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Iran J Pediatr. 2021 June; 31(3):e111184.
Published online 2021 July 13.
doi: 10.5812/ijp.111184.
Research Article
Comparing Mathieu and Tubularized Incised-Plate Urethroplasties for
Repairing Distal Penile Hypospadias: A Single-Center Experience with
Long-Term Outcome
Leily Mohajerzadeh 1, *, Arash Dooghaie Moghadam 1, Ahmad Khaleghnejad Tabari 1, Mohsen
Rouzrokh 1and Nadiya Moghimi1
1Pediatric Surgery Research Center, Research Institute for Children’s Health, Shahid Beheshti University of Medical Sciences, Tehran,Iran
*Corresponding author: Pediatric Surgery Research Center, Research Institute for Children’s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Email: Email:
mohajerzadehl@yahoo.com
Received 2020 November 17; Revised 2021 February 07; Accepted 2021 April 10.
Abstract
Background: Hypospadias is a congenital anomaly on the penis, in which the meatal orifice opens ventrally and proximal to the
tip of the penis. In this regard, two common treatment methods are tubularized incised-plate urethroplasty (TIP) and the Mathieu
incised-plate (MIP) technique. The present study aimed to compare the early and long-term outcomes of TIP and MIP among patients
with distal penile hypospadias.
Objectives: The study was also to evaluate the postoperative functional outcome of hypospadias over a long-term follow-up.
Methods: Fifty-nine patients were randomly selected and assigned to two groups (TIP (n = 31) and MIP (n = 28)). Demographic in-
formation, preoperative findings, and postoperative complications were collected from the two groups. The Hypospadias Objective
Scoring evaluation (HOSE) questionnaire and uroflowmetry were obtained to evaluate the long-term outcome of hypospadias re-
pair.
Results: The success rates of the surgical TIP and MIP techniques were 71.0% and 82.1%, respectively. Postoperative complications in
the TIP group were three (9.7%) distal UCF and four (12.9%) meatal stenosis. In the MIP group, two (7.1%) and three (10.7%) patients
suffered from distal UCF and meatal stenosis, respectively. Moreover, 89.3% of the patients in the MIP group and 80% of the patients
in the TIP group had acceptable HOSE. Regarding the uroflow rates in the MIP group, 12% and 58% of the participants were below the
5th percentile and above the 25th percentile, respectively. Concerning the uroflow rates of TIP, 32% of the patients were below the
5th percentile, and 18% of the participants were above 25th percentile.
Conclusions: Although there have been some reports on the superiority of TIP, we found these two techniques at approximately
equal levels with a slightly higher success rate for the MIP regarding the early outcomes. With the exception of the long-term out-
comes in cosmetic and functional evaluation, MIP is superior to TIP.
Keywords: Mathieu, TIP, Distal Penile Hypospadias, Uroflowmetry
1. Background
Hypospadias is a congenital defect of the penis, in
which the urethral meatus is located ventrally and prox-
imal to the tip of the penis from the glance to the per-
ineum (1,2). Regarding many factors such as the sever-
ity of Chordee, the presence of adequate supportive tissue
for urethral reconstruction, urethral plate quality, and sur-
geon’s experience, there is no agreement among surgeons
on the selection of an optimal hypospadias repair tech-
nique (3,4).
UCF is one of the most common complication among
patients suffering from hypospadias. The patient with UCF
commonly needs to undergo surgery once more at 6-12-
month intervals; however, its high failure rate is still high
(5).
Tabularized incised-plate (TIP) urethroplasty is a stan-
dard surgical technique to treat distal hypospadias. De-
spite its widespread use, it still exposes patients to some
complications, at the top of which is UCF. On the other
hand, the Mathieu incised-plate (MIP) technique is also
one of the most preferred alternative procedures, gener-
ally used in specialized centers (6).
The functional outcome of hypospadias repair is con-
sidered as a cosmetic outcome. In some studies, structured
scoring systems and uroflowmetry were used to assess re-
Copyright © 2021, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License
(http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly
cited.
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Mohajerzadeh L et al.
sults of hypospadias repair. Holland et al. (7) described
a scoring system incorporating an assessment of meatal
location and shape, urinary stream, erection straightness,
and the presence and complexity of any urethral complica-
tion.
