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Tubularized incised-plate (TIP) repair augmented by spongioplasty for distal and midpenile hypospadias

Authors:
Wael Gamal at Sohag University
Wael Gamal
Mohamed zaki Aldahshoury at Aswan University and sohag university
Mohamed zaki Aldahshoury
  • Aswan University and sohag university
Ahmed Rashid at University of Leeds
Ahmed Rashid
Mohamed Mostafa at Mkhair Consulting
Mohamed Mostafa
  • Mkhair Consulting
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Abstract

Introduction: The objective of the study was to evaluate the cosmetic and functional results of tubularized incised-plate (TIP) repair of distal and midpenile hypospadias, using the hemicorpora spongiosa as an additional cover in the Y to I maneuver. Methods: From February 2004 to February 2007, 50 patients with distal (n=30) and midpenile (n=20) hypospadias had surgical repair. The mean age of the patients was 4.2 years (range, 2-6 years). All patients received primary TIP repair with bilateral dissection of the hemicorpora spongiosa to cover the neourethra (spongioplasty). Results: The mean follow-up period was 12.6 months (range, 10-17 months). Of the 50 cases, 48 patients (96%) had successful outcome with regard to a straight urine stream, vertically slit meatus, and acceptable cosmetic appearance. Two patients with midpenile hypospadias developed a small fistula at the site of the native meatus. Both patients had successful fistula closure through a secondary repair 3 months later. Conclusion: Spongioplasty is a reliable and important adjunct for covering the neourethra in TIP hypospadias repair. This surgical technique results in a low rate of fistula formation.
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©2009 UroToday International Journal / Vol 2 / Iss 3 / June
doi:10.3834/uij.1944-5784.2009.06.13
http://www.urotodayinternationaljournal.com
ISSN 1944-5792 (print), ISSN 1944-5784 (online)
Wael Mohamed Gamal, Mohamed Zaki, Ahmed Rashid, Mohamed Mostafa, Abd El Monem Abouzeid
Sohag University Hospital, Sohag, Egypt
Submitted March 25, 2009 - Accepted for Publication April 21, 2009
ABSTRACT
www.urotodayinternationaljournal.com
Volume 2 - June 2009
Tubularized Incised-Plate (TIP) Repair Augmented by
Spongioplasty for Distal and Midpenile Hypospadias
INTRODUCTION
In the last 20 years major advances in instrumentation, suture
materials, and anatomical and histological understanding
have evoked an exponential number of new and modified
techniques for the correction of hypospadias. These surgical
advances have enabled the urologists to correct most cases of
hypospadias with excellent functional and cosmetic results [1].
The Snodgrass technique is the procedure of choice for distal
and midpenile hypospadias because it is versatile and easy to
perform. It also has good cosmetic outcome with a vertically-
orientated meatus that is similar to a normal circumcised
penis [3]. However, despite obvious surgical advances in
hypospadias repair, no single technique has been developed
that is completely without complications. The most common
and particularly annoying complication is urethrocutaneous
fistula [2,4].
Several procedures have been described for preventing fistula
formation [5]. The purpose of the present investigation was
to evaluate the results of tubularized incised-plate (TIP) repair
UroToday International Journal®
UI
J
INTRODUCTION: The objective of the study was to evaluate the cosmetic and functional results of tubularized
incised-plate (TIP) repair of distal and midpenile hypospadias, using the hemicorpora spongiosa as an
additional cover in the Y to I maneuver.
METHODS: From February 2004 to February 2007, 50 patients with distal (n=30) and midpenile (n=20)
hypospadias had surgical repair. The mean age of the patients was 4.2 years (range, 2-6 years). All patients
received primary TIP repair with bilateral dissection of the hemicorpora spongiosa to cover the neourethra
(spongioplasty).
RESULTS: The mean follow-up period was 12.6 months (range, 10-17 months). Of the 50 cases, 48 patients
(96%) had successful outcome with regard to a straight urine stream, vertically slit meatus, and acceptable
cosmetic appearance. Two patients with midpenile hypospadias developed a small fistula at the site of the
native meatus. Both patients had successful fistula closure through a secondary repair 3 months later.
CONCLUSION: Spongioplasty is a reliable and important adjunct for covering the neourethra in TIP
hypospadias repair. This surgical technique results in a low rate of fistula formation.
KEYWORDS: Hypospadius; Spongioplasty; Urethra.
CORRESPONDENCE: Wael M Gamal, MD, Department of Urology, Sohag University, 31 el nasr Street, Sohag,
Egypt (wael_saad_el_dien@hotmail.com).
©2009 UroToday International Journal / Vol 2 / Iss 3 / June
doi:10.3834/uij.1944-5784.2009.06.13
http://www.urotodayinternationaljournal.com
ISSN 1944-5792 (print), ISSN 1944-5784 (online)
UroToday International Journal®
original study
TIP Repair Augmented by Spongioplasty for Distal and Midpenile Hypospadias
of distal and midpenile hypospadias, using the hemicorpora
spongiosa as an additional cover in the Y to I maneuver.
