Hypospadias Surgery: An Illustrated Textbook

Foreword to the Second Edition
Foreword to the Second Edition
Preface to the Second Edition
Preface to the First Edition, 2004
Foreword to the First Edition, 2004
Foreword to the First Edition, 2004
Art Designers Acknowledgement
Contents
Contributors
Part I: General and Basic Science
	1: History of Hypospadias
		1.1	 Introduction
		1.2	 Evolution of Hypospadias Repair Techniques
			1.2.1	 The Early Period: The Period of Stretching and Glue
			1.2.2	 The Renaissance or Middle Ages Period: The Period of Tunneling
			1.2.3	 The Modern Period: The Period of Urethroplasty
		1.3	 Grades of Hypospadias
			1.3.1	 Grade I or Glanular Hypospadias (Q54.0)
			1.3.2	 Grade II or Distal Hypospadias (Q54.1)
			1.3.3	 Grade III or Proximal Hypospadias Without Severe Deep Chordee (Q54.2)
			1.3.4	 Grade IV or Perineal Hypospadias with Severe Deep Chordee (Q54.3)
			1.3.5	 Grade V or Cicatricial or Crippled Hypospadias
		1.4	 Chordee (Penile Curvature)
		1.5	 Stages of Repair
		1.6	 Suture Materials
		References
	2: Men Behind Principles and Principles Behind Techniques
		2.1	 Short List of Men Behind Principles
		2.2	 Abnormal Ventral Curvature of the Penis (Chordee) and Orthoplasty
		2.3	 Abnormal Proximal Meatal Insertion and Urethroplasty
			2.3.1	 Urethral Mobilization
			2.3.2	 Use of Ventral Skin Distal to the Meatus
		2.4	 Use of Ventral Skin Proximal to the Meatus (Meatal-Based Flaps)
			2.4.1	 Use of Preputial Skin
			2.4.2	 Combined Use of Prepuce and Skin Proximal to the Meatus
			2.4.3	 Use of the Scrotum
			2.4.4	 Use of Dorsal Penile Skin
			2.4.5	 Use of Grafts
		2.5	 Use of a Protective Intermediate Layer
		2.6	 Abnormal-Looking Glans Penis and Glanuloplasty and Meatoplasty
		References
	3: Normal Development of the Penis and Urethra
		3.1	 Introduction
		3.2	 The Cloaca
			3.2.1	 Development and Fate of the Cloacal Membrane
			3.2.2	 Development of the Urogenital Fold
			3.2.3	 Development of the Urogenital Plate
			3.2.4	 Development of the Male Penile (Spongy) Urethra
				3.2.4.1	 Penile Urethra
				3.2.4.2	 Glanular urethra
		3.3	 Discussion
			3.3.1	 The Fate of the Cloacal Membrane
			3.3.2	 The Penile (Spongy) Urethra
			3.3.3	 The Glanular Urethra
			3.3.4	 The Median Perineal Raphe
		3.4	 The Migration Hypothesis
		3.5	 Conclusion
		3.6	 Derivatives of the Genital Tubercle
			3.6.1	 The Glans
			3.6.2	 The Corpora Cavernosa
			3.6.3	 The Corpus Spongiosum
		3.7	 Development of the Fascial Stroma
		3.8	 Development of the Median Perineal Raphe and Septum
		3.9	 Development of the Scrotum
		3.10	 Development of the Prepuce and Frenulum
		3.11	 Derivatives of the Mesonephric and Paramesonephric Ducts
		References
	4: Surgical Anatomy of the Penis and Urethra
		4.1	 Introduction
		4.2	 The Root of the Penis
		4.3	 The Body of the Penis
			4.3.1	 Coverings of the Penis
			4.3.2	 The Corpora Cavernosa
			4.3.3	 The Corpus Spongiosum
			4.3.4	 The Bulbospongiosus Muscle
			4.3.5	 The Penile (Spongy) Urethra
		4.4	 The Glans
			4.4.1	 Dimensions of the Glans
			4.4.2	 Glans-Penis Ratio
			4.4.3	 Fossa Navicularis
			4.4.4	 The External Urethral Meatus
		4.5	 The Prepuce
		4.6	 The Frenulum
		4.7	 The Median Raphe
		4.8	 Nerve Supply of the Penis
			4.8.1	 Somatic Innervation
			4.8.2	 Autonomic Innervation
			4.8.3	 Neurovascular Bundle
		4.9	 Suspensory Ligaments
		4.10	 Normal Size of the Penis
			4.10.1	 Normal Size of the External Genitalia in Adults
			4.10.2	 Anoscrotal Distance (ASD) (Figs. 4.13 and 4.14)
			4.10.3	 Penile Length
			4.10.4	 Tanner Classification of Sexual Maturity Stages in Boys (Fig. 4.16)
		4.11	 Blood Supply of the Skin of the Penis and Prepuce
			4.11.1	 Preputial Arterial Supply and Venous Drainage
			4.11.2	 Surgical Considerations
		4.12	 Conclusions
