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Comparison of tubularized incised plate urethroplasty combined with a meatus-based ventral dartos flap or dorsal dartos flap in hypospadias

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Wei Jia at University of Waterloo
Wei Jia
Guo-chang Liu
Guo-chang Liu
Guo-chang Liu
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Li-yu Zhang
Li-yu Zhang
Li-yu Zhang
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Ying-quan Wen
Ying-quan Wen
Ying-quan Wen
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Abstract and Figures

Purpose Tubularized incised plate urethroplasty (TIPU) is the preferred surgical option for distal and mid-shaft hypospadias repair. Neourethra dartos flap coverage is routinely used as a protective layer with good results. We modified meatus-based ventral dartos flap (MBVDF) to TIPU by dissecting the proximal mid-ventral dartos attached urethra and leaving the subcutaneous fascia connecting the meatus, and retrospectively compared the outcomes of using MBVDF with single dorsal dartos flap (DDF) on the complication rates of TIPU. Methods We present 2 surgeons’ experiences with 356 patients with distal and mid-shaft hypospadias between January 2010 and December 2014. Patients were divided into two groups. Group DDF included 185 patients (mean age 29 months) underwent TIPU with DDF rotated laterally covering the suture lines of the neourethra. Group MBVDF included 171 patients (mean age 26 months) underwent TIPU with MBVDF covering the suture lines of the neourethra. Statistical analysis of patient basic information and complications was performed by two independent sample t test and Chi square test or Fisher’s exact test. Results There were no statistical differences in age, type of hypospadias, and follow-up time between the two groups. The mean operative time in the group MBVDF (68.93 ± 8.32 min) was significantly shorter than in the group DDF (73.60 ± 9.06 min). Ventral skin necrosis (2.7 %) and penile rotation (3.8 %) in group DDF was significantly higher than group MBVDF which did not occur. The differences in other complication rates including fistula rate (2.7 vs 2.9 %) between the groups were not statistically significant. Conclusion DDF and MBVDF with TIPU are similarly effective methods for decreasing fistula in hypospadias repair. MBVDF with TIPU may be an easier method and can avoid ventral skin necrosis and penile rotation.
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ORIGINAL ARTICLE
Comparison of tubularized incised plate urethroplasty combined
with a meatus-based ventral dartos flap or dorsal dartos flap
in hypospadias
Wei Jia
1,2
•Guo-chang Liu
2
•Li-yu Zhang
2
•Ying-quan Wen
2
•Wen Fu
2
•
Jin-hua Hu
2
•Zhe Wang
3
•Qiu-ming He
3
•Hui-min Xia
1,3
Accepted: 5 January 2016 / Published online: 18 January 2016
ÓSpringer-Verlag Berlin Heidelberg 2016
Abstract
Purpose Tubularized incised plate urethroplasty (TIPU)
is the preferred surgical option for distal and mid-shaft
hypospadias repair. Neourethra dartos flap coverage is
routinely used as a protective layer with good results. We
modified meatus-based ventral dartos flap (MBVDF) to
TIPU by dissecting the proximal mid-ventral dartos
attached urethra and leaving the subcutaneous fascia con-
necting the meatus, and retrospectively compared the out-
comes of using MBVDF with single dorsal dartos flap
(DDF) on the complication rates of TIPU.
Methods We present 2 surgeons’ experiences with 356
patients with distal and mid-shaft hypospadias between
January 2010 and December 2014. Patients were divided
into two groups. Group DDF included 185 patients (mean
age 29 months) underwent TIPU with DDF rotated later-
ally covering the suture lines of the neourethra. Group
MBVDF included 171 patients (mean age 26 months)
underwent TIPU with MBVDF covering the suture lines of
the neourethra. Statistical analysis of patient basic infor-
mation and complications was performed by two
independent sample ttest and Chi square test or Fisher’s
exact test.
