Lessons learnt from Snodgrass tip urethroplasty: a study of 75 cases

Introduction and objectives Snodgrass tubularized incised plate urethroplasty and 2 modifications were evaluated in 75 hypospadiacs (distal and midpenile).Patients and methods The initial 25 patients (group A), underwent Snodgrass tubularized incised plate urethroplasty. In the next 25 patients (group B), the urethral plate defining incision and Snodgrass urethrotomy were not extended distally to the glans tip and the neourethra was reconstructed (distal to proximal) over a spacer. In the last 25 patients (group C), dorsal free skin grafting of the raw area (following Snodgrass urethrotomy) was done.Results In group A, all patients developed meatal stenosis and required intermittent dilatation for 3 months. In groups B and C meatal stenosis did not occur.Conclusions Restriction or elimination of the raw area in the region of the neomeatus as in groups B and C effectively prevents meatal stenosis following Snodgrass repair.     

Analysis of meatal location in 1,244 healthy men Definition of the normal site justifies the need for meatal advancement in pediatric anterior hypospadias cases

The normal site of the external urethral meatus on the glans penis and the need for meatal advancement in patients with anterior hypospadias was studied. The location of the external meatus was analyzed in 1,244 men (mean age 28 years) with classification of the meatal position in relation to the tip of the glans and corona. The quality of erections and sexual intercourse, the presence of a penile curvature, urinary stream, and ability to void in a standing position were assessed in an interview. In 1,198 men (96.3%) the meatus was located on the distal third of the glans, in 43 (3.5%) on the middle third, (B), and in 3 (0.2%) on the posterior third. In no case was it located below the corona. One of the 3 men with the meatus on the posterior third had an associated mild penile curvature that did not cause difficulty in sexual intercourse. This study suggests that the normal site of the external meatus is at the tip of the glans. The definition of the normal site and the percentage of men with a normal meatal position justifies the need for meatal advancement in patients with anterior hypospadias when the goals of current hypospadias surgery are considered. Accepted: 17 June 1998     

Simplifying the surgical approach to glanular and coronal hypospadias: longitudinal urethral incision and glanuloplasty

ObjectiveMeatal advancement with glanuloplasty incorporated (MAGPI) is an appropriate approach for most glanular and coronal hypospadias. The very low incidence of complications with this technique (i.e., fistulas, meatal regression and stenosis) makes MAGPI very competitive if compared with other approaches proposed for similar anatomical defects. In certain cases, however, the MAGPI approach has led to an unsatisfactory neo meatus; instead of a natural slit-like appearance, the meatus can look too rounded and puckered.MethodsThe last 84 patients referred to our unit with indications suitable for MAGPI (mean age 39 months) were operated on using a novel approach: the glanuloplasty was associated with a simple deep urethral plate incision, extending along the urethral channel, and left unsutured.ResultsAt minimum follow up of 12 months two meatal regressions to mid glans were recorded. No meatal stenosis was seen in this series.ConclusionThis approach allowed us to achieve a conical glans with a natural looking meatus, avoiding urethral sutures.     

Outcome analysis of tubularized incised urethral plate using dorsal dartos flap for proximal penile hypospadias repair

PurposeTo assess the outcome of tubularized incised plate (TIP) urethroplasty in conjunction with a dorsal dartos flap for primary proximal penile hypospadias.Materials and methodsForty-nine patients with proximal penile hypospadias underwent a one-stage TIP urethroplasty with single-layer closure using polyglactin suture. A dorsal dartos (subcutaneous) flap, harvested from the dorsal penile shaft was used to cover the neourethra ventrally. Glanuloplasty was also performed in all cases. All patients had a well preserved urethral plate after straightening of the penis. Complications and cosmetic appearance were documented during follow-up.ResultsMean patient age at surgery was 23 months (16–72 months). Mean operative time was 180 min (154–240 min). At the mean follow-up of 36 months, the overall complication rate was 12% (4 fistulae, 1 meatal stenosis). Glandular dehiscence occurred in one patient, and 38 patients (78%) required dorsal Nesbit plication. No patient had residual chordee, neourethral stricture or a urethral diverticulum, and the neomeatus with a slit-like appearance was positioned at the glans tip.ConclusionsTIP urethroplasty with dorsal dartos layer covering the neourethra is an effective treatment for primary proximal penile hypospadias with a preserved urethral plate and without severe curvature. There is a good cosmetic outcome with low risk of complications.     