METHODS
Participants
The participants were 50 children with well-developed
spongial tissue (those with underdeveloped spongial tissue
were excluded from this study). Their mean age was 4.2 years
(range, 2-6 years). The hypospadiac meatus was distal in 30
children (60%) and midshaft in 20 (40%). None of the patients
had associated congenital anomalies or needed preoperative
hormonal therapy.
Procedure
All children received primary hypospadias repair using standard
primary TIP urethroplasty, in conjunction with spongiosal
tissue covering of the neourethra to prevent the occurrence
of urethrocutaneous fistula. The operation was done under
general anesthesia without the use of tourniquet.
After draping the patient from the umbilicus to the upper
part of the thigh, the penis was placed on tension with a
glans traction suture and the dorsal hood was lysed from
the glans head. The urethral meatus was calibrated and the
integrity, thickness, and width of the urethral plate and skin
were assessed. Mucosal collar traction sutures were placed on
the ventrolateral inner prepuce, as described by Firlit [6]. The
collars were distracted laterally to tent the ventral skin at the
level of the native meatus. A micro-knife was used to make an
incision from tip to tip from each marking suture of the mucosal
collars. The incision in the midline was adjusted to skirt around
the native urethral meatus. Extreme care was taken to incise
only through the dermis on top of the distal urethra (Figure 1).
Orthoplasty was performed by dorsal tunica albuginea placation,
if needed. Two parallel longitudinal incisions separated the
urethral plate from the glans wings. The urethral plate was
then incised in the midline from the hypospadiac meatus to the
area just proximal to the glans tip. The urethral plate was then
Figure 1. Two Parallel Longitudinal Marks Around the
Urethral Plate (Arrows Show Well-Formed Spongial
Tissue). doi: 10.3834/uij.1944-5784.2009.06.13f1
Figure 2. Neourethra Formation and Dissection of the
Hemicorpora Spongiosa.
doi: 10.3834/uij.1944-5784.2009.06.13f2
Figure 3. Approximation of the Hemicorpora to Cover
the Neourethra (Y into I Maneuver).
doi: 10.3834/uij.1944-5784.2009.06.13f3
UI
J
UroToday International Journal®
©2009 UroToday International Journal / Vol 2 / Iss 3 / June
doi:10.3834/uij.1944-5784.2009.06.13
http://www.urotodayinternationaljournal.com
ISSN 1944-5792 (print), ISSN 1944-5784 (online)
www.urotodayinternationaljournal.com
original study
tubularized over a suitable silicone stent using 6/0 polyglactin
sutures. The spongial tissue was dissected from the underlying
tunica albuginea on its lateral edges deep enough to be closed
without tension (Figure 2). Then, medial approximation of the
two dissected hemicorpora spongiosa created a covering layer
over the TIP urethroplasty (Figure 3).
The glans wings were approximated with no tension and closed
with 6/0 monofilament sutures in two layers. The remainder of
the penile skin shaft was closed in one layer as in Figure 4. A
urethral stent was secured to the glans with 5/0 polypropylene
sutures for 5 days in all cases. A dressing was applied around
the penis in the stretched position. Oral antibiotics and
oxybutynin were used to prevent postoperative infection and
bladder irritation, respectively.
RESULTS
All patients were repaired in one stage. The mean operative
time was 85.9 minutes (range, 77-110 minutes). All patients
were discharged after removal of the urethra stent. Mean
duration of follow-up was 12.6 months (range, 10-17 months).
Of the 50 patients, 48 (96%) voided in a straight stream and
had a vertically slit meatus at the tip of a straight circumcised
penis (Figure 5). The remaining 2 patients (4%) with midpenile
hypospadias developed a small fistula at the site of the native
urethral meatus. They underwent multilayer closure after 3
months and the outcome was successful in both cases.
DISCUSSION
The success rate of TIP repair in almost every type of hypospadias
defect has approached 90% [1,7]. Urethrocutaneous fistula is
the most common complication in up to 16% [1,7]. Interposition
of well-vascularized tissue between the penile skin and
neourethra is essential to decrease the incidence of fistula [8,9].
Many procedures have been described to achieve vascularized
coverage of the suture line [10,11]. In the original article by
Snodgrass in 1994 [3], a dorsal-based dartos flap was used for
urethral coverage. Although harvesting of dartos tissue from
dorsal penile and/or preputial skin has become a standard
technique, it has potential complications such as penile torsion,
chordee formation, or skin loss when aggressive dissection
between the skin and dorsal dartos is conducted. Additionally,
it adds some time to reconstruction.
