Hypospadias in children. The ex-president of the microbial bureau was placed under house arrest

Hypospadias (Q54)

Pediatrics, Pediatric Urology

general information

Short description

Union of Pediatricians of Russia

ICD 10: Q54

Hypospadias- one of the most common malformations of the penis, the main symptom of which is dystopia of the external opening of the urethra on the ventral surface of the penis. Also characteristic symptoms of the disease are splitting of the glans penis and “apron-shaped” foreskin with excess skin on the dorsal surface and deficiency on the ventral surface. The severity of the defect and the complexity of its correction are largely determined by the deformation of the cavernous bodies, which occurs in approximately 25% of patients with hypospadias.

Classification

Coding according to ICD-10

Hypospadias (Q54):

Q54.0 - Hypospadias of the glans penis;

Q54.1 - Penile hypospadias;

Q54.2 - Hypospadias, penis-scrotal;

Q54.3 - Perineal hypospadias;

Q54.4 - Congenital curvature of the penis.

Classification

The first classification of hypospadias was proposed by Kaufman in 1866. He identified the capitate, stem, perineal and perineal-scrotal forms of the defect. Most of the currently existing classifications of hypospadias do not have any fundamental differences. They are based on determining the localization of the dystopic meatus and the deformation of the cavernous bodies. Thus, the most popular gradation of hypospadias was proposed by Barcat in 1971. (Table 1).

Table 1 - Barcat classification (frequency in %).

However, from a practical point of view, it is more convenient to use the following classification:

Capitate hypospadias

In this form, the meatus is located on the head proximal to its normal location. These cases of hypospadias may appear fairly easy to correct; it often happens that there is pronounced hypoplasia of the distal part of the urethra, ventral tilt of the head or chord;

Hypospadias with distal divergence (separation) of the corpus spongiosum and mild or no chord;

Hypospadias with proximal divergence of the corpus spongiosum and notochord

Methods for correction of the chord and urethroplasty over a large area have been well developed, and therefore these two forms are easier to surgically treat;

Hypospadias disabled people

Examples of diagnoses

Hypospadias coronal form.

Hypospadias scrotal form. Urethral stricture.

Etiology and pathogenesis

Normal sexual differentiation depends on testosterone and its metabolites, as well as the presence of functional androgen receptors. It is known that genetic defects in the androgen metabolic system lead to hypospadias. However, androgen abnormalities that lead to severe forms of hypospadias do not explain the occurrence of mild and moderate forms.

There is a hypothesis that hypospadias occurs due to abnormal cellular signals between the tissues of the phallus during embryonic development; To confirm this, the ontogeny of markers of epithelial and smooth muscle differentiation in developing male and female genitalia was studied. A test of the hypothesis of epithelial-mesenchymal interactions during normal growth and differentiation of the penis was performed by Kurzrock et al., who used the mouse genital tubercle as a model. With a normal signal, normal development and differentiation of the genital tubercle (determined by the presence of cartilage) was noted; removal of the developing epithelium greatly slowed down the growth of the genital tubercle. The study of the patterns of penile growth has led to a revision of the embryology of urethral development.

The classic common model of urethral development in boys suggests that the urethral plate is “raised” by urethral folds that fuse ventrally from the proximal to the distal end. Unlike the proximal region, the urethra, which forms in the glans region, is covered with stratified squamous epithelium.

One theory supports the idea that the fusion of the urethral folds extends the entire length of the urethra to the apex of the glans. Another suggests that solid endodermal growth of the epidermis “canalizes” the capitate urethra.

A new theory has been proposed to explain the formation of the distal urethra. When examining fetal sections of the phallus (gestational age 5-22 weeks), it was found that the urethral plate is a continuation of the urogenital sinus. It continues to the tip of the phallus and is in an open state during the entire period of development of the urethra. The entire urethra, including the capitate section, is formed due to dorsal expansion and disintegration of the urethral plate with simultaneous ventral growth and fusion of the urethral folds. Sections of the distal urethra did not reveal endodermal growth. However, differentiation of the endodermal urethral plate into stratified squamous epithelium has been proven histochemically. Next, the epithelium of the mouse fetal bladder was recombined with the mesenchyme of the rat fetal genital tubercle and “grown” under the kidney capsule of a mouse without a thymus. The bladder epithelium differentiated into stratified squamous epithelium. Thus, with an underlying mesenchymal signal during the development of the capitate urethra, differentiation of the urothelium into stratified squamous epithelium is induced.

Epidemiology

This pathology occurs on average in 1 in 300 newborn boys (Yu.I. Isakov 1974, N.A. Lopatkin 1998). In 1980-1990 the incidence of hypospadias doubled. A US CDC study found that the incidence of hypospadias increased from 20.2 to 39.7 per 10,000 boys (1970 to 1993). In different regions, the incidence of hypospadias varies from 1 in 4,000 to 1 in 125 boys.

Clinical picture

Symptoms, course

Clinical picture

Hypospadias classically has 3 associated anomalies:

1. Ectopic opening of the urethral meatus;

2. Ventral curvature of the penis (chord);

3. Foreskin in the form of a “hood” with a pronounced excess of skin on the dorsum penis and a lack of skin on the ventrum penis.

It should be noted that the chord and the “hood” are not always found. The hypospadias meatus can be found under the normally formed foreskin. The notochord is often isolated, without ectopia of the urethral meatus. Often the curvature is associated with hypoplasia of the corpus spongiosum.

Anatomically, the defect can affect the entire ventral surface of the penis from apex to base:

1. There is a ventrally “open” head;

2. There is a missing segment of the urethral tube of varying length, which is replaced by a urethral plate extending from the ectopic meatus to the apex of the glans between the two corpora cavernosa;

3. There is a hypoplastic tubular urethra, not surrounded by corpus spongiosum;

4. Divergence of the corpus spongiosum is always proximal to the ectopic meatus. The “column” of each corpus spongiosum extends fan-shaped and laterally to the head;

5. Below the divergence of the corpus spongiosum, all structures forming the ventrum penis are normal;

6. Arteria frenulum is always absent;

7. Dorsum penis is always normal.

It is believed that the notochord is a direct consequence of pathological proximal divergence of the corpus spongiosum and hypoplasia of the ventral tissues of the penis. The occurrence of a chord is associated with the following factors:

- “attachment” of ventral hypoplastic skin to the underlying structures (urethra) in most cases;

Fan-shaped spread laterally and upwards of the diverged corpus spongiosum;

- “attachment” of the urethral plate and hypoplastic distal urethra (without corpus spongiosum) to the surface of the corpora cavernosa;

In rare cases - asymmetric development of corpora cavernosa.

Embryologically, there are 2 types of hypospadias:

1. Cases involving the penile urethra resulting from impaired tubularization of the urethral plate (horizontal segment of the urogenital sinus) at 11 weeks of gestation;

2. Cases involving the capitate urethra, resulting from impaired embryogenesis in the 4th month of gestation (account for 75% of cases).

Diagnostics

Complaints and anamnesis

The patient or parents (caregivers) may complain of an unusual shape of the penis, the location of the opening of the urethra on the ventral surface of the penis, urine flowing in an unusual direction, and urination only in a sitting position.

Physical examination

During the clinical examination of patients, in addition to the traditional examination (percussion, palpation and auscultation), special importance is attached to the examination of the external genitalia and a detailed assessment of the component elements of the defect. It is recommended to determine the size of the penis, the shape of the head and the severity of the scaphoid fossa, the degree of curvature of the corpora cavernosa, possible options for rotation of the penis, identification of rough scars from previous surgical interventions, and attention is also paid to the size of the foreskin and scrotum.

Comments: Identification of combined defects of the penis and urethra can significantly reduce the number of postoperative complications.

1. Stenosis of the external opening of the urethra (meatostenosis). This defect often accompanies hypospadias.

2. Dysplastic changes in the distal urethra and the skin of the ventral surface of the penis in the form of thinning, impaired blood supply and mobility. These features significantly complicate urethroplasty and subsequent healing of the urethra. The use of altered skin as a plastic material is impractical.

3. Congenital curvature of the penis is most common with hypospadias. The leading pathomorphological cause of penile curvature in patients with hypospadias is insufficient development of the skin and fascia on its ventral surface and, in some cases, curvature of the corpora cavernosa. The urethral track plays a minor role in the curvature. Very often, curvature of the penis is accompanied by the presence of dysplastic changes in the distal urethra and the skin of the ventral surface of the penis.

4. Congenital rotation of the penis. To achieve a good cosmetic result, such patients are recommended to undergo detorsion (unwinding) and fixation of the penis in the correct position.

5. Ectopia of the penis. Visually, in such patients, the scrotum resembles the labia majora, and the penis resembles a hypertrophied clitoris. Moving the skin of the scrotum allows you to restore the correct anatomical position of the penis. As a rule, this defect is observed in proximal forms of hypospadias.

6. Urogenital sinus (utriculus) is observed in children with proximal hypospadias. Small sizes (up to 10 ml) and rapid emptying of the sinus do not pose a risk of postoperative complications (as a source of infection). The gigantic size of the sinus (up to 350 ml), with impaired emptying and infection, requires radical excision of the uterine bud. An integrated approach allows you to assess the patient’s initial condition and choose the optimal method of surgical treatment. However, it must be recognized that the degree of curvature of the penis and the quality of the urethral plate cannot be adequately assessed even with a detailed visual examination. Making a decision on tubularization of the neourethra or choosing another method of correction is advisable only after decutanization of the penis, its complete straightening and visualization of the urethral plate.

Laboratory diagnostics

It is not required to confirm the diagnosis.

Instrumental diagnostics

Comments:Combined urodynamic examination includes uroflowmetry and retrograde cystometry. Considering the non-invasiveness and simplicity of the technique, children aged 2 to 18 years are recommended to undergo a uroflowmetric examination, which today is a screening method for determining disorders of the urodynamics of the lower urinary tract, namely the contractility of the bladder detrusor and the resistance of the vesicourethral segment. This examination is carried out twice. Before surgery and after surgical correction.

Complications

The most common postoperative complications:

1. Unsatisfactory cosmetic result - very common. The views of the surgeon and the patient on cosmetic results are often diametrically opposed.

2. Fistulas are the second most common complication. If the fistula persists for more than 6 months, repeat surgery is necessary. The incidence of this complication varies depending on the technique used. With the Mathieu operation - 4% of cases, with Onlay urethroplasty - reaches 15%, with the Snodgrass operation - 1-4%. This complication is more common with free grafts than with vascular pedicle grafts.

3. Strictures - are currently less common, as they are caused by circular anastomoses, which are performed quite rarely. Previously often encountered when using the Hodgson technique.

4. Retraction of the meatus and divergence of the head - prevention consists of adequate mobilization of the wings of the head. This complication most often occurs during MAGPI surgery.

5. Persistent chord - mainly due to the inexperience of the surgeon. Careful correction of the chord and performing an artificial erection test allows you to avoid this complication.

6. Urethrocele - there are 2 types. The first type is noted at the level of the reconstructed urethra, when there is an inadequate diameter of the neourethra, or concomitant meatostenosis. This type of urethrocele often occurs during urethroplasty using bladder mucosa. The second type may occur proximal to the neourethra, when part of the urethra is not surrounded by normal spongy tissue and the urethra is pulled outward during miction. In these cases, it is necessary to excise excess urethral tissue and correct distal stenosis.

7. Remote psychological problems. Few studies have been published examining long-term psychological problems in children after hypospadias correction. The sexual life of patients with hypospadias is generally undisturbed and begins later than in the general population. Patients with hypospadias have greater difficulty finding sexual contacts compared to the control group (33% vs. 12%, respectively). Erections and fertility are usually not affected.

8. Relapse of hypospadias - the reappearance of the external opening of the urethra in the place where it was before the operation. Usually associated with unsuccessful healing of the junction of the neourethra with its abnormal external opening. Recurrence of hypospadias is considered to be non-engraftment (rejection) of the newly created urethra, which also returns the situation to its preoperative state or even worsens it. Most often, recurrent hypospadias is eliminated as a result of two or multi-stage operations.

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Treatment

Conservative treatment

Not carried out

Surgery

Operative hypospadiology is one of the most difficult areas of pediatric urology, with a significant complication rate, even in the experienced hands of a surgeon. The last century has been marked by the emergence of a large number of new surgical techniques, of which today there are more than 300 types. The relevance of this problem lies in the correct choice of one or another technique, the end result of which will be a good functional and cosmetic result, with a minimum number of postoperative complications.

The choice of methods for correcting this pathology is established during the diagnostic process and is determined by the type of hypospadias, the size of the head of the penis, the severity of its curvature or chord, as well as the condition of the urethral area and the skin of the foreskin, which are used to create the missing section of the urethra. The operation must be carefully planned by the surgeon, its technique must be clearly justified.

. In case of classic hypospadias with an abnormal asymmetric foreskin, it is not recommended to carry out surgical treatment in the neonatal period to preserve the foreskin in order to optimize the choice of surgical tactics in the future.

. Correction of hypospadias in otherwise healthy patients is recommended from the age of six months.

. For distal forms of hypospadias, it is recommended to give preference to the following methods:

For capitate and coronal forms - MAGPI (meatal advavcement and glanduloplasty, meatoglanduloplasty, developed in 1981 by Duckett J.W.).

For a deep ventral groove of the head of the penis - GAP (glans approximation plasty), an operation to bring together the “wings” of the head, proposed by Zaontz (1991), W. Snodgrass, P. Mathieu, or its modification by Barcat, who supplemented the operation with a more thorough dissection of the urethral platform and wings of the glans penis and more complete multilayer closure of the neourethra, which led to a decrease in the likelihood of fistula formation.

Comments: When performing the MAGPI operation, a bordering skin incision is made with a distance of 3 mm from the coronary sulcus, including the dystopic meatus. A dorsal meatotomy is performed using the Heinicke-Mikulicz principle (the meatus is incised longitudinally and sutured transversely). The dystopic external urethral opening with a small part of the urethra is moved to the tip of the penis and the lateral edges of the glans are connected above it (meatoplasty). Thus, the urethral tube is not created, and the meatus with the distal urethra is moved to the apex of the glans. The absence of urethral sutures virtually eliminates the formation of fistulas. A urethral catheter is not installed. The operation can be performed on an outpatient basis. This surgical intervention allows for particularly good correction of anterior forms of hypospadias. In this case, certain conditions are necessary: intact and mobile skin of the external opening of the urethra, a small meatus, a pronounced median groove on the ventral surface of the head. However, with these forms of hypospadias, in a significant number of cases there is no cavernous tissue of the distal urethra, the wall of which is represented by thin translucent skin.

