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Ok, one, one doctor H House who is our junior register is going to present about hypospadias. And uh, we are really honored um that uh, Professor Sad, she has not only um, he, he's joining us uh to give his uh opinion and, and advice and how he does things. Um but he has also uh contributed in mentoring uh HGA in preparation of her talk um from our department. Uh I don't think anybody needs a special introduction for professor. So he is uh the current president of the College of Pediatric Surgeons of South Africa for second three-year term in a row. She is a qualified general surgeon with fellowship in vascular surgery and pediatric surgery. Um, and she, uh, she's actually, uh, she has been mentoring our registers for the last few years and he, I can consider him not only a friend of the department of pediatric Surgery, but he's a personal friend as well. So some welcome. And uh, I'm also glad that Professor Colin Lazarus is also able to attend as is Professor Headley, even though Professor Headley has said that he would comment on the topic he's here to learn. But we are honored with his presence. So HGA, you can start. Ok, good evening everyone. My topic for today is hypospadias. I'll start with embryology and work my way slowly through so that we can understand what hypospadias is all about. Um uh in the embryo and genital development, males and females start at the same point. So they start with a genital tubercle which is the yellow spot that you see on the picture. Um a genital fold which is the green part and the genital swelling, which is the purple part, the genital swelling will eventually develop into the scrotum. And boy, the genital fold will um develop into the penis and the urethra and the boy and then the genital tubercle will become the glance. So looking at how this actually develops over time. In the first week, we can see the glands, we can see um the genital swellings um where the scrotum will develop. And we can see the genital fold that has already partially closed. And as time goes on, it closes up further further, the dorsal hood develops. Um the urethral plate develops in the middle and the scrotum further develops by the ninth week, the penis starts elongating and as it starts elongating, the urethral plate develops and then following shortly afterwards, the urethra itself gets enveloped um and follows a bit in the lagging process behind the elongation of the penis. You can still see um that there's the dorsal hood that's present and that will remain present for a bit longer. By the 11th week, you can see that the urethral opening has reached the corona um and is busy closing and then we will um start working its way to the tip of the glance as it works its way up, the urethra gets closed. Um And as a last step, the um pre forms and closes from a dorsal towards the ventral aspect only once the urethra has reached the tip of the penis. What is not shown in these pictures is that all penis initially have a Cordy that straightens um Only once the urethra has completed development, um We'll come back to that later. When we consider some more of the pathology, the embryology is important so that we can understand the different pathologies that we encounter with the spas as there are a spectrum of problems. Um However, the embryological development doesn't fully explain all the pathologies we see. So there are other parts that might play a role as to why something goes wrong, but I haven't covered that here. There's still a lot that's under investigation. Currently, the next thing that we need to understand is the actual anatomy, blood supply and nerve supply of the penis. You can see in the cross section that a big part of the penis is the um um cavernous. Uh um The two I'm confusing, my own words, apologies, the copa cavernosa with their own arch in the middle, they are covered by the tunica albuginea. And then on the dorsal part, we have the deep dorsal vein, the two dorsal arteries. And then at one o'clock and 11 o'clock, the dorsal nerves that becomes important when we do penile blocks or plication for these, we'll come back to that. Um At the ventral aspect, we have the urethra with the, the urethral arteries and then the um corpus spongiosum with the spongiosal veins lateral to that. All of that is enveloped in the bux fascia, um which is then covered by subcutaneous tissue and then the skin, the nerve supply comes, as we've said from the dorsum and it in innervates um going down towards the ventrum from there. And um therefore, once these nerves on the dorsum are blocked, everything else should be fine. But that means we have to be careful um for innervation of the ventral part of the penis. When we do our dissection and our repair, then coming to more of the morphology and classification of um what is hypospadias? It is con considered to be three part, there's a abnormal foreskin that comes from an incomplete closure around the glands like we saw at the stage of the embryology um where it usually forms a dorsal hood. Then there's the Cordy, which means there's a ventral bent of the penis which can have multiple causes. And then there's an abnormal urethral opening, which is the most obvious one that we notice the urethral opening can be anywhere along the penis. So it can be glandular, it can be uh coronal subcoronal along the penile shaft down to the proximal penis midst and all perennial. It's then has been classified in um different ways over the decades. As you can see, the most used one currently is the most pro uh most distal um urethral opening, even though it's not on the tip, it's still on the gland, it's uh called glandular hyperia. Some of those don't need much surgical