The cosmetic results have become as important as the
functional outcomes in hypospadias repair. Belman [10]
wrapped the neourethra with a de-epithelialized preputial
skin flap, which was rotated to the ventrum from the dorsal
aspect. The incidence of fistula was only 3.5%. However,
Figure 4. Skin Coverage Following Spongioplasty.
doi: 10.3834/uij.1944-5784.2009.06.13f4
Figure 5. Six Months Following Spongioplasty.
doi: 10.3834/uij.1944-5784.2009.06.13f5
Wael Mohamed Gamal, Mohamed Zaki, Ahmed Rashid,
Mohamed Mostafa, Abd El Monem Abouzeid
UI
J
©2009 UroToday International Journal / Vol 2 / Iss 3 / June
doi:10.3834/uij.1944-5784.2009.06.13
http://www.urotodayinternationaljournal.com
ISSN 1944-5792 (print), ISSN 1944-5784 (online)
UroToday International Journal®
original study
TIP Repair Augmented by Spongioplasty for Distal and Midpenile Hypospadias
most of the hypospadias that Belman repaired using the de-
epithelialized flap were distal ones in addition to the previously
mentioned complications of dartos flap. For this reason, the
authors of the present investigation preferred an easy method
for urethroplasty using covering from the local surrounding
spongial tissue (spongioplasty). The success rate was 96% with
only 4% fistula formation. Mezzine et al [12] reported that
the immediate results of spongioplasty are good and long-term
follow-up shows maintenance of the cosmetic and functional
results. The same results were also reported by Yerkes et al [13].
The authors are aware that a series of 50 patients with a mean
follow-up of 12.6 months is not enough to make a comment
regarding the results of the technique. A larger series with
a longer follow-up period is needed to prove the efficacy
of the technique. Because the authors could not achieve a
100% complication-free rate with the surgical technique, they
hypothesize that an additional covering by either preputial
dartos or de-epithelialized preputial skin can be used to
reinforce the repair.
CONCLUSION
Use of the spongial tissue as an intermediate layer in urethral
coverage is a technique that can be easily incorporated into
many existing hypospadias repairs. In this small patient series,
it contributed to a low rate of urethrocutaneous fistulas.
In addition, it alleviates tension on the repair, with low
complication rate for penile torsion, chordee formation, and
dorsal skin loss. It is also less time consuming than the dartos
flap covering.
REFERENCES
[1] Cheng EY, Vemulapallis N, Kropp BP, et al. Snodgrass
hypospadias repair with vascularized flap: the perfect
repair for virgin cases of virgin hypospadias. J Urol.
2002;168(4, pt 2):1723-1726.
[2] Peter D. Furness, III: Successful hypospadias repair with
a vertical based vascular dartos pedicle for urethral
coverage. AUA. 2003;169:1825-1827.
[3] Snodgrass W. Tubularized, incised plate urethroplasty for
distal hypospadias. J Urol. 1994;151(2):464-465.
[4] Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone
A, Ehrlich R. Tubularized incised plate hypospadias repair:
results of a multicenter experience. J Urol. 1996;156(2, pt
2):839-841.
[5] Retik AB, Borer JG. Primary and reoperative hypospadias
repair with the Snodgrass technique. World J Urol.
1998;16(3):186-191.
[6] Firlit CF. The mucosal collar in hypospadias surgery. J Urol.
1987;137(1):80-82.
[7] Guralnick ML, al-Shammari A, Williot PE, Leonard MP.
Outcome of hypospadias repair using the tubularized,
incised plate urethroplasty. Can J Urol. 2000;7(2):986-991.
[8] Borer JG, Retik AB. Current trends in hypospadias surgery.
Urol Clin North Am. 1999;26(1):15-37.
[9] Ulman I, Erikc¸ IV, Avanoolu A, Gokdemir A. The effect
of suturing technique and material on complication
rate following hypospadias repair. Eur J Pediatr Surg.
1997;7(3):156-157.
[10] Belman AB. De-epithelialized skin flap coverage in
hypospadias repair. J Urol. 1988;140(5, pt 2):1273-1276.
[11] Kirkali Z. Tunica vaginalis: an aid in hypospadias surgery.
Br J Urol. 1990;65(5):530-532.
[12] Mezzine S, Beaudoin S, Bargy F. Medium and long-term
evaluation of spongioplasty in hypospadias repair [in
French]. Prog Urol. 2005;15(3):519-523.
[13] Yerkes EB, Adams MC, Miller DA, Pope JC IV, Rink RC,
Brock JW III. Y-to-I wrap: use of the distal spongiosum for
hypospadias repair. J Urol 2000;163(5):1536–1539.
TO CITE THIS ARTICLE: Gamal WM, Zaki M, Rashid A,
Mostafa M, Abouzeid AM. Tubularized Incised-Plate
(TIP) Repair Augmented by Spongioplasty for Distal and
Midpenile Hypospadias. UIJ 2009 Jun;2(3).
doi:10.3834/uij.1944-5784.2009.06.13.
UI
J
... Additionally, it reduces stress on the healing process and has a minimal risk of complications from penile torsion, chordee development, and dorsal skin loss. Also, it takes less time than the dartos flap covering (7) . Because it lessened the degree of penile curvature and allowed dorsal plication to be avoided in more than half of the hypospadias patients who displayed moderately severe curvature, spongioplasty could be used as an additional procedure after dartos flap coverage of the neourethra following TIP urethroplasty (9) . ...
