Hypospadias is a Greek word that refers to the ventral fissure of the penis. Hypospadias is a congenital malformation of the male external genitalia caused by hypospadias, a hypoplastic anterior urethra. The opening of the urethra is not at the tip of the head of the penis, but at the coronal sulcus near the normal urethral opening, on the ventral side of the penis, or in severe cases, in the scrotum or even the perineum, resembling a woman. The closer the urethral opening is to the root of the penis, the more obvious the shortening of the ventral side of the penis and the curvature of the penis will be.
I. Prevalence of hypospadias
There are obvious regional differences in the incidence of hypospadias, for example, the incidence per 1000 people is 0.26 in Mexico, while in Scandinavia it is 2.6, and in our country it is 2.5~3. The incidence rate also varies in different geographic areas of the country. Since the 1960s and 1970s, the trend of increasing incidence of hypospadias has been reported repeatedly, especially in the more industrially developed European and American countries. The most accepted explanation for the increasing incidence of hypospadias is that the ubiquitous “endocrine-disrupting substances” in the environment interfere with the normal development of the fetus.
Clinical features of hypospadias
Sometimes the foreskin is intact and covers the ectopic urethral opening, which only appears when the foreskin is retracted. Such patients may be mistakenly circumcised and cause a shortage of material for future urethroplasty, resulting in surgical difficulties.
2, abnormalities in the location of the urethra due to interrupted urethral development, the urethra can open at any part of the glans to the perineum. According to the location of the urethra is different, suburethral cleft will be typed, there are many methods of typing, at present, it is mainly typed according to the location of the urethral opening after correction of penile curvature.
3, penile curvature one of the main signs of hypospadias is penile curvature deformity. Usually, the severity of penile curvature is related to the location of the ectopic urethral orifice, and the closer the urethral opening is to the segment, the more severe the penile curvature. In addition, penile torsion is not uncommon in hypospadias, with an incidence of up to 16%.
The severity of the clinical symptoms depends on the location of the urethral opening and the degree of penile curvature.
Risk factors for hypospadias
1. Maternal factors Gold and Bongiovanni proposed in 1967 the role of maternal progesterone in the development of hypospadias. It is known from the previous literature that the administration of hexestrol to pregnant women leads to genital tract malformations in the offspring. Maternal exposure to progestin or progestin-combined estrogen during pregnancy was associated with a 4-fold higher chance of developing hypospadias in the offspring (8,3% compared to 1,8% in controls). In addition, the dietary factors of the mother can also influence the development of the disease. One study in the UK found that. Vegetarian pregnant women had a higher chance of having a child with hypospadias than regular omnivores; mothers who drank soy milk and ate soy products for a long time were more likely to have a son with hypospadias. It has also been found that as the mother’s age at childbirth increases, the chances of the offspring suffering from hypospadias also increases.
2.Father’s factor and the father’s directly related factor is his fertility. Some studies have found that some patients with cryptorchidism also have urogenital abnormalities, and about half of them have hypospadias. About 34% of the fathers of patients with hypospadias had scrotal or testicular abnormalities (such as cryptorchidism, syringomyelia, testicular dysplasia), while only 3% of the fathers of sons with normal external genitalia suffered from external genital diseases. This suggests that any one genital disorder is a high risk factor for another. The interconnectedness of these male genital malformations suggests that they may be due to common causative factors.
3. Parental occupational factors There is growing evidence that environmental factors play an important role in the development of hypospadias. It has been confirmed that many pesticides as well as everyday chemicals can cause malformations of the male reproductive system, so whether parental occupational exposure can cause congenital malformations in the offspring deserves further study. Although there is no direct evidence that those occupations can induce hypospadias in the offspring, the mother’s occupation is the most likely to be exposed to potassium phthalate and to potential EDs. In addition, heavy use of fungicides and chlorinated herbicides also increase the chance of the disease.
