Download Circumcision & hypospadias Dr.Bilal Azzam

Circumcision
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Definition:
Phimosis: stenosis of the preputal ring with
an inability to retract the foreskin.
Paraphimosis: retention of the retracted
foreskin in a position proximal to the coronal
sulcus.
Balanitis: inflammation of the foreskin.
Posthitis: inflammation of the glans.
Meatitis: inflammation of the urethral
meatus.
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Retractability of the
foreskin
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Birth 5%
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6months 15%
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1year 50%,
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3years 90%.
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Potential benefits of circumcision
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Protection against penile cancer.
Protection against urinary tract
infection.
Protection against sexually transmitted
diseases.
Protection against carcinoma of the
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Indications
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Medical
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Pathological Phimosis
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White, scarred prepuce (BXO - absolute)
May cause ballooning, bleeding, dysuria or retention
Alternatives are preputioplasty / steroid cream
Recurrent Balanitis
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Religious
Exclude diabetes
Urinary Tract Infection Prophylaxis
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Protects against UTI in infants with VUR, PUJ, posterior
valves and hydronephrosis 1
In VUR: 63% v 19% of circumcised boys suffered UTIs
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1 Herden CDA. J Urol 1999
Contraindications to
circumcision
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Hypospadias.
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Other associated genital anomalies.
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Unstable or sick infant.
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Family history of bleeding tendency.
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Contraindications
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Premature Infants
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Congenital Penile Abnormalities
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Hypospadias, episapdias, chordee, penile
webbing or concealed penis
Blood Dyscrasias
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Complications of
circumcision.
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Serious: life threatening: infection and
bleeding. Not life threatening: fistula
amputation.
Not serious: Inadequate skin removal
(incomplete circumcision). Excessive
skin removal. Inclusion cyst. Skin
bridges etc.
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Complications
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Chordee
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Urethrocutaneous Fistula
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Urethral injury during excision of prepuce
Necrosis
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Secondary to circumcision is related to excess skin
removal
May occur secondary to surgery or infection
Only use bipolar electrocautery sparingly and never
with a ‘clamp’ device
Amputation of Glans
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May occur using a ‘clamp’ device
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Complications
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Death
Bleeding (2-5%)
Suture sinus tracts
Infection (2%)
Phimosis and
concealed penis
Adhesions
Meatal stenosis
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Chordee
Urethrocutaneous
fistula
Necrosis
Amputation
Hypospadias
Meatitis
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Surgical technique
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Principles: freeing the foreskin,
identifying the meatus, retracting the
foreskin, identifying the coronal sulcus.
Anesthesia: Local, General, None.
Instruments: Gomco clamp, Plasty
bell, etc.
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The ideal circumcision
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Neonatal age.
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Local anesthesia.
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Selective delay for those who need so.
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Instruction to parents about
risks.infection, bleeding.
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Follow up.
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HYPOSPADIAS
Hypo- below, Spadon- orifice
Urethral meatus opens on ventral side of the
penis, proximal to the tip of glans penis
Incidence ……..1/125 to 1/250
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Hypospadias
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Definition: Is a congenital defect of the
penis resulting in incomplete development of
the urethra, corpora cavernosa, and prepuce.
Clinically results in deflection of the urinary
stream and abnormal appearance of the
penis.
Severe hypospadias is associated with
chordee which may result in infertility
secondary to difficulty in insemination.
Cosmetic and functional defect.
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Subcoronal hypospadias
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Types of hypospadias
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EMBRYOLOGY
Cloacal membrane, genital tubercle, labioscrotal
swellings
Androgen stimulation…phallus elongation
3 phases of urethral formation
Posterior urethra formation
Anterior urethra formation
Glandular segment formation
Prepuce formation
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PARTS OF HYPOSPADIAS
Meatus … usually non-stenotic
Stenosis more common in distal hypospadias
Megalomeatus intact prepuce
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SKIN…..
Ventral defect & dorsal hood
Urethral delta
Hood of monk….Cobra eyes
Defects of spongiosum
Defects of cavernosa
Defective urethral plate
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CURVATURE
Skin attachments
Bucks defect
Urethral plate
Cavernosa defects
Problems of unhealthy urethra
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CLASSIFICATION (LOCATION)
DISTAL
Glandular, Coronal, Distal penile
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MIDPENILE
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Midshaft
PROXIMAL
Proximal penile, Penoscrotal, Scrotal, Perineal
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Classification
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Anterior 50%, the meatus is on the
glans, coronal or subcoronal position.
Middle 30%, the meatus is on the
shaft of the penis.
Posterior 20%, the meatus is
between the perenium and the
penoscrotal junction.
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Associated anomalies
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Undescended testis 10-30% depending on the
severity of the hypospadias.
Inguinal hernia 10%.
Utricle, remnant of the Mullairian duct system.
Urinary tract anomalies are infrequent in isolated
hypospadias.
Hypospadias alone or when associated with hernia do
not require further investigations.
Severe hypospadias, specially when associated
with undescended testis should be investigated for
possible intersex with karyotyping and endocrine
workup.
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ASSOSIATION WITH OTHER DEFECTS
Renal agenesis, dysplasia, reflux
Prostatic utricle
Hernia
: 9%
Cryptorchidism
: 9%
Father
: 9%
Siblings
: 14%
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Treatment
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Surgery is best performed 6-18 months of
age.
Single stage versus multistage repair.
Outpatient versus inpatient.
Goal of repair: normal urethra, normal glans.
Final goal: straight shaft, normal skin normal
appearing meatus, normal skin coverage, and
normal penoscrotal position.
Correction of functional and cosmetic defect
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is the goal of hypospadias surgery.
Operations
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Utilization of local tissue, skin, tabularization,
flaps, grafts, urethral advancement.
Utilization of adjacent tissue, skin, prepuce,
penile skin scrotal skin in the form of flaps or
grafts.
Utilization of remote tissue, skin mucosa,
buccal, bladder.
Staged repair.
Operations for chordee correction.
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Results & complications
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Success rate
70-100% depends on
The severity of the hypospadias
The surgical technique
The surgeon.
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HYPOSPADIAS & INTERSEX
? Form of androgen insufficiency
Mixed gonadal dysgenesis
Androgen insensitivity
Testosterone synthesis defects
5 alpha reductase defects
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COMPLICATIONS
BLEEDING & HEMATOMA
MEATAL STENOSIS
URETHROCUTANEOUS INFECTION
URETHRAL DIVERTICULA
RECURRENT CURVATURE / STRICTURE
BREAK DOWN
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