. In proximal forms, when choosing surgical tactics, most patients are recommended to undergo urethroplasty according to the W. Snodgrass method, which has proven itself not only for distal, but also for proximal forms of hypospadias, overhead surgical interventions according to Onlay or Hodgson II, as well as 2-stage operations .

A comment:

Characteristics of the Snodgrass urethroplasty method. This technology differs from the Duplay method by a longitudinal incision along the ventral surface of the glans penis. This incision allows you to reduce the line of the urethral suture without tension if the head of the penis is small or if the head is flattened.

Characteristics of the modified method of urethroplasty type Hodgson-II (F-II). The method is used for anterior and middle forms of hypospadias without ventral deformation of the penile shaft or with curvature, which can be eliminated by preserving an epithelial flap on the ventral surface of the penis between the hypospadias meatus and the apex of the glans penis. This operation belongs to a large group of "flip-flap" urethral plastic surgery, in which a flap on the ventral surface of the penis is used to form one of the walls of the artificial urethra. Urologists sometimes call this flap a "base" or "flip" flap. The width of this flap is usually half the circumference of the urethra.

Hypospadias is often accompanied by meatal stenosis, therefore, in order to eliminate stenosis on the lateral sides of the hypospadias meatus, two short incisions of the urethra are made at four and eight o'clock, so as not to increase the degree of dystopia of the external opening. The length of the incision varies from 1 to 3 mm depending on the age of the patient and the severity of meatal stenosis. The incision line was preliminarily crushed with a mosquito-type hemostatic clamp. After eliminating the meatal stenosis, the main stage of the operation begins.

A U-shaped incision is made on the ventral surface of the penis, bordering the meatus along the proximal edge. The incisions are made at such a distance from each other that the width of the strip left is equal to half the circumference of the urethra being formed.

The inner layer of the foreskin is crossed 3-4 mm from the coronary sulcus, then the skin of the penis is mobilized to the base. Often the fibrous chord extends proximal to the hypospadias meatus, almost reaching the penoscrotal angle. Thus, the tactic of completely exposing the corpora cavernosa of the penis is justified for all forms of hypospadias, allowing the erectile tissue to be freed from congenital fibrous cords, which significantly limit the growth of the penile shaft in the future. The criterion for complete excision of scar tissue can be the “artificial erection” test, which allows one to reliably assess the degree of curvature of the penile shaft. In the author’s version, two triangular sections are de-epidermized on the ventral surface of the head, after which a preputial flap of the artificial urethra is formed, referred to in the literature as “flap”. In this case, at the end of the operation, the ventral surface of the glans penis is represented by the skin of the prepuce, and the meatus has a transverse location. The function of the penis does not suffer after this operation, but the cosmetic defect remains.

. It is recommended to carry out two-stage surgical procedures in certain cases, for example, when in distal forms the urethral platform is deformed, sclerotic and unsuitable for urethroplasty, as a result of which it is subject to complete excision, as well as in proximal forms, with pronounced curvature of the penis. .

Comments:the use of two-stage surgical procedures in certain cases makes it possible to create a functionally correct penis and obtain a good cosmetic result. This is especially true for proximal forms, with pronounced curvature of the penis, when at the first stage it is better to perform its optimal straightening, form a full-fledged urethral plate, and at the second stage, use the Snodgrass technique or an overhead type of operation.

. In the presence of concomitant curvature of the penis, the following surgical tactics are recommended to straighten the penis: excision of tissue on the ventral surface of the penis, complete preservation of the urethral track with corrugation of the tunica albuginea on the back of the penis and partial separation of the urethral platform from the corpora cavernosa with its intersection in the tension zone . Or use an approach when straightening the penis is achieved after displacing the skin proximally from it, as well as during a skin incision proximal to the dystopic meatus and excision of scar tissue in this area.

A comment: straightening of the penis must be carried out under the control of artificial erection, regardless of the method of performing the operation.

If there is rotation of the penis, in order to achieve a good cosmetic result, such patients are recommended to have detorsion (untwisting) and fixation of the penis in the correct position.

Rehabilitation

No specific rehabilitation measures have been developed for patients with hypospadias.

Prevention

No specific preventive measures have been developed for patients with hypospadias.

Leading children

Treatment of hypospadias is carried out inpatiently (in conditions that provide round-the-clock medical supervision and treatment). The average stay in a 24-hour hospital is 10 days, in some cases up to 21 days.

If the treatment outcome is favorable, further inpatient observation is not required. An examination by a urologist is necessary 1 week after discharge from the hospital to identify and/or prevent early postoperative complications. The second examination is 1 month after discharge from the hospital. It is necessary to evaluate the cosmetic result and functional parameters (visual assessment of the diameter of the jet, if technically possible, performing uroflowmetry). The child should also be examined for possible complications: urethral fistulas, urethral diverticula, urethral stenosis, urethral lysis. Further observation is as indicated.

1 month after surgery, local anti-scar therapy is carried out with local agents.

Dynamic observation of the patient

After urethroplasty, dynamic monitoring is necessary in the following mode: 1 month after surgery, 6 months, 1 year and then after 3-5 years. The assessment of effectiveness is based on the determination of functional indicators of urination, assessment of the cosmetic effect and the presence of postoperative complications.

Forecast

Outcomes and prognosis

A good result of hypospadias correction surgery is the achievement of all or most of the goals of this correction, i.e. straightening the penis, restoring the missing section of the urethra and transferring its external opening to the top of the head of the penis. The most important thing is to restore the normal functions of the penis - normal male-type urination and ejaculation, ensuring that the seed enters the posterior vaginal vault.

Evaluation of the results of surgical operations carried out according to the following criteria:

I. Good result:

1. Complete expansion of the corpora cavernosa. The problem of straightening the penis with hypospadias during surgery is solved first. The choice of method depends on the severity of the curvature or chord. First, a so-called paracoronal (around the border of the glans penis) incision is made, the urethral area is encircled by this incision and preserved. The skin of the penis and the fleshy membrane are displaced towards the base of the penis at the level of the fascia backa. With minor curvatures of the penis, which occur with the capitate and distal-trunk forms of hypospadias, straightening is achieved only by mobilizing the shaft of the penis. Moderately severe curvatures in proximal forms of hypospadias are corrected by applying plications (cutting and suturing ellipses of the tunica albuginea of the corpora cavernosa of the penis according to Physick - Nesbit - Baskin). Significant curvatures in proximal, scrotal (scrotal), penoscrotal and perineal forms of hypospadias, as well as in cases of damaged and sclerotic urethral platform, are corrected by crossing or excision of the urethral plate, with the placement of a newly created urethra in its place;

2. Complete cosmetic correction of the defect. Creation of an anatomically correctly formed penis with a slit-like vertical meatus in the area of the scaphoid fossa. The task of recreating the missing section of the urethra (urethroplasty) and its normal external opening (meatoplasty) is much more difficult and is solved during the operation after straightening the penis (orthroplasty);

3. Complete functional correction of the defect. Normal uroflowmetry indicators, a stream directed along the axis of the penis;

4. No complications;

5. Complete agreement of views regarding a positive cosmetic and functional result, both on the part of the surgeon and on the part of the patients’ parents.

II. Satisfactory result

1. The corpora cavernosa are straightened with a minimal angle of ventral deformation, the external opening of the urethra is located slightly proximal to the scaphoid fossa;

2. The act of urination is not impaired;

3. There are postoperative complications (fistulas, strictures).

III. Unsatisfactory result

1. The deformation of the penis is completely preserved, the urethral tube has a significant defect;

2. The act of urination is impaired;

3. Poor cosmetic result.

Information

Sources and literature

Clinical recommendations of the Union of Pediatricians of Russia
1. 1. Prodeus P.P., Staroverov O.V. Hypospadias. M.; 2003 2. Baskin L.S., Colborn T., Himes K. Hypospadias and endocrine disruption: is there a connection? Environ. Hlth. Perspective. 2001; 109: 1175-83. 3. Laurence S., Baskin L.S., Michele B. Ebbers Hypospadias: anatomy, etiology, and technique. J. Pediatr. Surg. 2006; 41 (3): 463-72. 4. Marchenko A.S., Smirnov I.E., Zorkin S.N., Apakina A.V., Sukhodolsky A.A., Shakhnovsky D.S. Treatment of children with hypospadias. Pediatric surgery. 2013. No. 5. P. 40-44. 5. Baskin L.S., Erol A., Li Y. et al. Urethral seam formation and hypospadias. Cell Tissue Res. 2001; 305:379-87. 6. Baskin L.S. Hypospadias and urethral development. J. Urol. 2000; 163(3):951-6. 7. Cunha G., Baskin L. Development of the penile urethra. In: Baskin L.S. (ed.). Hypospadias and genital development. Philadelphia: Kluwer Academic. Plenum; 2004: 87-100. 8. Sabatelli P., Palma E., Angelin A. et al. Critical evaluation of the use of cell cultures for inclusion in clinical trials of patients affected by Collagen VI myopathies. J Cell Physiol. 2012; 227(7):2927-35. 9. Holmes N.M., Miller W.L., Baskin L.S. Lack of defects in androgen production in children with hypospadias. J. Clin. Endocrinol. 2004; 89: 2811-6. 10. Silver R., Russell D. 5alpha-Reducatase type 2 mutations are present in some boys with isolated hypospadias. J. Urol. 1999; 162: 1142-5. 11. Kurzrock E., Baskin L., Cunha G. Ontogeny of the mal1e urethra: theory of endodermal differentiation. differentiation. 1999; 64: 115-22. 12. Kurzrock E., Baskin L., Li Y. et al. Epithelial-mesenchymal interactions in the development of the mouse fetal genital tubercle. Cells Tissues Organs. 1999; 164: 1015-20. 13. Baskin L.S. Hypospadias: a critical analysis of cosmetic outcomes using photography. Br. J. Urol. Int. 2001; 87: 534-9. 14. Snodgrass W., Koyle M., Manzoni G., Hurwitz R., Caldomone A., Ehrlich R. Tubularized incised plate hypospadias repair. results of a multicenter experience. J. Urol. 1996; 156:839-41. 15. Erol A., Baskin L.S., Li Y.W. et al. Anatomical studies of the urethral plate: why preservation of the urethral plate is important in hypospadias repair. Br. J. Urol. Int. 2000; 85 (6): 728-34. 16. Snodgrass W. Does tubularized plate hypospadias repair create neourethral strictures? J. Urol. 1999; 162: 1159-61. 17. Lopes J.F., Schned A., Ellsworth P.I. et al. Histological analysis of urethral healing after tubularized incised plate urethroplasty. J. Urol. 2001; 166: 1014-7. 18. Kurzrock E.A., Jegatheesan P., Cunha G.R., Baskin L.S. Urethral development in the fetal rabbit and induction of hypospadias: a model for human development. J. Urol. 2000; 164: 1789-92. 19. Braga L.H., Pippi-Salle J.L., Lorenzo A.J. et al. Comparative analysis of tabularized incised plate versus island flap urethroplasty for penoscrotal hypospadias. J. Urol. 2007; 178 (4, pt. 1): 1451-7. 20. Macedo A. Jr., Rondon A., Ortiz V. Hypospadias. Curr. Opin. Urol. 2012; 22(6): 447-52. 21. North K., Golding J. A maternal vegetarian diet in pregnancy is associated with hypospadias/The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. Br. J. Urol. Int. 2000; 85 (1): 107-13. 22. Snodgrass W. Tubularized incised plate for distal hypospadias. J. Urol. 1994; 151 (2): 464-5 23. Tashpulatov B.K. Differentiated approach to the choice of surgical tactics in children with hypospadias: abstract. dis.... cand. medical sciences M.; 2009 24. Bleustein C.B., Esposito M.P., Soslow R.A., Felsen D., Poppas D.P. Mechanism of healing following the Snodgrass repair. J. Urol. 2001; 165: 277-9. 25. Kim K. S., Torres C. R., Yucel S. et al. Induction of hypospadias in a murine model by maternal exposure to synthetic estrogens. Environ. Res. 2004; 94 (3): 267-75. 26. Ricard-Blum S. Cold Spring Harb Perspect Biol. 2010; 10: 1101/cshperspec.a004078. http://cshperspectives.cshlp.org on June 13, 2012. 27. Geng A., Tanell C., Gungar C. et al. Histopathological evaluation of the urethra after the Snodgrass operation: an experimental study in rabbits. Br. J. Urol. Int. 2002; 90(9):950-2. 28. Tuygun C., Bakirtas H., Gucuk A., Cakici H., Imamoglu A. Uroflow findings in older boys with tubularized incised plate urethroplasty. Urol. Int. 2009; 82 (1): 71-76. 29. Haddad A., Kirwan T., Aitken K. et al. Establishing biological rationale for preoperative androgensin hypospadias surgery. Dial Pediatr. Urol. 2012; 33 (3): 13 30. Cheng E.Y., Vemulapalli S.N., Kropp B.P. et al. Snodgrass hypospadias repair with vascularized dartos flap: the perfect repair for virgin cases of hypospadias? J. Urol. 2002; 168 (4, pt. 2): 1723-6. 31. Chia S.E. Endocrine disruptors and male reproductive function-a short review. Int. J. Androl. 2000; 23(Suppl. 2): 45-6. 32. Gordon M.K., Hahn R.A. Collagens. Cell Tissue Res. 2010; 339: 247-57. 33. Hiekkinen A., Tu H., Pihlajaniemi T. Collagen XIII: a type II transmembrane protein with relevance to musculoskeletal tissues, microvessels and inflammation. Int. J. Biochem. Cell Biol. 2012; 44: 714-7.

Information

Keywords

Hypospadias

Dystopia

Deformation of the corpora cavernosa

Malformation of the penis

Cleft glans penis

. "apron-shaped" foreskin

List of abbreviations

MAGPI - meatal advavcement and glanduloplasty (meatoglandulloplasty)

GAP - glans approximation plasty (operation to bring the “wings” of the head together, proposed by Zaontz (1991))

Criteria for assessing the quality of medical care

Table 1 - Organizational and technical conditions for the provision of medical care.