Glans meatus proportion in hypospadias versus normal: Does marking reference points impact outcome?

ObjectiveThe aims of this study were to assess anatomical landmarks with reference to urethral meatus and glans in hypospadias and compare the findings with those of healthy individuals, and to assess whether marking reference points helps in improving outcome.Methods1. Patients who underwent repair for hypospadias had reference points marked. Vertical meatal length, ventral glans closure and glans meatus proportion were derived, and the values compared with those obtained from healthy boys. 2. The outcomes of TIP repair after marking reference points (Group I) were compared with those of a similar group without skin markings (Group II).Results1. There was significant difference in the age distribution of hypospadiac patients and healthy individuals, reflected in the meatal length and ventral glans closure. However, there was no significant difference in glans meatus proportion. 2. The fistula rate was 2/35 (5.7%) in group I compared with 5/47 (10.5%) in group II. The meatal stenosis was 2/35 (5.7%) in group I and 4/47 (8.5%) in group II.Conclusion1. Anatomical landmarks in hypospadias are similar to those found in healthy individuals. 2. Marking reference points prior to incision helps to reduce the rate of meatal stenosis and fistula.     

The importance of patient selection in the treatment of distal hypospadias using modified Koff procedure

ObjectiveWe present our experience in the treatment of distal hypospadias using a modified Koff procedure, emphasizing the importance of patient selection for a good outcome.Materials and methodsIn 2003–2008, 90 patients, mean age 52.1 months, underwent surgical repair of distal hypospadias using urethral advancement according to Koff, modified with a Ψ incision on the tip of the glans. Meatal defect was glanular in six (8%), subglanular in 24 (26%) and coronal in 60 (66%) cases. Mild chordee was present in 19 patients (21%). Follow-up was 8–66 months. All patients were evaluated in terms of cosmetic results, and early and late postoperative complications.ResultsAll patients showed excellent cosmetic results with urethral meatus on the tip. There was only one postoperative fistula due to extensive use of electrocautery during urethral mobilization that was surgically corrected 8 months after appearance. One patient had a postoperative meatal stenosis treated conservatively. No cases of residual chordee were detected.ConclusionsSuccessful use of the modified Koff procedure depends on careful selection of patients. Good candidates are those with distal or mid-shaft hypospadias, presenting with: (1) absence or low degree of ventral chordee; (2) distal plate of urethra well developed; (3) distance between meatus and tip of glans at most 10–12 mm; and (4) glanular morphology preserved.     

尿道板纵切卷管尿道成形术治疗尿道下裂22例

目的 探讨尿道板纵切卷管尿道成形术（Snodgrass法）手术治疗尿道下裂的适应证、手术技巧、并发症。方法 2005年9月～2006年11月本院应用Snodgrass手术治疗尿道下裂22例。年龄2～18岁。首次手术16例，采用尿道板正中切开卷管。再次手术6例，采用残余尿道板或阴茎皮肤正中切开卷管。卷管长度1～10cm。新尿道采用F6或飚号的硅胶气囊尿管作为支架管，术后10～14d拔除。结果 22例中18例一次手术成功，阴茎伸直良好，外形美观，排尿正常，成功率81．8％（18／22）。尿瘘3例，均已行尿瘘修补术痊愈。尿瘘并尿道狭窄1例，尿道扩张后狭窄改善，尿瘘待手术。结论 Snodgrass手术操作相对简单，手术者容易掌握，术后外形美观，并发症少。     