... About one third of the poor spongiosum cases had proximal hypospadias, indicating that the more proximal the hypospadias, the less developed is the spongiosum (17) . Aiming to achieve the best results, this study included only distal hypospadias cases unlike other studies in which about half of the study sample was of distal type and the other half was mid penile (7) or included all types of hypospadiac meatal locations (6) . This study included primary cases only (4,19) , but unlike the single-center experience with 500 cases published in 2009 in which about one eighth of the cases had at least one unsuccessful prior surgery (6) . ...
... A protective barrier between the neourethra and the skin is one of the key elements in minimizing the development of fistulas (15) . In this study we decided to follow the footsteps of some of the recent reports using the mobilized approximated spongiosum as a standalone covering layer after urethroplasty (17,19) but other publications choose to assess the supporting effect of spongioplasty in conjunction with the standard TIP urethroplasty repair, including dorsal preputial dartos flap (7,10) . Many attempts were done trying to select the best second layer cover for repairing different forms of hypospadias that some of them investigated the extra added effect of reconstructing forked corpus spongiosum compared to the standard standalone dartos flap as a second layer (1,9and18) and others divided the study sample into two halves and compared between the dartos flap and the spongioplasty as the second layer (12) . ...
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... Recently, spongioplasty is more frequently used as a healthy interposing tissue layer. [9,10] Disadvantages of the techniques of spongioplasty described in the literature are a superimposition of suture line of neourethra, spongioplasty, and skin closure; conical shape of the urethra and comprising the blood supply of spongiosum by both medial and lateral mobilization of spongiosum. Superimposition of suture line is likely to increase the chances of fistula. ...
... [21][22][23][24] In the present study, overall incidence of complications was 5% which is lower than the reported. The fistula rate in TIPU with spongioplasty ranges from 4% to 40%, [9,10,20,[25][26][27][28] and fistula rate in present series with double breasting spongioplasty is 1.66% which is significantly lower than the reported in the literature. The fistula rates reported with conventional spongioplasty by the same operating surgeon in similar circumstances (7.96-14.28%) ...
... Gamal et al. [9] 2009 50 2 4 Conventional ...
Double breasting spongioplasty in tubularized/tubularized incise plate urethroplasty: A new technique
Article
Full-text available
  • Jan 2016
  • Indian J Urol
Introduction The main disadvantage of currently described techniques of spongioplasty is superimposition of 3 suture lines (neourethra, spongioplasty, and skin closure) which is likely to increase the chances of a fistula. We describe and evaluate the results of a double breasting spongioplasty in urethroplasty. Methods A prospective study of 60 primary hypospadias was undertaken by double breasting spongioplasty from August 2012 to March 2014. Mobilization of the urethral plate and the spongiosum is done by creating a plane just proximal to the meatus. Double breasting spongioplasty is done after tubularization of urethral plate. First layer of spongiosum is sutured toward lateral side of the neourethra covering the suture line. A second double breasting layer is sutured over the first layer with its suture line toward the opposite side covering the suture line of the first layer; thus avoiding overlapping of suture lines of all the three layers. Results Age of the patients varied from 10 months to 16 years with a mean and median of 3.73 and 3.50 years, respectively. Hypospadias was distal, mid, and proximal in 38, 10, and 12 cases, respectively. Chordee was noticed in 35 cases and torque in 28 cases. Overall complication rate was 5% and fistula rate was 1.66%. Conclusions Double breasting spongioplasty avoids superimposition of suture line and adds two layers of spongiosum over neourethra, thus decreases the chances of urethral fistula and gives cylindrical shape to neourethra.
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... A spongial layer has been used by some surgeons to prevent fistulae and other complications. In recent years, the use of spongial tissue as an intermediate layer between the urethra and the skin repair lines has become more popular171819202122. This procedure was described in 2000 by Yerkes [18] and Beaudoin [19] in their separate trials. ...
... Later in 2003, Dodat et al. found no fistula formation in any of the 51 patients who underwent TIP urethroplasty and spongioplasty [23]. Gamal et al. performed urethral tubularization using the Snodgrass technique, releasing the paraurethral spongial tissue and approximating it onto the neourethra [20], then approximating the glandular wing and suturing the penile skin. In their study, they reported that 2 (4%) of 50 patients developed fistulae. ...
Comparison of dartos flap and dartos flap plus spongioplasty to prevent the formation of fistulae in the Snodgrass technique
Article
Full-text available
  • Mar 2011
  • INT UROL NEPHROL
The aim of our study was to evaluate the role of paraurethral spongial tissue plus dartos flap using an additional urethral cover to prevent fistula formation in patients who underwent surgery with the Snodgrass technique. A retrospective study was performed on 161 patients aged 10 months to 15 years who underwent midpenile and distal hypospadias repair using the Snodgrass technique. The patients were assigned to one of two groups. In Group I (75 patients), the neourethra was covered with the dartos flap, and in Group II (86 patients), the neourethra was covered with the dartos flap plus spongioplasty. Urethral fistulae were encountered in six cases (8%) in Group I, and no fistulae were encountered in Group II. The use of corpus spongiosum as an intermediate layer in urethral coverage, combined with the dartos flap, reduces the likelihood of fistula formation. This procedure can be applied easily and effectively to prevent the formation of fistulae.