Results There were no statistical differences in age, type
of hypospadias, and follow-up time between the two
groups. The mean operative time in the group MBVDF
(68.93 ±8.32 min) was significantly shorter than in the
group DDF (73.60 ±9.06 min). Ventral skin necrosis
(2.7 %) and penile rotation (3.8 %) in group DDF was
significantly higher than group MBVDF which did not
occur. The differences in other complication rates includ-
ing fistula rate (2.7 vs 2.9 %) between the groups were not
statistically significant.
Conclusion DDF and MBVDF with TIPU are similarly
effective methods for decreasing fistula in hypospadias
repair. MBVDF with TIPU may be an easier method and
can avoid ventral skin necrosis and penile rotation.
Keywords Hypospadias Tubularized incised plate
Urethroplasty Dartos flap
Introduction
Tubularized incised plate urethroplasty (TIPU) is presently
the preferred surgical option for distal and mid-shaft
hypospadias repair [1]. Neourethra dartos flap coverage is
routinely used as a protective layer for better results in
terms of postoperative complications, especially with
regard to fistula formation. Although many different types
of dartos flaps have been described [1–5], two techniques
have obtained wide acceptance for use in distal and mid-
shaft hypospadias repair: the dorsal and the ventral dartos
flap. There is still some debate about which covering flap is
the most suitable technique in terms of complication rates
in TIPU [6].
Co-first author: Guo-chang Liu.
&Hui-min Xia
xia-huimin@foxmail.com
1
Southern Medical University, Guangzhou 510515, People’s
Republic of China
2
Department of Pediatric Urology, Guangzhou Women and
Children’s Medical Center, Guangzhou 510623, People’s
Republic of China
3
Department of Pediatric Surgery, Guangzhou Women and
Children’s Medical Center, Guangzhou 510623, People’s
Republic of China
123
Pediatr Surg Int (2016) 32:411–415
DOI 10.1007/s00383-016-3860-y
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Two case-controlled studies and one RCT compared foreskin preservation vs. circumcision in distal hypospadias repair (45)(46)(47). Five RCTs and one casecontrolled study (48)(49)(50)(51)(52)(53) compared variant modifications of Snodgrass repair. ...
... Five RCTs and one case-controlled study compared variant modifications of Snodgrass repair (48)(49)(50)(51)(52)(53). Three RCT (49,52,53) compared dartos flap with non-dartos flap repair. ...
... p = 0.093; I 2 = 0%, Supplemental Figure 3). One case-controlled study (51) found that Snodgrass repair combined with a meatus-based ventral dartos flap or dorsal dartos flap was similarly effective with respect to UCF. Other two RCTs (48,50) showed a lower morbidity with the use of platelet-rich plasma layer (48) and lateral augmentation (50) in non-proximal hypospadias surgery. ...
Complications Following Primary Repair of Non-proximal Hypospadias in Children: A Systematic Review and Meta-Analysis
Article
Full-text available
  • Dec 2020
Purpose: The aim of this study was to systematically review the literature on the complications and postoperative outcomes of children with non-proximal hypospadias. Methods: Electronic databases including PubMed, Embase, and Cochrane Library CENTRAL were searched systematically from January 1990 to June 2020 for the literature that reported the postoperative outcomes of patients with non-proximal hypospadias. Non-proximal hypospadias encompassed distal and mid-penile hypospadias. Results: We included 44 studies involving 10,666 subjects. Urethrocutaneous fistula (UCF) was the most common complication with an incidence of 4.0% (95% CI, 3.1–5.0%). Incidence of overall complications was 8.0% (95% CI, 6.3–9.8%). Meta-regression analysis revealed that length of urethral stent indwelling (coefficient 0.006; 95% CI, 0.000–0.011; p = 0.036) and penile dressing (coefficient 0.010; 95% CI, 0.000–0.021; p = 0.048) were two risk factors for UCF. Multivariate meta-regression analysis did not identify any independent risk factors for UCF. No differences were found between stent and stentless groups in non-proximal hypospadias regarding incidences of UCF (OR, 0.589; 95% CI, 0.267–1.297), meatal stenosis (OR, 0.880; 95% CI, 0.318–2.437), and overall complications (OR, 0.695; 95% CI, 0.403–1.199). No differences were found between foreskin preservation and circumcision in terms of complications either. Conclusions: UCF is the most common complication following hypospadias repair with an incidence of 4.0%. Independent risk factors for UCF were not identified in the current research. Distal hypospadias repair without stent indwelling is not likely to compromise the postoperative outcome. Further studies should be designed to explore the differences between different surgical approaches and the potential risk factors for complications following hypospadias repair.