2. Objectives
Considering the remarkable impacts of the disease on
the physical and psychological status of the patients and
their guardians, its inescapable needs for surgery, and
its probable complications, this study discusses the long-
term outcomes and complications of TIP and MIP.
3. Methods
3.1. Patients
The distal penile hypospadias cases referred to
our surgery clinic during 2006 - 2011 were included in
this study. All surgeries were undergone by a highly-
experienced surgeon, who was competent in both TIP and
MIP techniques.
Fifty-nine patients were randomly selected and as-
signed to two groups (TIP (n = 31) and MIP (n = 28)). Af-
ter excluding the patients with a previous history of hy-
pospadias surgery, urethral plate < 8 millimeters, penile
Chordee > 30 degrees, and hypoplastic urethra proximal
to hypospadias meatus as well as those who were unwill-
ing to participate in the study, 59 patients with distal shaft
hypospadias were included in the study. In all cases, an
artificial erection test was performed on the operating ta-
ble to check for the elimination of Chordee after penile de-
gloving. In all cases, a single dartos flap was used. More-
over, all patients benefited from a standardized sandwich
dressing.
The HOSE questionnaire (7) and uroflowmetry were
used to evaluate the long-term outcomes of hypospadias
repair. Furthermore, the patients were followed up at two
stages (namely early and late). The patients were then ap-
pointed to participate in their first follow-up visit during
Days 7 - 14 post-surgery. The second and the third follow-up
visits were set three and six months after the surgery, and
the last visit was about 90 months after surgery.
The required data were collected by importing the pa-
tient’s information into the certain forms developed by the
researchers, which encompassed demographic indirma-
tion, presence or absence of Chordee, duration of hos-
pitalization, number of performed surgical procedures,
postoperative complications (e.g., UCF and Chordee level),
duration of urethral catheterization, and need for re-
hospitalization. Then the participants were called and
asked for a visit and uroflowmetry.
In the last visit, about 90 months after surgery, meatal
location and shape, urinary stream, erection straightness,
and presence of fistula were assessed, and scoring was per-
formed based on the instructions of the HOSE question-
naire. Acceptable and non-acceptable HOSE scores were set
to be 14 - 16 and ≤13, respectively.
Uroflowmetry procedures and its possible benefits and
complications were explained to the patients’ guardians,
and their informed consent to participant in the study was
obtained. Then uroflowmetry was performed, and maxi-
mum flow rate (Q-max), average flow rate (Q-ave), voided
volume (vv), time to maximum flow, flow time, and void-
ing time were recorded. Afterward, maximum urine flow
rate to voided volume inserted in Iranian Kajbafzadeh et
al. (8) Uroflowmetry nomogram (8). In definition, normal
flow > 25th percentile, equivocal obstruction 5th - 25th per-
centile, and obstructed flow < 5th percentile considered.
3.1. Analyzed Factors and Statistical Analysis
The data on the demographic information, preopera-
tive findings, perioperative outcomes, and postoperative
complications were collected from the TIP and MIP groups,
tabulated, and compared using the SPSS software (IBM SPSS
Statistics for Windows, version 22.0. Armonk, NY, USA). The
chi-square tests, Fisher’s exact-test, and Mann Whitney U-
test were used to compare the results. In this study, P <
0.05 was set as the significance level.
3.2. Ethical Considerations
Type of assessment, uroflowmetry procedures, the pos-
sible benefits, and complications of uroflowmetry were ex-
plained to the patient’s guardians. No additional inter-
vention or cost was imposed on the patients in this study.
Patients’ information was used in this study as encoded
parameters observing the confidentiality principle. The
personal information of no patient was included in this
research, and only the statistical analysis of the data was
presented in general. The informed consent was obtained
from the legal guardian(s) of each participant, and the pa-
tients were excluded from the study if the patient or their
parents were not willing to participate in the study. The
study was approved by the Institutional Board Review and
the Medical Ethics Committee of the Shahid Beheshti Uni-
versity of Medical Sciences.