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... The most common and annoying complication is urethrocutaneous fistula. To minimize the fistula rate, several procedures have been described, i.e. tunica vaginalis used as a blanket to wrap the urethra [1], or spongial tissue as an intermediate layer in urethral coverage [2], and a two-layer closure of the neourethra in conjunction with a vascularized dartos flap [3]. Retik et al. [4] used a dorsal dartos flap to wrap the neourethra after a meatalbased flap hypospadias repair. ...
Interposition of dartos flaps to prevent fistula after tubularized incised-plate repair of hypospadias
Article
Full-text available
  • Jun 2011
Objective: To evaluate the effect of urethral coverage by a single- or double-layered dorsal dartos flap after tubularized incised-plate (TIP) repair of hypospadias on fistula formation. Patients and methods: In this retrospective study we evaluated sequential patients with hypospadias who underwent TIP urethroplasty with a dorsal dartos interpositional flap between April 2008 and December 2009. We reviewed their medical records for the site of hypospadias, previous hypospadias repair, single- or double-layered dartos flap and postoperative complications. The patients were divided into two groups; in group A the urethra was covered by a single layer of dartos fascia, and in group B the urethra was covered by double layers of dartos flap. Results: Of 91 patients who opted for hypospadias repair during the time of the study, 62 had a TIP urethroplasty with a dorsal dartos flap; of these 62, three did not fulfil the requirement of the minimum follow-up, so 59 were eligible for the study (32 in group A and 27 in group B). Preoperative clinical data were comparable in both groups. At a mean of 12.2 months of follow-up, there was no reported fistula in group B, while two patients in group A developed a urethrocutaneous fistula (P = 0.19). Meatal stenosis occurred in two patients in group A and one in group B (P = 0.66). Conclusion: There was no significant difference in subsequent urethrocutaneous fistula between a double-layered dorsal dartos flap and single layer for covering the urethra as a part of TIP urethroplasty for repairing hypospadias.
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... Gamal [30] 2009 50 2 (4) ...
Outcome of tubularized incised plate urethroplasty with spongioplasty alone as additional tissue cover: A prospective study INTRODUCTION
Article
Full-text available
  • Oct 2014
Introduction: Introduction: Additional cover after neourethra formation, to decrease the fi stula rate, has been described using the dartos, tunica, denuded skin and corpus spongiosum. The use of corpus spongiosum alone to cover the neourethra is infrequent. The objective of this study was to evaluate the effi cacy of spongioplasty alone as an intervening layer in the prevention of urethral fi stula following tubularized incised plate urethroplasty (TIPU). Materials and Methods: Materials and Methods: A prospective study was performed of including 113 primary hypospadias cases undergoing TIPU with spongioplasty from June 2010 to March 2012. Correction of chordee was carried out by penile degloving alone in 5, mobilization of urethral plate with spongiosum in 22 and combination of both in 45 cases. Intra-operatively, spongiosum was taken to be poorly developed if it was thin and fibrous, moderate if good spongiosal tissue with good vascularization and well-developed if healthy robust spongiosum, which became bulkier than native spongiosum after tubularisation. Spongioplasty was done in a single layer after mobilization of spongiosum, starting just proximal to the native meatus and into the glans distally. Results: Results: The mean age of the patient was 11.52 years. The type of hypospadias was distal, mid and proximal in 81, 12 and 20 cases respectively. Spongiosum was poorly developed in 13, moderate in 53 and well-developed in 47 cases. The mean hospital stay was 8-10 days and follow-up ranged from 6 months to 2 years. Urethral fi stula was seen in six patients (11.3%) with moderate spongiosum (distal 1, mid 1 and proximal 4), and three (23.03%) with poorly developed spongiosum (one each in distal, mid and proximal) with an overall 7.96% fi stula rate. None of the patients with well-developed spongiosum developed a fi stula. Poorer spongiosum correlated with a greater number of complications (P = 0.011). Five out of thirteen cases with poor spongiosum (38.46%) had proximal hypospadias, i.e. more proximal was the hypospadias, poorer was the development of the spongiosum (P = 0.05). Meatal stenosis was seen in two patients (1.76%) with proximal hypospadias, one with moderate and the other with poorly developed spongiosum. More proximal was the hypospadias, greater were the number of complications (P = 0.0019). Conclusion: Conclusion: TIPU with spongioplasty reconstructs a near normal urethra with low complications. Better developed and thicker spongiosum results in lower incidence of fi stula and meatal stenosis. More proximal hypospadias is associated with poorer spongiosum. We recommend spongioplasty to be incorporated as an essential step in all patients undergoing tubularized incised-plate repair for hypospadias.
