment. The process of urination usually occurs in a sitting position, the implementation of sexual acts with this kind of disease is not possible due to the curvature of the organ.There is also irritation of the skin of the scrotum,
- Perineal hypospadias - the meatus is located behind the scrotum. The patient has a small organ, bifurcation of the scrotum. The difficult process is to establish the gender of the newborn. This type of disease can be combined with the course of cryptorchidism, the development of inguinal hernia, the presence of dropsy of the testicle membranes,
- Pathology according to the type of chord - a short undeveloped urethra is observed, which provokes the deformation of the penis to the bottom. The correct location of the meatus is noted. In the erectile process, the penis resembles the appearance of a bow; painful sensations are possible that interfere with the normal implementation of intercourse.
The main defect correction method is surgical intervention.
The operation is most often performed at an early age, when the child reaches 2 years of age. In this case, the chances of a successful outcome increase.
Surgery is necessary in order to:
- restore urination,
- to prevent violations of the structure and functionality of the organs of the genitourinary system,
- to maintain intimate function in the future,
- to eliminate an aesthetic defect, prevent the development of psychological problems associated with it.
Causes of the disease
The development of this pathology can trigger the following phenomena:
- The wrong process of fetal development (from 7 to 15 weeks) - this period is characterized by the beginning of the creation of the human sexual structure,
- Genetic, chromosomal malfunctions,
- The presence of complications caused by viral diseases that occur during pregnancy - rubella, flu,
- Illiterate use of hormonal substances,
- Intrauterine infections,
- The presence of stressful situations,
- Inadequate food intake
- Alcohol abuse during pregnancy.
Surgery and postoperative care
Surgical intervention may include a single operation, or carried out in 2 stages.
During the operation, the doctor corrects the shape of the penis, if it deforms, adjusts the shape and size of the urinary canal, moves the urethral opening to a physiologically correct place, circumcises the foreskin, if its pathological proliferation takes place.
- The procedure lasts 2-3 hours, is carried out under general anesthesia, in most cases the child is well tolerated.
- However, the child still needs long recovery period, special care throughout.
- Since at first the urination process can cause significant pain to the baby, a special catheter is inserted into the urethral opening, through which the outflow of urine is carried out.
In addition, a small patient is shown antibiotic therapy to prevent the development of infectious diseases. Painkillers may be required.
The maximum restriction of mobility is recommended, in the first time after the operation bed rest is necessary. The duration of the recovery period depends not only on the form of the disease, but also on the age of the child. It is known that the younger the patient, the easier he has surgery.
About the causes of hypospadias
The capitate form of this pathology is considered not only the easiest, but also its most common variety, it is estimated that 70% of all carriers of hypospadias suffer from it.
In boys with this form of penile anomaly, the urethral opening is located on the head itself, but not at its apex, but is shifted slightly down. With such a pathology, the child’s sexual organ is only slightly curved, the boy can urinate while standing, while urine flows out of the canal in a very thin stream.
Hypospadias can occur in the period from 10 to 14 weeks of pregnancy, since it is at this time that the urethra is formed in the fetus. Pathology appears for various reasons. Among them, the most common are:
- In vitro fertilization (IVF). A pregnant woman, while carrying a child, takes female hormones that adversely affect the formation and development of male genital organs.
- Excessive use of hormonal drugs. If a woman took hormonal pills as a means of protection for a long time before pregnancy (more than a year), then there is a risk of such a pathology in the unborn baby. The representative of the fair sex can take hormones not of her own free will, but at the insistence of the doctor, when it comes to the threat of a miscarriage from an already pregnant woman. In this case, the gynecologist recommends hormonal therapy, which helps to convey the fetus to the end of the term, but does not guarantee the birth of a child without hypospadias.
- Hereditary factor. There is a possibility of an anomaly in a boy if his father, and sometimes father and grandfather, suffered one of its forms.
- Nutrition of a pregnant woman. In modern food, there are substances such as disruptors (pesticides, fungicides, androgenic destroyers), they can change the hormonal status of the bearing fetus and disrupt its formation.