intervention from our side. Then the distal ones are um coronal, subcoronal um down to distal and mid shaft of the penis and then proximal is from proximal penis um at the penal base and penis, scrotal and perennial. Um We'll come to why it's important as to see where exactly the opening is because it determines outcome and it determines the way we go about um repairing these ones. So the mainstay of treating the hypospadias is surgical repair. It's considered a cosmetic and a functional surgery and should be done by 6 to 18 months of age of the boy. Um The reason for this is that before six months, the anesthetic risk and the anesthetic expertise needed is considerably larger. If after six months of age, the Children are a bit bigger and anesthetic risk decreases. Um But over time these boys start learning what a normal boy looks like how normal boys pee and by 18 months of age, we would prefer to have completed the surgery so that they have a normal functional penis and can identify as normal boys with normal sexual behavior uh for their ages. Um The other important thing that we need for the surgery is very fine instruments. We're working with very delicate tissues. Um and the better and more delicate we do the operation, the better the outcome which also goes in hand in hand with needing magnification. Most surgeons consider loops to be sufficient. However, some surgeons say uh use microscopy to aid the repair and to help visualize the different structures they're working with. Um Another important aspect is hemostasis. This can be achieved either with a tourniquet at the base of the penis, depending on the pathology we're working on or with adrenaline injection around the incision site or and with adrenaline soaked, swabs and bipolar um cauterization if needed, suture, materials are needed that are needed or need to be absorbable and very fine ones. Um The recommended ones are six or a seven or and then lastly urinary diversion, which is a bit of a controversy. A lot of surgeons consider urinary diversion important um especially once the neourethra has been formed or created. Um However, some room keep the catheter in for seven days and say that it will um reduce the incidence of um narrowing of the urethra as the tissue can heal around the size of the catheter. Others say that the catheter is a foreign body and can cause pressure and can cause um fistula formation while it's in there or have a high risk of fistula formation. So some surgeons actually remove the catheter after day two of operation. And others say that we should rather completely divert the urine and put a suprapubic catheter. However, that seems to most surgeons very um invasive and not needed. The majority of surgeons put a urinary catheter or a feeding tube of a good size. And in small boys, especially on with a double nappy principle that the catheter is put through the first nappy and drains into the second one. And mom only has to change the uh first nappy if the child has passed any stool, the next part, the objectives of the surgery, first, we need to have a good assessment of what is actually going on. The glands need to be assessed for its configuration, whether it has a cleft, whether it's an incomplete cleft or a flat glands where the urethral opening is and whether it's narrow and needs some dilatation. Um sometimes a urethral opening moves more proximal once the Cordy has or doesn't actually, but it looks more proximal once the Cordy has been released. Um The other thing that needs to be looked at is the quality of skin on the ventral aspect, distal to the urethral opening, whether the urethral plate is adequate and good enough to use for a repair. But also look at the proximal urethral opening and the skin around it. Sometimes the skin there is so thin that it needs incision and coverage as well. And then look at the scrotum. Um, are the testes descended, exclude a bifid scrotum or a penoscrotal transposition and look at the KD. Um There's two options to assess QD intra op. Um The first one is via traction. Um, put a thread through the glance and pull it up and see if there's any tethering. However, most surgeons consider that as inadequate. So the current gold standard is the artificial erection test. Um where we inject saline into the corpus cavernosum and see where, how straight is the penis and whether that's um straight to where we need to um correct any coding the downside to using the artificial erection test that, that it results in unnecessary implication and shortening of already short penis. Um Once we've assessed all of that, we, we've already spoken a bit about the urethral meatus that needs to be located and then relocated to the tip of the glands by other means of urethroplasty. Um then it's covered by a protective intermediate layer uh to prevent fistula formation. The next part is to form a symmetric conically shaped glance and scrotoplasty if needed and then sco cover the whole penis and all the operated sides with skin again one way or the other. There is multiple ii don't know probably 50 to 100 different options of how to repair hypospadias. I will only be discussing the two that we do most commonly here in our unit. Um However, there are many, many different options that the surgeon needs to be aware of and for the different types of hyperia and the different problems we encounter and how we can repair them. The first one we do commonly is the snot graft procedure or otherwise called tuberalis incised plate repair. Um This one is described mostly for more distal hypospadias. However, there's also described a so called long snot grafts where even if the urethral opening is more proximal, it's still done. Um On picture a you can see there's a urethral