By Jeyashree Sundaram, MBA
Hypospadias treatment is classified into different types by its location and severity. Midshaft, perineal, penoscrotal, and glanular or distal hypospadias are the major classifications of the disease.
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These are related to defects like chordee and hooded foreskin that results in the lag of void standing and unsatisfactory erection during intercourse. Surgery is the only possible method, which is dependent on the location and severity of the defect.
Meatal advancement and granuloplasty or MAGPI technique
In this stage, the repair is focused on straightening the penile path while defects examined in the degree of curvature are treated next. Surgery is done either under the perineum or in the scrotum skin. In the first step inside the glans, a traction suture is placed along with a silicone catheter tube inside the bladder of meatus.
Degloving the meatus lies in the next step, in which a circumferential incision is carried out around the penis skin, which is just beneath the coronal groove. Chordee tissue is then resected in the junction of penoscrotal. A resorbable suture is used (either 6.0 or 7.0).
With a two layer closure the glans wings are created and glanuloplasty is then performed. For a normal conical strand, ventral aspect of distal stitch is incorporated. When the skin gets peeled off from the shaft, tethered tissue bands are removed, finally resulting in straightening of the penis.
Tubularized incised plate (TIP) technique: Establishing the graft is done via tubularization technique. For severe hypospadias, the surgery comprises of dissection of the lining of the penis erectile path. The graft can be processed by placing an in-lay next to the hinging mid-line. Glansplasty is usually performed for creation of meatus and deep placement of the neo-meatus. Dissection is performed at the bottom of the penis and in some complex redo cases; tunica vaginalis flap acts as a possible graft to interpret this additional layer. A trans-urethral indwelling catheter is left after this stage and later removed after a week.
GAP repair technique: This technique is based on the Thiersh Duplay techniques, with the same procedure as in TIP. In this technique, wide urethral plate has been closed alongside the dorsal aspect without relaxing incision.
Flap technique — Mathieu procedure
This process starts with the measurement of defective location from glans tip to meatus. On the shaft skin of the penis, equal markings are done to make cautious dissection of flaps on subcutaneous tissue.
The flap is then flipped approximately (around 7–8 mm) to the lateral lines of urethral plate. The width of the flaps is tapered to 5–6 mm at the lateral point of glans. The fibrous joint (suture) is then covered using a flap tissue, and finally lateral stitching is done. The meatus gets developed up to the glans.
The wings of the glans are approximated and the suture gets covered by dartos flap, a connection tissue found in the penis. Finally, the adjacent blood vessels are dressed appropriately.
Treating Mid-penile Hypospadias
Technique uses onlay island flap and is applicable to patients with mid-shaft hypospadias without chordee. Similar to the MAGPI technique, circumferential incision is made and the penile shaft is preserved. After measuring the penile defect, the foreskin is cut rectangularly and dissected to conserve for its pedicle to the penis base. Tubularization techniques are performed on the urethral plate with anastomosis in the absence of urethral plate or insufficiency. The neo-urethra is then dressed with traditional tunis vaginalis or dartos.
Treating Proximal Hypospadias
Single stage repairs: Under single stage repair, the following techniques are performed:
Transverse Island flap (TIP): The process starts with penis degloving and chordee correction. The inner foreskin is inflated like a pedicle graft and then en-covering urethral plate using ventral transpose, as like onlay flap. Stitching can be done by ignoring regular anastomosis in order to avoid a baggy-like structure; however, it is dressed to prevent urethral diverticulum.
One stage repair with KOYONAGI-NONOMURA: In this technique, from the shaft skin a wide graft is harvested so as to make proper stitching in perputial hood. Harvested graft is then tubularized for single stage correction. This technique is an essence of two-stage accomplished in a single stage.
TIP urethroplasty: This is a successful treatment in distal hypospadias that can be used in treatment even in the absence of chordee. The process can be carried out in some complicated operations, as mentioned in distal TIP. Not all the attempts in TIP are as good as acknowledged, but show compromising results after redo.
Two-stage repairs: The first stage comprises of the removing excess chordee and splitting the glans by transecting urethral plate and excising the tethering tissues on chordee from corpora. A fine graft is harvested from foreskin. Before harvesting, the outlining of required layer will be marked and then infiltrated using sharp incisions. The harvested graft is then processed by quilt stitching on the graft, in order to minimize the risk of losing the graft, and causing trauma and even blood spill.
The second stage is done around 6 months after the first stage as there a need for some healing time. Then tubularizing urethral plate is done and chordee gets treated more vigorously. Preferentially, dartos flap is used and transposed for better vascularization. In addition, the dartos flaps provide plastic proofing layers. A stent of 8F or 10F is tubularized and three fine layers are achieved in the final process. Moreover, the graft from prepuce is utilized, which is comparatively subtle.