I. What exactly is hypospadias?
In fact, the external genitalia and urethra begin to develop at 8 weeks of embryonic life and are completed at 15 weeks, when the urethral groove gradually fuses along the ventral surface of the penis from the proximal distal end to form the urethra up to the tip of the glans penis. Due to the lack of fetal testosterone or its insufficient action, the urethral groove does not completely close to the tip of the penile head and stops at different stages and different types of hypospadias occur, and because the urethral groove is fused from proximal to distal, distal hypospadias is more common.
The incidence of hypospadias is 1 in 300 male children, and it is known that the use of estrogen and progesterone in women during pregnancy can significantly increase its incidence. Hypospadias also has a genetic predisposition and is a polygenic disease.
Symptoms of hypospadias
The clinical manifestations have 3 characteristics.
1. abnormal location of the external urethral opening, which can be anywhere from the proximal end of the normal urethra to the perineal urethra.
2. abnormal foreskin distribution. The foreskin is concentrated on the dorsal side of the glans in a “turban shape”, the ventral foreskin of the penis has a “V” shaped defect, and the foreskin tether is absent.
3, penis downward curvature. The penis is bent ventrally, the glans is flattened like a spade, the penis is bent down, especially when erect, mainly due to the proliferation of fibrous tissue around the urethral opening.
It can be divided into 4 types depending on the location of the urethral opening.
1, head of the penis, coronal groove type.
2.Penile body type.
3, penile scrotal type.
4, perineal type.
What are the associated deformities of hypospadias?
Hypospadias can be combined with cryptorchidism and inguinal hernia, up to 9%. Prostatic cysts occur in severe hypospadias, as well as combined penile scrotal transposition, penile torsion, micropenis, and anorectal malformations.
IV. Examination of hypospadias
Hypospadias of the penile scrotal type and perineal type is often complicated by scrotal splitting, and the sex of the external genital organs is difficult to determine, so oral and buccal mucosal smear and karyotype examination should be performed to determine the sex. Urethroscopy and cystoscopy can be performed to understand the development of the male internal reproductive organs; excretory urography can be performed to understand whether congenital malformations of the duplicated kidney and ureter are combined. For patients with hypospadias, excretory urethrography can be a routine test. However, it is of little value in glottic hypospadias because the incidence of upper urinary tract anomalies is not higher in these patients than in the general population. Children with combined cryptorchidism can be examined using ultrasound for testicular location; those who cannot be definitively identified or those with true hermaphroditism may opt for laparoscopic techniques.
V. Diagnosis of hypospadias
When hypospadias is combined with bilateral cryptorchidism, attention should be paid to whether there is gender abnormality, and it should be distinguished from male and female pseudohermaphroditism and true hermaphroditism. In recent years, laparoscopic gonadal examination with biopsy technique is a minimally invasive surgery and is being promoted, while open surgery has the tendency to be eliminated.
VI. Treatment of hypospadias
Hypospadias treatment is surgery, there are more than 400 kinds of surgical methods, probably the most surgical methods disease. The purpose of surgery is to correct hypospadias and urethroplasty. Considering the psychological aspects, most advocate a one-stage surgical repair to complete it. General penile head and coronal groove type often use urethral advancement and penile head shaping; penile corporal type without penile hypospadias may consider using the addition of island foreskin flap method; those with penile hypospadias may choose transverse foreskin island flap urethroplasty, buried foreskin method; severe hypospadias may choose free grafts to replace the urethra, such as bladder mucosa, buccal mucosa, etc.
The most common surgical complication of hypospadias is urethral fistula.
The incidence is 15-30%. If it occurs it needs to be repaired by urethral fistula 6 months after surgery, after local scar softening and blood supply reconstruction. The second is urethral stricture, which requires urethral dilatation in the early 3 months and surgical treatment if it is ineffective. The second is urethral dilatation. Small urethral dilatation secondary to stricture relieves itself after the stricture is lifted; larger urethral dilatation requires dilated urethral cropping urethroplasty.
Eight, some considerations of hypospadias surgery
1, the age of surgery for hypospadias: some studies show that the effect of surgery is not related to age. Generally, 6-18 months is easily accepted, and early treatment can relieve the psychological pressure of the child and his family.
2, surgical instruments and sutures: repair of hypospadias is a fine surgery, surgery requires fine instruments or ophthalmic instruments, if necessary, you can wear a magnifying glass surgery. The sutures are 5-0, 6-0 absorbable sutures with anti-infection effect and do not need to be removed.
3, incision dressing: dressing dressing to fix the penis, to prevent edema bleeding, to protect the role of the incision, not easy too tight or too loose. At present, basically the use of surgical self adhesive bandage dressing effect is satisfactory.
4, urine drainage: early cystostomy drainage of urine is rarely used, most of the use of indwelling catheter, play the role of drainage of urine and support the urethra, retain the urethra for more than 1 week, pay attention to the fixation of the urethra.
5, postoperative medication: sacral anesthesia can be used to reduce postoperative pain; oral belladonna combination can be taken to relieve bladder irritation; oral hexestrol can be taken to inhibit penile erection to relieve postoperative pain.
6.In conclusion, the complications of hypospadias surgery are still many and the failure rate is still high. Meticulous surgical skills, thorough hemostasis and infection prevention can improve the success rate of the surgery.