ArticlePublisher preview available

Modified tubularized incised plate urethroplasty reduces the risk of fistula and meatal stenosis for proximal hypospadias: a report of 63 cases

Authors:
Hamid Arshadi at Tehran University of Medical Sciences
Hamid Arshadi
Shabnam Sabetkish at Australian Regenerative Medicine Institute
Shabnam Sabetkish
  • Australian Regenerative Medicine Institute
Abdol-Mohammad Kajbafzadeh at Tehran University of Medical Sciences
Abdol-Mohammad Kajbafzadeh
Read publisher preview
Download citation
To read the full-text of this research, you can request a copy directly from the authors.

Abstract and Figures

Purpose: To report the feasibility of modified tubularized incised plate (TIP) urethroplasty technique for proximal hypospadias in 63 cases. Methods: From January 2004 to March 2010, 63 patients underwent one-stage TIP urethroplasty (modified Snodgrass technique repair) using 2-3 of three covering layers (corpus spongiosum, dartos, and tunica vaginalis). The primary meatus was proximal penile, penoscrotal, scrotal, and perineal in 38, 13, 10, and 2 patients, respectively. All patients had chordee that was corrected with dorsal plication. Glanuloplasty was performed in all cases. Complications and cosmetic results were documented after 6-72 months of follow-up. Results: A total of 63 boys with proximal hypospadias underwent Snodgrass hypospadias repair at a mean age of 8.5 months (range 6-54). Mean operative time was 210 ± 35 min. Patients were followed up with 6-month intervals for up to 6 years postoperatively. After 6 years of follow-up, nine urethrocutaneous fistulae, four bleeding, four meatal stenoses, and one urethral stricture were reported. Cosmetic result was satisfactory according to parent's opinion and another surgeon. No residual chordee was observed in any cases (without artificial correction). Conclusion: In conclusion, this preliminary report can be estimated as an alternative technique with acceptable complication and cosmetic results for proximal hypospadias correction.
Figures - available from: International Urology and Nephrology
This content is subject to copyright. Terms and conditions apply.
A preview of this full-text is provided by Springer Nature.
Learn more
Content available from International Urology and Nephrology
This content is subject to copyright. Terms and conditions apply.
Vol.:(0123456789)
1 3
Int Urol Nephrol (2017) 49:2099–2104
DOI 10.1007/s11255-017-1725-5
UROLOGY - ORIGINAL PAPER
Modified tubularized incised plate urethroplasty reduces therisk
offistula andmeatal stenosis forproximal hypospadias: areport
of63 cases
HamidArshadi1· ShabnamSabetkish1· Abdol‑MohammadKajbafzadeh1
Received: 31 August 2017 / Accepted: 9 October 2017 / Published online: 16 October 2017
© Springer Science+Business Media B.V. 2017
Conclusion In conclusion, this preliminary report can be
estimated as an alternative technique with acceptable com-
plication and cosmetic results for proximal hypospadias
correction.
Keywords Tubularized incised plate urethroplasty·
Proximal hypospadias· Fistula· Meatal stenosis·
Complication· Cosmetic
Abbreviation
TIP Modified tubularized incised plate
Introduction
Hypospadias is the most common malformation of the male
external genitalia (1/200–1/300 males), the prevalence of
which seems to be increasing [1]. As compared to differ-
ent types of hypospadias (proximal, distal, and mid-shaft),
reconstruction of proximal (posterior) hypospadias remains
a rare and disputing problem among pediatric urologists,
especially with concomitant chordee. The preoperative
assessment of glans size should be taken into consideration,
especially in proximal hypospadias cases, due to the fact that
this circumstance can result in intersex disorder [2].
Vertical, slit-like meatus, and no need to skin flaps for
the creation of neourethra are among the notable benefits
of tabularized incised plate (TIP) urethroplasty procedure
[3]. Graft urethroplasty and island flap onlay urethroplasty
were considered to be ideal choices for proximal hypospa-
dias repair, but the application of these techniques has been
limited due to less cosmetic outcome achievement compared
to other procedures [4]. The need to add tissue to the ure-
thral plate to achieve a neourethra of adequate size has been
considered as a common thread in flip-flaps, onlay preputial
Abstract
Purpose To report the feasibility of modified tubularized
incised plate (TIP) urethroplasty technique for proximal
hypospadias in 63 cases.
Methods From January 2004 to March 2010, 63 patients
underwent one-stage TIP urethroplasty (modified Snodgrass
technique repair) using 2–3 of three covering layers (corpus
spongiosum, dartos, and tunica vaginalis). The primary mea-
tus was proximal penile, penoscrotal, scrotal, and perineal in
38, 13, 10, and 2 patients, respectively. All patients had chor-
dee that was corrected with dorsal plication. Glanuloplasty
was performed in all cases. Complications and cosmetic
results were documented after 6–72months of follow-up.
