دانلود کتاب Hypospadias Surgery: An Illustrated Textbook

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