Hypospadias.
This is a congenital defect in which the floor of the urethra is absent. It is usually associated with curvature of the penis, the normal position of the urethra being represented by a fibrous band which has contracted, curving the organ downward. The deficiency may affect a very small or a large portion of the length of the urethra. Thus, the canal may terminate at any point between the normal position of the ex ternal meatus and the perineum. The different forms are classified according to the position of the orifice of the ure thra into: (1) balanic, those terminating at the base of the glans; (2) penile, those terminating at any point along the pen dulous urethra; (3) perineal, those ter minating at some point in the perineum.
The cause of hypospadias is arrest of development. The diagnosis is readily made upon inspection. The patient is led to consult the surgeon on account of the abnormal point of exit of the urine.
Treatment.—It is usually unnecessary to interfere in cases of the balanic va riety, inasmuch as the normal functions are not greatly interfered with.
Instead of forming a new urethra in balanic hypospadias, the existing one may be dissected free and extended so as to make it do the service of a new canal. First, a transverse incision is made across the lower surface of the glans, which em braces the hypospadiac opening. By pull ing the lower wound margin downward, the urethra can be exposed and separated from its surrounding tissue without be ing injured. Then, after a longitudinal incision has been made alongside the median line of the groove, by dissecting the edges of the groove, two flaps are to be formed and cut of in order to give a freshened surface. Now the hypospa.diae orifice of the urethra is drawn forward and sutured to the initial point of these freshened margins of the groove, and op posite to it another suture is introduced in the same manner. If, now, the poste rior portion of the displaced urethra is slightly inverted in its longitudinal direc tion, the retracted margins of the integu ment are pulled together and united above the urethra. The shape of the
wound, which at first was transverse, becomes longitudinal, forming a sup port for the urethra, which is thus kept straight at the same time. The creation of a new channel not having been neces sary, the insertion of a tube will be use less. Carl Beck (N. V. Sled. Jour., Jan. 29, '9S).
A new operation for hypospadias of the glans penis as performed by Barden heuer is as follows:— The skin on the lower surface of the penis above the glans is dissected back and the urethra freed by dissection from the spongiosa for such a distance that it can be readily carried to the end of the penis. The gland is then perforated by a trocar, where the urethra should pass; the freed urethra is drawn through this canal and stitched in position. The skin is then united by a sufficient number of sutures.
The after-treatment consists in the em ployment of boric-acid ointment, fre quently removed. The stitches are re moved on the eighth to the fourteenth day. Breuer (Cent. f. Chir., Nov. 5, '9S).
The operation for glandular hypospa dias personally recommended is as fol lows:— The urethral orifice, together with its corpus spongiosum, is freed from its sur roundings, the dissection being carried well backward. The glans is tunneled through, and the urethra is pulled for ward, and the meatus is sewn to the ex ternal surface. The advantages claimed for the operation are: 1. It does away with the necessity of operating in several sittings.
2. It insures greater certainty of union, other methods frequently requiring repe tition of the operation and secondary measures for closure of fistulm.
3. As there is an absence of any canal requiring to be covered over, a catheter ca denterire is unnecessary. No subse quent constriction of the opening is to be apprehended.
4. The urethra remains surrounded by its corpus cavernosum, and the new ex ternal orifice by erectile tissue in a nearly normal fashion,—the latter circumstance being highly desirable for the proper ejaculation of semen. Von Hacker (Beit. z. klin. Chir., B. 22, H. 1, '99).