Table 2 - Quality criteria for assessing medical care

№	Quality criteria	The Power of Recommendation	Level of evidence
1	A consultation with a urologist or pediatric urologist-andrologist was performed.	1	A
2	The type of hypospadias and the presence of curvature and rotation of the penis were determined.	1	A
3	A urodynamic examination was performed (patients aged 2 to 18 years).	1	A
4	An ultrasound examination of the kidneys, urinary tract, and bladder was performed (if necessary, to exclude concomitant pathologies).	1	WITH
5	Urethroplasty and/or straightening of the penis and/or elimination of rotation of the penis was performed (if hypospadias was detected and if there were indications and no contraindications).	1	IN
6	Positive dynamics were achieved after surgical treatment of functional indicators of the act of urination: absence and/or improvement of signs of urination disorders according to the clinical picture and/or uroflowmetry data.	1	A

According to the European Association of Urology (EAU) guidelines, the scientific basis for various recommendations or statements has been classified in terms of level of evidence and recommendation. The criteria for level of evidence and type of recommendation are presented below.

Table A1 - Scheme for assessing the level of recommendations

WITH degree of reliability of recommendations	Risk-benefit ratio	Methodological quality of available evidence	Explanations for application of recommendations
		Reliable consistent evidence based on well-performed RCTs or compelling evidence presented in some other form.	A strong recommendation that can be used in most cases in the majority of patients without any modifications or exceptions
	The benefits clearly outweigh the risks and costs, or vice versa	Evidence based on the results of RCTs performed with some limitations (inconsistent results, methodological errors, indirect or random, etc.) or other compelling reasons. Further studies (if conducted) are likely to influence and may change our confidence in the benefit-risk estimate.	A strong recommendation that can be applied in most cases
	The benefits are likely to outweigh the potential risks and costs, or vice versa	Evidence based on observational studies, unsystematic clinical experience, results of RCTs performed with significant shortcomings. Any estimate of effect is considered uncertain.	Relatively strong recommendation, subject to change as higher quality evidence becomes available
	The benefits are comparable to the possible risks and costs	Reliable evidence based on well-performed RCTs or supported by other compelling data. Further research is unlikely to change our confidence in the benefit-risk assessment.	The choice of the best strategy will depend on the clinical situation(s), patient, or social preferences.
	The benefits are comparable to the risks and complications, but there is uncertainty in this assessment.	Evidence based on the results of RCTs performed with significant limitations (inconsistent results, methodological flaws, indirect or random), or strong evidence presented in some other form. Further studies (if conducted) are likely to influence and may change our confidence in the benefit-risk estimate.	An alternative strategy may be a better choice for some patients in certain situations.
	Ambiguity in assessing the balance of benefits, risks and complications; the benefits may be weighed against the possible risks and complications.	Evidence based on observational studies, anecdotal clinical experience, or RCTs with significant limitations. Any estimate of effect is considered uncertain.	Very weak recommendation; alternative approaches may be used equally.

*In the table, the numerical value corresponds to the strength of recommendations, the letter value corresponds to the level of evidence

These clinical recommendations will be updated at least once every three years. The decision to update will be made on the basis of proposals submitted by medical professional non-profit organizations, taking into account the results of a comprehensive assessment of drugs, medical devices, as well as the results of clinical testing.

Appendix A3. Related documents

Procedures for providing medical care:

1. Order of the Ministry of Health and Social Development of the Russian Federation dated April 16, 2012 N 366n “On approval of the Procedure for the provision of pediatric care”

2. Order of the Ministry of Health of Russia dated October 31, 2012 N 562n “On approval of the Procedure for providing medical care in the field of pediatric surgery”

Appendix B. Patient management algorithms

Appendix B: Patient Information

Hypospadias is a developmental abnormality in which the external opening of the urethra is located on the undersurface of the penis, below the center of the glans.

In a normal penis, the opening of the urethra (orifice) is located at the end of the penis. If hypospadias is severe and surgery is not performed, urine may flow in an unusual direction. Because of this, boys with severe untreated hypospadias are forced to urinate while sitting.

Severe forms of hypospadias can also affect the future ability to erect the penis, which in some cases leads to difficulties during sexual intercourse and, accordingly, reduces the possibility of conceiving a child.

According to the location of the external urethral opening, there are various forms of hypospadias. The most common classification of hypospadias is that proposed by Barcat. Anterior (65-70%): subdivided into capitate, coronal and distal - stem form. Medium (10-15%): medium-stem form. Posterior (20%): proximal-trunk, foam-scrotal, scrotal, perineal form. This pathology can be either without deformation of the cavernous bodies, or with slight or severe curvature of the latter.

During the clinical examination of the patient, special importance is attached to the examination of the external genitalia and a detailed assessment of the constituent elements of the defect. Determination of the size of the penis, the shape of the head and the severity of the scaphoid fossa, the degree of curvature of the corpora cavernosa, possible options for rotation of the penis, identification of rough scars from previous surgical interventions, attention is also paid to the size of the foreskin and scrotum

It has been established that the optimal time for surgical correction of hypospadias is considered to be between 6 months and 2 years of age, before the child begins to learn toilet skills and consciously evaluates his or her gender.

The urologist is faced with the task of choosing the most optimal methods for surgical correction of hypospadias, in which the end result will be an anatomically correctly formed penis with mandatory restoration of the capitate urethra, the presence of urination with normal external (non-spraying stream directed along the axis of the penis) manifestations, and uroflowmetric indicators , achieving psychosexual adaptation of the child, which also depends on the cosmetic result of surgical correction.

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“The charge has not yet been brought against him, and it is not true,” says Andreeva. “There was no extortion.” According to the lawyer, “this concerns the relationship between two people.” “A man who owes Alexander Nikolashin a large sum wrote a statement to the police about extortion. This was a definite obligation to Nikolashin, which was not fulfilled. And the agreement they signed stipulated that in case of non-compliance, a penalty should be paid,” the lawyer noted. According to her, the defense has documents that prove Nikolashin’s innocence. “We will ask for their involvement,” the lawyer added.

As follows from the data in SPARK, Alexander Nikolashin graduated from the Saratov Military Command School in 1988. From 2008 to 2014, he was a member of the supervisory board of OJSC Moscow Credit Bank. From 2012 to 2013, Nikolashin was the president of Moscow Credit Bank OJSC, and from 2013 to 2014, the president of MKB Capital LLC, as indicated in SPARK. From 2008 to 2012, he also served as Chairman of the Board of the Moscow Credit Bank. In total, Nikolashin worked at the MKB from 1994 to 2016. In the 1990s, he was the head of the MKB security service.

Close to Rosneft

MKB was created in 1992, and is now one of the largest Russian banks in terms of assets (sixth place in the Russian banking system, according to Interfax-CEA) and the second private bank in terms of this indicator after Alfa Bank. At the end of the second quarter, the bank's assets amounted to 1.9 trillion rubles. In terms of the volume of attracted deposits from the population, MKB is among the top ten Russian banks. The main owner of the bank is the Rossium concern of Roman Avdeev (his share is 56%).

MKB is the only bank from the so-called Gavrilov’s list that escaped reorganization (besides him, the list included B&N Bank, Promsvyazbank and FC Otkritie). Alfa Capital's director for work with wealthy clients, Sergei Gavrilov, argued that the situation around those on the list “could be finally resolved in the fall” of 2017.

MKB is often associated with Rosneft. In October 2017, Rosneft structures replenished the bank’s capital by 22 billion rubles, including their deposits. As Bloomberg wrote, MKB is actively selling bonds abroad through its Irish structure. In particular, bonds worth $500 million were sold in February 2018. At the same time, as the agency noted, the raised financing allowed the bank to expand lending to Rosneft, which is deprived of access to international capital markets due to sanctions.

“The bank did not go to court”

After leaving the bank, Nikolashin was deputy chairman of the board at one of the largest Russian car dealer holdings - Avtospetstsentr Group of Companies, whose main creditor is MKB.

The RBC bank could not confirm that the person indicated in the court materials is the former president of the MKB, specifying that they “know nothing about his fate.”

“The bank did not go to court; it is unknown at the bank whether the person involved in the case, Nikolashin, is the ex-president of MKB, as well as the essence of the claims against Nikolashin,” the bank told RBC.

MKB did not contact law enforcement agencies regarding the debts of Autospetscenter, added to MKB. A representative of Autospetscenter told RBC that Nikolashin officially left his post at the company in January 2018.

Catad_tema Diseases of the urinary system - articles

Hypospadias in children

ICD 10: Q54

Year of approval (revision frequency): 2016 (reviewed every 3 years)

ID: KR345

Professional associations:

Union of Pediatricians of Russia

Approved

Union of Pediatricians of Russia

Agreed

Scientific Council of the Ministry of Health of the Russian Federation __ __________201_

GAP - glans approximation plasty (operation to bring the “wings” of the head together, proposed by Zaontz (1991))

Terms and Definitions

New and narrowly focused professional terms are not used in these clinical guidelines.

1. Brief information

1.1 Definition

Hypospadias– one of the most common malformations of the penis, the main symptom of which is dystopia of the external urethral opening on the ventral surface of the penis. Also characteristic symptoms of the disease are splitting of the glans penis and “apron-shaped” foreskin with excess skin on the dorsal surface and deficiency on the ventral surface. The severity of the defect and the complexity of its correction are largely determined by the deformation of the cavernous bodies, which occurs in approximately 25% of patients with hypospadias.

1.2 Etiology and pathogenesis

1.3 Epidemiology

1.4 Coding according to ICD-10

Hypospadias(Q54):

Q54.0 - Hypospadias of the glans penis;

Q54.1 - Penile hypospadias;

Q54.2 - Hypospadias, penis-scrotal;

Q54.3 - Perineal hypospadias;

Q54.4 - Congenital curvature of the penis.

1.5 Classification

Table 1- Barcat classification (frequency in %).

However, from a practical point of view, it is more convenient to use the following classification:

Capitate hypospadias

Hypospadias with distal divergence (separation) of the corpus spongiosum and mild or no chord;
Hypospadias with proximal divergence of the corpus spongiosum and notochord

Methods for correction of the chord and urethroplasty over a large area have been well developed, and therefore these two forms are easier to surgically treat;

Hypospadias disabled people

These are patients after several unsuccessful operations with scar tissue, abnormal meatus, strictures, urethral discrepancy, fistulas, causing poor cosmetic and psychological results.

1.6 Examples of diagnoses

Hypospadias coronal form.
Hypospadias scrotal form. Urethral stricture.

1.7 Clinical picture

Hypospadias classically has 3 associated anomalies:

Ectopic opening of the urethral meatus;
Ventral curvature of the penis (chord);
Foreskin in the form of a “hood” with pronounced excess skin on dorsum penis and lack of skin on ventrum penis.

Anatomically, the defect can affect the entire ventral surface of the penis from apex to base:

There is a ventrally “open” head;
There is a missing segment of the urethral tube of varying length, which is replaced by a urethral plate extending from the ectopic meatus to the apex of the glans between the two corpora cavernosa;
There is a hypoplastic tubular urethra, not surrounded corpus spongiosum;
Divergence corpus spongiosum always proximal to the ectopic meatus. The “column” of each corpus spongiosum extends fan-shaped and laterally to the head;
Below divergence corpus spongiosum all the structures that form ventrum penis, normal;
Always missing arteria frenulum;
Dorsum penis always normal.

It is believed that the notochord is a direct consequence of pathological proximal divergence corpus spongiosum and hypoplasia of the ventral tissues of the penis. The occurrence of a chord is associated with the following factors:

“attachment” of ventral hypoplastic skin to the underlying structures (urethra) in most cases;
fan-shaped distribution laterally and upwards of the divergent corpus spongiosum;
“attachment” of the urethral plate and hypoplastic distal urethra (without corpus spongiosum) to the surface corpora cavernosa;
in rare cases - asymmetric development corpora cavernosa.

Embryologically, there are 2 types of hypospadias:

Cases involving the penile urethra resulting from impaired tubularization of the urethral plate (horizontal segment of the urogenital sinus) at 11 weeks of gestation;
Cases involving the capitate urethra, resulting from embryogenesis disturbances in the 4th month of gestation (account for 75% of cases).

2. Diagnostics

2.1 Complaints and anamnesis

2.2 Physical examination

During the clinical examination of patients, in addition to the traditional examination (percussion, palpation and auscultation), special importance is attached to the examination of the external genitalia and a detailed assessment of the component elements of the defect. It is recommended to determine the size of the penis, the shape of the head and the severity of the scaphoid fossa, the degree of curvature of the corpora cavernosa, possible options for rotation of the penis, identification of rough scars from previous surgical interventions, and attention is also paid to the size of the foreskin and scrotum.

It is recommended to evaluate the presence of factors complicating the correction of hypospadias.

Comments: Identification of combined defects of the penis and urethra can significantly reduce the number of postoperative complications.

Stenosis of the external opening of the urethra (meatostenosis). This defect often accompanies hypospadias.
Dysplastic changes in the distal urethra and the skin of the ventral surface of the penis in the form of thinning, impaired blood supply and mobility. These features significantly complicate urethroplasty and subsequent healing of the urethra. The use of altered skin as a plastic material is impractical.
Congenital curvature of the penis is most common with hypospadias. The leading pathomorphological cause of penile curvature in patients with hypospadias is insufficient development of the skin and fascia on its ventral surface and, in some cases, curvature of the corpora cavernosa. The urethral track plays a minor role in the curvature. Very often, curvature of the penis is accompanied by the presence of dysplastic changes in the distal urethra and the skin of the ventral surface of the penis.
Congenital rotation of the penis. To achieve a good cosmetic result, such patients are recommended to undergo detorsion (unwinding) and fixation of the penis in the correct position.
Ectopia of the penis. Visually, in such patients, the scrotum resembles the labia majora, and the penis resembles a hypertrophied clitoris. Moving the skin of the scrotum allows you to restore the correct anatomical position of the penis. As a rule, this defect is observed in proximal forms of hypospadias.
Urogenital sinus (utriculus) is observed in children with proximal hypospadias. Small sizes (up to 10 ml) and rapid emptying of the sinus do not pose a risk of postoperative complications (as a source of infection). The gigantic size of the sinus (up to 350 ml), with impaired emptying and infection, requires radical excision of the uterine bud. An integrated approach allows you to assess the patient’s initial condition and choose the optimal method of surgical treatment. However, it must be recognized that the degree of curvature of the penis and the quality of the urethral plate cannot be adequately assessed even with a detailed visual examination. Making a decision on tubularization of the neourethra or choosing another method of correction is advisable only after decutanization of the penis, its complete straightening and visualization of the urethral plate.

2.3 Laboratory diagnostics

It is not required to confirm the diagnosis.

