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P a g e | 377
Comparison of the use of graft augmented tubularized split (GATS)
and tubularized incised plate urethroplasty (TIPU) techniques for
hypospadias repair in patients with narrow plate and small glans
Ahsen Karagözlü Akgül 1, Sadık Abidoğlu 2, G ürsu Kıyan 3, Embiye Adalı 4, Halil Tuğtepe 5
How to cite: Akgül AK, Abidoğlu S, Kıyan G, Adalı E, Tuğtepe H. Comparison of the use of graft augmented tubularized split (GATS) and tubularized incised plate urethroplasty
(TIPU) techniques for hypospadias repair in patients with narrow plate and small glans. J Surg Med. 2022;6(3):377-381.
J Surg Med. 2022;6(3):377-381. Research article
DOI: 10.28982/josam.980401
1 Ministry of Health, Marmara University Pendik
Training and Research Hospital, Department of
Pediatric Surgery, Division of Pediatric Urology,
Istanbul, Turkey
2 Marmara University, Faculty of Medicine,
Department of Pediatric Surgery, Division of
Pediatric Urology, Istanbul, Turkey
3 Marmara University, Faculty of Medicine,
Department of Pediatric Surgery, Istanbul, Turkey
4 Marmara University, Faculty of Medicine,
Department of Pediatric Surgery, and Ministry of
Health, Istanbul Dr Lutfi Kirdar City Hospital,
Department of Pediatrics, Istanbul, Turkey
5 Maltepe University, Department of Pediatric
Surgery, Istanbul, Turkey
ORCID ID of the author(s)
AKA: 0000-0003-3250-605X
SA: 0000-0002-8654-8856
GK: 0000-0001-5461-353X
EA: 0000-0001-8206-8057
HT: 0000-0001-7465-2739
Corresponding Author
Ahsen Karagözlü Akgül
Ministry of Health, Marmara University Pendik
Training and Research Hospital, Department of
Pediatric Urology, Fevzi Çakmak, Muhsin Yazıcıoğlu
Cd No:10, 34899 Pendik/İstanbul, Turkey
E-mail: ahsenkaragozlu@yahoo.com
�
Ethics Committee Approval
The study has been approved by Marmara University
Faculty of Medicine Clinical Research Ethics
Committee on 04.12.2020 with protocol number
09.2020.1333.
Informed consent for both participation and
publication was obtained from parents of the patients
who included this study.
All procedures in this study involving human
participants were performed in accordance with the
1964 Helsinki Declaration and its later amendments.
�
Conflict of Interest
No conflict of interest was declared by the authors.
�
Financial Disclosure
The authors declared that this study has received no
financial support.
�
Published
2022 March 25
Copyright © 2022 The Author(s)
Published by JOSAM
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC
BY-NC-ND 4.0) where it is permissible to download, share, remix,
transform, and buildup the work provided it is properly cited. The work
cannot be used commercially without permission from the journal.
Abstract
Background/Aim: Hundreds of repair techniques were described for hypospadias repair. It is still a
problem to choose the right technique in hypospadias repair for patients with narrow plate and small glans,
because the patients with narrow urethral plate and small glans usually suffer from complications. GATS
(Glans Augmented Tubularized Split) is an alternative technique with different details from grafted TIPU
(Tubularized Incised Plate Urethroplasty). The aim of this study is to compare the outcomes of TIPU and
GATS procedures on these difficult cases.
Methods: This retrospective cohort study consists of the analysis of patients who underwent GATS and
TIPU procedures in our department between January 2017 and January 2020. Patients with distal and
midpenile hypospadias and with shallow groove, glans smaller than 17 mm, and plate narrower than 8mm
were included the study. Patient with follow-up shorter than 1 year or incomplete data and secondary cases
were excluded. Patients were divided into two groups according to the technique performed, as 25 patients
in TIPU group and 20 patients in GATS group.
Results: The mean diameter of glans were 15.3 mm and 14.5 mm, mean width of plate were 5.2 mm and
4.1 mm in TIPU and GATS groups respectively. Complications were observed in 7 (28%) patients of
TIPU group and in 2 (10%) patients of GATS group (P>0.05). Urethral stenosis in one patient, urethral
fistula in two patients, urethral dehiscence in two and urethral stenosis and diverticula in one patient,
urethral stenosis and fistula in one patient were detected in TIPU group. Urethral fistula in one patient and
urethral dehiscence in one patient were observed in GATS group.