New concept in urethral advancement for anterior hypospadias

ObjectiveWe report on our experience with urethral mobilization and advancement as a treatment for anterior hypospadias.Patients and methodsFrom January 2004 to March 2007, 55 out of 160 children with anterior hypospadias were managed by urethral mobilization and advancement; 46 had a mean follow-up period of 25 months (range 6–38) and are the subjects of this report. Their ages ranged from 2.5 to 12 years with mean age 4.5 years. The dissection began proximally in the avascular plane above the tunica albuginea covering each corpus cavernosum medially until reaching beneath the corpus spongiosum up to the hypospadiac meatus. Tension-free urethral anastomosis was achieved. The ventral glans was incised deeply at the interballanitic groove. The two glans wings and ventral glanular mucosal flaps were mobilized laterally. Interrupted sutures were placed through the tunica albuginea of corpus spongiosum to the corpora cavernosa. The mobilized urethra was wrapped by dartos fascia. The urethral stent was removed 24 h postoperatively.ResultsThree-fold urethral mobilization was sufficient to achieve tension-free urethral anastomosis. A slit-like orthotopic meatus, with conically shaped glans and straight penis, was achieved in all but one subcoronal case with mid-glans meatal retraction during our early experience. Postoperative urethral fistula was not recorded in any patient. Satisfactory urinary stream for parents and child was reported in 42/46. Peak flow rate was within normal range (upper 50% percentile) in all.ConclusionUrethral mobilization should begin proximally. Three-fold penile urethral mobilization, deep interballanitic incision and wide dissection of the glans can provide a slit-like orthotopic meatus with conical glans and straight penis in cases of anterior hypospadias without hypoplastic distal urethra and persistent ventral curvature after penile skin degloving, regardless of the presence of unhealthy, narrow urethral plate, shallow glanular groove, and flat or small glans.     

Tubularized incised plate (TIP) urethroplasty (Snodgrass) in primary hypospadias repair.

In the past TIP urethroplasty became a preferred technique for distal hypospadias repair, and subsequently gained worldwide popularity and acceptance. The procedure gives good functional results and a cosmetic appearance that is superior to that obtained by flip-flap or onlay preputial flap repairs. In addition, this procedure is associated with a fairly low rate of complications. From 06/2000 to 04/2004 we performed 100 primary TIP urethroplasties in patients with distal hypospadias. The age of the patients at the time of surgical correction was 16 months to 10 years with a mean of 41.4 months. All patients underwent the procedure under general anesthesia supplemented by additional pain management with a penile block anesthesia or caudal anesthesia. The surgical technique is described. During follow-up (23.5 months) we observed 2 types of complications: formation of a urethrocutaneous fistula (5 pts., 5 %) and formation of meatal stenosis (17 pts., 17 %) with a steady decrease with no stenosis formation in the last 8 months of this series. A key point might be the length of the dorsal incision of the urethral plate which should not touch the dorsal lip of the anticipated neomeatus. There were no other complications, and the cosmetic results were good in all cases.     

Evaluation of distally folded onlay flap in repair of distal penile hypospadias

ObjectiveTo evaluate the results of using a distally folded onlay flap in the repair of distal penile hypospadias, with regard to meatal stenosis, urethrocutaneous fistula and esthetic outcome.Patients and methodsThis prospective study involved 36 patients with mean age 3.2 years (range 1–4); 18 had a shallow urethral plate, 10 a small glans, and 8 had undergone a previous operation but still had available preputial skin. All underwent the elective technique of distally folded onlay flap, which was carried out under general anesthesia using a 4× magnifying loupe. Starting with penile degloving and then harvesting the transverse island preputial flap provides a flap about 1 cm longer than the urethral plate. Two lateral incisions are made along the urethral plate with no need for dissection deep into the glanular wings. The flap is sutured to the urethral plate, leaving 1 cm distal to the tip of the glans, which is folded back to be sutured to the edges of the glanular wings.ResultsThere were no cases of meatal stenosis or requirement for urethral dilatation. Two patients had a urethrocutaneous fistula; one closed spontaneously while the other needed surgical repair 6 months later. Regarding esthetic appearance, 32 were scored good and 4 satisfactory.ConclusionThis versatile technique offers satisfactory results regarding meatal stenosis, urethrocutaneous fistula and esthetic outcome.     

