There are many factors to be taken into account for surgical repair, new procedures are emerging, and repair surgery requires a high degree of individualization, making the choice of procedure an issue. Specialized research has led to the development of “hypospadias” (hypospadiology), where “near-normal appearance” is the first goal of surgical treatment. The results of long-term follow-up of adult cases after hypospadias surgery show that the appearance is the first factor that affects the patient’s evaluation of the long-term results of the surgery, and the psychological impact of poor appearance is an important cause of poor sexual function and dissatisfaction with sexual life. The pursuit of good appearance becomes an important influencing factor in the choice of surgical procedure.
I. The goal of surgical treatment for hypospadias
1.Appearance close to normal.
2.Erection straightening.
3.Orthodontic opening of the urethra.
4.Appropriate urinary flow and line.
5.Low complications.
II. Lesion assessment
1, penile head size and groove depth and width.
2, urethral plate development, flat type, groove type, width, etc.
3, the presence or absence of urethral stenosis
4. the presence or absence of dysplasia of the distal urethra and whether it is fibrous and needs to be removed
5, whether there is narrowing of the urethra and the condition of the diverticulum expansion site
6, the degree of penile curvature and possible etiological typing.
7, the degree of penile scrotal transposition.
8, the development of the proximal ventral penile skin and foreskin cap, and the morphology of the foreskin cap should be analyzed for those who may reconstruct the urethra with foreskin.
Third, the principles and contents of surgical correction
1.Penis straightening.
2, urethroplasty.
3, urethroplasty and penile head formation.
4.Urethral outer layer coverage.
5.Penis and scrotum shaping.
IV. Major changes in the trend of surgical selection
The research on the etiology and pathogenesis of hypospadias has progressed relatively slowly, but on the basis of morphological research results, the principles of clinical surgical correction have produced significant changes.
1. the recognition and management of penile curvature occupies an important place in the choice of surgical procedure for hypospadias
2. an increase in the proportion of procedures that preserve the urethral plate
3. an increase in the requirement for one-stage repair
4. the elevated importance of the pursuit of good appearance
5.The application of oral mucosa replacement repair of urethra has increased.
V. Principles of choosing the basic surgical procedure for hypospadias
Suburethral cleft (after skin decortication) is divided into distal type, middle type and proximal type.
Distal type: assessment of penile shape, position of the urethral orifice, width and depth of the groove of the penile head (urethral plate), presence or absence of curvature, and whether or not dorsal folding can be performed Surgical options are MAGPI, Mathieu, TIP (Snodgrass), in situ penile flap coiled tube, and urethral drag-out.
Mid-segment type: 1, no curvature, dorsal foldable TIP (Snodgrass), transverse or longitudinal island foreskin flap onlay; 2, curvature requiring severance of urethral plate, distal urethral dysplasia, stricture Select transverse Duckett or longitudinal island foreskin flap.
Proximal segment type: assess the degree of curvature and whether the dorsal fold can be corrected, penile length, foreskin shape and volume; 1, curvature can be corrected Duplay, Onlay; 2, sever the urethral plate Duplay + longitudinal (transverse) flap, Koyanaki,staged surgery, buccal mucosa phase II surgery.
VI. Oral mucosa for urethral replacement
1, it is currently believed that oral mucosa is one of the best options when free graft is needed for urethral reconstruction
2. oral mucosa can be used for urethral reconstruction in a coiled tube or capped (onlay, dorsal or ventral) fashion
3. It is suitable for heavy cases of hypospadias and urethral stricture, and is also a good choice for the repair of disabling hypospadias.
VII. About staged surgery
On the basis of technical progress and operational proficiency, it is required to perform one-stage repair of hypospadias as far as possible; in similar cases, the total complication rate, number of reoperations and difficulty of reoperations for one-stage repair are better than those for staged surgery, and the indications for two-stage surgery should be limited; in a few heavy cases, the length of urethra to be reconstructed is large, the development of penile scrotum is poor, there is a shortage of local replacement materials, and the combined deformities are complicated (penile scrotal transposition, penile occlusion, prostate In a few heavy cases, the urethra needs to be reconstructed with a large length, the scrotum is poorly developed, there is a shortage of local replacement materials, and the combined deformities are complex (transposition of the scrotum, ankylosis, prostate, etc.). When choosing staged surgery, the task of the first-stage surgery should be to create good repair conditions for the second-stage surgery, rather than simply correcting the hypospadias. Issues that should be considered for the first-stage surgery.
1. adequate correction of the hypospadias.
2. The reconstructed “urethral plate” should be in good condition, flat, and avoid or reduce suture scarring.
3.reconstruction of the head of the penis with small volume and shallow and narrow navicular fossa.
4. In some cases, slightly loose skin below the coronal sulcus can be retained to avoid the use of the skin of the head of the penis for urethroplasty in the second stage, and the distal part of the formed urethra can be moved forward or laterally to the distal part of the head of the penis, while the skin of the ventral part of the head of the penis can be used for better distal urethral inclusion.
5. eliminating or improving local combined deformities such as scrotal para-cleavage and penile scrotal transposition.
6 A section of proximal urethra should be reconstructed as much as possible when conditions permit to reduce the length of the stage II shaped urethra.
In heavy cases, when it is expected that the first-stage repair may seriously affect the appearance in case of satisfying the urethral reconstruction, a staged operation can be considered, with the first stage reconstructing part of the urethra, improving the morphology of the penile head, correcting the concurrent scrotal para-cleft, penile scrotal transposition, etc., and the second stage making in situ flap or TIP surgical repair to achieve a satisfactory appearance.