|Year : 2015 | Volume
| Issue : 4 | Page : 195-198
Comparison between tubularized incised plate urethroplasty and other types of urethroplasty for mid and distal penile hypospadias
Anju Verma, Gaurav Gupta, Faisal Ameer, Abhishek Jain, Sunil Kaval
Department of Surgery, LLRM Medical College, Meerut, Uttar Pradesh, India
|Date of Web Publication||21-Jan-2016|
Dr. Anju Verma
Senior Resident, Department of Surgery, LLRM Medical College, Meerut - 250 004, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Hypospadias is a common congenital anomaly seen in the male child. The aim of this study was to compare tubularized incised plate (TIP) urethroplasty and other types of single stage urethroplasty for mid and distal penile hypospadias.
Patients and Methods: Seventy-seven patients having mid and distal penile hypospadias were assessed prospectively and retrospectively from March 2010 to September 2014. The study had retrospective (March 2010-February 2013) and prospective (April 2013-September 2014) divisions. Forty-four patients underwent surgical repair using TIP technique and 33 patients, using other urethroplasties (Mathieu, meatal advancement and glanuloplasty incorporation, and Asopa techniques). Patients were reviewed at 2 weeks, 1-month, and 3 months after discharge. Data including fistula formation, cosmetic disfigurement, and duration of the surgery were collected and the two groups were compared.
Results: In both retrospective and prospective groups, TIP urethroplasty has a better outcome than other type of urethroplasties for both mid and distal hypospadias. The fistula formation rates were 31.82% (7) and 64.70% (11) in distal and 31.82% (7) and 62.5% (10) in mid hypospadias in TIP and other urethroplasty group, respectively, significant result in distal hypospadias. The cosmetic disfigurement rates were 5.88% (1) and 17.64% (3) in distal and 9.09% (2) and 18.75% (3) in mid hypospadias in TIP and other urethroplasty group, respectively. Mean operative time duration in TIP urethroplasty was 90.79 min and 110.15 min in other urethroplasty group and was statistically significant.
Conclusion: TIP urethroplasty is a simple procedure for treatment of both mid and distal penile hypospadias, with less complications and satisfactory results as compared to other urethroplasties. Cosmetic appearance of urethral meatus was also more satisfactory with TIP urethroplasty than other urethroplasties.
Keywords: Distal penile hypospadias, mid penile hypospadias, tubularized incised plate urethroplasty, urethroplasty
|How to cite this article:|
Verma A, Gupta G, Ameer F, Jain A, Kaval S. Comparison between tubularized incised plate urethroplasty and other types of urethroplasty for mid and distal penile hypospadias. Arch Int Surg 2015;5:195-8
|How to cite this URL:|
Verma A, Gupta G, Ameer F, Jain A, Kaval S. Comparison between tubularized incised plate urethroplasty and other types of urethroplasty for mid and distal penile hypospadias. Arch Int Surg [serial online] 2015 [cited 2020 Jul 8];5:195-8. Available from: http://www.archintsurg.org/text.asp?2015/5/4/195/174656
| Introduction|| |
Hypospadias is a common congenital anomaly seen in the male child in which there is abnormal external urethral meatus opening on the ventral aspect of the glans penis to perineum that may be associated with chordee or hood.  Currently, hypospadias affects approximately 1-250-300 live male births.  There are several classifications of hypospadias. Anterior hypospadias consisting of glanular and coronal types account for 50% of all hypospadias while middle hypospadias consisting of distal, midshaft, and proximal penile types account for 30% of hypospadias cases. Posterior hypospadias consist of penoscrotal, scrotal and perineal types account for 20% of cases.
There are many surgical procedures described for the repair of hypospadias and none is superior to the other. There are probably more than 200 reported original methods of urethral reconstruction.  The aim of hypospadias surgery is not only to achieve a functional penis but also a normal cosmetic appearance. The most common repairs to correct hypospadias are Mathieu, meatal advancement and glanuloplasty incorporation (MAGPI) and tubularized incised plate (TIP) urethroplasty. The cause of hypospadias is still not certain and is controversial. Its treatment remains demanding as well as challenging. Complications are frequent which makes management frustrating. Considering the increasing number of patients with hypospadias coming to our OPD we conducted a study comparing the various techniques of repair. The aim of this study was to compare TIP urethroplasty and other types of single stage urethroplasty for mid and distal penile hypospadias.
| Patients and Methods|| |
This study was conducted at the Department of Surgery, LLRM Medical College, Meerut, Uttar Pradesh, India from March 2010 to September 2014. Patients admitted to Department of Surgery with distal and mid penile hypospadias between the ages of 10 months and 30 years were included in this study. In our college, hypospadias is operated in three units of pediatric, plastic, and urosurgery with an appropriate protocol of investigations and follow-up. A total of 77 patients were studied. Patients with proximal hypospadias and hypospadias with any associated congenital anomaly were excluded. Study had retrospective (March 2010-February 2013, 43 patients) and prospective (April 2013-September 2014, 34 patients) divisions which was properly planned. In both divisions, patients with distal and mid hypospadias were randomized to TIP and other urethroplasties (Mathieu, MAGPI, and Asopa. MAGPI for distal type only, Mathieu mainly for distal type and in selected mid type, Asopa for mid hypospadias). Standard TIP urethroplasty described by Snodgrass was used  and MAGPI, Mathieu and Asopa were done as standard technique described.  Informed consent for enrollment in the study was taken from every patient. Permission from College Ethical Committee for the study was also taken.