Tubularized incised plate hypospadias repair for distal hypospadias

PurposeWe report surgical technique and outcomes in consecutive patients with primary distal hypospadias.Materials and methodsA prospectively maintained database of all patients operated by WS in 2000–2008 was reviewed for pertinent data in consecutive patients.ResultsA total of 551 consecutive patients of mean age 17 months underwent distal tubularized incised plate hypospadias repair by urethral plate tubularization with (459) or without (92) midline incision. Follow up occurred for 426 (77%) at a mean of 8.2 months. Calibration and/or uroflowmetry were obtained in 279 (65%). Complications developed in 19 (4%), including nine fistulas, nine glans dehiscences and one delayed meatal stenosis from balanitis xerotica obliterans. These complications could not be attributed to meatal location, urethral plate configuration or incision, suture materials or methods for urethroplasty and glansplasty, or to use or not of a dartos flap barrier layer.ConclusionsNo contraindication to urethral plate tubularization with or without incision was found in 551 consecutive patients operated for distal hypospadias. Reliability of the procedure was confirmed by the low complication rate and success using varied suture materials and methods.     

Snodgrass hypospadias repair with onlay overlapping double-layered dorsal dartos flap without urethrocutaneous fistula: Experience of 156 cases

ObjectiveTo evaluate the neourethra covering created by a vascularized overlapping double-layered dorsal dartos flap for preventing urethrocutaneous fistula in the Snodgrass hypospadias repair (tubularized incised plate).Patients and methodsBetween March 2003 and January 2008, 156 boys (mean age, 4.5 years) were enrolled for hypospadias repair. Preoperative position of the urethral meatus was subcoronal in 37, at the distal shaft in 61 and mid-shaft in 58 boys. All patients underwent the Snodgrass hypospadias repair. The neourethra was then covered with an overlapping double-layered dorsal dartos flap before glans and skin closure.ResultsAll 156 patients underwent successful reconstruction. With a mean follow up of 23 months (range 6–42), all boys had a satisfactory subjective cosmetic and functional result with a vertically oriented, slit-like meatus at the tip of the glans. No urethrocutaneous fistula or urethral stenosis occurred.ConclusionAs the neouretha covering is an integral part of the Snodgrass hypospadias repair, a dorsal well vascularized double-layered dartos flap is a good choice for preventing urethrocutaneous fistula formation.     

冠状沟型尿道下裂一期修复术

目的 提出冠状沟型尿道下裂一期手术新术式。方法 应用包皮和阴茎皮肤联合皮瓣成形尿道，利用原龟头裂与包皮皮瓣成形尿道外口。结果 临床应用２０例，一次手术成功１９例，１例并发尿道瘘。结论 本法成形尿道皮瓣血运良好，不易发生皮瓣坏死，并发症少。利用龟头裂成形尿道外口，避免了尿道外口狭窄，术后尿道外口位于龟头顶端，阴茎外形接近于正常。     

Overnight urethral stenting after tubularized incised plate urethroplasty for distal hypospadias

Objectives  

The duration of urethral stenting after tubularized incised plate (TIP) urethroplasty for hypospadias varies among surgeons. Typically the catheter is left for up to 7 days with the goal of minimizing post-operative complications. We describe our experience with overnight stenting for distal TIP hypospadias repair.     

Urethral plate grafting improves the results of tubularized incised plate urethroplasty in primary hypospadias

ObjectiveWe conducted a competitive efficacy trial in order to examine whether grafting the raw area of the urethral plate (UP) with inner preputial skin in children with primary hypospadias (PH) during tubularized incised plate urethroplasty (TIP) improves the results of the operation.Material and methodsFifty consecutive patients with pathology ranging from glanular to proximal penile PH were randomized into two groups, comparable for age and pathology, to be operated on either with TIP or a grafted TIP (G-TIP) procedure. Three patients failed the re-examination protocol, so the TIP group comprised 23 children aged 9.0 months–9.6 years (mean age 3.4 years) and the G-TIP group comprised 24 children, aged 10.0 months–9.4 years (mean 3.5 years). The patients were followed up for a period of 2–5 years (mean 3.2 years).ResultsWithin the TIP group, we observed the development of fistula with concomitant neourethral stenosis in two cases (8.7%), stenosis without fistula in four (17.4%), and glans dehiscence in one case (4.35%). Within the G-TIP group there was one case of fistula without stenosis (4.16%), no case of neourethral stenosis, and one case of glans dehiscence (4.16%). Two cases of non-slit-like meatus were observed in the TIP group. The results show that the complications of neourethral stenosis are significantly reduced (p < 0.05) in the G-TIP group, as is the total number of complications and unsatisfactory results. The duration of the TIP operation was 72–110 (mean 92) min, and for the G-TIP 100–136 (mean 115) min. No postoperative symptoms were observed that could be attributed to prolonged anesthesia time.ConclusionUP grafting with inner preputial skin, when added to the TIP procedure in the treatment of PH, results in a significantly smaller number of unsatisfactory results, and particularly fewer cases of neourethral stenosis. G-TIP can be used as the procedure of choice in PH patients.     