Results A total of 63 boys with proximal hypospadias
underwent Snodgrass hypospadias repair at a mean age
of 8.5months (range 6–54). Mean operative time was
210±35min. Patients were followed up with 6-month
intervals for up to 6years postoperatively. After 6years of
follow-up, nine urethrocutaneous fistulae, four bleeding, four
meatal stenoses, and one urethral stricture were reported.
Cosmetic result was satisfactory according to parent’s opin-
ion and another surgeon. No residual chordee was observed
in any cases (without artificial correction).
Electronic supplementary material The online version of this
article (doi:10.1007/s11255-017-1725-5) contains supplementary
material, which is available to authorized users.
* Abdol-Mohammad Kajbafzadeh
kajbafzd@sina.tums.ac.ir
1 Pediatric Urology andRegenerative Medicine Research
Center, Section ofTissue Engineering andStem Cells
Therapy, Children’s Hospital Medical Center, Tehran
University ofMedical Sciences, No. 62, Dr. Qarib’s Street,
Keshavarz Boulevard, Tehran1419433151, Iran
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... The Snodgrass technique has gained popularity due to its simplicity, low complication rate, and favorable cosmetic results. Because the natural urethral plate is preserved and no tissue grafts are required, the Snodgrass technique offers advantages in terms of operative time, postoperative recovery, and overall patient satisfaction [13]. ...
Safety and Effectiveness of Meatal Mobilization (MEMO) Technique for Glandular, Coronal, and Subcoronal Hypospadias Repair in Children: A 5-Year Single-Center Study with 105 Hypospadias
Article
Full-text available
  • Apr 2024
Background: This study aims to compare outcomes of treatment, in terms of early and late complications, between the Snodgrass and meatal mobilization (MEMO) techniques in children operated on because of distal hypospadias. Methods: The medical records of 127 children who underwent glandular, coronal, or subcoronal hypospadias repair between 1 January 2019 and 31 December 2023 were retrospectively reviewed. A total of 105 children met the inclusion criteria and were included in further analysis. The inclusion criteria were pediatric patients who underwent glandular, coronal, or subcoronal hypospadias repair using MEMO (n = 49) or the Snodgrass technique (n = 56) as a comparative group. The primary outcome of this study was the incidence of early and late complications with two different surgical techniques. Secondary outcomes were the duration of surgery, the length of hospital stay, the number of readmissions or unplanned returns to the operating room, and repeat surgeries between groups. Results: The median age of all patients was 17 (interquartile range, IQR 13, 29) months, with a median follow-up of 26 (IQR 17, 34) months. Regarding the type of hypospadias, the majority of patients in both groups were categorized as coronal and subroronal hypospadias. Regarding the incidence of postoperative complications, a significantly lower incidence of postoperative complications was found in the MEMO group compared to the Snodgrass group (n = 4; 8.2% vs. n = 14; 25%; p = 0.037). An urethrocutaneous fistula was the most common complication in the Snodgrass group (n = 8; 14.3%), while in the MEMO group, only one patient (2%) developed a fistula (p = 0.034). The incidence of meatal stenosis (p = 0.621) and wound infections (p > 0.999) was low in both groups. No further complications were recorded during the follow-up period. Duration of surgery (41 min (IQR 38, 47) vs. 51 min (IQR 45.5, 61); p < 0.001), duration of hospitalization (1 day (IQR 1, 2) vs. 3 days (IQR 2, 6); p < 0.001), and time to catheter removal (3 days (IQR 2.5, 5) vs. 6 days (IQR 6, 8); p < 0.001) were significantly lower in patients operated on with MEMO compared to the Snodgrass technique. Only one case of readmission due to severe wound infection which led to suturing line dehiscence was recorded in the Snodgrass group. The incidence of redo surgery was significantly lower in the MEMO group than in the Snodgrass group (n = 3; 6.1% vs. n = 11; 19.6%; p = 0.048). Conclusions: MEMO is a safe and effective technique that can be used for the treatment of distal hypospadias. It showed excellent outcomes, cosmetic results, and a low incidence of complications as well as a significantly shorter duration of surgery compared to the Snodgrass technique.
View
... The existing surgical approaches for PH are controversial, with the most important debates being over preserving versus disconnecting the urethral plate and one-versus two-stage surgery. For PH treatment, Arshadi et al. [10] used the tubularized incised plate technique; in their study, all participants had mild penile curvatures. However, if the penile curvature exceeds 30° after foreskin removal, urethral plate retention is not appropriate. ...