plate marked out and here already in inside um de loving the penis and a catheter inserted. Um and then the urethral plate is co covered over that catheter. Um If it's not wide enough to cover the catheter, we can incise the base of the plate to widen it, that incision will re epithelialize and um gives us more space to close or form a new urethra. Um Once the urethra is closed with a continuous suture, we take usually um subcutaneous tissue, uh fascia from the preps and wrap it over the near urethra to form a so called waterproofing layer. However, it's more important to prevent fistula formation that way than it's actually to form a completely waterproof layer. And then once that's complete, to recover everything with the skin usually, it requires splitting the pre down to um needed level and then wrap it around the penis. Trim it where needed. The aim is to um close the gland and the um skin around the penis so that it looks like a normal cone shaped penis. Um usually looks like a circus, uh um circumcised penis and a suture line should be in the midline on the ventral part so that it can look like a normal suture line. Um The Snodgrass procedure is only done for patients who don't have a Cordy or a very, very, very mild Cordy. Then the second operation we do commonly is for more proximal um hypospadias and especially if there's Cordy present. So in the first stage at picture a here, you can see um the scrotal hypospadia with the catheter going in here um with a Cordy present. This is done more with the test that I described earlier where you put a string through the uh glance and pull it up and see how severe it is. You can also see the hood. Um again, um initial dissection is done to remove the ventral tethering around the urethral plate. Um and if needed, the artificial erection test is done to see if that was adequate. Whether any further steps need to be taken. Picture c shows a application of the dorsal site to pull the penis more straight. However, that shortens the penis slightly once it's confirmed that the penis is straight. Um we can start closing the um uh penis again with skin. Often the glance is incised. Sometimes the urethral plate on the glands can be uh left behind or doesn't need to be incised. And then the prep is split and the skin wrapped around the penis in a fashion to create adequate um skin cover for a urethral plate. Once we go to the second stage, the catheter is usually left in for 1 to 2 days POSTOP just to give it some time to heal. And in the last picture, you can see the completed operation once that is all healed. Six months later, we then do the second stage picture a shows a bit of a preop view. Again, like in the not graft procedure, we mark out the urethral plate um around to around the urethra incise that and then create a new urethra as we're done with a snot graft procedure, then cover it with um fascia from the creeps and then again, close the whole penis skin around it. Um again in a fashion so that the tip of the glance of the penis is in a cone shaped fashion and the suture line preferably in the midline on the ventral aspect to have as good looking penis as possible. The aim here is also to bring out the urethral opening to the tip of the glance. However, that's not always possible in a very severe hypospadias and then picture L shows the completed repair. Then one other abnormality that falls into the spectrum is called Cordy without hypospadias. These boys have a normal urethral meatus. A normal glance, they may have atretic urethral spongiosum and they may have a thin urethra on the penile shaft and they definitely have a Cordy. They may or may not have a dorsal hood. Most of them have a normal foreskin. There are four types of them. The first one is um called a relatively mild one. There's just some skin tethering which can be dealt dealt with in the degloving of the penis and then a pen plasty. The second type is fascial Cordy, which needs a bit of more extensive surgery. It needs excision of the abnormal dense fibrous tissue and then pen plasty. The third type is already a more severe version with corporal disproportion. The ventral part of the uh um corporal cavernosum is shorter than the dorsal part of the um cavernosa. This requires um dorsal midline plication and then pin plasty to correct. And then the last, the f fourth one is the worst one out of all of them with urethral tethering. That means the urethra is too short and those need basically a hypospadias repair um with a neourethra being formed, um often done with a Snodgrass procedure in summaries. Hypospadias are a very common congenital abnormality. We have seen many in our apartment. Um and if we can do elective surgeries have at least one a week that we need to repair. Fortunately, the majority of them are distal hypospadias, about 70 to 80% of the of all hypospadias. And they have very good outcomes. They generally have can pee standing upright. They have good sexual um function as adults and have normal fertility. Ideally, they need to be followed up until adulthood. They um can have problems with stenosis and fistula formation. Some also need psychological support and follow up and should really be followed up into adulthood. However, for majority of these patients that's not done unfortunately, and then remember for the more proximal hypospadias. Um And the more severe ones, we need to look out for other abnormalities, including disorders of sexual differentiation, renal or urethral uh ureteric abnormalities, some rare ones present with anorectal abnormalities as well. Thank you. Are there any questions? Uh Hlga, that was an excellent presentation and I'm glad that you also stuck to time exactly 25 minutes. And um yeah, that was, that was