Manejo De La Hipospadia Severa

Management of severe hypospadias

Massimo Catti, Delphine Demede, Anne-Frederique Valmalle, Pierre-Yves Mure, Frederic Hameury, Pierre Mouriquand
Department of Pediatric Urology, Debrousse Hospital, Claude-Bernard University, Lyon, France
Correspondence Address:
Pierre Mouriquand
Department of Pediatric Urology, Debrousse Hospital, 29, rue Soeur Bouvier, 69322, Lyon Cedex 05
Year : 2008 |  Volume : 24  |  Issue : 2  |  Page : 233-240 INDIAN JOURNAL OF UROLOGY
Abstract |   | |
Many classifications of hypospadias have been published, mainly based on the position of the ectopic meatus, which is an insufficient criterion to define the severity of this malformation. What really marks the proximal landmark of this malformation is the level of division of the corpus spongiosum,which is always proximal to the ectopic meatus. In this article, we will focus on the most severe forms of hypospadias which include those with a proximal division of corpus spongiosum (below the midshaft), important chordee and a poor development of the ventral radius, reflecting a marked hypovirilization of the genital tubercle, and cripple hypospadias resulting from several previous failed surgicalprocedures. The principle of hypospadias surgery will be reviewed together with the outcome of the current surgical techniques. Furthermore, common complications will be outlined. There is no minor or major hypospadias and all forms require a solid experience of the surgeon, as minor looking hypospadias may turn out to be far more complex to repair than they appear once the ventral radius of thepenis has been dissected.

Keywords: Hypospadias, Urethral plate, Chordee, Fistula, Dehiscence, Stenosis, Urethrocele, Duplay urethroplasty, Mathieu urethroplasty, Onlay urethroplasty, Koyanagi urethroplasty, Buccal graft urethroplasty, Bracka urethroplasty
Definition and Anatomy |   | |

A possible definition of hypospadias is the incomplete virilization of the genital tubercle causing aninsufficient development of the tissues forming the ventral aspect of the penis.

Three associated anomalies are classically found in hypospadias: an ectopic position of the urethral meatus, a ventral curvature of the penis (chordee), and a defect of the ventral prepuce. A hypospadiac penis presents, from the tip to the base: a ventrally opened glans penis, an absent frenular artery and amissing segment of urethral tube which is replaced by a urethral plate extending from the ectopic meatus up to the glans cap. The tubular urethra proximal to the ectopic meatus is hypoplastic, not surrounded by any corpus spongiosum and covered by a thin layer of skin tightly stuck on it.

The division of the corpus spongiosum is always proximal to the ectopic meatus and is often outlined on theventral skin by a small cutaneous ridge. Proximally to the division of the corpus spongiosum, all structures forming the ventral aspect of the penis are normal as well as the dorsum.

Consequently, what really marks the proximal landmark of this malformation is not the position of the ectopic meatus, but the level of division of the fan-shaped corpus spongiosum which represents the summit of aventral triangular defect, the two sides being represented by the two lateral pillars of atretic spongiosum and the basis by the glans plate. This triangle is easily outlined by drawing two lines following on each side the junction between the inner and outer aspects of the prepuce. Where the two lines cross is where the corpus spongiosum splits [Figure - 1].
Figure 1: Division of corpus spongiosumThe penile ventral curvature is the direct consequence of the hypoplastic tissues laying in the ventral triangular defect described above. The thin ventral skin is often very adherent to the underlying hypoplastic urethra. Its freeing (penile degloving) sorts out the curvature in most cases. The hypoplastic pillars of spongiosum extending upward in a fan-shaped situation on each side of the...