hypospadias surgery ,how to avoid complications
TRANSCRIPT
HYPOSPADIAS SURGERY :How to avoid
complications ?
H S AsopaAsopa Hospital
Agra India
OPERATORWHO SHOULD OPERATE ? Paediatric Urologist Urologist Plastic Surgeon Paediatric Surgeon Hypospadiologist
EXPERIENCE
4 – 5 Techniques See many, assist many & do many Then teach many
SELECTION OF PROPER TECHNIQUE 4 – 5 Techniques and their evolution Era of two stage repair One stage transverse prepucial tube MAGPI Ventral prepucial patch Tubularised incised urethral plate (Snodgrass)
Pre operative decisionsMIDWAY - after degloving Location of meatus Meatal Calibre Glans configuration Quality of ventral penile skin proximal to meatus Presence of chordee after degloving Prepuce Preference/Experience of the surgeon
MAGPI INDICATIONS Glanular or ? coronal meatus Flat or convex glans Narrow meatus Skin and mucosa proximal to meatus thick & healthy No chordee or mild chordee to be corrected by dorsal plication
Less than 10% of all cases
Special precautions Raising glans flap / Excision of glans margins
Avoid Wide Meatus Sub coronal / concave glans
PRESERVATION & UTILISATION OFURETHRAL PLATE
T.I.P (Snodgrass) Dorsal free graft Onlay transverse prepucial patch Perimeatal flap
Considerations No chordee or mild chordee Configuration of glans Calibre of meatus and urethra Skin proximal to meatus Condition of urethral plate Presence or absence of prepuce
INCISED URETHRAL PLATE TUBULARISATION - Snodgrass
Concave glans Wide Meatus Skin & ventral mucosa proximal to meatus healthy No chordee or minimal chordee Healthy thick urethral plate
Best results in Distal penile meatus
Precautions Lateral incisions only upto mid glans
DORSAL FREE GRAFT ON INCISED URETHRAL PLATE
Flat glans Narrow urethral plate Meatus narrow or wide No chordee or minimal chordee
Indications
ONLAY TRANSEVERSE PREPUCIAL PATCH
No chordee or minimal chordee
Narrow urethral plate Narrow meatus Glans flat or conical Attenuated ventral
mucosa or distal urethra
TRANSVERSE PREPUCIAL SKIN TUBE
Considerable chordee Conical glans – Glans tunnel Flat or shallow glans - Glans
wings Good adequate prepuce Young patients Upto penoscrotal level
Flap - AsopaIsland flap - Duckett
TWO STAGE Byars Free graft - Prepuce - Buccal mucosa
Indications
Special considerations
Chordee ++ Meatus scrotal or perineal Inadequate prepuce Preference of surgeon
Lay open glans Start suture line from glans to meatus Smooth ventral skin Excise hair bearing skin around meatus
GENERAL CONSIDERATIONS
Vascularity
Flap - Island - Skin based dorsal flaps - flaps
Free Grafts - Dorsal Lateral - Ventral - Tube - Unreliable
Minimal tissue damage - Thumb and forefinger- Skin hooks- Stay sutures
Correct tissue planes - start proximally
GENERAL CONSIDERATIONS Contd…
Cover ventral suture line - Dartos - Tunica - Spongiosa Eccentric suture line of skin
cover
GENERAL CONSIDERATIONS Contd…
Sutures- Fine ( 6/0, 7/0 ) absorbable- Chromic catgut - through
mucosa and skin- Vicryl - for glans and
spongiosa Inversion of mucosa & skin Subcuticular whenever
possible Avoid tension - Scrotal
flaps Two layers Distance between sutures
GENERAL CONSIDERATIONS Contd…
Local antibiotics Systemic antibiotics Haemostasis
- Minimal and precise cautery - Adrenaline - Tourniquet - Circular dressings
Catheter - 6 Fr Protex or Poly vinyl chloride (PVC) - Polyurethane - Silastic
Diversion
GENERAL CONSIDERATIONS Contd…
Magnification - Operating microscope - Loupes Pre operative hormones
Scrotal bury
CHECKLIST
Meatus Calibre
Site After chordee correction Proximal skin mucosa Glans Conical Flat Concave Size
Urethral plate Wide / Narrow Thick / Thin
Patients considerations
CHECKLIST Contd…
Chordee - Pre Op
- After degloving - After correction Prepuce
Technique
Suture material
Catheter