Hypospadius - CWU 130

What are the 4 main theories to explain the cause of congenital chordee WITHOUT hypospadius

1) Skin tethering 2) Fibrotic Dartos & Buck's fascia 3) Corporal disproportion 4) congenitally short urethra (rare)

Ideal timing of hypospadias repair?

AAP - 1996 recommends 6-12 mo, more complications in older patients

What is the classification of hypospadius?

Based on location of hypospadic meatus AFTER repair of chordee (orthoplasty): 1) Anterior (distal): glanular, coronol, subcoronal (50-70%) 2) Middle: distal penile, midshaft, proximal (30%) 3) Posterior (proximal): penoscrotal, scrotal, perineal (20%)

What is the importance of assessing penile curvature?

Critical step in hypospadius repair - usually performed after degloving penile shaft skin. Artificial erection (NS) vs pharmacologic erection (PGE1)

What are indications to evaluate for endocrine abN and/or intersex

Hypospadius + UDT Isolated posterior hypospadius

Options for MIP (Megameatus intact prepuce)?

"Pyramid" procedure MAGPI Thiersch-Duplay Mathieu flap

What is the evaluation of child with hypospadius?

- Hx: diff voiding, degree of curve, UTIs, antenatal hx + med exposure, Dev hx, PMHx, meds, FHx hypospadius - P/E - Growth chart, abdo exam (masses, SP/flank tenderness, bladder), external genitalia (micropenis, meatal location, deficiency of spongiosum, hernia, hydrocele and UDT) - Intersex eval if necessary - for those with posterior hypospad and/or UDT - Imaging - no routine if isolated hypospad, if posterior can consider VCUG - Pre-op hormone manipulation - controversial - stimulation (hCG) vs supplementation (T, DHT) vs nothing, increases penile size and length (~50%) allowing for more simple repairs

Describe a Koyanagi flap

- Set up as previous flap procedures 1) Triangle-shaped incision including hypospadiac meatus, preputial skin, and circumcision incision around glans (button hole) 2) divide prepucial flap 3) rotate and perform ventral onlay-type flap procedure on existing urethral plate 4) 2 layers 5) coverage

What are the 3 main theories to explain the cause of congenital chordee WITH hypospadius?

1) AbN development of urethral plate - Snodgrass disagrees 2) AbN fibrotic mesenchymal tissue at urethral meatus 3) corporal disproportion - differential growth of N dorsal cavernosal tissue & abN ventral tissue

What are the indications for hypospadius repair?

1) Allow micturition in a standing position 2) Allow sexual intercourse 3) Allow effective insemination 4) Cosmesis

Describe the main steps of a MAGPI distal hypospadias repair

1) Circumferential subcoronal incision - made 5mm prox and parallel to corona 2) If present, the typical transverse glanular "bridge" in the urethral plate is incised longitudinally 3) Incised bridge is then reapproximated transversely in Heineke-Mikulicz fashion 4) Ventral edge of meatus is pulled distally (with aid of stay suture) and medial edges of glans are then trimmed 5) Midline approximation of glans edges in 2 layers with simple, interrupted suture 6) Superficial approximation of glans and skin with simple interrupted sutures

What are the 5 basic principles important in hypospadius repair?

1) Correction of penile curvature (Orthoplasty) 2) Urethroplasty 3) Meatoplasty 4) Glanuloplasty 5) Skin coverage

What is the recommended approach to hypospadias repairs?

1) Deglove penile shaft skin + preserve urethral plate 2) Assess degree of curvature prior to formal repair: no chordee = 1-stage urethroplasty, mild-to-mod chordee = orthoplasty + 1 stage urethroplasty, severe chordee = orthoplasty +/--transverse release of tethering urethral plate + 1-or2-stage urethroplasty 3) 2nd layer neourethral coverage 4) Meatoplasty + glanuloplasty + skin coverage

what are the management options for hypospadias?

1) Distal - Advancement (MAGPI), tubularization (TIP, Thiersch-Duplay), Flaps (Mathieu) 2) Middle - Tubularization (TIP), Flaps (Mathieu, Only flaps - OIF, Split-prepuce OIF) 3) Proximal - Single stage (Flaps - OIF, onlay-tube-onlay; tubularization - duckett TPIF, Koyangi), 2-stage urethroplasty

What are some long-term issues post-hypospadias?

