Prepuce-Sparing hypospadias repair with tubularized incised plate urethroplasty

Objectives:   Modifications in surgical methods of hypospadias repair have been influenced by social considerations. Most Japanese parents wish their children to retain their foreskin during hypospadias repair. We report on short-term results of foreskin reconstruction associated with hypospadias repair.
Methods:   Of 44 tubularized incised plate urethroplasty-patients, 42 (95%) underwent foreskin reconstruction at the time of urethroplasty during the last 2 years. After the urethroplasty was completed, the foreskin was re-approximated in three layers.
Results:   Complications related to urethroplasty consisted of fistula in two patients with penoscrotal hypospadia, and mild stenosis of the glandular urethra in one patient. Complications related to foreskin reconstruction included dehiscence of the ventral foreskin in two patients. In all cases parents were well satisfied with the reconstructed prepuce.
Conclusions:   Pre-operative information about preputial reconstruction should be given to parents if they would prefer their son to be uncircumcised.     

Tubularized incised plate urethroplasty for hypospadias reoperations in 100 patients

Objectives To determine the key points for a successful redo hypospadias procedure using tubularized incised plate urethroplasty operation. Methods A retrospective chart review of a cohort of 100 patients (Mean age: 4.5 years, range: 2–12) who had undergone a redo tubularized incised plate urethroplasty operation was performed. Fischer exact and Chi square tests were used for statistical analysis. Results The incidence of complications of tubularized incised plate urethroplasty reoperation after failed repairs of meatal advancement and glanuloplasty procedure (n: 14), meatal based flap (n: 36), and tubularized incised plate urethroplasty (n: 50) were 29% (n: 4), 22% (n: 8) and, 28% (n: 14) respectively (P > 0.05). The overall complication rate was 26% (n: 26). Eighteen patients (18%) had fistula, five had meatal stenosis (5%), two had dehiscence (2%) and one had neourethral stenosis (1%). Postoperatively, fistula was closed in 18 patients and 5 underwent meatoplasty. Two patients with dehiscence and one with neourethral stenosis underwent an unsuccessful third redo tubularized incised plate urethroplasty reoperation and they were candidates for a complex hypospadias repair (3%). The ultimate success rate of tubularized incised plate urethroplasty reoperation after treatment of complications was 97%. Conclusion Tubularized incised plate urethroplasty is a safe and efficacious alternative procedure for hypospadias reoperations if the urethral plate has no scars and outcome is favourable if the first failed hypospadias repair is a meatal based flap procedure. The complication rate increases if the urethral plate has been previously incised in the midline and a redo third redo must be avoided.     

Comprehensive analysis of six years experience in tubularised incised plate urethroplasty and its extended application in primary and secondary hypospadias repair

OBJECTIVE: We evaluated the potential of tubularised incised plate (TIP) urethroplasty in primary and secondary hypospadias repair focusing on the extended application of this procedure, the utility and handling of the urethral plate and operative results. METHODS: In this retrospective study, we analysed the medical records of 228 children with different levels of the hypospadiac meatus who underwent a TIP procedure between February 1997 and December 2002. The children were followed a mean of 42 months. Our medical records provided us with details about the location of the hypospadiac meatus, the width of the urethral plate before and after midline incision, primary versus secondary surgery, complications as well as notes on the extended application of the TIP procedure. RESULTS: The overall postoperative complication rate was 7.8%. The overall fistula rate was 5.7%, with 4.1% in primary distal, 9.6% in primary proximal and 7.5% in secondary repair respectively. We had one case of meatal stenosis (0.4%) and one of urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). Due to the encouraging results, the frequency of TIP procedure in hypospadias surgery increased from 33% in 1997 to 82% in 2002. CONCLUSION: In our study the TIP procedure has emerged as the first-choice technique in primary hypospadias repair--irrespective of the level of the hypospadiac meatus and the width of the original urethral plate. This procedure has also proved to be favourable for many cases at secondary surgery.     

