SURGERY UROLOGIC CONDITIONS

AY 2021-2022 MALEN M. GELLIDO, M.D.

Renal Module 03/14/2022

TOPIC OUTLINE • Pictures A,B,C and D— standard hypospadias

I. Hypospadias • Pictures E and F— severe hypospadias
a. Definition/Classification
b. Treatment
II. Cryptorchidism
a. Definition
b. Indications
c. Complications
d. Treatment
e. Palpable Testis and Orchiopexy
f. Non-palpable Testis
III. Hydrocele
a. Non-communicating Hydrocele
b. Communicating Hydrocele
c. Diagnosis
d. Treatment

LEGEND:
Clinical Guide
PPT Lecturer Book
Correlation/SGDs Questions
● ❖


I. HYPOSPADIAS Figure 2. Phenotypic differentiation of the external genitalia
in male and female embryos
a. Definition/Classification
v 8th week AOG still cannot distinguish male or female
Defined as a combination of any or all of the following associated phenotypically
penile anomalies:
o Ectopic urethral meatus
v Meatus is normally located at the tip of
the glans penis
o Penile curvature (chordee)
o Ventral foreskin deficiency with incomplete
foreskin closure around the glans, leading to the
appearance of a dorsal hooded prepuce

v 1 in 150-300 babies will have hypospadias
Figure 1. Types of Hypospadias
 SURGERY UROLOGIC CONDITIONS

a urethral opening as close as possible to the

ventral tip of the penis
o Surgical correction should result in a properly
directed urinary stream and a straightened penis
upon erection
o The corrected penis will be similar in
appearance to a circumcised normal penis
• Timing
o General consensus within the pediatric urology
community, is to perform surgery between six
months and one year of age in full-term, healthy
infants
o For preterm infants, repair is delayed until age-
adjusted catch-up growth has occurred and
other health issues that could affect safety of
Table 1. Classification of hypospadias based on physical findings anesthesia have resolved
o This timing allows ample time for completion of
a two-stage procedure in patients with severe
hypospadias
o In general, six months is the minimum time
needed between staged procedures for severe
hypospadias to ensure complete wound healing
following the initial surgery
• Surgical Procedures
o Numerous techniques to repair hypospadias are
available and used based upon the severity of the
defect
o All of the interventions are performed under
general anesthesia and, in most cases, as a same-
day (ambulatory) procedure without an
overnight admission to the hospital
o The time of surgery varies from one to three
hours and depends upon the severity of the
hypospadias deformity
Figure 3. Examples of mild glanular hypospadias 1. Primary Tubularization

v Forme fruste
v The white arrow is pointing to what should be the normal
location of the meatus

b. Treatment

• Urologic referral is not needed for patients with mild
defects and if surgical reconstructions is not requested by
the family/caregiver
• This includes patients with forme fruste of hypospadias
(incomplete or partial presence of hypospadias) and
patients with standard distal hypospadias (eg urethral
opening at the proximal glans, coronal margin, or just
below the coronal margin) and without penile curvature
• Urologic referral and correction are reserved for those
patients in whom there is a potential functional or
developmental issue including:
o Significant deflection of the urinary system
o Inability to urinate from a standing position
Figure 4. Primary Tubularization Procedure
o Erectile dysfunction due to penile curvature

leading to intercourse difficulties
o Tubularized urethroplasty, with or without
o Fertility issues due to sperm deposition
incision of the urethral plate (tubularized incised
o Concern for developmental issues based on the
plate (TIP)), is commonly used for glandular and
appearance of the hypospadias
penile shaft hypospadias repair.
• Goal
o This procedure consists of making a new urethra
o The goal of surgical correction is to create a
by rolling a ventral strip of penile shaft skin that
penis with normal function and appearance with

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 SURGERY UROLOGIC CONDITIONS