2.4 Instrumental diagnostics

A urodynamic examination is recommended.

Comments: Combined urodynamic examination includes uroflowmetry and retrograde cystometry. Considering the non-invasiveness and simplicity of the technique, children aged 2 to 18 years are recommended to undergo a uroflowmetric examination, which today is a screening method for determining disorders of the urodynamics of the lower urinary tract, namely the contractility of the bladder detrusor and the resistance of the vesicourethral segment. This examination is carried out twice. Before surgery and after surgical correction.

An ultrasound examination of the upper urinary tract is recommended to exclude concomitant pathology.

3. Treatment

3.1 Conservative treatment

Not carried out

3.2 Surgical treatment

In case of classic hypospadias with an abnormal asymmetric foreskin, it is not recommended to carry out surgical treatment in the neonatal period to preserve the foreskin in order to optimize the choice of surgical tactics in the future.

Correction of hypospadias in otherwise healthy patients is recommended from the age of six months.

For distal forms of hypospadias, it is recommended to give preference to the following methods:

For capitate and coronal forms - MAGPI (meatal advavcement and glanduloplasty, meatoglandulloplasty, developed in 1981 by Duckett J.W.).

With a deep ventral groove of the head of the penis - GAP ( glans approximation plasty), an operation to bring together the “wings” of the glans, proposed by Zaontz (1991), W. Snodgrass, P. Mathieu, or its modification by Barcat, who supplemented the operation with a more thorough dissection of the urethral platform and wings of the glans penis and a more complete multilayer closure of the neourethra, which led to a decrease in the likelihood of fistula formation.

Comments:When performing the MAGPI operation, a bordering skin incision is made with a distance of 3 mm from the coronary sulcus, including the dystopic meatus. A dorsal meatotomy is performed using the Heinicke-Mikulicz principle (the meatus is incised longitudinally and sutured transversely). The dystopic external urethral opening with a small part of the urethra is moved to the tip of the penis and the lateral edges of the glans are connected above it (meatoplasty). Thus, the urethral tube is not created, and the meatus with the distal urethra is moved to the apex of the glans. The absence of urethral sutures virtually eliminates the formation of fistulas. A urethral catheter is not installed. The operation can be performed on an outpatient basis. This surgical intervention allows for particularly good correction of anterior forms of hypospadias. In this case, certain conditions are necessary: intact and mobile skin of the external opening of the urethra, a small meatus, a pronounced median groove on the ventral surface of the head. However, with these forms of hypospadias, in a significant number of cases there is no cavernous tissue of the distal urethra, the wall of which is represented by thin translucent skin.

In proximal forms, when choosing surgical tactics, most patients are recommended to undergo urethroplasty according to the W. Snodgrass method, which has proven itself not only for distal, but also for proximal forms of hypospadias, overhead surgical interventions according to Onlay or Hodgson II, as well as 2-stage operations .

A comment:

Characteristics of the Snodgrass urethroplasty method. This technology differs from the Duplay method by a longitudinal incision along the ventral surface of the glans penis. This incision allows you to reduce the line of the urethral suture without tension if the head of the penis is small or if the head is flattened.

Characteristics of the modified method of urethroplasty type Hodgson-II (F-II). The method is used for anterior and middle forms of hypospadias without ventral deformation of the penile shaft or with curvature, which can be eliminated by preserving an epithelial flap on the ventral surface of the penis between the hypospadias meatus and the apex of the glans penis. This operation belongs to a large group of "flip-flap" urethral plastic surgery, in which a flap on the ventral surface of the penis is used to form one of the walls of the artificial urethra. Urologists sometimes call this flap a "base" or "flip" flap. The width of this flap is usually half the circumference of the urethra.

It is recommended to carry out two-stage surgical procedures in certain cases, for example, when in distal forms the urethral platform is deformed, sclerotic and unsuitable for urethroplasty, as a result of which it is subject to complete excision, as well as in proximal forms, with pronounced curvature of the penis. .

Comments: the use of two-stage surgical procedures in certain cases makes it possible to create a functionally correct penis and obtain a good cosmetic result. This is especially true for proximal forms, with pronounced curvature of the penis, when at the first stage it is better to perform its optimal straightening, form a full-fledged urethral plate, and at the second stage, use the Snodgrass technique or an overhead type of operation.

In the presence of concomitant curvature of the penis, the following surgical tactics are recommended to straighten the penis: excision of tissue on the ventral surface of the penis, complete preservation of the urethral track with corrugation of the tunica albuginea on the back of the penis and partial separation of the urethral platform from the corpora cavernosa with its intersection in the tension zone . Or use an approach when straightening the penis is achieved after displacing the skin proximally from it, as well as during a skin incision proximal to the dystopic meatus and excision of scar tissue in this area.

A comment: straightening of the penis must be carried out under the control of artificial erection, regardless of the method of performing the operation.

If there is rotation of the penis, in order to achieve a good cosmetic result, such patients are recommended to have detorsion (untwisting) and fixation of the penis in the correct position.

4. Rehabilitation

No specific rehabilitation measures have been developed for patients with hypospadias.

5. Prevention and clinical observation

5.1 Prevention

No specific preventive measures have been developed for patients with hypospadias.

5.2 Managing children

If the treatment outcome is favorable, further inpatient observation is not required. An examination by a urologist is necessary 1 week after discharge from the hospital to identify and/or prevent early postoperative complications. The second examination is 1 month after discharge from the hospital. It is necessary to evaluate the cosmetic result and functional parameters (visual assessment of the diameter of the jet, if technically possible, uroflowmetry). The child should also be examined for possible complications: urethral fistulas, urethral diverticula, urethral stenosis, urethral lysis. Further observation is as indicated.

1 month after surgery, local anti-scar therapy is carried out with local agents.

5.3 Dynamic monitoring of the patient

6. Additional information affecting the course and outcome of the disease

6.1 Complications

The most common postoperative complications:

Unsatisfactory cosmetic result- occurs very often. The views of the surgeon and the patient on cosmetic results are often diametrically opposed.
Fistulas This is the second most common complication. If the fistula persists for more than 6 months, repeat surgery is necessary. The incidence of this complication varies depending on the technique used. With the Mathieu operation - 4% of cases, with Onlay urethroplasty - reaches 15%, with the Snodgrass operation - 1-4%. This complication is more common with free grafts than with vascular pedicle grafts.
Strictures– are currently less common, as they are caused by circular anastomoses, which are performed quite rarely. Previously often encountered when using the Hodgson technique.
Retraction of the meatus and divergence of the head– prevention consists of adequate mobilization of the wings of the head. This complication most often occurs during MAGPI surgery.
Conserving chord– is mainly due to the inexperience of the surgeon. Careful correction of the chord and performing an artificial erection test allows you to avoid this complication.
Urethrocele– There are 2 types. The first type is noted at the level of the reconstructed urethra, when there is an inadequate diameter of the neourethra, or concomitant meatostenosis. This type of urethrocele often occurs during urethroplasty using bladder mucosa. The second type may occur proximal to the neourethra, when part of the urethra is not surrounded by normal spongy tissue and the urethra is pulled outward during miction. In these cases, it is necessary to excise excess urethral tissue and correct distal stenosis.
Remote psychological problems. Few studies have been published examining long-term psychological problems in children after hypospadias correction. The sexual life of patients with hypospadias is generally undisturbed and begins later than in the general population. Patients with hypospadias have greater difficulty finding sexual contacts compared to the control group (33% versus 12%). Erections and fertility are usually not affected.
Recurrence of hypospadias- newly appeared external opening of the urethra in the place where it was before the operation. Usually associated with unsuccessful healing of the junction of the neourethra with its abnormal external opening. Recurrence of hypospadias is considered to be non-engraftment (rejection) of the newly created urethra, which also returns the situation to its preoperative state or even worsens it. Most often, recurrent hypospadias is eliminated as a result of two or multi-stage operations.

6.2 Outcomes and prognosis

The outcome of surgical operations is assessed according to the following criteria:

Good result:

Complete expansion of the corpora cavernosa. The problem of straightening the penis with hypospadias during surgery is solved first. The choice of method depends on the severity of the curvature or chord. First, a so-called paracoronal (around the border of the glans penis) incision is made, the urethral area is encircled by this incision and preserved. The skin of the penis and the fleshy membrane are displaced towards the base of the penis at the level of the fascia backa. With minor curvatures of the penis, which occur with the capitate and distal-trunk forms of hypospadias, straightening is achieved only by mobilizing the shaft of the penis. Moderately severe curvatures in proximal forms of hypospadias are corrected by applying plications (cutting and suturing ellipses of the tunica albuginea of the corpora cavernosa of the penis according to Physick – Nesbit – Baskin). Significant curvatures in proximal, scrotal (scrotal), penoscrotal and perineal forms of hypospadias, as well as in cases of damaged and sclerotic urethral platform, are corrected by crossing or excision of the urethral plate, with the placement of a newly created urethra in its place;
Complete cosmetic correction of the defect. Creation of an anatomically correctly formed penis with a slit-like vertical meatus in the area of the scaphoid fossa. The task of recreating the missing section of the urethra (urethroplasty) and its normal external opening (meatoplasty) is much more difficult and is solved during the operation after straightening the penis (orthroplasty);
Complete functional correction of the defect. Normal uroflowmetry indicators, a stream directed along the axis of the penis;
No complications;
Complete agreement of views regarding a positive cosmetic and functional result, both on the part of the surgeon and on the part of the patients’ parents.

Satisfactory result

The corpora cavernosa are straightened with a minimal angle of ventral deformation, the external opening of the urethra is located slightly proximal to the scaphoid fossa;
The act of urination is not impaired;
There are postoperative complications (fistulas, strictures).

Unsatisfactory result

The deformation of the penis is completely preserved, the urethral tube has a significant defect;
The act of urination is impaired;
Poor cosmetic result.

Criteria for assessing the quality of medical care

Table 1- Organizational and technical conditions for the provision of medical care.

table 2- Quality criteria for assessing medical care

	Quality criteria		Level of evidence
	A consultation with a urologist or pediatric urologist-andrologist was performed.
	The type of hypospadias and the presence of curvature and rotation of the penis were determined.
	A urodynamic examination was performed (patients aged 2 to 18 years).
	An ultrasound examination of the kidneys, urinary tract, and bladder was performed (if necessary, to exclude concomitant pathologies).
	Urethroplasty and/or straightening of the penis and/or elimination of rotation of the penis was performed (if hypospadias was detected and if there were indications and no contraindications).
	Positive dynamics were achieved after surgical treatment of functional indicators of the act of urination: absence and/or improvement of signs of urination disorders according to the clinical picture and/or uroflowmetry data.

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Kim K.S., Torres C.R., Yucel S. et al. Induction of hypospadias in a murine model by maternal exposure to synthetic estrogens. Environ. Res. 2004; 94 (3): 267-75.
Ricard-Blum S. Cold Spring Harb Perspect Biol. 2010; 10: 1101/cshperspec.a004078. http://cshperspectives.cshlp.org on June 13, 2012.
Geng A., Tanell C., Gungar C. et al. Histopathological evaluation of the urethra after the Snodgrass operation: an experimental study in rabbits. Br. J. Urol. Int. 2002; 90(9):950-2.
Tuygun C., Bakirtas H., Gucuk A., Cakici H., Imamoglu A. Uroflow findings in older boys with tubularized incised plate urethroplasty. Urol. Int. 2009; 82 (1): 71-76.
Haddad A., Kirwan T., Aitken K. et al. Establishing biological rationale for preoperative androgensin hypospadias surgery. Dial Pediatr. Urol. 2012; 33(3):13.
Cheng E.Y., Vemulapalli S.N., Kropp B.P. et al. Snodgrass hypospadias repair with vascularized dartos flap: the perfect repair for virgin cases of hypospadias? J. Urol. 2002; 168 (4, pt. 2): 1723-6.
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Appendix A1. Composition of the working group

Baranov A.A. Academician of the Russian Academy of Sciences, Professor, Doctor of Medical Sciences, Chairman of the Executive Committee of the Union of Pediatricians of Russia.

Namazova-Baranova L.S. Academician of the Russian Academy of Sciences, Professor, Doctor of Medical Sciences, Deputy Chairman of the Executive Committee of the Union of Pediatricians of Russia.

Zorkin S.N., Professor, Doctor of Medical Sciences, member of the Union of Pediatricians of Russia

Kovarsky S.L., Professor, Doctor of Medical Sciences

Menovshchikova L.B., Professor, Doctor of Medical Sciences

Fayzulin A.K., Professor, Doctor of Medical Sciences

Poddubny I.V., Ph.D. Doctor of Medical Sciences Professor

Akopyan A.I.,

Borisova S.A. Candidate of Medical Sciences, member of the Union of Pediatricians of Russia

Petrova M.G., Member of the Union of Pediatricians of Russia

Apakina A.V.– doctor of the highest category, pediatric surgeon, pediatric urologist-andrologist, member of the Union of Pediatricians of Russia, member of the Association of Pediatric Surgeons of Russia

Shakhnovsky D.S.– pediatric urologist-andrologist, member of the Union of Pediatricians of Russia

Kolmakov O.Yu., Member of the Union of Pediatricians of Russia

Pediatric urologists-andrologists;
Local pediatricians;
Pediatric surgeons;
General practitioners (family doctors);
Students of medical universities;
Students in residency and internship.

Methods used to collect/select evidence:

Search in electronic databases.

Description of methods used for collecting/selecting evidence:

The evidence base for publication is publications included in the Cochrane Library, EMBASE and MEDLINE databases. The search depth was 5 years.

Methodological examination is based on several key questions that focus on those features of the study design that have a significant impact on the validity of the results and conclusions. These key questions may vary depending on the types of studies, and the questionnaires used to standardize the publication assessment process.