Conclusion: GATS procedure is an alternative method for difficult cases with narrow urethral plate and
small glans with less complications than TIPU technique.
Keywords: Hypospadias, Narrow urethral plate, Small glans, Shallow groove, Grafting, Complication
J Surg Med. 2022;6(3):377-381. GATS vs TIPU
P a g e | 378
Introduction
Hypospadias repair is one of the most common
surgeries in pediatric urology. In this context, more than one
hundred surgical techniques have been described in the literature
for hypospadias repair, yet there is still no consensus on the
technique that can serve as the gold standard technique.
Tubularized incised plate urethroplasty (TIPU)
technique was first described by Snodgrass in 1994 [1] and has
become the most commonly used technique for hypospadias
repair since then. The rates of complications reported to have
been associated with TIPU vary between 0% and 60% [2, 3]. The
patients with narrow plate, small glans and shallow groove
generally bear higher complication risks, and are thus commonly
considered as difficult hypospadias cases [3, 4].
TIPU generally results in narrow neourethra in
hypospadias cases with narrow plate, and subsequently in
inelastic narrow urethra [5].
Surgeons attempted to solve the mentioned
complications observed in hypospadias cases considered as
difficult through the augmentation of the plate with graft [6].
Additionally, Snodgraft or inlay tubularized plate urethroplasty
techniques were described and performed with less or similar
complications [6-9]. In these techniques, plate is incised deeply,
graft is applied inside the plate and tubularization is performed
on a urethral stent. Grafts should be inlayed to increase the width
of the plate, improve re-epithelialization, and prevent scar
formation [10, 11]. In both of these techniques, the final meatus
position is mostly glanular, yet not at the top of the glans, which
is thus not an optimal position. On the other hand, in graft
augmented tubularized split (GATS) [12] technique, plate and
also glans are incised till the top of the glans deeply, and in this
way the meatus is moved to the distal end of the glans (Figure 1).
The defect is augmented with graft and the procedure is
completed with tubularization of the neourethra. GATS
technique provides a wider neourethral plate, a neomeatus that is
positioned at the distal end of the glans, which is the optimum
position, and also a slit-like meatus. Therefore, use of GATS
procedure in hypospadias cases may lead to lower complication
rates, although it is considered as a difficult procedure. But the
debate in this issue for difficult cases with narrow and shallow
plate and small glans still continues, whether TIPU is sufficient
or a graft should be placed on the incised area. In our report, we
compare the outcomes of the TIPU and GATS techniques in
these difficult hypospadias cases with narrow plate, small glans
and shallow groove and tried to determine whether the grafting
of narrow urethra and deepen the shallow groove decreases the
complications after GATS procedure.
Figure 1: Differences between the TIPU (on the left) and the GATS (on the right) techniques
in terms of incised area
Materials and methods
The study has been conducted upon the required ethics
committee approval has been obtained from the Marmara
University Faculty of Medicine Clinical Research Ethics
Committee on 04.12.2020 with protocol number 09.2020.1333.
The clinical data of the patients with hypospadias, who
underwent either TIPU or GATS procedures, between January
2017 and January 2020, in the clinic, where the study was
conducted, were reviewed retrospectively. The clinical data of
the patients, which were recorded to be analyzed within the
scope of this study, included all penile anatomical details, i.e.
diameter of the glans, width of the plate and length of penis in
both stretched and normal positions, and classification of the
groove of the glans as shallow (flat), mild (intermediate) or deep
(like a cleft). Patients with distal and mid-penile hypospadias,
shallow groove, glans diameter less than 17 mm, and plate width
smaller than 8 mm, were included in the study; whereas patients,
who were followed up clinically for less than 1 year as well as
the patients, who require secondary surgery or were circumcised,
were excluded from the study. Consequentially, a total of 45
patients were included in the study. These 45 patients were
divided into two groups based on the hypospadias repair
technique they underwent, as the TIPU group, which included 25
patients and as the GATS group, which included 20 patients.
Patients’ age at the time they underwent the surgery,
diameter of glans, width of plate, the type of hypospadias and the
complications they had, and their follow up times were
compared.
