This article will touch upon the Hypospadias disease, its types, surgical techniques and the anatomy of the penis in order to better clarify the subject. We will initially explain the treatment phases of patients with complex Hypospadias , who previously underwent several unsuccessful surgeries.
What is Hypospadias?
Hypospadias is a congenital anomaly that should be repaired at childhood age. In Hypospadias, the urinary outlet that opens to the edge of the penis, opens to another point on the bottom surface of the organ and anywhere between the perineum and the penis edge. It seen once in every 200 births. It is more common with children that were born through the in vitro fertilization method. Hypospadias is examined under 3 classes, which are front (anterior), middle (midpenile) and rear (proximal). These patients cannot discharge urine forwards. More importantly, these children may not perform sexual intercourse when they become adults as the penis is curved downwards.
Cause of Hypospadias Curvature
Functions of penis are urine discharge and sexual intercourse. We see two strong, binocular shaped, spongy-type bars that erect the penis in the transverse section of the penis (corpus cavernosum). Underneath them, there is the urine discharge channel we call the urethra. This is covered by a weaker spongy tissue (corpus spongiosum). These formations have been wrapped by 4 different layers (the skin, dartos, buck fascia and corpus spongiosum). The congenital non-development of one or several of such layers that wrap the urinary channel in Hypospadias cases is the cause of curvature. Furthermore, the less developed these 4 layers, the higher the degree of curvature becomes.
Another cause for curvature is the insufficient development of the lower sides of these two lateral bars (corpus cavernosum) compared to their upper surfaces.
In sum, the cause of curvature is the non-development of the skin, dargos and buck fascias as well as of the thick sheath that is located in the bottom surface of the corpus spongiosum and corpus cavernosum, which is called tunica albuginea.
Does Curvature Occurs in the Penis Although Hypospadias Isn’t Present?
Curvature may also occur in penis in the absence of Hypospadias (when the hole is its normal location). We diagnose the majority of these patients at advanced age, which condition is called non-hypospadias curvature. Simple types don’t require surgery but advanced types are operated, as entry to the vagina will be problematic.
Diagnosis of Hypospadias
Diagnosis is made by a simple physical examination made right after birth. The foreskin hasn’t developed in the bottom surface of the penis (prophet circumcision). It resembles a hood. The urinary hole is situated below the normal. The penile head (glans) may be separated at the bottom. There is curvature during erection. Diagnosis by physician to determine the degree of curvature will be easier if while the child sleeps, parents take a photograph of the erected penis. Degree of curvature may represent a cause for infertility as it may lead to problems while transferring sperms.
Should Children with Hypospadias be Circumcised?
The difficulty of the Hypospadias surgery is determined by the degree of curvature rather than the location of the urinary hole. That is because the tissues at the bottom surface of the penis have never developed or have insufficiently developed. The foreskin is required for giving a tube shape to the deficiently formed urinary channel and also grafting the insufficient penis skin, which emerges after the penile curvature, is corrected. For this reason, children with hypospadias should never be circumcised. In cases where tissues are insufficient, we take grafts from distant tissues and use them for constructing the urinary channel and complementing the missing tissues around the penis. This procedure will be much difficult in circumcised children.
Types of Hypospadias
Front and Middle Type Hypospadias
The more rear the hypospadias hole is located, the more curvature in the penis occurs. Even in simple cases where the hole opens to the front section, the number of patients with advanced levels of curvature isn’t low. Front hypospadias, meaning cases where the hole isn’t located very low may seem simple, but the degree of curvature is a more important factor then the location of the hole. That is because correcting the curvature is more difficult then moving the hole to its normal location. Higher degrees of curvature cause more deficient development in the tissues at the bottom surface of the penis. These tissues should be completed by grafts and tissue transfer. In sum, Hypospadias surgery is a complicated one in both cases.
Advanced Level Hypospadias (Penoscrotal and Perineal)
Roughly stated, fifty percent of patients are born with front hypospadias and the other fifty percent are born with middle and rear section hypospadias. The hole is located at the perineum in the most advanced type of hypospadias. In these patients, the sac that hosts the testes (scrotum) has been divided into two as a congenital disorder. One testis or two testes may not be present at their locations in advanced type hypospadias patients (undescended testis). Genetic examination (karyotype), ultrasonography and hormone analysis are performed in terms of dual-gender. When required, we also examine the interior of the abdomen by telescopic tools (diagnostic laparoscopy).