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... 3,4 There are still debates in the intermediate steps of this technique. [5][6][7] The research and studies continue to improve the TIPU technique, reduce its complications, and get better penile appearance. ...
... 17 In a series of 356 cases by 2 surgeons, it was revealed that TIPU surgeries performed with ventral dartos flap took significantly shorter time than those performed with DDF, and complications of penile rotation and ventral skin necrosis were also higher in the DDF group. 6 Bleeding during hypospadias repair is not only related to the "amount of bleeding" and the problems it may cause. In this surgery, in which microsurgical techniques are used, less bleeding ensures that the surgical area remains cleaner and provides suturation under clearer vision. ...
Dorsal Dartos Flap Prepared Before Urethroplasty, Less Bleeding of Operation: A New Perspective on Hypospadias
Article
Full-text available
  • Apr 2022
Background: The benefits of preparing the dorsal dartos flap before urethroplasty were investigated. Materials and methods: Patients with coronal, subcoronal, and distal penile hypopadias without severe cordee who underwent surgical repair between October 2016 and September 2020 were included in the study. Tubularized incised plate urethroplasty technique was applied to all patients. The patients were divided into two groups: In Group 1, the dorsal dartos flap was prepared after urethroplasty, which is the commonly used technique today, and sutured on the neourethra. In Group 2, the dorsal dartos flap was prepared before the post-degloving urethroplasty. The amount of bleeding, the duration of the surgery, and the complications between the two groups were recorded and compared. Results: Twenty-two patients who could be followed up for at least 3 months were examined. There were 10 patients in Group 1 and 12 patients in Group 2. A statistically significant difference was found between the amount of bleeding of the operation in the two groups. Duration of operation, hematoma, infection, skin necrosis, or glanular dehiscence were not observed in any patient. Conclusions: Preparing the dorsal dartos flap, before urethroplasty significantly reduces the amount of bleeding. This may be a new modification alternative in hypospadias surgery.
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... Unfortunately, the different studies comparing the results of urethroplasties performed with and without a cover flap may have some weak points. Some series do not include a control group without any cover flap [8,[16][17][18]. Some others include controls, but compare a limited number of patients [13]. ...
... Some others include controls, but compare a limited number of patients [13]. Last, some studies do not include all types of hypospadias [3,[16][17][18] or perform a specific comparison for each phenotype [8,15,17]. The systematic use of a flap remains thus debatable and depends on the surgeon's habits. ...
A cover flap reduces the rate of fistula after urethroplasty whatever the severity of hypospadias
Article
Full-text available
  • Jul 2021
  • WORLD J UROL
Objective To determine which patients should benefit from the interposition of a well-vascularized flap between the neourethra and the penile skin and if it should be performed even in mild hypospadias. Patients and methods A retrospective study on patients with a primary hypospadias repair was performed (2003–2017). Only patients undergoing urethroplasty based on the principle of a tubularization were selected to ensure comparable groups. Patients were assigned in two groups according to the use or not of a cover flap. Univariate analysis and adjusted logistic regression were used to evaluate the relation between postoperative complications, the severity of hypospadias, the use of flap and patients’ characteristics. Results Three-hundred and seventy-six patients were included with anterior (59.3%), midshaft (27.4%) and posterior hypospadias (13.3%). The median follow-up was 54 months (24 months–17 years). The overall rate of fistula was 11.7% (n = 44). Comparing the outcome in children with flap (n = 217) to controls (n = 159) showed that the use of a flap reduces the rate of fistula (6.5 vs 18.9%, p < 0.001). Stratification of the study according to the phenotype reveals that the more severe the hypospadias, the more protective was the flap (OR = 2.6 for anterior, 5.5 for midpenile, 7.1 for posterior hypospadias). The flap remains nevertheless significantly effective whatever the phenotype (p < 0.05 for anterior, p = 0.01 for midpenile, p = 0.02 for posterior hypospadias). Conclusions The more severe the hypospadias, the more effective is the cover flap to avoid fistula. It remains nevertheless suitable even in anterior hypospadias and the use of a cover flap should not be limited to the surgery of severe phenotypes.