Surgical procedure
All procedures were performed under general anesthesia
and penile block was performed at the beginning of the
procedure. Antibiotic prophylaxis was administered one hour
prior the surgery. The procedures started with U incision around
the hypospadiac meatus ending on both sides of the plate (Figure
2a). Degloving and dissection of the glanular wings were
performed in case of both TIPU and GATS techniques. A deep
midline incision that is limited to inside the urethral plate was
performed in TIPU technique. A deep midline incision was also
performed in GATS technique, yet the incision was extended
distally to the top of the glans, that is, a few millimeter further to
the point the urethral plate ends. In the GATS technique, the
graft was harvested from the inner prepuce and placed in the
incised plate and also in the incised area on the glans (Figure 2b).
7/0 PDS (polydioxanone suture) was used to fix the graft inner
border of the plate. In addition, a few fixation sutures were
placed between graft and base, in the midline in particular.
Subsequently, the urethral plate was tubularized over 6 or 8 Fr
(French) urethral catheter in two layers in both techniques; first
layer with continuous subcuticular 7/0 Vicryl sutures and second
layer with interrupted subcuticular 7/0 Vicryl sutures (Figure 2c).
A pedicle flap from dartos fascia was prepared and placed on the
neourethra as a cover. Glanuloplasty was performed with 6/0
PDS sutures. Urethral catheter was left in place for seven days
postoperatively. Patients were followed up during the second
week, first month and third month after the surgery. Thereafter,
the follow up of patients were conducted by means of patient
visits made to the outpatient clinic every 3 months until the end
of the first year from the surgery, and annually thereafter. During
J Surg Med. 2022;6(3):377-381. GATS vs TIPU
P a g e | 379
these follow visits, patients were evaluated for penile cosmetics,
meatal and urethral stenosis, urethrocutaneous fistula by means
of physical examination, and their neourethras were calibrated by
means of 6-8 Fr catheter and video voiding device.
Figure 2: GATS procedure. 2a: U incision around the narrow urethral plate. *Distal end of
the urethral plate. **Top of the glans. 2b: Grafting the incised area. 2c: Tubularization of the
grafted neo-urethral plate.
Statistical analysis
SPSS 21.0 (IBM Statistical Package for Social Sciences
version 21.0) software package was used to conduct the
statistical analyses of the research data. Quantitative variables
were expressed as numbers, mean or median values. Probability
(P) values of <0.05 were deemed to indicate statistical
significance. Mann-Whitney U test was used to compare
information such as age, diameter of glans, width of plate and
follow-up time, whereas Pearson’s Chi-squared test was used to
compare the categorical variables between the groups.
Results
There was no statistically significant difference between
the groups in terms of age, hypospadias type and glans diameter
(P>0.05 for each) (Table 1). Additionally, all patients had
shallow groove. The mean width of plate values were 5.2 mm
and 4.15 mm in TIPU and GATS groups, respectively
(P=0.045). The mean width of the plate in GATS group was
narrower than the width in TIPU group. Complications were
observed in 7 patients in the TIPU group, and in 2 patients in the
GATS group (Table 1). Of the patients, who developed a
complication in the TIPU group, two patients had urethral fistula,
two patients had urethral dehiscence, one patient had urethral
stenosis, one patient had urethral stenosis and diverticula, and
one patient had urethral stenosis and fistula. On the other hand,
of the patients, who developed a complication in the GATS
group, one patient had urethral fistula and another patient had
urethral dehiscence. The complication rates and severity of the
cases were higher in TIPU group (28%) than in the GATS group
(10%), albeit not statistically significantly (P=0.134). None of
the patients had hormonal therapy or underwent plication for
chordee. The median follow up times were 19 and 28.5 months
in TIPU and GATS groups, respectively.
Table 1: Demographic and clinical characteristics of the patients included in the study
TIPU Group
GATS Group
Total
P-value
Mean age (months) mean (SD)
(min-max)
33.6 (20.2)
(10-84)
34.35 (22.2)
(6-81)
(6-84)
0.917*
Hypospadias type
Distal
Midpenile
6
19
6
14
12
33
0.651**
Mean width of the plate (mm)
(min-max)
5.2
(3-8)
4.15
(2-8)
0.045***
Diameter of the glans (mm)
(min-max)
15.32
(12-17)
14.55
(10-17)
0.141***
Number of patients with a
complication
7 (28%)
2 (10%)
9 (20%)
0.134**
Median follow-up time (months)
19 (13-26)
28.5 (12-55)
19 (12-55)
0.108***
SD: Standard deviation, * t-test, **Pearson’s Chi-Squared test, *** Mann-Whitney U Test
Discussion
More than one hundred surgical techniques have been
described in the literature for hypospadias repair in order to have
better cosmetic and functional outcomes. Most common
complications are urethrocutaneous fistula, meatal stenosis and
the stricture of neourethra, dehiscence and diverticulum. These
complications are seen more frequently in patients with narrow
plate, shallow groove and small glans [4, 13]. Narrow urethral
plate of less than 8 mm wide is associated with higher
complication rates in the postoperative period. 40% of patients
with shallow groove, 15% of patients with moderate groove, yet
none with deep groove, develop narrow neourethra following the
surgery [4]. It was reported in a prospective randomized study
conducted by Sarhan et al. that urethral plate width affects the
outcome of the surgery and that the plate width should be 8 mm
or more for tubularization [14]. Accordingly, the major challenge
is to repair the hypospadias in cases with narrow plate and
shallow groove. In this context, only the patients with urethral
plate width less than 8 mm, glans smaller than 17 mm, and
shallow groove, were included in this study.