Width proportion of the urethral plate to the glans can serve as an appraisal index of the urethral plate in hypospadias repair

Objectives

To find a new appropriate evaluation for urethral plate quality in hypospadias repair, with particular interest in the width proportion of the urethral plate to the glans, serving as an appraisal index.

Methods

Data were prospectively collected from prepubertal boys who underwent primary tubularized incised plate hypospadias repair between January 2014 and April 2016 in one center. Intrinsic parameters of the penis (meatal location, glans width, urethral plate width and curvature degree) were measured during the operation. Urethroplasty complications were recorded during follow up. The correlation between width proportion of the urethral plate to the glans and urethroplasty complications was analyzed.

Results

Primary tubularized incised plate repair was carried out in 442 patients (mean age 2.8 years, range 0.5–12 years). At mean follow up of 26 months (range 12–38 months), urethroplasty complications occurred in 59 (13.3%) patients. The width proportion of the urethral plate to the glans was weakly correlated to both the glans width and meatal location. The width proportion of the urethral plate to the glans ranged from 0.18 to 0.73, with a mean of 0.39. The cut‐off value of width proportion of the urethral plate to the glans was determined to be 0.36 by the receiver operating characteristic curve. Urethroplasty complications occurred in 17 out of 254 patients (6.7%) with width proportion of the urethral plate to the glans >0.36, and 42 out of 188 patients (22.3%) with width proportion of the urethral plate to the glans ≤0.36. The width proportion of the urethral plate to the glans ≤0.36 showed an increased odds of 4.819‐fold (95% confidence interval 2.548–9.112, P < 0.001) risk of urethroplasty complications compared with width proportion of the urethral plate to the glans >0.36. Midshaft and proximal meatal location also increased the risk of urethroplasty complications.

Conclusions

The present study highlights the value of the width proportion of the urethral plate to the glans for objectivity and accuracy in urethral plate evaluation, which in turn serves as an independent factor influencing outcomes in tubularized incised plate repair.

     

改良尿道板纵切卷管技术在尿道下裂治疗中的临床应用

目的:探讨尿道板纵切卷管技术(TIP)在尿道下裂治疗中的临床应用和体会。方法:收集行TIP手术的尿道下裂患儿169例,年龄1.5~12岁,平均3.68岁,术后平均随访2年(6个月至3年)。TIP技术在Snodgrass手术的基础上进行改进,即纵切开尿道板,术后留置尿道支架,平均住院时间10 d。结果:169例患儿中18例(10.6%)术后有并发症,最常见并发症为尿道狭窄(9例,5.3%),其次为尿道皮肤瘘(8例,4.7%)。结论:TIP技术是一种可以适用于大多数尿道下裂的手术方法,临床经验和技术的总结,有助于提高使用这种方法的成功率,减少并发症的发生。     

The association between caudal block and urethroplasty complications of distal tubularized incised plate repair: experience from a South China National Children’s Medical Center

BackgroundThe effect of caudal block (CB) on the incidence of urethroplasty complications in hypospadias repair remains controversial. The evidence is conflicting, and some confounding bias issues need to be addressed. We sought to study a more homogenous group of distal hypospadias patients undergoing primary tubularized incised plate (TIP) repair by a senior pediatric urology surgeon in the past 2 years to examine the relationship between urethroplasty complications and the use of CB.MethodsWe reviewed our database to identify consecutive patients who had undergone hypospadias repairs by a senior director surgeon at our Center between January 2018 and November 2020. To be eligible to participate in the study, patients had to meet the following inclusion criteria: (I) have distal hypospadias; (II) have undergone a primary TIP repair; and (III) have attended follow-up appointments for a minimum period of 6 months. The primary outcome was the development of urethroplasty complications during the follow-up period. The principal variable of interest was whether or not CB was used perioperatively. The patients were categorized into a CB group (general anesthesia combined with CB) or a control group (general anesthesia only). Other potential risk factors were analyzed, including patient age at operation, patient weight, glans width, and the length of the urethral plate defect.ResultsThirty (12.2%) of the distal patients developed postoperative surgical complications. The postoperative surgical complication rates were similar between the different anesthesia groups. Weight, the length of the urethral plate length, and glans width did not contribute to the risk. Age was the only independent risk factor for postoperative surgical complications, and the complication rates increased in older patients.ConclusionsOur data from consecutive TIP repairs in distal hypospadias patients indicated no association between the use of CB anesthesia and the postoperative urethroplasty complication rate. Patients who were older in age when they underwent surgery had a higher risk of complications.     