1) Gender Identity issues - hypospadias NOT assoc with abN gender-role behaviour, DOES NOT interfere with development of gender-typical masculine behaviour. Proximal +/- UDT raises question of intersex 2) Cosmesis - ~40% of kids & adolescents desire functional and/or cosmetic penile improvements 3) Psychosexual issues - hypospadias pts more likely to have negative genital appraisal, 2x more likely to aviod seeking sexual contact 4) Urine flow - Uroflowmetry is valuable in identifying asymptomatic urethral strictures in some pts, low flow rates often seen post-TIP 5) sexual fn & fertility - relatively N adult sexual function and fertility, less sexually active, have a smaller # of partners and seem to be less satisfied with sex life

What are some important surgical principles to consider during hypospadias repair?

1) Hemostasis - use biopolar sparingly - monopolar dispered along vessels, too much can cause necrosis and fistulae 2) Suture type & technique - delicate forceps, accurate placement of neourethral sutures to ensure inversion of edges of epithelial surfaces, fistula rate might be lower with subcuticular suturing, 4x higher stricture rate with PDS 3) Catheter placement - there may be NO advantage to placement of urethral catheter for most distal repairs, may be better for TIP procedures 4) Dressings - seems to be little or no advantage to application of a dressing post-hypospadias repair, no dressing + abx ointment may be adequate - increased comfort and easier care

What are the different approaches to re-do hypospadias repair?

1) Immediately adjacent or local tissue flaps (preferred) - a) TIP urethroplasty - excellent option, 90% success; complications of 15-30% in redo. Ideal in redos as native vascularity of urethral plate has not been altered, and no need for additional flaps (so lack of prepuce not an issue) -b) OIF - 15% complications vs 10% in primary -c) Mathieu flap - 25% complication vs 1% primary -d) TPIF - 25% complication 2) Free graft with local or extragenital tissue - a) Tubularized free skin graft urethroplasty - b) free graft buccal or bladder mucosa; onlay vs tubularized, 1st stage buccal onlay + 2nd stage tubularization - 20-25% complication rate, for more severe re-do cases 3) 1st stage meshed STSG + 2nd stage tubularization with tunica vaginalis flap - last resort

Main options for neourethral formation?

1) Immediately adjacent tissue transfer (simple TIP) 2) Local tissue flaps (need to be thin, non-hirsute and reliably tailored - island vs peninsula flaps); fasciocutaneous flaps (Dartos) - vessels preserved, axial blood supply and drainage provided by branches of deep & superficial external pudendal vessels (medial branches of femoral) 3) Local or extragenital free grafts - Optimal graft survival depends on well-vascularized recipient site, 48 hrs of imbibition followed by 48 hrs of insoculation

Describe the main steps of a Mathieu flap for distal hypospadias

1) Measure length of defect - from meatus to tip of glans 2) Equal legnth from meatus onto proximal penis 3) Marked, inj with dilute epinephrine 4) circumferential subcoronal incision from lateral edges of marked urethral plate 5) Penile skin degloved 6) glans wings incised deeply, orthoplasty prn 7) Flap is elevated from penile vetrum in a proximal to distal direction 8) flap folder over at meatus and sutured to urethral plate with running subcuticular sutures 9) Tubularized over 6 Fr catheter 10) Dorsal sc pedicled flap harvested, divided in midline 11) one half dartos flap over neourethra, maturation of meatus, skin coverage

What are the Delayed complications following a hypospadias repair

1) Meatal stenosis - usually d/t technical issues. Tx - meatal dilation/meatotomy if mild, complex flap procedure if concomitant complex distal stricture. 2) Urethrocutaneous fistula - may be assoc w/ distal urethral stricture, meatal stenosis, tissue ischemia, failure to add 2nd layer coverage and/or failure to invert epithelial edges. 2nd layer coverage significantly reduces rates. Tx - larger or multiple fistulae may require incision and delayed repeat repairs 3) Urethral strictures - more common with proximal repairs. Tx - 50% successful treatment by cold knife (VIU), extensive stricture may require free graft or vascularized flap, mucosal or meshed STSG are other options 4) Urethral diverticulum - uncommon, may be assoc with distal stricture or meatal stenosis. Tx - repair by circumferential skin incision + degloving, diverticular excision, urethral closure & "pants over vest" sc tissue coverage 5) Recurrent chordee - likely due to either extensive fibrosis of reconstructed urethra, corporeal disproportion or both 6) BXO - may present with difficult micturition, meatal stenosis, or neourethral stricture. Tx - repair should involve use of bladder or buccal mucosal free grafts 7) Intraurethral hair - only occurs when hirsute skin is used. Tx - laser ablation of hair

4 main factors to consider when determining the appropriate repair for hypospadias?

