I. What is hypospadias? What is the treatment and outcome of hypospadias? Hypospadias is the most common congenital malformation of the male genital system, with an incidence of 3-4/1000. It is believed to be recessively inherited, and if a couple has a child with hypospadias, there is a 10% chance that other children will be born. Normally, after the seventh week of embryonic life, the urethral folds gradually fuse from the proximal end of the urethra to the glans to form a tube called the urethra, a process that depends on the androgens secreted by the embryonic gonads and on the response of the embryonic urethral groove and folds to testosterone. Hypospadias is caused when the formation of a tube in the wall of the urethral fold is impaired. In addition, the interstitial tissue at the urethral opening does not develop, forming a fan-shaped fibrous cord that surrounds the external urethral opening and extends and embeds in the glans. There are four characteristics of hypospadias: 1. abnormal urethral opening; 2. deformity of penile flexion to the ventral side; 3. accumulation of foreskin on the dorsal side of the penis and lack of foreskin on the ventral side and absence of foreskin tethering; 4. hypospadias, which extends from the penile tethering to the abnormal urethral opening, forming a thick fibrous band. II. How many types of hypospadias are there? Clinically, there are 5 types according to the location of the urethral opening. 1. Penile head type: The urethral opening is in the middle of the ventral part of the coronary sulcus. Except for the narrow urethral opening, this type does not affect the function of urination and sexual intercourse, so it can be treated without surgery. Foreign countries emphasize cosmetology and advocate surgery to move the urethral opening forward to a normal position. 2.Penile body type: the urethral opening is on the ventral side of the penis and needs to be corrected surgically. The picture below shows the comparison before and after surgery. 3.Penile scrotal type: the urethral opening is at the junction of the scrotum penis and the penis is severely flexed. 4.Scrotal type: The external urethral opening is located in the scrotum. In addition to the general characteristics of hypospadias, the scrotum is generally poorly developed and may have different degrees of division, sometimes accompanied by cryptorchidism. 5. Perineal type: The urethral orifice is located in the perineum, the scrotum is divided, the penis scrotum is completely or incompletely transposed, if the external genital development is extremely poor, the penis is short and flexed and seriously shaped like female vulva, sometimes parents mistakenly raise it as a girl. 3. Why do I need surgery for hypospadias? What is the purpose of surgery? In type II or above hypospadias, the penis is obviously flexed and the urethral opening is low, so the penis cannot be straightened when urinating, and the excluded urine is blocked by the penis, so it is easy to splash wet pants. In the case of hypospadias, due to penile flexion, there are difficulties in sexual intercourse and abnormal position of the urethral orifice in adults, which affects ejaculation. Therefore, hypospadias must be surgically corrected, otherwise it cannot lead to normal sexual life and infertility in adults. Diagnosis of hypospadias is not difficult, but for the scrotal and perineal types, it needs to be differentiated from pseudohermaphroditic diseases. In men, it is difficult to distinguish scrotal and perineal hypospadias with bilateral cryptorchidism from male pseudohermaphroditism. In females, pseudohermaphroditism is due to congenital adrenal hydroxylase deficiency causing cortical hyperplasia resulting in an enlarged clitoris resembling the labia minora, with the urethral opening located at the root of the enlarged clitoris resembling hypospadias. The vagina is small and sometimes not easily detected, but its sex chromosome is xx. Treatment of hypospadias usually requires surgery. The purpose of surgery is, first, to be able to stand and urinate normally, and second, to be able to have normal sexual life and fertility as an adult. Therefore, it is necessary to correct the deformity of the penis, straighten the penis; reconstruct the urethra, circumcision, penile head plastic surgery to make it look as perfect as possible. The normal function of urination and ejaculation is restored through surgery. The history of plastic surgery for hypospadias is more than 100 years old and there are more than 200 surgical methods. Each method has its own strengths and weaknesses, and the surgical methods are mainly divided into two categories: one-stage surgery is to correct hypospadias and reconstruct the urethra in one operation; staged surgery is to first correct hypospadias and make a good transfer of foreskin, and then perform urethral reconstruction after 6 to 12 months. The choice of surgical method should be flexible according to the type of hypospadias, the patient’s specific situation, and the experience and habits of the surgeon. Generally speaking, penile hypospadias can be operated in one stage, while scrotal and perineal hypospadias can be operated in one stage or in stages, depending on the situation. Regarding the age of surgery, opinions are not unanimous, and most scholars believe that all treatment should be completed before school age. Therefore, surgery to correct the flexion deformity requires removal of the ventral fibrin of the penis and complete straightening of the penis. The urethra is shaped and the opening position is made as close to normal as possible. Surgical indications: Except for coronal hypospadias without penile flexion deformity, all other types of hypospadias must be corrected by surgery. When should a child with hypospadias be operated? In the past, when staged surgery was used, the age of surgery was from 2 to 5 years old when the first stage of penile flexion correction was performed, and urethroplasty was completed at puberty. With the improvement of surgical instruments, materials (mainly sutures), and techniques, the age of surgery has advanced and Duckett believes that surgery can be performed at only 3 months of age, with anesthesia to ensure safety. And the easily accepted age is between 6 and 18 months. The ability of the child to stand and urinate after early surgery can reduce the psychological burden on the child. And it can avoid multiple surgeries and reduce the cost of surgery, and the growth of penis is very small within 3 years old, which will not affect the development of penis. V. What are the complications and prevention after hypospadias surgery? Complications are common complications, such as urinary fistula, stricture, wound infection and splitting, etc. Preventing complications is the trick to get success. Adequate preparation before surgery, delicate operation during surgery and careful care after surgery can reduce the occurrence of complications. Pre-operative cleaning of the perineal skin keeps the surgical site clean and reduces the chance of wound infection. Lie in bed for a long time after surgery, learn to defecate in bed, and empty the bowels on the morning of surgery, so that there is no risk of wound bleeding and wound dehiscence due to forceful defecation after surgery. If the stool is dry after surgery, it is better to eat more fruits and vegetables, etc., and if necessary, use corkage to promote bowel movement. After surgery, be careful not to squeeze the penis to avoid poor wound healing, especially parents should pay attention to the child not to lie on his side at night, which can easily crush the wound. All cases of urethroplasty require drainage of urine, and it is more common in China to do suprapubic cystostomy with a stent tube with lateral holes left in the formed urethra. The cystostomy tube is used to drain urine, and red urine, or hematuria, may often occur after surgery, which generally does not require special treatment, and it is appropriate to drink more water to prevent blood clots from blocking the fistula. Due to the stimulation of the suprapubic cystostomy tube, children often have the urge to defecate and itching in the anus or perineum, which usually requires no special treatment. VI. What should I pay attention to after discharge? What is the prognosis? After urethroplasty, the new urethra is weak due to the lack of urethral corpus cavernosum protection and the anterior wall of the urethra. It is better not to play with toys that may press the penis and perineum, such as bicycle, wooden horse, etc. for two years. After discharge from the hospital, pay attention to the urinary line. If the urinary line becomes smaller, go to the hospital for urethral dilatation. If you go to the hospital only when you have difficulty in urinating, you may have serious urethral stricture and need to operate again. It is also important to note that if the skin on the ventral side of the penis is infected after surgery, it should be treated promptly because the anterior wall of the urethra is weak and not protected by the urethral corpus cavernosum, which can easily break down and lead to urethral fistula. If there are no complications after hypospadias surgery and the penis develops well later, more than 95% can get married and have children