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... Surgical repair of this anatomical anomaly is the treatment of choice. Tubularized incised plate (TIP) repair is considered as one of the most popular methods for the surgical repair of hypospadias, which is used by many urologists today [6]. ...
Effectiveness of caudal epidural block on interaoperative blood loss during hypospadias repair: A randomized clinical trial
Research
Full-text available
  • May 2018
Background Intraoperative blood loss is considered to be an important issue in hypospadias surgery. Some studies have demonstrated the utility of caudal epidural block (CEB) in this regard among pediatric patients with hypospadias. Though there is evidence in favor of the use of CEB as the only anesthetic method for pediatric surgeries, it is usually used in combination with general anesthesia. In this form of use, it could have more favorable outcomes for both intra-and postoperative periods. There are few studies regarding the effectiveness of CEB on intraoperative blood loss.
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... Even with this high success rate of surgical repair, the incidence of postoperative urinary stula reaches 16 percent [6]. At present, researchers are focusing on how to improve surgical procedures and select better free alternative tissues [7], however, the incidence of urinary stula has not decreased signi cantly [8]. Studies on pharmacological interventions, especially the use of traditional Chinese medicine to prevent urinary stula after hypospadias, have not been reported. ...
Astragalus polysaccharide reduces the incidence of postoperative urethral fistula in the rabbit model of hypospadias
Preprint
Full-text available
  • Jan 2023
Background Hypospadias is a common congenital malformation in pediatric urology. Surgery is the only treatment option for hypospadias, and urinary fistula is the most common complication after hypospadias repair. Purpose The purpose of this study was to establish a model of surgical hypospadias in New Zealand rabbits followed by TIP urethroplasty, postoperative administration of Astragalus polysaccharides (APS), and to study the effect and mechanism of APS on the prevention and treatment of urinary fistula after surgery. Material and Methods New Zealand male rabbits were randomly divided into 5 groups: Control group, was fed normal feed without surgery; The operation group, TIP was performed after the establishment of a surgical hypospadias model, and normal feed feeding was given after surgery. In the intervention groups, after the establishment of the surgical hypospadias model, TIP was performed, and the low dose of APS (100mg/kg), the medium dose (200mg/kg), and the high dose (300mg/kg) were mixed into feed feeding, and the urinary fistula rate was statistically calculated after 10 consecutive days of feeding. Results The incidence of urinary fistula was significantly lower than that in the surgical group after the addition of APS, and with the increase of the intervention dose of APS, the incidence of urinary fistula showed a decreasing trend. After removing penile tissue, HE examination and WB analysis were performed, compared with the control group, the urethral epithelial cells at the incision site of the operation group were loosely arranged, the layers were reduced, and the inflammatory cells were significantly increased. Compared with the operation group, the urethral epithelial cells at the incision site of the APS intervention group were closely arranged, the layers increased, the inflammatory cells were significantly reduced, and the number of new capillaries increased. In addition, compared with the operation group, the expression levels of TNF-a and NF-kb2 proteins in the intervention group were significantly reduced, and the levels of TGF-β1 and FGF-1 were significantly increased. Conclusion The intervention of APS can reduce local inflammatory response, enhance local fibrosis, and reduce the incidence of urinary fistula after hypospadias.
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... Regardless of its favourable results, it has some adverse effects of hypospadias surgery, and the Snodgrass technique, especially the most troublesome and distressful of all, is urethrocutaneous fistula formation. To avoid complications, the newly formed urethra is covered with a second protective layer of dartos 7 . However, various methods of harvesting dartos flap have been described to reduce the chances of fistula formation [8][9][10][11][12] . ...
Effectiveness of Ventral Dartos Flap as the Second Layer in Distal and Mid-Penile Hypospadias Repair.
