embryology and anatomy of hypospadias

Embryology &Embryology &
Anatomy ofAnatomy of
HypospadiasHypospadias
Dr Sumer YadavDr Sumer Yadav
Mch plastic surgeryMch plastic surgery
dr sumer yadav,mch plasticdr sumer yadav,mch plastic
surgery,surgery,

Definition:Definition:
HypospadiasHypospadias
 Defined as : An abnormal ventral opening ofDefined as : An abnormal ventral opening of
urethral meatus located anywhere from theurethral meatus located anywhere from the
ventral aspect of glans penis to perineumventral aspect of glans penis to perineum
 Can be associated withCan be associated with
 An abnormal ventral curvature of penis (chordee)An abnormal ventral curvature of penis (chordee)
 An abnormal distribution of foreskin with a hoodAn abnormal distribution of foreskin with a hood
present dorsally and deficient foreskin ventrallypresent dorsally and deficient foreskin ventrally
surgery,surgery,

surgery,surgery,

EmbryologyEmbryology
surgery,surgery,

The beginningThe beginning
 2 embryonic structures play an important2 embryonic structures play an important
part in the development of urogenitalpart in the development of urogenital
system:system:
 Intermediate mesodermIntermediate mesoderm
 CloacaCloaca
surgery,surgery,

 Formation of head and tail foldsFormation of head and tail folds
 Yolk sac enclosed within the embryoYolk sac enclosed within the embryo
 Tube lined by endoderm in the embryoTube lined by endoderm in the embryo
surgery,surgery,

 Formation of primitive gutFormation of primitive gut
 Gut is in wide communication with yolkGut is in wide communication with yolk
sacsac
 3 parts of gut with respect to3 parts of gut with respect to
communication to yolk sac:communication to yolk sac:
 Cranial – foregutCranial – foregut
 Mid – midgutMid – midgut
 Caudal – hidgutCaudal – hidgut
surgery,surgery,

 With growth, yolk sac becomes smallWith growth, yolk sac becomes small
 It is now known as definitive yolk sacIt is now known as definitive yolk sac
 Connecting channel is called vitello-Connecting channel is called vitello-
intestinal ductintestinal duct
 Part of hind gut caudal to the attachmentPart of hind gut caudal to the attachment
of allantoic diverticulum is called cloacaof allantoic diverticulum is called cloaca
surgery,surgery,

 Cloaca has two parts separated byCloaca has two parts separated by
urorectal septum:urorectal septum:
 Dorsal: primitive rectumDorsal: primitive rectum
 Ventral: primitive urogenital sinus (UGS)Ventral: primitive urogenital sinus (UGS)
surgery,surgery,

Cranial: vesico urethral partCranial: vesico urethral part
 Primitive UGSPrimitive UGS
Caudal: definitive UGSCaudal: definitive UGS
 At the junction of the two, lies theAt the junction of the two, lies the
opening of mesonephric ductsopening of mesonephric ducts
surgery,surgery,

 Definitive UGS has 2 parts:Definitive UGS has 2 parts:
 Cranial: PelvicCranial: Pelvic
 Caudal: PhallicCaudal: Phallic
surgery,surgery,

Development of maleDevelopment of male
external genitaliaexternal genitalia
 With formation of urorectal septum, coacalWith formation of urorectal septum, coacal
memb divides into urogenital memb and caudalmemb divides into urogenital memb and caudal
anal membanal memb
 Urogenital memb elongates longitudinallyUrogenital memb elongates longitudinally
 On its both sides, mesoderm heaps up to formOn its both sides, mesoderm heaps up to form
2 longitudinal elevations called primitive2 longitudinal elevations called primitive
urethral folds, and 3 other elevations: genitalurethral folds, and 3 other elevations: genital
tubercle, rt. & lt. genital swellingstubercle, rt. & lt. genital swellings
surgery,surgery,