Risk factors for postoperative complications following one-stage proximal hypospadias repair involving the disconnection of the urethral plate: a retrospective study
Article
Full-text available
  • Oct 2023
  • BMC Pediatr
Background: Children with hypospadias are at risk of serious physical and mental health problems, including abnormal urination, sexual dysfunction, and infertility. The sole available treatment is the surgical restoration of genital appearance and function. Proximal hypospadias (PH) correction is more challenging and carries a higher risk of complications than does distal hypospadias correction, with a higher likelihood of postoperative complications requiring additional surgery, resulting in considerable economic and psychological strain for families. Herein, we aimed to identify factors associated with complications following one-stage PH repair with urethral plate disconnection. Methods: We retrospectively analyzed data from 236 children who underwent PH repair at our center between December 2020 and December 2022. We collected information on age, surgical procedure, length of the reconstructed urethra (LRU), glans width (GW), ventral curvature, surgical approach, preoperative androgen use, suture type, presence of prostatic utricle, body mass index, season of surgery, anesthesia type, low birth weight, preterm birth, follow-up period, and complications. Surgical complications included urethral fistulas, urethral diverticula, anastomotic strictures, urethral strictures, glans dehiscence, and penile curvature recurrences. The study population was divided into complication and no-complication groups, and univariate and multivariate analyses were conducted. Results: Of the 236 patients with PH who had a median follow-up of 10.0 (8.0, 14.0) months, 79 were included (33.5%) in the complication group and 157 were included (66.5%) in the no-complication group. In the univariate analysis, age (P < 0.001), LRU (P < 0.001), degree of penile curvature (P = 0.049), and PH with prostatic utricle (P = 0.014) were significantly associated with complications after PH repair. In the multivariate logistic regression analysis, LRU (P<0.001, odds ratio [OR] = 3.396, 95% confidence interval [CI]: 2.229-5.174) and GW (P = 0.004, OR = 0.755, 95%CI: 0.625-0.912) were independent factors influencing postoperative complications. The optimal LRU threshold was 4.45 cm (area under the curve, 0.833; sensitivity, 0.873; specificity, 0.873; P<0.001, OR = 3.396, 95% CI: 2.229-5.174). Conclusions: LRU and GW are independent factors affecting PH complications. An LRU of < 4.45 cm and an increased GW can reduce the risk of complications.
View
... The tubularized incised plate (TIP) repair is based on an old principle of urethral plate tubularization which is known as the Thiersch-Duplay procedure (4) . if the urethral groove was not wide enough for tubularization in situ, alternative approaches such as the Mathieu urethroplasty or a vascularized island flap were determined (5) . ...
View
... TIP urethroplasty formed a centrally and vertically positioned meatus that resembled the normal urethral meatus; in addition, it is thought to allow for better cosmetic results (18). On the other hand, it has been shown that the incision of the urethral plate (19). ...
The effect of staged TIP urethroplasty on proximal hypospadias with severe chordee
Article
Full-text available
  • Aug 2022
Background Proximal hypospadias with severe chordee is still a formidable challenge for most pediatric urologists, and the treatment approach remains controversial. Here, we describe a modified two-stage technique to repair proximal hypospadias with severe chordee. Methods We retrospectively identified 53 children referred for proximal hypospadias with severe chordee from July 2016 to July 2019, who underwent a two-stage urethroplasty. In group 1, the children were repaired with staged tubularized incised plate (TIP) urethroplasty, while Byars’ two-stage urethroplasty was attempted in group 2. We corrected chordee by releasing all remaining attachments to the corpora after degloving the penis, transceting the urethral plate, and dorsal plication. The mean age of patients in the first stage of surgery was 26.6 months in group 1 and 24.8 months in group 2. Postoperative complications in the two groups included: fistula, urethral stricture, urethral diverticulum, and glanular dehiscence. Results A total of 20 cases were repaired with staged TIP urethroplasty (group 1), and 33 cases were repaired with Byars’ two-stage urethroplasty (group 2). The length of follow-up in group 1 was 39.8 ± 10.1 months, and in group 2, it was 38.1 ± 8.7 months ( P > 0.05). After the second stage of surgery, 1 case (5%) in group 1 and 11 cases (33.3%) in group 2 developed a urinary fistula ( P < 0.05). One case (5%) in group 1 and three cases (9.1%) in group 2 had urethral stricture ( P > 0.05). All strictures were cured by repeated dilation, and no patient required reoperation. No cases in group 1 and one case (3%) in group 2 had urethral diverticulum ( P > 0.05). There was no residual chordee in both groups. Two cases (10%) in group 1 and 13 cases (39.3%) in group 2 required reoperation ( P < 0.05). Conclusions Staged urethroplasty is appropriate to repair proximal hypospadias with severe chordee. Particularly, staged TIP urethroplasty is a good choice for patients with proximal hypospadias and severe chordee, especially those with better penile development, wider urethral plate, larger glans, and deeper navicular fossa of the urethra.