		References
			Suggested Readings
	5: Altered Development of Prepuce in Hypospadias and Its Clinical Relevance
		5.1	 Introduction
		5.2	 Theories of Preputial Development
		5.3	 Characteristics of Male Genital Skin in Different Genital Locations (Table 5.1)
		5.4	 COVER Technique for Skin Reconstruction in Hypospadias Repair (COVER: Cobra eyes’ Ventral Reapproximation)
		References
	6: Morphology of Hypospadias
		6.1	 Introduction
		6.2	 The Glans
			6.2.1	 Glans Dimensions in Hypospadias
		6.3	 The Meatus
		6.4	 The Urethral Plate
		6.5	 The Prepuce
		6.6	 The Proximal Penile Urethra
		6.7	 Corpus Spongiosum
		6.8	 Bulbospongiosus Muscle
		6.9	 The Penoscrotal (Median) Raphe
		6.10	 Penile Torsion
		6.11	 Size of the Penis
		6.12	 The Scrotum
		6.13	 Anoscrotal Distance (ASD)
		6.14	 Suprapubic Fat
		6.15	 The Testis
		6.16	 The Prostate
		6.17	 Other Associated Anomalies
		References
	7: Pathogenesis of Hypospadias: The Disorganization Hypothesis
		7.1	 Introduction
		7.2	 Normal Urethral Development (The “Migration Hypothesis”)
		7.3	 The Glans
		7.4	 Penile Urethra
		7.5	 The Urethral Plate
		7.6	 Chordee
		7.7	 The Corpus Spongiosum
		7.8	 The Corpus Cavernosum
		7.9	 The Prepuce and Frenulum
		7.10	 Median Raphe
		7.11	 Torsion and Rotation
		7.12	 Megameatus Intact Prepuce (MIP)
		7.13	 Penoscrotal Transposition and Bifid Scrotum
		7.14	 Anoscrotal Distance (ASD)
		7.15	 Discussion
		7.16	 Disorganization Hypothesis (Fig. 7.28)
		References
	8: The Urethral Plate and Chordee
		8.1	 The Urethral Plate
			8.1.1	 Introduction
			8.1.2	 Definition of the Urethral Plate
				8.1.2.1	 Medical Dictionary Definition
				8.1.2.2	 Embryological Definition
				8.1.2.3	 Anatomical Definition
				8.1.2.4	 Surgical Definition
				8.1.2.5	 Other Definitions
			8.1.3	 Morphology of the Urethral Plate
			8.1.4	 Epithelial Lining of the Normal Urethra and the Urethral Plate
			8.1.5	 Quality of the Urethral Plate
			8.1.6	 Width of the Urethral Plate
			8.1.7	 Variations of the Urethral Plate in a Single Patient
			8.1.8	 Histology of the Urethral Plate
			8.1.9	 Effect of Age on the Urethral Plate
		8.2	 Chordee (Penile Curvature)
			8.2.1	 Introduction and Origin of the Term Chordee
			8.2.2	 Definition
			8.2.3	 Surgical Anatomy of Penile Fascia
				8.2.3.1	 Normal Fascial Coverings of the Penis
			8.2.4	 Morphology of Chordee
			8.2.5	 Is There a Chordee Tissue?
			8.2.6	 Histology of the Chordee
			8.2.7	 Etiology of Chordee
			8.2.8	 Erection Tests
			8.2.9	 Grades of Chordee
			8.2.10	 Is the Penile Curvature an Angle or an Arc?
			8.2.11	 How to Measure the Chordee Angle?
			8.2.12	 When to Correct Chordee?
			8.2.13	 Frankfurt Protocol of Chordee Correction
				8.2.13.1	 Timing of Chordee Correction: Early Correction of Chordee at 6 Months
				8.2.13.2	 Intraoperative Assessment and Planning
				8.2.13.3	 Ventral Degloving of the Penis
				8.2.13.4	 Tunica Albuginea Externa Excision (TALE)
					Assessment of Curvature After the TALE Procedure
					Tunica Vaginalis Flap (TVF)
				8.2.13.5	 Abdominal Wall Fixation
			8.2.14	 Chordee Without Hypospadias and Paper-Thin Urethra
			8.2.15	 Glanular Tilt
			8.2.16	 General Principles of Chordee Correction
				8.2.16.1	 Techniques That Lengthen the Ventral Side of the Penis
					Tunica Albuginea Longitudinal Excision (TALE)
					Fairy Cuts
					STAG and STAC Procedure
					Incision of Tunica Albuginea and the Use of Grafts or Flaps
				8.2.16.2	 The Use of Dermal Grafts
				8.2.16.3	 The Use of Small Intestinal Submucosa (SIS)
				8.2.16.4	 The Use of Buccal Mucosa
				8.2.16.5	 Tunica Vaginalis Grafts or Tunica Vaginalis Flap (TVF)
				8.2.16.6	 Techniques That Shorten the Dorsal Side of the Penis (Fig. 8.54)
					Nesbit Procedure
					Tunica Albuginea Plication (TAP)