 Genital tubercle becomes cylindrical andGenital tubercle becomes cylindrical and
enlarges greatly to form penisenlarges greatly to form penis
 By epithelial ingrowth, glans is formedBy epithelial ingrowth, glans is formed
and then coronary sulcus appearsand then coronary sulcus appears
 Prepuce is formed by the reduplication ofPrepuce is formed by the reduplication of
ectoderm, covering the distal part ofectoderm, covering the distal part of
phallusphallus
surgery,surgery,

Urethral developmentUrethral development
 Proposed by Glenister in 1954Proposed by Glenister in 1954
 Urogenital memb lies in a linear grooveUrogenital memb lies in a linear groove
 On its either sides are primitive urethralOn its either sides are primitive urethral
foldsfolds
 Groove elongates with the phallus andGroove elongates with the phallus and
extends on its undersurface, lined byextends on its undersurface, lined by
ectodermectoderm
 Called primitve urethral groove (PUG)Called primitve urethral groove (PUG)
surgery,surgery,

 At 10 mm stage, (4At 10 mm stage, (4thth
week) thickening ofweek) thickening of
anterior wall of endodermal cloacaanterior wall of endodermal cloaca
 Solid mass of endodermal cells derivedSolid mass of endodermal cells derived
from the UGS extends into the phallusfrom the UGS extends into the phallus
 Called urethral plateCalled urethral plate
 PUG is now fully formedPUG is now fully formed
 Urethral plate has now enlarged andUrethral plate has now enlarged and
extends deeper in the phallusextends deeper in the phallus
surgery,surgery,

 Urogenital memb has broken down soUrogenital memb has broken down so
that endoderm of caudal part of UGS isthat endoderm of caudal part of UGS is
seen from outsideseen from outside
 Degeneration of core cells of urethralDegeneration of core cells of urethral
plate leads to deeper groove k/aplate leads to deeper groove k/a
definitive urethral groove. Its margins aredefinitive urethral groove. Its margins are
k/a definitive urethral foldsk/a definitive urethral folds
surgery,surgery,

 At 11At 11thth
week, 50 mm stage, Leydig cellsweek, 50 mm stage, Leydig cells
of testis increase in no., size, andof testis increase in no., size, and
function and under the effect offunction and under the effect of
androgens the definitive urethral foldsandrogens the definitive urethral folds
grow towards each other and fuse togrow towards each other and fuse to
form a median rapheform a median raphe
 In this way DUG is converted into a tubeIn this way DUG is converted into a tube
which is urethrawhich is urethra
surgery,surgery,

 A pre-requisite of urethral fold fusion isA pre-requisite of urethral fold fusion is
 the canalisation of the solid urethral platethe canalisation of the solid urethral plate
 formation of urethral groove bounded onformation of urethral groove bounded on
each sides by the urethral foldseach sides by the urethral folds
 If any of the above is abnormal, urethralIf any of the above is abnormal, urethral
fold fusion is likely to be impaired.fold fusion is likely to be impaired.
surgery,surgery,

 The fusion starts caudally andThe fusion starts caudally and
progresses craniallyprogresses cranially
 This extends only upto glans penisThis extends only upto glans penis
 The formation of distal most part ofThe formation of distal most part of
urethra has been explained by twourethra has been explained by two
theories.theories.
surgery,surgery,

 The classical “ectodermal ingrowthThe classical “ectodermal ingrowth
theory” states that the distal most part oftheory” states that the distal most part of
urethra is of ectodermal originurethra is of ectodermal origin
 It is formed by the canalisation andIt is formed by the canalisation and
ingrowth of the solid mass of ectodermalingrowth of the solid mass of ectodermal
cells as far proximally as the valve ofcells as far proximally as the valve of
GuerinGuerin
surgery,surgery,

 But the recent “endodermal differentiationBut the recent “endodermal differentiation
therory” by Kurzrock (1999) which is based ontherory” by Kurzrock (1999) which is based on
the result of IHC staining for differentthe result of IHC staining for different
cytokeratins states …..that the urethral platecytokeratins states …..that the urethral plate
extends to the tip of the phallus and maintainsextends to the tip of the phallus and maintains
patency and continuity throughout uretharlpatency and continuity throughout uretharl
developmentdevelopment
 Therefore the epithelium of entire urethraTherefore the epithelium of entire urethra
originates from UGS and is endodermaloriginates from UGS and is endodermal
surgery,surgery,

