Table Of ContentHADIDI •AZMY Hypospadias Surgery
Springer-Verlag Berlin Heidelberg GmbH
Ahmed T. Hadidi· Amir F. Azmy (Eds.)
Hypospadias
Surgery
An Illustrated Guide
With 173Figures in 482Separate Illustrations,
Mostly in Color
• Springer
ProfessorDr,AhmedT.Hadidi
Cairo UniversityHospital
32HaroonStreet32,EIMessahaDokki
Cairo 12311,Egypt
Mr.AmirF.Azmy
RoyalHospitalfor Siek Children
Yorkhill, GlasgowG38ST,UnitedKingdom
ISBN 978-3-662-07843-3 ISBN 978-3-662-07841-9 (eBook)
DOI10.1007/978-3-662-07841-9
LibraryofCongressCataloging-in-Publication
Hypospadias surgery:anillustratedguide/]edited by]AhmedT.Hadidi,AmirF.Azmy.p.;cm.
Includesbibliographicalreferencesand index.
1. Hypospadias-Surgery. 2. Genitourinary organs-Surgery. 3.Pediatric urology.4. Children
Surgery.1.Hadidi,Ahmed T.(AhmedTaher),1958-II.Azmy,A.A.F. [DNLM:1.Hypospadias
surgery.2.Hypospadias-complications.3.SurgicalProcedures, Operative-methods. WJ 600
H998 2004] RD137.H976.2004 617.4'63-dc21 2003045746
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To
my father, Taher,
for leadinghis children into intellectualpursuits;
my mother,Mawaheb,
for devoting herlifeto her children;
my uncle, Helmy,
for setting an outstanding example to follow;
my professors,A. Loutfiand N.Kaddah,
for showingme the excitement andjoy ofpaediatric surgery;
my mentors,Dan Youngandlohn Duckett,
for paving the wayto international recognition.
A.T.H.
To
mywife,Fatma,
for herlove,encouragement and continuing support;
my daughter,Iman, and my son, Ayman,
for their understanding;
my mentor,Herbert Eckstein,
for introducingme to paediatric urology.
A.F.A.
Foreword
The challenge of hypospadias correction has always lopment and its consequences as wellas giving gui
tested the ingenuityofsurgeons and, although many dance on methods of surgical correction.The edito
of the older methods have been discredited and rial duo ofHadidi and Azmyare tobe congratulated
discarded, the diversity of procedures in current on assembling a distinguished and expert team to
practicesuggests that theperfectoperationhasyetto fulfilthis requirement.Thisvolume willbeindispen
be devised. Evidently there have been important sable readingforallthose called upon to treathypo
advances during the past 30 years, and the results spadias, but it is gratifying to see that although the
nowobtainedwould bethe envyofoldersurgeons. It techniques ofplasticsurgeryhavecontributedto the
isinstructiveto note that particularattention isnow newer methods, it is the paediatric urologists who
given to securing a meatus at the tip of the glans are now principally concerned. Hopefully they will
(even in those minor degrees of hypospadias which ensurethat hypospadiasisfullycorrectedearlyinlife
would formerly have been left untreated), reflecting and that adult urologists will no longer be asked to
the pursuit of physical perfection which now fuels rescue sadly mismanaged young men with serious
the popularityofcosmeticsurgery. sexual and psychologicalhandicaps.
There wasundoubtedlyaneed foracornprehensi
vetextdealingwith allaspects ofthe abnormaldeve- SirDavidInnesWilliams
Foreword
An illness or abnormality that attracts a continuing nage systems. Although the penile repairs can be
bibliography of many hundreds of journal articles groupedinto fiveor six major principles,depending
implies that there are unresolved problems.Such is on the tissues used, each has been subject to count
the situationin hypospadias.And yet,at first glance, lessvariations asone surgeon after anotheradds yet
this is very surprising. Here is a deformity in an another modification to an already thrice-rnodified
organ so overtlyrecognisable for c1inicaland epide variation of a procedure adapted from a principle
miologicalstudy,so easilyaccessiblefor tissuehisto derived from the original! Further,some repairs are
logyandhistochemistry,andsoamenable,one could successful only in the hands of the original propo
assume, to the simplest of plastic surgical repair, nent, and the subtleties escape the novice, who, in
giventhatthereistotal surgicalaccessandexposure, frustration, flips to yet anothertechnique. Hypospa
surrounded by ample available tissues, and with a dias isbedevilledbysurgeonswho swap to the latest
rich bloodsupplyforhealing; itshouldbe a"gift"for gimmickandnever acquirethe expertiseofapracti
even moderate surgical prowess! Yet nothing could cedtechnique,which isessentialforgoodresults.We
be further from the truth. still debate the place of one- or two-stage repairs.