- Ecological disasters occurring in the world also cause genital abnormalities in male infants.
- Diseases of a pregnant woman. During gestation, women are not protected from diseases and infections. Severe influenza or rubella can contribute to impaired formation of the male genital organs.
The occurrence of pathology can also occur due to genetic mutations of the fetus. Less common were cases where hypospadias was caused by regular hair spray, which the woman used throughout her pregnancy. It is established that this cosmetic product contains a harmful chemical substance - phthalate. For the entire 9 months of pregnancy, expectant mothers should use only pure products, including a lot of proteins, to refuse harmful cosmetics in order to prevent hypospadias, and instead of hormones, if possible and necessarily after consultation with a gynecologist, take traditional medicine . But what if the causes of the disease cannot be prevented, and the baby still showed genital pathology?
Hypospadias - types of pathology and modern methods for its elimination
Hypospadias is a defect in the male external genitalia. It is formed in the first weeks of fetal development. The frequency of occurrence reaches 1 case per 150-200 newborns, and doctors observe a tendency to increase the incidence of pathology.
What is hypospadias?
For the first time having heard the diagnosis of hypospadias, what kind of disease it is, most mothers can hardly imagine it. This term is used to denote an abnormality in the development of the external genitalia. The disease is characterized by improper location of the urethra. It opens in the area of the glans penis or nearby, in severe cases, near the scrotum.
Hypospadias has recently become more frequent. In this case, doctors record the simultaneous presence of other pathologies that accompany this type of violation. Among those:
- Peyronie's disease
- urethral dysplasia
- splitting of the foreskin.
Hypospadias - causes
There are several theories that explain why hypospadias occurs in children. When diagnosing a disease, doctors often find it difficult to answer, which was the reason in a particular case. Among the frequent provoking factors, experts call the following:
- Point gene mutations associated with adverse environmental conditions.
- Genetically determined mutation (hereditary predisposition).
- The use of hormonal drugs when bearing a male fetus (used when there is a threat of termination of pregnancy).
- The presence in the diet of products containing disruptors (destroy the male sex hormones) - substances used to process crops, pesticides and herbicides.
- Long-term use of hormonal contraceptives.
How to diagnose this pathology?
Capitate hypospadias is an anomaly that must be treated, but first of all, doctors should diagnose the disease. How can you understand that a child has just this form of the disease?
In the first days of a child’s life, he is examined by a doctor who must pay attention to the appearance of the penis and how the baby sends the physiological needs.
Perineal or scrotal hypospadias is immediately noticeable during examination, since in these cases the baby's penis can be so undeveloped that a newborn male child can be confused with a girl.
If the specialist is consulted by parents with a one-year-old child and older and complain that he “relieves the need” only while sitting, this also indicates that the boy has scrotal pathology.
Since the capitate form is not so pronounced, doctors will need to conduct additional studies.
One of the diagnostic methods is urofluometry. Genital ultrasound is also common.
Experienced doctors advise to do an additional ultrasound of the bladder and kidneys, as sometimes other anomalies can be observed along with hypospadias in children: urogenital sinus, hydronephrosis, inguinal hernia.
Thus, additional ultrasound will give an overall picture of the disease, and the doctor will be able to prescribe the right treatment. If other pathologies were found in addition to hypospadias, then doctors first eliminate them, for example, correct the urinary tract with hydronephrosis, and then proceed to the direct treatment of penile abnormalities.
Hypospadias - capitate
The diagnosis of capitate hypospadias is made when the external opening of the urethra is lower than it should be. This form is often accompanied by a narrowing of the urethra, which over time leads to a decrease in its thickness in the lower part.
The patient is often disturbed by a violation of urination. In this case, there is no change in the shape of the penis. This fact complicates the diagnosis of the disease at an early age: capitate hypospadias in children is rarely diagnosed.
Untimely detection of capitate hypospadias leads to impaired erectile function.