1) Native meatal location 2) Penile size 3) Penile curvature 4) Characteristics of ventral, proximal shaft skin

What are some current trends in hypospadias repair?

1) Preservation of urethral plate if possible 2) Completion of repair in 1-stage whenever possible, 2-stage repair for very severe hypospadias & re-do cases 3) Use of SIS interposition graft to correct severe chordee is gaining popularity 4) TIP urethroplasty gaining popularity for primary & re-do repairs of distal & middle hypospadias 5) OIF also being used more often (lower rate of fistula relative to TPIF, Split prepuce In-situ Onlay variation of OIF also becoming popular 6) Preference for onlay (vs tubularized) techniques 7) Increased use of pedicled, vascularized onlay flaps rather than free grafts 8) For hypospadias w/ deficient ventral skin, buccal mucosa is preferred material

Management of chordee with or without hypospadius?

1) Release of skin tethering (+/- skin transfer) - mild 2) Nesbit (shortens penile length - corrects glans tilt) 3) Heineke-Mikulicz (trans incisions in tunica on shorter side closed longitudinally to gain length) 4) Tunica albuginea plication (Baskin & Duckett) 5) Corporal rotation (Koff & Eakins) - ventral midline incision + medial rotation of corpora + suture fixation - single-stage recon w/o shortening length 6) Grafts - Dermal (ideal for short phallus with severe chordee), SIS interposition (for severe ventral chordee), tunical vaginalis free graft (severe chordee - can use as ventral corporal patch) 7) Total penile disassembly -ideal for correctio of glans tilt, bentral chordee w/o hypospadias and chordee with hypospadias

Describe the main steps of a TIP urethroplasty

1) Suture in glans 2) Outlie urethral plate - usually 7-9mm 3) Dilute epinephrine inj deep to site of incision 4) parallel longitudinal incisions from tip of glans to hypospadic meatus demarcating urethral plate 5) transverse incision made across skin overlying urethra - proximally to complete U-shaped incision 6) Deglove penis, orthoplasty prn 7) longitudinal midline incision of urethral plate from lvl of hypospadiac meatus to tip of penis as necessary 8) urethral plate tubularized over 6 Fr silastic catheter 9) wide meatus 10) 2nd layer coverage of neourethra with well-vascularized sc dartos flap harvested from dorsal preputial and shaft skin 11) Glans wings approximated, skin coverage

Describe the main steps of an OIF repair for middle hypospadias defects

1) Traction suture 2) Urethral plate measured and marked (6mm) 3) Parrallel longitudinal incision outlining urethral plate from hypospadiac meatus to glans tip 4) circumferential incision in distal penile shaft from lateral edges of plate 5) Orthoplasty prn 6) Defect measured 7) same legnth defect is harvested as rectangular onlay from preputial skin (peidicled) 8) Rectangled flap rotated longitudinally and passed to ventrum - tubularization over 6 Fr silastic with 6-0 Dexon 9) 2nd layer coverage of neourethra with advancement of inferolateral border of onlay pedicle or tunica vaginalis flap 10) Maturation of meatus 11) glans approximation and skin closure

Describe the main steps of a TPIF (Duckett tube) for proximal hypospadias defects

1) Traction sutures in glans and prepuce 2) Ventral midline longitudinal cut from hypospadiacc urethral meatus to distal circucising incision 3) Penile shaft degloved 4) Division of urethral plate PRN + orthoplasty prn 5) Length from urethral meatus to glans tip measured 6) Same legnth of a transversely oriented rectangle of preputial skin is harvested (15mm wide) 7) Once inner prepuce is dissected from outer layer, flap is tubularized 8) Neourethral anastomosis made with running, subQ suture and then inverting Lembert suture for 2nd layer 9) Neourethra transferred to penil ventrum on tension-free pedicle - oriented so suture line is facing ventral surface of corpora 10) Dorsal aspect of native meatus is fixed to ventrum of cavernosa before being anastomosed with neourethra 11) Small circular incision is marked in glans at proposed site of neomatus 12) Wide channel is fashioned around 18Fr sound to accomadate passage of distal neourethra 13) core of glans excised to achieve sufficient caliber, or deep midline incision and advancement 14) Proximal anastomosis first, and distal end passed through glans channel - fixed to glans 15) Meatus matured 16) Dartos flap used as 2nd layer, coverage of neourethra, silastic catheter secured to glans & skin closed

What are the optiosn for meatal & glanular reconstruction for hypospadias repair?

