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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 4  |  Page : 201-205

MAGPI technique for distal penile hypospadias; modifications to improve outcome at a single center


1 Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
2 Department of Physiology, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication8-Dec-2017

Correspondence Address:
Dr. Aditya P Singh
Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_37_16

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  Abstract 

Background: Hypospadias is the most common congenital anomaly of urogenital organs in boys. We reviewed our experience with modification in the meatal advancement and glanuloplasty incorporated (MAGPI) technique of hypospadias repair. We point out some modifications and outcomes of this technique in this study.
Patients and Methods: We identified all patients who underwent modified MAGPI repair of the distal hypospadias by a single surgeon over a 10-year period. We performed a retrospective chart review by outdoor assessment postoperatively. We assessed parents' satisfaction with functional and cosmetic outcomes. Decision to undergo this type of repair was intraoperative, depending on position and mobility of the meatus, and the quality of periurethral tissue. We made some modifications in the original technique of the MAGPI including no trimming of the edge of the glans in granuloplasty, incorporation of the collar in the granuloplasty; leading to glans augmentation and taking stay suture over the ventral wall of the urethra with some perimeatal tissue.
Results: Our study was a retrospective analysis. We collected data retrospectively and outcomes were assessed by the outpatient department visits in follow-up. We identified 150 patients, with a median age of 6 years (3–8 years). Position of meatus was glanular 90 (60%) or coronal 60 (40%). Chordee was minimal in our study and was corrected by only penile degloving. Urethral stenting was required in all patients for 3–4 days. There was no case of fistula, meatal regression, stenosis, mucosal prolapse, or second procedure. Cosmetic outcome was deemed satisfactory in 98% (147/150).
Conclusion: In selected cases, our modifications in the MAGPI hypospadias repair provide excellent functional and cosmetic outcomes with minimal complications.

Keywords: Distal hypospadias, hypospadias repair, meatal advancement and glanuloplasty incorporated


How to cite this article:
Shukla AK, Singh AP, Sharma P, Shukla J. MAGPI technique for distal penile hypospadias; modifications to improve outcome at a single center. Arch Int Surg 2016;6:201-5

How to cite this URL:
Shukla AK, Singh AP, Sharma P, Shukla J. MAGPI technique for distal penile hypospadias; modifications to improve outcome at a single center. Arch Int Surg [serial online] 2016 [cited 2018 Oct 18];6:201-5. Available from: http://www.archintsurg.org/text.asp?2016/6/4/201/220326


  Introduction Top


Hypospadias is a condition in which the location of the urethral meatus is on the ventral aspect of the penis. Hypospadias is the most common congenital anomaly of urogenital organs in boys, with an incidence of approximately 1 in 250 newborns.[1] Recently, case selection has been advised to avoid possible complications and limitations. While the meatal advancement and glanuloplasty incorporated (MAGPI) repair continues to give satisfactory outcomes, its critics have noted its association with meatal regression and meatal stenosis. Our aim was to review our experience with some modifications in the original MAGPI repair to reduce complications and improve outcome.


  Patients and Methods Top


We retrospectively reviewed all patients who underwent MAGPI hypospadias repair in our department from 2005 to 2015 by one surgeon. This was followed by assessment in the follow-up clinic during interview with the parents or patients. The decision to undertake this type of repair was intraoperative, depending on the position and mobility of the meatus as well as the quality of periurethral tissue and quality of the urethra pxoximal to the meatus. We performed MAGPI in the glanular, coronal (exclude subcoronal), stenotic meatus, excluding cases with deep glanular groove, wide urethral plate, and proximal urethra adherence to the skin. To test its mobility, the meatus should be pulled distally using a Micro-Adson forceps. Surgical technique was in accordance with the original MAGPI technique with some modifications [Figure 1], including no trimming of the edge of the glans in granduloplasty and incorporation of the collar in the granduloplasty, leading to glans augmentation and taking stay suture over the ventral wall of the urethra with some perimeatal tissue. The mean outpatient follow-up period was 1 year. All patients were reviewed 5 times. We analyzed adverse outcomes such as meatal stenosis, meatal regression, fistula, persistent chordee, mucosal prolapse, poor cosmesis, and the need for reoperation. The outdoor assessment consisted of assessing parental satisfaction and complications. Outdoor assessment was done by cosmetic appearance (conical shape glans, meatus, scarring) and parent satisfaction.
Figure 1: (a-f) Pictorial diagram of the steps of surgical technique