Tubularized-incised plate urethroplasty in adults

OBJECTIVE: To evaluate the results of tubularized incised-plate (TIP) urethroplasty for distal and midshaft hypospadias in adults, and to underline technical aspects to decrease complications. PATIENT AND METHODS: From December 1999 to January 2004, 13 patients with hypospadias and aged 18-26 years had a TIP urethroplasty as a primary repair. Five had distal penile and eight had midshaft hypospadias. In all cases a TIP urethroplasty was used as described for children. Urinary drainage was by a urethral Nelaton catheter connected to a urine bag. RESULTS: The catheter was removed after 10 days and the patients asked to attend a follow-up at 1, 3 and 6 months and then 6-monthly; the maximum follow-up was 3 years and the minimum was 3 months. One patient developed a fistula after the repair of distal penile hypospadias, which closed spontaneously after a month. All patients with a successful repair voided with a single straight urinary stream in a forward direction. They had a normally situated slit-like glanular meatus. CONCLUSION: TIP repair in adults is associated good results. There is no difference in terms of wound healing, infection, complication rates and overall success between the TIP repair in children and adults. The cosmetic and functional outcome was comparable to that in children.     

Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair

OBJECTIVE: To evaluate the importance of urethral covering using vascularized dorsal subcutaneous tissue for preventing fistula in the Snodgrass hypospadias repair. PATIENTS AND METHODS: The study included 67 children (aged 1-11 years) who had hypospadias repaired between April 1998 and May 2003, including 51 with distal and 16 with midshaft hypospadias. In all children, a standard tubularized incised-plate urethroplasty was followed by reconstruction of new surrounding urethral tissue. A longitudinal dartos flap was harvested from excessive dorsal preputial and penile hypospadiac skin, and transposed to the ventral side by a buttonhole manoeuvre; it was sutured to the glans wings around the neomeatus, and to the corpora cavernosa over the neourethra. Thus the neourethra was completely covered with well-vascularized subcutaneous tissue. RESULTS: At a mean (range) follow-up of 21 (6-65) months, the result was successful, with no fistula or urethral stenosis, in all 67 children. CONCLUSION: We suggest that urethral covering should be part of the Snodgrass procedure. A dorsal well-vascularized dartos flap, buttonholed ventrally, is a good choice for preventing fistula. Redundancy of the flap and its excellent vascularization depends on the harvesting technique.     

游离组织瓣移植分期尿道下裂修复术

目的：总结游离组织瓣移植分期尿道下裂修复术的经验。方法：采用游离皮瓣或(和)口腔黏膜瓣移植分期修复术治疗男性尿道下裂58例，其中冠状沟型10例，阴茎体型36例，阴囊型9例，会阴型3例；首次手术45例，二次或多次手术后13例。单纯应用包皮皮瓣移植者35例，单纯应用耳后皮瓣移植者8例，单纯应用口腔黏膜瓣移植者6例，联合应用包皮皮瓣和耳后皮瓣移植者6例，联合应用包皮皮瓣、耳后皮瓣和口腔黏膜组织瓣移植者3例。结果：一期手术移植组织瓣成活56例(97％)，包皮瓣坏死2例。二期手术后因感染使成形的新尿道完全裂开5例，发生尿漏8例，成功43例(77％)。40例随访6个月，排尿通畅，阴茎外观好。结论：游离组织瓣移植分期修复术治疗尿道下裂成功率较高，并发症少，术后阴茎外观好，是适用于各型尿道下裂治疗的一种较好方法。     