					Heineke-Mikulicz Technique
			8.2.17	 Does Dorsal Plication Produce Shortening of the Penis?
				8.2.17.1	 Penile Disassembly Technique
			8.2.18	 Dissection of the Urethral Plate/Urethra
			8.2.19	 Dissection of the Neurovascular Bundle
			8.2.20	 Total Urethral Mobilization
			8.2.21	 Split and Roll Technique
			8.2.22	 Recurrent/Persistent Chordee in Adolescents and Young Adults (Fig. 8.62)
		References
	9: Classification and Assessment of Hypospadias
		9.1	 Introduction
		9.2	 Anatomical Classifications of Hypospadias
		9.3	 Why Do We Need to Classify Hypospadias?
		9.4	 Factors that Influence Outcome of Hypospadias Surgery
			9.4.1	 Site of Meatus (M)
			9.4.2	 Chordee (C)
			9.4.3	 Type and Size of the Glans (G)
			9.4.4	 The Urethral Plate (U)
		9.5	 The Hypospadias International Score (MCGU)
		9.6	 The Hypospadias Operative Checklist (HOC)
		9.7	 Postoperative Assessment
		References
	10: Epidemiology of Hypospadias
		10.1	 Prevalence
		10.2	 Etiology of Hypospadias Is Multifactorial
		10.3	 Testicular Dysgenesis Syndrome
		10.4	 Estrogen Hypothesis
		10.5	 The Role of Environmental Factors in the Etiology of Hypospadias
			10.5.1	 Exogenous Exposure to Estrogens
				10.5.1.1	 Oral Contraceptives
				10.5.1.2	 Assisted Reproductive Technology
		10.6	 Endogenous Hormone Levels
			10.6.1	 Endogenous Estradiol Levels
			10.6.2	 Placental Insufficiency
		10.7	 Clinical Factors
			10.7.1	 Pregnancy Complications
			10.7.2	 Maternal Drug Use
			10.7.3	 Maternal Intrauterine DES Exposure
		10.8	 Behavioral Factors
			10.8.1	 Parental Age
			10.8.2	 Maternal Diet
			10.8.3	 Other Lifestyle Factors
		10.9	 Occupational Factors
			10.9.1	 Exposure to Pesticides
			10.9.2	 Other Occupational Exposures
		10.10	 Living Environment
		10.11	 Conclusion
		References
	11: Genetic Aspects of Hypospadias
		11.1	 Genes Involved in the Embryology of the Male External Genitalia
			11.1.1	 Indifferent Stage
			11.1.2	 Early Patterning
			11.1.3	 Masculinization
		11.2	 Genes Implicated in the Etiology of Isolated Hypospadias
		11.3	 Study Types
		11.4	 Study Results
		11.5	 Other Genes
		11.6	 Common Clinical Conditions with Gene Defects
			11.6.1	 46,XX Disorder of Sex Development (DSD)
			11.6.2	 46,XY DSD
			11.6.3	 The Dysgenetic Gonad
			11.6.4	 Partial and Complete Androgen Insensitivity Syndromes
		References
	12: Hormones and Growth of the Genital Tubercle
		12.1	 Introduction
		12.2	 The Genital Tubercle
			12.2.1	 Chromosomal and Genetic Effects on Sexual Determination and Sexual Differentiation
		12.3	 Theory of Sexual Differentiation
		12.4	 The Balance Between Sex Determination Genes
			12.4.1	 Hormonal Effects on Sexual Differentiation and Genital Growth
		12.5	 Hypothalamic-Pituitary-Gonadal (HPG) Axis Activation (Fig. 12.4)
			12.5.1	 During Fetal Life (First Surge)
				12.5.1.1	 The Fetus
					Testosterone and Dihydrotestosterone
				12.5.1.2	 The Placenta
				12.5.1.3	 The Mother
				12.5.1.4	 The Environment
			12.5.2	 Mini-puberty (Second Surge)
		12.6	 Clinical Application and Importance of Minipuberty
			12.6.1	 Puberty (Third Surge)
		12.7	 Role of Leptin
		12.8	 Environmental Influence on Genital Growth
		12.9	 Tanner Classification
		12.10	 Summary
		References
	13: The Role of Preoperative Androgen Stimulation in the Management of Hypospadias