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Surgical technique

Surgery was performed under general anesthesia and caudal block with infiltration with 1:100000 xylocaine and adrenalin solution. Circumferential subcoronal incision was made [Figure 2]. Degloving of the penis was done up to the mid penile region leaving behind a 2 mm size “Firlit collars.” A longitudinal incision was made in the stenotic meatus 2 mm proximally and calibrated with 10 Fr size silastic NG tube. The meatal advancement was accomplished by a Heineke–Mikulicz vertical incision and horizontal closure using 6-0 vicryl of the transverses septum just distal to the meatus. Then, the stay suture was placed over the ventral wall of the urethra with some perimeatal tissue and pulling it forward. Glanduloplasty was done without dissection and trimming of the glans. Vertical mattress sutures PGA 6-0 were taken incorporating the collar. Dorsal prepuce was cut in the midline to cover the penile shaft. Size 6-Fr NG tube was passed and left in situ. Simple penile dressing was done. Catheter was removed after 3–4 days.
Figure 2: Preoperative (a), Intraoperative (b and c) and postoperative view of our modified MAGPI technique (d) postoperative view of our modified MAGPI technique

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  Results Top


The total number of patients who underwent this type of repair during the study period was 150. The patients' age at surgery ranged from 3 to 8 years, with a mean age of 6 years. Ninety patients were aged 5–6 years. The characteristics of the patients are shown in [Table 1]. Overall outcome was deemed satisfactory in 98% (147/150) of the cases. There were no urinary complaints in our study. There was no persistent chordee and did not require any dorsal plication to correct chordee in our study. There was no case of urethral mucosal prolapse. There was no case of fistula, meatal regression, or meatal stenosis. None of the patients had a second procedure for a complication [Table 2]. Good urinary stream and follow-up images are shown in [Figure 3].
Figure 3: (a) Good urinary stream and (b-d) follow-up images

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Table 1: Characteristics of 150 patients with hypospadias

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Table 2: Outcome of treatment in patients that had modified MAGPI surgery

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  Discussion Top


More than 300 surgical techniques for hypospadias repair have been described.[2] The MAGPI repair is the preferred method in glandular type, whereas the tubularized incised plate (TIP) repair is preferred for other cases of distal hypospadias.[3] The MAGPI procedure allows the surgeon to avoid an urethroplasty, and provides a reliable, reproducible procedure for reconfiguring the glans and meatus without the use of catheters and with a very low morbidity rate. The MAGPI technique was devised by Duckett in 1981.[4]

Distal hypospadias is the most common variety accounting for 70% of all cases.[4],[5] Though the MAGPI technique offered improved cosmetic and functional results without the need for formal urethroplasty, complications and limitations of the procedure have been reported. The reported incidence of complications following MAGPI repair, which required reoperation, ranges from 1.2 to 10%.[6],[7] There was no reoperation in the present study. Meatal regression and stenosis remain commonly cited problems. Meatal regression occurs when the glanduloplasty does not hold. Proponents of the procedure have attributed high rates of meatal regression and stenosis to poor patient selection with those selected having a meatus located too far proximal and those with severe chordee.[6] We included only glandular and coronal hypospadias with minimal chordee and excluded more proximal hypospadias in our study. Chordee was corrected by degloving only up to the mid shaft. It did not require any dorsal plication in our study. We had no complication in our study because we followed case selection criteria to repair hypospadias. Modifications to the initial description have been described to reduce the incidence of meatal regression by bringing glandular tissue together in a more solid ventral closure.[6] We had a modification in our study. We incorporated the collar in the glanduloplasty, which helped us in augmentation of the glans. An additional layer approximating deep glans tissue was added that replaced the vertical mattress stitches in the initial description. Epithelial layer closure superficially was also incorporated to secure closure. We repaired glans with the collar in simple or vertical mattress sutures in our study. Meatal stenosis occurs when the meatus is too narrow; therefore, using the Heineke–Mikulicz procedure of cutting vertically to open the dorsal aspect of the meatus and suturing transversely can minimize this complication.[7] There was no meatal stenosis in our study. We performed adequate ventral meatotomy and calibration with a 10-Fr NG tube. Considering the complications or limitations of the procedure, many alternative techniques are available. The majority are based on neourethra formation, which is usually associated with higher morbidity rate and perhaps less satisfactory cosmetic results.[8],[9]