a very good understanding, a good uh embryology and on purpose, we, we decided to restrict your operative um description only to the two commonest procedures, which we do. Uh so that we have plenty of time for prof sheikh to comment and Prof Lazarus and Doctor Moola also to comment. So uh you have done quite well. I'll just uh invite Prof Shek now to comment. Um uh I've also in the chat box written about half a dozen questions for him, but he can choose um how he wants to start. He can start with a general comment uh and then go to the questions. It's entirely his choice. Sad, welcome. Thank you. Uh Me. Thanks for asking me to be part of this meeting. I really appreciate that and I think uh Doctor NHO is done. Oh, very good. Ok. Yeah, outlining what's go. No, Samantha, your voice is breaking a lot. No. Uh ok. Let me just try this again and see. Ok, just reconnected. Um Me. Is that any better me? Is this any better with this reconnection? No, this is perfect. This is perfect. Ok, thanks. Yeah, I was just saying. Thank you for having me and um we had so I briefly discussed with doctor now. How about and so great if oh, oh sorry, sad. You're breaking again. Uh uh just do another connection. Yeah, please. Wow. All right. Uh Whilst that's connecting up. Is this any? Sorry, it starts, it starts then uh then the voice starts breaking up. Well, I, I my dog, my dog. Hi me. Sorry. Uh I got kicked out of the meeting. Is this any better? This is much better? All right, so yeah, so just thanks. Thanks for having me again. Um I've gone over briefly some of the points uh that uh Doctor Naha covered, but I mean she's covered the majority of the thing, the majority of the areas that need to be covered in this topic. Uh A few general comments, I think if Prof Hadley is on, he will, he will recall telling us very often that if there are a number of operations for any one condition, then none of them work very well. And uh if there is just one operation for one condition and an example, we often use is pyloric stenosis, then it means that operation works perfectly. And I think hyperphagia is a very clear example of uh that particular area. So the hypospadias I is very, there's so many different uh presentations. There are so many different combinations of uh pathologies that you will find in clinical. Sorry, sad. We're losing you again. Mm mhm I'm I'm sorry, I'm not sure what that is doing. So I've, I've just changed over to uh mobile connection now. Yeah, hopefully this won't trouble us anymore. Yeah. So if so you need to have a, a number of different approaches and uh different sort of surgical methods available to you. Uh just in general uh other important things to remember that um we've got to understand a little bit about the epidemiology of this condition. It is becoming increasingly common throughout the world and certainly amongst uh in my practice, as you have mentioned in your practice, it's becoming very common and I do very much the same thing that you guys do. I limit the complex hyperphagia to one a week and uh the more distal hyperphagia to two a week. Otherwise, my operating lists would drag on uh forever. Uh The aim ultimately should be that if we can identify what's causing all of this, we can prevent this particular condition. Because despite the improvement in surgical techniques and the measurable outcomes we have, there is still a long term uh price that these patients pay uh in a clinic where they look they were screening patients for prostatic hypertrophy. So most of the patients were around 45 to 50 years of age. They found 15% of the patients who presented, they had some form of distal hyperphagia that had been undiagnosed and untreated. And in that 15% 90% of them had had problems related to fertility. So it it is it is an issue both from a functional, as well as from a cosmetic point of view. Uh in terms of the surgery, these Children should be referred to the pediatric surgeon fairly early. I would suggest that around 4 to 6 months of age, the concerns about anesthetic risks and anesthetic related problems uh for after about 4 to 6 months of age is not as major anymore as it used to be. But in either case, planning your surgery and trying to ensure that you have your surgery completed by 18 months of age, it does not give you a a lot of time if you start at about six months because a number of patients will complicate despite what most of us will say that we don't see fistulas, we don't have fistulas. I think a large number of patients will complicate. So in, in uh my practice, the patients should be referred early, preferably by about four months of age. And there are a group of those patients who will be referred to the uh endocrinologist as well for investigation. Uh the endocrinologist in our town prefer to see all patients with proximal hypospadias uh uh soon after birth and these patients will be investigated by them both from an endocrine point of view as well as from uh uh urinary tract. Uh point of view. The other patients should that should be referred are those patients which have a hypospadias with an absent gonad, even if it's just unilateral and those patients should also be assessed. This assessment is not purely to look for disorders of sexual development. But I also specifically to look for what the underlying hormonal abnormality may be as this will guide therapy in the future. And in a number of these Children, they will have uh simple or relatively easy to correct hormonal uh issues which will require some sort of intervention at around uh teenage years. Now, the reason this has become more important is simply because we can uh look at the pathways of testosterone, uh metabolism a lot better uh just to go on quickly then to answer