View
... No complications were seen on follow-up in patients with proximal penile hypospadias. Arshadi et al. [14] performed TIPU in 63 cases of proximal hypospadias with a fistula rate of 14.2%. They suggested TIPU as a reliable and effective procedure for proximal hypospadias in patients with glans size > 14 mm and minimal to moderate chordee. ...
Outcome of spongioplasty alone as second layer of tubularised incised plate urethroplasty in patients with hypospadias
Article
Full-text available
  • Dec 2022
Background Spongioplasty alone or in combination with local tissue flaps can be used as a second layer for the prevention of complications of tubularised incised plate urethroplasty (TIPU) of hypospadias repair. It can be used when wide urethral plate and well-developed robust spongiosum are present. This study aims to review the success rate and complications of TIPU performed utilising spongioplasty alone as a second layer in Type 3 well-developed robust spongiosum. Methods This is a retrospective observational study conducted between January 2015 and December 2019 at a tertiary care centre. A total of 21 patients aged 4–15.4 years with primary hypospadias having a Type 3 well-developed robust spongiosum, Glans score ≤ 2, Meatal score ≤ 4, and Shaft score ≤ 3 underwent TIPU using spongioplasty alone as a second layer. The hospital stay ranged from 10 to 14 days and follow-up from 12 to 36 months. Results Hypospadias was distal in 12 (57.1%), mid in 5 (23.8%), and proximal penile in 4 (19.1%) patients. The mean Glans Meatus Shaft score was 6.1 ( G = 1.25, M = 2.95, S = 1.9) with a range of 3–9. An early post-operative complication of preputial oedema and bladder spasm developed in 1 (4.7%) patient each. Meatal stenosis developed in 1 (4.7%) patient. None developed urethrocutaneous fistula. At 3 months all patients had good urinary flow (> 15 ml/s) and good cosmesis. All the patients/parents (in case of minors) were satisfied with the result. Conclusion Spongioplasty alone as the second layer after TIPU for primary penile hypospadias in patients with well-developed robust spongiosal tissue is associated with minimal, easily manageable complications.
View
... Commonly used materials include the surrounding sarcoid or dartos fascia, pedicled skinned foreskin or scrotal flaps, and even testicular sheath flaps (19)(20)(21). We also used the tunica vaginalis spongiosum and dartos as covering layers, as Arshadi et al. (22) did. Given the high incidence of urethrocutaneous fistula in proximal hypospadias, we use as much of this healthy tissue as possible to cover the neourethra while ensuring a tension-free urethroplasty. ...
Application of Allogeneic Human Acellular Dermal Matrix Reduces the Incidence of Fistula in Hypospadias Repair
Article
Full-text available
  • Mar 2022
Background Urethrocutaneous fistula is one of the most common complications arising from hypospadias surgery. The purpose of our study was to investigate the effectiveness and safety of allogeneic human acellular dermal matrix (HADM) application as a means of preventing the occurrence of urethrocutaneous fistula following hypospadias surgery. Methods This is a non-randomized study of 219 cases (out of 270 patients with hypospadias) which satisfied inclusion and exclusion criteria. These patients were divided into two groups: 101 HADM patients, and 118 control patients (who did not receive HADM). In the control group, 77 boys were treated by single-stage urethroplasty (TIP) and 41 underwent staged urethroplasty (Thiersch-Duplay). In the HADM group, 59 boys underwent the TIP and 42 underwent the Thiersch-Duplay. In the postoperative period, we recorded the incidence of infection, urethrocutaneous fistula, and urethral stricture complications in these two groups of patients. The effectiveness and safety of HADM in preventing urethrocutaneous fistula following hypospadias surgery were evaluated according to these indicators. Results In the control group, following the operation there were 16 cases of infection, 38 cases of urethrocutaneous fistula after extubating, and 5 cases of urethral stricture. In the HADM group, there were 19 cases of postoperative infection, 12 cases of urethrocutaneous fistula after extubating, and 5 children with urethral stricture. In comparing the two groups, it was found that the postoperative infection rate (13.6 vs. 18.8%) and the incidence of urethral stricture (4.2 vs. 5.0%) were not statistically significant ( P > 0.05), while the postoperative urethrocutaneous fistula rate (32.2 vs. 11.9%) was statistically significant ( P < 0.001). Conclusion It is found that HADM application can significantly reduce the incidence of urethrocutaneous fistula complications, without increasing the risk of infection and urethral stricture.
View
... More than 300 approaches exist to treat hypospadias both within China and internationally; however, none of these are considered as the best surgical method by all physicians (23). The Glans-Urethral Meatus-Shaft (GMS) hypospadias score could provide guidance for the selection of surgical methods to treat severe hypospadias, in which the presence and the severity of the chordee are the key factors in selecting the surgical method (24). ...