The general rule especially for complex surgeries is that “the first surgery is the most successful one”. That is because the integrity of the tissues hasn’t been disrupted. Apart from the liver and the skin tissue (epithelium), all injures are healed not by renewing the original tissues by a filling material produced by the body (scar tissue). This bad scar tissue renders the second surgery more difficult. That is because while correcting the curvature, one should also clean the scar tissue. After badly conducted unsuccessful operation, one may not achieve good results despite many future surgeries performed thereafter. Only experienced surgeons achieve success.
No surgery on patients with complex hypospadias (who previously underwent unsuccessful hypospadias surgeries) is like each other. One should assess each case separately. A surgeon expert on this subject should know all surgery types, possess the command of tissue transfer methods and be experienced therein.
There is no drug treatment for hypospadias. No surgery may be required in cases where no curvature present and the hole is 1-2mm below normal. Because the patient urinates normally and there is no problem in penile erection. Performing hypospadias surgery at one or two years of age has been generally accepted. It is performed under general anesthesia. Patients can be discharged within one day. The purpose is correcting the curvature in the penis (orthoplasty), bringing the urinary channel to its normal location (urethroplasty and glanuloplasty) and to give the penis a flat and satisfactory cosmetic structure that allows sexual intercourse and sperm transfer. Special thin suture materials (6.0-7.0) and magnifiers are used during surgery.
Single-phase methods yield successful results in surgeries of hypospadias at the front and middle sections. Two-phased methods are more successful in advanced hypospadias. Trying to correct patients with advanced hypospadias in a single phase is a mistake. It usually fails. Later, operations that involve more than two phases are needed in experienced hands.
Surgeries of Front and Middle Hypospadias
Simple Hypospadias cases are those where the hole is close to the normal location, 4 layers above the urinary channel have developed normally and there is a small curvature. After mentioning front hypospadias surgery, we will talk about surgeries for advanced level Hypospadias and complex hypospadias.
More than 200 techniques have been recommended throughout the history of HYPOSPADIAS surgery. 8-10 pcs of them are popular today. The Hypospadias Surgery consists of 4 steps, which are correcting the penile curvature, constructing the urinary channel, shaping the glans (penis head), and reshaping the penis skin cosmetically.
First step of the surgery is rendering the penis flat (orthoplasty). The penis skin is incised all around from the bottom of the hypospadias hole (circumcision incision) and peeled till the organ’s root. On the other hand, the rear urinary channel, which is intact at the behind, should be peeled from the peripheral adherences until the perineum (radical bulbar proximal dissection). This allows that a penis, which seems small at the beginning due to curvature, reaches normal length by a correctional procedure. One frequent mistake is not performing this radical bulbar proximal dissection. Meaning that unsuccessful operations, physicians are only occupied with the missing tissue in front of the hypospadias hole and think that this is the sole reason behind curvature. But one shouldn’t forget that tissues below this hole are further causes of curvature and these should be cleaned. If the front (distal) and the rear (proximal) procedures are not made, curvature doesn’t fully ameliorate fully even if the deficiently formed urinary channel is successfully corrected. These patients can urinate normally but one cannot talk about a successful surgery. There can be no healthy sexual intercourse, as curvature isn’t corrected. And these patients are included in the group called “complex hypospadias”.
The second step of the surgery is repairing the deficient and defective urinary channel (urethra) (urethral reconstruction - neo urethra). The urethra base (urethral plate) of the upper tissue, which has developed healthy, is longitudinally incised with a depth of 1-2mm until the Hypospadias hole. Two sides are separated laterally for 3-4 mm and two strips are obtained. These strips are sutured with each other at the middle line from their edges. The incision is left open. This leaves a 3-5 mm gap at the back and a tube is formed at the back owing to the self-renewal feature of the epithelium tissue. This Snodgrass (TIPU) method, which is called by the name of person that invented it, opened a new age in Hypospadias surgeries. As it’s known, the epithelium (skin) and the liver are two exceptional tissues that repair themselves with original tissues when injured. Other tissue and organs renew themselves with scar tissue (filling material), not with their original tissues. As the interior surface of the urinary channel bears epithelium tissue characteristics, it renews itself with original tissue and this 3-4 cm gap creates a channel. We veil the front of this tube, which is previously constructed, by moving the peripheral tissues of the penis. In Snodgrass technique, a stricture may occur in the 3-4 mm gap during the rehabilitation phase. But while we patch the 3-4 mm gap with a graft taken from the mouth or the foreskin, we also circumvent this possible complication and therefore prevent the risk of stricture.