Morphology and urodynamics after longitudinal urethral plate incision in proximal hypospadias repairs: long-term results.

AIM: To determine whether longitudinal neourethra incision disturbs the healing and growth of the neourethra, and to see how it affects the urine flow after proximal hypospadias repairs. SUBJECTS AND METHODS: Nine patients were examined, in whom longitudinal incision had been performed 9 - 15 years earlier, after previous penis lengthening operations. Calibration, urethrography, endoscopy, and urodynamics were carried out in all patients. RESULTS: In all but 1 patient the external meatus had steadily been growing in width, and in 8 out of 9 it was within the normal size range. Urethroscopy showed single hairs growing into the lumen in 3 patients. No scarring was demonstrated in any patient. Saccular dilatation of the neourethra was found in 6 out of 9, urethral stricture was shown in only 1 patient. Peak flow rate was within 2 SD in 5 patients, and below 2 SD in 3. Average flow rate was below 2 SD in 6 patients and in all patients it was markedly low. In the patient with urethral stricture both peak flow rate and average flow rate were well below normal. CONCLUSIONS: Although longitudinal neourethra incision allows for easy and safe closure, longitudinal incision may result in functional meatal stenosis with formation of a wide neourethra. This may be due to disproportional low resistance of the urethral wall, compared with external meatus, to urine flow.     

Foreskin reconstruction does not increase urethroplasty or skin complications after distal TIP hypospadias repair

AimTo compare urethral and skin complications between consecutive patients undergoing distal TIP (tubularized incised plate) hypospadias repair with prepucioplasty versus circumcision.MethodsProspective case-cohort study comparing urethroplasty and skin complications between consecutive patients undergoing distal TIP with prepucioplasty versus circumcision. Those with <1 month follow-up or prior circumcision were excluded. Decision for prepucioplasty or circumcision was made exclusively by caregivers. Operative technique was the same except skin closure. Postoperative foreskin retraction was deferred ≥6 weeks after prepucioplasty.ResultsOf 343 circumcision and 85 prepucioplasty cases, median age and follow-up were 8 (3–420) and 7 (1.5–97.5) months, respectively. Urethroplasty complications occurred in 30 (8.7%) circumcision patients [16 fistulas, 13 glans dehiscences, 1 meatal stenosis due to balanitis xerotic obliterans (BXO) 5 years postoperatively], versus 7 (8.0%) after prepucioplasty [4 fistulas, 2 glans dehiscences, 1 urethral stricture], p = 1.0. Skin complications resulting in reoperation occurred in 7 (2.0%) circumcision patients and 2 (2.3%) prepucioplasty patients, including an unsightly dorsal whorl in 1 and BXO 66 months postoperatively in another, p = 1.0.ConclusionPrepucioplasty does not increase urethroplasty or skin complications after distal TIP hypospadias repair. We found no contraindication for prepucioplasty among consecutive patients, indicating hypospadiologists can manage the foreskin in distal repairs according to caregiver preference.     

Incomplete diphallus: correction in one stage

We report a patient with an anorectal malformation and an abnormal penis with an isolated prepuce, double glans, and two corpora cavernosa. A right main urethra opened into the bladder neck; the right meatus was hypospadiac. The proximal end of the left accessory urethra opened into the right prostatic urethra and the left meatus was orthotopic. Severe chordee and normal urinary flow through both meatuses were present. At the age of 4 years, the diphallus was corrected. Both corpora cavernosa were dissected and the urethra was reconstructed, lengthening the right urethra with a 2.5-cm fragment of left urethra as a free graft excised from the emergence point and joined to the main urethra pasteriorly. The right urethra, whose meatus was hypospadiac and lateral, was dissected until a medial course was obtained. The glans was reconstructed using the lateral aspect of each glans; both medial aspects were extirpated. To correct the urethral trajectory, the urethra was fixed to the tip of the glans. A penis with two corpora cavernosa, a single glans, and a complete urethra with a meatus at the tip of the glans was obtained. The prepuce was reconstructed from the dorsal redundant aspect. The postoperative course was satisfactory.     