In our study, we performed modified MAGPI up to the age of 8 years because later in age the glandular tissue does not remain supple and causes complication related to repair. Distal hypospadias has no functional problems and is rarely associated with fibrous chordee. There was minimal chordee in our study because we included only glandular and coronal hypospadias. Patients' main concern is the deviation and splaying of urinary stream in addition to unacceptable cosmetic appearance. Our experience as well as that of other surgeons showed that, though most of the cases achieved good cosmetic results, the technique cannot be applied universally to all types of distal hypospadias.[10] Most authors reported excellent results with glandular hypospadias, however, in cases of coronal and subcoronal hypospadias, complications were constantly reported.[11] We only included coronal hypospadias with shallow glandular groove and mobile urethra in our study.

Variations of MAGPI procedure have been reported to make this procedure amenable to borderline cases such as coronal hypospadias, megameatus, and cases with chordee. Somoza et al. described removing a triangular segment of glandular tissue distal to the meatus, and dissection of the dorsal and lateral urethral sides, accomplishing the urethral advancement without any tension. Strips of glandular epithelium are excised on each side, and glans tissue is sutured above the ventral urethral wall.[12] Another modification was not to dissect and trim the glans for glanduloplasty with incorporation of the collar leading to tensionless repair, so we did not have any fistula, meatal regression, and meatal stenosis in our study. While Duckett et al.[6] reported complication rate as fistula (0.45%), meatal regression (0.6%), no meatal stenosis, second surgery (1.2%), and residual chordee in 0.09%. Our results are more favorable than the original MAGPI repair. The presences of distal chordee, glandular tilt, fibrotic urethral meatus, or thin paraurethral skin are important limiting factors for MAGPI. Case selection has been advised to avoid the possible complications of the meatal regression and stenosis.[13] We followed case selection strictly in our study, and hence, we did not have any complication with better functional and cosmetic outcome in our study. The hypospadiac penis that is amenable to the MAGPI is characterized by a dorsal web of tissue within the glans that deflects the urine from either a glandular or a slightly subcoronal meatus. The urethra itself must have a normal ventral wall, without any thin or atretic urethral spongiosum, and it must be mobile such that it can be advanced into the glans.

The decision to undertake this type of repair was intraoperative, depending on the position and mobility of the meatus and the quality of periurethral tissue, and the quality of the urethra pxoximal to the meatus. We performed MAGPI in the glandular, coronal (exclude subcoronal), and stenotic meatus, excluding cases with deep glandular groove, wide urethral plate, and proximal urethra adherent to the skin. In our study, there was no mucosal prolapse. Some authors recommended mucosal prolapse as a complication but in our study we did not find any such problem and with no urinary complaints. There was skin tag after glanduloplasty in our study, however, it was not so problematic, and in follow-up, it looks like a frenulum after remodeling.

It is important not to stretch indications for MAGPI repair such as selecting patients with a proximal meatus. Issa and Gearhart reported 8 cases of meatal regression; 5 had meatal regression which was attributed to a technical failure, and 3 had severe regression suggesting poor patient selection.[11] On the other hand, Gibbons has suggested that cases with subcoronal meatus or possible chordee are suitable for MAGPI with some modification to the technique. He described a creation of a vascularized meatal-based flap, which provides excellent flexibility.[14] One of the few disadvantages of the MAGPI repair is the unsatisfactory look of the meatus, and some surgeons would argue that a nice slit-like meatus could hardly be fashioned by a nonmodified MAGPI repair. In our experience, this has not been a commonly encountered issue. The key of success in our study is proper intraoperative selection criteria for MAGPI.