Comparison of Penile Appearance and Outcomes Between Prefabricated Urethra and Pre-implanted Urethral Plate for Treatment of Children With Severe Hypospadias: A Retrospective Study
Article
Full-text available
  • Sep 2021
Objective: To compare the effect of prefabricated urethra and pre-implanted urethral plate in the treatment of severe hypospadias in children. Methods: We retrospectively analyzed the clinical data of 53 patients who diagnosed as severe hypospadias underwent staging urethroplasty from January 2015 to January 2018 in the Department of Pediatric Surgery, First People's Hospital, Zunyi City. The patients were divided into two groups: group A ( n = 25) were treated with prefabricated urethra and group B ( n = 28) were treated with pre-implanted urethral plate. After the second stage surgery, the ratios of complications such as urethral fistula, urethral stenosis, urethrocele, and recurrence chordee were compared. The penis was scored from meatus, glans, shaft skin, general appearance by the parents, blinded urologists according to The Pediatric Penile Perception Score, and the scores were compared too. Results: All patients were followed up after two stage operations for an average of 28 months. Glans dehiscence occurred in two patients (8%), urethral orifice stenosis occurred in one (4%) and urethral fistula occurred in three (12%) in group A. No urethral stenosis, urethrocele and recurrence chordee was observed. One patient presented urethral plate inactivation (3.6%), two patients presented urethral fistula (7.1%) and one patient presented urethral stenosis (3.6%) in group B. No urethrocele, glans dehiscence and recurrence chordee was observed. The total complication rate in group A was 24 and 14.3% in group B, respectively, and the difference was not statistically significant ( P = 0.582). The differences between two groups scored by parents in glans ( P = 0.030) was statistically significant. The differences between two groups scored by operators in meatus ( P = 0.041), shaft skin ( P = 0.000), glans ( P = 0.001), and general appearance ( P = 0.007) were statistically significant. The differences between two groups scored by counterparts in meatus ( P = 0.006), shaft skin ( P = 0.003), glans ( P = 0.010), and general appearance ( P = 0.014) were statistically significant. Conclusion: Both prefabricated urethra and pre-implanted urethral plate methods are suitable for correction of severe hypospadias as staging surgery in children. In general, pre-implanted urethral plate is more worthy of spread because it is much more applied in patients with small glans and achieve good appearance of penis.
View
... Some studies have indicated a complication rate of ∼10% for distal and over 50% for proximal hypospadias repairs (2). Many techniques have been described, and although no single, best method of urethroplasty has been clearly identified (3), investigators recently reported that beneficial modifications to hypospadias surgery could improve operative results (4,5). It is currently accepted that any urethroplasty requires that some healthy vascular tissue be interposed between the urethroplasty and the skin (3,6). ...
Using Buck's Fascia as an Integral Covering in Urethroplasty to Restore the Anatomical Structure of the Penis in One-Stage Hypospadias Repair: A Multicenter Chinese Study Comprising 1,386 Surgeries
Article
Full-text available
  • Aug 2021
Objectives: The objective of the study is to investigate the feasibility and efficacy of urethroplasty with a Buck's fascia integral-covering technique (BFIC) to wrap and restore the normal anatomical structure of the penis in one-stage hypospadias surgery. Methods: One-stage surgeries for hypospadias management were performed using BFIC from January 2016 to September 2020 at four high-volume medical centers in China. The technique integrates Buck's fascia with glans wings to mobilize and wrap the urethra and restore penile anatomical relationships. The clinical data, postoperative follow-up data, and complications were recorded, and the results were analyzed. Results: A total of 1,386 patients were included in the study: 1,260 cases of primary hypospadias and 126 cases of re-operations; distal in 382 cases (27.6%), mid-shaft in 639 (46.1%), proximal in 365 (26.3%); tubularized incised plate (TIP) in 748 cases, inlay-graft in 124, onlay-graft in 49, Mathieu in 28, free-tube graft urethroplasty in 406, and 31 of hybrid procedures. One thousand one hundred forty-two patients (82.4%) were found to have penile curvature (>10°) after artificial erection and all corrected by dorsal plication/s or transection of the urethra plate (UP) simultaneously. The median followed-up time was 27 months (6–62). A total of 143 (10.3%) complications were recorded: 114 (9.0%) in the primary operations and 29 (23%) in the re-operations, 15 (3.9%) in distal hypospadias, 61 (9.5%) in mid-shaft, and 67 (18.4%) in proximal. The complication rate in UP preservation and transection was 10.1 and 10.8%, respectively. Of all case complications, there were 73 (5.2%) of fistula, 10 (0.6%) of dehiscence, 22 (1.6%) of meatal stenosis, 21 (1.5%) of stricture, 6 (0.7%) of diverticulum, and resident curvature in 11 cases (1.2%). The overall complication rate in TIP and free-tube procedure was 9.8 and 9.9%, respectively, and fistula occurred in primary TIP of 33 cases (4.9%). Conclusions: Buck's fascia with the glans can be used as an integral covering technique in one-stage distal to proximal hypospadias and primary or re-operative hypospadias repair. It is safe, feasible, and effective for the repair of hypospadias.
