standard-title FAQ FOR PARENTS > 31-40 Frequently Asked Questions - For Parents

FAQ FOR PARENTS > 31-40

Frequently Asked Questions - For Parents

Frequently Asked Questions (FAQ)

Questions and answers about Hypospadias.

31. Which techniques are preferred for hypospadias-repair?

More than 300 operative techniques have been described for the correction of hypospadias. The surgeon should use the technique that brings in his own hand the best results.

The following algorithm summarizes Professor Hadidi´s protocol for different forms of hypospadias:

32. I have noticed that the Tubularised Incised Plate (TIP) technique (sometimes known also as “Snodgrass-Technique”) is NOT in the algorithm of operations performed in the hypospadias center, why?

About one third of patients referred to the Hypospadias Centre had a failed TIP procedure. The concept of the TIP procedure results in leaving a large raw surface in the reconstructed urethra. This raw surface usually contracts during healing resulting in a very narrow urethra and persistent fistula. Occasionally, the whole wound disrupts completely and urine comes out from the original opening. The condition becomes more complicated when the surgeon during the TIP procedure has excised the forskin. This makes the job of correction more difficult as there is no excess skin available to reconstruct the narrow urethra.

Pin point meatus after TIP more urine from fistula
 partial dehiscence complete dehiscence

33. What is the preferred technique for glanular hypospadias (Grade I)?

When the child has glanular hypospadias without chordee and the urethra is long enough to reach the tip of the glans, Professor Hadidi prefers to use the Double-Y-Glanuloplasty (DYG) technique. In this technique, the urethra is mobilized and brought to the tip of the penis. In other words, there is no new urethra reconstruction needed and therefore, the success rate is more than 98 %.

34. What is the preferred technique for distal hypospadias (Grade II)?

When the urethral opening is in the outer half of the penis without deep chordee, Professor Hadidi prefers to use the Slit- Like Adjusted Mathieu (SLAM) technique. In this technique, a skin flap from the penile skin is turned upward to form the lower surface of the new  urethra. The new urethra can be made as wide as the original urethra and the success rate of this technique in experienced hands is more than 95 %. Complications that include fistula, stenosis, wound dehiscence are less than 5%.

The “Slit-Like Adjusted Mathieu (SLAM)” for distal  Hypospadias:

35. What is the preferred technique for proximal Hypospadias without deep chordee (Grade III a)?

When the urethral opening is in the inner half of the penis without deep chordee, professor Hadidi prefers to use the lateral Based Onlay (LABO) technique. In this technique, a skin flap from the penile skin as well as the prepuce is turned around to form the lower surface of the new urethra. The new urethra can be made as wide as the original urethra. The technique has particular value in patients with small glans and the success rate of this technique in experienced hands is more than 93%. Complications that include fistula, stenosis, wound dehiscence are less than 7%.

The “Lateral Based Onlay (LABO) -Technique” for proximal Hypospadias without deep chordee:

36. What is the preferred technique for Proximal Hypospadias with deep chordee (Grade IIIb)?

When the urethral opening is in the inner half of the penis with deep chordee, Professor Hadidi prefers to use the lateral Based (LAB) technique. In this technique, the hypoplastic tissues that prevents the penis from being straight are excised and skin flap from the penile skin as well as the prepuce is turned used to reconstruct the whole new urethra. The new urethra can be made as wide as the original urethra. The success rate of this technique in experienced hands is more than 85 %. Complications that include fistula, stenosis, wound dehiscence and diverticulum are less than 15 %.

The lateral Based (LAB) flap for proximal Hypospadias with deep chordee:

37. What is the preferred technique for Perineal Hypospadias (Grade IV)?

When the urethral opening lies in the perineum and the scrotum is usually divided, sometime one or both testes are not in the scrotum, Professor Hadidi prefers to perform a two stage urethral reconstruction. In the first operation, the chordee is excised, the testes when high are brought down to the scrotum and the glans is opened widely and covered with preputial skin as a preparation for urethroplasty. In the second operation, urethroplasty is made to the tip of the glans. The success rate of this technique in experienced hands is more than 85 %. Complications that include fistula, stenosis, wound dehiscence and diverticulum  are less than 15 %.

The two stage repair for perineal Hypospadias with deep chordee:

before operationafter the first operation2 yrs after 2nd operation

38. What is chordee? Are there different types? Does this affect surgery? If the penis is curved, how would it be corrected, is this necessary and when?

Chordee means downward curvature of the penis. The curvature is usually most obvious during erection, but resistance to straightening is often apparent in the flaccid state as well. Chordee is usually but not always associated with hypospadias.

80 % of distal hypospadias have no curvature as well. The remaining 20 % have curvature due to shortening of the skin that is usually corrected during the operation of hypospadias.

According to Professor Hadidi experience, 50 % of the patients with proximal hypospadias have no chordee or superficial chordee that can be corrected by skin mobilization. The other 50% of proximal hypospadias (Grade IIIb) have deep curvature that has to be corrected by excision of the short hypoplastic tissue that is usually present distal to the urethral opening.

Almost all patients with perineal hypospadias (Grade IV) have deep chordee that has to be corrected in the first stage operation.

Essentially, there two main types of chordee associated with hypospadias. Superficial and deep chordee.

The  SUPERFICIAL type is usually present in 20% of distal hypospadias and in about 50% of proximal hypospadias. It is important to notice that in superficial chordee, the tethering bands and the penile curvarture are present proximal to the hypospadias meatus (Fig).

The 2nd type of chordee is the DEEP  chordee. It is usually present in about 50% of proximal hypospadias and about 10 % of distal hypospadias. It is important to notice that in deep chordee, the hard, rigid tethering bands and the penile curvarture are present distal  to the hypospadias meatus (Fig.).

 
Superficial chordeeDeep Chordee

39. What is “Nesbit-Procedure” and when should it be performed?

The “Nesbit-Procedure” is a procedure that tries to correct ventral curvature of the penis by shortening the upper surface of the penis (dorsal plication). This usually results in further shortening of the penis.

Prof. Hadidi does not recommend this approach for the correction of the penile curvature, as it results in shortening an already short penis (correcting one deformity below by creating another deformity above).

In addition, many adults complain of short penis and painful erection following the Nesbit procedure or dorsal plication.

When a child has hypospadias associated with deep chordee (penile curvature), the first step is to correct the chordee. There are two approaches for this; Possibility a: is to excise all the hypoplastic tissues that prevents the penis from being striaght. With this approach, the penis is more straight and longer than before surgery. Possibility b; is to shorten the upper surface of the penis. With this apporach, the penis is straight but shorter than before surgery. In addition, many adults complain of pain with erection as the penile body needs space for expansion and is restricted above by the sutures and below by the hypoplastic tissue.

40. What happens to the foreskin at the end of the operation?

There are 3 possiblities regarding the remaining foreskin after urethral reconstruction; 1) to leave it as it is and perform either forskin reconstruction or circumcision after 6 months.2) to do circumcision at the end of urethral reconstruction. 3) to do foreskin reconstruction at the end of urethral reconstruction.

Professor Hadidi prefers to leave the foreskin as it is and deal with it according to the wish of the parents 6 months after urethral reconstruction.This will be discussed in more details at a later question.

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