Hypospadias in the form of a chord is a variety of capitate form and is diagnosed when the external opening of the urethra remains in the usual place on top of the head or on the coronal groove.
The foreskin is located on the back surface in the form of a hood. But in about 40% of boys with this pathology, the foreskin has a normal shape, completely covering the head.
Often this complicates the timely diagnosis of pathology, which is found only in the puberty.
Hypospadias - stem form
Stem hypospadias develops with underdevelopment or complete absence of the spongy part of the urethra. With this form of pathology, the urethral opening is located along the cancellous body of the penis.
Depending on its location, the shape of the penis and its degree of curvature also change.
The changes are so noticeable visually that the diagnosis of pathology is not difficult, therefore, it is detected at an early stage.
Coronary hypospadias in children is often diagnosed. The disease is characterized by the opening of the urethra in the coronary sulcus, which is accompanied by a displacement of the foreskin of the penis. Changes greatly complicate the act of urination, so doctors try to correct the violation almost immediately after diagnosis. The only treatment is surgical, as with all types of hypospadias.
Hypospadias - scrotal form
The scrotal form is rare in comparison with other types of pathology.Scrotal hypospadias is the most complex form of the disease. Its characteristic feature is the similarity of the external genitalia of the boy with the female genitalia.
Meat is located in the scrotum, the penis is underdeveloped, twisted, has the wrong location. Often a child with a scrotal form is sent for examination for genetics.
The purpose of the event is to establish the true sex of the baby, as it is difficult to visually determine it.
Hypospadias - Symptoms
Violation of the urination process is a central symptom of the disease. Hypospadias and enuresis are inextricably linked. Urine output occurs in an atypical place, the number of acts of urination exceeds the norm. Due to changes in the shape and size of the penis, adults with this disorder are not able to normally have sexual intercourse.
Depending on the form of the disease, the exit of the urethra may be located:
- on the body of the penis,
- on the head
- on the scrotum
- in the perineum.
In most cases, hypospadias is diagnosed at birth. When examining a child, the following symptoms of pathology take on themselves:
- downward movement of the urethra,
- change in the skin covering the head (hood-shaped foreskin) and scrotum (splitting of the scrotum with proximal hypospadias),
- resized penis,
- member curvature during erection.
Hypospadias in a child - operation
With a diagnosis of hypospadias, treatment is possible exclusively by surgery. A favorable time for surgery is the age of the child in the range of 1-3 years. If possible, doctors try not to delay the operation - many recommend doing it after the baby is six months old. This is the best time when the penis is small in width, length, and healing is faster.
There are many types of operations to solve the problem. In each case, the doctor individually determines how to carry out the correction. In general, the operation boils down to the following:
- Restoring the missing part of the urethra.
- The movement of the urethra to its normal place.
- Correction of the form of the penis.
- Full preservation of erectile function and giving the body an aesthetic appearance.
Hypospadias - types of operations
Surgeons have developed more than 150 methods of surgical treatment of the disease. Their nature directly depends on the severity of the pathology. So, mesotomy with hypospadias is used with a pronounced narrowing of the urethra. It is worth noting that complex forms of the disease are recommended to be treated with surgery in 2 stages:
- Elimination of curvature of the trunk of the penis.
- The formation of the urethra.
It is worth noting that surgery for hypospadias may not be carried out.
In the coronary form, when there is no curvature of the penis and urethra of sufficient diameter, surgery is not required. Hypospadias alone is not an indication for surgery.
Doctors consider it inappropriate to conduct surgery only with the aim of removing the external opening on the glans penis.
Complications after hypospadias in a child
As the observations of doctors show, with a diagnosis of hypospadias, surgery may not always be successful. So:
- With the simultaneous correction of pathology, the number of postoperative complications reaches 25–50%.
- The use of two-stage correction reduces the risk of complications by 5%, so doctors adhere to this treatment algorithm.
Hypospadias: what methods of operations exist and in which cases should they be resorted to?
In addition to the incorrect location of the urethral opening during hypospadias, curvature of the penis is often observed.