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... Gamal [30] 2009 50 2 (4) ...
Outcome of tubularized incised plate urethroplasty with spongioplasty alone as additional tissue cover: A prospective study INTRODUCTION
Article
Full-text available
  • May 2014
  • Indian J Urol
Introduction: Additional cover after neourethra formation to decrease the fistula rate, has been described using the dartos, tunica, denuded skin and corpus spongiosum. The use of corpus spongiosum alone to cover the neourethra is infrequent. The objective of this study was to evaluate the efficacy of spongioplasty alone as an intervening layer in the prevention of urethral fistula following tubularized incised plate urethroplasty (TIPU). Materials and Methods: A prospective study was performed including 113 primary hypospadias cases undergoing TIPU with spongioplasty from June 2010 to March 2012. Correction of chordee was carried out by penile degloving alone in 5, mobilization of urethral plate with spongiosum in 22 and combination of both in 45 cases. Intra-operatively, spongiosum was taken to be poorly developed if it was thin and fibrous, moderate if good spongiosal tissue with good vascularization and well-developed if healthy robust spongiosum, which became bulkier than native spongiosum after tubularisation. Spongioplasty was done in a single layer after mobilization of spongiosum, starting just proximal to the native meatus and into the glans distally. Results: The mean age of the patients was 11.53 years. The type of hypospadias was distal, mid and proximal in 81, 12 and 20 cases respectively. Spongiosum was poorly developed in 13, moderate in 53 and well-developed in 47 cases. The mean hospital stay was 8-10 days and follow-up ranged from 6 months to 2 years. Urethral fistula was seen in six patients (11.3%) with moderate spongiosum (distal 1, mid 1 and proximal 4), and three (23.03%) with poorly developed spongiosum (one each in distal, mid and proximal) with an overall 7.96% fistula rate. None of the patients with well-developed spongiosum developed a fistula. Poorer spongiosum correlated with a greater number of complications (P = 0.011). Five out of thirteen cases with poor spongiosum (38.46%) had proximal hypospadias, i.e. more proximal was the hypospadias, poorer was the development of the spongiosum (P = 0.05). Meatal stenosis was seen in two patients (1.76%) with proximal hypospadias, one with moderate and the other with poorly developed spongiosum. More proximal was the hypospadias, greater were the number of complications (P = 0.0019). Conclusion: TIPU with spongioplasty reconstructs a near normal urethra with low complications. Better developed and thicker spongiosum results in lower incidence of fistula and meatal stenosis. More proximal hypospadias is associated with poorer spongiosum. We recommend spongioplasty to be incorporated as an essential step in all patients undergoing tubularized incised-plate repair for hypospadias.
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Evaluation of Tubularized Incised Plate Urethroplasty with Spongioplasty-Dartosoraphy Reinforcement in Pediatric Hypospadias: A Randomized Controlled Study
Article
  • Jan 2024
  • EUR J PEDIATR SURG
Introduction The original description of tubularized incised plate urethroplasty (TIPU) was provided by Snodgrass in 1994. The results were significantly improved by several modifications. To decrease the incidence of complications, interposing a vascularized flap after tubularization of the neourethra is recommended. The extent to which the type of interposed tissue has a direct effect on the rate of complications and cosmetic outcomes after TIPU repair is considered the answer to the main hypothesis of this study. Materials and Methods This prospective controlled randomized trial was conducted in the Department of Pediatric Surgery, Al-Azhar University, Cairo, Egypt, between May 2019 and May 2023. A total of 220 patients were included in this study. Patients were randomly assigned to either group A or group B. Group A included 110 patients who underwent TIPU with spongioplasty–dartosoraphy reinforcement. The other 110 patients (group B) underwent TIPU with dorsal dartos flap interposition, without spongioplasty. Results Complications developed in 34 of 220 patients (15.4%). In group A, complications developed in 11 of 110 patients (10.0%). In group B, complications occurred in 23 of 110 patients (20.9%). Although the fistula rate, glanular dehiscence, disruption, and meatal stenosis were not significantly different between the study groups, the skin necrosis rate was significantly lower in group A than in group B. The overall complication rate was significantly lower in group A than in group B. Also, the difference in the mean Hypospadias Objective Scoring Evaluation between the two groups was statistically significant. Conclusion TIPU with spongioplasty–dartosoraphy reinforcement is an effective modification of conventional TIPU. This modification appears to reduce the rate of complications and yield better cosmetic outcomes.