Tubularized incised plate urethroplasty (TIPU)
technique is the most commonly used hypospadias repair
technique both in the world and in the clinic, where this study
was conducted. Braga et al. reported that the complication rates
associated with TIPU ranged between 0% and 50%, with a
median value of 7.3% [2]. This huge variation in the
complication rates associated with TIPU can be attributed to the
anatomy of the hypospadias and level of experience of the
surgeon. Accordingly, only the patients, who were operated by
the same experienced pediatric urologists, were included in this
study. The main anatomic features of the hypospadiac penis that
affect the surgical outcome are the location of the meatus,
chordee, width of the plate, diameter of the glans, and depth of
the groove. Tugtepe et al. [13] presented a scoring system to
predict the complications that may arise following the
hypospadias surgery. They demonstrated in the study they
conducted with 394 patients who underwent TIPU that the
complications were higher in those with narrow plate, shallow
groove, chordee, and small glans [13, 15]. On the other hand,
Bush and Snodgrass reported short term outcomes of TIPU in
224 cases, 80% of whom had narrow urethral plate (< 8 mm),
and concluded that width of the urethral plate does not affect the
outcome of TIPU [16]. Some authors suggest that the incision of
the plate may provide enough width for tubularization of the
urethra, and some surgeons suggest that the area without epitelle
tissue may heal with scar tissue later and the caliber of the
neourethra may reduce in long term. Leslie et al. performed an
experimental animal study to assess the status of the urethra at 4
to 8 weeks-time following urethroplasty without incision, TIPU,
or grafted TIPU [17]. The tubularized incised plate defect was
bridged by urothelium, while the preputial graft in the incised
plate kept its original histological characteristics. However,
simple tubularization of the narrow urethra led to significant
decrease in flow. TIPU and grafted TIPU resulted in similar
urethral flow dynamics [17]. In another study conducted in 2000,
Holland and Smith reported that the incision of the plate is
similar to urethrotomy and that it heals with scar tissue instead of
epithelization. They concluded that the depth of the urethral
a b c
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P a g e | 380
groove and width of the plate affect the caliber of the neourethra,
and that shallow groove and narrow plate were associated with
narrow neourethra and urethrocutaneous fistula following TIPU
[4].
TIPU vs grafted TIPU
In another study conducted in 2000, Kolon and
Gonzales [7] described a new technique involving inner preputial
free graft to augment urethral plate in TIPU. They reported to
have performed the incision on the plate as described in the
Snodgrass technique without extension from the end of the plate
to the top of the glans and grafting the plate before
tubularization. Consequentially, they reported a complication
rate of 6% in 32 patients, also taking complications such as glans
dehiscence and ventral skin breakdown into consideration, but
they did not have any patient that had meatal stenosis, neo-
urethral stricture, urethrocutaneous fistula or diverticulum,
during the 21-month follow up period. Gundetti et al. [8]
reported that they did not observe any meatal stenosis but only
one recessed meatus associated with the use of grafted TIPU
technique. In their prospective study, Silay et al. [9] reported to
have performed the grafted TIPU procedure with a 9.8%
urethrocutaneous fistula rate. Shuzhu [6], Eldeeb [10] and Helmy
[11] et al. compared the outcomes of TIPU and grafted TIPU
procedures, and did not find any significant difference between
the two procedures. The authors of the aforementioned studies
indicated that the graft was placed on the incised area, limited
with the plate and not extended to the tip of the glans. To the
contrary of the findings reported in those studies, Mouravas et al.