would have formed the urethra if development

had not been arrested

2. Onlay Island Flap

Figure 5. Onlay Island Flap Procedure
Figure 7. Two-Stage Procedure (2nd operation)
o For more severe hypospadias, an onlay island
flap is used in which the urethra is created by o The second operation is performed at least six
transferring a vascular strip of inner foreskin months later, after healing is complete from the
onto the ventral skin (urethral plate) first procedure
o The skin is sewn to the urethral plate in an onlay o In this stage, the urethra is reconstructed using
fashion, hence the name of the procedure. the transferred dorsal skin that is now on the
o Purpose: maintain the vascular supply. ventral aspect of the penis in a manner similar to
the primary tubularization
3. Two-Stage Procedure • What surgical procedure is needed?
o The choice of surgical procedure is dependent on
the type of hypospadias based on the:
§ appearance of the foreskin
§ urethral location
§ presence and degree of penile
curvature
o For standard hypospadias, the procedure of
choice is primary tubularization, and when
necessary, incision of the urethral plate
o For severe hypospadias, there is no consensus
or data on the best surgical approach, and the
procedural choice is primarily based on the
clinician’s personal experience and preference
• Outcomes
o Surgical correction generally results in an
excellent outcome in boys with standard
hypospadias with a good cosmetic and
functional repair, satisfactory genital self-
perception, sexual performance, and fertility in
Figure 6. Two-Stage Procedure the majority of patients with hypospadias
o There are mixed results regarding
o For the most extreme or severe forms of reintervention
hypospadias, including cases with significant
penile curvature, a two-stage approach is used to
straighten the penis and create a new urethral
opening
o In the first operation, if mild to moderate, can be
corrected by the insertion of dorsal midline
plication sutures in the nerve-free zone at the 12
o’clock position, which straightens the penis
o After correction of the curvature excess dorsal
foreskin is transferred to the ventral side of the
penis, as this tissue is required to the second
stage

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II. CRYPTORCHIDISM d. Treatment

• Timing of Surgery
o Surgical treatment of undescended testes is
recommended as soon as possible after four
months of age for congenitally undescended
testes and definitely should be completed before
the child is two years old (ideally before one
year)
o In children with testicular ascent later in
childhood, surgery generally should be
performed within six months of identification

Figure 8. Cryptorchidism e. Palpable Testis and Orchiopexy


a. Definition

• Cryptorchidism by definition suggests a hidden testis—
a testis that is not within the scrotum and does not
descend spontaneously into the scrotum by four months
of age
• Most testes that are undescended at birth complete their
descent within the first three to four months of life
• Spontaneous descent in term infants is rare after four
months of age


b. Indications for referral in phenotypic males with
cryptorchidism include Figure 9. Palpable Testis

• Phenotypically male newborn infants with bilaterally non-
palpable testes, unilaterally non-palpable testis with
hypospadias, or suspected disorder of sex
• Bilateral non-palpable testes in boys beyond infancy

• Congenital unilateral non-palpable testis— Referral for
examination under anesthesia and exploratory surgery,
ideally between 4 and 12 months of age
• Congenital palpable undescended testis (unilateral or
bilateral) in infants— Referral for evaluation and possible
orchiopexy (procedure to put the testis in the proper
place), ideally between 4 and 12 months of age
• Ascending testis in boys beyond infancy— Referral for
evaluation and possible orchiopexy whenever the physical
examination change is noted
• Palpable tissue in the scrotum that is thought to be an
atrophic testis— Referral for exploratory surgery to
exclude an intra-abdominal testis Figure 10. Orchiopexy
• Difficulty differentiating between undescended, retractile
or ectopic testis (at any age)— Refer for evaluation and • Orchiopexy is a well-established surgical procedure for
possible orchiopexy if beyond four months of age repositioning undescended or ectopic testes that are
palpable
c. Complications and Sequalae • The testis and cord are freed from surrounding
attachments, and the testis is manipulated into the
• Inguinal hernia scrotum and sutured in place
• Testicular torsion • The procedure is performed through an inguinal and/or
• Subfertility scrotal incision
• Testicular cancer • Primary orchiopexy is possible if the testis is of normal
size and appearance and the testicular vessels are of
adequate length

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• In a 2012 systematic review, the average success rate for o Groin exploration is carried out if testicular
primary orchiopexy was 96%, with success defined by vessels and vas deferens are visualized exiting
scrotal position of the testis the internal ring
• A detailed knowledge of the retroperitoneal anatomy is
required to achieve safe and adequate mobilization of the III. HYDROCELE
high undescended testis
• Thus, orchiopexy is an operation that is best performed by • A hydrocele is a fluid accumulation between the parietal
surgeon with a full-time interest in pediatric urology and visceral layers of the tunica vaginalis
• Orchiopexy is safe in infants younger than one year
• The most significant complication is testicular atrophy a. Non-communicating Hydrocele
(related to ischemic injury secondary to the dissection of
the testicular vessels and/or postoperative swelling and
inflammation)
• In a 2012 systematic review, the pooled rate of testicular
atrophy following primary orchiopexy was 1.8%
• Other potential complications include reascend of the
testis), inguinal hernia, infection and bleeding

f. Non-palpable Testis

• Imaging
o Imaging is not routinely warranted to locate
non-palpable testes
o Imaging studies lack the sensitivity and the
specificity to alter the need for exploratory
surgery