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Spongioplasty in Hypospadias Repair
Chapter
  • Jan 2022
The corpus spongiosum is a spongy tissue that surrounds the urethra. Historically, spongiosum in hypospadias was considered as fibrous tissue and one of the causes of chordee. Traditionally, spongiosum was resected to correct the chordee with or without dorsal plication in moderate to severe hypospadias. However, with TIPU’s increasing popularity as the most commonly performed procedure, various healthy tissues have been interposed. The tissues are dorsal/lateral/ventral based dartos flap, scrotal dartos, de-epithelized local penile skin, inner prepucial dartos flap, preputial flap, paraurethral tissue, spongiosum, and tunica vaginalis flaps. Although the spongiosum is a healthy vascular tissue and spongioplasty reconstructs the near-normal urethra with minimal complications, but it is still less frequently used. Spongioplasty improves the results of hypospadias repair including re-operative cases and flap urethroplasty. Since the spongiosum is part of the urethra, so attempts should be made to preserve and utilize the spongiosum in hypospadias repair.KeywordsHypospadias repairHealthy interposing tissueSpongiosumSpongioplastyDartos flapsComplications of hypospadias repairTIPUModified TIPUUrethroplastyDouble breasting spongioplastyReconstructive surgery
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Tip Repair Augmented by Spongioplasty for Distal and Midpenile Hypospadias
Article
Full-text available
  • Jan 2009
  • UroToday
ABSTRACT INTRODUCTION: The objective of the study was to evaluate the cosmetic and functional results of tubularized incised-plate (TIP) repair of distal and midpenile hypospadias, using the hemicorpora spongiosa as an additional cover in the Y to I maneuver. METHODS: From February 2004 to February 2007, 50 patients with distal (n=30) and midpenile (n=20) hypospadias had surgical repair. The mean age of the patients was 4.2 years (range, 2-6 years). All patients received primary TIP repair with bilateral dissection of the hemicorpora spongiosa to cover the neourethra (spongioplasty). RESULTS: The mean follow-up period was 12.6 months (range, 10-17 months). Of the 50 cases, 48 patients (96%) had successful outcome with regard to a straight urine stream, vertically slit meatus, and acceptable cosmetic appearance. Two patients with midpenile hypospadias developed a small fistula at the site of the native meatus. Both patients had successful fistula closure through a secondary repair 3 months later. CONCLUSION: Spongioplasty is a reliable and important adjunct for covering the neourethra in TIP hypospadias repair. This surgical technique results in a low rate of fistula formation.
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The Effect of Suturing Technique and Material on Complication Rate Following Hypospadias Repair
Article
Full-text available
  • Jun 1997
Ninety-seven children with distal hypospadias were treated surgically using perimeatal-based flap urethroplasty (Mathieu procedure) in a two and a half years period. A review of the medical records revealed two distinct groups of patients according to the suturing type and suture material. In the first group of 36 patients (group I), neourethra was constructed using 6/0 polyglactine (Vicryl) in a single layer, full-thickness, uninterrupted fashion. Skin flaps were approximated using interrupted simple 5/0 polyglactine (Vicryl) sutures. In the second group of 61 patients (group II), 7/0 polydioxanone (PDS) was used in the urethral anastomosis performed in a subcuticular, uninterrupted fashion. The skin flaps were closed using interrupted simple 5/0 rapidly absorbable polyglactine (Rapid Vicryl) sutures. Patients were followed-up from 6 to 12 months. Urethral or meatal stenosis was not observed in any patient. There was no infectious complication. Urethrocutaneous fistula rate was significantly higher in group I (16.6%) compared to group II (4.9%) (p < 0.01). Complication rate following hypospadias repair can be reduced by the use of a subcutaneous suture technique utilizing polydioxanone suture material in urethroplasties.
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Primary and Reoperative Hypospadias Repair With the Snodgrass Technique
Article
  • Oct 1999
This report documents our experience with primary and reoperative repair of anterior and middle hypospadias using the tubularized, incised plate (TIP) urethroplasty (Snodgrass technique) and provides a detailed description of the operative procedure. A total of 31 patients (27 primary; 4 reoperative) underwent TIP urethroplasty. The patients' age at primary of reoperative hypospadias repair ranged from 5 months to 26 years. Excellent functional and cosmetic results were achieved in all but one patient, who developed an urethrocutaneous fistula. On the basis of our experience we feel that the Snodgrass TIP urethroplasty is a technique to be strongly considered for primary and reoperative repair of distal and, in some instances, midshaft hypospadias. Further experience is necessary to determine the applicability of this technique for repair of more proximal and complex hypospadias defects. True for all commonly used classification systems, glanular and subcoronal (anterior) as well as distal penile, midshaft, and proximal penile (middle) defects constitute the great majority of all hypospadias [1]. Regardless of the technique employed for repair of such defects, attention to orthoplasty (as needed), urethroplasty, meatoplasty and glanuloplasty, and, finally, skin coverage is universal [1-3]. Most glanular hypospadias defects should be amenable to the meatal advancement and glanuloplasty (MAGPI) technique, with the functional and cosmetic results being excellent, provided there is adequate urethral mobility and no chordee [4, 5]. Several successful procedures with acceptable complication rates are available for the repair of coronal, subcoronal, and mid-T and distal penile shaft hypospadias with minimal chordee. Among the most commonly used of these techniques are the meatal based flap (Mathieu) [6], the onlay island flap [7], the modified Barcat technique [8], and the King [9] and Snodgrass [10] modifications of the Thiersch-Duplay [11] technique. Initially described in 1994, the Snodgrass technique [10], also called the tubularized, incised plate (TIP) urethroplasty, combines modifications of the previously described techniques of urethral plate incision [12] and tubularization [11]. On the basis of the results of a multicenter experience [13] and initial favorable results in our hands, we have increased the frequently of and indications for our use of this technique. Herein we review our experience and provide a detailed description of the TIP urethroplasty technique for primary and reoperative hypospadias repair.
