Overview

Definition:
-Hypospadias is a congenital condition in males where the urethral meatus opens on the ventral aspect of the penis, proximal to its normal position at the tip of the glans
-Peri-operative surgical role refers to the management and responsibilities of the surgical team before, during, and immediately after hypospadias repair surgery.
Epidemiology:
-The incidence of hypospadias varies globally, reported between 1 in 250 to 1 in 500 male births
-It is one of the most common congenital anomalies of the genitourinary tract
-Associated anomalies, particularly undescended testes and inguinal hernias, occur in up to 10% of cases.
Clinical Significance:
-Untreated hypospadias can lead to difficulties with urination (e.g., spraying stream), sexual dysfunction, impaired fertility, and psychological distress
-Surgical correction aims to restore normal anatomical function and appearance, allowing for a straight urinary stream, normal erection, and satisfactory sexual function
-Understanding the peri-operative role is crucial for successful surgical outcomes and patient well-being.

Indications For Surgery

Primary Indication:
-Correction of anatomical defect to achieve a functionally and cosmetically normal penis
-This includes straightening the penis, creating a meatus at the glans tip, and allowing for normal voiding and sexual function.
Reconstructive Indications: Repair of recurrent or complex hypospadias, particularly in cases with severe penile curvature (chordee), significant meatal stenosis, or inadequate urethral length from previous failed surgeries.
Associated Conditions: Concurrent repair of other genital anomalies such as cryptorchidism or inguinal hernia may be indicated at the time of hypospadias repair, depending on age and surgeon preference, to minimize anesthesia exposure.

Preoperative Preparation

Patient Assessment:
-Comprehensive history focusing on voiding pattern, family history, and associated anomalies
-Thorough physical examination including assessment of meatal location, penile curvature (chordee), presence of a dorsal hood of foreskin, and palpation of testes
-Evaluation for associated GU anomalies is essential.
Investigations:
-Karyotyping may be considered in cases of intersex variations or severe anomalies
-Renal ultrasound is often performed to screen for associated renal anomalies
-Urodynamic studies are rarely indicated preoperatively unless significant voiding dysfunction is suspected.
Anesthesia Considerations:
-Choice of anesthesia (general, regional, or combined) depends on patient age, complexity of repair, and surgeon preference
-Careful peri-operative fluid management and temperature control are paramount
-Antibiotic prophylaxis is standard to reduce surgical site infection risk.
Surgical Planning:
-Choice of surgical technique (e.g., Mathieu, Duckett, SNAG, MAGPI) depends on the degree of hypospadias, presence of chordee, and surgeon's expertise
-Detailed discussion with parents regarding the procedure, expected outcomes, potential complications, and follow-up plan is crucial.

Intraoperative Role And Techniques

Urethral Reconstruction:
-Mobilization of the urethral plate, division of any fibrous bands causing chordee, and creation of a new urethra using various techniques (e.g., tubularized incised plate (TIP), glanular urethral reconstruction, island flap)
-Ensuring adequate urethral length and tension-free anastomosis are critical.
Chordee Correction:
-Straightening the penis by dorsal plication or release of ventral scar bands
-Release of chordee must be balanced with maintaining adequate blood supply to the neourethra.
Meatal Creation: Creating a well-formed meatus at the tip of the glans, often with a glanular wings technique or by advancing tissue to create a neomeatus, ensuring it is spatulated and positioned correctly.
Dressing And Drainage:
-Application of a non-adherent dressing to the surgical site
-A urinary catheter (e.g., feeding tube, Foley catheter) is typically placed to stent the neourethra and ensure adequate drainage
-Some techniques may involve a suprapubic catheter
-Hemostasis must be meticulous.

Postoperative Care And Monitoring

Immediate Postoperative Period:
-Close monitoring of vital signs, urine output, and pain management
-Adequate analgesia is essential
-Maintaining fluid balance and monitoring for signs of bleeding or wound complications
-Catheter care and early ambulation are encouraged.
Wound Management:
-Keeping the surgical site clean and dry
-Dressing changes as per protocol
-Monitoring for signs of infection, dehiscence, or hematoma
-Edema is common and usually resolves spontaneously.
Catheter Management:
-The urinary catheter is typically removed after 5-10 days, depending on the surgical technique and surgeon preference
-Initial voiding trials are performed to assess for patency of the neourethra and absence of significant obstruction
-Education for parents on catheter care and signs of obstruction.
Pain Control:
-Effective pain management is vital, often involving a combination of oral analgesics, and sometimes opioid analgesics for the first few days
-Parental reassurance and education on pain assessment and management are key.

Complications And Management

Early Complications:
-Bleeding, hematoma formation, wound infection, meatal stenosis, urethrocutaneous fistula (leakage of urine from an unintended opening), and urethral obstruction
-Penile edema and bruising are common but expected.
Late Complications:
-Meatal stenosis, urethrocutaneous fistula, urethral stricture, penile curvature (recurrent chordee), scarring, and cosmetic dissatisfaction
-Long-term concerns may include impaired sexual function and fertility.
Management Of Complications:
-Fistulas and strictures often require secondary surgical repair
-Meatal stenosis may be managed with meatotomy
-Recurrent chordee may necessitate further straightening procedures
-Regular follow-up is crucial for early detection and management of late complications.

Key Points

Exam Focus:
-Understand the classification of hypospadias, common surgical techniques (TIP, Mathieu), the principles of chordee correction, and the management of peri-operative complications like fistulas and strictures
-DNB/NEET SS often test on algorithm of management and indications for redo surgery.
Clinical Pearls:
-Meticulous surgical technique, tension-free anastomosis, and appropriate post-operative care are crucial for successful outcomes
-Early identification and management of chordee are vital
-Always consider associated anomalies and patient psychological well-being.
Common Mistakes:
-Inadequate chordee correction leading to residual curvature
-tension on the suture lines causing dehiscence or fistula
-inadequate stenting of the neourethra leading to obstruction
-poor cosmetic outcome due to inadequate meatal reconstruction
-ignoring associated anomalies.