In severe forms of this disease, not only problems with urination arise - such a pathology can subsequently make conception problematic (and even impossible).
This disease is treated exclusively by surgery, while the operation is performed in early childhood. This is justified not only by minimizing the risk of causing a child psychological trauma, but also by some other physiological aspects.
Hypospadias correction method according to the principles of “onlay-tube-onlay” and “onlay-tube” (F-VIII, F-IX) (Fayzulin 2003)
One of the most formidable complications that occur after urethral plastic surgery, with posterior and secondary forms of hypospadias, is urethral stenosis. Urethral bougienage and endoscopic dissection of the narrowed portion of the urethra often lead to relapse of stenosis and, ultimately, to reoperation.
Urethral stenosis, as a rule, is formed in the area of the proximal urethral anastomosis, superimposed on the principle of "end to end". In the process of searching for a rational method of defect correction, a method was developed that avoids the use of end anastomosis, which has received the term “onlay-tube-onlay” in the literature.
The operation begins with a curly cut. To do this, a flap resembling the letter U is cut out on the ventral surface of the glans penis. The width of the flap is formed according to the age diameter of the urethra, and it is half the circumference of the urethra. Then, the incision is extended along the midline of the ventral surface of the trunk from the base of the U - shaped incision to the hypospadias, leaving 5-7 mm from its distal edge. Around the meatus, a skin flap is cut, turned in an angle in the distal direction. The flap width is also half the circumference of the urethra. The next step is to make a bordering incision around the glans penis until the cut lines merge on the ventral surface.
The skin of the stem of the penis is mobilized according to the principle described above. Then the fibrous chord is excised until the cavernous bodies are completely expanded, after which they begin to create the artifact urethra.
On the dorsal surface of the skin flap, a figured “island” is cut out, resembling a “two-handed rolling pin” in shape. The length of the entire dorsal flap is formed depending on the deficit of the urethral tube. The proximal narrow fragment of the flap in its width and length should correspond to the proximal skin islet of the ventral surface, and the distal narrow fragment of the mobilized skin is created similarly to the distal on the trunk of the penis.
The fundamental position in the process of flap formation remains the exact ratio of the cut angles. It is a spatial understanding of the configuration of the future urethra that avoids stenosis in the postoperative period.
The skin “island” formed on the dorsal skin flap is mobilized using two microsurgical forceps. Then, at the base of the flap, in a blunt way, a window is created through which naked cavernous bodies are transferred dorsally. The proximal narrow dorsal fragment is sutured with the proximal ventral onlay principle by a continuous intradermal suture. Starting points on the dorsal and ventral flaps must match. The main fragment of the artificial urethra is also sutured continuously into the tube. The distal section is formed similarly to the proximal in the mirror image. The urethra is created on a urethral catheter No. 8 CH.
The principle of “onlay-tube-onlay” is used for undeveloped glans penis, when the surgeon has doubts about the stage of its closure. In patients with a well-developed head, the onlay-tube principle is used.
To do this, one skin island is cut out on the ventral surface, bordering the meatus according to the principle described above. A flap resembling a “one-handed rolling pin” is created on the dorsal surface, with the handle facing the base of the trunk of the penis. After creating the urethral tube, the distal part of the artifactal urethra is de-epithelialized just enough to close the mobilized edges of the head above the urethra.
The edges of the head are stitched together with interrupted sutures above the created urethra. Naked cavernous bodies are covered with mobilized skin of the penis.
Description of the pathology of the capitate
In the capitate form of hypospadias, the urethra shifts to the area between the center of the head and the coronary groove. The shape of the penis is slightly distorted. Pathology is diagnosed in newborns at the first examinations, since the urethral opening is not in the place where it is provided for by the human anatomy. The main symptoms of pathology are:
- The displacement of the urethral opening to the side from where it should be.
- At the place where the urethra should be released, there is a plate of skin that continues to the coronary sulcus.
- Urination often occurs in a thin stream due to narrowing of the urethra.
- The shape of the genital organ may be somewhat curved.