In a retrospective group of 43 patients (distal- 24, mid- 19), 27 were operated by TIP technique and 16 were operated by other urethroplasties. Moreover, in the prospective group out of 34 patients (distal- 15, mid- 19), 17 were operated by TIP technique and 17 were by other urethroplasties. Investigations including complete blood count, urine examination, ultrasonography of the abdomen and uroflowmetry were done in all patients.
Duration of surgery was noted in every patient. All patients were given antibiotic prophylaxis. A urethral stent was kept for 9-12 days. Patients were reviewed at 2 weeks, 1-month and 3 months after discharge and follow-up was done early by observation of urinary stream, asking about symptoms such as straining and splayed stream, observation and recording of complications, and in late period by observation for fistula formation, meatal stenosis, cosmetic disfigurement such as rotation or deformation of shape of the external urethral meatus. Chi-square test was used to evaluate differences in complication rates of TIP and other urethroplasties for both distal and mid penile hypospadias and Student's t-test was used to evaluate the operative time difference between TIP and other urethroplasties.
| Results|| |
A total of 77 patients were studied. In the retrospective group (n = 43), 27 patients were operated by TIP technique and in the prospective group (n = 34), 17 were operated by TIP technique. Patient's age ranged from 10 months to 30 years with mean of 10.7 years. Number and age distribution of patients is shown in [Table 1]. Maximum number of the patients was between 3 and 7 years of age. In all groups treated by the various techniques, the age distribution of the patients was similar.
Operation time ranged from 75 to 100 min (mean = 90.79 min) for TIP urethroplasty and from 90 to 120 min (mean = 110.15 min) for other type of urethroplasties with P < 0.05. On comparing the duration of TIP urethroplasty in retrospective and prospective group for distal and mid hypospadias separately, there was a decrease in mean duration for the prospective group as compared to the retrospective group for both distal and mid hypospadias. [Table 2] shows a comparison of duration between retrospective and prospective divisions. Duration of surgery decreased in the prospective study.
|Table 2: Comparison of duration in retrospective and prospective group for distal and mid hypospadias for TIP urethroplasty |
Click here to view
The postoperative complications are shown in [Table 3]. After TIP urethroplasty, there were 14 (31.81%) patients who developed urethrocutaneous fistula in a total of 44 patients and in other urethroplasties 21 (63.63%) patients had fistula formation in a total of 33 patients. And cosmetic disfigurement occurred in 3 (6.81%) patients in TIP urethroplasty group and in 6 (18.18%) in other urethroplasties.
|Table 3: Comparison of fistula formation and cosmetic disfigurement in TIP and other urethroplasty groups for distal and mid hypospadias |
Click here to view
For fistula formation the P = 0.106 for retrospective group and 0.143 for prospective group, both statistically not significant. On comparing total TIP and other techniques, in TIP techniques out of total 22 patients, 7 patients (31.81%) had fistula formation while in other urethroplasty group out of 17 patients, 11 patients (64.70%) had fistula formation. This was statistically significant (P < 0.041). For cosmetic disfigurement, P = 0.12 for retrospective group and 0.46 for prospective group, which is statistically not significant. And on comparing total TIP and other techniques, in TIP techniques out of total 22 patients, 1 patient (5.88%) had cosmetic disfigurement, and in other urethroplasty group out of 17 patients, 3 patients (17.64.%) had cosmetic disfigurement. The difference was statistically not significant.
For fistula formation P value calculated using Chi-square test which came 0.46 for retrospective group and 0.06 for prospective group, which was statistically not significant. And on comparing total TIP and other techniques, in TIP techniques out of total 22 patients, 7 patients (31.81%) had fistula formation and in other urethroplasty group out of 16 patients, 10 patients (62.50%) had fistula formation. For this P value came 0.06 and was statistically not significant.
For cosmetic disfigurement, P value came 0.905 for retrospective group and 0.178 for prospective group, which was statistically not significant. And on comparing total TIP and other techniques, in TIP techniques out of total 22 patients, 2 patients (9.09%) had cosmetic disfigurement and in other urethroplasty group out of 16 patients, 3 patients (18.75%) had cosmetic disfigurement. For this P value came 0.38 and was statistically not significant. From above results we can see that in prospective group results are better than retrospective group, though not statistically significant.
| Discussion|| |
Hypospadias is the most common penile congenital anomaly which occurs in approximately 1:250-1:300 live births.  In the last 20 years, major advances in instrumentation, suture material, better understanding of anatomy and creative thought have evoked an exponential number of new and modified techniques, to correct this condition.  The aim of most of more than 200 repairs was to achieve a normal-appearing circumcised penis that was straight with the meatus within the glans, usually at a one-stage procedure. Despite obvious surgical advances in hypospadias repair, no single technique has been without complication. 