 Petiot and co-workers(2003) found outPetiot and co-workers(2003) found out
that mice lacking III b isoform ofthat mice lacking III b isoform of
Fibroblast growth factor receptor 2Fibroblast growth factor receptor 2
exhibit severe hypospadiasexhibit severe hypospadias
surgery,surgery,

 There is further evidence that under theThere is further evidence that under the
correct cellular signalling conditions,correct cellular signalling conditions,
endodermally derived epithelium (UP)endodermally derived epithelium (UP)
differentiates into stratified squamousdifferentiates into stratified squamous
epithelium phenotype present in fullyepithelium phenotype present in fully
developed distal granular urethradeveloped distal granular urethra
surgery,surgery,

Development of penisDevelopment of penis
 The elongating phallus is covered externallyThe elongating phallus is covered externally
by the ectoderm that gives rise to te penile skinby the ectoderm that gives rise to te penile skin
 Most of the penis is derived from theMost of the penis is derived from the
mesodermal cells forming the corporal bodies,mesodermal cells forming the corporal bodies,
connnective tissue and dermisconnnective tissue and dermis
 Corporal tissue is first recognised as distinctCorporal tissue is first recognised as distinct
dense mesenchymal condensations within thedense mesenchymal condensations within the
shaft of the developing penisshaft of the developing penis
surgery,surgery,

Preputial developmentPreputial development
 At 40 mm stage, preputial tissue did notAt 40 mm stage, preputial tissue did not
uniformly surround the phallus in theuniformly surround the phallus in the
form of a circle but in the form of anform of a circle but in the form of an
oblique orientation, radiating out onoblique orientation, radiating out on
either side of phallus from the point ofeither side of phallus from the point of
urethral openingurethral opening
 The urethral opening is placed well backThe urethral opening is placed well back
on the ventral surface of the phalluson the ventral surface of the phallusdr sumer yadav,mch plasticdr sumer yadav,mch plastic
surgery,surgery,

 Preputial tissue appears as a hoodPreputial tissue appears as a hood
dorsally and gradually become less welldorsally and gradually become less well
marked ventrally as it approaches themarked ventrally as it approaches the
meatusmeatus
 Complete covering of the glans occurs atComplete covering of the glans occurs at
130 mmm stage or 20130 mmm stage or 20thth
week ofweek of
developmentdevelopment
surgery,surgery,

Anatomy of penisAnatomy of penis
 Five layers of tissue cover the penis:Five layers of tissue cover the penis:
 Penile skinPenile skin
 Supf layer of penile fasciaSupf layer of penile fascia
 Tela subfascialisTela subfascialis
 Deep layer of penile fasciaDeep layer of penile fascia
 Tunica albugineaTunica albuginea
surgery,surgery,

Penile skinPenile skin
 Properties :Properties :
 MovableMovable
 ExpandableExpandable
 Adaptable to urinary contactAdaptable to urinary contact
 Advantageous for urethral tube reconstructionAdvantageous for urethral tube reconstruction
b/c it is:b/c it is:
 AvailableAvailable
 VascularVascular
 DistensibleDistensible
surgery,surgery,

Supeficial / dartosSupeficial / dartos
fasciafascia
 Part of membranous layer of Colle’sPart of membranous layer of Colle’s
fasciafascia
 Mobile as it is loosely attached to theMobile as it is loosely attached to the
layer belowlayer below
 Contains vessels for skin…SPA & SDVContains vessels for skin…SPA & SDV
surgery,surgery,

Tela subfascialisTela subfascialis
 Thin connective tissue beneath DartosThin connective tissue beneath Dartos
and Colles’and Colles’
 Prominent at the base of penisProminent at the base of penis
 Covers the extra corporeal segment ofCovers the extra corporeal segment of
cavernous artry , vein and nervecavernous artry , vein and nerve
surgery,surgery,