Table P1- Scheme for assessing the level of recommendations

Risk-benefit ratio	Methodological quality of available evidence
	Reliable consistent evidence based on well-performed RCTs or compelling evidence presented in some other form.
The benefits clearly outweigh the risks and costs, or vice versa	Evidence based on the results of RCTs performed with some limitations (inconsistent results, methodological errors, indirect or random, etc.) or other compelling reasons. Further studies (if conducted) are likely to influence and may change our confidence in the benefit-risk estimate.
The benefits are likely to outweigh the potential risks and costs, or vice versa	Evidence based on observational studies, unsystematic clinical experience, results of RCTs performed with significant shortcomings. Any estimate of effect is considered uncertain.
The benefits are comparable to the possible risks and costs	Reliable evidence based on well-performed RCTs or supported by other compelling data. Further research is unlikely to change our confidence in the benefit-risk assessment.	The choice of the best strategy will depend on the clinical situation(s), patient, or social preferences.
The benefits are comparable to the risks and complications, but there is uncertainty in this assessment.	Evidence based on the results of RCTs performed with significant limitations (inconsistent results, methodological flaws, indirect or random), or strong evidence presented in some other form. Further studies (if conducted) are likely to influence and may change our confidence in the benefit-risk estimate.	An alternative strategy may be a better choice for some patients in certain situations.
Ambiguity in assessing the balance of benefits, risks and complications; the benefits may be weighed against the possible risks and complications.	Evidence based on observational studies, anecdotal clinical experience, or RCTs with significant limitations. Any estimate of effect is considered uncertain.

*In the table, the numerical value corresponds to the strength of recommendations, the letter value corresponds to the level of evidence

NO YES

Appendix B: Patient Information

Hypospadias is a developmental abnormality in which the external opening of the urethra is located on the undersurface of the penis, below the center of the glans.

Today, not a single doctor can say that his method is the best. Dozens of surgeons from different countries contributed to the improvement of technical techniques. The skill of a surgeon consists in mastering the entire arsenal of treatment methods and the ability to apply them creatively, guided by the characteristics of the pathology and the interests of the patient.

Hypospadias is a congenital malformation of the penis, characterized by clefting of the posterior wall of the urethra in the interval from the head to the perineum, clefting of the ventral edge of the preputial sac, ventral curvature of the shaft of the penis, or the presence of one of the listed signs.

Over the past 30 years, the frequency of births of children with hypospadias has increased from 1:450-500 to 1:125-150 newborns. The increasing frequency of births of children with various forms of hypospadias and the high incidence of postoperative complications, which reaches 50%, have led to the search for optimal methods of surgical treatment of this urological disease throughout the world.

ICD-10 code

Q54 Hypospadias

Causes of hypospadias

The causes of hypospadias are pathological changes in the endocrine system, as a result of which the external genitalia of the male fetus are not sufficiently virilized. The involvement of a hereditary factor in the development of hypospadias in children has now been proven. According to the observations of urologists, the frequency of familial hypospadias varies between 10-20%. Currently, many syndromes are known in which one or another form of disruption of sexual differentiation of the external genitalia occurs, leading to the formation of hypospadias in boys.

Sometimes making the correct diagnosis is not an easy task, the wrong solution of which can lead to erroneous tactics in the treatment process and, in some cases, lead to a family tragedy. In this regard, identifying the level at which an error occurred in the complex process of formation of the genital organs is a defining moment at the stage of diagnosing a patient with hypospadias.

Forms

Primary gonads are formed between the 4th and 5th week of fetal development. The presence of the Y chromosome ensures the formation of the testes. It is believed that the Y chromosome encodes the synthesis of the Y-antigen protein, which promotes the transformation of the primary gonad into testicular tissue. Embryogenic phenotypic differences develop in two directions: internal ducts and external genitalia are differentiated. At the earliest stages of development, the embryo contains both female (paramesonephric) cells. and male (mesonephric) ducts.

The internal genital organs are formed from the Wolffian and Müllerian ducts, which are located nearby in the early stages of embryonic development in both sexes. In male embryos, the Wolffian ducts give rise to the epididymis, vas deferens and seminal vesicles, while the Müllerian ducts disappear. In female embryos, the Müllerian ducts develop into the fallopian tubes, uterus, and upper vagina, while the Wolffian ducts regress. The external genitalia and urethra in fetuses of any sex develop from a common anlage - the urogenital sinus and genital tubercle, genital folds and elevations.

Fetal testicles are capable of synthesizing a protein substance (anti-Mullerian factor), which reduces the paramesonephric ducts in the male fetus. In addition, starting from the 10th week of intrauterine development, the fetal testicle, first under the influence of human chorionic gonadotropin (hCG), and then its own luteinizing hormone (LH), synthesizes a large amount of testosterone, which affects the indifferent external genitalia, causing their masculinization. The genital tubercle, increasing, transforms into the penis, the urogenital sinus into the prostate and prostatic part of the urethra, and the genital folds merge. forming the male urethra. The meatus is formed by retraction of epithelial tissue into the head and merges with the distal end of the formed urethra in the area of the scaphoid fossa. Thus, by the end of the first trimester, the final formation of the genital organs occurs.

It should be noted that for the formation of the internal male genital organs (genital ducts), the direct action of testosterone is sufficient, while for the development of the external genital organs, the influence of its active metabolite dihydrotestosterone, formed directly in the cell under the influence of a specific enzyme - 5-a-reductase, is necessary.

Currently, many classifications of hypospadias have been proposed, but only the Barcat classification allows an objective assessment of the degree of hypospadias, since the assessment of the form of the defect is carried out only after surgical correction of the shaft of the penis.

Classification of hypospadias according to Barcat

Anterior hypospadias.
- Capitate.
- Venechnaya.
- Anterior trunk.
Average hypospadias.
- Medium-stem.
Posterior hypospadias.
- Post-trunk.
- Stem-scrotal.
- Scrotal.
- Perineal.

Despite the obvious advantage, the Barcat classification has a significant drawback. It does not include a special form of this anomaly, hypospadias without hypospadias, which is sometimes called chordae type hypospadias. However, based on the pathogenesis of the disease, “hypospadias without hypospadias” is a more appropriate term for this type of anomaly, since in some cases the cause of ventral deviation of the penile shaft is exclusively dysplastic skin of the ventral surface without a pronounced fibrous chord, and sometimes the fibrous chord is combined with deep dysplastic processes in the the very area of the urethra.

In this regard, it is logical to expand the Barcat classification by adding a separate nosological unit - hypospadias without hypospadias.

In turn, there are four types of hypospadias without hypospadias:

Type I - ventral deviation of the shaft of the penis is caused exclusively by dysplastic skin of its ventral surface;
Type II - curvature of the shaft of the penis is caused by a fibrous chord located between the skin of the ventral surface of the penis and the urethra;
Type III - curvature of the shaft of the penis is caused by a fibrous chord located between the urethra and the cavernous bodies of the penis;
Type IV leads to curvature of the shaft of the penis due to a pronounced fibrous chord in combination with a sharp thinning of the wall of the urethra (urethral dysplasia).

Diagnosis of hypospadias

An in-depth clinical analysis, including a full range of urodynamic tests, as well as x-ray urological, radioisotope and endoscopic diagnosis of hypospadias, allows us to determine the tactics for further treatment of the patient.

Sometimes in the practice of a pediatric urologist, situations arise when, due to diagnostic errors, a child with a karyotype of 46 XX, but with virile genitals, is registered as male, and a child with a karyotype 46 XY, but with feminized genitals, is registered as female. The most common cause of problems in this group of patients is erroneous karyotyping or no karyotyping at all. Changing the gender of children at any age is associated with severe psycho-emotional trauma for parents and the child, especially if the patient’s psychosexual orientation has already taken place.

There are cases when girls with congenital adrenal hyperplasia and clitoral hypertrophy were diagnosed with hypospadias, with all the ensuing consequences, and, on the contrary, a boy with testicular feminization syndrome was raised as a girl until puberty. It is often during puberty that the lack of timely menstruation attracts the attention of specialists, but by this time the child has already formed sexual identity, or, in other words, social gender.

Thus, any child with abnormalities of the external genitalia should be examined in a specialized institution. In addition, even in children with intact genitals, it is necessary to perform an ultrasound of the pelvic organs immediately after birth. Currently, more than 100 genetic syndromes accompanied by hypospadias are known. Based on this fact, it is advisable to consult a geneticist, who in some cases helps to clarify the diagnosis and focus the attention of urologists on the features of the manifestation of a particular syndrome during the treatment process.

In solving this problem, the endocrinological aspect is most important, since the causes of hypospadias are based on disorders of the endocrine system, which, in turn, explains the combination of hypospadias with micropenia, scrotal hypoplasia, various forms of cryptorchidism and disorders of the obliteration of the vaginal process of the peritoneum (inguinal hernia and various forms of hydrocele of the testicle and spermatic cord).

In some cases, congenital malformations of the kidneys and urinary tract are detected in children with hypospadias, so ultrasound of the urinary system must be performed in patients with any form of hypospadias. More often, urologists encounter PMR, as well as hydronephrosis, ureterohydronephrosis and other anomalies of the urinary system. When hypospadias is combined with hydronephrosis or ureterohydronephrosis, plastic surgery of the affected segment of the ureter is initially performed, and only after 6 months. It is advisable to treat hypospadias. If vesicoureteral reflux is detected in a patient with hypospadias, it is necessary to clarify its cause and eliminate it.

Treatment of hypospadias

Understanding the pathogenesis of hypospadias determines the correct tactics of the surgeon and contributes to the successful treatment of hypospadias.

Treatment of hypospadias is carried out exclusively by surgery. Before surgery, it is necessary to conduct a comprehensive examination of the patient to differentiate hypospadias from other disorders of sex development. For this purpose, in addition to a general examination of the patient, karyotyping is required (especially in cases where hypospadias is combined with cryptorchidism).

Surgical treatment of hypospadias has the following goals:

complete straightening of the curved corpora cavernosa, providing an erection sufficient for sexual intercourse;
creation of an artificial urethra from tissues devoid of hair follicles of sufficient diameter and length without fistulas and strictures;
urethroplasty using the patient’s own tissue with adequate blood supply, ensuring the growth of the created urethra as the physiological growth of the cavernous bodies;
moving the external opening of the urethra to the top of the glans penis with a longitudinal arrangement of the meatus;
creation of free urination without deviation and splashing of the stream;
maximum elimination of cosmetic defects of the penis for the purpose of psycho-emotional adaptation of the patient in society, especially when entering into sexual relations.

With the introduction of the latest scientific advances into modern medicine, ample opportunities have opened up to reconsider a number of concepts in penile plastic surgery. The presence of microsurgical instruments, optical magnification and the use of inert suture material made it possible to minimize surgical trauma and perform successful operations in children from 6 months. Most modern urologists around the world prefer one-stage correction of hypospadias at an early age. Attempts by some urologists to perform a one-stage operation on newborn boys or children aged 2-4 months did not justify themselves. Most often, hypospadias correction is performed at 6-18 months. since at this age the ratio of the size of the cavernous bodies and the supply of plastic material (the actual skin of the penis) is optimal for performing surgical procedures.

In addition, at this age, performing corrective operations has minimal impact on the child’s psyche. As a rule, the child quickly forgets the negative aspects of postoperative treatment, which does not subsequently affect his personal development. Patients who have undergone multiple surgical interventions for hypospadias often develop an inferiority complex.

All types of developed surgical intervention technologies can be divided into three groups:

methods using your own tissues of the penis;
methods using patient tissue located outside the penis;
methods using advances in tissue engineering.

The choice of method often depends on the technical equipment of the clinic, the experience of the surgeon, the age of the patient, the effectiveness of preoperative preparation and the anatomical features of the genital organs.

Algorithm for choosing a method of surgical treatment of hypospadias

The choice of surgical treatment method directly depends on the number of methods that the surgeon is fluent in, since a number of techniques can be used with equal success for the same form of defect. Sometimes meatotomy is sufficient to solve the problem, and sometimes it is necessary to perform complex microsurgical operations, so the determining points for choosing a method are as follows:

location of the hypospadias meatus;
narrowing of the meatus;
preputial sac size;
ratio of the sizes of the cavernous bodies and the skin of the penis;
dysplasia of the skin of the ventral surface of the penis;
degree of curvature of the cavernous bodies;
size of the head of the penis;
depth of the groove on the ventral surface of the glans penis;
degree of rotation of the penis;
penis size;
the presence of synechiae of the foreskin and the degree of their severity;
topic of the shaft of the penis, etc.

Currently, more than 200 methods of surgical correction of hypospadias are known. However, this article presents operations that have a fundamentally new direction in plastic genital surgery.

The first attempt at surgical correction of hypospadias was made by Dieffenbach in 1837. Despite the interesting idea of the operation itself, unfortunately, it was not successful.

The first successful attempt at urethroplasty was performed by Bouisson in 1861 using rotated scrotal skin.

In 1874, Anger used an asymmetrical displaced flap of the ventral surface of the shaft of the penis to create an artificial urethra.

In the same year, Duplay used a tubularized ventral skin flap for plastic surgery of the urethra according to the Thiers principle, proposed for the correction of truncal epispadias in the 60s of that century. The operation was performed in one or two stages. In cases of distal forms of hypospadias, the operation was carried out in one stage; in cases with proximal forms, urethral plastic surgery was performed several months after preliminary straightening of the shaft of the penis. This operation has become widespread throughout the world, and currently many surgeons who do not know the technique of one-stage hypospadias correction use this technology.

In 1897, Nove and Josserand described a method for creating an artificial urethra using an autologous free skin flap. taken from the non-hairy part of the body surface (inner surface of the forearm, abdomen).

In 1911, L. Ombredant attempted a full-stage correction of the distal form of hypospadias, in which the artificial urethra was created using the flip-flap principle using the skin of the ventral surface of the penis. The resulting wound defect was closed with a displaced split prepuce flap according to the principle developed by Thiersch.

In 1932 Mathieu. using the Bouisson principle. performed successful correction of distal hypospadias.

In 1941, Humby proposed using the buccal mucosa to create a new urethra.

In 1946, Cecil, using the principle of Duplay and Rosenberger in 1891, performed a three-stage plastic surgery of the urethra in the trunk-scrotal form using trunk-scrotal anastomosis at the second stage of the surgical procedure.

Memmelaar in 1947 described a method for creating an artificial urethra using a free flap of the bladder mucosa. In 1949, Browne described the method of distal urethroplasty without closure of the internal platform of the artificial urethra, counting on independent epithelization of the non-tubularized surface of the artificial urethra.

The founder of a number of operations aimed at creating an artificial urethra using a vascular bundle was Broadbent, who in 1961 described several variants of such operations.

In 1965, Mustarde developed and described an unusual method of urethroplasty using a tubularized rotated ventral skin flap with tunnelization of the glans penis.

In 1969-1971 N. Hodgson and Asopa developed the Broadbent idea and created a number of original technologies that allow the correction of severe forms of hypospadias in one stage.

In 1973, Durham Smith developed and introduced the principle of the mixed de-epithepial flap, which subsequently became widespread throughout the world for the correction of hypospadias and excision of urethral fistulas.

