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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 6  |  Issue : 2  |  Page : 88-92
Versatility of tubularized incised plate urethroplasty in the management of different types of hypospadias: 5-year experience


1 Departments of Pediatric Surgery and Urology, Al-Azhar University, Cairo, Egypt; King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
2 Departments of Pediatric Surgery and Urology, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia

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Date of Web Publication29-Jul-2009
 

   Abstract 

Background: The outcomes of urethroplasty in the management of different types of hypospadias have continued to improve since the introduction of the tubularized incised plate (TIP) urethroplasty (Snodgrass method). The aim of this study was to evaluate the feasibility and applicability of TIP urethroplasty in the management of different types of hypospadias. Materials and Methods: This work was carried out at Al-Azhar University Hospital, Cairo, Egypt in the period from January 2002 to December 2002 and King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia; in the period from January 2003 to January 2007 by the same authors. The medical records of 175 boys with different types of hypospadias, who underwent TIP urethroplasty, were critically reviewed. Their age ranged from 9 to 36 months (mean age; 22.72 ± 7.75 months).The period of follow-up was ranged from 7 to 60 months (mean 34.42 ± 15.41). Results: All families were happy with penile aesthetic appearance. The total number of boys with different types of hypospadias was 175 (145 1ry and 30 2ry). Out of 175 cases, the overall urethrocutaneous fistula rate was 11 (6.29%), and the overall rates for glanular dehiscence, urethral stricture, meatal stenosis and meatal regression were 4 (2.29%), 5 (2.86%), 17 (9.71%), and 10 (5.71%), respectively. All cases of urethral stricture and most cases of meatal stenosis 12 (6.86%) responded well to regular urethral dilatation. Meatoplasty was performed in only 5 (2.85%) cases (1 of 1ry and 4 of 2ry cases). Secondary surgery for fistula repair and glans closure was successful in all patients. All children void with a single straight urinary stream in a forward direction, and have a rounded glans with vertical slit- like terminal glanular meatus. The mean hospital stay was 4.6 days. Conclusion: TIP urethroplasty with neourethral coverage using a vascularized pedicle of dartos flap is versatile and simple operation in management of different types of hypospadias. It has a good functional and cosmetic outcome.

Keywords: Hypospadias, snodgrass repair, tubularized incised plate urethroplasty

How to cite this article:
Al-Saied G, Gamal A. Versatility of tubularized incised plate urethroplasty in the management of different types of hypospadias: 5-year experience. Afr J Paediatr Surg 2009;6:88-92

How to cite this URL:
Al-Saied G, Gamal A. Versatility of tubularized incised plate urethroplasty in the management of different types of hypospadias: 5-year experience. Afr J Paediatr Surg [serial online] 2009 [cited 2019 Nov 13];6:88-92. Available from: http://www.afrjpaedsurg.org/text.asp?2009/6/2/88/54770

   Introduction Top


Hypospadias is one of the most common congenital anomalies occurring in approximately 1 of 200 to 1 of 300 live births. [1] Many operations have been described for hypospadias repair. The introduction of tubularized incised plate (TIP) urethroplasty by Snodgrass in 1994, resulted in a revolution in management of different types of hypospadias (distal and proximal, either new or reoperative cases) as documented by many reports. [2],[3],[4],[5],[6],[7] The purpose of this retrospective review is to present our experience with the tubularized incised plate TIP urethroplasty for management of different types of hypospadias over the past five years and to emphasize that TIP urethroplasty with neourethral coverage using a vascularized pedicled flap of dartos fascia is versatile and simple operation with good functional and cosmetic outcome.


   Materials and Methods Top


A total of 175 boys with different types of hypospadias either primary (new) or secondary (previously failed repair) with distal, mid shaft, or proximal meatal position had been operated at two tertiary institutes during two consecutive periods by the same authors who were already familiarized with the technique of TIP urethroplasty. A total of 15 patients were operated at Al-Azhar University Hospitals, Cairo, Egypt, between January 2002 and December 2002; and 160 patients at King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia, in the period from January 2003 to January 2007. The period of follow-up was ranged from 7 to 60 months (mean 34.42 ± 15.41 months). Their age ranged from 9 to 36 months (mean age; 22.72 ± 7.75 months). The study was reviewed and approved by the review board and written consent of patient's parents in accordance with the human rights committee guidelines of the hospital was taken. The length of hypoplastic urethra ranged from 0.5-1.5 cm. The preoperative clinical data of patients were summarised in [Table 1].