your questions before I drag on for too long. Your first question in terms of uh single or two stage, I always try a single stage uh operation in in the number of in the majority of patients. This will work fine. And the two stage operations is limited to either the complex patient who has had multiple previous procedures. And then he referred for a second opinion or the patient that has such severe Cordy that that even using all the available uh prep use would not allow me to provide adequate skin cover to the entire penile shock. Uh Just to briefly sort of mention in the same breath in terms of uh the code D uh related issues. Although doctor now did mention that the oh sorry me from a single stage procedure, it's not grass. I mean, it's not grass is my standard go to procedure. It's, it's what I always plan to do in all my patients as uh the first line. Obviously, this may change if I have uh a patient who's been, who's had a circumcision erroneously or a patient who's had multiple previous procedures. But in general, the snot graft or the incised place uh incised plate, tuber, um tubularized urethroplasty is what uh what I would do. Um in terms of the code D, it's once again, I would always go for the plication without any resection of tissue. But in the very severe cor if I think I can perform the entire procedure as a single stage with a resection, then I'm not too, too phased by resecting a small wedge of tissue in order to correct the Cordy. And the reason for this is that there has been some work. In fact, quite a lot of work that shows that even resecting this, you may get a shorter penis at the time of the procedure. But this usually corrects within 6 to 9 months. And in a teenage years in looking at a small group of patients who had wedge resections implications versus other methods of uh correction of K. They found that there was no real difference in uh penile growth at puberty. So even though you resect a wedge of tissue and to the parents, it's going to look like a shorter penis that they've come out with. Ultimately, there is catch up growth. So a resection of a wedge is ii, do it very infrequently but when it is required and I think I can complete a procedure as a single stage and avoid any further procedures, then I would offer that particular group of patients. Um A wedge resection for the uh the next question was refer to the snot grat, I start off attempting a snot graft, irrespective of where the uh urethral meatus is. And uh if I find that it's not going to be possible. And my limiting factor is always availability of preputial skin to ensure adequate cover of the penis, then I would go ahead and do a two stage, uh, procedure. Similarly for very severe Coria, I would once again try for a single stage but if it doesn't work out and I don't have enough skin, I don't have any problems. Uh, changing that to a two-stage procedure. Uh, for both these group of patients I will have at the back of my mind. Any of the different type of flap procedures, including a mat, if I have to do it or it, it, it's ultimately a decision that you make during the procedure. And if I need to use some sort of um flap, I will have to adapt and use it at that stage. Testosterone. Yes, we do use it. This is where it's important that he has some sort of endocrine workup because it's no use giving testosterone as a test dose to a child who will have underlying uh who has underlying resistance to testosterone or underlying receptor issues with testosterone. Previously, the recommendation used to be, you give them a dose of testosterone and after a month assess what the response is and if there is no response and the testosterone is not going to work, I think we're at the stage now where we have an idea as to whether there is an underlying uh problem in terms of testosterone receptors or in terms of testosterone production. So we would use testosterone, we would use depo testosterone, but we would not use the long acting depo the, we would use the short acting depo the one for three weeks and we would give three doses depending on the growth. So we get the first dose, get reassessed after a month, uh get a second dose at the end of that month. If there is adequate growth and there's increase in growth, we may even give them a third dose. But uh the decision on when to stop the testosterone depends purely on whether you've achieved. What you've started out. What I often find though is that with testosterone, you would get uh and increase a greater increase in the width of the penis or diameter of the penis as compared to length. This is, this is actually quite a good thing uh from my point of view because it does provide you with a fair amount of extra skin which you can use to uh develop flaps to cover any uh skin deficiencies that you may have. From a dressing point of view. I usually try to ensure hemostasis as uh using mainly bipolar dialy. I use very little um local anesthetic with adrenaline, but I use quite a lot of bipolar dialy at a very low setting. And I try to get as, as dry uh field as I can at the end of the procedure. And if once I have ensured that I use a dressing called QT cell. This is a transparent uh uh plastic sort of cellular dressing which is extremely comfortable, very soft, it is transparent and II just apply one roll around uh the penis and uh that usually I leave on for as long as it stays on. In some Children, it stays on for an hour and in others it stays on for a week. But once the dressing is off, I usually recommend that the dressing stay off. And the general care of the patient is keeping the area clean, using cotton wool and warm water or a hand shower. After every uh nap, every nappy that soils uh it has to be damp, dry with a face