• Exploratory surgery
o Diagnostic and potentially therapeutic
• The first surgical objective is to determine whether or not
the testis is present; viable testes are positioned and fixed Figure 11. Non-communicating Hydrocele
within the scrotum; nonviable testicular remnants are
removed • The hydrocele depicted is non-communication (there is
• At the time of surgery, approximately 10% of boys with no connection between the hydrocele and the peritoneum;
non-palpable testes are found to have blind-ending • the fluid comes from the mesothelial lining of the tunica
testicular vessels, indication an absent testicle vaginalis) due to an imbalance in the production and
• Examination under anesthesia is the first step in the resorption
surgical management of the clinically non-palpable testis
• In a series of 263 non-palpable testes, 18% were palpable b. Communicating Hydrocele
in the groin during examination under anesthesia,
obviating the need for laparoscopy

• Exploration of the groin is the first step in the open
inguinal approach
• If cord structures or testicular remnants are found, they
are removed and the procedure is terminated. Why?
Because it is not functional and baka maging cancer pa.
• Exploration proceeds to the peritoneum if the groin
exploration is negative.

• Laparoscopic approach
o The laparoscope, placed via the umbilicus, is
used to examine the inguinal rings. Determine
the patency of the processus vaginalis, and the
examine the Wolffian structures and testicular
vessels
o The finding of blind-ending spermatic vessels, Figure 12. Communicating Hydrocele
confirming the absent testis, permits
termination of the procedure without a groin
incision

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c. Diagnosis
Guide Questions
1. Which of the following is NOT a feature of hypospadias?
a. Ventral chordee
b. Hooded foreskin
c. Dorsally placed meatus
d. Proximal meatus

2. T or F: Most cases of hypospadias are treated as an ambulatory

procedure under general anesthesia.

3. What is the proper order of steps for the surgical reconstruction

of hypospadias?
a. Straightening of the penis-Urethroplasty-Balanoplastycyc
b. Urethroplasty-Balanoplasty-Straightening of the penis
c. Balanoplasty-Straightening of the penis-Urethroplasty
Figure 13. Transillumnation of the Scrotum
d. Balanoplasty-Urethroplasty-Straightening of the penis

• Diagnosis of hydrocele can be made by physical 4. Which brings the testicle into the scrotum and sutures it into
examination and transillumination of the scrotum that place?
demonstrates a cystic fluid collection a. Cystotomy
b. Orchiectomy
Communicating VS non- communication c. Gastropexy
d. Orchiopexy

For communicating: nn the history, you can ask, nawawala po ba 5. Ideal age for orchiodopexy in cryptorchidism is best done before?
ung bukol? Sa umaga wala, pag dating sa hapon/ gabi nandyan, a. 1 month of age
lumalaki na sya. – this is because in the recumbent position, the fluid b. 6 months of age
gets reduced. c. 1 year of age
d. 2 years of age
d.Treatment
6. Bilateral, non-palpable testes may be approximately managed in
all of the following except:
• Management a. Observation over 2-3 years with repeat examination every 6
o Surgical repair is indicated for communicating months.
hydroceles that persist beyond one to two years b. Bilateral inguinal or abdominal exploration with orchidopexy
of age and for idiopathic, non-communicating if the testes are identified
hydroceles that are symptomatic or compromise c. Ultrasound to locate an intra-abdominal testis
d. HCG stimulation test
the skin integrity
o The management of asymptomatic hydroceles in 7. Which of the following statements concerning hydrocele/ hernia
a neonate or child younger than one to two years repair in infants is FALSE?
of age usually is supportive a. A simple hydrocele may be observed for 9-12 months and
• Hydroceles that are present in newborns, whether may resolve spontaneously
communication or non-communicating, usually resolve b. Non-incarcerated infantile hernias may be observed up to 1
spontaneously by the second birthday, unless they are year and may resolve spontaneously
c. Tunica vaginalis over the testis should be incised with or
accompanied by an inguinal hernia or are large
without excision of excess tunica before replacing the testis in the
• Communicating hydroceles in patients older that two scrotum
developments of incarcerated inguinal hernia d. The hernial sac can usually be isolated and divided without
opening the external oblique fascia

C,T,A,D,C,A,B

References:

• Dr. Gellido’s lecture

Figure 14. Hydrolectomy

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