1) V-flap glanuloplasty - adjunct to tubularized skin graft urethroplasty, extensive dissection of glans w/ development of midline anterior flap of glans epithelium, removal of subepithelial tissue from glans flap, flap fixed to tunica of corpora, makes widely patent complication-free meatus 2) Double-faced preputial flap - flap transposed ventrally for enhancement of glans and meatus, for small and deformed glans 3) Glanular W-flap meatoplasty

What are options for ensuring adequate skin coverage after hypospadias repair

1) Ventral transfer of preputial skin - either with buttonhole through skin for through-passage of glans, or midline longitudinal split of prepuce or dosal penile skin + lateral transfer 2) Transverse outer preputial island flap

Describe the main steps of a split prepuce in-situ OIF for middle hypospadias defects

1) stay suture in glans 2) Prepuce is s;lit in dorsal midline and penile shaft skin degloved 3) Urethal plate outlined 4) Island onlay flap is harvested from one half of the split prepuce 5) Onlay flap sutured to urethral plate starting with a running 7-0 Dexon full thickness than completed with subcuticular running suture 6) Neomeatus matured 7) Edges of vascularized onlay pedicle are secured lateral to the nonurethral suture line as 2nd layer coverage 8) Repair is completed with skin coverage and securing of 8Fr silastic catheter to glans

What are the Peri-operative complications following a hypospadias repair

1)Bleeding/hematoma (most common) - can lead to infection or repair breakdown, think about bleeding disorder if excessive. Tx - start with compressive dressing, may require exploration & evacuation of hematoma 2) Wound infection - uncommon, Tx - if suspected, culture, ABx, I&D prn and debride prn 3) Breakdown of repair - due to ischemia of local tissue or graft/flap, repair under tension, excessive cautery use, hematoma formation. Tx - need to debride all necrotic tissue before repair 4) Urinary retention - if no catheter used

How common is hypospadias?

1/250 live male births Majority are distal Rate of hypospadius increasing (not just d/t mild forms reported) - Familial prevalence: 6-8% fathers of affected boys have hypospadius; 14% male siblings of affected boys have hypospadius - 8.5x more common in one of monozygotic male twins compared iwth singleton live male births, may be due to inability of single placenta and lower hCG levels to meet requirements of 2 developing male fetuses

How common are chromosomal abnormalities in boys with hypospadius?

6% of boys with hypospadius - majority found in severe 5% of boys with UDT 22% of boys with hypospadius + UDT: Must r/o intersex state in these boys even if not ambiguous; 30% of boys with hypospadius + UDT + NON-ambiguous genitalia are intersex; and 3x more likely intersex if testes are impalpable; and more common with proximal hypospadius

What is hypospadius?

Association of 3 anomalies of the penis: 1) abN ventral opening of urethral meatus 2) AbN ventral chordee (variable presence - 25%) 3) AbN distributio of foreskin with dorsal "hood" and deficient ventral foreskin (variable)

How is bladder and buccal mucosa harvested?

Bladder - bladder distended with saline and detrusor muscle dissected off underlying mucosa, rectangular donor site harvested (10% greater than size of defect) - if combined with distal tubularized skin or buccal mucosa, can take 1:1 Buccal - GA with nasotracheal intubation, diluted epi injected submucosally. Appropriate-sized graft taken from mucosa of cheek and/or lip; avoid Stensen's duct, mucosa harvested superficial to buccinator muscle. Close edges with 5-0 chromic

When is the ideal time to re-operate for comlications post-hypospadias repair?

Bleeding, infection or debridement-->Immediate re-explor Re-operatione for all other complications should be delayed for at least 6 mo

What are the options for neourethral coverage (2nd layer)?

Decreases rate of urethrocutaneous fistula 1) Subcutaneous dartos flap - can be raised from dartos layer underlying dorsal prepuce; can be raised laterally too 2) Tunica vaginalis flap - first advance inferolateral border of neourethral mesentary over edges of neourethra, testis delivered into operative field and gubernacular attachments release, tunica vag incised and flap isolated and widely mobilized on vascular pedicle, flap secured over neourethra, testis replaced in scrotum 3) corpus spongiosum - for distal hypospadias repair, paraurethral (spongiosal) tissue approximation in midline

What are the 5 classes of congenital chordee WITHOUT hypospadius?