Inalmosteveryfacetwelackcompleteunderstan Some repairs frankly offend major surgical princi
ding. We have gaps in genetic information; the plesin theircomplexity,in the fashioning offlaps,in
embryologyisunsettledastothe natureofthe tissue disrespectfor bloodsupply,andin inadequatelayers
organizers,the relative contributions ofthe ectoder and tension.What are the indications to use aspeci
mal folds and rnesothelium, or whether the defor ficrepairinagivenc1inicalsituation?Doweneed ten
mityisnot"developmental"atall,butrather,asDou different proceduresfor ten different situations,with
glas Stephens asserts, the result of distortion and the attendantrisk ofinsufficientvolume ofexperien
displacementofearly foetal cellsbyexternalpressu ceto acquire the necessaryexpertisein any ofthem,
re;whythe great variationin c1inicaltypes, e.g.vari or can we reduce these to a manageable and well
ations in orifice size andsite and degree of chordee, practiced two or three adequate techniques with
or a large penile shaft orifice but no chordee, or a appropriate adaptations? In what circumstances is
coronalorifice with completeprepuce,or anormally urinary diversion required and by means of which
sited terminal orifice but marked chordee? Wehave technique?
incomplete understandingof the pathologyof chor The problems do not stop with the completion of
dee, from the simplistic and probably mythical apparently successful surgery. I know of no surgery
"whiteband"ofDenis Browneto the varyingcontri that can quite humble a surgeon as much as hypo
butions of skin, fasciallayers and corpora,andwhat spadias-it carries avicious bite with its list of com
determines their contributions. The confusion is plications, most galling when they can occur years
evenmoremarkedinthe surgicalmanagement.With later,suchasaverylatefistula orthemanifestationof
alesioninwhich over200differentrepairshavebeen recurrentchordee.Addtothis listproblemsofejacu
described, a cynic may be excused in c1aimingthat lation or sexual function and the psychological
none can be very satisfactory! We have proceeded effectsbefore andafter surgeryorinlaterlife,and we
through Browne repairs and scrotal flaps,to Duplay have alesion to test the ingenuity,inventiveness and
tubes,tofreeskin grafts,toislandflapsand onlays,to resilience ofsurgeons asmuch asanyin surgery.
bladderand buccal mucosal repairs,to ahost ofsin Thesearejustsome ofthe unresolvedproblemsin
gle-stage innovations, to different concepts of chor the surgery of hypospadias. Given this maelstrom
dee correction andwith all manner ofbladderdrai- therecould benobettertimeforthe compilationofa
X Foreword
volume bringingtogetherthe verybestauthoritiesin In asubjectwith reportsspreadsowidelythroug
acritical analysis ofallaspects ofthe malformation. hout a vast list of publications, the book is a major
Under the stimulating editorship of Ahmed Hadidi contribution to the effort to reduce to manageable
andAmir Azmy,themselves leaders in this field, the proportions the current accumulated knowledge of
contributions of an international faculty of world hypospadias,with each area beingassessedandana
leadershavebeenassembled.Asaperusalofthe table lysed by experts.We surely need such a volume. I
of contents will show,the book covers all the major have everyexpectationthat the breadthofcoverand
operative repairs, described in many cases by their the quality of the contributors are such that our
originators,butthebookismuchmorethanacollec puzzling unknowns will be addressed,and surgeons
tion of techniques.It rightly also covers the general will have at hand an authoritative guide to practical
aspectsofhistory,epidemiology,genetics,ernbryolo management.