4. Results
Of the 59 patients in the study, 31 patients underwent
the TIP surgery, and 28 persons underwent MIP. The partic-
ipants’ mean age at the first surgery was 29.53 and 30.33
months in the TIP and MIP groups, respectively. The age at
2 Iran J Pediatr. 2021; 31(3):e111184.
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Mohajerzadeh L et al.
the time of assessment ranged from 5 - 11 years old, with a
mean follow-up age of 90 months.
Of the 31 surgically-treated patients with TIP, 28 pa-
tients (90.3%) revealed no concurrent anomalies, only two
cases (6.5%) had unilateral undescended testis (UDT), and
one case (3.25%) suffered from an inguinal hernia. Of the
28 patients treated with the MIP procedure, 23 cases (82.1%)
showed no concurrent anomalies, and three cases (10.7%)
of unilateral UDT, one case (3.6%) of an inguinal hernia, and
one case (3.6%) of mental retardation were reported. In the
two surgical groups, P = 0.853 for the concomitant anoma-
lies with hypospadias, indicating no statistical difference
between the two groups.
Three patients in the MIP group and three patients in
the TIP group had Chordee < 30; hence, Chordee was re-
paired in all patients with dorsal plication.
There was no statistically significant difference be-
tween the surgical technique and the need for the home-
ostasis method (P = 0.141). Eleven patients in the TIP group
required epinephrine, and nine persons needed a tourni-
quet to establish homeostasis, while two patients in the
MIP group required a tourniquet, and 20 cases required
to inject epinephrine to maintain homeostasis. In both
groups, repairs were performed with polydioxanone (PDS)
suture material. Among the patients treated by both tech-
niques, a silastic dripping stent catheter was used after
surgery.
The success rates were 71.0 % and 82.1% for the TIP and
MIP techniques, respectively. Regarding the postoperative
complications in follow-ups, the TIP group reported three
cases (9.7%) of distal UCF, four cases (12.9%) of meatal steno-
sis, one case (3.2%) of urethral stricture, and one case (3.2%)
of Chordee. In the MIP group, only two (7.1%) and three
(10.7%) patients suffered from distal UCF and meatal steno-
sis, respectively, and no other postoperative complication
was observed in this group (Table 1).
Regarding the incidence of complications in each tech-
nique, especially the presence of UCF and meatal steno-
sis, which are considered as the significant complications
of hypospadias correction surgery, and especially which
method is more appropriate to choose, the results of the
present study indicated that the patients in the TIP group
experienced UCF more frequently than the MIP group and
that there was a significant relationship between the pres-
ence of UCF and the used technique.
On the other hand, the study revealed the same results
for the complication of meatal stenosis in the two surgery
groups (P = 0.795), and their correlation was considered
statistically insignificant.
In all patients with UCF, a redo operation was per-
formed successfully to repair the fistula. The HOSE results
in the last follow up are demonstrated in (Table 2).
In the MIP group, 89.3% of the participants had an ac-
ceptable HOSE, and 80% of the cases in the TIP group had an
acceptable score (Figure 1) (P = 0.893). This correlation was
considered statistically insignificant. The mean voided vol-
ume and the flow rate regarding the type of surgery are
presented in (Table 3 and Figure 2).
Regarding the uroflow rates in the MIP group, 12% of
the patients were below the 5th percentile, 31% patients
were between the 5th and 25th percentiles, and 58% of the
patients were above the 25th percentile. Regarding the
uroflow rates in the TIP group, 32% of the cases were below
the 5th percentile, 50% of patients were between the 5th
and 25th percentiles, and 18% of the patients were above
the 25th percentile (Figure 3).
The uroflowmetry assessment results showed a statis-
tically significant correlation between the presence of ob-
structive voiding and the surgery technique (P = 0.018).
The development of obstructive voiding was significantly
higher in the TIP group than the MIP group.
5. Discussion
Hypospadias is a congenital defect in the meatal ori-
fice of the penis, the treatment of which requires surgi-
cal repair. Various urethroplasty techniques have been in-
troduced for the hypospadias treatment; however, they
have been associated with some complications regarding
the severity of hypospadias, patients’ age, history of previ-
ous surgical repairs, and soft tissue support status. More-
over, the complications include a variety of rapid onset in-
cidences such as surgical site infection and hematoma, or
delayed events, including meatal retraction and stenosis,
wound dehiscence, diverticulum, and urethrocutaneous
fistula (UCF).
