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Evaluation of the outcomes of eccentric
circummeatal based ap with limited urethral
mobilization, tubularized incised plate uretroplasty
and meatal advancement and glanuloplasty in distal
hypospadias repair: A safe method for young
surgeons
Sinan Kılıç ( dr.sinankilic@yahoo.com )
Gebze Yuzyil Hospital
Samed Verep
Gebze Yuzyil Hospital
Research Article
Keywords: Hypospadias, Urethroplasty, Operation, Children
Posted Date: June 1st, 2023
DOI: https://doi.org/10.21203/rs.3.rs-3000359/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
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Abstract
Objective:
This study was aimed to evaluate the results of patients who underwent distal hypospadias repair with
tubularized incised plate urethroplasty (TIP), Eccentric circummeatal based ap with limited urethral
mobilization (ECMB-LUM), and Meatal Advancement and Glanuloplasty (MAGPI) techniques. Also, we
aimed to emphasize that ECMB-LUM results are an effective and safe method for young surgeons.
Patients and Method:
In this study, we conducted a retrospective review of the medical records of all patients who underwent
distal hypospadias repair at clinic of pediatric surgery and urology in our institution between January
2017 and December 2022. A total of 69 patients with distal hypospadias underwent surgery. Nine cases
were operated using glanular approximation (MAGPI), and 27 cases underwent the Snodgrass procedure
(TIP). Thirty-three cases of distal hypospadias were operated on using an eccentric circummeatal-based
ap with combined limited urethral mobilization (ECMB-LUM). We evaluated these 69 patients based on
factors such as age at surgery, meatus position, presence of ventral curvature or glanular tilt, previous
surgeries, duration of catheterization and hospitalization, as well as early and late postoperative
complications.
Results:
The mean age at operation was 2.6+/-1.1 years. The position of the meatus was coronal in 38 patients
(55%), glanular in 14 (20 %) and subcoronal in 17 (24 %). Four patients (0,5%) were re-operated, two of
them underwent cosmeticly meatotomy, and the others underwent preputial ap cutting because the
preputium was too much. The initial operation methods consisted of 9 (13%) patient MAGPI, 27 (39%)
TIPU and 33 (47%) ECMB-LUM. The MAGPI method was preferred only for the repair of patients with
granular hypospadias. While the ecmb-lum method was predominantly preferred in patients without
coronal and additional penile anomalies, the TIP method was predominantly preferred in patients with
additional anomalies and hypospadia at the subcoronal level. There was no stula in any patient and
wound infections, glans dehiscence as well. Meatal stenosis developed in 12 (17%) patients and they
were included in the meatal dilatation program.
The average length of catheterization was 5.46+/-1.4 days. All patients were discharged with a urethral
catheter on the rst postoperative day. The families were informed about the training on catheter care.
The patients were seen in the outpatient clinic every day until the urethral catheter was removed. All
patients demonstrated a normally positioned vertical slit-like glanular meatus. The patients were
examined at intervals of one week, one month, and six months. At each control of the patients, voiding
calibration and direction were monitored and noted.
Conclusion:
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TIPU is very popular method currently. Although it has an advantage to repair of penil chordee and
perform circumcission in the same session, there are some diculties in its application and learning.
ECMB-LUM is easier and safe method to perform. This technique acceptable for young surgeons who are
just learning about hypospadias surgery. We did not see any stula complication in any method, meatal
stenosis was more common in TIP and meatal recession was more common in ECMB-LUM.
Introduction
Hypospadias is common congenital abnormality in males. It's described by the abnormal positioning of
the urethral opening, mostly accompanied by penile curvature and an underdeveloped foreskin that
covers the ventral penis. Urethral meatus is found on the distal portion of the penile shaft, in
approximately 70% of cases. This particular presentation is considered a milder form of hypospadias and
is not typically associated with additional urogenital deformities (1). The incidence of hypospadias is 3.1
per 1000 male live births (2). Hypospadias has a diverse range of clinical presentations. Consequently,
there have been around 300 described techniques for surgical repair (3). Two explanations may be
considered for the high number of surgical repair techniques. One is the clinical diversity, and the other is
an effort to surgically treat hypospadias with additional penile anomalies such as chordee or tilt in the
same session. The meatus and glanular conguration are crucial factors that impact the choice of
surgical approach. (4). Since many methods have been described for the surgical repair of hypospadias,
the best method is still debated. In the last 20 years, TIP has become very popular and is still up to date.
