Hypospadias Surgery | Prof. Dr. Ahmed Hadidi
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INFORMATION
DOCTORS - PART 4
Grade II or Distal Hypospadias: “The Slit-like adjusted Mathieu (SLAM) Technique”
The meatal-based flap technique of Mathieu is the most popular technique for distal hypospadias repair and has withstood the test of time. However, the major drawback of the original Mathieu technique is the final appearance of the meatus (a smiling meatus that is not very terminal). The Slit-like adjusted Mathieu (SLAM) helps to employ the Mathieu operation in all forms of distal hypospadias and gives a terminal, slit-like meatus. This includes about 70 to 80% of patients with hypospadias. The only contraindication is the presence of severe chordee distal to the hypospadiac meatus (very rare in distal hypospadias).Operative steps:
- The boundaries of the urethral plate are outlined with a U-shaped incision.
- Flap mobilisation: Sharp scissors deepen the incision starting near the coronal sulcus. Fascia and corpus spongiosum are included with the flap.
- Angle epithelium excision: Epithelium at the proximal two angles of the flap is excised, preserving fascia.
- Urethroplasty: Flap edges are fixed to the converging urethral plate edges. A second continuous sealing suture line is added.
- V-Excision: A triangle is removed from the flap tip to create a slit-like meatus.
- Glans and skin closure: Glanular wings are approximated around the new urethra; the meatus has one stitch at 6 O’clock.
Fig. 9: The SLAM technique for distal hypospadias
Grade IIIa – Proximal Hypospadias: “Lateral Based Onlay (LABO) Flap”
The lateral Based Onlay (LABO) flap may be used in proximal hypospadias without deep chordee that requires division of the urethral plate to straighten the penis. It is of particular value in patients with small glans. The lateral penile skin and part of the prepuce are used to reconstruct the new urethra, leading to fewer complications and a shorter hospital stay.Operative steps:
- A U-shaped incision is outlined; flaps converge to a slit-like meatus.
- Flap mobilisation: The right incision is deepened near the coronal sulcus.
- Apex suture: Tip of the medial LABO flap is sutured 2 mm proximal to the urethral plate edge.
- Urethroplasty: Flap is sutured to the left edge of the urethral plate.
- Turning the flap: Flap is turned over the catheter.
- Intermediate layer: Scrotal dartos/tunica vaginalis used as a protective second layer.
- Glans and skin closure: Completed with one stitch at 6 O’clock.
Fig. 10: LABO technique for proximal hypospadias
Grade IIIb – Proximal Hypospadias with Deep Chordee: “Lateral Based Flap”
The lateral based flap can be used in all types of proximal hypospadias. This flap with double blood supply combines the advantages of meatal-based flap and preputial pedicle flap techniques. It allows for extensive excision of ventral chordee and urethral plate without damaging the flap.Operative steps:
- Deep Y-shaped incision on the glans; a core of soft tissue excised to create space.
- Meticulous excision of chordee and fibrous bands.
- Rectangular skin strip outlined, avoiding hair-bearing areas.
- Mobilisation of the flap through the dorsum down to the penis root.
- Skin tubularised around 10 Fr Nelaton catheter.
- Neomeatus created by suturing the new urethra to the glans.
- Protective vascular layer used to cover neourethra.
- Skin closed simulating ventral raphae.
- Suprapubic cystocath inserted for 10–14 days.
Fig. 11: Steps of lateral-based (LB) flap technique