[18] reported complication rates of 30.4% and 8.3% associated
with the use of TIPU and grafted TIPU, respectively.
TIPU vs GATS
The meatal position of the neourethra following TIPU
or grafted TIPU procedure is generally not located at the top of
the glans. Instead, the end of the neourethra lies in glanular
position in most cases due to the distal end of the urethral plate.
GATS is a procedure performed with a very deep incision on the
urethral plate that extends to the top of the glans and which
provides a good deep groove and a wide plate. The graft is used
to augment the neo-plate or neo-groove and neo-slit in the glans
tip. In comparison, Ahmed and Alsaid reported as a result of the
study they conducted using a similar technique, that is, preputial
inlay graft with TIPU procedure without a control group, that
they have achieved excellent (96.09%) cosmetic and functional
results regardless of the width and depth of plate or size of the
glans, and that urethrocutaneous fistula was developed in only
3.91% of the patients [19]. Similarly, Asanuma reported a
urethrocutaneous fistula rate of 3.6% in the study conducted in
2007 with 28 patients, who underwent dorsal inlay graft
urethroplasty [20], whereas Nerli et al. [21] reported a
urethrocutaneous fistula rate of 0% in the study they conducted
with 12 patients with proximal hypospadias, who underwent
dorsal inlay graft urethroplasty. Urethroplasty was performed
using a technique similar to GATS in all these studies, in which
no meatal or neo-urethral stenosis was observed and wide slit-
like meatus was achieved at optimum position. However, the
width of the urethral plate was not indicated in these studies,
which constitutes a limitation of these studies, since no solution
was suggested as to the choice of the most appropriate technique
for hypospadias repair in patients with narrow plate, shallow
groove and small glans.
Making a direct comparison of the success and
complication rates of the techniques used for hypospadias repair
using the research data available in the literature is difficult, due
to reasons such as varying patient selection criteria or patient
selection bias and varying types of hypospadias in these
researches. Despite the fact that the features of urethral plate are
deemed to be an important risk factor affecting the outcomes of
hypospadias repair techniques, the results of the studies
conducted to assess the urethral plate are highly subjective [22].
In comparison, only patients with shallow groove, urethral plates
less than 8 mm wide and glans diameter smaller than 17 mm,
were included in this study. Consequentially, the complication
rates were determined as 28% and 13% in the TIPU and GATS
groups, respectively. Urethrocutaneous fistula was observed in 3
patients in the TIPU group and only in 1 patient in the GATS
group. There was no case of meatal or urethral stenosis in the
GATS group. Nevertheless, the difference between the groups in
terms of complications was not found to be statistically
significant. The complication rates found in this study may
appear to be higher than those reported in the literature.
However, this should not come as a surprise, since all the cases
included in this study were cases that are considered as difficult
hypospadias cases, contrary to the cases reported in the studies
available in the literature, most of which neither mentioned width
of the plate nor diameter of the glans.
We usually select the GATS technique for difficult
cases with narrow plate, shallow groove and small glans. We did
not compare all patients who underwent GATS with patients
who underwent TIPU. To eliminate selection bias we compare
the patients with similar difficulty by excluding patients with
glans bigger than 17 mm, and plate wider than 8 mm and patients
without shallow groove.
The mean follow up time reported in the literature for
hypospadias cases is longer than 12 months in most studies [6, 7,
10, 19-21]. Even though a decrease is observed in the rate of
complications by the 6th month after the surgery, there remains a
risk up until the 12th month from the time of the surgery.
Therefore, the patients with follow-up times longer than 12
months were included in this study. The median follow-up time
of the patients included in this study was 20 months (min.12 and
max. 55) months.
Limitation
There were some limitations of this study. First, it was
carried out as a retrospective cohort study. Secondly, the study
group consisted of relatively a small number of patients. Lastly,
the quality of spongiosum was not recorded in patients’ data.
Therefore, prospective, randomized, double-blind studies with
larger populations are needed to corroborate the findings of this
study.
Conclusion
The findings of this study suggest that grafting the
deeply incised plate and split glans may reduce the fistula rate
and prevent meatal or neo-urethral stenosis. Additionally, even
though the difference was not statistically significant, lower
complication rates achieved with GATS technique as compared
to the TIPU technique. In conclusion, GATS technique stands
J Surg Med. 2022;6(3):377-381. GATS vs TIPU
P a g e | 381
out as a good alternative to TIPU technique, particularly for use
in difficult hypospadias cases with narrow plate and small glans.
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