Modul Reading

Nico Odolf Yordanius

1871022010

Supervisor:
DR Dr Gede Wirya Kusuma Duarsa, M.Kes,
SpU(K)

Program Studi Spesialis Ilmu Bedah Fakultas Kedokteran Universitas Udayana

 Introduction

• Hypospadia is defined as a three associated anatomical anomalies of the

penis :
• An abnormal ventral opening of the urethral meatus
• An abnormal ventral curvature of the penis known as chordee
• Abnormal distribution of the foreskin with a redundant hoodlike foreskin in the dorsum
while deficient in the ventral aspect

Sukasah, Chaula et all. 2013. Illustrated Guideline Of Hypospadia Surgery. Lingkar Studi Bedah Plastik .
 Penile Length

https://www.worlddata.info/average-penissize.php
 Penoscrotal Anatomy

Gulia, Rajesh.2014. Atlas of Urethroplasty. Jaypee Brothers Medical Publishers (P) Ltd
 Penoscrotal Anatomy

Gulia, Rajesh.2014.
Atlas of Urethroplasty.
Jaypee Brothers
Medical Publishers (P)
Ltd
 Penoscrotal Anatomy

Gulia, Rajesh.2014. Atlas of Urethroplasty. Jaypee Brothers Medical Publishers (P) Ltd
 Penoscrotal Anatomy

Gulia, Rajesh.2014. Atlas of Urethroplasty. Jaypee Brothers Medical Publishers (P) Ltd
 Penoscrotal Anatomy

Gulia, Rajesh.2014. Atlas of Urethroplasty.

Jaypee Brothers Medical Publishers (P) Ltd
 Penoscrotal Anatomy

Gulia, Rajesh.2014. Atlas of Urethroplasty. Jaypee Brothers Medical Publishers (P) Ltd
 Etiology

Genetic

Placental insufficiency
Envirome
ntal
Androgen disruption

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition. Hypospadias(p906).Elsevier.
C. Radmayr, G. Bogaert, B. Burgu, H.S. Dogan, J.M. Nijman, J. Quaedackers, Y.F.H. Rawashdeh, M.S. Silay, R. Stein, S. Tekgül, 2022. Paediatric Urology. EAU Guidelines. European Association of Urology..
 Worldwide trends in the
prevalence of hypospadias
and geographic regions with
extraordinary low EPIDEMIOLO
prevalence (<5/10,000 total GI
births) and high prevalence
(>50/10,000 total births)
Based on a
multicenter study at
12 pediatric urology
referral center
hospitals in Indonesia,
there were 591 cases
of hypospadias during
2017 (Duarsa et al,
2019)

• Springer, A., van den Heijkant, M. and Baumann, S. (2016) ‘Worldwide prevalence of hypospadias’, Journal of Pediatric Urology, 12(3), pp. 152.e1-152.e7. doi: 10.1016/j.jpurol.2015.12.002.
• Duarsa, G. W. K. et al. (2019) ‘Common Practice of Hypospadias Management by Pediatric Urologists in Indonesia: A Multi-center Descriptive Study from Referral Hospitals’, Open Access Macedonian Journal of Medical Sciences, 7(14), pp.
2242–2245. doi: 10.3889/oamjms.2019.628.
 EMBRIOL
OGI
• Dihydrotestosterone at
the 8- to 12-week
gestational phase is a key
mediator in the proper
development of the penis.
• Male urethra closure is an
androgen-dependent
process, contrasting its
formation to that of the
female urethra

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021.

Campbell-Walsh-Wein Urology Twelfth Edition. Hypospadias(p906).Elsevier.
 Classification

Hadidi A.T .2004. Hypospadia Surgery. Berlin Heidelberg

 DIAGNOSIS

History Taking:
History
• A complete prenatal and family history
• The direction and strength of the patient’s urinary stream, as
well as the curvature of the penis with erections.
Penile exam:
• Location and appearance of the meatus
• Quality and depth of urethral plate
• Size and configuration of the glans
• Degree of chordee
• Integrity of the ventral skin
• Amount of dorsal hooded foreskin available
• A careful scrotal and inguinal exam
• Detection of disorder of sex development (DSD).