In 1974, Cities and MacLaughlin first used and described the artificial erection test, in which, after applying a tourniquet to the base of the penis, sodium chloride (sodium chloride isotonic solution for injection 0.9%) was injected intracavernosally. This test made it possible to objectively assess the degree of curvature of the penile shaft.

In 1980, Duckett described a one-stage hypospadias correction using the skin of the inner layer of the prepuce on a vascular pedicle. In 1983, Koyanagi described an original method of one-stage correction of proximal hypospadias with a double vertical urethral suture.

In 1987, Snyder developed a method of urethroplasty using the inner layer of the prepuce on a vascular pedicle according to the principle of two flaps, or onlay urethroplasty.

In 1989, Rich applied the principle of longitudinal dissection of the ventral flap for distal hypospadias in combination with the Mathieu technology, performing urethroplasty with less tissue tension, thereby reducing the likelihood of developing postoperative complications.

In 1994, Snodgrass developed the idea further by using the same ventral surface dissection technique in combination with the Duplay technique.

Operation technique

To provide technical assistance in the surgical correction of hypospadias, the urologist must have in-depth knowledge of the anatomy of the penis. This knowledge makes it possible to optimally straighten the cavernous bodies, cut out a skin flap, which is supposed to be used to create an artificial urethra while preserving the vascular bundle, and close the wound surface without damaging important anatomical structures . Underestimating this problem can lead to serious complications, including disability. Successful treatment of hypospadias largely depends on technical equipment. As a rule, for surgical correction of hypospadias, urologists use a binocular loupe with 2.5-3.5x magnification or a microscope, as well as microsurgical instruments. Most often, an abdominal scalpel is used 15. anatomical and surgical tweezers with a minimal tissue gripping area, an atraumatic needle holder, hummingbird-type tweezers, small single-pronged and double-pronged hooks, as well as absorbable monofilament atraumatic suture material 6 0-8 0. During the operation, avoid crushing the tissues used to create the artificial urethra. For this purpose, small hooks or microsurgical retractors should be used. For long-term fixation of tissues in a certain position, it is advisable to use suture threads that do not cause damage to the skin flap.

When correcting any form of hypospadias, it is advisable to perform complete mobilization of the corpora cavernosa in the space between the superficial fascia of the penis and the Buck's fascia. This manipulation makes it possible to perform a complete revision of the cavernous bodies and carefully excise the fibrous chord, which, even with distal forms of hypospadias, can be located from the head to the penoscrotal angle, limiting further growth of the penis. Mobilized skin of the penis allows you to more freely complete the stage of closing the cavernous bodies, eliminating the possibility of tissue tension. One of the basic principles of genital plastic surgery that contributes to achieving a successful result remains the principle of loosely laid flaps without tissue tension.

Sometimes, after mobilization of the skin of the penis, signs of impaired microcirculation in the flap are noted. In these cases, the stage of urethral plastic surgery should be postponed until the next time, or, after performing urethral plastic surgery, the area of ischemic tissue should be shifted away from the vascular pedicle supplying the urethra, in order to avoid vascular thrombosis.

Upon completion of the stage of urethral plastic surgery, it is advisable to shift the line of subsequent sutures in order to prevent the formation of urethral fistulas in the postoperative period. Thiersch used this technique more than 100 years ago to correct the stem form of epispadias.

Most urologists agree that in the process of performing surgical procedures it is necessary to minimize the use of an electrocoagulator or use minimal coagulation modes. Some surgeons use 0.001% epinephrine (adrenaline) to reduce tissue bleeding. Spasm of peripheral vessels in some cases prevents an objective assessment of the condition of skin flaps and can lead to erroneous tactics during surgery. It is much more effective to use a tourniquet applied to the base of the cavernous bodies to achieve the same effect. However, it should be noted that it is necessary to remove the tourniquet from the cavernous bodies for a while every 10-15 minutes. During the operation, it is recommended to irrigate the wound with antiseptic solutions. Sometimes urologists, for prophylactic purposes, use a single daily dose of a broad-spectrum antibiotic in an age-appropriate dose.

Upon completion of the surgical procedure, an aseptic bandage is applied to the penis. Most surgeons tend to use a glycerol (glycerol) dressing in combination with a porous elastic bandage. An important point is to apply a loose gauze bandage soaked in sterile glycerol (glycerin) in one layer in a spiral from the head to the base of the penis. Then a thin porous elastic bandage (for example, a ZM Conat bandage) is applied over the gauze bandage. A strip 20-25 mm wide is cut out of the bandage. Then, using the same principle, one layer of bandage is applied in a spiral from the head to the base of the penis. There should be no tension on the bandage during the application of the bandage. It should only follow the contours of the shaft of the penis. This technique allows you to maintain adequate blood supply in the postoperative period, while limiting the increasing swelling of the penis. By the 5-7th day of the postoperative period, the swelling of the penis gradually decreases, and the bandage shrinks due to its elastic properties. The first change of the dressing is usually made on the 7th day if it is not soaked in blood and retains its elasticity. The condition of the bandage is assessed visually and by palpation. A bandage soaked in blood or lymph dries quickly and does not perform its function. In this case, it should be changed by first moistening it with an antiseptic solution and leaving it for 5-7 minutes.

Urinary diversion in the postoperative period

An important aspect in genital plastic surgery remains urine diversion in the postoperative period. Over the long history of genital surgery, this problem has been solved by various methods - from the most complex drainage systems to banal transurethral diversion. Today, most urologists consider it necessary to drain the bladder for a period of 7 to 12 days.

Many urologists use cystostomy drainage in the postoperative period, sometimes in combination with transurethral diversion. Some authors consider puncture urethrostomy, which ensures adequate urine diversion, to be the optimal method for solving this problem.

The vast majority of urologists consider effective urine diversion, which allows the bandage to be kept on the penis without contact with urine for a long time, as an essential component of a set of measures aimed at preventing possible complications.

Many years of experience in surgical correction of hypospadias objectively prove the rationality of using transurethral urine diversion in patients with any form of the defect.

An exception may be patients in whom tissue engineering achievements were used to create an artificial urethra. In this group of patients, it is logical to use a combined urinary diversion - puncture cystostomy in combination with transurethral diversion for up to 10 days.

It is recommended to use a urethral catheter with end and side holes No. 8 CH as the optimal catheter for bladder drainage. The catheter should be inserted into the bladder no deeper than 3 cm in order to prevent involuntary detrusor contractions and urine leakage.

It is not recommended to use catheters with a balloon, which causes irritation of the bladder neck and constant contraction of the detrusor. In addition, removal of the Foley catheter increases the risk of injury to the artificial urethra. The reason for this is that the balloon, inflated for 7-10 days, is not able to collapse to its original state in the postoperative period. An overstretched wall of the balloon leads to an increase in the diameter of the removable catheter, which can contribute to partial or complete rupture of the artificial urethra.

In some cases, urine leakage in addition to the urethral catheter persists, despite the optimal location of the drainage. This circumstance is usually associated with the posterior position of the bladder neck, resulting in constant irritation of the bladder wall by the catheter. In these cases, it is more effective to leave a stent in the urethra inserted proximal to the hypospadias meatus, in combination with drainage of the bladder through puncture cystostomy [Fayzulin A.K. 2003].

The urethral catheter is fixed to the head of the penis at a certain distance (15-20 mm) for easier crossing of the ligature when removing the catheter. It is advisable to apply a duplicate interrupted suture over the edge of the bandage and tie it with an additional knot to the urethral catheter. This way, the urethral catheter will not pull on the head of the penis, causing pain to the patient. The outer end of the catheter is connected to the urinary receiver or diverted into a diaper or diaper.

Typically, the urethral catheter is removed in the interval from 7 to 14 days, paying attention to the nature of the stream. In some cases, there is a need to bougienage the artificial urethra. Since this manipulation is extremely painful, it is performed under anesthesia. After the patient is discharged from the hospital, it is necessary to conduct a follow-up examination after 1, 2 weeks, 1, 3 and 6 months. and then once a year until the growth of the penis is completed, focusing the parents’ attention on the nature of the flow and erection.

Wound drainage

Drainage of a postoperative wound is performed only in cases where it is impossible to apply a compression bandage to the entire surgical area: for example, if the urethral anastomosis is applied proximal to the penoscrotal angle.

For this purpose, use a thin tube No. 8 CH with multiple side holes or a rubber outlet, which is brought out from the side of the skin suture line. The drain is usually removed the day after surgery.

Characteristics of individual methods of surgical correction of hypospadias

MAGPI method

The indication for the use of this technique is the location of the hypospadias meatus in the area of the coronary sulcus or the glans penis without ventral deformation of the latter.

The operation begins with a bordering incision around the glans penis, 4-5 mm away from the coronary sulcus, and on the ventral surface the incision is made 8 mm proximal to the hypospadias meatus.

When making an incision, maximum care must be taken due to the thinning of the tissue of the distal part of the urethra over which the incision is made, and the threat of the formation of a urethral fistula in the postoperative period.

The skin incision is made through the entire thickness to the Buck's fascia. After this, the skin of the penis is mobilized, allowing the vessels that nourish the skin to be preserved. After cutting the skin of the penis itself, the superficial fascia is lifted using tweezers and cut with vascular scissors. The tissues are spread bluntly between the superficial fascia and the Buck's fascia. With proper dissection of the fascia, mobilization of the skin occurs almost bloodlessly.

Then, using vascular scissors, the soft tissue of the penis is carefully separated along the skin incision, gradually moving from the dorsal surface to the lateral sides of the penis in the interfascial space. Particular attention should be paid to manipulations in the area of the ventral surface, since it is here that the skin of the penis, the superficial fascia and the tunica albuginea (Buck's fascia) are intimately fused, which can lead to injury to the wall of the urethra.

The skin is removed from the shaft of the penis to the base, like a stocking, which makes it possible to eliminate the skin torsion that sometimes accompanies distal forms of hypospadias, and also to create a mobile skin flap.

At the next stage, a longitudinal incision is made along the scaphoid fossa of the penis, including the dorsal wall of the hypospadias meatus for the purpose of meatotomy, since distal forms of hypospadias are often accompanied by meatal stenosis.

The incision is made quite deep to cross the connective tissue bridge located between the hypospadias meatus and the distal edge of the scaphoid fossa. Thus, the surgeon achieves smoothing of the ventral surface of the head, eliminating the ventral deviation of the stream during urination.

The wound on the dorsal wall of the meatus takes on a diamond shape, which ensures the elimination of any meatal narrowing. The ventral wound is sutured with 2-3 transverse sutures using a monofilament thread (PDS 7/0).

For glanuloplasty, a single-tooth hook or microsurgical forceps is used, with which the skin edge proximal to the hypospadias meatus is raised towards the head so that the ventral edge of the surgical wound resembles an inverted V.

The lateral edges of the wound on the head are sutured with 2-3 U-shaped or interrupted sutures without tension on an age-sized urethral catheter.

When closing a wound defect with the remnants of mobilized skin, there is no single method that is universal for all cases of skin grafting, since the degree of dysplasia of the ventral skin, the amount of plastic material on the shaft of the penis and the size of the preputial sac vary widely. The method of closing the skin defect proposed by Smith is more often used, in which the preputial sac is split with a longitudinal incision of the latter along the dorsal surface. Then the resulting skin flaps are wrapped around the shaft of the penis and stitched on the ventral surface to each other or one under the other.

In most cases, the remaining skin is sufficient to freely close the defect without any movement of tissue, and a mandatory point from a cosmetic point of view is excision of the remnants of the prepuce.

In some cases, to close a ventral wound defect, the Tiersh-Nesbit principle is used, in which a hole is created in the avascular zone of the dorsal skin flap through which the head of the penis is moved dorsally, and the defect on the ventral surface is covered with fenestrated prepuce tissue. Then the coronal skin edge of the wound is sutured to the edge of this hole, and the wound on the ventral surface of the shaft of the penis is sutured in the longitudinal direction with a continuous suture.

Method of urethroplasty for megalomeatus without the use of prepuce (MIP)

The indication for the use of this technology is the coronal form of hypospadias without ventral deformation of the penile shaft, confirmed by an artificial erection test.

The operating principle is based on the Tiersch-Duplay technology without the use of prepuce tissue. The operation begins with a U-shaped incision along the ventral surface of the glans penis, bordering the megameatus along the proximal edge (Fig. 18-89a). Using sharp scissors, the side walls of the future urethra are carefully isolated without crossing the split spongy body of the urethra. Most often, there is no need for deep separation of the walls, since the deep navicular fossa allows the formation of a new urethra without the slightest tension.

The urethra is formed on a urethral catheter. The transurethral catheter must move freely in the lumen of the created channel. As a suture material, it is optimal to use a monofilament absorbable thread 6/0-7/0.

In order to prevent paraurethral urine leakage in the postoperative period, a continuous precision urethral suture is used. A skin suture is applied in a similar manner.

Relocation of the urethra with glanuloplasty and prepuce plastic surgery for distal forms of hypospadias

Indications for the use of this method are capitate and coronal forms of hypospadias without signs of dysplasia of the distal urethra. At the beginning of the operation, the bladder is catheterized. The operation begins with a submeatal crescent-shaped skin incision, which is made 2-3 mm below the meatus.

This incision is extended vertically, bordering the meatus on both sides and continuing upward until they meet at the apex of the glans penis. The meatus is isolated using a sharp and blunt method, then the distal urethra is mobilized. Behind the urethra there is a fibrous layer. It is very important not to lose the layer during the process of secretion of the urethra and not to damage its wall and cavernous bodies. At this stage of the operation, special attention is paid to maintaining the integrity of the urethra and thin skin of the penis, which reduces the risk of postoperative fistula formation. Mobilization of the urethra is considered complete when the urethral meatus reaches the apex of the glans penis without tension. To excise the remaining chord near the coronary sulcus, two incisions are made, each of which is about 1/4 of its circumference. After complete mobilization of the urethra, its reconstruction begins. The meatus is sutured to the tip of the glans penis using an interrupted suture. The head is closed over the displaced urethra with interrupted sutures. The skin of the prepuce is given a natural appearance by transversely dissecting its ventral part on both sides and connecting vertically. Thus, the head is covered with the restored foreskin. After the operation, the penis acquires a normal appearance, the meatus is located at the top of the glans, the skin of the prepuce borders the glans. The transurethral catheter is removed on the 7th day after surgery.