		13.1	 Introduction
		13.2	 Evidence of Use in Distal Hypospadias
		13.3	 Outcomes
		13.4	 Adverse Effects
		13.5	 Systematic Reviews and Meta-Analyses
		13.6	 Modes of Delivery, Dosage, and Schedule
		13.7	 Timing from Administration to Surgery
		13.8	 Conclusion
		References
	14: Timing of Surgery
		14.1	 Introduction
		14.2	 Emotional Development
		14.3	 Sexual Development
		14.4	 Psychological Effects of Surgery and Anesthesia
		14.5	 Improvement in Technical Aspects of Surgery and Advances in Pediatric Anesthesia
		References
	15: General Principles
		15.1	 Introduction
		15.2	 The First Consultation
		15.3	 History
		15.4	 Examination
		15.5	 Hypoplasia of the Penis
		15.6	 Preoperative Hormonal Stimulation
		15.7	 Informed Written Consent
		15.8	 Decision Regret
		15.9	 Penoscrotal Transposition
		15.10	 The Role of Imaging
		15.11	 Associated Anomalies
		15.12	 Ambiguous Genitalia and Disorders of Sex Development (DSD)
		15.13	 Is Hypospadias Part of DSD?
		15.14	 Should Hypospadias Surgery Be Postponed Until the Child Reaches the Age of Consent?
		15.15	 The Story of My Life with Hypospadias
			15.15.1 An Adult Patient Perspective
		References
	16: Plastic Surgery Principles
		16.1	 Introduction
		16.2	 Skin
		16.3	 Wound Healing
			16.3.1	 Hypertrophic Scarring and Keloid
		16.4	 Grafts
			16.4.1	 Split Skin Grafts
			16.4.2	 Full-Thickness Skin Grafts
			16.4.3	 Cultured Epithelial and Dermal Grafts
			16.4.4	 Skin Graft Survival
			16.4.5	 Buccal Mucosal Graft (BMG)
		16.5	 Flaps
			16.5.1	 Random Flaps
			16.5.2	 Axial Flaps
			16.5.3	 Fasciocutaneous Flaps
		References
	17: Principles of Hypospadias Surgery
		17.1	 Introduction
		17.2	 Preoperative Preparation
		17.3	 Positioning
		17.4	 Magnification
		17.5	 Traction, Retraction, and Tension
		17.6	 Tissue Handling and Viability
		17.7	 Instruments
		17.8	 Suture Material and Knots
		17.9	 Suturing Techniques
		17.10	 Tissue Sealants
		17.11	 Hemostasis
		17.12	 The Width of the Neourethra (Fig. 17.4)
		17.13	 Urinary Diversion
		17.14	 Perineal Urethrotomy
		17.15	 Natural Perineal Urethrotomy
		17.16	 Suprapubic Cystostomy
		17.17	 Urethral Catheterization
		17.18	 Dressings
		References
	18: Analgesia and Pain Control
		18.1	 Introduction
		18.2	 What Difference Does It Make for a Child and Its Family that It Has Hypospadias?
		18.3	 Preparation for Surgery and Anaesthesia
		18.4	 Informed Consent
		18.5	 History and Laboratory Tests
		18.6	 Specific Fears and Risks About Anaesthesia
			18.6.1	 Will My Child Wake Up After Anaesthesia?
			18.6.2	 Can My Child’s Intellect Be Impaired by Anaesthesia?
			18.6.3	 Can My Child Become Lame From Caudal Anaesthesia?
		18.7	 The Day of the Operation
		18.8	 Presence or Absence of Parents During Induction
		18.9	 Mask or IV Induction?
		18.10	 Airway
		18.11	 Cuffed or Uncuffed Tube?
		18.12	 Regional Anaesthesia (Fig. 18.1)
		18.13	 Epidural Analgesia
		18.14	 Penile Block
		18.15	 Local Application
		18.16	 Summary of Agents Used
		18.17	 Maintenance of Anaesthesia
			18.17.1	 A Airway—See Above
			18.17.2	 A Anaesthesia
			18.17.3	 B Breathing
			18.17.4	 C Circulation
			18.17.5	 D Drugs
			18.17.6	 E Temperature Management (Environment)
		18.18	 Emergence from Anaesthesia
		18.19	 Recovery Room
		18.20	 On the Ward
		References
Part II: Operative Techniques
	19: Grade I: Glanular Hypospadias; Double Y Glanulomeatoplasty (DYG) Technique
		19.1	 Introduction
		19.2	 Selection of Patients
		19.3	 Operative Technique
		19.4	 Postoperative Care
		19.5	 Complications and Follow-Up
		19.6	 Discussion
		References
	20: MAGPI and Modified MAGPI
		20.1	 Introduction
		20.2	 Selection of Patients
		20.3	 Operative Technique (Fig. 20.1)
			20.3.1	 Meatoplasty
			20.3.2	 Glanuloplasty
			20.3.3	 Modifications
		20.4	 Results
		20.5	 Complications
		20.6	 Conclusion
		References
	21: The Meatal-Based Flap Principle
		21.1	 Introduction
		21.2	 The Mathieu Procedure
		21.3	 The Mustardé Procedure
		21.4	 The Barcat Modification
		21.5	 The Horton-Devine Flip-Flap Procedure
		21.6	 Selection Criteria for the Mathieu Technique
		21.7	 The Mathieu Technique and Relevant Modifications and Controversies (Fig. 21.4)
			21.7.1	 Stenting
			21.7.2	 Reinforcement of the Neourethra Using Local Tissues
			21.7.3	 How to Improve the Appearance of the Meatus in Mathieu Cases
			21.7.4	 Chordee
			21.7.5	 Hinging of Urethral Plate
			21.7.6	 Mathieu as a Rescue Operation
			21.7.7	 Results and Complications
		21.8	 The Y-V Glanuloplasty Modified “Mathieu” Technique [13, 56]
			21.8.1	 Selection of Patients
			21.8.2	 Operative Technique
				21.8.2.1	 Y-V Glanuloplasty
				21.8.2.2	 Parameatal Flap Design
				21.8.2.3	 Neourethra Reconstruction
				21.8.2.4	 Meatoplasty and Glanuloplasty
				21.8.2.5	 Urinary Diversion
				21.8.2.6	 Dressing
			21.8.3	 Results and Conclusion
		21.9	 The Inverted Y-V Glanuloplasty Modified “Mathieu” Technique
		References
	22: The Slit-Like Adjusted Mathieu (SLAM) Technique
		22.1	 Introduction
		22.2	 Selection of Patients
		22.3	 Operative Technique
		22.4	 Patients and Methods