Devine and Horton - 73 1) Very thin "mucaous membrane" urethra + deficiency of corpus spongisum from site of curvature out to glans (severe) 2) urethra surrounded by N spongiosum with abN Buck's & dartos fascia 3) abN dartos fascia only 4) Corporal disproportion 5) Congenitally short urethra

What is the management of post-op erections & bladder spasm?

Erections - can use epidural PCA, ketoconazole (monitor for hepatotoxicity), amyl nitrate, valium Bladder spasms - judicious use of anti-choilnergics in catheterized patients

Describe a 2-stage proximal hypospadias repair

First stage = orthoplasty + transfer of healthy tissue to ventral shaft - ventral incision to circumcision incision, deglove & orthoplasty - Preputial skin may all be required for skin coverage afterwards. - Flap and free grafts placed ventrally Second stage = performed > 6 mo after 1st stage - urethroplasty, meatoplasty, glanuloplasty, skin coverage - basically thiersch-Duplay fashion - Can free graft as needed to augment plasty

what is the ideal anesthetic/analgesic for hypospadias repair?

GA + locoregional anesthetic better than pre-op alone Caudal or dorsal nerve block

What is a hypospadias cripple?

Hx of multiple, unsuccessful hypospadias repair attempts, with significant resultant penile deformity. Very difficult b/c they require extensive repair amid scarred and devitalized tissue

What tests are involved in the evaluation of a cihld with hypospadius for endocrine AbN'ity or intersex?

Lab: Karyotype, molecular testing, biochemi, gonadal (histology) testing - abN karyotype found in 20% hypo +UDT Imaging: U/S + Genitography, pre-op VCUG +/- cysto if concomitant scrotal or perineal defect

What is the role of pre-op androgen supplementation/replacement?

Mainly for small peis - usually assoc with prox hypospad Testosterone ointment x2wk pre-op (inconsistent results) q1wk IM testosterone (2mg/kg/dose) for 2-3wk pre-op (increase penile size and available skin and local vascularity), daily DHT cream x 4 wks pre-op Pre-pubertal exogenous testosterone DOES NOT adversely affect ultimate penile growth

what is the role of pre-op androgen stimulation?

May decrease degree of hypospadias & chordee, improve tissue quality * allow for more simple repair Twice weekly sc or im hCG (250 or 500 IU) for 6-8 wk pre-op; for kids < 5 yo , may see increase in penile size & length and a decrease in hypospadias & chordee severity, may notice increased vascularity & thickness of proximal corpus spongiosum

What are the general principles of re-do hypospadias repair?

Minimum wait time is 6 mo after previous failed repair, no attempts at repair until all edema, infection and/or inflammation has resolved, RUG +/- VCUG may be needed in complex re-do hypospadius repairs, assess adequacy of local tissue vs need for extragenital tissue grafts

How is hypospadius diagnosed?

Most found at newborn P/E, may be missed in: a) Milder forms of hypospadius b) non-retractile prepuce c) Megameatus intact prepuce variant (MIP) - likely distal invagination problems - isolated hypospadius may be only visibile indication of significant abN'ity

Etiology of hypospadius?

Multi-factorial: a) Environmental or endocrine disruptors: earlier maternal progestin use with prox hypospadius, more common in IVF b) Endocrinopathy, enzymatic abN'ity or local tissue abN'ity - abN androgen production by fetal testis, parital AIS in target tissues (Reifenstein's), insufficient T and/or DHT synthesis (defective/deficient 5AR), defective androgen receptor quality and/or quantity, 3-beta-hydroxysteroid dehydrogenase deficiency (produces profound CAH) assoc incomplete masculine development & hypospadius c) Manifestation of arrested development (most plausible) - premature cessation of T/DHT stimulation secondary to premature involution of fetal leydig cells

What is the "endodermal differentiation theory"?