View
... In several studies, SA in pediatric patients showed a decreased incidence of hypotension, hypoxia, bradycardia and postoperative apnea in comparison to GA [13] SA is being used frequently in sub-diaphragmatic surgeries to relieve postoperative pain and to achieve sensory block with muscle relaxation and decrease stress response so the recovery is fast in pediatric population [3] In this study, the patients remained hemodynamically stable during intraoperative period except a brief increase in HR before performing procedure. This may be because of atropine and ketamine used during procedure. ...
View
Standard Snodgrass urethroplasty versus Snodgrass with glans augmentation urethroplasty for distal hypospadias: A comparative study
Article
  • Mar 2024
Introduction Hypospadias is one of the most common congenital anomalies of the male genitourinary system. The Snodgrass urethroplasty is the most common worldwide accepted procedure for distal hypospadias. Various modifications have been made to reduce common complications, such as urethra-cutaneous fistula and meatal stenosis. In this study, we compare the results of hypospadias repair using the standard Snodgrass urethroplasty technique and Snodgrass urethroplasty with glans augmentation. Materials and Methods This is a single institution series from January 2020 to January 2023. One hundred patients with distal hypospadias were included in the study. Out of these, 50 patients underwent the standard Snodgrass repair (Group 1), whereas another 50 patients underwent the Snodgrass urethroplasty with glans augmentation technique (Group 2). Results The average follow-up period was 8 months. Four patients in Group 1 developed a fistula, and three had meatal stenosis (two were managed by meatal dilatations, and one with severe meatal stenosis was managed by meatotomy). In comparison, none of the patients in Group 2 developed a fistula, and only one developed meatal stenosis, which was managed by meatal dilatation. Partial skin necrosis was noted in three patients in Group 1 and two patients in Group 2. The final cosmetic appearance was acceptable. Conclusions Snodgrass urethroplasty with glans augmentation is an effective procedure with a low complication rate and good cosmetic results.
View
Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: A single-center experience
Article
Full-text available
  • Sep 2014
It is still debatable whether single- or two-stage urethroplasty is a more suitable technique for treating hypospadias with severe chordee after urethral plate transection. This retrospective study evaluated these two techniques. A total of 66 patients of proximal hypospadias with severe chordee were divided into two groups according to the techniques they underwent: 32 and 34 patients underwent single-stage (Duckett) or two-stage urethroplasty, respectively. Median ages at presentation were 7.5 years and 11.0 years in single-stage and two-stage repair groups, respectively. Median follow-ups were 28.5 months (20-60 months) and 35 months (18-60 months) in the single-stage and two-stage groups, respectively. The meatus of the neourethra was located at the top of the glans in all patients. No recurrence of chordee was found during follow-up, and all patients or parents were satisfied with the penile length and appearance. Complications were encountered in eight patients in both groups, with no statistically significant differences between the two techniques. The late complication rate of stricture was higher after the single-stage procedure (18.75% vs 0%). The complication rate after single-stage repairs was significantly lower in the prepubescent subgroup (10.52%) than in the postpubescent cohort (46.15%). These results indicate that the urethral plate transection effectively corrects severe chordee associated with proximal hypospadias during the intermediate follow-up period. Considering the higher rate of stricture after single-stage urethroplasty, two-stage urethroplasty is recommended for proximal hypospadias with severe chordee after urethral plate transection.
View
Hypospadias
Chapter
  • Oct 2011
Hypospadias is considered the result of arrested development, leaving incomplete urethral formation sometimes associated with ventral penile curvature. The minority of cases occurring with other syndromes, or when there is also undescended testis, warrant a preoperative karyotype to detect intersex disorders. Otherwise the only preoperative evaluation needed is assessment of glans size, as there may be benefit from preoperative testosterone therapy to increase glans diameter, usually in proximal hypospadias. Today most primary cases are corrected by tubularizing the urethral plate – tissue that should have originally created the urethra when development stopped. Prepucial flaps remain an option for repair, as do planned 2-stage flap or graft procedures. The majority of hypospadias complications relate to urethroplasty, most commonly including fistulas, obstruction to the neourethra (by meatal stenosis or urethral stricture), or wound dehiscence. Incidence varies by technique used and extent of the hypospadias defect (distal versus proximal). Reoperative urethroplasty can be accomplished using similar methods as for primary surgery, but complication rates are greater. At times excision of scarred tissues with planned 2-stage graft repairs is required to re-create a neourethral plate to subsequently tubularize.