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Tunica Vaginalis: an Aid in Hypospadias Surgery
Article
  • Jun 1990
  • Br J Urol
Summary— Despite the improvements that have been made in equipment and in the techniques of h?pospadias repair, some patients still present with failed repairs and urethral fistulas. In such patients the lack of prepuce leads to difficulty in obtaining adequate tissue for further reconstruction. In 14 patients with hypospadias who had already undergone surgery, a tube was formed from proximal penile or scrotal skin and wrapped by pedicled tunica vaginalis; 4 patients with urethral fistulas were treated in the same way after primary repair of the fistulas. Excellent cosmetic and functional results were achieved in all but 1 case. The technique is simple, has few complications and is recommended in the treatment of patients with failed hypospadias repair and urethral fistulas.
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De-Epithelialized Skin Flap Coverage in Hypospadias Repair
Article
  • Dec 1988
The results in 84 hypospadias repairs using a de-epithelialized skin flap are reported. A variety of 1-stage repairs were applied including those of King, Mathieu, Mustardé and Duckett, and a combined midline and transverse island flap for perineal hypospadias. In each repair a flap of transposed prepuce was swung ventral, de-epithelialized and applied over the urethroplasty. In all but 2 repairs complete coverage of the urethra was achieved by this technique. Reoperation was required in 7 patients (8 per cent) but in only 3 (3.5 per cent) ws this to close a urethrocutaneous fistula. The addition of a de-epithelialized flap to create a layer completely covering the neourethra appears to reduce the incidence of fistulas significantly.
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The Mucosal Collar in Hypospadias Surgery
Article
  • Feb 1987
Formation of a mucosal collar from the inner surface of the prepuce offers the surgeon who performs hypospadias repairs the opportunity to create a cosmetically normal-appearing phallus. This technique results in transposition of mucosal membrane type of tissue to the subglandular area to complete the normal repair.
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Tubularized, Incised Plate Urethroplasty for Distal Hypospadias
Article
  • Mar 1994
A technique is described for correction of distal hypospadias with minimal chordee by tubularizing the urethral plate. The key step is deep longitudinal incision of the plate, which allows for tubularization without the need for additional flaps. The resultant neourethra is functionally adequate and an excellent cosmetic result with a vertically oriented meatus is achieved. A total of 16 boys underwent the procedure with no case of meatal stenosis or fistula occurring during a median followup of 22 months.
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Tubularized Incised Plate Hypospadias Repair: Results of a Multicenter Experience
Article
  • Sep 1996
We report a multicenter experience using tubularized incised plate urethroplasty to correct distal hypospadias. A total of 148 patients underwent repair by 6 pediatric urologists at different institutions in the United States and Europe. Tubularized incised plate repair created a functional neourethra with a vertically oriented meatus. Complications, including meatal stenoses and fistulas, occurred in 10 patients (7%). Tubularized incised plate urethroplasty can be performed in most cases of distal hypospadias. Cosmetic results are superior to those of other popular techniques.
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Primary and Reoperative Hypospadias Repair With the Snodgrass Technique
Article
  • Feb 1998
This report documents our experience with primary and reoperative repair of anterior and middle hypospadias using the tubularized, incised plate (TIP) urethroplasty (Snodgrass technique) and provides a detailed description of the operative procedure. A total of 31 patients (27 primary; 4 reoperative) underwent TIP urethroplasty. The patients' age at primary of reoperative hypospadias repair ranged from 5 months to 26 years. Excellent functional and cosmetic results were achieved in all but one patient, who developed an urethrocutaneous fistula. On the basis of our experience we feel that the Snodgrass TIP urethroplasty is a technique to be strongly considered for primary and reoperative repair of distal and, in some instances, midshaft hypospadias. Further experience is necessary to determine the applicability of this technique for repair of more proximal and complex hypospadias defects.
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Current trends in hypospadias repair
Article
  • Mar 1999
  • UROL CLIN N AM
There is no single, universally applicable technique for hypospadias repair. Command of a technically straightforward repair with few complications and proven success and versatility in a reasonable range of hypospadias defects are desired goals. Several well-established techniques exist for the repair of all hypospadias defects. The Snodgrass tubularized incised plate urethroplasty, a recent contribution with exemplary early results, has become a popular technique for primary and preoperative repair of middle and anterior hypospadias. Other innovative modifications, and technical advances, such as the use of laser and tissue solder, continue to emerge. With time, these may herald improvements to even the most basic of sound principles involved in all hypospadias repair.
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