cloth and they use a hair dryer and warm to dry it. It's very important then that they apply a thick layer of uh Vaseline or some sort of nappy cream onto the nappy itself and that acts as a protective barrier and protects the penis. I think uh when I used to use dressings and put them on those, those were real dramatic uh um problem for the uh provided real issues for the parents. I do almost all my hypospadia surgery, even the very proximal one that's a day case. And the catheter is usually, and the Children go home with the catheter uh usually the evening or the next day. So I try to limit the work that the parents have to do at home occasionally. If there is a problem with oozing and bleeding, then what I would do it apply uh some of the QD cell uh over there a bit of course, and strap the penile shaft onto the anterior abdominal wall with a layer of uh transparent dressing like uh a Tegaderm. And we would then remove this after two or three days. Um A salvage buckle mucosal graft has become the go to uh for me, it, it is a lot less uh scary than most people would think. And it's a fairly easy procedure. It's quite easy to get the graft itself and it uh forms a, a really nice layer and it's really healthy tissue to use good, nice, adequate tissue to use. Uh occasionally for the real difficult ones where these patients come in as a hyperplasia, cripple. I have used some of the uh de epithelialized sort of cellular matrix is that we use the plastic surgeons use and we use as a, as a mesh that has been in the in the occasional patient, it has been really difficult and in a small number of patients where I see them in the early teen years, having undergone multiple procedures, I've occasionally resorted to using uh sinus vein as a conduit and covering that with skin um from the uh a skin graft or uh available skin. Uh The last question in terms of the uh tunica, a Virginia application, I use uh a proline suture. I usually do it with just two incisions. There are some other techniques that I have used. There's a technique called a 16 point technique which is basically marks out a number of spots. It's almost like a plat that you do. Uh But that's been for really severe cases in older kids. Uh II very rarely have to resect a wedge, but it's careful dissection, make sure that I preserve the vessels and the nerves on the dorsum. It's almost always a dorsal sort of plication that I do. Uh the, the normal incision and applicate this with one or two proline sutures that are usually a 60 or a 70 nonabsorbable uh type of suture. Um II think for a lot, for a lot of the surgical technique type of questions that uh that uh prophet has asked. It would, it's a lot easier with pictures and a lot easier with, uh to have shown me some pictures. Sorry, I didn't expect uh that otherwise I would have probably shown a couple of pictures of exactly what I do. But I hope that that covers the principles of uh how I approach them. No, that, that's, that's fine, so much. Um No, I think you have answered my questions. I'll just make a couple of brief comments before I invite uh Professor Colin Lazarus to, to comment and a advice. Um, you know, um in the early part of uh my practice here, uh uh Doctor Colin Lazarus did uh single stage decade PLS with uh reasonably good results. But when I started doing them, uh my results with uh single stage were not acceptable at all. And so that's why I resorted to because I am, I call myself an occasional hypospadia surgeon. So I resorted to, to two stage repair, which is like braca repair. And uh and my results are reasonable. I still have minimum 30% fistula rate after second stage closure, which I suppose uh is just being honest. And um, as you also correctly said that, um, that the decision making is a dynamic process. So depending on the severity of the pathology and your expertise and your level of confidence, II make a plan. And um I then I'm prepared to modify the plan um uh along the way of the operation. But um we have stopped doing magpie procedure many years ago. I don't think we have done one for probably about 20 years. We used to do Matthew flap, but that also we stopped and I did a few only island uh grafts or flaps. Uh But otherwise, uh the sn grass procedure also, I think uh Professor Colin Lazarus does it the way you do it. Um But my results were uh reasonable only when I did it for distal hypospadias with sort of mild quality. But my results when I did it for proximal apis with were not good. So I just uh uh resorted back to two stage repair. And um what I teach these uh young people is that at least we need to have uh uh as a pediatric surgeon, they need to be comfortable or convergent in doing a basic sn graft procedure. A two stage procedure and how to close a urethral fistula. Um, I think these are mandatory operations and the rest I think is, is, uh, as you go along, maybe you see, and once you qualify, you can do some other, uh, operations, uh, as per your choice. Um, so I think that is just my two cents. Um, I'll invite uh Professor Colin Lazarus to give his, uh thoughts. He has also vas experience of Hypospadia surgery. Colin Yes. Hi, Marland. And uh hello to the colleagues. Uh It's great to be in the presence of uh both sad uh and Larry. And uh, so let me just greet you both and thank you for participating in our meeting also just to thank Helga for her presentation. Um, he went through the uh principles and, and went through quite quickly. It's, um, such an interesting topic, hyperia. And, um, I want to say that from myself, um, once I was exposed to the Snodgrass technique, uh that has become the way in which I manage all distal hyperspaces. And, um, I found that I II would hate, I would not even suggest that they're