If the pathology is left untreated, this may adversely affect sexual health in the future.
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Our experts will be happy to answer all your questions.
There are no exact reasons provoking the development of hypospadias of the glans penis. There are a number of factors that are highly likely to influence and can serve as causes of hypospadias:
- Taking hormonal drugs during pregnancy.
- Taking oral contraceptives with a high estrogen content.
- Hereditary predisposition.
- Poisoning by harmful substances.
- Genetic mutations.
- Bad environmental situation.
- Infections during the first weeks of pregnancy.
There is a scientific version that links pathology with the use of hairspray. The product contains flatate, which is harmful to the body. It is better to refuse aggressive styling products during pregnancy.
Characterization of the method of urethroplasty with "hypospadias without hypospadias" type IV. (F-IV and F-V) (Fayzulin 1994)
One of the options for the correction of “hypospadias without hypospadias” of the fourth type is the technology of replacing a fragment of a dysplasic urethra based on operations such as Hodgson-III (F-IV) and Duckett (F-V). The principle of the operation is to preserve the capitate of the urethra and replace the displaced portion of the stem urethra with an insert from the skin of the dorsal surface of the penis or inner sheet of prepuce on the feeding leg with a double urethral anastomosis of the “onlay-tube-onlay” type.
Technique of operation F-IV. The operation begins with a bordering incision around the glans penis.
The skin on the ventral surface with "hypospadias without hypospadias" is often not changed, therefore, a longitudinal incision along the ventral surface is not performed. The skin of the penis is removed as a “stocking” to the base of the trunk. Produce excision of superficial fibrous strands. Then a resection of a dysplasia urethral tube deprived of the corpus cavernum is performed from the coronary sulcus to the beginning of the erectile body of the urethra. In some cases, the fibrous chord is located between the dysplastic urethra and the corpora cavernosa. The chord is excised without any problems due to wide access. The degree of rectification of the trunk of the penis is determined using the test "artificial erection".
The next step is to cut out a rectangular flap on the dorsal surface of the skin flap, the length of which corresponds to the size of the urethral defect, and the width to the circumference of the urethra, taking into account the age of the patient.
Then, two “windows” are formed in the proximal and distal sections of the created flap for further movement of the trunk of the penis. The epithelial flap is sutured on the catheter with a continuous suture, departing 4-5 mm from the ends of the flap. This technique allows you to increase the cross-sectional area of the terminal anastomoses and, accordingly, reduce the percentage of urethral stenosis, since the experience of surgical treatment of hypospadias has shownthat in almost all cases of narrowing of the urethra occurred precisely in the area of the end joints.
Then the penis moves along Nesbit twice: initially through the proximal “window” to the dorsal surface, and then through the distal opening to the ventral side. The last movement is preceded by an onlay-tube anastomosis between the proximal end of the artifical urethra and the hypospadias meatus. After the second movement of the trunk of the penis through the distal "window", a distal anastomosis is applied between the outlet end of the new urethra and the leading end of the capitate of the own urethra according to the "tube-onlay" principle similar to the first. Urethral anastomoses were superimposed on an urethral catheter No. 8-10 CH.
To close the skin defect on the dorsal surface of the penis, a gentle mobilization of the lateral edges of the wound of the dorsal flap is performed, after which the wound is closed by stitching the edges together with a continuous suture. The remains of the skin around the head are sutured with the distal edge of the mobilized flap, also continuously. The defect on the ventral surface of the penis is closed with a longitudinal intradermal suture. When performing urethroplasty, it is necessary to avoid the slightest tension of the tissue, which produces marginal necrosis and divergence of the suture line.
To correct “hypospadias without hypospadias” in combination with urethral dysplasia, you can also use the modified Duckett operation (F-V).
The determining factor for this operation is the presence of a well-developed foreskin, in which the width of the inner leaf is sufficient to create the missing fragment of the urethra.