The third step of the surgery is correct the glans (penis head). The bottom surface of the glans is split in hypospadias patients. After the tube is constructed, the penis head wings that are split in two sides are joined at the middle line and this anatomic disorder is therefore corrected.
The fourth step of the surgery is to move the excessive skin and other tissues on the skin and therefore remove the gap in the tube and the bottom surface. We ensure integrity and therefore obtain a cosmetic penis.
What is a Complex Hypospadias?
Patients that previously underwent unsuccessful surgeries are called complex hypospadias cases. When unsuccessful operations cannot construct the urinary channel and correct the penis curvature, there is no tissue left around the genital organ, which we can use. These patients are stated to have complex hypospadias. We encounter patients with complex hypospadias at advanced ages as their previously underwent many surgeries and their penises couldn’t be corrected. Treatment is only possible by more experienced surgeons that are competent about tissue transfer.
The tissues surrounding the penis haven’t been developed depending on the degree of hypospadias. As the tissue is consumed during previous surgeries, complex hypospadias patients don’t have sufficient tissue remaining. In this case, we use the interior mouth mucosa, sublingual tissue, skin from the rear ear and bladder mucosa as grafts. Artificial tissues and grafts aren’t in practical use today. As the peripheral penis tissues are insufficient in patients with advanced level hypospadias and complex hypospadias, we frequently need grafts called skin grafts that are taken from the hairless zone.
The basic principle applied for patients with advanced level hypospadias and complex hypospadias is to transfer a sufficient amount of tissue. It is to correct the penis curvature and construct the urinary channel through this tissue transfer. The important thing is to possess a command of tissue transfer techniques.
Surgeries for Advanced Level Hypospadias and Complex Hypospadias
Performing advanced level hypospadias and complex hypospadias surgeries in two phases increase the success rate. The important factors for hypospadias are the degree of curvature and the development status of 4 layers that cover the urinary channel. Penis curvature can be between 30-120 degrees in advanced level hypospadias. Meaning that when the skin and the tissues thereunder are more underdeveloped, therefore more curvature is present, the patient has a higher level of hypospadias. Surgeries for advanced level hypospadias and complex hypospadias are similar in terms of constructing urinary tubes. The mouth mucosa is the most ideal graft (patch). It is taken from lips and the interiors of both cheeks. One frequently asked question is the rehabilitation phase of the wound in the mouth. The patients may orally take food the next day. There is no need to suture the graft-donor zone. It completely renews itself within one-two weeks. It poses no problems for the patient. This is especially used for constructing the urinary channel.
During the first phase of advanced level hypospadias surgery, we broadly lay a mouth mucosa to the bottom surface of the penis. Also, the abundant penis skin on the penis is moved to the lateral and bottom surface of the penis. In complex hypospadias cases, this procedure is performed after removing and cleaning all bad tissues associated with previous operations. Taking the graft, ensuring its union with the destination and its maintenance require separate skill and experience. During this state, we transfer sufficient volume of penis skin for the second surgery, meaning that we plan the procedure and transfer the tissue for the second phase during the first one. The waiting period for the second surgery depends on the union, softening and optimization of this tissue.
During the second surgery, the graft laid on the bottom surface of the penis is freed, joined at the middle line and given a tube shape. The top of this penis is covered by the penis skin and subcutaneous tissue.
The penis skin tissues, which were moved during the first phase, are coated on the tube that was created during the second phase in order to strengthen it as a second layer and to cover the penis.
Treatment is much more difficult for patients that have undergone various unsuccessful surgeries. It requires the complete repair of the penis again. If there is insufficient skin to cover the penis after the tube is created, the penis skin is then created by taking skin grafts from hairless regions of the body (both groins etcetera).