With the application of TIP by many surgeons, some methods used in the past have been abandoned.
The TIP method, which was also known in the past years but became popular again with W. Snodgrass,
is now the most preferred repair method all over the World (5, 6). The fact that penile curvature can be
corrected and urethral plate incision has become important in the same session are among the most
important reasons for choosing the TIP method. In addition to these advantages of the TIP method, there
are also some diculties in learning and applying. Meatal advancement methods (ECMB-LUM), which
are easier to perform than TIP, can be used, especially in patients with coronal meatus without penile
curvature such as chordee and tilt. MAGPI may also be preferred if the meat is "moving" and "point" in
selected cases of glanular hypospadias.
Beck initially described the technique of urethral advancement in 1898 (7), and also it was gained
popularity through the contributions of Belman (8), Waterhouse and Glassberg (9), and Koff (10). Urethral
mobilization and meatal advancement, with various modications, have emerged as a recognized and
safe surgical procedure for the repair of distal hypospadias. Extensive mobilization of the urethra is
performed from the hypospadiac meatus to the glans tip. However, it is crucial to acknowledge that
excessive mobilization of the urethra and relocation of the meatus to the glans tip may lead to potential
devascularization or secondary ventral curvature.
In 1999, Turken et al. introduced a modied combined approach for the correction of distal hypospadias,
incorporating limited urethral mobilization and the utilization of a well-vascularized eccentric
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circummeatal ap for short urethral reconstruction (11). Successful results of this method were presented
in a study by Alkan et al. (12) published in 2008 and another study by Ekinci et al. in 2016 (13).
In this study, we aimed to present the results of three different surgical techniques commonly employed
in the management of hypospadias. These techniques include the TIP (Tubularized Incised Plate)
method, which is the most frequently preferred and popular approach, the ECMB-LUM (Eccentric
Circummeatal-Based Flap with Limited Urethral Mobilization) method, known for its ease of
implementation, and lastly, the MAGPI (Meatoplasty and Glanuloplasty) method, which is considered
safe for selected cases of glanular hypospadias.
Patients and methods
Following the approval of the study protocol by the human research ethics committee, a retrospective
review of medical records was conducted for patients who underwent surgical interventions for distal
hypospadias using the TIP (Tubularized Incised Plate), MAGPI (Meatoplasty and Glanuloplasty), and
ECMB-LUM (Eccentric Circummeatal-Based Flap with Limited Urethral Mobilization) techniques between
2017 and 2022. Various parameters and outcomes were evaluated, including the age of patients at the
time of surgery, preoperative and postoperative meatal position, duration of urethral catheterization and
hospitalization, occurrence of early and late complications such as bleeding, hematoma, surgical site
infection, urethrocutaneous stula, meatal stenosis, meatal regression, and glanular dehiscence, previous
history of hypospadias repairs, and the need for secondary surgical interventions. Postoperative follow-
up examinations were conducted at one week, as well as at one and six months after the procedures.
Meatal stenosis was dened as the inability to pass an 8 Fr catheter through the meatus in patients
experiencing a complaint of a weak urinary stream. A total of 69 patients with distal hypospadias
underwent surgical interventions, with 9 cases receiving glanular approximation and 27 cases undergoing
the Snodgrass procedure. Additionally, 33 patients with distal hypospadias and a suitable distal urethra
underwent the technique involving the eccentric circummeatal-based ap combined with limited urethral
mobilization. Patients who underwent the pyramid and gap methods for intact preputium megameatus,
as well as those with proximal hypospadias, were excluded from the study.
Operative techniques
Preoperative evaluation and patient selection:
All patients were examined before surgery. The position, calibration, and mobility of meatus were noted.
The presence of penile curvature and the position of the prepuce were noted. Undescended testis and
additional urinary system anomalies were also noted.
The MAGPI procedure was preferred in patients with meatus opening at the glanular level and also
mobile and pintpoint meatus. TIP method was preferred in cases with penile curvature and subcoronal
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meatal opening. The ECMB-LUM method was preferred in cases with coronal meatus opening without
penile curvature.
a. MAGPI
The MAGPI (Meatoplasty and Glanuloplasty) procedure is considered one of the most challenging
techniques in hypospadias surgery. While the method may be described as relatively simple, its correct
implementation requires signicant experience and expertise. The MAGPI technique can only be
successfully applied in cases with sucient meatal mobility and a distal urethra. It should not be used in
situations where the meatus is xed, periurethral spongy tissue is insucient, the skin anterior to the
urethra is excessively thin and adherent, or in cases with a wide meatus as seen in the Megameatus
Intact Prepuce (MIP) variant. Additionally, for this method to be applicable, the presence of a ventral
brous cord and glanular tilt should be absent in the patient.