A distinctive feature of this operation from the classic Duckett operation is the preservation of the capitate of the urethra with a double urethral anastomosis of the “onlay-tube-onlay” type after creating the artifical urethra from the inner sheet of the prepuce and moving it to the ventral surface of the penis. The skin defect is closed according to the above principle.
Andrologist consultation on capitate hypospadias
At the consultation, the specialist conducts an examination and a survey to determine the causes of the pathology and the method for its elimination.
The International Children's Andrology Center in Moscow brought together the best specialists and modern technical capabilities for effective diagnosis and treatment.
All manipulations in the clinic take place without fear and pain, the rehabilitation period is minimal. Confirmation is reviews of grateful parents, which can be found on the site.
Characterization of the method of urethroplasty using a lateral flap (F-VI) (Fayzulin 1995)
The urethroplasty method is a modification of the Broadbent operation (1959-1960). The fundamental difference between this technology is the total mobilization of cavernous bodies in patients with the posterior form of hypospadias. The method also involves the separation of a skin flap used to create an artifact urethra with a hypospadias meatus. Broadbent technology used a urethral anastomosis according to the Duplay principle, and in a modified version, it used the principle “end to end”, “onlay-tube” or “onlay-tube-onlay”.
The operation begins with a bordering incision around the glans penis. Then the incision is extended along the ventral surface to the hypospadias meatus with the margin of the latter, 3-4 mm indent from the edge. After mobilization of the skin of the penis to the base of the trunk with the intersection of lig. suspensorium penis excise the fibrous chord.
Having assessed the true deficit of the urethra, after the expansion of the penis, it becomes obvious that, as a rule, it significantly exceeds the supply of plastic material of the penis shaft itself. Therefore, to create an artifact urethra, one of the edges of the skin wound, which has minimal signs of ischemia, is used throughout. To do this, impose four holders in the proposed area to create a flap corresponding to the length of the urethral deficit.Then, the borders of the flap are marked with a marker and incisions are made along the indicated contours. ccThe depth of the incision along the side wall should not exceed the thickness of the skin proper, in order to preserve the vascular pedicle. The flap shape is created using the onlay-tube-onlay technology described above.
A particularly important point is the allocation of the vascular pedicle, since the thickness of a full-layer flap does not always allow this manipulation to be performed easily. On the other hand, the length of the vascular pedicle should be sufficient for free rotation of the new urethra on the ventral surface with the urethral suture line facing the cavernous bodies.
The artifical urethra is formed on the principle of “onlay-tube-onlay” (see above).
After moving the urethra to the ventral surface, sometimes axial rotation of the trunk of the penis occurs at 30-45 degrees, which can be eliminated by rotating the skin flap in the opposite direction. The operation is completed by applying a compression dressing with glycerin.
Characterization of the method of urethroplasty in children with a posterior form of hypospadias using urogenital sinus (F-VII) (Fayzulin 1995)
Often in children with severe hypospadias, urogenital sinus is detected. Normally, in the process of genital formation, the sinus transforms into the prostate and posterior urethra. However, in 30% of patients with severe hypospadias, sinus persists. The sizes of the sinus are variable and can vary from 1 cm to 13 cm, and the higher the degree of violation of sexual differentiation, the greater the sinus. Almost all patients with pronounced sinus lack the prostate gland, and the vas deferens are either completely obliterated or can open into the sinus. The inner lining of the urogenital sinus is represented, as a rule, by urothelium, adapted to the effects of urine. Given this circumstance, the idea arose to use urogenital sinus tissue for plastic surgery of the urethra.
This idea was first implemented in a patient with true hermaphroditism with a karyotype of 46 XY and viril genitalia.
During a clinical examination, the child was diagnosed with perineal hypospadias, the presence of gonad in the scrotum on the right and gonad in the inguinal canal on the left. During the operation, when revising the inguinal canal, an ovotestis was revealed on the left, i.e. mixed gonad having female and male germ cells with histological confirmation. The mixed gonad has been removed. The urogenital sinus is isolated, mobilized and rotated distally.