Opposes ectodermal ingrowth theory - States urethral plate extends distally all the way to tip of phallus & maintains patency & continuity throughout urethral development - States entire urethra originates from UG sinus/ecdoderm - Endodermal tissue can differentiate distally into stratified squamous epithelium with proper signalling

Describe embryologic development of urethral plate and urethra

Origin of plate is an outgrowth from walls of cloaca and UG sinus 4th wk - urethral plate seen as thickening of anterior wall on endodermal cloaca Primary urethral groove established by development of urethral folds on the ventrum of the phallic portion of the UG sinus on either side of urethral plate - covered by surface epithelium 8th wk - Secondary urethral groove - after disintegration of roof of primary groove - leads to definitive urethral groove 9th wk - preputial tissue exists as dorsal hood 11th wk - Increased leydig cell fn (more T) results in fusing of urethral folds ventrally in midline to form urethra: proximal glanular urethra from urethral plate (endodermal), distal glanular urethrla from lamellar ingrowth (ectodermal origin) 20th wk - complete preputial covering of glans

Describe the embryologic development of the neurovascular anatomy of the penis

Similar innervation but different vascularity (particularly distally) Nerves: originate prox as 2 well-defined bundles under pubic rami superior and slightly lateral to urethral, as 2 crural bodies converge to form corpus cavernosa, nerve diverge to enter junction between corpora cavernosa & urethral spongiosum, nerves fan out from 11 and 1-o'clock all along penis - no nerves at 12-o'clock Vascularity - extensive vascularity of distal urethral spongiosum & glans in hypospadic penises - incision into these rich endothelial-lined sinuses may result in release of EGFs that encourage tissue repair w/o significant scar/stricture

List anomalies associated with hypospadius?

UDT (7-9%) - mainly in boys with posterior hypospadias Inguinal hernia/hydrocele - 10-15% - 49 different clinical syndromes (WAGR, Fraser's, Beckwith-Wiedemann, Simpson-Golabi-Behmel, Schizel-Diedion) - 80% also assoc with micropenis, scrotal abN'ity and UDT - Supports enocrinopathic cause of hypospadius - NO NEED TO ASSESS UPPER TRACTS - not assoc with renal anomalies

What are the preferred urethroplasty techniques used for the different types of hypospadias?

Use of well-vascularized local tissue is preferred During orthoplasty, when possible, should preserve urethral plate for incorporation into urethroplasty 1) Distal - repair with advancement technique; if simple advancement not possible, consider tubularized (TIP) or flap (perimeatal-based flap techniques if shallow glanular groove) 2) Middle - tubularization or vascularized flap techniques 3) proximal - tubularization or flap or 2-stage techniques

Describe a Barcat Balanic Groove Flap technique for hypospadias repair

Very similar to Mathieu flap, with inclusion of dissection of urethral plate distal to meatus + advancement of approximated (now tubularized) flaps to tip of glans 1) Measure length of defect - from meatus to tip of glans 2) Equal legnth from meatus onto proximal penis 3) Marked, inj with dilute epinephrine 4) circumferential subcoronal incision from lateral edges of marked urethral plate 5) Penile skin degloved 6) glans wings incised deeply, orthoplasty prn 7) Flap is elevated from penile vetrum in a proximal to distal direction 8) dissection of urethral plate distal to meatus + advancement of approximated (now tubularized) flaps to tip of glans 9) flap folder over at meatus and sutured to urethral plate with running subcuticular sutures 10) Tubularized over 6 Fr catheter 11) Dorsal sc pedicled flap harvested, divided in midline 12) one half dartos flap over neourethra, maturation of meatus, skin coverage

Describe a Thiersch-Duplay urethrplasty for hypospadias

Very similar to TIP urethroplasty, without the incision of the urethral plate 1) Suture in glans 2) Outlie urethral plate - usually 7-9mm 3) Dilute epinephrine inj deep to site of incision 4) parallel longitudinal incisions from tip of glans to hypospadic meatus demarcating urethral plate 5) transverse incision made across skin overlying urethra - proximally to complete U-shaped incision 6) Deglove penis, orthoplasty prn 7) urethral plate tubularized over 6 Fr silastic catheter 8) wide meatus 9) 2nd layer coverage of neourethra with well-vascularized sc dartos flap harvested from dorsal preputial and shaft skin 10) Glans wings approximated, skin coverage

Why does the "arrested development" theory of hypospadius make sense?

When meatus is still proximally located, dorsal hood exists and penis is curved Penile curvature is part of early stages of N penile dev Dorsal hood is present early in N penile development

What is recommended ABx regimen for hypospadias?

single broad-spectrum IV dose pre-op if being catheterized Post-op prophylactic keflex until catheter removed - decreases incidence of febrile UTIs