4, infant factors infant’s low weight is currently one of the more certain risk factors. Foreign scholars have found that hypospadias is associated with intrauterine growth retardation, and that the three parameters of hypospadias and intrauterine growth (and weight, length and head circumference of the newborn) are inversely proportional. When all three parameters are affected, the incidence of hypospadias can be up to 4 or 5%. In contrast, when all three parameters are normal, the incidence of hypospadias is very low. The overall decrease of these parameters indicates that the damage appears in early pregnancy.
Genetic factors have been shown in a number of domestic and foreign studies to be the suspected genes for hypospadias: SRD5A2, HSD17B3, AR. These suspected genes may undergo transcriptional mutations and interact with environmental factors, resulting in altered gene expression and a significantly higher risk of developing the disease. Allelic variants related to androgen action or metabolism may lead to the development of hypospadias in the organism, such as the action of the suspected gene and anti-androgen substances in the environment, which can lead to the development of the disease when a certain threshold is exceeded.
5.Endocrine disorders and environmental factors
IV. Timing of surgery for hypospadias
The timing of treatment for hypospadias varies, and textbooks from the 1980s suggested that surgery should be completed before school age. However, with advances in anesthesia and surgical techniques and medical devices, some scholars believe that children can undergo surgery for hypospadias repair at 6 to 18 months of age, depending on a variety of different factors. To mitigate psychological complications, the surgery should be done as early as possible. Genital deformities should be corrected before the child can feel his congenital defect and the parents’ anxiety and worry, in order to prevent adverse effects on his self-image and emotional development. Of course, the timing of the surgery is also influenced by the degree of penile development, i.e., the adequacy of the size of the chosen material. Taking into account the national characteristics and the specific material of the child, we often choose patients around 3 years old for surgery, and the youngest is one and a half years old.
VI. Surgical treatment of hypospadias
The treatment of hypospadias has a history of thousands of years, because of its high technical requirements, difficulty, postoperative complications, and unsatisfactory results. It is only in the last 20 years, with the continuous progress of medical technology and the introduction of innovative medical materials, the treatment effect of this disease has been significantly improved.
1, hypospadias cure criteria.
Complete correction of hypospadias, urethral opening in glans orthogonal position, penis appearance close to normal, good urethral urinary function, and normal sexual life in adulthood.
2.Urethral hypospadias typing.
Suburethral cleft surgery should be performed according to the specific pathological type to choose the appropriate surgical method. Classification according to the location of the urethral opening: proximal type: urethral opening in the scrotum, perineum, penile root; middle type: urethral opening in the mid-penile position; distal type: urethral opening in the glans, coronal groove, penis near the coronal groove area.
3.Contents of the first-stage repair of hypospadias.
Undercurved penis correction, urethroplasty, urethroplasty and glansoplasty, phalloplasty (covering of the penis), scrotoplasty, and trend of hypospadias repair are one-stage repair, and most doctors and families of sick children accept this option. Severe hypospadias with prepuce dysplasia should be staged. Some reoperators should be considered for staged surgery.
4.The choice of the surgical procedure for one-stage repair of hypospadias should be based on the following principles.
The plane of the position of the urethral opening, the degree of penile curvature, the condition of the urethral plate and glans, the condition of the repair tissue, and the surgical style that the doctor has mastered.
5. Use of repair materials.
Urethral plate tissue, tipped foreskin flap tissue, penile flap, scrotal flap, free foreskin piece, free bladder mucosa, free buccal mucosa.
6.Surgical equipment required for hypospadias surgery.
Visualization equipment: including magnifying glass and other visualization and magnification instruments; surgical instruments: instruments used in microplasty and microsurgery: tissue forceps; small scissors: miniature iris scissors; small needle holder: microscopic ophthalmic needle holder; small circular knife: 15 gauge blade; measuring equipment: delicate steel ruler for accurate measurement of urethral opening and flap scale to achieve precise surgery. The sutures used are absorbable polymer monofilament sutures, which are characterized by high tensile strength, mild tissue reaction and corrosion resistance. It is conducive to tissue healing and prevention of inflammation.