Tubularized incised plate urethroplasty for megameatus intact prepuce hypospadias variant: First reported case in Indonesia

Introduction and importanceMegameatus intact Prepuce (MIP) is a rare variant of hypospadias characterized by a wide meatus with a normally conformed prepuce, no chordee, and usually no effects in micturition or sexual physiology. However, quality of life and psychosexuality may be affected.Case presentationA 6-year-old-boy was referred by a general practitioner to the hospital due to an abnormality of the urethral meatus. The patient did not have any complaints. A large external urethral orifice at the ventral area of the coronal glans was discovered. The prepuce was normally-conformed, and there weren’t any signs of chordee. The patient was diagnosed with an MIP hypospadias variant and underwent a tubularized incised plate (TIP) urethroplasty. During the follow-up, one week after the procedure, the patient did not have any complaints. Physical examination showed excellent anatomical and functional outcome based on the cosmetic appearance resembling a normal penis and urinary stream.Clinical discussionAwareness regarding this abnormality is necessary as MIP is often not diagnosed until circumcision. Even though MIP patients are usually asymptomatic, surgery should still be considered based on aesthetic and psychosexual reasons. TIP urethroplasty was chosen for this patient based on the clinical findings of this patient. TIP procedure for MIP patients could result in an excellent penile performance and function with a very low complication rate.ConclusionTIP urethroplasty is able to fulfil satisfactory cosmetic and functional outcomes for the MIP hypospadias variant. Awareness of the disorder should be increased to prevent potential psychosexual disturbances.     

Comparative study of dartos fascia and tunica vaginalis pedicle wrap for the tubularized incised plate in primary hypospadias repair

OBJECTIVES: To report a prospective comparative study on using dartos fascia, i.e. subcutaneous tissue of penile skin and tunica vaginalis pedicled wrap (TVPW) from the parietal layer of the tunica vaginalis of the testis, for a one-stage tubularized incised-plate (TIP) repair for hypospadias. PATIENTS AND METHODS: Forty-nine patients (mean age 4.6 years, range 1-22) with hypospadias of different types (varying from coronal to penoscrotal) were repaired in one of three hospitals over 3 years. All patients were repaired using the TIP technique, with dartos fascia wrap used in 20 and TVPW in 29, without using a loupe or microscope during surgery. Urinary diversion and splinting were provided by a urethral catheter. The operative duration for both groups was similar at approximately 2 h. RESULTS: In the dartos fascia group there were three (15%) fistulae, but there were none in the TVPW group. CONCLUSIONS: Although the dissection for TVPW seems to be cumbersome theoretically, it is not difficult. The combination of TIP and TVPW in primary repair may be a good alternative to other techniques.     

TIP术式在伴有解剖不良因素的尿道下裂Ⅰ期成形术中的应用

目的:探讨保留尿道板纵切卷管尿道成形术(TIP术)在伴有解剖不良因素的尿道下裂Ⅰ期成形术中的应用效果。方法:回顾性分析尿道下裂TIP术式Ⅰ期成形191例,将尿道开口位置、阴茎头及尿道板发育状况、阴茎下曲程度视为易导致TIP术后并发症及影响外观的解剖不良因素,采用SPSS 10.0统计数据,对其临床效果进行相关性分析。结果:①TIP术后并发症发生率与尿道开口位置密切相关,尿道开口越近,并发症发生率越高(χ2=24.291,P<0.01);②TIP术后并发症发生率与阴茎头及尿道板发育状况、阴茎下曲程度密切相关。伴有解剖不良因素的尿道下裂如小阴茎头型、尿道板发育不良型及伴有重度阴茎下曲型,采用TIP术后并发症发生率高于阴茎挺直、阴茎头及尿道板发育良好的尿道下裂(χ2=25.419,P<0.01)。结论:TIP术式的选择应根据尿道下裂类型、阴茎头及尿道板发育状况、阴茎下曲程度并结合术者经验来应用,以期达到成功率高并外形美观的效果。     

