Fig. 667
Diagrammatic sections showing different varieties of hypospadias: 1, hypospadias with imperforate glans; 2, hypospadias with blind canal in glans; 3, with barrier placed between penile urethra and balanitic groove; 4, typical case of hypospadias; 5, hypospadias with normal meatus; 6, penile urethra opening below glans; 7, absence of the whole inferior part of the penile urethra; 8, hypospadias with absence of urethra through glans; 9, case of d’Arnaud; 10, case of Lacroix; 11, case of Lippert with normal meatus. (Kauffmann.)
Fig. 668
Hypospadias. Liberation of anterior urethra and tunnelling the glans. (Hartmann.)
Fig. 669
Hypospadias. Drawing the liberated urethra through the tunnel in the glans. (Hartmann.)
Most cases of hypospadias are accompanied by other defects on the inferior surface of the penis and the scrotum, which, more or less, bind them down and interfere with the normal method of urination as well as of insemination. The indications, then, in such cases are to straighten the penis and to restore the continuity of the urethra. The former may be accomplished by transverse incisions through the bands which cause the curvature, or, if necessary, division of the intracavernous septum, or even of the sheaths of or the cavernous bodies themselves. Wedge-shaped pieces of cavernosa have often been successfully excised. The restoration of the urethra is a much more difficult matter, especially in an extensive case, to make it sufficient for insemination. The methods may be grouped under simple canalization or approximation and the construction of flaps. Nearly all of these methods are more or less simple in theory but difficult in practice, and frequently unpromising because of the difficulties in securing final union of tissues, no matter how neatly united, where the same may be interfered with by the presence of urine or the occurrence of erections. The former may be prevented by a perineal section, with drainage of the bladder, and this is probably the best method to adopt in nearly all of these cases. The latter is to some extent overcome by drugs, but is sometimes produced by the local irritation of the operation and the dressings. To describe all these methods would require a long chapter. They have included efforts at tunnelling the glans, by the passage of a trocar, maintaining the channel by keeping within it some bougie or foreign body until its interior has healed, then connecting this up with the balance of the urethra ([Figs. 668] and [669]). The urethral passage-way is rarely sufficiently wide to permit of approximation of freshened edges by stitches, and these will almost surely pull out. Therefore some more plastic method of formation of flaps must be devised. Many ingenious expedients have been suggested, among them the utilization of a strip of skin, dissected up on one side, whose external surface is turned in and made to vicariate as mucous membrane, while its raw surface, now faced outward, is covered with another flap, raised either from the penis itself or from the scrotum. It is the operations based on this general plan which have given the best results in well-marked cases, and yet they have to be conducted with great care. American surgeons, among them particularly Beck, of New York, have done a great deal to advance the plastic surgery of these parts and for these purposes. He, for instance, has especially exploited the movability of the urethra, and shown how by dissecting it out it may be drawn forward and made much more available. Beck has suggested a similar method of displacement and reëmployment of the urethra for epispadias.