Article
Full-text available
  • Sep 2021
Background: Various methods have been used to reconstruct mid-penile hypospadias; still, massive failure rates and leading complications have been indicated. The present study observes the effectiveness of a technique using a well-vascularized dartos flap as a second layer in distal and mid- penile hypospadias repair. Methodology: This is a cross-sectional study conducted between 2017-2019. A total of 110 male children with hypospadias were operated on. The children with mid-penile or slightly more proximal hypospadias, with or without ventral chordae and with the intact prepuce, were included in the study. Outcome measures comprised of surgical results with the absence of any serious side effects, decent flow, meat stenosis, fistula and dehiscence of glans. Results: The median follow-up duration was 12 months. There were 72 cases of mid penile hypospadias (66.7%), and in 36 cases (33.3%), the meatus was slightly more dorsal. The age of the patients ranged from 1.1 to 11 years, with a mean age of 3.52 ± 2.74 years. Surgery was successful in 105 (95.5%) cases. Four patients presented with meatal stenosis and one with meatal stenosis plus fistula, more than 2 months after surgery. Meatal stenosis was managed by meatoplasty, and in the case of a urethral fistula, the patient was re-operated after at least 6 months. Conclusion: Ventral dartos flap is a safe, effective method with less adverse effect and less time-consuming in patients with distal and mid-penile hypospadias.
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... To reduce fistula formation rates, the most accepted technique is a covering layer between neo-urethra and the reconstructed skin. Although Dartos flaps are widely used for the covering layer, the preputial skin or mucosal grafts (with the majority of oral mucosa) and novel bio-materials are also suggested to be effective as the dartos flaps [9,[20][21][22]. Assuming the better wound healing reduces urethrocutaneous fistula formation, medications which promotes wound healing could be an alternative strategy to increase the success of hypospadias surgery. ...
Does intraurethral erythropoietin administration effect wound healing after hypospadias correction? an experimental rat study
Article
Full-text available
  • Oct 2021
  • INT UROL NEPHROL
Objectives To analyze effects of intraurethral EPO application on urethral wound healing by defining hystopathologic changes in a rat model of hypospadias.MethodsA hypospadias model was created in 30 rats and randomized into 3 groups of 10. For 14 days, the first group was administered 25 iu EPO instillation intraurethrally once a day, while group 2 was administered with 50 iu EPO in the same manner. The third group was assigned as control group. On the day 15, rats were sacrificed and penectomies were performed. One independent pathologist who is blinded to groups and treatments evaluated the penis samples.ResultsHistopathologic examinations yielded the mean fibrosis scores (± SD) as 1.9 ± 0.568, 1.1 ± 0.786 and 2.5 ± 0.535 in groups I, II and III, respectively. There was significant difference between the EPO groups and the control group (p = 0.04-I, p = 0.003-II). The mean inflammation scar scores (± SD) were determined as 1 ± 1.054, 2 ± 1.247, 2.63 ± 0.744 in groups I, II and III, respectively. There was a significant difference in terms of inflammation between control group and group I (p = 0.005). Mean congestion scores (± SD) were found 1.2 ± 0.789 in groups I–II and 0.75 ± 0.463 in group III (p = 0.310). Hyperemia was seen in 60% 70% and 37.5% in groups I, II and III, respectively (p = 0.387).Conclusion Intraurethral EPO therapy effected urethral wound healing in a good way. Thus it could be feasible to treat the patients with after hypospadias surgeries and to improve success rates.
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... DF is a layer of connective tissue found in the penile dorsal or ventral area, foreskin, and scrotum and can be used in hypospadias or fistula repair in different techniques [34,35]. TVF can be harvested through a penile incision by degloving up to the root of the penis [26] or with an additional scrotal incision that reaches and covers the neourethra through a subcutaneous scrotal tunnel [36]. ...