Deep /Buck’s fasciaDeep /Buck’s fascia
 Continuous with the layers of abdominalContinuous with the layers of abdominal
and perineal fasciaand perineal fascia
 Covers two corpora cavernosa andCovers two corpora cavernosa and
corpora spongiosum separatelycorpora spongiosum separately
 Covers deep dorsal vein , artery andCovers deep dorsal vein , artery and
nervenerve
surgery,surgery,

Tunica albugineaTunica albuginea
 Encloses corpora cavernosaEncloses corpora cavernosa
 Has two layers:Has two layers:
 Outer longitudinalOuter longitudinal
 Inner circularInner circular
 Intercavernous septum provides freeIntercavernous septum provides free
vascular communications between thevascular communications between the
septumseptum
surgery,surgery,

LigamentsLigaments
 Two in no.:Two in no.:
 Supf fundiform: Thickening of scarpa fascia,Supf fundiform: Thickening of scarpa fascia,
originating at linea alba,splits to surround theoriginating at linea alba,splits to surround the
base of penis and joins Colles’ fasciabase of penis and joins Colles’ fascia
 Suspensory liagament proper: beneath theSuspensory liagament proper: beneath the
fundiform ligament, attaches to symphysisfundiform ligament, attaches to symphysis
pubis, maintains penile position during coituspubis, maintains penile position during coitus
surgery,surgery,

Arterial supplyArterial supply
 Penis is supplied by two systemsPenis is supplied by two systems
 Superficial : two symmetrically arrangedSuperficial : two symmetrically arranged
longitudinal vessselslongitudinal vesssels
 Originate from the EPAOriginate from the EPA
 Lie in the supf layer of supf fascia of penisLie in the supf layer of supf fascia of penis
 Supply skin and prepuceSupply skin and prepuce
 Divide into dorsolateral and ventrolateral branchDivide into dorsolateral and ventrolateral branch
 Anastomose with deep system at coronal sulcusAnastomose with deep system at coronal sulcus
surgery,surgery,

 Deep system : originates from internalDeep system : originates from internal
pudendal arterypudendal artery
 Divides into four branches after piercing theDivides into four branches after piercing the
urogenital diaphragmurogenital diaphragm
 They are bulbourethral, urethral, cavernousThey are bulbourethral, urethral, cavernous
and dorsal artery of penisand dorsal artery of penis
surgery,surgery,

 Bulbourethral artery : short and wideBulbourethral artery : short and wide
 Postr gp of branches supply the bulb ofPostr gp of branches supply the bulb of
urethraurethra
 Antr gp of branches supplies proximal ¼ ofAntr gp of branches supplies proximal ¼ of
C.spongiosumC.spongiosum
 Urethral artery : originates from penile ,Urethral artery : originates from penile ,
cavernous , dorsal arteriescavernous , dorsal arteries
 Lies b/w C.spongiosum and T. albugineaLies b/w C.spongiosum and T. albuginea
surgery,surgery,

 Cavernous artery :Cavernous artery :
 Deep artery of penisDeep artery of penis
 Arises before termination of penile arteryArises before termination of penile artery
 Enters at the jn. Of two crura and continues uptoEnters at the jn. Of two crura and continues upto
the tip of corpusthe tip of corpus
 Dorsal artery :Dorsal artery :
 termination of penile arteytermination of penile artey
 At the dorsolateral surface of penisAt the dorsolateral surface of penis
 B /W deep dorsal vein and dorsal nerveB /W deep dorsal vein and dorsal nerve
surgery,surgery,

 Glans and frenulum :Glans and frenulum :
 Artery of glans is the termination of dorsalArtery of glans is the termination of dorsal
arteryartery
 Present ventrolaterally near coronal sulcusPresent ventrolaterally near coronal sulcus
 Frenular branches enter ventrally at eachFrenular branches enter ventrally at each
side of distal shaftside of distal shaft
surgery,surgery,