The MAGPI procedure, as originally described by Duckett in 1981, was performed. For each case, the
meatus was calibrated using urethral bougies to assess its suitability for this technique. Meatal
catheterization was carried out using a 6F catheter. Following the placement of suspension sutures, a
circumcision incision was made, creating a collar-like ap beneath the meatus. A classic vertical incision
was then made distal to the meatus, and the incision was closed transversely using a single suture. After
the release of the glans wings, glanuloplasty was performed. Due to the preference for circumcision over
preputial reconstruction in Turkey, the procedure was concluded with the circumcision step.
b. ECMB-LUM
Preputial traction is applied near the dorsal coronal sulcus to avoid scarring on the glans. An eccentric
circummeatal-based ap is marked, with the proximal part being twice the length of the distal part. The
ap is carefully dissected from the underlying urethra and Buck's fascia. Attention is given to preserving
the delicate distal urethra to prevent stula formation. In cases where the glans is at or the glanular
groove is shallow, the glanular wings are separated until the groove reaches adequate depth. The
eccentric ap is sutured to the glans tip, creating a slit-shaped meatus and reducing the risk of stenosis.
This technique simulates the natural structure of the male urethra, resembling the anteriorly dilated fossa
navicularis.
c. TIP
The TIP (Tubularized Incised Plate) technique was performed according to Snodgrass' description. After
placing a traction suture at the neomeatus just distal to the ectopic meatus, a circumferential incision
was made 1–2 mm below the meatus. The penile skin was then dissected until the penoscrotal junction.
In cases suspected of having a chordee, an articial erection was induced to assess the presence of the
chordee and dorsal plication was performed if necessary. Subsequently, the urethroplasty stage was
initiated. The urethral plate was dissected laterally with two parallel longitudinal incisions, separating it
from the glans wings. Following the placement of a 6F urethral stent in the meatus, the mobilized urethral
plate was vertically incised in the midline, as described by Snodgrass. The incision was closed with a
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double-layer, continuous 7/0 polydioxanone suture over the stent. In all cases, a ap was created using
the penile dartos fascia located proximal to the urethral anastomosis to protect the newly formed urethra.
Finally, the mucosal opening formed by the preputial skin was closed with a rapid-absorbing 5/0
polyglactin suture.
Results
The mean age at operation was 2.6+/-1.1 years. The position of the meatus was coronal in 38 patients
(55%), glanular in 14 (20%) and subcoronal in 17 (24%). Four patients (0,5%) were re-operated, two of
them underwent cosmeticly meatotomy, and the others underwent preputial ap cutting because the
preputium was too much. The initial operation methods consisted of 9 (13%) patient MAGPI, 27 (39%)
TIPU and 33 (47%) ECMB-LUM. The MAGPI method was preferred only for the repair of patients with
granular hypospadias. While the ecmb-lum method was predominantly preferred in patients without
coronal and additional penile anomalies, the TIP method was predominantly preferred in patients with
additional anomalies and hypospadia at the subcoronal level. There was no stula in any patient and
wound infections, glans dehiscence as well. Meatal stenosis developed in 12 (17%) patients and they
were included in the meatal dilatation program.
The average length of catheterization was 5.46+/-1.4 days. All patients were discharged with a urethral
catheter on the rst postoperative day. The families were informed about the training on catheter care.
The patients were seen in the outpatient clinic every day until the urethral catheter was removed. All
patients achieved a normally situated vertical slit-like glanular meatus.
When all patients were evaluated, meatal stenosis requiring dilatation was observed in 12 (17%) patients.
Three of these patients were operated with the ECMB-LUM method, and the remaining nine patients were
operated with the TIP method. Meatal stenosis was not observed in the MAGPI method. Therefore,
complications of meatal stenosis were found in 9% and 33%, respectively. Meatal strictures were mild
and 11 managed to void at the desired calibration after the rst dilatation and after two dilatation
procedures. Scar revision and prepuce reconstruction were performed in two patients. These patients
were patients who were operated on with the TIP procedure. Meatal regression was detected in two of all
patients. Simple metatotomy with dilatation was performed on these patients, and it was ensured that
they were uneventful in terms of aesthetic appearance (Table1: Complication of all patient).