The treatment techniques aim to achieve the voiding
in an upright position, develop a standard voiding stream,
and maintain the normal penile shape and function (8-10).
In the present study, we compared the TIP and MIP tech-
niques as the most popular urethroplasty techniques for
hypospadias among most surgeons.
In this study, 59 patients met the inclusion criteria, and
the collected data were recorded and evaluated. Of the par-
ticipants, 31 patients underwent surgical repair using the
TIP technique, and 28 persons were treated using the MIP
techniques.
In Manzoni’s et al. (11) study, the age of 6 - 12 months was
considered as the best age for performing a repair surgery
for hypospadias. However, the patients’ mean ages in the
first surgery in this study were 29.53 months in the TIP
group and 30.33 months in the MIP group. Moreover, there
was no significant difference between the two groups re-
garding age.
Iran J Pediatr. 2021; 31(3):e111184. 3
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Mohajerzadeh L et al.
Table1. Participants’ Characteristics
Characteristics TIP Group Mathieu Group
Frequency 31 28
Mean age at first surgery,mo 29.53 30.33
Concurrent anomalies, % 9.2 17.9
Chordee before surgery (frequency) 3 3
Suture material Polydioxanone (PDS) Polydioxanone (PDS)
Urinary stent Silastic dripping stent Silastic dripping stent
Duration of Urinary stent, d 6 6
Ucf1, % 9.7 7.1
Meatal stenosis, % 12.9 10.7
Urethral stricture, % 3.2 0
Chordee after surgery,% 3.2 0
Table2. Hypospadias Objective Scoring Evaluation (HOSE) Outcome in Last Follow-up
HOSE Outcome Score Frequency in TIP Group (N = 31) Frequency in Mathieu Group (N = 28)
Meatal location
Distal glans 4 25 24
Proximal to glans 3 6 4
Coronal Proximally on the penile 2 0 0
Shaft 1 0 0
Meatal shape
Vertical slit 2 25 25
Circular 1 6 3
Urinary stream
Single stream 2 25 25
Spray 1 6 3
Erection
Straight 4 23 25
Mild angulation (< 10 u) 3 8 3
Moderate angulation (> 10 u but < 45 u) 2 0 0
Severe angulation (> 45 u) 1 0 0
Fistula
None 4 31 28
Single subcoronal or more distal 3
Single proximal 2
Multiple or complex 1
Acceptable HOSE outcome, % 80 89.3
Many studies have reported the inguinal hernia and
UDT as the most common concomitant anomaly among
hypospadias patients, with the incidence rates of 9% and
6%, respectively (12-15). In our study, the incidence rate of
the former was 1.7%, and the incidence of UDT was 8.5 % (5
out of 59 patients).
The presence of the bilateral UDT is much more high-
lighted among these patients because of the probability of
4 Iran J Pediatr. 2021; 31(3):e111184.
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Mohajerzadeh L et al.
Figure 1. Comparing HOSE outcomes between two groups
Mathieu Mean
Mathieu N
Mathieu Std. Deviation
TIP Mean
TIP N
TIP Std. Deviation
Total Mean
Total N
Total Std. Deviation
Statistics
Variables
Values
250
200
150
100
50
0
Acceleration (ml/s/s)
flow at 2 Seconds (ml/s)
Voided Volume (ml)
Time to Peak Flow (sec)
Flow Time (sec)
Voiding Time (sec)
Average Flow (ml/s)
Uroflow-Maxium Flbw (ml/s)
Figure 2. Comparing Uroflowmetry parameters between two groups
underlying chromosomal disorders. However, none of the
patients reported bilateral UDT in the present study.
In a systematic review, Wilkinson et al. investigated the
outcomes of the TIP and MIP techniques and reported the
Iran J Pediatr. 2021; 31(3):e111184. 5
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Mohajerzadeh L et al.
Figure 3. Uroflowmetry nomogram in both groups
incidence rates of postoperative complications in 6.7% of
patients undergoing MIP surgery and 6.9% of the patients
in the TIP group (6). Another two randomized clinical trials
also reported the same complication rates for both of these
techniques (16,17).