Then the sine is modeled into the tube according to the Mustarde principle to the penoscrotal angle. The distal artifical urethra was formed by the Hodgson-III method.
Urethral plastic surgery using tissue engineering methods (F-V-X) (Faizulin A.K., Vasiliev A.V. 2003)
The need to use plastic material devoid of hair follicles is dictated by a high percentage of long-term postoperative complications. Hair growth in the urethra and the formation of calculi in the lumen of the created urethra create significant problems for the patient's life and great difficulties for the plastic surgeon.
Currently, technologies based on the achievements of tissue engineering are becoming more widespread in the field of plastic surgery. Based on the principles of treating burn patients with the use of allogeneic keratinocytes and fibroblasts, the idea arose of using autologous skin cells to correct hypospadias.
To this end, a patient is sampled of a skin site in a hidden area of 1-3 cm2, immersed in a preservative and delivered to a biological laboratory.
Human keratinocytes are used in the work, since the epithelio-mesenchymal relationships do not have species specificity (Cunha et al., 1983, Haffen et al., 1983). Flaps of skin 1x2 cm in size are placed in an Eagle medium containing gentamicin (0.16 mg / ml) or 2000 units / ml penicillin and 1 mg / ml streptomycin.The prepared skin flaps are cut into strips of 3 x 10 mm, washed in a buffer solution, placed in a 0.125% dispase solution (Sigma) in DMEM and incubated at 4 ° C for 16-20 hours or in a 2% solution of dispase for 1 hour at 37 ° C . After this, the epidermis is separated from the dermis along the line of the basement membrane. The suspension of epidermal keratinocytes obtained by pipetting is filtered through a nylon mesh and precipitated by centrifugation at 800 rpm for 10 min. Then the supernatant is drained and the pellet is suspended in the culture medium and plated in plastic bottles (Costar) at a concentration of 200 thousand cells / ml of medium. The first three days, keratinocytes are grown in complete nutrient medium: DMEM: F12 (2: 1) with 10% fetal calf serum (Biolot, St. Petersburg). 5 μg / ml insulin (Sigma), 10-6M isoproterenol (Sigma), 5 μg / ml transferrin (Sigma). Then the cells are grown in DMEM: F12 (2: 1) medium with 5% serum, 10 ng / ml epidermal growth factor, insulin and transferrin and the medium is regularly changed. After the cells form a multilayer layer, differentiated suprabasal keratinocytes are removed, for which the culture is incubated for 3 days in DMEM without Ca2 +. After this, the keratinocyte culture is transferred to a complete medium and after a day passaged on the surface of a living tissue equivalent formed by fibroblasts enclosed in a collagen gel.
Preparation of live tissue equivalent
The mesenchymal base of the graft, a collagen gel with fibroblasts, is prepared as described previously (Rogovaya et al., 2004) and poured into Petri dishes with a Spongostan sponge (J&J). The final gel polymerization with the sponge and fibroblasts enclosed inside takes place at 37 ° C for 30 minutes in a CO2 incubator. The next day, epidermal keratinocytes at a concentration of 250 thousand cells / ml are planted on the surface of the dermal equivalent and cultured for 3-4 days in a CO2 incubator in a complete medium. 1 day before transplantation, the living equivalent is transferred to a complete medium without serum.
As a result, in a few weeks, a three-dimensional cell structure is obtained on a biodegradable matrix. The dermal equivalent is delivered to the clinic and formed into the urethra, stitched into the tube or using the “onlay” principle for urethroplasty. Most often, according to this technology, they replace the perineal and scrotal departments of the articular urethra, where the risk of hair growth is greatest. The urethral catheter is removed on day 7-10. After 3-6 months, distal urethroplasty is performed according to one of the methods described above.
When evaluating the results of surgical treatment of hypospadias, it is necessary to pay attention to functional and cosmetic aspects that minimize the psychological trauma of the patient and optimally adapt it in society.
The prevention of this pathology should be considered the exclusion of drugs, external environmental factors and food products that impede the normal development of the fetus, received in the literature the term disruptors.