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Table 1
Complications of all patient
TIP ECMB-LUM MAGPI Total
Urethral Fistula None None None None
Meatal Stenosiz 9 (33%) 3 (9%) None 12
Meatal Regresion None 1 (3%) 1 (11%) 2
Glans dehiscence None None None None
Discussion
The primary goal in the surgical management of hypospadias is to achieve a structurally and functionally
normal penis with minimizing complications. In cases of distal hypospadias, functional impairments are
uncommon. Thus, it should be aimed to avoid complications with as little invasive surgery as possible.
Over the years, hypospadias surgery has diversied with different surgical techniques and their
modications. Several techniques are commonly utilized for the repair of distal hypospadias, including
glanular approximation (GAP), meatal advancement and glanuloplasty (MAGPI), Koff procedure, Mathieu
procedure, Thiersch-Duplay procedure, and tubularized incised plate (TIP) repairs. Over time, these
techniques have undergone continuous renement and adaptation in order to enhance their ecacy and
success rates.
Algorithms for hypospadias surgery are presented to resolve the confusion due to technical method
redundancy (14, 15). In the discussion of which method is better, each author and clinic tends to present
the results of the method they frequently use (16).
Young surgeons who want to perform hypospadias surgery should prefer distal hypospadias cases with
low sexual dysfunction in the future. Distal hypospadias is a general group and is divided into subgroups
within itself. If the choice of technique is clearly demonstrated depending on the level of the meatus and
whether there is additional penile anomaly such as curvature, this accurate method may contribute to the
reduction of complications. In addition, in some cases of distal hypospadias, preferring methods with a
lower complication rate such as ECMB-LUM may create a good learning curve for initial surgeries. Three
studies have noted that the ECMB-LUM technique has been successfully performed with low
complications (11, 12, 13). In our study, similar to these studies, urethral stula, which is one of the most
feared complications of hypospadias, was not observed. In a recent review published, it was reported that
the general complication of proximal hypospadias surgery rates for Onlay urethroplasty, Duckett's
tubularized ap urethroplasty, Koyanagi repair, and Bracka 2-stage repair were found to be 32%, 34%,
49%, and 43%, respectively. The stula rates were reported as 13%, 18%, 21%, and 23%, respectively (17).
In this review article, which includes cases of distal hypospadias, the rate of stula was 5.7%, and the rate
of meatal stenosis was 3.1% in patients who underwent only TIP (18).We did not encounter any stula
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complication in our study, but we observed the rate of meatal stenosis more than in the literature.
Patients who were included in the dilatation program voided without any problems afterward.
MAGPI (meatoplasty and glanuloplasty) was rst described by Duckett in 1981 (19). Duckett and Snyder
stated that this technique is not appropriate for patients with ventral thin skin and whose meatus is not
suciently mobile. In addition, this method should not be preferred in cases where the glans penis is
small and at and the meatus is wide. (20). Therefore, although it is dicult to nd the correct patient for
MAGPI, this method should be preferred in patients with the correct criteria because of its low
complication rate. We did not encounter any complications related to the MAGPI procedure.
In recent years, tubularized incision plate urethroplasty (TIP/TIPU or Snodgrass procedure) has gained
immense popularity. It is considered to be the most common distal repair procedure in the world today
(21). The nature of the meatus, previous circumcision or repair of hypospadias (primary or secondary),
and glanular conguration do not affect the chosen surgical technique (22).This technique, along with
Snodgrass, has gained popularity in the last 20 years. It has gained support for its applicability in many
situations. In addition, Snodgrass made some modications to this method, making the technique more
seamless. He emphasized the importance of the urethral plate and incising it, and although he initially
suggested bringing a ap from the prepuce, he is now using a ap from the penile fascia instead (23, 24).
Since this method has multiple stages, there are some diculties in learning and performing. These
diculties were mentioned in some studies (25, 26, 27). If it is studied well enough, very successful
results have been obtained in the TIP method.
In our study, we performed surgical procedures after carefully determining which method would be used
for 69 patients. With this study, we wanted to emphasize that the ECMB-LUM method is preferred in cases
where there is no curvature in the penile examination of the patients and the meatus is at the coronal
level or more distal, because the number of surgical steps and the duration of surgery are low.
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