This careful selection resulted in excellent outcomes from the modified MAGPI procedure with no meatal stenosis or meatal regression. On the other hand, we could be criticized for choosing a case of megameatus for MAGPI repair, as it was advised that this type of hypospadias would best be repaired using the pyramid or Mathieu procedure.[6] Nevertheless, other reports have suggested that megameatus intact prepuce (MIP) variant of hypospadias is not an absolute contraindication for this type of repair, with published satisfactory success rates.[15] Corpus spongiosum advancement is a new technique ideal for distal hypospadias repair. This procedure has several advantages over many other procedures currently employed for repair of distal hypospadias.[16]


  Conclusions Top


Excellent surgical results are determined by meticulous surgical technique and careful case selection. Our aim of study is to show the importance of the case selection and some modifications in the original MAGPI technique to improve the results in term of complications, functionality, and cosmetics. Surgical procedure for hypospadias should be decided after case selection intraoperatively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Baskin LS, Himes K, Colborn T. Hypospadias and endocrine disruption: Is there a connection? Environ Health Perspect 2001;109:1175-83.  Back to cited text no. 1
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2.
Germiyanoglu C, Nuhoglu B, Ayyildiz A, Akgul KT. Investigation of factors affecting result of distal hypospadias repair: Comparison of two techniques. Urology 2006;68:182-5.  Back to cited text no. 2
    
3.
Springer A, Krois W, Horcher E. Trends in hypospadias surgery: Results of a worldwide survey. Eur Urol 2011;60:1184-9.  Back to cited text no. 3
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4.
Duckett JW. MAGPI (meatoplasty and glanuloplasty): A procedure for subcoronal hypospadias. Urol Clin North Am 1981;8:513-9.  Back to cited text no. 4
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5.
Sweet RA, Schrott HG, Kurland R, Culp OS. Study of the incidence of hypospadias in Rochester Minnesota, 1940-1970 and case control comparison of possible etiologic factors. Mayo Clin Proc 1974;49:52.  Back to cited text no. 5
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6.
Duckett JW, Snyder HM. The MAGPI hypospadias repair in 1111 patients. Ann Surg 1991;213:620-5.  Back to cited text no. 6
    
7.
Ghali AM, el-Malik EM, al-Malki T, Ibrahim AH. One-stage hypospadias repair. Experience with 544 cases. Eur Urol 1999;36:436-42.  Back to cited text no. 7
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Devine CJ Jr, Horton CE. Hypospadias repair. J Urol 1977;118:188.  Back to cited text no. 8
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9.
King LR. Cutaneous chordee and its implication in hypospadias repair. Urol Clin North Am 1981;8:397.  Back to cited text no. 9
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10.
Ozen HA, Whitaker RH. Scope and limitations of the MAGPI hypospadias repair. Br J Urol 1987;59:81.  Back to cited text no. 10
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11.
Issa MM, Gearhart JP. The failed MAGPI: Management and prevention. Br J Urol 1989;64:169-71.  Back to cited text no. 11
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12.
Somoza I, Liras J, Abuin AS, Mendez R, Tellado MG, Rios J, et al. New Modern Magpi. Cir Pediatr 2004;17:76-9.  Back to cited text no. 12
    
13.
Duckett JW, Snyder HM. Meatal advancement and glanuloplasty hypospadias repair after 1000 cases: Avoidance of meatal stenosis and regression. J Urol 1992;147:665.  Back to cited text no. 13
    
14.
Gibbons MD. Nuances of distal hypospadias. Urol Clin North Am 1985;12:169-74.  Back to cited text no. 14
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15.
Bar-Yosef Y, Binyamini J, Mullerad M, Matzkin H, Ben-Chaim J. Megameatus intact prepuce hypospadias variant: Application of tubularized incised plate urethroplasty. Urology 2005;66:861-4.  Back to cited text no. 15
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16.
Dutta HK. Meatal and corpus spongiosum advancement: A better technique for distal hypospadias repair. Pediatr Surg Int 2013;29:633-8.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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