Method of urethroplasty type Mathieu (1932)

Indications for the use of this technology are the capitate form of hypospadias without deformation of the shaft of the penis with a well-developed scaphoid fossa, in which the urethral defect is 5-8 mm in combination with full skin of the ventral surface, which has no signs of dysplasia.

The operation is performed in one stage. Two parallel longitudinal incisions are made along the lateral edges of the scaphoid fossa lateral to the hypospadias meatus and proximal to the latter for the length of the urethral tube deficiency. The width of the skin flap is half the circumference of the created urethra. The proximal ends of the incisions are connected to each other.

In order to reliably cover the created urethra, the spongy tissue of the glans penis is mobilized. This is a very delicate task; it is performed by carefully cutting along the connective tissue bridge between the cavernous body of the head and the cavernous bodies until the rotated flap is placed in the newly created niche, and the edges of the head are freely closed over the formed urethra.

The proximal end of the skin flap is mobilized to the hypospadias meatus and rotated distally, overlaying it on the base flap so that the corners of the top of the selected flap coincide with the tops of the incisions on the base flap using the flip-flap type. The flaps are sewn together with a lateral continuous intradermal precision suture from the top of the head to the base of the flap on the urethral catheter.

The next step is to stitch the mobilized edges of the glans penis with interrupted sutures over the formed urethra. Excess preputial tissue is resected at the level of the coronary sulcus. The operation is completed by applying a compression bandage with glycerol (glycerin). The catheter is removed on the 10-12th day after surgery.

Tiersch-Duplay type urethroplasty method

The indication for this operation is the coronal or capitate form of hypospadias in the presence of a well-developed glans penis with a pronounced scaphoid groove.

The principle of the operation is based on the creation of a tubularized flap on the ventral surface of the penis and therefore has well-founded contraindications. This operation is not advisable to perform in patients with trunk and proximal forms of hypospadias. since the urethra is created according to the principle of Tiersch and Duplay. practically devoid of main feeding vessels and, accordingly, has no prospects for growth. Children with proximal forms of hypospadias operated on using this technology suffer from “short urethra” syndrome during puberty. In addition, the incidence of postoperative complications after using this technique is the highest.

The operation begins with a U-shaped incision along the ventral surface of the penis, bordering the hypospadias meatus along the proximal edge. Then the edges of the wound on the head are mobilized, penetrating the connective tissue septum between the spongy tissue of the head and the cavernous bodies. Then the central flap is sewn into a tube on a catheter No. 8-10 CH with a continuous precision suture, and the edges of the head are sewn together with interrupted sutures over the formed urethra. The operation is completed by applying a compression bandage with glycerol (glycerin).

Method of urethroplasty using the buccal mucosa In 1941, G.A. Humby first proposed the use of the buccal mucosa as a plastic material for the surgical correction of hypospadias. Many surgeons have used this method, but J. Duckett actively promoted the use of buccal mucosa for reconstruction of the urethra. Many surgeons avoid using this technology due to the high rate of postoperative complications, which varies from 20 to 40%.

There are one-stage and two-stage operations for reconstruction of the urethra using the buccal mucosa. In turn, one-stage operations are divided into three groups:

plastic surgery of the urethra with a tubularized flap of the buccal mucosa;
plastic surgery of the urethra using the “patch” principle;
combined method.

In any case, the buccal mucosa is initially collected. Even in an adult, it is possible to obtain a maximum flap measuring 55-60x12-15 mm. It is more convenient to harvest a flap from the left cheek if the surgeon is right-handed, standing to the left of the patient. It must be remembered that the flap should be taken strictly from the middle third of the lateral surface of the cheek in order to avoid injury to the ducts of the salivary glands. An important condition should be considered distance from the corner of the mouth, since a postoperative scar can lead to deformation of the mouth line. Ransley (2000) for the same reason does not recommend using the mucous membrane of the lower lip for this purpose. In his opinion, the postoperative scar leads to deformation of the lower lip and impaired diction.

Before harvesting the flap, an injection is made with a 1% solution of lidok and na or a 0.5% solution of procaine (Novocaine) under the mucous membrane of the cheek. A flap is sharply cut out and the wound defect is sutured with interrupted sutures using 5/0 chrome-plated catgut threads. Then. also in a sharp way, remove the remains of the underlying tissue from the inner surface of the mucous membrane. Next, the treated flap is used for its intended purpose. In cases where the urethra is formed according to the principle of a tubular flap, the latter is formed on a catheter with a continuous or interrupted suture. Then the formed urethra is sutured end to end with the hypospadias meatus and a meatus is created, closing the edges of the dissected head above the artificial urethra.

When creating the urethra using the “patch” principle, it should be remembered that the size of the implanted mucosal flap directly depends on the size of the base skin flap. In total, they must correspond to the age-related diameter of the urethra being formed. The flaps are sutured together with a lateral continuous suture using 6/0-7/0 absorbable sutures on a urethral catheter. The wound is closed with the remnants of the skin of the shaft of the penis.

The buccal mucosa is used less frequently when there is a deficiency of plastic material. In such situations, part of the artificial urethra is formed using one of the described methods, and the deficiency of the urethral tube is eliminated using a free flap of the buccal mucosa.

Similar operations in patients with completed growth of the cavernous bodies are certainly of interest. However, regarding pediatric urological practice, the question remains open, since it is impossible to exclude a lag in the development of the artificial urethra from the growth of the cavernous bodies of the penis. Patients with hypospadias operated on at an early age using this technology may develop short urethra syndrome and secondary ventral deformation of the penile shaft.

Method of urethroplasty using a tubularized inner layer of the prepuce on a vascular pedicle

The Duckett technique is used for one-stage correction of the posterior and middle forms of hypospadias, depending on the supply of plastic material (the size of the foreskin). The technology is also used in severe forms of hypospadias with severe skin deficiency in order to create an artificial urethra in the scrotal and scrotal-trunk sections. An important point is the creation of a proximal fragment of the urethral tube from skin devoid of hair follicles (in this case from the inner layer of the foreskin), with the prospect of distal urethroplasty using local tissues. The defining point is the size of the preputial sac, which limits the possibilities of plastic surgery of the artificial urethra.

The operation begins with a bordering incision around the head of the penis, 5-7 mm away from the coronary sulcus. The skin is mobilized to the base of the penis according to the principle described above. After mobilization of the skin of the penis and excision of the fibrous chord, an assessment of the true deficiency of the urethra is made. Then a transverse skin flap is cut out from the inner layer of the foreskin. An incision on the inner surface of the prepuce is made to the depth of the skin of the inner layer of the foreskin. The length of the flap depends on the size of the urethral tube defect and is limited by the width of the preputial sac. The flap is sutured into a tube on a catheter with a continuous precision intradermal suture using atraumatic monofilament absorbable sutures. The remains of the inner and outer layers of the foreskin are stratified in the avascular zone and are subsequently used to close the wound defect on the ventral surface of the penis. An important stage of this operation is the careful mobilization of the artificial urethra from the outer epithelial lamina without damaging the vascular pedicle. Then the mobilized urethral tube is rotated onto the Vienna surface to the right or left of the shaft of the penis, depending on the location of the vascular pedicle in order to minimize the bending of the supplying vessels. The formed urethra is sutured to the hypospadias meatus in an end-to-end fashion using an interrupted or continuous suture.

Anastomosis between the artificial urethra and the glans penis is performed using the Hendren method. To do this, the epithelial layer is dissected to the cavernous bodies, after which the distal end of the created urethra is placed in the formed hollow and sutured to the edges of the scaphoid fossa with interrupted sutures above the formed urethra. Sometimes in children with a small head of the penis, it is impossible to close the edges of the head. In these cases, the Browne technology, described in 1985 by V. Belman, is used. In the classic version, tunneling of the glans penis was used to create an anastomosis of the distal part of the artificial urethra. According to the author, stenosis of the urethra occurred with a frequency of more than 20%. Using the Hendren and Browne principle allows us to reduce the incidence of this postoperative complication by 2-3 times. To close the cavernous bodies of the penis, previously mobilized skin of the outer layer of the prepuce is used, dissected along the dorsal surface and rotated to the ventral surface according to the Culp principle.

Method of island urethroplasty on a vascular pedicle according to the principle of the Snyder-III patch

This technology is used in patients with coronal and trunk forms of hypospadias (anterior and middle forms according to Barcat) without curvature of the penile shaft or with minimal curvature. Patients with severe curvature of the penile shaft often require intersection of the ventral skin track to fully straighten the corpora cavernosa. An attempt to straighten the penis with a pronounced fibrous chord using the dorsal plication method leads to a significant shortening of the length of the penile shaft.

The operation is not indicated in patients with hypoplastic foreskin. Before surgery, it is necessary to assess the correspondence of the size of the inner layer of the prepuce and the distance from the hypospadias meatus to the apex of the head.

The operation begins with a U-shaped incision along the ventral surface of the penis, bordering the hypospadias meatus along the proximal edge. The width of the ventral flap is formed by at least half of the age-related circumference of the urethra. Then the incision is extended to the sides, bordering the head of the penis, retreating 5-7 mm from the coronal sulcus. Skin mobilization is carried out according to the method described above. The fibrous chord is excised on the sides of the ventral flap. In case of persistent curvature of the penile shaft, plication is performed along the dorsal surface.

The next step is to cut out a transverse skin flap from the inner layer of the prepuce, corresponding in size to the ventral flap. The incision is made to the depth of the skin of the inner layer of the foreskin. Then the prepuce flap is mobilized in the avascular zone, exfoliating the prepuce layers. The skin "island" is mobilized until it moves to the ventral surface without tension. The flaps are sewn together with a continuous subcutaneous suture on the urethral catheter. Initially, the mesenteric edge is sutured, then the opposite one. The mobilized edges of the head are sutured with interrupted sutures over the formed urethra. The exposed cavernous bodies are covered with the remnants of mobilized skin.

Combined method of urethroplasty using the FIII-Duplau method

Indication for surgery is the scrotal or perineal form of hypospadias (posterior according to the Barcat classification), in which the meatus is initially located on the scrotum or perineum at a distance of at least 15 mm proximally.

The operation begins with a bordering incision around the head of the penis, 5-7 mm away from the coronary sulcus. Along the ventral surface, the incision is extended longitudinally to the penoscrotal angle. Then the skin of the penis is mobilized until it moves to the scrotum along the ventral surface. Along the dorsal and lateral surfaces, mobilization of the skin is carried out to the penosymphyseal space with dissection lig. suspensorium penis.

At the next stage, urethroplasty is performed using the F III technology, and the gap from the hypospadias meatus to the penoscrotal angle is performed using the Duplay method. N. Hodgson suggests suturing fragments of the artificial urethra end to end on a urethral catheter No. 8 CH. It is known that the number of postoperative complications when using end anastomoses reaches 15-35%. In order to minimize complications, the onlay-tube or onlay-tube-onlay principle, described below, is currently used. The wound defect is sutured with a continuous blanket suture. The operation is traditionally completed by applying a glycerol (glycerol) dressing.

The combined principle of urethroplasty for proximal forms of hypospadias can also consist of an island tubularized skin flap from the inner layer of the foreskin (Duckett principle) and the Duplay method, as well as the Asopa technology in combination with the Duplay method.

Method of urethroplasty F-II

This method of surgical correction of hypospadias is based on the principle developed by N. Hodgson (1969-1971). But essentially this is a modification of a well-known method. Used for anterior and middle forms of hyposladia.

In 50% of patients with distal hypospadias, congenital meatus stenosis is diagnosed. Surgery begins with bilateral lateral meatotomy according to Duckett. The length of the incisions varies from 1 to 3 mm depending on the age of the patient and the severity of the stenosis. The incision line is preliminarily crushed with a mosquito-type hemostatic clamp, and after dissecting the meatus, an interrupted suture is applied to the incision area, but only if blood leakage from the edges of the wound is noted. After eliminating the meatus stenosis, the main stage of the surgical procedure begins.

A U-shaped incision is made on the ventral surface of the penis, edging the meatus along the proximal edge. In the classic version, the width of the base flap is made equal to half the circumference of the urethra. A modified incision on the ventral surface is made along the edge of the scaphoid fossa, which does not always correspond to half the circumference of the urethra. Most often, the shape of this cut resembles a vase with a widened neck, narrowed neck and widened base.

In these cases, the opposing flap is formed in such a way that when the flaps are applied, a perfectly straight tube is obtained. In those places where expansion was formed on the base flap, a narrowing is created on the donor flap, and vice versa.

A shaped incision on the ventral surface is made in order to maximize the preservation of the glans tissue for the final stage of glanuloplasty and more convenient access to the connective tissue intercavernous groove separating the spongy tissue of the glans penis and the cavernous bodies.

Mobilization of the skin of the penis is carried out using standard technology up to the peno-scrotal angle. In cases where the deep dorsal vein of the penis has a perforating vessel associated with a skin flap, surgeons try not to cross it. Maximum preservation of the venous angioarchitecture of the penis makes it possible to reduce venous stasis and, accordingly, reduce the degree of swelling of the penis in the postoperative period. For this purpose, the perforator vessel is mobilized to the level until the dorsal flap is placed freely, without the slightest tension, after moving the skin flap to the ventral surface. In cases where mobilization of the flap is impossible due to the tension of the vessel, the vein is ligated and dissected between the ligatures without coagulation. Coagulation of the perforating vessel can lead to thrombosis of the main venous trunks.

The prepuce flap for forming the urethra is cut to the thickness of the skin of the outer layer of the foreskin. Only the skin is dissected without damaging the subcutaneous tissues, which are rich in vessels feeding the preputial flap.

The shaft of the penis is moved using the Tiersch-Nesbit technique. Given the presence of meatotomy incisions, there was a need to modify the principle of suturing skin flaps. In this case, a basic interrupted suture is applied 3 o'clock from the right edge of the meatus, and then, while suturing the urethral flaps, the dorsal flap is sutured to the tunica albuginea in close proximity to the ventral edge. This technique allows you to create a sealed urethral suture line without technical difficulties and avoid urinary leaks.

According to the method proposed by N. Hodgson, the ventral surface of the glans penis remains covered with preputial skin, which creates a clear cosmetic defect with a good functional result. In the future, when the patient enters into sexual activity, this type of head causes tactless questions and even complaints from sexual partners, which, in turn. sometimes leads to nervous breakdowns and the development of an inferiority complex in a patient who has undergone surgery.

In the modification of the final stage of this operation (F-II), a solution to this problem is proposed. The essence lies in de-epithelialization of the distal part of the artificial urethra using microsurgical scissors and suturing the edges of the glans penis over the formed urethra; this technique allows you to imitate the natural appearance of the glans penis.