 Prepuce :Prepuce :
 Supplied by the supf penile arteries,Supplied by the supf penile arteries,
branches of inferior EPAbranches of inferior EPA
 Divide into anteolateral and posteolateralDivide into anteolateral and posteolateral
branchesbranches
 End at coronal sulcusEnd at coronal sulcus
 Donot communicate with the circulation ofDonot communicate with the circulation of
the rest of the penisthe rest of the penis
surgery,surgery,

Venous drainageVenous drainage
 Three systems :Three systems :
 SupfSupf
 IntermediateIntermediate
 DeepDeep
 Superficial : from prepuce, skin andSuperficial : from prepuce, skin and
subcutaneous tissue multiple veins run on thesubcutaneous tissue multiple veins run on the
dorsolateral surface of penis under the supfdorsolateral surface of penis under the supf
penile fascia to form SDV that drains intopenile fascia to form SDV that drains into
saphenous vein.saphenous vein.
surgery,surgery,

 Intermediate :Intermediate :
 Drains glans, C. spongiosum and distal 2/3Drains glans, C. spongiosum and distal 2/3
of C. cavernosaof C. cavernosa
 Consists of deep dorsal vein and circumflexConsists of deep dorsal vein and circumflex
veinsveins
 Reetrocoronal plexus drains into deepReetrocoronal plexus drains into deep
dorsal veindorsal vein
 Deep vein ultimately reaches internal iliacDeep vein ultimately reaches internal iliac
veinvein
surgery,surgery,

 Deep system :Deep system :
 Consists of cavernous , crural and bulbarConsists of cavernous , crural and bulbar
veinsveins
 cavernous veins are the principle drainagecavernous veins are the principle drainage
system of the corpora , drained by thesystem of the corpora , drained by the
proximal 1/3 of penis through emissary veinsproximal 1/3 of penis through emissary veins
 Unite between crura to form large thin walledUnite between crura to form large thin walled
main cavernous veins, lying undermain cavernous veins, lying under
cavernous arteries and nervescavernous arteries and nerves
surgery,surgery,

 So they are less accesible for surgicalSo they are less accesible for surgical
ligationligation
 Crural veins unite to drain into internalCrural veins unite to drain into internal
pudendal vein and sometimes prostaticpudendal vein and sometimes prostatic
plexusplexus
 Bulb drained by bulbar veins draining intoBulb drained by bulbar veins draining into
prostatic plexusprostatic plexus
surgery,surgery,

Urethral anatomyUrethral anatomy
 Adult male urethra: 18-20 cmAdult male urethra: 18-20 cm
 AnteriorAnterior
 Proximal bulbar; entirely within the perineumProximal bulbar; entirely within the perineum
 Pendulous or penile; from suspensory ligament toPendulous or penile; from suspensory ligament to
the meatusthe meatus
 PosteriorPosterior
 Pre-prostaticPre-prostatic
 ProstaticProstatic
 MembranousMembranous
surgery,surgery,

Anterior UrethraAnterior Urethra
 Lies within C. spongiosumLies within C. spongiosum
 Starts below the perineal membrane,Starts below the perineal membrane,
surrounded by bulbo spongiosussurrounded by bulbo spongiosus
 Curves downwardsCurves downwards
 Dilated at its termination, k/a navicularDilated at its termination, k/a navicular
fossafossa
surgery,surgery,

NeurovascularNeurovascular
anatomyanatomy
 Nerves that innervate the penisNerves that innervate the penis
 Originate proximallyOriginate proximally
 Under the pubic ramiUnder the pubic rami
 Supr and lateral to urethraSupr and lateral to urethra
 In the form of two well defined bundlesIn the form of two well defined bundles
 There was a difference found outThere was a difference found out
between normal and hypospadiacbetween normal and hypospadiac
urethraurethra
surgery,surgery,

 As the two crural bodies converge intoAs the two crural bodies converge into
the corpora cavernosa, the nervesthe corpora cavernosa, the nerves
diverge, spreading around the corporadiverge, spreading around the corpora
cavernosa to its junction with the urethralcavernosa to its junction with the urethral
spongiosumspongiosum
 Nervous tissue fans out in this mannerNervous tissue fans out in this manner
from 11 and 1 O’clock position and is notfrom 11 and 1 O’clock position and is not
confined to two straight bundlesconfined to two straight bundles
surgery,surgery,