膀胱粘膜一期尿道成形术的改进

应用膀胱粘膜一期尿道成形术治疗尿道下裂９１例，其中阴茎型１８例，阴茎阴囊型３９例，阴囊型２１例，会阴型１３例，成功率９６．７％。介绍了对解剖畸形的认识，手术中各步骤操作方法的要点和术后处理的每个环节。     

纵行阴茎腹外侧肉膜瓣在远端尿道下裂Ⅰ期修复术中的应用

目的:探讨阴茎纵行腹外侧肉膜瓣在远端尿道下裂Ⅰ期修复术中的应用价值。方法:对55例阴茎远端型尿道下裂患者先行尿道板纵切卷管尿道成形术(TIP)修复尿道,然后采用阴茎纵行腹外侧阴茎肉膜瓣对修复新尿道进行覆盖。结果:55例患者均获得类似包皮环切术后样外观,尿道外口开口于阴茎头顶端呈裂隙状;仅4例(7.3%)于冠状沟处发生尿道瘘。结论:在远端尿道下裂Ⅰ期修复术中,以阴茎纵行腹外侧肉膜瓣对新尿道加以覆盖,能有效降低尿道瘘的发生率,且修复后阴茎获得类似包皮环切术后样外观。     

Tubularized incised plate urethroplasty for proximal hypospadias

OBJECTIVES: Numerous surgical procedures have been used to correct distal hypospadias. Among them, the tubularized incised plate urethroplasty (Snodgrass procedure) has become a mainstay for the repair of distal hypospadias. We applied the procedure to proximal hypospadias. METHODS: Three patients with proximal hypospadias underwent a tubularized incised urethral plate urethroplasty. The location of the meatus was proximal penis in one, penoscrotal margin in one and scrotum in one. A perimeatal incision was made and the two paramedian incisions were extended to the tip of the glans. The skin of the penile shaft was dissected free to the penoscrotal junction and bands of fibrous tissue were excised until the corpus spongiosum proximal to the meatus was completely exposed inside the scrotum. The urethral plate was then incised in its midline from the tip of the glans to the hypospadiac meatus and was tubularized without tension. The neourethra was covered with a pedicle of subcutaneous tissue dissected from the dorsal skin or the scrotal skin to avoid fistula formation. RESULTS: The tubularized incised urethral plate urethroplasty was carried out successfully in one stage on three patients with proximal hypospadias. CONCLUSIONS: The Snodgrass procedure is suitable for correcting hypospadias in patients with a healthy urethral plate. It is also suitable in patients with proximal hypospadias.     

Comprehensive analysis of tubularized incised-plate urethroplasty in primary and re-operative hypospadias

OBJECTIVE: To retrospectively review our experience of the tubularized incised-plate (TIP) urethroplasty over the last 4 years. PATIENTS AND METHODS: From 1998 to December 2001, 133 patients (mean age 7 years, sd 4, range 1-22), had a TIP urethroplasty by one surgeon for primary (103) and re-operative (30) hypospadias; the defects included 106 (79%) distal and mid-shaft, and 27 (21%) posterior shaft. The neourethra was covered by a subcutaneous flap in 66 (50%) patients or by corpus spongiosa (spongioplasty) in 31 (23%), with no cover in the remaining 36 (27%). In the last 20 patients (15%) a modified meatoplasty was used; the site and size of the new meatus was predetermined on the glans around a suitable catheter before any incision. Urethral stents were not used after repair in 39 (29%) patients, and regular meatal dilation was used only in patients with voiding difficulty and obvious tendency to stenosis. The presence of complications requiring re-operation and overall general appearance were recorded. RESULTS: The mean (sd) follow-up was 10 (5) months; there were 24 complications in 20 patients (15%), including a small fistula in 12 (9%), complete disruption of the repair in 4 (3%), meatal stenosis in seven (5%) and neourethral stricture in one (0.8%). Complications were not significantly different between primary and re-operative cases, and unaffected by the use of the stents. On univariate analysis complications were significantly higher with running than interrupted sutures, in repairs in the first 2 years of the study, in patients with posterior hypospadias, and in those with no neourethral coverage. However, the last two factors were the only significant independent risk factors in a multivariate analysis. Regular urethral dilatation was indicated in 43 patients (32%). Modified meatoplasty was associated with a significantly lower requirement for regular dilatation (P < 0.05) and no meatal stenosis. In the 113 complication-free patients the operation gave an excellent cosmetic appearance with a vertical slit meatus on the tip of conical glans in 110 (97%); there was slight meatal retraction in the remaining three patients. CONCLUSION: The TIP repair is a reliable method for treating both distal and proximal penile shaft hypospadias, is suitable for both primary and re-operative cases, and is more versatile than other repairs. Covering the neourethra with a flap or spongioplasty significantly improves the results. Regular urethral dilatation is required in a third of patients but modified meatoplasty obviates the need for regular dilatation and eliminates the risk of meatal stenosis.     