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition. Hypospadias(p906).Elsevier.
 The Glans Meatus and Penile Shaft (GMS)
Score

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition. Hypospadias(p906).Elsevier.
Age Of Surgery

Age Of Surgery

Hadidi A.T .2004. Hypospadia Surgery. Berlin Heidelberg

Penile Length

Penile Length

Hadidi A.T .2004. Hypospadia Surgery. Berlin Heidelberg

Algorithm for the management of hypospadias

EAU Guidelines

C. Radmayr, G. Bogaert, B. Burgu, H.S. Dogan, J.M. Nijman, J. Quaedackers, Y.F.H. Rawashdeh, M.S. Silay, R. Stein, S. Tekgül, 2022.
Paediatric Urology:Hypospadias. EAU Guidelines. European Association of Urology..
 Surgical Goal

Achieve a natural
Micturition while appearance  a straight,
Normal sexual function
standing symmetric penis with a
natural terminal meatus

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition. Hypospadias(p906).Elsevier.
HYPOSPADIA SURGICAL TECHNIQUES
 Operative Steps Of Hypospadias Surgery

• Chordectomy
• Orthoplasty (straightening)
• Urethroplasty
• Meatoplasty and Glanuloplasty
• Penoscrotal Transposition
• Skin Coverage

Hadidi A.T .2004. Hypospadia Surgery. Berlin Heidelberg

ASSESMENT & MANAGEMENT OF VENTRAL PENILE CURVATURE

• Algorithm for management of penile

curvature. Once the penis is degloved,
artificial erection is performed.
• If the curvature is resolved, the urethroplasty
can be completed.
• If there is persistent penile curvature, we
use a measurement of 30 degrees as the
defining measurement for performing a
dorsal plication or a corporal lengthening
procedure.

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition.
Hypospadias(p906).Elsevier.
DISTAL HYPOSPADIA

• ADVANCEMENT PROCEDURES
• MEATOPLASTY AND GLANULOPLASTY PROCEDURE (MAGPI)

• TUBULARIZATIONS TECHNIQUES
• GLANS REAPPROXIMATION PROCEDURES

• TUBULARIZED INCISED PLATE REPAIR

MEATOPLASTY AND GLANULOPLASTY
PROCEDURE (MAGPI)

The Meatal Advancement Glanuloplasty (MAGPI) Procedure.

(A)Heineke-Mikulicz rearrangement with longitudinal incision
is made and then closed in a horizontal fashion.
(B) Mucosal collar is marked with holding sutures placed.
(C) Penis partially degloved.
(D) Holding suture placement (a, b, c).
(E)Distal retraction to provide meatal advancement (a), vs.
proximal retraction (b, c).
(F) Glanular spongiosum exposed after excision of glans edges.
(G,H) Alternatively marker used to inscribe V along glanular
edges and V-shaped tissue segment excised.
(I) Approximation of the glans in two layers.
(J) Completed repair with mucosal collar.

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition.
Hypospadias(p906).Elsevier.
MEATOPLASTY AND GLANULOPLASTY
PROCEDURE (MAGPI)
TUBULARIZED INCISED PLATE
REPAIR

Distal Tubularized Incised Plate (TIP) repair

(A) Circumscribing skin incision.

(B)Incision along the visible junction of the glans
wings to the urethral plate.
(C)Deep, midline incision of the urethral plate
extending to the underlying corpora.
(D) Tubularizing the urethral plate from distally to
proximally. Note that the first stitch is about 3
mm proximal to the end of the urethral plate,
creating an oval opening.
(E) The neourethra is covered with a dartos flap.
(F)Glansplasty creating the neomeatus
and continuing down to the corona.
(G) Repair and circumcision completed.