Surgical technique

Under complete a septic technique, a traction suture of 5-0 silk is placed in the glans to stabilize the penis during the procedure and help in demonstration of the abnormal curvature and redundant dorsal preputial skin. A circumscribing incision is made 2 mm proximal to the hypospadiac meatus, and the penis is degloved to the penoscrotal junction in cases with proximal meatus. In cases of hypoplastic urethra (the urethra devoid of corpus spongiosum), the meatus was preserved in all patients by a de-epithelialisation of hypoplastic urethra. Artificial erection is conducted to verify the penile shaft without bending. If the penis is straight, TIP repair is continued; parallel longitudinal incisions are then made approximately 6 to 8 mm apart to separate the glans from the lateral margins of the plate and the glanular wings are mobilized to facilitate subsequent glans closure without tension. Then, the edges of the urethral plates are gently retracted laterally with fine forceps to delineate the midline which is deeply incised with tenotomy scissors from the hypospadiac meatus to the end of the plate, just below the tip of glans penis [Figure 1]. The incised urethral plate is tubularized without tension over a catheter of an appropriate size (6Fr or 8Fr), using continuous subepithelial (non- interrupted) 6/0 polyglactin sutures [Figure 2]. The epithelium of the urethral plate is inverted toward the lumen to avoid fistula formation. Thereafter, the corpus spongiosum alongside the plate is sutured together over the neourethra with the "Y to I" technique. In all cases, a vascularized dartos fascia flap harvested either from the prepuce or the penile shaft is used to cover the urethroplasty as a second layer. It is placed in such a manner as to cover the original suture line and sutured with periurethral tissue. Care must be taken to avoid rotation of the penis [Figure 3]. Then, the lateral glans wings are re-approximated over the neourethra using vertical mattress 6/0 polyglactin sutures [Figure 4].

If the curvature is less than 30 degree, dorsal plication of the corporal tissue in the midline is performed to preserve the urethral plate [Figure 5] and [Figure 6]. In case of severe chordee, more than 30 degree, excision of the chordee is followed by covering the ventral raw area with preputeal skin as a first stage. Then, TIP urothroplasty is performed as a second stage after 6 months.

Then, preputeal skin is divided in midline and rotated on both sides of the shaft of the penis to cover the second layer of dartos fascia and sutured to the subglanular skin edge to cover the ventrum of the penis. In circumcised patients, penile ventral skin is approximated and sutured to cover the ventrum of the penis. Then, a straight catheter within the urethra is secured distally to the glans with the traction suture. Urinary diversion was carried out via a percutaneous suprapubic vesicostomy in cases with proximal hydospadiac meatus either primary or secondary. A compression dressing is applied and left in place for 4-7 days. Prophylactic IV antibiotics was started 30 minutes before the induction of anesthesia and continued for 36 hours postoperatively. The first exchange of dressing is applied 48 hours after surgery to assess the viability of the repair and to detect the acute postoperative complications (bleeding, haematoma and edema), and continued daily till catheter removal. The duration of the catheter indwelling ranged from 7 to 10 days according to the length of the neourethral. All patients were kept on regular follow-up in outpatient clinic at the end of first, third, and sixth month. Calibration was done only for selected patients that appeared to have meatal stenosis and urethral stricture.


   Results Top


All families were happy with penile aesthetic appearance. The total number of boys with different types of hypospadias was 175 (145 1 ry and 30 2 ry ). Out of 175 cases, the overall urethrocutaneous fistula rate was 6 (4.14%) in 1 ry cases and 5 (16.67%) in 2 ry cases. The overall rates for glanular dehiscence, urethral stricture, meatal stenosis, and meatal regression were 4 (2.29%), 5 (2.86%), 17 (9.71%), and 10 (5.71%), respectively.