complication free, but I find that procedure one that, um, I can do reasonably successfully. Um, most of the time, particularly for the distal uh or, or even mid penile shaft hypospadias who do not have a lot of d, um, and I, and I'm sure that is the way to go. Um, very happy with that procedure. I think it has made a really, really big difference to our work as pediatric surgeons. I don't have any confidence in my ability to do a Hypospadias, uh, a Snodgrass type of Hypospadias repair for those that are proximal unlike you somewhat. But then I'm not doing three a week, um, nor even three a month. Um So, uh what I would say is that when I see that there is significant QD and when the opening is well proximal, I have no hesitation in planning a two stage procedure. Uh And in my first stage, um the, the um cor cor the, the, the degloving of the penis and excision of any scar tissue invariably makes the meatus even more proximal and used a technique of um mobilizing the inner surface of the prep on its vascular pedicle and bring it around the side of the penis or sometimes over the penis in order to lay it down to provide the bed for the tubularized flap that we would want to do um at a, at a second stage. And for me again, that's the only procedure that I do under those circumstances. Um And I know that it works well for most of my patients, but it is true that some will develop a fistula um which is not the worst. The worst, of course, is having any form of stricture. And, um, fortunately that hasn't been a frequent occurrence, but those are the two procedures I use for the overwhelming number of my patients. Yes, I've used buccal mucosal frap flaps. Fortunately only needed to do it on a few occasions and I agree with you somewhat. They are, um, uh, it, it, it's not, it sounds horrendous but it's not particularly difficult and it provides an excellent bed uh for uh a subsequent procedure. It may look awful uh initially, but it settles down and you have, you have that very nice uh bed of tissue to tubularise at a second stage. I wanted to, I wanted to ask you what stent you use uh somewhat because um I must say that over a long time, perhaps because of working in the public sector, not having access to, to um uh uh the delicate stents that are available had used, had got used to using feeding tubes. Uh And then recall a patient on whom um the rigidity of the feeding tube and the way I had positioned the double diaper for the dressing ended up in the patient uh developing a really big fistula on the ventral aspect from pressure necrosis. And II, so I just wonder what soft stent you do use. And uh that may be something to put on my list. Now, I think I've said enough. Uh bar one and that is that I was very glad early in my general surgical training to do a six month job in plastic surgery because I think that the respect for tissues is integral to any um uh high post spad work. And that I think is a very important lesson. Thank you. So uh you can please uh come in. Thanks mo uh Thanks for the welcome and the acknowledgement. Uh like I said, you've probably, you've got way more experience in these things than I have and you probably made it, made your points a lot clearer than, than I did. But uh I agree with, with all the points that you have made, especially the fact that if you've spent some time doing plastic surgery that respect for tissue will definitely make a big difference. And, and you'll also be able to use that to, to make, do whatever little tissue you've got from a penile standpoint of view. I've been through the whole process of feeding tubes to double J stents that uh or and single J stents that we use for uh the ureters to the specialized cook stent that they had for the. But over the past uh few years I've gone back to using a feeding tube, but it's a very specific feeding tube. It's made by Von. And it is the feeding tube that I think the majority of the hospitals have now sort of the private hospitals anyway, have standardized as their feeding tubes. It is a silicone tube. It's very soft it's mainly the PVC and the polyurethane type of tubes that uh we, we used to use as feeding tubes that cause all the problems that you've, that you've mentioned. But this particular tube is a von tube. It has a very special attachment for a syringe. And it was designed simply to prevent people from uh, from putting in using normal syringes down a nasogastric or a feeding tube. So, it's made by von silicone tube. It's very soft, it's very reasonably priced. And uh that's the one that I've sort of resorted to, to using. Um ok, so uh thank you. Um I'm just going to now ask Doctor Moola to comment. Uh Doctor Moola is our consultant, pediatric surgeon and he uh has done three months of fellowship with Professor John Lazarus last year and he's almost like a defect of pediatric urologist. So, Doctor Majola, good afternoon everyone. Um Thanks for, for a good talk. I actually don't have any comments uh with my low knowledge and skill that I've acquired over the few years. The only difference that I've noticed with uh when I was at in Red Cross with uh Prof John, is he does most of his um hypospadias uh a single stage, even the approximal ones uh will take that into effect that he sees quite a lot because he's always has a hyper was on his table. So that is with uh skill and expertise and hence his work on just doing first stage or single stage all the time. But what he does as well cause he, he doesn't have any special stent or tubes for tuberalis over. So he will start with an eight French uh normal feeding tube um that he will tuber over. But when we are done with the, the repair or the urethroplasty, then he will change to the smaller five French feeding tube, which then