The midterm success rates of tubularized incised plate urethroplasty in reoperative patients with distal or midpenile hypospadias

To review the midterm results of tubularized incised plate (TIP) urethroplasty (Snodgrass method) in reoperative patients with distal or midpenile hypospadias. The results of TIP urethroplasty in 37 patients who had previously failed hypospadias repair were reviewed. Of the patients, 21 (56.8%) had coronal, 11 (29.7%) had subcoronal, and 5 (13.5%) had midpenile hypospadias. The mean age was 4.1 (2–16) years. Twenty-three patients had one operation and 14 patients had two operations previously. Of all the patients, 14 did not have a foreskin because of circumcision. The urethral plate had been disturbed in 6 patients, but there was not apparent scarring of the plate. Postoperative follow-up was 2.3 years with a range of 1.1–3.9 years. Genital examination, urethral calibration, and uroflowmetry were performed in control. Satisfaction of the families about the function and appearance of penis was also evaluated. Successful functional and cosmetic results were achieved in 29 patients (78.4%). All the families were happy with penile aesthetic appearance. The urethral plate seemed healthy at the operation in nine patients who had undergone TIP urethroplasty before and the outcomes were successful in eight of them. The operation was successful in 19/23 (82.6%) patients who had undergone one operation before and in 10/14 (71.4%) patients with two operations as well (P<0.05). In addition, sufficient outcomes were obtained in also 11 of the 14 patients with circumcision. The success rate was higher in patients <5 years (P<0.05). The rate was also higher during the recent period (2001–2003) since the experience we had increased (P<0.05). TIP urethroplasty was unsatisfied in four of the six patients who had had disturbed urethral plate before and in five of eight patients who did not have sufficient amount of dartos tissue for flap to cover neourethra. Complication was observed in eight patients (21.6%): four had a pinpoint fistula, two had wound dehiscence, one had meatal stenosis, and one had mild meatal regression and a short neourethral stricture. All of these complications were repaired successfully at a later date. The mean hospital stay was 4.6 days. TIP urethroplasty provides good functional and cosmetic midterm outcomes in most of the reoperative patients with distal or midpenile hypospadias unless contraindicated by previous resection or gross scarring of the urethral plate. This procedure seems not to disturb the urethral plate and, therefore, it can be applied on reoperative patients who had undergone TIP urethroplasty before. It can also be used in a circumcised patient when there is a lack of foreskin.     

The extended Mathieu procedure in coronal,distal penile,and midshaft hypospadias repair

The Mathieu procedure was adequately modified for glanular, coronal, and midshaft hypospadias variants with chordee and/or urethral hypoplasia in order to anatomically reconstruct the penis. A total of 129 patients aged 12 months to 22 years with coronal (35.7%), distal penile (51.9%), and midshaft (12.4%) hypospadias were operated upon. Chordee was found in 33.3% and distal urethral hypoplasia in 15.5% of the patients. The ventral flap was based anatomically on the external meatus, the glans was made pyramidal with an apical external meatus, the prepuce was resutured, and the neurethra was buried deeply within the glans. In patients with distal urethral hypoplasia the external meatus was incised proximally; in chordee the urethral plate was mobilized off the corpora cavernosa. Fistulas were uncommon (3.4%) in the primarily operated patients. The external meatus was always apical, and no stenosis was demonstrated at follow-up. The prepuce was reconstructed in 71.5% of patients. The extended Mathieu procedure appears recommendable for all coronal, distal penile, and midshaft variants regardless of associated anomalies of the penis. It also seems suitable for secondary repairs. The prepuce can be reconstructed in the majority of patients. The complication rate is significantly low compared to other methods, and the extended Mathieu operation is a good teaching tool with a high success rate and versatility.