		22.5	 Results and Complications
		22.6	 Discussion
		References
	23: Megameatus Intact Prepuce (MIP) Deformity
		23.1	 Introduction
		23.2	 Morphology
		23.3	 Incidence and Classification
		23.4	 Theories of Pathogenesis
		23.5	 Surgical Management
		23.6	 Pyramid Repair
		23.7	 Hill Repair
		23.8	 Nonomura Meatal-Based Foreskin Flap
		23.9	 MIP Management in the Hypospadias Center, Frankfurt
		23.10	 Important Surgical Tips
		References
	24: Thiersch-Duplay Principle
		24.1	 Introduction
		24.2	 Preoperative Evaluation
		24.3	 Selection of Patients
		24.4	 Operative Technique
		24.5	 Results
		24.6	 Conclusion
		24.7	 Editorial Comment by Mark R. Zaontz
		24.8	 History
		24.9	 Operative Technique
		24.10	 Discussion and Modifications
		References
	25: The “Inverted-Y Thiersch” (IT) Technique
		25.1	 Introduction
		25.2	 Principles of the Inverted Y Thiersch (IT)
		25.3	 Patients and Methods
		25.4	 Operative Technique
		25.5	 Results and Complications
		25.6	 Discussion
		References
	26: Incision of the Urethral Plate
		26.1	 Introduction
		26.2	 History of the Midline Incision
		26.3	 Preoperative Assessment
		26.4	 Androgen Stimulation
		26.5	 Operative Technique and Tips and Tricks
			26.5.1	 Step 1: Operative Assessment
			26.5.2	 Step 2: Degloving and Chordee
			26.5.3	 Step 3: Glans and Urethral Plate Dissection
			26.5.4	 Step 4: Incision of the Urethral Plate and Urethroplasty
			26.5.5	 Step 5: Urethroplasty Coverage and Glansplasty
			26.5.6	 Step 6: Foreskin Reconstruction
		26.6	 Surgical Dressing
		26.7	 Results
		26.8	 Reoperative Urethroplasty
		26.9	 Conclusion
		References
	27: Dorsal Inlay TIP (DTIP)
		27.1	 Introduction
		27.2	 Preoperative Evaluation
		27.3	 Operative Technique
			27.3.1	 Primary Distal Hypospadias Repair
				27.3.1.1	 Penile Degloving and Preparation of the Ventral Dartos Flap
				27.3.1.2	 Chordee Correction
				27.3.1.3	 Urethroplasty
				27.3.1.4	 Preputial Graft Harvesting and Fixation
				27.3.1.5	 Glanuloplasty
				27.3.1.6	 Skin Closure
			27.3.2	 Reoperations
				27.3.2.1	 Preoperative Evaluation
				27.3.2.2	 Urethroplasty
		27.4	 Results
		27.5	 Conclusion
		References
	28: Urethral Advancement for Treatment of Distal Hypospadias
		28.1	 Introduction
		28.2	 Operative Technique
		28.3	 Discussion
		28.4	 Editorial Comment by Dr. Patrick McKenna
		References
	29: The Glanular Urethral Disassembly (GUD) Technique: An Alternative to Distal Hypospadias
		29.1	 Introduction
		29.2	 Operative Technique
		29.3	 Clinical Data
		29.4	 Discussion
		29.5	 Conclusion
		References
	30: Proximal Hypospadias With Small Flat Glans: The Lateral-Based Onlay (LABO) Flap Technique
		30.1	 Introduction
		30.2	 Selection of Patients
		30.3	 Operative Technique
		30.4	 Important Technical Points
		30.5	 Patients and Methods
		30.6	 Results and Complications (Figs. 30.2, 30.3, 30.4, and 30.5)
		30.7	 Discussion
		References
	31: The Onlay Island Hypospadias Repair
		31.1	 Introduction
		31.2	 Operative Technique
			31.2.1	 Timing
			31.2.2	 Design of Glanuloplasty
			31.2.3	 Incisions
			31.2.4	 Penile Skin Dropped Back
			31.2.5	 Elevation of Glans Wings
			31.2.6	 Artificial Erection
			31.2.7	 Design of Onlay Island Flap
			31.2.8	 Glanuloplasty
			31.2.9	 Skin Closure
			31.2.10	 Urethral Stenting
			31.2.11	 Dressing
			31.2.12	 Aftercare
		31.3	 Outcomes
		31.4	 Conclusion
		References
	32: Perineal Hypospadias: The Bilateral-Based (BILAB) Skin Flap Technique
		32.1	 Introduction
		32.2	 Selection of Patients
		32.3	 Operative Technique (Figs. 32.1 and 32.2)
			32.3.1	 Chordee Excision
			32.3.2	 Glans Split
			32.3.3	 Incision and Mobilization of the Foreskin
			32.3.4	 New Urethral Plate
			32.3.5	 Urethroplasty
			32.3.6	 Protective Intermediate Layer
			32.3.7	 Meatoplasty and Glanuloplasty
			32.3.8	 Urine Drainage
			32.3.9	 Dressing
		32.4	 Patients and Methods
		32.5	 Results and Complications (Figs. 32.2 and 32.3)
		32.6	 Discussion
		References
	33: Chordee Excision and Distal Urethroplasty (CEDU) for Perineal Hypospadias
		33.1	 Introduction
		33.2	 Selection of Patients
		33.3	 Operative Technique (Figs. 33.1, 33.2, 33.3, 33.4)
			33.3.1	 Chordee Excision (Tunica Albuginea Longitudinal Excision (TALE))
			33.3.2	 Incision of the Glans
			33.3.3	 Incision and Mobilization of the Foreskin
			33.3.4	 New Urethral Plate
			33.3.5	 Distal Urethroplasty (Fig. 33.1f–h)
			33.3.6	 Meatoplasty and Glanuloplasty (Figs. 33.3 and 33.4)
			33.3.7	 Urine Drainage
			33.3.8	 Abdominal Wall fixation
			33.3.9	 Dressing
			33.3.10	 Stage II: Perineal (Proximal) Urethroplasty (Fig. 33.4c, d)
		33.4	 Patients, Results, and Complications (Figs. 33.2 and 33.3)
		33.5	 Hormone Therapy
		33.6	 CEDU Technique in Adults
		33.7	 Discussion
		33.8	 Value of Abdominal Wall Fixation
		References
	34: Preputial Island Flaps
		34.1	 Introduction
		34.2	 The Operative Steps of Duckett Technique
		34.3	 Mixed Interposition Neourethroplasty
		34.4	 Addressing the Glans
			34.4.1	 How Best to Address the Glans?
		34.5	 Dorsoventral Transfer of Preputial Tube Urethroplasty