gy and pathology; surgical principles,ancillary aids
andanaesthesia;the long- termevaluationofresults, E.Durham Smith,AO,MD,MS,FRACS,FACS,
induding early and late complications; and, impor Hon.FRCS(Eng.,Edin.,Glas.,Ire.)
tantly,an overview ofmanagementtobringperspec EmeritusConsultantSurgeon
tiveto this complexlesion. RoyalChildren'sHospital, Melbourne,Australia
Preface
HypospadiasSurgery:AnIllustrated Guide and paediatricsurgical associations in the USA,UK,
Australia,Japan and Europe.
Someofthe chaptersarewrittenbynon-surgeons
Hypospadiasisagrievousdeformitywhichmustever and present new and important knowledge concer
move us to the highestsurgicalendeavour.The refas ning epidemiology,genetics,and childpsychology.
hioningofthe urethraoffers aproblem as formidable Thebook isweIlillustratedwithamplecolourdia
asanyinthewide fieldofourart.The fruitsofsuccess grams and photographs ofvarious operations toget
are beyond rubies - the gratitude of a boy has to be
her with manytechnical tips.There isawidediversi
experiencedto be believed.
ty of opinion and a large number of operations are
T.TwistlugtonHiggins,London,1941 described. Information is occasionally intentionally
repeated when the circumstancesdemand.
Hypospadiology,defined as the in-depth studyof the
Thebookconsists ofthree sections.
art andscienceofthe surgicalcorrectionofhypospa
Section 1 contains chapters dealing with the
dias, iscurrentlyflourishing. Recently,heateddebates
historical perspective:the evolution ofhypospadias
have ensured,challengingthe age-old truthingrained
surgery,the basic principles of repair, the detailed
in the historieteachingson this fascinatinganomaly.
Thesenew conceptshave promptedthis treatiseas embryology and anatomical studies, the epidemio
acontributiontothisanthologyonthesubject.Appro logyandgeneticsofhypospadias.Furthercontribu
priateto the momentare two ofourfavourite quota tions deal with general principles,includingexami
tions:"Scepticisrn blossoms on the compost of expe nation,imaging,intersexuality,preoperative prepa
rience"and"Opinions abound where truths are hard
rationandhormonalstimulation,assessmentofthe
to prove",
results of hypospadias surgery, principles of plastic
lohn Duckett,Philadelphia,1995 surgeryand general principles of hypospadias sur
gery. Sutures, stenting materials and dressings are
described,and acomprehensivechaptercoverspain
The purpose of this comprehensive, weIl-illustrated control.
textbook is to help interested surgeons to develop Section 2indudeschaptersdescribing the operati
vision, philosophy and talent, rather than just enu ve techniques for correction of the proximal and
merate techniques. In this wayweaim to provide an distaltypes ofhypospadias.There isemphasis onthe
up-to-date global view of the management of the useofsingle-stage repairinseveretypes ofhypospa
child with hypospadias, focusing primarily on the dias. However, the need for two-stage repair is
care of the condition and its associated problems. discussed indetail.Currentcontroversial issuessuch
Thebookwillbeofspecificinteresttopaediatricand as the relative merits of single- versus two-stage
adulturologists,paediatricand general surgeons and repair, flaps versus grafts, dressings and urinary
plastic surgeons. diversion aredebated in depth.
Thebook isan example ofinternational coopera Section 3dealswith thecomplicationsofhypospa
tion.Forty-sixexperts from 12countriesonfivecon dias surgery and their management, complex redo
tinents havecontributedtoit. repairs, long-term results in adolescence, and
Eachof the chapters in the book iswritten byan psychologicaladjustments.
authority in the field of hypospadiology.Ateam of Lastly,the editorspresenttheirpersonal overview
world dass contributors present their expert opi of the current surgical techniques and potential
nions. Theauthors are members ofmajor urological developments inhypospadias surgery.