 Also seen is the absence of neuronalAlso seen is the absence of neuronal
structures at 12 O’clock position alongstructures at 12 O’clock position along
the whole length of penisthe whole length of penis
 That’s why penile block in hypospadias isThat’s why penile block in hypospadias is
given using an approach slightly offgiven using an approach slightly off
midline at 10.30 and 1.30 positionsmidline at 10.30 and 1.30 positions
surgery,surgery,

Relative vascularityRelative vascularity
 Baskin and colleagues(1998) found outBaskin and colleagues(1998) found out
that there was extensive vascularity ofthat there was extensive vascularity of
the distal urethral spongiosum and glansthe distal urethral spongiosum and glans
in a hypospadiac penis as compared to ain a hypospadiac penis as compared to a
norml penisnorml penis
 This had implications in repair ofThis had implications in repair of
hypospadiashypospadias
surgery,surgery,

 They proposed that an incision in theseThey proposed that an incision in these
parts (distal urethral spongiosum andparts (distal urethral spongiosum and
glans), rich in large endothelial linrdglans), rich in large endothelial linrd
sinuses, results in the release ofsinuses, results in the release of
epithelial growth factors which encourageepithelial growth factors which encourage
tissue repair without significant scar ortissue repair without significant scar or
stricturestricture
surgery,surgery,

Chordee in UrethraChordee in Urethra
 Chordee:Chordee:
 strand of connective tissue stretched like a chordstrand of connective tissue stretched like a chord
 b/w the meatus and glans,b/w the meatus and glans,
 giving rise to bow stringinggiving rise to bow stringing
 Kaplan (1975) proposed that ventral curvatureKaplan (1975) proposed that ventral curvature
is a normal stage of embryogenesis. Penileis a normal stage of embryogenesis. Penile
curvature represents arrested development atcurvature represents arrested development at
this earlier stagethis earlier stage
surgery,surgery,

 Arrest in development may involve C.Arrest in development may involve C.
spongiosum resulting in:spongiosum resulting in:
 Inadequate / short urethraInadequate / short urethra
 Fibrosis from excessive growth of ectodermal tissueFibrosis from excessive growth of ectodermal tissue
 Penile curvature is more common in prematurePenile curvature is more common in premature
infantsinfants
 80-85% chordee due to skin and dartos80-85% chordee due to skin and dartos
abnormalityabnormality
surgery,surgery,

Types of ChordeeTypes of Chordee
A.A. With hypospadiasWith hypospadias
 Ventral curvatureVentral curvature
 True fibrous chordee; deficiency or fibrousTrue fibrous chordee; deficiency or fibrous
replacement of the normally elastic urethral platereplacement of the normally elastic urethral plate
 C. cavernosa deficiency may be seen.C. cavernosa deficiency may be seen.
 Rx: tissue divided transversely to release tetheringRx: tissue divided transversely to release tethering
of distal penile shaft.of distal penile shaft.
 C. cavernosa deficiency may cause corporalC. cavernosa deficiency may cause corporal
disproportion, leading to residual ventral curvaturedisproportion, leading to residual ventral curvature
surgery,surgery,

B.B. Without hypospadiasWithout hypospadias
 CongenitalCongenital
 Occurs in three forms :Occurs in three forms :
 Class I : Deficient spongiosum with a thinClass I : Deficient spongiosum with a thin
mucous membrane urethramucous membrane urethra
 Class II : Normal C. spongiosum , abnormalClass II : Normal C. spongiosum , abnormal
Bucks and Dartos fascBucks and Dartos fasc
 Class III : Urethra ,C. spongiosum , BucksClass III : Urethra ,C. spongiosum , Bucks
fascia normal and Dartos fascia is abnormalfascia normal and Dartos fascia is abnormal
surgery,surgery,