		34.6	 Operative Technique (Fig. 34.5)
		References
	35: The Modified Asopa (Hodgson XX): The Procedure to Repair Hypospadias with Chordee
		35.1	 Introduction
		35.2	 Operative Technique
		35.3	 Conclusion
		References
	36: Koyanagi Technique and Its Modifications in the Management of Proximal Hypospadias
		36.1	 Introduction
		36.2	 The Original Technique [9–11]
			36.2.1	 Step 1: Outlining the Skin Incision (Fig. 36.1a, b)
			36.2.2	 Step 2: Chordectomy and Creation of Parameatal Foreskin Flap (Fig. 36.1c)
			36.2.3	 Step 3: Bisecting the Glans and Creation of Glanular Wings
			36.2.4	 Step 4: Ventralization and Tubularization of the Parameatal Foreskin Flaps (Fig. 36.1g)
			36.2.5	 Step 5: Glanulomeatoplasty
			36.2.6	 Step 6: Byarization of the Dorsal Foreskin and Its Subcutaneous Tissue for Skin Closure (Fig. 36.1i, j)
			36.2.7	 Step 7: Skin Closure (Fig. 36.1k)
		36.3	 The Modified Technique [8, 16, 17]
		36.4	 Tips and Tricks in the Application of Modified Koyanagi Technique for Proximal Hypospadias [8, 16, 18]
		36.5	 Discussion
		36.6	 Conclusion
		References
	37: The Yoke Hypospadias Repair
		37.1	 Introduction
		37.2	 Operative Technique
		References
	38: Dorsal Longitudinal Penile Skin Island Flap in One-Stage Repair of Hypospadias with Penoscrotal Transposition
		38.1	 Introduction
		38.2	 Operative Technique
			38.2.1	 Penile Degloving
			38.2.2	 Curvature Correction
			38.2.3	 Urethroplasty
			38.2.4	 Glanuloplasty
			38.2.5	 Scrotoplasty
			38.2.6	 Penile Skin Reconstruction
			38.2.7	 Dressing
			38.2.8	 Urinary Diversion
		38.3	 Results
		38.4	 Complications
		38.5	 Comment
		Further Reading
	39: Grafts for One-Stage Repair
		39.1	 Introduction
		39.2	 Graft Material and Graft Biology
		39.3	 Full-Thickness Skin Free Graft (Wolfe)
		39.4	 Preputial Skin Graft
		39.5	 Buccal Mucosa Graft
			39.5.1	 Operative Technique
		39.6	 Inlay Patch
		39.7	 Onlay Patch
		39.8	 Graft Tube Urethroplasty
		39.9	 Compound Tube
		39.10	 Clinical Experience and Results
		39.11	 Bladder Mucosal Grafts
			39.12	 Operative Technique
		39.13	 Results
		39.14	 Editorial Comment
		References
	40: Two-Stage Graft Urethroplasty; Free Full-Thickness Wolfe Graft
		40.1	 Introduction
		40.2	 Selection of Patients
		40.3	 Operative Technique
			40.3.1	 First Stage
			40.3.2	 Second Stage (Fig. 40.6)
		40.4	 Results
		40.5	 One-Stage Versus Two-Stage Graft
		40.6	 Graft Growth and Puberty
		40.7	 Tips and Tricks in Special Situations
		References
	41: The Cecil-Culp Technique
		41.1	 Introduction
		41.2	 Original Description of the Operative Technique (Fig. 41.1)
		41.3	 Use in Primary Repairs
		41.4	 Use of the Cecil Concept Following Multiple Failed Repairs
		41.5	 Non-hypospadias Uses
		41.6	 Trauma
		41.7	 Conclusion
		References
	42: The Foreskin and Circumcision
		42.1	 Introduction and History of Circumcision
		42.2	 Surgical Anatomy of the Prepuce
		42.3	 Histology of the Foreskin
		42.4	 Embryology and Development of the Prepuce
		42.5	 Morphology of the Prepuce in Hypospadias (Fig. 42.4)
		42.6	 Fate of the Prepuce in Hypospadias
		42.7	 Patient Consent for the Fate of the Prepuce in Hypospadias
		42.8	 Surgical Correction of the Prepuce in Hypospadias
			42.8.1	 Foreskin Reconstruction
			42.8.2	 Circumcision
		42.9	 Circumcision of the Prepuce in Hypospadias
		42.10	 Foreskin Reconstruction in Hypospadias
		References
	43: Protective Intermediate Layer
		43.1	 Introduction
		43.2	 Skin De-epithelialization
		43.3	 The Tunica Vaginalis Flap
		43.4	 The Dorsal Subcutaneous Flap
		43.5	 The Scrotal Dartos Flap
		43.6	 Triple Breasting of the Meatal Based Flap
		43.7	 External Spermatic Fascia Flap
		43.8	 The Hypoplastic Spongiosum Layer
		43.9	 The Ventral Dartos Flap
		43.10	 The Buck’s Fascia Flap
		43.11	 Fibrin Sealants
		43.12	 The Platelet-Rich Fibrin Membrane
		43.13	 Protective Intermediate Layer in the Hypospadias Center, Frankfurt
		References
	44: Procedures to Improve the Appearance of the Meatus and Glans
		44.1	 Introduction
		44.2	 Normal Anatomy of the Glans and Meatus (Fig. 44.1)
		44.3	 The Fossa Navicularis
		44.4	 Normal Dimensions of the Glans and Penis in Infants and Adults
			44.4.1 Glans: Penis Ratio
		44.5	 Classification of the Glans in Hypospadias
		44.6	 Evolution of Surgery on the Glans in Hypospadias
		44.7	 How to Have a Slit-Like Meatus
		44.8	 How to Have a Wide Meatus and Avoid Meatal Stenosis
		44.9	 How to Correct Meatal Stenosis
		44.10	 Techniques to Improve the Appearance of the Glans (Figs. 44.27, 44.28, 44.29, and 44.30)
			44.10.1 Double Y-Glanulomeatoplasty
			44.10.2 Unilateral SLAM
			44.10.3 Inverted Y SLAM Technique
			44.10.4 Redo SLAM Technique
		References
	45: Buried Penis (BP)
		45.1	 Introduction
		45.2	 Morphology of Buried Penis
		45.3	 Operative Technique (Fig. 45.2)
		45.4	 Patients, Results, Complications, and Follow-Ups (Figs. 45.3 and 45.4)
		45.5	 Discussion
		References
	46: Penile Torsion (PT)
		46.1	 Introduction
		46.2	 Etiology
		46.3	 Classification of Penile Torsion
		46.4	 Surgical Correction of Penile Torsion