TIP urethroplasty is one of several established successful methods of repairing distal and mid hypospadias. Since its initial description in 1994 by Snodgrass, extensive, successful, and varied experience with this technique has been reported.  Several principles are responsible for the success, versatility, and preference of TIP urethroplasty. These principles include generous vascularity of the urethral plate, relative simplicity of the technique, consistent availability of tissue necessary to complete the repair and excellent cosmesis. Over that, in repeated cases, the vascularity of the urethral plate is not thought to be changed, additional skin flaps are not necessary for urethroplasty or for penile shaft skin coverage since mobilized ventral penile shaft skin is usually sufficient and also the dorsal releasing incision of the urethral plate, which are rich in large endothelial lined sinuses, results in the release of epithelial growth factor, encouraging tissue repair. This may explain absent significant scar and stricture formation after TIP urethroplasty. 
Urethrocutaneous fistula is the most common particularly, annoying complication of hypospadias repair. 
The outcome of hypospadias repair has classically been assessed by the reoperation rate secondary to fistula, diverticulum, stenosis, and residual penile curvature. Accepted outcomes with these standards are obtained by one-stage surgery in most patients with a 5-15% complication rate.  The mean duration of the surgery was shorter for the TIP urethroplasty than other type of repair in our study as observed in many previous studies. ,,,, Reported incidence of urethrocutaneous fistula by Haq et al.  is 3.3% in TIP and 7.7% in Mathieu's repair. Ali et al.  reported this difference as 9.5% and 14.3%, respectively, and we have come across this difference as 31.81% in TIP and 63.63% in other type of repair. Although when the retrospective and prospective groups were compared, the percentage of fistula formation has been decreased significantly, from 35.29% to 20% in distal hypospadias and from 50% to 16.66% in mid hypospadias, which shows that hypospadias surgery has a learning curve.
In their study, Oswald et al.  observed repair disruption in 3.33% for TIP and 6.66% for Mathieu's repair and Samore et al.  reported 0% and 10%, respectively. While in our study, repair disruption occurred in 6.81% and 18.18%, respectively. In our study, functional result and cosmesis were highly satisfactory with the TIP urethroplasty than with other type of urethroplasties. TIP technique creates a vertically oriented, slit-like meatus that resembles the normal urethral meatus which are observed in many previous studies. ,,
| Conclusion|| |
The study concludes that TIP urethroplasty is much more effective and reliable method for making neourethra in cases of distal and mid hypospadias because of its less operative time and lower complication rates than other types of single stage urethroplasties. Moreover, cosmetic appearance is highly satisfactory with TIP urethroplasty. However, when a healthy urethral plate is not available, other urethroplasties can be used.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mouriquand PD, Persad R, Sharma S. Hypospadias repair: Current principles and procedures. Br J Urol 1995;76 Suppl 3:9-22.
Baskin LS. Hypospadias and urethral development. J Urol 2000;163:951-6.
Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5.
Hadidi AT, Azmy AF. Hypospadias Surgery, An Illustrated Guide. Heidelberg: Springer Verlag; 2004.
Cheng EY, Vemulapalli SN, Kropp BP, Pope JC 4 th
, Furness PD 3 rd
, Kaplan WE, et al.
Snodgrass hypospadias repair with vascularized dartos flap: The perfect repair for virgin cases of hypospadias? J Urol 2002;168(4 Pt 2):1723-6.
Furness PD 3 rd
, Hutcheson J. Successful hypospadias repair with ventral based vascular dartos pedicle for urethral coverage. J Urol 2003;169:1825-7.
Borer JG, Retik AB. Current trends in hypospadias repair. Urol Clin North Am 1999;26:15-37, vii.
Borer JG, Bauer SB, Peters CA, Diamond DA, Atala A, Cilento BG Jr, et al.
Tubularized incised plate urethroplasty: Expanded use in primary and repeat surgery for hypospadias. J Urol 2001;165:581-5.
Garibay JT, Reid C, Gonzalez R. Functional evaluation of the results of hypospadias surgery with uroflowmetry. J Urol 1995;154(2 Pt 2):835-6.
Anwar-ul-haq, Akhter N, Nilofer, Samiullah, Javeria. Comparative study of Mathieu and Snodgrass repair for anterior hypospadias. J Ayub Med Coll Abbottabad 2006;18:50-2.
Oswald J, Körner I, Riccabona M. Comparison of the perimeatal-based flap (Mathieu) and the tubularized incised-plate urethroplasty (Snodgrass) in primary distal hypospadias. BJU Int 2000;85:725-7.
Hassib AH. Comparative study between Mathieu′s repair and TIP in treatment of distal hypospadias. Egypt J Plast Reconstr Surg 2005;29:141-8.
Samore MA, Malik MS, Iqbal Z. Mathieus repair versus TIP in distal hypospadias. Pak J Surg 2006;22:154-8.
Al-Saied G, Gamal A. Versatility of tubularized incised plate urethroplasty in the management of different types of hypospadias: 5-year experience. Afr J Paediatr Surg 2009;6:88-92.
[Table 1], [Table 2], [Table 3]