Comparison of effect between dartos fascia and tunica vaginalis fascia in TIP urethroplasty: a meta-analysis of comparative studies
Article
Full-text available
  • Oct 2020
  • BMC Urol
Background Tubularized incised plate (TIP) urethroplasty is the most commonly performed procedure for hypospadias. Several flap procedures have been recommended to decrease the postoperative complication rate in TIP repair, but no single flap procedure is ideal. This study aimed to compare the outcomes of dartos fascia (DF) and tunica vaginalis fascia (TVF) as intermediate layers in TIP urethroplasty. Methods We searched PubMed, EMBASE, the Cochrane Library, Web of Science, clinicaltrials.gov, and other sources for comparative studies up to April 16, 2020. Studies were selected by the predesigned inclusion criteria. The primary outcomes were postoperative complications. The secondary outcomes were functional and cosmetic outcomes. Results The pooled RR with 95% CI were calculated. We extracted the relevant information from the included studies. Only 6 comparative studies were included. No secondary outcomes were reported. The RR of the total complications rate for DF was 2.41 (95% CI 1.42–4.07, P = 0.0001) compared with TVF in TIP repair. For each postoperative complication, the RRs were 6.48 (2.20–19.12, P = 0.0007), 5.95 (1.13–31.30, P = 0.04), 0.62 (0.25–1.52, P = 0.29), and 0.75 (0.23–2.46, P = 0.64) for urethrocutaneous fistula, prepuce-related complications, meatal/urethral stenosis, and wound-related complications, respectively. Conclusions This meta-analysis reveals that compared to DF, TVF is a better option in TIP repair in terms of decreasing the incidence of the total postoperative complications, urethrocutaneous fistula, and prepuce-related complications. However there is limited evidence for functional and cosmetic outcomes. Overall, larger prospective studies and long-term follow-up data are required to further demonstrate the superiority of TVF over DF. Trial registration PROSPERO CRD42019148554.
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Comparison of Dartos flap and spongioplasty in Snodgrass urethroplasty in distal penile hypospadias
Article
Full-text available
  • Jul 2021
Background Hypospadias surgery has been continuously evolving, although there is no single technique which can be said to be perfect and suitable for all types of hypospadias. Tubularized incised plate (TIP) urethroplasty (Snodgrass procedure) is presently the most common surgical procedure performed for distal penile hypospadias (DPH). The aim of this study was to compare the outcome of TIP urethroplasty using Dartos flap (DF) and spongioplasty as second layer in DPH. Methods A total of 30 patients of DPH were repaired using TIP urethroplasty with DF or spongioplasty as second layer from January 2017 to June 2018. Out of 30 patients, TIP with DF was done in 15 patients (group A) and TIP with spongioplasty was done in the remaining 15 patients (group B). Preoperative mean age and weight were comparable in both groups. Postoperative complications, namely, postoperative edema, residual chordee, urethrocutaneous fistula (UCF), meatal stenosis and final cosmesis, were recorded. Results In both groups, complications included postoperative edema (Gp A-1Gp B-1), residual chordee (Gp A-1, Gp B-1), UCF (Gp A-3, Gp B-4), meatal stenosis (Gp A-1, Gp B-5) and poor cosmesis (Gp A-3, Gp B-4). Wound infection was managed with appropriate antibiotics, and meatal stenosis responded to calibration in five patients. Although it seems that DF has a better outcome clinically, the difference between the two techniques was statistically not significant. Conclusion DF as an additional cover to TIP is associated with an acceptable complication and has good cosmesis compared with spongioplasty; however, the difference is not statistically significant.
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Comparison Between Dorsal and Ventral Dartos Flap Interposition in A Tubularized Incised Plate Repair of Distal Hypospadias
Article
Full-text available
  • Feb 2021
Background: The tubularized incised plate urethroplasty procedure is the operation of choice for hypospadias. The most common complication is urethrocutaneous fistula and various procedures have been described for preventing it. Objectives: to evaluate the outcome of dorsal versus ventral dartos flaps coverage of the neourethra after tubularized incised plate repair of distal hypospadias. Patients and methods: our study including 85 cases, aged 10 months to 12 years (mean age 3.4 years) with distal hypospadias were evaluated from April 2017 to April 2020 at alnajaf medical center, Najaf, Iraq. All patients underwent the tubularized incised plate urethroplasty operation. The Patients divided in two groups: group A (41 patients) dorsal dartos flap was used; and group B (44 patients) a ventral dartos flap was used. Results: The postoperative follow-up was 6-24 months (mean 9 months). Urethrocutaneous fistulas were observed 2 patients (4.8%) in groups A and 3 patients (6.8%) in group B. one patient in each group developed meatal stenosis. Two cases (4.8%) of iatrogenic penile torsion in a dorsal flap group. Conclusion: No significant difference between dorsal and ventral flap for fistula prevention. Ventral flaps are easier to obtain and interpose the neourethra.