 Explanations for penile curvatureExplanations for penile curvature
 Abnormal development urethral plateAbnormal development urethral plate
 Abnormal condensation of mesenchymalAbnormal condensation of mesenchymal
tissue at the urethral meatus that formstissue at the urethral meatus that forms
chordee tissuechordee tissue
 Growth differential b/w normally formedGrowth differential b/w normally formed
dorsal corporeal tissue and abnormal ventraldorsal corporeal tissue and abnormal ventral
urethral plateurethral plate
surgery,surgery,

Molecular basisMolecular basis
 Fetal testicle produces testosteone andFetal testicle produces testosteone and
the cells of fetal external genitaliathe cells of fetal external genitalia
express 5-alpha reductase to convertexpress 5-alpha reductase to convert
testosterone to DHTtestosterone to DHT
 Its significance lies in the fact that in-Its significance lies in the fact that in-
utero exposure to anti-androgensutero exposure to anti-androgens
reduces the size of genital tubercle andreduces the size of genital tubercle and
can cause hypospadias also.can cause hypospadias also.
surgery,surgery,

Hypospadias assoc withHypospadias assoc with
Gestational Rx withGestational Rx with
ProgestinsProgestins
surgery,surgery,

SignificanceSignificance
 Hormonal manipulation helps in the pre-Hormonal manipulation helps in the pre-
operative preparationoperative preparation
 Testosterone enanthate IM 2 mg/kg 5 and 2Testosterone enanthate IM 2 mg/kg 5 and 2
weeks before reconstructive penile surgeryweeks before reconstructive penile surgery
showed increase in penile size, skin availabilityshowed increase in penile size, skin availability
and vascularityand vascularity
 Local application of DHT cream also hasLocal application of DHT cream also has
similar resultssimilar results
 Timing : pre-pubertal exogenous administrationTiming : pre-pubertal exogenous administration
of testosteroneof testosterone
surgery,surgery,

Importance of surgicalImportance of surgical
anatomyanatomy
 Factors to assess the appropriateFactors to assess the appropriate
surgical technique :surgical technique :
 Meatal positionMeatal position
 Degree of chordeeDegree of chordee
 Development of C. spongiosumDevelopment of C. spongiosum
 Thinness of urethraThinness of urethra
 Ventral shaft elasticity and thicknessVentral shaft elasticity and thickness
 Depth of glanular grooveDepth of glanular groove
surgery,surgery,

Effect of each factorEffect of each factor
on decisionon decision
 Meatal position and characteristicMeatal position and characteristic
 At corona_MAGPI techniqueAt corona_MAGPI technique
 Fish mouth_flip flap or MathieuFish mouth_flip flap or Mathieu
 Midshaft without chordee_onlay island flapMidshaft without chordee_onlay island flap
without tubularisation of its innner face orwithout tubularisation of its innner face or
perimeatal based tube repairperimeatal based tube repair
surgery,surgery,

 Degree and type of chordee : preferredDegree and type of chordee : preferred
techniquestechniques
 Ventral deflection and mild to moderateVentral deflection and mild to moderate
chordee_onlay island flapchordee_onlay island flap
 Extensive chordee with distalExtensive chordee with distal
meatus_mobilised transverse island flapmeatus_mobilised transverse island flap
(Duckett)(Duckett)
 Extensive chordee with proximalExtensive chordee with proximal
meatus_two stage repairmeatus_two stage repair
surgery,surgery,

 Development of C. spongiosum :Development of C. spongiosum :
 Corporal rotation and suture fixation of C.Corporal rotation and suture fixation of C.
cavernosa is done for severe curvaturecavernosa is done for severe curvature
 Splitting of intercavernous septum by ventralSplitting of intercavernous septum by ventral
midline incision and freeing of dorsalmidline incision and freeing of dorsal
neurovascular structures facilitate medial rotationneurovascular structures facilitate medial rotation
of corporaof corpora
surgery,surgery,

