Hypospadias Surgeries Overview

MAGPI: Meatal Advancement and Glanuloplasty

  • Indication: distal hypospadias without chordee (no more than 1cm proximal to glans)
  • Preop: make sure ventral skin proximal to meatus is thick and mobile – this allows it to be moved distally
    • If perimeatal skin is poor quality, will need onlay repair
  • Contraindication: don’t do if meatus too proximal, if there is not enough laxity of neighboring skin,  and if there is no tissue bridge between glans and meatus
  • STEPS of the procedure:
    1. ventral transverse incision just proximal to corona and meatus
    2. mobilize skin on dartos fascia down to penoscrotal junction
    3. make deep vertical incision in the glans just distal to the meatus; distal cut into glans should be close to location of new meatus; sometimes wedge resection required
    4. close vertical incision transversely (Heineke Mikulics) – this advances meatus
    5. pull proximal edge of meatus with holding stitch or skin hook to make inverted “V”
    6. excise medial glans tissue to make glans wings
    7. close deep glans tissue
    8. close superficial epidermis after removing excess epidermis
    9. excise dorsal hood and close penis
    10. NOTE: must frequently calibrate urethra with bougie/sound
    11. NOTE: if ventral skin deficient, split dorsal skin dorsally to create Byer’s flaps
    12. approximate vertex of Byers flaps dorsally to coronal skin and bring Byer’s flaps ventrally, excising redundant tissue and suture flaps to eachother in the midline

MAGPI Arap modification

  • Indication: if difficult to make dorsal glans incisions and perform Heineke-mikulicz type advancement, then can perform Arap mod
  • Steps:
    1. make ventral hemi-circle transverse incision just proximal to corona
    2. place two holding sutures at the ventral aspect and pull distally to create a “V”
    3. close the V starting at the vertex
    4. steps 8-12 as above

GAP:  Glans approximation procedure (Zaontz)

  • Indication: wide and deep glanular groove with a non-compliant or fish-mouth meatus
  • Steps:
    1. Make U incision with vertex of “U” under meatus
    2. Make “C” (in ref to surgeon) incision on L and reverse “C” incision on R with both meeting in the middle and continuous with “U” vertex
    3. Close skin ventrally using both C flaps
    4. excise excess skin and cover penis

Mathieu: “flip flap” 

  • Indication: hypo with minimal chordee
  • Steps:
    1. Identify distance between desired location of meatus and hypo meatus
    2. Make “U” incision proximal to hypo meatus with tips of U just proximal to meatus and vertex even more proximal (vertex with flip over as a flap)
    3. Make “J” and reverse “J” incisions to isolate urethral plate on L and R, with inferior aspect of J cut creating glans wings
    4. Bring flap up making sure to preserve dartos for blood supply
    5. suture on side of urethral plate to flap; suture other side
    6. close glans wings in the midline
    7. place meatal sutures to fix flap to medialized glans wings
    8. Byer’s flaps closure as before

Duckett: Onlay Preputial Island Flap

  • Indication: midshaft or proximal hypospadias without chordee
  • Steps:
    1. Make U incision starting from where meatus should be on glans down to hypo meatus with vertex of U swinging just proximal to hypo meatus
    2. incise skin 5mm proximal to coronal sulcus
    3. make glans wings by deepening glans incisions on each side of the U
    4. sometimes helpful to excise small V at hypomeatus to freshen up urethral edges
    5. place holding sutures in dorsal hood skin and mark out transverse rectangle
    6. raise this rectangular inner preputial flap on a dartos blood supply proximally making sure not to devascularize it
    7. rotate rectangle flap and secure it in onlay fashion onto urethral plate
    8. make sure to excise excess skin and preserve dartos fascia to maximize blood supply (want 12-14Fr urethra)
    9. close glans wings; neomeatus sutures
    10. Byer’s flaps as appropriate

Thiersch-Duplay: Ventral tube repair

  • Indication: redo hypo repairs and staged repairs
  • Steps:
    1. V incision in glans with vertex at proximal glans
    2. Make urethral strip with parallel longitudinal incisions down to hypomeatus (want 1.5cm wide infant; 2.5cm children; 3cm adult)
    3. Mobilize edges of dorsal urethral plate minimally with scissors
    4. Place silicone catheter
    5. Bring distal aspects of plate to fill up V incision made in the glans; V incision makes glans wings
    6. Lateral edges of urethral plate brought up to the V are closed to tubularize the urethra
    7. place interrupted sutures to tubularize urethral plate in 3 or 4 places
    8. close remainder of urethra
    9. close glans wings
    10. cover penis with Z plasty/Byers flaps

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