Our study revealed a complication rate of 29.0% and
17.1% for the TIP and MIP techniques, respectively. This
higher complication rate in this study could be explained
based on the number of the participants. Further stud-
ies are recommended to detect the same issue with larger
sample sizes.
The likelihood of complications, especially UCF and
meatal stenosis in the TIP and MIP groups, was assessed
in many studies and revealed a significant difference be-
tween the two groups in terms of complications (6,10,18-
20). In our present study, we found a statistically signifi-
cant difference between the TIP and MIP groups regarding
UCF and meatal stenosis rates.
The effect of suturing material on developing compli-
cations in hypospadias patients has already been evalu-
ated. For example, Ulman et al. stated a markedly greater
likelihood of fistula formation in the group of patients
treated with vicryl material stitch compared to the PDS
group (21). However, Cimador et al. (22) found no signifi-
cant difference between these two materials in their study.
Accordingly, we used the same suture material for the two
group.
HOSE and uroflowmetry are non-invasive and trouble-
free means to evaluate the long-term outcomes of children
after hypospadias repair. Regarding the uroflow rates in
the MIP group, 12% of the subjects were below the 5th per-
centile, 31% patients were between the 5th and 25th per-
centiles, and 58% of the patients were above the 25th per-
centile.
Regarding the uroflow rates in the TIP group, 32% of
subjects were below the 5th percentile, 50% of patients
were between the 5th and 25th percentiles, and 18% of the
cases were above the 25th percentile. The uroflowmetry as-
sessment results revealed a statistically significant correla-
tion between the presence of obstructive voiding and the
surgery technique (P = 0.018). The development of obstruc-
tive voiding was significantly higher in the TIP group than
the MIP group.
Given that many studies have reported remarkable im-
provement in functional obstructive voiding at puberty,
watchful waiting and following the concerned parameters
by examination and uroflowmetry are proposed to avoid
unnecessary intervention (23).
5.1. Conclusions
The present study concluded the higher success rate
and the better outcome of the Mathieu procedure, espe-
cially the long-term outcomes of cosmetic and functional
evaluation, compared to the TIP method. One of the limi-
tations of this study is small sample size; hence, future re-
searchers are highly recommended to address this issue in
further studies.
6 Iran J Pediatr. 2021; 31(3):e111184.
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Mohajerzadeh L et al.
Table3. Uroflowmetry Parameter
Surgical Technique Uroflow-Maximum
Flow,mL/s
Average Flow, mL/s Voiding Time, s Flow Time, s Time to Peak flow,s Voided Volume,mL Flow at 2 Seconds,
mL/s
Acceleration, mL/s/s
Mathieu
Mean ±SD 8.5000 ±0.56569 6.9000 ±0.28284 36.2000 ±11.73797 29.4500 ±7.42462 17.8000 ±7.07107 206.1000 ±60.38692 1.5500 ±1.62635 0.4000 ±0.14142
N 28 28 28 28 28 28 28 28
TIP
Mean ±SD 5.1400±2.48254 5.1000 ±2.02978 16.4000 ±10.31576 15.4000 ±10.38581 6.1400 ±4.42922 77.3800 ±52.71216 3.3200 ±2.56359 1.1200 ±1.07098
N 31 31 31 31 31 31 31 31
Total
Mean ±SD 6.1000 ±2.61725 5.6143 ±1.87921 22.0571 ±13.68391 19.4143 ±11.31804 9.4714 ±7.33365 114.1571±80.03191 2.8143±2.35968 0.9143 ±0.94415
N 59 59 59 59 59 59 59 59
Footnotes
Authors’ Contribution: Study design, operative work,
manuscript writing, and repeated editing: Leily Moha-
jerzadeh. Data Acquisition: Arash Dooghaie Moghadam
and Nadiya Moghimi. Study design: Ahmad Khaleghnejad
Tabari and Mohsen Rouzrokh.
Conflict of Interests: There is no conflict of interest.
Ethical Approval: This study was approved by Ethics
Committee of Faculty of Medicine, Shahid Beheshti Univer-
sity, Tehran, Iran (code: IR.SBMU.MSP.REC.1397.618).
Funding/Support: There is no funding and support.
Informed Consent: The informed consent was obtained
from the legal guardian(s) of each participant in the study.
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