View
View
Distal hypospadias repair using only glans wing mobilization and approximation
Article
  • Apr 2014
  • Can J Urol
Since its first description in 1994, tubularized incised plate (TIP) technique has become the most commonly performed hypospadias procedure and involves incision of the urethral plate with subsequent tubularization. Glans wings are then developed to cover the neourethra, thereby creating a cosmetically appealing repair. In some distal hypospadias cases, mobilization and approximation of glans wings is sufficient to create a normal appearing urethral meatus. A retrospective chart review of all pediatric urology patients who underwent hypospadias repair by a single surgeon at the University of Kentucky between July 1, 2010 and April 1, 2013 was performed. Of the 46 patients who underwent one-stage distal hypospadias repair during that time, we performed the technique described above on 13 patients with amenable anatomy. Patients were evaluated for functional and cosmetic outcomes as well as complications at subsequent office visits and via telephone. Patients who underwent distal hypospadias repair with our technique had excellent functional and cosmetic outcomes analogous to those who underwent standard TIP repair. The only major complication in the study group was wound dehiscence in one patient that was required a second surgery. All other patients had excellent cosmetic and functional results without fistula formation, strictures or diverticuli, and with excellent parent satisfaction. Perceived benefits of this technique include simplicity and rapidity of technique, applicability to glanular, coronal and subcoronal hypospadias, and avoidance of sutures between urethra and glans with potential decrease in meatal stenosis.
View
Duration of follow-up to diagnose hypospadias urethroplasty complications
Article
  • Nov 2013
Objective We report the time when hypospadias urethroplasty complications (UC) were diagnosed postoperatively. Methods The time UC occurred after primary distal and proximal TIP and TIP reoperations was obtained from prospectively maintained databases in consecutive patients. UC included fistulas, glans dehiscences, meatal stenoses, neourethral strictures and diverticula. Results Of 125 UC, 64% were diagnosed at the first postoperative visit and 81% were encountered within the first year after repair. Median time for diagnosis was 6 months (1.5-95) for fistulas, meatal stenoses/urethra strictures, and diverticulum, versus 2 months (1 week-24 months) for glans dehiscence. Conclusions The majority of UC are diagnosed at the first postoperative visit or within the first year following TIP hypospadias repair. Glans dehiscences are most often apparent by 2 months, whereas most fistulas and other UC are found by 6 months. After 1 year, 14 boys without UC have to be followed indefinitely to diagnose each additional complication.
View
Comparative outcomes of the tubularized incised plate and transverse island flap onlay techniques for the repair of proximal hypospadias
Article
  • Sep 2013
  • INT UROL NEPHROL
The optimal management of proximal hypospadias remains uncertain. In this study, the surgical outcomes of tubularized incised plate repair (TIP) and transverse island flap (TVIF) onlay urethroplasty in boys with hypospadias were compared. A total of 176 patients with proximal hypospadias underwent TIP (n = 83) or TVIF onlay repairs (n = 93) by a single surgeon and were evaluated retrospectively. No patient received a testosterone injection prior to surgery. A retrospective review of their medical records collected data regarding age at surgery, chordee, dorsal plication, hypospadias site, penoscrotal transposition, bifid scrotum, congenital hernia, undescended testis and any postoperative complications, including fistula, recurrent curvature, dehiscence, diverticulum, meatal stenosis and urethral stricture. The pediatric penile perception score (PPPS) was completed by parents to evaluate their perception of cosmetic outcomes. There was no statistical difference in age or any of the anatomical and clinical features of hypospadias. The median follow-up duration was 22 months (range 12-48 months) and 25 months (14-51 months) for the TIP and TVIF onlay groups, respectively. The overall complication rate in the TVIF onlay group was 21.5 % (20/93), which was higher than 18.1 % (15/83) in the TIP group, but the difference was not statistically significant (P = 0.569). The most common complication was urethrocutaneous fistula, occurring in 9.6 % (8/83) of the TIP group and 10.8 % (10/93) of the TVIF onlay group. There were no significant differences in the rate of any complication and the overall PPPS between the two groups. TIP and TVIF onlay are clinically equivalent for the repair of proximal hypospadias.
View
Single incisional approach for reconstruction of hypospadias and concomitant inguinal hernia
Article
  • Jun 2013
To demonstrate the feasibility, cosmetic outcome and therapeutic values of our single incisional approach in patients with both hypospadias and inguinal hernia (IH) in comparison with standard multiple incisional techniques. Sixty hypospadias-IH repairs were performed from February 2005 to February 2012. These patients were divided into two groups according to their age and hypospadias location. They were then separated randomly into multiple incision (MIG) and single incision (SIG) groups. Early and late complications were taken into consideration. Postoperative pain, need for analgesics, operative time, hospital stay and cosmetic results were recorded for further evaluation. Patients were followed up at 6-month intervals for up to 2 years postoperatively. Early and late complication rates were approximately the same in the two groups. 73.3% of patients in MIG and 96.6% in SIG attained an excellent cosmetic result according to two external surgeons. There was no case with poor cosmetic outcome in either group. More analgesic consumption was demanded in MIG patients. This method of surgery is reproducible with better cosmetic outcome and a slightly shorter hospital stay. It could be a viable option in the management of children with hypospadias and concomitant IH. Negligible postoperative pain and short operative time are the other advantages.