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition. Hypospadias(p906).Elsevier.
TUBULARIZED INCISED PLATE
REPAIR
TUBULARIZED INCISED PLATE
REPAIR
TUBULARIZED INCISED PLATE
REPAIR
TUBULARIZED INCISED PLATE
REPAIR
PROXIMAL HYPOSPADIA

• ONE-STAGE HYPOSPADIA REPAIR

• Transverse preputial island flap (TPIF) or the Duckett tube

• Onlay Island Flap (OIF)

• TWO-STAGE HYPOSPADIA REPAIR

• Two Stage Repair with Free Graft

• The Bracka two-stage repair uses a free graft

• The staged tubularized autograft (STAG) repair (modification of Bracka’s original description)

• Two Stage Repair with Pedicle Flap

• The Byars Flap Procedure

Onlay Island Flap (OIF)
Onlay Island Flap (OIF)
a The apex of glanuloplasty is identified (marked by
dots) . The shaded triangle shows the epithelium to
be excised. A subcoronal incision encircles the glans
and continues around the urethral plate.
b The penile skin is dropped back and the glanular
wings are mobilised.
c The inner preputial onlay flap with its pedicle is
developed and separated from the dorsal penile skin.
d Suturing the onlay flap to the urethral plate incorpo
rates generous bites ofthe spongiosum
Onlay Island Flap (OIF)
The Bracka two-stage repair

Bracka two-stage free graft repair

(A,B) Inner preputial free graft incision is
marked and harvested.
(C)Abnormal urethral plate is excised and
penis is degloved.
(D)Incision is extended into the
glans, mobilizing glans wings.
E) Preputial graft is secured into
place, including quilting sutures.
(F) Compression dressing is sutured into
place over the graft.

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition.
Hypospadias(p906).Elsevier.
 The Byars Flap Procedure
Two-stage hypospadias repair with Byars flap.
• (A) First stage: incisions are marked to allow degloving and mobilization of
ventral skin.
• (B) The penis is degloved to the penoscrotal junction. Any dysplastic, or
chordee, tissue is removed.
• (C) Artificial erection to assess penile curvature. For the purpose of the
illustration the curvature has already been corrected.
• (D) Either midline or parallel lateral glans (inset) incision(s) is (are) made in
the glans and glans wings developed.
• (E) Byars flaps are developed by incising the dorsal inner preputial skin in
the midline to the mucosal collar, yielding a proper skin fit dorsally.
• (F) The redundant dorsal skin is transposed ventrally and secured in place.
• (G) Second stage: a U-shaped Thiersch-Duplay incision is made for
tubularization.
• (H) Urethroplasty is performed, either in an interrupted or running
fashion, using a two-layer technique. Additional barrier layer with dartos
or tunica vaginalis can be performed.
• (I) Glans and shaft skin are approximated.

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition. Hypospadias(p906).Elsevier.
Outcomes
Postoperative
Care
• For distal hypospadias repairs with little interference with the urethra, no
urinary diversion may be required
• However, when a substantial length of urethra is reconstructed, most
surgeons would use some form of diversion. The choice is between a dripping
stent, a Foley catheter, and a suprapubic catheter.
• For complicated repairs, urinary diversion with a soft, pliable urethral stent
decreases rates of meatal stenosis and urethrocutaneous fistula
development.
• Urinary diversion is provided for a period of 3 to 21 days and varies
according to the complexity of the repair, the length of the urethroplasty,
and surgeon preference.
• Postoperatively, bladder spasm is common and can result in high-pressure
voiding around stents and catheters, placing undue stress on the
urethroplasty. This can be alleviated with the addition of oxybutynin until
stent removal.
 COMPLICATIONS

Alan W. Partin, Roger R Dmochowski, Louis R. Kavoussi, Craig A. Peters. 2021. Campbell-Walsh-Wein Urology Twelfth Edition. Hypospadias(p906).Elsevier.
Complications
Short-term complications
• Glans dehiscence
• Hematoma formation and infection

Long-term complications
• Urethrocutaneous fistula formation is the most commonly seen long-term complication and
typically presents within 1 year of repair.
• Meatal stenosis
• Recurrent chordee
• Urethral stricture
• Urethral diverticulum