LETTERS TO THE EDITOR
|Year : 2019 | Volume
| Issue : 4 | Page : 311-313
Etiopathogenesis of chordee in hypospadias
Sachchidananda Das, Sudarsan Sen
Department of Pediatric Surgery, Park Medical Research and Welfare Society, Kolkata, West Bengal, India
|Date of Web Publication||29-Aug-2019|
Dr. Sachchidananda Das
35 C, R M Datta Garden Lane, Kolkata - 700 010, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das S, Sen S. Etiopathogenesis of chordee in hypospadias. J Indian Assoc Pediatr Surg 2019;24:311-3
Apropos of the article “Acimi S. Anatomical explanation of the pathogenesis of proximal hypospadias. Journal of Indian Association of Pediatric Surgeons 2019;24:97-9.”
The conventional embryological concept of the development of proximal penile hypospadias is the failure of the genital folds to unite in the midline, due to nonfulfillment of regulatory mechanism of Mull such as secretion of androgens and fibroblast growth factor. Malformation of Mullerian Inhibiting substance, estrogen, progesterone and corticosteroids are also indicted for the abnormal development of proximal urethra. Virilization occurs between 12th and 14th intrauterine weeks.
Dr. Acimi, in his article, has rightly questioned the traditional embryological view. He has done the histological study of the tissue beneath the urethral plate with various staining procedure and detected dense fibrosis with some fibroblasts and smooth muscles that should not be there in the normal closure of urethral folds. The similar histopathological study was done by other authors as mentioned in the article. The abnormal histological feature in the suburethral plate region has led Acimi to believe that the cause of proximal penile hypospadias was a vascular necrosis of the distal part of corpus spongiosum, Buck's fascia, and dartos fascia. Horton and Devine believed the fibrous tissue to be the result of anomalous development of the structure which would have surrounded the normal urethra, the corpus spongiosu. Alternatively, the abnormal disintegration of the urethral plate and the missing mesenchymal ingrowth distal to the hypospadiac opening may give rise to fibrous tissue.
We are interested in Acimi's article as we also carried out a similar histopathological study of urethral plate in 1989–1991. Excision of the urethral plate was in vogue then as chordee was thought primarily due to contracted urethral plate and advantage of preserving it was not considered. We used to excise the plate from hypospadiac urethral opening to the corona right up to the tunica albuginea at the depth in one block and send it for histopathological study. It was a part of a thesis work done by the second author under the guidance of the first author. Surface epithelium was studied in eight cases. In three specimens, there was urothelium [Figure l] and in five specimens, there was squamous epithelium [Figure 2]. Structural character of the subepithelial tissue has been studied in 11 cases. In three cases, there were only fibrous tissue and in eight cases, lecunae of vascular channels were seen scattered in between fibrous tissues. There was irregular patchy broad fibrosis in between lacunae [Figure 3].
|Figure 1: Histopathology of fibrous cord showing corpus spongiosum, urothelium and fibrosis|
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|Figure 2: Histopathology of fibrous cord showing stratified squamous epithelium, fibrosis, blood vessels and inflammatory cells|
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|Figure 3: Histopathology of the fibrous cord showing attenuated corpus spongiosum and fibrosis|
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If the etiology of hypospadias was developmental failure of genital folds to meet each other, there would have been presence of normal corpus spongiosum tissue beneath the urethral plate. Rather than presence of attenuated spongy tissue and vascular lacunae. The surface epithelium would have been urothelium in all cases. However, in five out of eight cases, epithelia were replaced by stratified squamous epithelium. With these findings, our conclusion was that the embryonic mesenchymal tissue failed to invade the genital folds resulting in necrosis of the genital folds, leading to change of epithelial character in many cases and subepithelial fibrosis in all cases.
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Conflicts of interest
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| References|| |
Horton CE, Devine CJ Jr. Hypospadias. In: Mustardee JC, editor. Plastic Surgery in Infancy and Childhood. 2nd
ed. London: Churchill Livingstone; 1979. p. 436-71.
Duekett JW. Hypospadias. In: Campbell Urology. 5th
ed., Vol. 2. Philadelphia: WB Saunders Company; 1986. p. 1969-99.
Sen S. Chinicopathological study of hypospadias with special reference to the chordee. In: Dissertation Submitted for the Degree of Master of Surgery (General Surgery). University of Calcutta; 1989-1991. p. 47-8.
[Figure 1], [Figure 2], [Figure 3]