will obviously decrease the tension on the repair and hence uh possibly decrease any complications but obvious. But even with that, we still used to see a few patients coming back with uh fistulas, but we've never seen uh when I was there anyone with a breakdown or necrosis during or shortly after the the procedure. And he also advocate quite a lot for um using suprapubic catheters as well. If you feel that the tension on your sutures are, are are very tight, even using a five French tube that you struggle to get it down uh into the near urethra, then we would do a superpubic on those kids. Um But yeah, and then also he uses um A PDA S uh 70 for his repairs. Thank you. Ok, thank you. Um I'll just request uh doctor Manic Chen who is our consultant, pediatric surgeon and she uh I is, is our import from, from Durban. Thanks to prof and, and she is a permanent member of our staff forever. So yeah, please uh make your comment. Uh Hi, everyone. Thanks uh Proft and thank you to all the professors for uh joining us. We're very fortunate to have your expertise and your wisdom today. Um Just two quick comments. Uh The first one is that um I was taught uh actually by Mr VBA uh to do Az Plasty with the skin. Um So that's what I do in the first stage that we do here um in the pictures. I see that it's just closed um longitudinally. So maybe um I don't know how everyone else does it, but I just do Az Plasty every time. Um And then the other uh comments that I had and this is for properly is that Helga forgot the association with Nephroblastoma. Uh Yes, that, that's all for me. That's, that's mainly for. Thank you. Thank you. So, can I chip in? Yes, please. Yes, please. Um First of course, I'd like to greet Sad and, and Colin and yourself. Um You're quite, your show is quite right. Um It is associated with nephroblastoma occasionally. Um I, I'm just gonna say you can write what I know about repairing hyper spad on a piece of paper, stick it in your eye and it wouldn't make you blink. But there are, there are a lot of young people um listening to this and I and II would, I would just um warn them that a lot of, of, of practice is gon by expectations and they've got to learn to be skeptical about the things that they read and the things that they hear. And I've always maintained that there are three lies that men routinely tell. The first lie is, of course, I still love you, darling. The second line is my check is in the post and the third line is my hypospadias repairs. Nearly always do. Well, the the complication rate from this procedures are by any standards high and in many hands, horrendous. So it is um it is a field for the skilled surgeon and the frequent hyper spad surgeon. Thanks th th thank you pro as usual, your, your uh wise comments. Yes, prof I think uh I mean in the western world, there are uh hypospadias. So there are pediatric urologist who specialize in doing hypersed work. But I think uh the volume of work in the public sector is so high that all of us consultant, pediatric surgeons need to be able to do hypospadia surgery. Otherwise one person will keep doing hypospadias for his entire theater list and that's just not practicable. Uh So um I think uh you're absolutely right. Anybody who says that I have no or very few complications of hypospadia surgery is not telling you the truth because uh the tissue is dysplastic. The baby was born with dysplastic tissue and you are working with dysplastic and delicate tissue. So even though you acquire huge amount of, of, of experience, you use magnification, fine sutures you are a decent technical surgeon. Uh Still there are patients who are going to have complications and you need to be able to deal with the common complications which is like a fistula or a residual Cordy. Uh He uh do you wish to ask any questions to any of the professors? Uh The questions I have had uh the the questions I had have been answered so far already. Ok. No, that's, that's wonderful. Uh So, so I think uh last word from you and we are in exact good time. 60 minutes. So please give your comments and then we can say our thank you and goodbye. Thank you Melo. Once again. Just thanks for inviting me to this meeting. This, this is still a topic that uh I mean, the surgery itself is really enjoyable, but it's surgery that you have to enjoy. You have to be patient. Uh It's something that you've just got to basically sit down do the surgery and dedicate that particular 234 hours however long you want to, to that particular patient. And uh I think that's where the most important uh factor as far as outcome is concerned. So I understand that everybody needs to be able to do it. But as soon as you get the patient who, you know, is going to be more difficult than the usual and uh in any form of proximal life failures, I think it's worth taking the time to either send it to somebody else or get a collection and try and get somebody to come out and help do it a few times so you can become experienced enough. Uh We owe these uh these kids that because it's a long term uh functional outcome that we were aiming for. Once again, thanks to you. Uh It's really nice to hear from prophylaxis and uh pro again and uh the other faces uh whose names are seen under the participants when I had visited. So, thanks Melinda. Thank you very much. So when time permits, just send me the details of the cell dressing and the von feeding tubes, I did send you a whatsapp already. Oh, you have. Ok. Ok. Ok. Ok. Thank you everyone. Uh Thank you properly uh for us and some um we will, we will uh involve you. Uh some are sometime next year and properly. We will certainly involve you in, in oncology and general pediatric surgery related topics. Thank you. Yes, me and bye-bye. Thanks.