Tubularized incised-plate urethroplasty for secondary hypospadias surgery

PURPOSE: Reoperation for failed hypospadias has been considered to be seriously bothersome because abundant penile skin does not tend to remain for urethroplasty or for penile shaft skin coverage. In this study, the tubularization of incised urethral plate was employed for those who had no excessive penile skin after failure of hypospadias repair. METHODS: Five patients with hypospadias underwent tubularized incised-plate urethroplasty as salvage surgery. The surgical techniques necessary for the performance of the reoperation were not different from those for the primary repair. The urethral plate was incised sufficiently deeply in its midline from the tip of the glans to the regressed meatus. The incised urethral plate was tubularized without tension over a catheter of an appropriate size. RESULTS: Four of those who underwent secondary tubularized incised-plate urethroplasty were successfully repaired without complications. A urethrocutaneous fistula occurred at the corona in the remaining patient. CONCLUSIONS: The absence of preputial skin in reoperative cases makes tubularized incised-plate urethroplasty the ideal option, although the series was small and postoperative duration is still short. In addition, this procedure can give excellent functional and cosmetic results even in patients who require revisional hypospadias surgery.     

Tubularized incised-plate urethroplasty for distal and proximal hypospadias

OBJECTIVE: To describe the tubularized incised-plate (TIP) urethroplasty for distal and proximal hypospadias. PATIENTS AND METHODS: TIP urethroplasty was undertaken in 83 consecutive boys (mean age 14.1 months, sd 7.8) within the past 3 years; 65 (78%) had distal and 18 (22%) proximal penile hypospadias. This was the primary attempt at hypospadias repair in all children. RESULTS: All patients were assessed 7 days after surgery at the time of dressing and catheter removal, and subsequently at a median of 4 months in the clinic, before being discharged. The overall late complication rate was 12% and 10% required a second operation. There was a urethrocutaneous fistula in three (5%) of those with distal and in one of the 18 with proximal penile hypospadias (P = 0.56). Glans dehiscence in distal hypospadias occurred in one (1%) and three, respectively (P = 0.01). Secondary surgery for fistula repair and glans closure was successful in all patients. All children void with a single straight urinary stream in a forward direction, and have a normally situated vertical slit-like glanular meatus. CONCLUSIONS: TIP urethroplasty is a versatile, simple operation with good cosmetic results, which uses the urethral plate to its maximum potential.     

尿道下裂一期成形疗效分析

为提高尿道下裂一期成形手术的成功率，分析自１９８４～１９９５年６月收治的尿道下裂２３８例，其中行一期尿道成形１９９例，手术成功率８６．５％。婴幼儿组４１例成功率达９５．１％，认为提早尿道下裂修复术的年龄，使用显微外科技术和正确选择手术方法，合理设计皮瓣等能明显提高一期尿道下裂修复术的成功率。