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The effect of dorsal dartos flaps on complication rates in hypospadias repair: A randomised prospective study
Article
Full-text available
  • Aug 2014
  • J Pediatr Urol
Aim This study prospectively analysed the effect of using a dartos flap on the complication rates of TIPU (tubularised incised plate urethroplasty) in hypospadias repair. Material and methods Patients having TIPU repair for hypospadias at our university hospital between January 2010 and August 2013 were prospectively divided into two groups. Group 1 had TIPU repair with dorsal dartos flap, whereas group 2 had flapless repair. At the end of the follow-up period (mean 23.3m, median 20.2), complication rates were compared between two groups. Results There were 107 patients in each group. The overall complication rate was 9.3%. The complication rates were 12.1% in group 1 (6 glans dehiscence and 7 fistula) and 6.5% in group 2 (2 glans dehiscence and 5 fistula). The differences between complication rates and fistula were statistically insignificant (p=0.2511 and p=0.7710, respectively). Conclusion Our prospective and randomised study found that the use of dartos flaps in hypospadias offers no statistically significant advantage over flapless repair for complication rates.
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Multicentric experience on double dartos flap protection in tubularized incised plate urethroplasty for distal and midpenile hypospadias
Article
Full-text available
  • Sep 2011
  • PEDIATR SURG INT
We report a multicenter experience using double dartos flap to protect the neourethra in TIP urethroplasty for distal and midpenile hypospadias. A total of 394 patients underwent tubularized incised plate urethroplasty for primary distal and midpenile hypospadias using double dartos flap protection by ten pediatric surgeons and urologists at five different institutions. Tubularized incised plate urethroplasty protected by a double dartos flap was simple to perform and flaps were easy to obtain. Complications occurred in 23 patients (5.83%): fistulas 1.01% (4 cases), stenosis 0.25% (1 case), mild stenosis 2.53% (10 cases), dehiscence of ventral cutis 0.50% (2 cases) and penile torsion 1.26% (5 cases). All fistulae had a spontaneous resolution. Double dartos flap to protect tubularized incised plate urethroplasty is safe with a low complication rate. The neourethra is covered entirely with a double layer of vascularized tissue and the double coverage appears a good choice for preventing urethrocutaneous fistula formation.
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Tubularized incised plate urethroplasty for distal hypospadias: A literature review
Article
Full-text available
  • May 2008
  • Indian J Urol
The tubularized incised plate (TIP) urethroplasty or Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair due to its low complication rate, good cosmetic result, and technical simplicity. As a result, several articles have been published concerning various aspects and subtle variations of this procedure. The aim of this review is to critically and systematically analyze the published complication rates of TIP repair for distal hypospadias in children. We also reviewed the surgical modifications that have been introduced to the original technique and discussed the potential impact on the final outcome of the Snodgrass procedure.