All cases of urethral stricture and most of the cases of meatal stenosis 12 (6.86%), responded well to regular urethral dilatation. Meatoplasty was performed in only 5(2.85%) cases (1of 1 ry and 4 of 2 ry cases). Secondary surgery for fistula repair and glans closure was successful in all patients [Table 2]. All children void with a single straight urinary stream in a forward direction and have a rounded glans with vertical slit- like terminal glanular meatus. The mean hospital stay was 4.6 days [Table 1],[Table 2],[Table 3], summarize different types of hypospadias at time of surgery, early and late complications after TIP repair, respectively.


   Discussion Top


A technique to repair hypospadias with universal applicability in most variants would be appealing. The Snodgrass technique is a simple technical innovation that has revolutionised hypospadias surgery. Rich et al ., first described an incision in the urethral plate to obtain a cosmetically acceptable vertical slit-like meatus for the Mathieu repair. [8] This was subsequently adopted for the entire length of the urethral plate as a complement to the Thiersch-Duplay urethroplasty for distal hypospadias reported by Snodgrass. [2],[3],[4],[5]

The dorsal relaxing incision over the urethral plate results in a neourethra of more than 10F [2],[3],[4],[5] and does not seem to compromise the blood supply of urethral plate. [9],[10] It also results in reepithelialisation rather than fibrosis of the subcutaneous tissue which may later give rise to stricture of the neourethra. [4],[6],[11]

In 2001, Borer et al. , found that the risk of fistula was reduced by using second layer to cover the suture line, and recommended this maneuver after TIP urethroplasty. [6] In 2003, Samuel and Wilcox used a second layer of vascularized pedicle subcutaneous tissue harvested from the dorsal hooded prepuce provided cover for the urethroplasty to minimise the incidence of urethrocutaneous fistula. [7]

In 2003, Sozubir and Snodgrass mentioned that dartos pedicle flap obtained from the dorsal prepuce and shaft skin is used to cover the neourethra. In some patients with proximal hypospadias, the corpus spongiosum alongside the plate was sutured together over the neourethra with the "Y to I" technique before the dartos flap was applied. [12],[13]

In this series, the incised urethral plate was tubularized without tension over a catheter of an appropriate size (6Fr or 8Fr), using continuous subepithelial (non- interrupted) 6/0 polyglactin sutures. Then, the corpus spongiosum alongside the plate was sutured together over the neourethra with the "Y to I" technique. A second layer of vascularised dartos pedicle flap was harvested from the dorsal prepuce or penile shaft skin in circumcised patients to cover the suture line after TIP urethroplasty. We think this combined technique have resulted in good functional and cosmetic outcome.

In 2002, Elbakry concluded that postoperative regular urethral calibration should be considered as an integral part of the TIP urethroplasty to prevent the neourethral and/or meatal stenosis with subsequent urethral fistula. [14]

In 2002, Lorenzo and Snodgrass concluded that dilatation of the neourethra is unnecessary after TIP urethroplasty, and the calibration and uroflowmetry after 6 months of surgery may be useful to detect subclinical obstruction. They attributed the meatal stenosis detected in other series (El bakry 2002) to the technical error including failure to deeply incise the plate and/or tubularisation of urethral plate too far distally. [15]

In this series, meatal stenosis was observed in 9(6.21%) of 1 ry cases and in 8(26.67%) cases of 2 ry cases. Short neourethral stricture was seen in 2(01.38%) of 1 ry cases and 3(10%) of 2 ry cases, inspite of the deep incision and tubularisation of urethral plate adequately and they were kept under regular calibration in outpatient clinic.

In 2002, Snodgrass and Lorenzo concluded that TIP urethroplasty can be used for hypospadias reoperation, even when the urethral plate has been incised previously, but should be avoided when the urethral plate is obviously scarred or has been resected. [16]

In this series, TIP urethroplasty was used for hypospadias reoperation with successful results. Thin distal urethra devoid of spongiosum sometimes called 'hypoplastic urethra', has been noticed in approximately one-fourth of patients undergoing urethroplasty. [17] In this study, the hypoplastic urethra has been noticed in 25 (17.24%) among the primary cases.

Traditionally, the hypoplastic urethra is spatulated till the 'healthy' urethra with spongiosum cover is obtained and the urethroplasty is commenced. This step creates a more proximal hypospadias, thus increasing the chances of postoperative fistula. [18] In this series, the urethral hypoplasia is preserved by its deepithelialisation followed by fashioning of the neourethra then reinforced by suturing the corpus spongiosum alongside the plate together over the neourethra with the "Y to I" technique before the dartos flap is applied with good functional and cosmetic outcome.