View
Applications of triangular glanular flap in hypospadias repairs for different purposes
Article
  • May 2013
Abstract Hypospadias is a congenital anomaly of the penis with an ectopic, ventrally-placed meatus due to insufficient development of the anterior urethra. Tubularisation of glanular flaps without plate incision is performed with addition of a triangular flap in order to move the meatus more distally and avoid meatal stenosis. Subcoronally, mid-shaft, and coronally placed 41 hypospadias cases were treated with the tubularisation of the glanular flaps without incision of the urethral plate, a technique similar to TIP technique. Triangular flaps were added at the most distal end of one of the glanular flaps in all cases for different purposes. A medially-based triangular flap was elevated at the distal end of the right-sided longitudinal flap to carry the last suture more distally. The flap increased meatal diameter and carried the last suture more distally. No meatal stenosis was observed for an average of 18.02 (12-30) months. The final localisation of the meatus was satisfactory in all patients. Meatal stenosis, demonstrated after hypospadias repair, is a challenge for both the surgeon and the patient. A distal triangular glanular flap is planned to avoid this challenge. Besides, it helps to carry the meatus more distally. Promising results support the use of the glanular flap while longer follow-up is required for better evaluation.
View
Regular dilatation is unnecessary after tubularized incised‐plate hypospadias repair
Article
Objective To determine if patients who undergo tubularized incised-plate (TIP) urethroplasty need regular dilatation to prevent neourethral strictures or meatal stenosis. Patients and methods The follow-up of two consecutive series of patients who underwent primary TIP hypospadias repair by one surgeon was reviewed. The first 72 patients (group 1) had periodic neourethral calibrations for 1 year after repair, while the next 62 patients (group 2) had no routine dilatation, except for six patients (10%) in whom the meatus appeared to be small. Urethroscopy was performed in both groups at the time of fistula repair, skin revisions or during anaesthesia for unrelated procedures. Results There was no evidence of scarring in group 1; one case of meatal stenosis and one neourethral stricture were detected in group 2. The difference in outcome was not statistically significant (P = 0.4). Overall, the incidence of meatal stenosis was low (0.7%) and comparable with most recent series in which postoperative calibration was not used routinely. Conclusion Dilatation of the neourethra is unnecessary after TIP urethroplasty. Calibration or uroflowmetry 6 months after surgery may be useful to detect subclinical obstruction.
View
Tubularized incised plate urethroplasty for proximal hypospadias
Article
Objective To review our experience of using the tubularized incised plate (TIP) urethroplasty (useful in the treatment of distal hypospadias) to treat proximal hypospadias. Materials and methods From March 1997 to March 2000 primary repairs were carried out on 40 boys (mean age 4.5 years) with proximal hypospadias. After degloving the penile skin the meatus was at the mid-shaft in 10 boys, at the proximal penile shaft in 11, at the penoscrotal junction in 16, at the scrotum in two and at the perineum in one. The 21 patients with a mid or proximal shaft meatus were categorized as having mid-shaft and the other 19 as having posterior hypospadias. Tunica albuginea plication (TAP) was used to correct residual ventral curvature. The method of urethroplasty was adapted from that described by Snodgrass. The key step of the TIP repair is a midline incision of the urethral plate; a subcutaneous tissue flap dissected from the inner prepuce is used to cover the neourethra. An 8 or 10 F nasogastric tube is used as a urethral stent and removed 7 or 8 days after surgery. Follow-up endoscopy and urethral sounding were carried out in 17 of the patients aged < 6 years; the mean follow-up was 12.5 months. Results TAP was used to correct penile curvature in nine (23%) of the patients. Excluding stenosis, the TIP repair was successful in 20 (90%) of those with mid-shaft and in 16 of the 19 with posterior hypospadias; for all complications the respective rates were 19 of 22 and 15 of 19. The overall success rate was 88% for all 40 patients with proximal hypospadias; a urethrocutaneous fistula occurred in two of those with mid-shaft and three of those with posterior hypospadias. Urethral meatal stenosis occurred in four (12%) of the patients (two in each group); two were associated with a fistula and the other two had only mild meatal stenosis. The overall complication rate was 17.5% (three and four in the mid and the posterior hypospadias groups, respectively). The meatal stenosis was managed by simple dilatation in three and meatoplasty in one patient. Endoscopically, the mucosa of neourethra was pink and smooth in all 17 patients assessed. The calibre of all 17 neourethra was 8 F and in 13 was 10 F. Conclusion TIP repair is a reliable method for treating both mid-shaft and posterior hypospadias.
View