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Coverage of urethroplasty in pediatric hypospadias: Randomized comparison between different flaps
Article
  • Feb 2013
  • INT J UROL
Objectives The use of covering urethroplasty with flaps in hypospadias surgery has been well recommended. Various techniques have been described for flap harvesting. The aim of the present study was to compare the outcome and complication rate of dorsal preputial flaps and ventral dartos flaps. MethodsA total of 130 patients were prospectively evaluated from January 2008 to December 2011. Using the tubularized incised plate urethroplasty procedure, urethroplasty was carried out by a single surgeon. Patients were randomly divided in two groups: group A (57 patients), in which a preputial flap was carried out using three different techniques; and group B (73 patients), in which a single or a double ventral dartos flap was used. ResultsA total of 41 complications occurred in 24 patients. Urethrocutaneous fistulas were observed in 14.9%, quite equally distributed between groups A and B. There was only one urethrocutaneous fistula in a patient treated with the double ventral dartos flaps. Five cases (3.8%) of glans dehiscence were observed: four after single ventral dartos flap and one after dorsal preputial flap. Six patients in group A and seven in group B experienced meatal stenosis. In three cases of iatrogenic torsion of the penis, a dorsal preputial flap was laterally transposed. Finally, a lower complication rate was observed for double ventral dartos flap versus the other techniques. Conclusions The use of a double ventral dartos flap should represent the first-line technique for coverage of distal urethroplasty.
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Comparative Study of Dartos Fascia and Tunica Vaginalis Pedicle Wrap for the Tubularized Incised Plate in Primary Hypospadias Repair
Article
  • Nov 2004
To report a prospective comparative study on using dartos fascia, i.e. subcutaneous tissue of penile skin and tunica vaginalis pedicled wrap (TVPW) from the parietal layer of the tunica vaginalis of the testis, for a one-stage tubularized incised-plate (TIP) repair for hypospadias. Forty-nine patients (mean age 4.6 years, range 1-22) with hypospadias of different types (varying from coronal to penoscrotal) were repaired in one of three hospitals over 3 years. All patients were repaired using the TIP technique, with dartos fascia wrap used in 20 and TVPW in 29, without using a loupe or microscope during surgery. Urinary diversion and splinting were provided by a urethral catheter. The operative duration for both groups was similar at approximately 2 h. In the dartos fascia group there were three (15%) fistulae, but there were none in the TVPW group. Although the dissection for TVPW seems to be cumbersome theoretically, it is not difficult. The combination of TIP and TVPW in primary repair may be a good alternative to other techniques.
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Analysis of Risk Factors for Glans Dehiscence After Tubularized Incised Plate Hypospadias Repair
Article
  • Mar 2011
  • J UROLOGY
We determined the incidence of glans dehiscence and the associated risk factors after tubularized incised plate hypospadias repair. All data for patients undergoing tubularized incised plate hypospadias repair, surgical details and postoperative outcomes were prospectively maintained in databases. Data were analyzed with simple and multiple logistic regression to determine if patient age, preoperative testosterone use, meatal location (distal, mid shaft or proximal), glansplasty sutures (chromic catgut vs polyglactin) or primary vs revision tubularized incised plate procedure was associated with an increased risk of glans dehiscence. Glans dehiscence occurred in 32 of 641 patients (5%). Age at surgery, preoperative testosterone use and glansplasty suture did not impact the risk of glans dehiscence. Glans dehiscence occurred in 20 of 520 distal (4%), 1 of 47 mid shaft (2%) and 11 of 74 proximal (15%) tubularized incised plate repairs, with the odds of glans dehiscence being 3.6 times higher in patients with proximal vs distal meatal location. Patients undergoing reoperative (9 of 64, 14%) vs primary tubularized incised plate (23 of 577, 4%) had a 4.7-fold increased risk of glans dehiscence. Proximal meatal location and revision surgery, most commonly for prior glans dehiscence, increase the odds of glans dehiscence by 3.6 and 4.7-fold, respectively, suggesting anatomical and/or host factors (wound healing) are more important than age, type of suture or preoperative testosterone use in the development of this postoperative complication.
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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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Meatal based hypospadias repair with the use of a dorsal subcutaneous fistula
Article
  • Nov 1994
A technique using a dorsal dartos subcutaneous flap to wrap the neourethra after hypospadias repair is described. This method was used in a series of 204 meatal based repairs. Catheter drainage or diversion was not performed in any nontoilet trained child. The procedure was done on an ambulatory or 1-night hospitalization basis. No patient had a urethrocutaneous fistula. The additional covering of the neourethra with the dorsal subcutaneous flap appears to be excellent for avoiding the development of urethrocutaneous fistulas in patients with distal hypospadias.
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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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