To do this, microsurgical scissors curved along a plane excise the epidermis without capturing the underlying tissues in order to preserve the vessels of the skin flap, retreating 1-2 mm from the artificial meatus, meepithelialization is carried out to the projection level of the coronary sulcus. Then the lateral edges of the wound on the glans penis are stitched together over the created urethra with interrupted sutures without tension on the skin tissue, thus, it is possible to close the ventral surface of the glans penis, which makes it possible to bring the appearance of the glans penis as close as possible to the physiological state. The final stage of the operation does not differ from the standard method described above.

Method of urethroplasty for hypospadias without hypospadias type IV (F-IV, F-V)

One of the options for correcting hypospadias without type IV hypospadias is the technology of replacing a fragment of the dysplastic urethra based on operations of the N. Hodgson (F-IV) and Ducken (F-V) type. The principle of the operation is to preserve the capitate part of the urethra and replace the dysplastic fragment of the stem part of the urethra with an insert from the skin of the dorsal surface of the penis or the inner layer of the prepuce on a feeding pedicle with a double urethral anastomosis of the onlay-tube-onlay type.

Operation F-IV begins with a bordering incision around the head of the penis. The skin on the ventral surface with hypospadias without hypospadias is often not changed, so a longitudinal incision along the ventral surface is not made. The skin of the penis is removed like a stocking to the base of the shaft. Excision of superficial fibrous cords is performed. Then the displastic urethral tube, devoid of the corpus cavernosum, is resected from the coronary sulcus to the beginning of the spongy body of the urethra. In some cases, the fibrous chord is located between the dysplastic urethra and the cavernous bodies. The chord is excised without any problems due to wide access. The degree of straightening of the shaft of the penis is determined using an artificial erection test.

The next step is to cut out a rectangular skin flap on the dorsal surface of the skin flap, the length of which corresponds to the size of the urethral defect, and the width to the circumference of the urethra, taking into account the patient’s age.

Then, two holes are formed in the proximal and distal sections of the created flap for further movement of the shaft of the penis. The epithelial flap is sutured on a catheter with a continuous suture, departing 4-5 mm from the ends of the flap. This technique allows you to increase the cross-sectional area of the end anastomoses and, accordingly, reduce the frequency of stenoses of the urethra, since experience in the surgical treatment of hypospadias has shown that in almost all cases, narrowing of the urethra occurred precisely in the area of the end joints.

The penis is then moved along the Nesbit twice: initially through the proximal opening to the dorsal surface and then through the distal opening to the ventral side. The last movement is preceded by the application of an onlay-tube type anastomosis between the proximal end of the artificial urethra and the hypospadias meatus. After the second movement of the shaft of the penis through the distal opening, a distal anastomosis is applied between the outlet end of the new urethra and the adductor end of the capitate section of the own urethra according to the tube-onlay principle similar to the first. Urethral anastomoses are performed on a urethral catheter No. 8-10 CH.

To close the skin defect on the dorsal surface of the penis, gentle mobilization of the lateral edges of the dorsal flap wound is performed. after which the wound is closed by suturing the edges together with a continuous suture. The remaining skin around the head is sutured to the distal edge of the mobilized flap also continuously. The defect on the ventral surface of the penis is closed with a longitudinal intradermal suture. When performing urethroplasty, it is necessary to avoid the slightest tension of the tissue, which leads to marginal necrosis and divergence of the suture line.

To correct hypospadias without hypospadias in combination with urinary dysplasia, the modified Duckett procedure (F-V) can also be used.

The determining factor for performing this operation is the presence of a well-developed foreskin, in which the width of the inner layer is sufficient to create the missing fragment of the urethra. The distinctive point of this operation in comparison with the classic Duckett operation is the preservation of the capitate urethra with a double urethral anastomosis of the onlay-tube-onlay type after the creation of an artificial urethra from the internal layer of the prepuce and moving it to the ventral surface of the penis. The skin defect is closed according to the principle described above.

Method of urethroplasty using a lateral flap (F-VI)

This is a modification of Operation Broadbent (1959-1960)). The fundamental difference of this technology is the total mobilization of the cavernous bodies in patients with posterior hypospadias. The method also involves dividing a skin flap used to create an artificial urethra with a hypospadias meatus. The Broadbent technology used urethral anastomosis according to the Duplay principle, and in a modified version, according to the end-to-end principle, onlay-tube or onlay-tube-onlay.

The operation begins with a bordering incision around the head of the penis. Then the incision is extended along the ventral surface to the hypospadias meatus, bordering the latter, 3-4 mm from the edge. After mobilizing the skin of the penis to the base of the shaft with the intersection of lig. suspensorium penis, the fibrous chord is excised.

Having assessed the true deficit of the urethra after straightening the penis, it is obvious that it, as a rule, significantly exceeds the supply of plastic material of the shaft of the penis itself. Therefore, to create an artificial urethra along its entire length, one of the edges of the skin wound is used, which has minimal signs of ischemia. To do this, four supports are placed in the intended area for creating the flap. corresponding in length to the deficiency of the urethra. Then the boundaries of the flap are marked with a marker and cuts are made along the marked contours. The depth of the incision along the lateral wall should not exceed the thickness of the skin itself in order to preserve the vascular pedicle. The shape of the flap is created using the onlay-tube-onlay technology described above.

A particularly important point is the isolation of the vascular pedicle, since the thickness of the full-thickness flap does not always allow this manipulation to be performed easily. On the other hand, the length of the vascular pedicle should be sufficient for free rotation of the new urethra to the ventral surface with the line of the urethral suture facing the cavernous bodies. The artificial urethra is formed according to the onlay-tube-onlay principle. After moving the urethra to the ventral surface, axial rotation of the penile shaft sometimes occurs by 30-45*, which is eliminated by rotating the skin flap in the opposite direction. The operation is completed by applying a compression bandage with glycerol (glycerin).

Hypospadias correction method according to the onlay-tube-onlay and onlay-tube principle (F-VllI, F IX)

Stenosis of the urethra is one of the most serious complications that arise after its plastic surgery in posterior and middle forms of hypospadias. Bougienage of the urethra and endoscopic dissection of the narrowed portion of the urethra often lead to recurrence of stenosis and, ultimately, to re-operation.

Stenosis of the urethra, as a rule, is formed in the area of the proximal urethral anastomosis, applied on an end-to-end basis. In the process of searching for a rational method for correcting the defect, a method was developed to avoid the use of end anastomosis, called onlay-tube-onlay.

The operation begins with a shaped incision. To do this, a flap resembling the letter i is cut out along the ventral surface of the glans penis. The width of the flap is formed according to the age-related diameter of the urethra; it is half the circumference of the urethra. The incision is then extended along the midline of the ventral surface of the shaft from the base of the U-shaped incision to the hypospadias meatus. retreating h = 5-7 mm from its distal edge. A skin flap is cut out around the meatus, angled in the distal direction. The width of the flap is also half the circumference of the urethra. The next step is to make a bordering incision around the glans penis until the incision lines on the ventral surface merge.

The skin of the penis shaft is mobilized according to the principle described above. Then the fibrous chord is excised until the cavernous bodies are completely straightened. after which they begin to create an artificial urethra.

A shaped island resembling a two-handed rolling pin is cut out on the dorsal surface of the skin flap. The length of the entire dorsal flap is formed depending on the deficiency of the urethral tube. The proximal narrow fragment of the flap should correspond in its width and length to the proximal skin island of the ventral surface, and the distal narrow fragment of mobilized skin is created similarly to the distal one on the shaft of the penis. The fundamental point in the process of flap formation remains the exact ratio of the incision angles. It is the spatial understanding of the configuration of the future urethra that makes it possible to avoid stenosis in the postoperative period.

The skin island formed on the dorsal skin flap is mobilized using two microsurgical forceps. Then, a window is bluntly created at the base of the flap, through which the exposed cavernous bodies are transferred dorsally. The proximal narrow dorsal fragment is sutured to the proximal ventral one using the onlay principle with a continuous intradermal suture to the point indicated in the figure by number 3. The starting points on the dorsal and ventral flaps must coincide. The main fragment of the artificial urethra is also sutured into a tube continuously. The distal section is formed similarly to the proximal one in a mirror image. The urethra is created using a urethral catheter No. 8 CH.

The onlay-tube-onlay principle is used when the head of the penis is undeveloped, when the surgeon has doubts at the stage of its closure. In patients with a well-developed head, the onlay-tube principle is used (Fig. 18-96).

To do this, one skin island is cut out on the ventral surface, bordering the meatus according to the principle described above. A flap is created on the dorsal surface, resembling a one-handed rolling pin, with the handle facing the base of the shaft of the penis. After creating the urethral tube, the distal part of the artificial urethra is de-epithelialized just enough to close the mobilized edges of the head above the urethra. The edges of the head are sewn together with interrupted sutures over the created urethra. The exposed cavernous bodies are covered with mobilized skin of the penis.

Method of urethroplasty in children with posterior hypospadias using the urogenital sinus (F-VII)

Often, in children with severe forms of hypospadias, a urogenital sinus is detected. Normally, during the formation of the genital organs, the sinus is transformed into the prostate and posterior urethra. However, in 30% of patients with severe forms of hypospadias, the sinus remains. The size of the sinus is variable and can range from 1 to 13 cm, and the higher the degree of violation of sexual differentiation, the larger the sinus. Almost all patients with severe sinus do not have a prostate, and the vas deferens are either completely obliterated or open into the sinus. The internal lining of the urogenital sinus is usually represented by urothelium, adapted to the effects of urine. Considering this circumstance, the idea arose to use tissue from the urogenital sinus for plastic surgery of the urethra.

This idea was first put into practice in a patient with true hermaphroditism with a 46 XY karyotype and virile genitalia.

During a clinical examination, the child was diagnosed with perineal hypospadias, the presence of a gonad in the scrotum on the right and a gonad in the inguinal canal on the left. During the operation, during revision of the inguinal canal on the left, ovotestis was detected, confirmed histologically, i.e. mixed gonad containing female and male reproductive cells. The mixed gonad was removed. The urogenital sinus is isolated, mobilized and rotated distally.

The sinus is then modeled into a tube according to the Mustarde principle up to the peno-scrotal angle. The distal part of the artificial urethra was formed using the Hodgson-III method.

Plastic surgery of the urethra using tissue engineering methods (F-V-X)

The need to use plastic material devoid of hair follicles is dictated by the high incidence of long-term postoperative complications. Hair growth in the urethra and the formation of stones in the lumen of the created urethra create significant problems for the patient’s life and great difficulties for the plastic surgeon.

Currently, technologies based on the achievements of tissue engineering are becoming increasingly widespread in the field of plastic surgery. Based on the principles of treating burn patients using allogeneic keratinocytes and fibroblasts, the idea of using autologous skin cells to correct hypospadias arose.

For this purpose, a piece of skin with an area of 1-3 cm2 is taken from the patient in a hidden area of 1-3 cm2, immersed in a preservative and delivered to a biological laboratory.

Human keratinocytes are used in this work, since epithelio-mesenchymal relationships are not species specific (Cunha et al., 1983: Hatten et al., 1983). Skin flaps measuring 1x2 cm are placed in Eagle's medium containing gentamicin (0 16 mg/ml) or 2000 U/ml benzylpenicillin and 1 mg/ml streptomycin. Prepared skin flaps are cut into strips of 3x10 mm. washed in a buffer solution, placed in a 0.125% dispase solution in DMEM medium and incubated at 4 ° C for 16-20 hours or in a 2% dispase solution for 1 hour at 37 ° C. After this, the epidermis is separated from the dermis along the basal line membranes. The suspension of epidermal keratinocytes obtained by pipetting is filtered through a nylon mesh and precipitated by centrifugation at a speed of 800 rpm for 10 minutes. Then the supernatant is drained and the sediment is suspended in a culture medium and seeded into plastic bottles (Costaf) at a concentration of 200 thousand cells/ ml of medium. Then keratinocytes are grown for 3 days in a complete nutrient medium: DMEM:F12 (2:1) with 10% fetal calf serum. 5 μg/ml soluble insulin (human genetically engineered), 10"6M isoproterenol*3, 5 μg /ml transferrin. Cells are then grown in DMEM:F12 (2:1) with 5% serum, 10 ng/ml epidermal growth factor, insulin and transferrin, and the medium is changed regularly. After the cells form a multilayer layer, differentiated suprabasal keratinocytes are removed, for which the culture is incubated for three days in DMEM without Ca. After this, the keratinocyte culture is transferred to complete medium and, a day later, passaged onto the surface of a living tissue equivalent formed by fibroblasts enclosed in a collagen gel.

Preparation of living tissue equivalent

The mesenchymal base of the graft, collagen gel with fibroblasts, is prepared as described earlier and poured into Petri dishes with a Spongostan sponge. The final polymerization of the gel with the sponge and fibroblasts enclosed inside takes place at 37 °C for 30 minutes in a CO2 incubator. The next day, epidermal keratinocytes are planted on the surface of the dermal equivalent at a concentration of 250 thousand cells/ml and cultured for 3-4 days in a CO2 incubator in a complete medium. One day before transplantation, the live equivalent is transferred to complete medium without serum.

As a result, after a few weeks, a three-dimensional cellular structure is obtained on a biodegradable matrix. The dermal equivalent is brought to the clinic and formed into the urethra, stitched into a tube or using the onlay principle for urethroplasty. Most often, this technology is used to replace the perineal and scrotal sections of the artificial urethra, where the threat of hair growth is greatest. The urethral catheter is removed on the 10th day. After 3-6 months, distal urethroplasty is performed using one of the methods described above.

When assessing the results of surgical treatment of hypospadias, it is necessary to pay attention to functional and cosmetic aspects that allow minimizing the patient’s psychological trauma and optimally adapting him to society.

Prevention

Prevention of this disease should be considered the exclusion of medications, external environmental factors and food products that interfere with the normal development of the fetus and are called “disruptors” in the literature. Disruptors are chemical compounds that disrupt the normal hormonal status of the body.

These include all types of hormones that block the synthesis or replace the body’s own hormones, for example, when there is a threat of miscarriage, gynecologists often use hormonal therapy - as a rule, hormones of the female body, which, in turn, block the synthesis of male hormones responsible for the formation of the genital organs. Disruptors also include non-hormonal chemical compounds that enter the body of a pregnant woman with food (vegetables and fruits treated with insecticides and fungicides).