			46.4.1	 Grade I Penile Torsion (<45°)
			46.4.2	 Grade II Penile Torsion (Between 45° and 90°)
			46.4.3	 Grade III Penile Torsion (>90°)
		46.5	 Results and Complications
		References
	47: Congenital Urethral Duplication
		47.1	 Introduction
		47.2	 Classification and Terminology
		47.3	 Embryology
		47.4	 Presentation
		47.5	 Examination Findings
		47.6	 Investigation
		47.7	 Treatment
		References
	48: Enlarged Prostatic Utricle Associated to Hypospadias
		48.1	 Introduction
		48.2	 Diagnosis
		48.3	 Treatment
		48.4	 Open Techniques
		48.5	 Minimally Invasive Techniques
		48.6	 Outcomes
			48.6.1	 Endoscopic Techniques
			48.6.2	 Open Techniques
			48.6.3	 Minimally Invasive Techniques
		48.7	 Complications of Undiagnosed Prostatic Utricle
		48.8	 Infertility Issues
		References
	49: Penoscrotal Transposition
		49.1	 Introduction
		49.2	 Presentation and Associated Anomalies
		49.3	 Classification
		49.4	 Operative Technique
		49.5	 Ehrlich-Scardino Technique
		49.6	 Mori-Ikoma Technique
		49.7	 Shanberg-Rosenberg Technique
		49.8	 Current Technique Used for PST in Hypospadias Center, Frankfurt
		49.9	 Bifid Scrotum
		References
	50: Uncommon Conditions and Complications
		50.1	 Iatrogenic Hypospadias
		50.2	 Genitourinary Injuries in the Newborn
		50.3	 Congenital Urethrocutaneous Fistula Without Hypospadias
		50.4	 Congenital Urethrocutaneous Fistula with Hypospadias
		50.5	 Accessory Scrotum
		50.6	 Mole in the Glans
		50.7	 Hair Coil
		50.8	 Congenital Meatal Cyst
		50.9	 Lateral Chordee
		50.10	 Proximal Thin Urethra
		50.11	 Partial Dissection of the Epithelium of the Urethral Wall
		50.12	 Lymphedema of the Penis After Hypospadias Surgery
		50.13	 Adenoma After Hypospadias Repair
		50.14	 Squamous Cell Carcinoma After Hypospadias Repair
		50.15	 Hairy Urethra
		50.16	 Ulcer in an Adult with Uncorrected Hypospadias
		50.17	 Congenital Megalourethra
		50.18	 Suture Tracks
		50.19	 Smegma Mass
		50.20	 Female Hypospadias
		References
	51: Hypospadias Surgery in Adults
		51.1	 Introduction
		51.2	 Adults Are Not Big Children
		51.3	 Tips and Tricks When Operating on Adults
		51.4	 Classification of Hypospadias in Adults and Their Management
		51.5	 Presentation
		51.6	 Operative Technique
		51.7	 Management of Adult Hypospadias in the Hypospadias Center, Frankfurt, Germany
			51.7.1	 Failed Distal Hypospadias
			51.7.2	 Ugly Glans
			51.7.3	 Adult Rotation
			51.7.4	 Failed Proximal Hypospadias with Diverticulum
			51.7.5	 Adult with Severe Chordee
			51.7.6	 An Adult with Stricture and Severe Scarring
			51.7.7	 An Adult with Severe Stricture After 30 Operations
			51.7.8	 An Adult with Chordee and Severe Scarring After Six Operations
		51.8	 Conclusion
		References
	52: Flaps Versus Grafts
		52.1	 Flaps
		52.2	 Grafts
		52.3	 Flaps Versus Grafts
		References
	53: Single-Stage Versus Two-Stage Repair
		53.1	 Introduction
		53.2	 Aim of Hypospadias Surgery
		53.3	 One-Stage Repair
		53.4	 Two-Stage Repair
		53.5	 Thiersch-Duplay Technique as Modified by Byars (1951) and Durham Smith (1981)
			53.5.1	 First Stage
			53.5.2	 Second Stage
			53.5.3	 Skin Closure
			53.5.4	 Results
		53.6	 Denis Browne Technique
			53.6.1	 Results
		53.7	 One and Half Stages Repair
		References
	54: Stenting Versus No Stenting
		54.1	 Introduction
		54.2	 Urinary Diversion
		54.3	 Some Modern Catheters and Stents
		54.4	 Natural Perineal Urethrotomy
		References
	55: Dressing Versus No Dressing
		55.1	 Introduction
		55.2	 Wound Healing and Duration of Dressing
		55.3	 Sources of Dressing Contamination
		55.4	 Advantages and Disadvantages of Dressing
		55.5	 Types of Dressings
		References
	56: Editorial Overview of the Current Management of Hypospadias
		56.1	 Introduction
			56.1.1	 Hypospadias Classification
			56.1.2	 The Urethral Plate
			56.1.3	 Chordee Management
			56.1.4	 Two-Stage Repair for Severe Proximal and Perineal Hypospadias
			56.1.5	 The Use of Grafts Rather Than Flaps
			56.1.6	 Protective Intermediate Layers
			56.1.7	 Preoperative Hormone Therapy
			56.1.8	 Technical Surgical Details
			56.1.9	 Operative Techniques
				56.1.9.1	 Techniques for Glanuloplasty and Meatoplasty (Grade I)
				56.1.9.2	 Techniques for Distal Hypospadias (Grade II)
				56.1.9.3	 Techniques for Proximal Hypospadias Without Chordee (Grade III)
				56.1.9.4	 Techniques for Perineal Hypospadias (Grade IV)
		56.2	 Protocol of Management in the Hypospadias Center, Frankfurt
		References
Part III: Complications
	57: Early Complications
		57.1	 Infection
		57.2	 Meatal Stenosis
		57.3	 Loss of Skin Flaps
		57.4	 Edema
		57.5	 Hemorrhage
		57.6	 Postoperative Erection
		57.7	 Retrusive Meatus
		57.8	 Bladder Spasm
		57.9	 Catheter Blockage
		References
	58: Meatal Stenosis and Urethral Strictures
		58.1	 Introduction
		58.2	 Definition
		58.3	 Incidence
		58.4	 Causes of Postoperative Meatal Stenosis
		58.5	 Causes of Urethral Stricture
		58.6	 Presentation
		58.7	 Diagnosis of Stenosis and Stricture
		58.8	 Treatment
			58.8.1	 Meatal Stenosis
			58.8.2	 Urethral Stricture
		References
	59: Functional Urethral Obstruction (FUO)