 Depth of glanular groove :Depth of glanular groove :
 Deep glanular defects with with coronal orDeep glanular defects with with coronal or
glanula defects augurs well for GAP (glansglanula defects augurs well for GAP (glans
approximation procedure)approximation procedure)
surgery,surgery,

 Vasculature :Vasculature :
 Perimeatal based flaps like Mathieu shouldPerimeatal based flaps like Mathieu should
not be used for tissues with doubtfulnot be used for tissues with doubtful
vascularity as adventitial blood supply mayvascularity as adventitial blood supply may
not be adequatenot be adequate
 Split prepuce in situ onlay modification ofSplit prepuce in situ onlay modification of
OIF preserves the blood supply to one halfOIF preserves the blood supply to one half
of prepuce (onlay segment harvestedof prepuce (onlay segment harvested
longitudinally) than OIF where it is harvestedlongitudinally) than OIF where it is harvested
transverselytransversely
surgery,surgery,

 In cases of doubtful vascularity whereIn cases of doubtful vascularity where
two staged repairs are used , welltwo staged repairs are used , well
vascularised tissue is transferred in thevascularised tissue is transferred in the
first stage to be used for neourethrafirst stage to be used for neourethra
formation in the second stageformation in the second stage
surgery,surgery,

 Specially in cases of one stage repair :Specially in cases of one stage repair :
 Snodgrass repair :Snodgrass repair :
 it is tubularised incised plate urethroplastyit is tubularised incised plate urethroplasty
 Combines urethral plate incision andCombines urethral plate incision and
tubularisationtubularisation
 neourethra is covered with vascularisedneourethra is covered with vascularised
subcutaneous tissue / dartos flap harvestedsubcutaneous tissue / dartos flap harvested
from dorsal prepucial and shaft skinfrom dorsal prepucial and shaft skin
surgery,surgery,

 Duckett repair :Duckett repair :
 Onlay prepucial transverse island flapOnlay prepucial transverse island flap
 Prepuce can be divided into inner mucosalPrepuce can be divided into inner mucosal
and outer prepucial layer as there isand outer prepucial layer as there is
arborisation of supf vessels in thearborisation of supf vessels in the
subcutaneous tissuesubcutaneous tissue
 Neourethra is dissected on its pedicle in anNeourethra is dissected on its pedicle in an
attempt to create two blood supplies one forattempt to create two blood supplies one for
neourethra and other for prepucial skinneourethra and other for prepucial skin
surgery,surgery,

 Modified Asopa or Hodgson XX :Modified Asopa or Hodgson XX :
 Double faced transverse island flapDouble faced transverse island flap
 Uses pedicles from the supf externalUses pedicles from the supf external
pudendal system for both the flaps , one thatpudendal system for both the flaps , one that
is tubularised and also one used for coveris tubularised and also one used for cover
 Neourethra is left attached to theNeourethra is left attached to the
undersurface of foreskin so the skin andundersurface of foreskin so the skin and
neourethra share a common blood supplyneourethra share a common blood supply
surgery,surgery,

Some other anomaliesSome other anomalies
 Concealed penisConcealed penis
 Caused by a developmental anomaly inCaused by a developmental anomaly in
which dartos fascia develops as an inelasticwhich dartos fascia develops as an inelastic
structure that restrains the extension ofstructure that restrains the extension of
penis and hold it below the symphysispenis and hold it below the symphysis
 Shaft is held there by the dysgenic bands ofShaft is held there by the dysgenic bands of
tissue in the dartos fascia layertissue in the dartos fascia layer
surgery,surgery,

 Webbed penis :Webbed penis :
 Skin web extending from the median rapheSkin web extending from the median raphe
of scrotum to the ventral aspect of penisof scrotum to the ventral aspect of penis
 Web division allows normal penileWeb division allows normal penile
appearance and functionappearance and function
surgery,surgery,

 The fact remains that whatever repair weThe fact remains that whatever repair we
undertake there is no technique whichundertake there is no technique which
give 100% resultsgive 100% results
surgery,surgery,


surgery,surgery,

embryology and anatomy of hypospadias

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embryology and anatomy of hypospadias