In conclusion, this retrospective review of our surgical experience over the last five years have emphasized that TIP urethroplasty with neourethral coverage using a vascularized dartos pedicle flap of subcutaneous tissue is versatile, single-stage, and simple operation in management of different types of hypospadias. It has good functional and cosmetic results. The accumulated surgical experience and refinements in TIP urethroplasty covered by second layer of vascularized pedicle dartos flap, the choice of fine suture material of good quality, and use of magnification tools have contributed to improved the outcomes.

 
   References Top

1.Baskin LS, Colborn T, Himes K. Hypospadias and endocrine disruption: Is there a connection? Environ Health Perspect 2001;109:1175-83.  Back to cited text no. 1    
2.Snodgrass W. Tubularized incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5.  Back to cited text no. 2  [PUBMED]  
3.Snodgrass W, Koyle M, Manzoni G, Horowitz R, Caldamone A, Ehrlich R. Tubularized Incised Plate hypospadias repair, results of a multicenter experience. J Urol 1996;156:839-41.  Back to cited text no. 3    
4.Snodgrass W, Koyle M, Manzoni G, Horowitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair for proximal hypospadias. J Urol 1998;159:2129-31.  Back to cited text no. 4    
5.Snodgrass W. Does Tubularized Incised Plate hypospadias repair create neourethra strictures? J Urol 1999;162:1159-61.  Back to cited text no. 5  [PUBMED]  
6.Borer JG, Bauer SB, Peters CA, Diamond DA, Atala A, Cilento BG. Tubularized incised plate urethroplasty: Expanded use in proximal and repeat surgery for hypospadias. J Urol 2001;165:581-5.  Back to cited text no. 6    
7.Samuel M, Wilcox DT. Tubularized incised-plate urethroplasty for distal and proximal hypospadias. BJU Int 2003;92:783-5.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Rich MA, Keating MA, Snyder HM 3 rd , Duckett JW. Hinging the urethral plate in hypospadias meatoplasty. J Urol 1989;142:1551.  Back to cited text no. 8    
9.Baskin LS, Erol A, Ying WL, Cunha GR. Anatomic studies of hypospadias. J Urol 1998;160:1108-15.  Back to cited text no. 9    
10.Erol A, Baskin LS, Li YW, Liu WH. Anatomical studies of the urethral plate: Why preservation of the urethral plate is important in hypospadias repair. BJU Int 2000;85:728-34.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Horasanii K, Perk C, Yesildere T. The effect of catheterisation time on tissue regeneration after a deep urethral plate incision. BJU Int 2000;87:20.  Back to cited text no. 11    
12.Sozubir S, Snodgrass W. A new algorithm for primary hypospadias repair based on tip urethroplasty. J Pediatr Surg 2003;38:1157-61.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Yerkes EB, Adams MC, Miller DA, Pope JC 4 th , Rink RC, Brock JW 3 rd . Y-to-I wrap: Use of the distal spongiosum for hypospadias repair. J Urol 2000;163:1536.  Back to cited text no. 13    
14.Elbakry A. Further experience with Tubularized-incised urethral plate technique for hypospadias repair. BJU Int 2002;89:291-4.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Lorenzo A, Snodgrass W. Regular dilatation is unnecessary after Tubularized incised plate hypospadias repair. BJU Int 2002;89:94-7.  Back to cited text no. 15    
16.Snodgrass WT, Lorenzo AJ. Tubularized incised-plate urethroplasty for hypospadias reoperation. Br J Urol Int 2002;89:98-100.  Back to cited text no. 16    
17.Yang SS, Chen YT, Hsieh CH, Chen SC. Preservation of the thin distal urethra in hypospadias repair. J Urol 2000;164:151-3.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Sarin YK, Manchanda V. Preservation of urethra devoid of corpus spongiosum in patients undergoing urethroplasty. Indian J Urol 2006;22:326-8.  Back to cited text no. 18    Medknow Journal

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Correspondence Address:
Gamal Al-Saied
King Abdul Aziz Specialist Hospital, Taif, POB 10127, Saudi Arabia

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.54770

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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