		59.1	 Introduction
		59.2	 Patient’s Presentation
		59.3	 Diagnostic Investigations
		59.4	 Management
		59.5	 Discussion
		References
	60: Hypospadias Fistula
		60.1	 Introduction
		60.2	 Definition
		60.3	 Incidence of Fistula Formation
		60.4	 Causes of Fistula Formation
		60.5	 Fistula Prevention
		60.6	 Types and Sites of Fistula
		60.7	 Timing of Fistula Closure
		60.8	 Guidelines and Steps of Fistula Closure
		References
	61: Genital Lichen Sclerosus (Balanitis Xerotica Obliterans): BXO
		61.1	 Background
		61.2	 Etiology
			61.2.1	 Infection
			61.2.2	 Endocrinology
			61.2.3	 Immunology and Genetics
			61.2.4	 Anatomy, Trauma, and Other Causes
		61.3	 Epidemiology, Symptoms, and Diagnosis
		61.4	 Treatment
			61.4.1	 Medical Treatment
				61.4.1.1	 Corticosteroids
				61.4.1.2	 Calcineurin Inhibitors (Tacrolimus)
			61.4.2	 Surgical Treatment
			61.4.3	 Other Treatment Options
				61.4.3.1	 Photodynamic Therapy (PDT)
				61.4.3.2	 Cryotherapy
				61.4.3.3	 Systemic Therapies
		61.5	 LS and Hypospadias
		61.6	 Long-Term Outcome of LS-Related Urethral Surgery
		61.7	 LS and Penile Cancer
		References
	62: Urethral Diverticula and Acquired Megalourethra
		62.1	 Introduction and Incidence
		62.2	 Presentation and Diagnosis
		62.3	 Types of Diverticula
		62.4	 Etiology and Mechanism of Diverticulum Formation
		62.5	 Prevention of Diverticulum Formation
			62.5.1	 Formation of Wide Urethra and Meatus
			62.5.2	 Approximation of the Bifurcated Corpus Spongiosum and Surrounding Fascia
			62.5.3	 The Use of Grafts Rather Than Flaps in Proximal and Perineal Hypospadias
		62.6	 Management of Diverticulum
			62.6.1	 Mild or Small Diverticulum
			62.6.2	 Anterior or Distal Diverticulum
			62.6.3	 Posterior or Proximal Diverticulum
		62.7	 Surgical Tips and Tricks
		References
	63: Management of Failed Hypospadias Surgery
		63.1	 Introduction
		63.2	 Why Complications Are Common After Hypospadias Surgery?
		63.3	 Emergency Management
		63.4	 Timing of Redo Surgery
		63.5	 Role of Pre-operative Hormone Therapy
		63.6	 Role of Nitroglycerine and Hyperbaric Oxygen Therapy
		63.7	 Management of Persistent/Recurrent Chordee
		63.8	 Different Techniques Used for Failed Hypospadias
			63.8.1	 The Salvage Mathieu and SLAM Technique for Failed Distal Hypospadias
			63.8.2	 Urethral Mobilization and the DYG Technique for Failed Coronal Hypospadias
			63.8.3	 The LABO Technique for Failed Proximal Hypospadias
			63.8.4	 The LABO Technique for Failed Proximal Hypospadias After Failed Buccal Mucosal Graft
			63.8.5	 The Use of Two-Stage BILAB for Failed Proximal Hypospadias
			63.8.6	 Management of Hypospadias with Inadequate Healthy Tissues
			63.8.7	 How to Deal with Lack of Skin Cover?
		References
	64: Complex and Redo Hypospadias Repairs: Management of 402 Patients
		64.1	 Introduction
		64.2	 Urethroplasty
		64.3	 Results of the First 152 Patients
		64.4	 Second Series of 250 Patients
		64.5	 Persistent and Recurrent Chordee
		64.6	 Recurrent Fistula
		64.7	 Recurrent Glans Dehiscence
		64.8	 Tissues and Skin Ischemia
		64.9	 Penile Resurfacing
		64.10	 Conclusion
		References
Part IV: Long-Term Results
	65: Long-Term Consequences of Hypospadias Repair
		65.1	 Introduction
		65.2	 Surgical Outcomes
			65.2.1	 Measures of Success
		65.3	 Hypospadias in Adult Life
			65.3.1	 General Appearance
			65.3.2	 The Prepuce
			65.3.3	 The External Urinary Meatus
			65.3.4	 Micturition
			65.3.5	 Sexuality
			65.3.6	 Penile Size
		65.4	 Surgical Complications
			65.4.1	 Late Complications
			65.4.2	 Incidence
			65.4.3	 Stricture Repair
			65.4.4	 Chordee
		65.5	 New Cases in Adults
		65.6	 Nonsurgical Complications in Adults
			65.6.1	 Fertility
		65.7	 Psychological Outcomes and Consent to Surgery
		References
	66: Long-Term Follow-Up in Hypospadias Repair: What Is It and Are We There Yet?
		66.1	 Conclusion
		References
	67: Hypospadias: Psychosocial and Sexual Development and Consequences
		67.1	 Introduction
		67.2	 Appearance, Satisfaction, and Psychosocial Development
		67.3	 Hypospadias and Sexuality
		67.4	 Consequences According to Time of Surgery
			67.4.1	 Patients Operated on in Childhood
			67.4.2	 Patients Operated on During Adulthood
			67.4.3	 Non-operated on Patients
		67.5	 Own Clinical Experience
		67.6	 Conclusion
		References
	68: Tissue Engineering and Future Frontiers
		68.1	 Background
			68.1.1	 Tissue Engineering
			68.1.2	 Tissue Engineering in Urology
			68.1.3	 Impediments
			68.1.4	 Expertise and Collaborations
		68.2	 A Method for Tissue Engineering for Hypospadias Repair
			68.2.1	 Cell Harvesting and Culture
			68.2.2	 Preparation of Transplants
			68.2.3	 Hypospadias Repair
			68.2.4	 Follow-Up
		68.3	 Future Frontiers
		References
	69: Systematic Steps on How to Write a Scientific Paper on Hypospadias
		69.1	 Introduction
		69.2	 Application of the STROBE Statement Items
			69.2.1	 Title and Abstract (Item 1a and 1b)
				69.2.1.1	 Title
				69.2.1.2	 Abstract
			69.2.2	 Introduction Section
				69.2.2.1	 Background/Rationale (Item 2)
				69.2.2.2	 Objectives (Item 3)
			69.2.3	 Method Section
				69.2.3.1	 Study Design (Item 4)
				69.2.3.2	 Setting (Item 5)
				69.2.3.3	 Eligibility Criteria (Item 6)
				69.2.3.4	 Variables (Item 7)
				69.2.3.5	 Data Sources/Management (Item 8)
				69.2.3.6	 Bias (Item 9)
				69.2.3.7	 Study Size (Item 10)
				69.2.3.8	 Statistical Methods (Item 11 a–d)
				69.2.3.9	 Control for Confounding
				69.2.3.10	 Subgroup Analysis
				69.2.3.11	 Handling Missing Data
				69.2.3.12	 Sensitivity Analyses
			69.2.4	 Result Section
				69.2.4.1	 Participants (Item 12 a–c)
					Numbers of Participants at Each Stage
					Reasons for Nonparticipation
					Flow Diagram
				69.2.4.2	 Descriptive Data (Item 13a,b)
					Study Participants
					Missing Data
				69.2.4.3	 Outcome Data (Item 14)
				69.2.4.4	 Main Results (Item 15)
					Unadjusted and Adjusted Estimates
			69.2.5	 Discussion Section
				69.2.5.1	 Key Results (Item 16)
				69.2.5.2	 Limitations (Item 17)
			69.2.6	 Other Information
				69.2.6.1	 Generalizability (Item 18)
				69.2.6.2	 Funding (Item 19)
				69.2.6.3	 Summary of Findings Table (Item 20)
		References
	70: Hypospadias Centers, Training, and Hypospadias Diploma
		70.1	 Centralization in Hypospadias Surgery
		70.2	 Training of the Hypospadias Surgeon
		70.3	 Hypospadias Diploma
		References
Index