|Year : 2017 | Volume
| Issue : 2 | Page : 48-51
Tubularized incised plate urethroplasty with dorsal dartos flap cover and asymmetrical prepucial flaps: A valuable option in hypospadias repair?
Yogender S Kadian1, Kajal Pradeep1, Mahavir Singh2
1 Department of Paediatric Surgery, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
2 Department of Surgery, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
|Date of Web Publication||4-Apr-2018|
Dr. Yogender S Kadian
Department of Paediatric Surgery and Surgery, Pt. B.D. Sharma PGIMS, Rohtak, Haryana
Source of Support: None, Conflict of Interest: None
Background: Snodgrass or tabularized incised plate (TIP) repair is the most common technique for distal penile hypospadias cases. However different variations of this procedure have been tried in attempts to reduce the complications. The variations reported are for the cover of the neourethra and creations of prepucial flaps In this study the authors report another variation devised by them in which there is dorsal prepuce is divided into two unequal parts.
Patients and Methods: We have managed 35 patients of distal hypospadias without chordee with hypospadias were managed wherein the neourethra was created by incised urethral plate and it was covered by a dorsal dartos flap taken from 1/3rd portion of asymmetrically divided prepuce after discarding its outer layer and rest 2/3rd of the two layered prepuce used to cover the penile shaft.
Results: Three (8.57 %) patients developed a fistula at the coronal level, of which one closed spontaneously within three months of repair while two healed after a surgical repair. There was retraction of the meatus in one patient. All the remaining patients had acceptable cosmetic and functional outcome.
Conclusion: The tubularized incised plate repair with suggested modification of asymmetrical division of dorsal prepuce and use of dartos flap to cover the neourethrais a good option in select patients of hypospadias without chordee. The advantage is that there is no overlapping of suture lines of the neourethra and skin and it takes care of glanular tilt. However the cosmesis is not as good as in cases where there is symmetrical division of prepucial flaps.
Keywords: Dartos flap, hypospadias, neourethra, tubularised incised plate
|How to cite this article:|
Kadian YS, Pradeep K, Singh M. Tubularized incised plate urethroplasty with dorsal dartos flap cover and asymmetrical prepucial flaps: A valuable option in hypospadias repair?. Arch Int Surg 2017;7:48-51
|How to cite this URL:|
Kadian YS, Pradeep K, Singh M. Tubularized incised plate urethroplasty with dorsal dartos flap cover and asymmetrical prepucial flaps: A valuable option in hypospadias repair?. Arch Int Surg [serial online] 2017 [cited 2018 Sep 23];7:48-51. Available from: http://www.archintsurg.org/text.asp?2017/7/2/48/229184
| Introduction|| |
Hypospadias is one of the most common congenital anomalies of the male genital system with a reported incidence of 1 per 200–300 live male births. More than 200 techniques have been described for repairing hypospadias but none is considered a standard method. In 1994, Snodgrass described tubularized incised plate (TIP) urethroplasty for distal penile hypospadias repair, which is essentially an in-situ tubularization of dorsally incised urethral plate. This technique is now commonly used in patients of hypospadias without chordee., However, there is always a need for an additional tissue layer between the neourethra and the overlying skin to avoid formation of a urethrocutaneous fistula. This soft tissue flap is usually raised from the preputial skin; however, this may result in penile torsion and devascularization of the preputial skin which is often used in reconstruction of the penile skin. A ventral dartos flap has been used to cover the neourethra to avoid these complications. Nevertheless, complications such as fistula, meatal stenosis, urethral flap necrosis, and dehiscence are still encountered.,, Surgeons have been using small variations in the technique to limit such complications., The present study is also a variation of the technique of Snodgrass repair in which the dorsal prepuce is divided into two unequal parts (1/3rd and 2/3rd) and a dartos flap taken from the 1/3rd part to cover the neourethra and the remaining 2/3rd portion of double-layered prepuce rotated from the opposite side to cover the penile shaft. The advantages and limitations of the present technique over the well described procedures are discussed.
| Patients and Methods|| |
Thirty-five patients of distal hypospadias operated over a period of 4 years (2010–2013) were included in the study. The mean age was 3.2 years (range 18 months to 12 years). Patients with distal hypospadias (subcoronal 16, distal penile 19), having good prepucial hood, adequate urethral plate (6–8 mm size), and without chordee were included in the study. Patients with persistent chordee after degloving of shaft, poor quality of urethral plate, and previously operated or circumcised ones were excluded from the study. Moreover, an informed consent was taken from the parents regarding the present surgical technique, its outcome, as well as success or failure rate.
All patients were operated under general anesthesia supplemented with caudal block. A stay suture was applied over the glans and a U-shape incision was given along the lateral edges of urethral plate with proximal extension up to the skin over the external meatus. This incision was extended dorsally 2–3 mm away from the coronal junction and complete degloving of the shaft on the ventral as well as dorsal aspects of penile shaft was done. Artificial erection test was done in all cases to confirm the straightening of the penile shaft. Then, the urethral plate was incised in the midline extending from the meatus up to just below the tip of glans and mobility of the urethral strips was also assessed [Figure 1]a. The glanular wings were raised and the divided urethral plate was tubularized over a 6 or 8 FG size catheter with vicryl 6 O continuous sutures. The splayed-out corpus spongiosum lying on either side of the urethral plate was mobilized and sutured with 6 O vicryl interrupted sutures [Figure 1]b. A vertical incision was given at the junction of one-third and two-third of the width of the prepuce [Figure 1]c. The dissection was done between the two layers of one-third of prepuce and a subcutaneous flap taken from the inner aspect and the outer skin was excised. This flap was rotated and taken from one side to cover the neourethra [Figure 2]a, the remaining two-third of both prepucial layers (outer skin and inner dartos layer) were rotated from the opposite side as for the flap to cover the penile shaft and glanuloplasty was also done [Figure 2]b. The skin closure was then done to cover the penile shaft to complete the repair. Compressive dressings were applied and antibiotics (cefotaxime and amikacin) were given for five days. The postoperative picture shows edema of the prepucial layers which were rotated to cover the neourethra [Figure 2]c; [Figure 3]a. The urethral catheter was removed after 8–10 days. Patient passed urine with good stream and a rim of prepuce is seen only on one side where two-third of the asymmetrically divided prepuce is placed on the neourethra [Figure 3]b. Postoperative photograph with no glans tilt [Figure 3]c.
|Figure 1: (a) Incised urethral plate; (b) neourethra created; (c) sorsal prepuce divided into two unequal flaps|
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|Figure 2: (a) Flap covering the neourethra; (b) double-layered prepuce covering the penile shaft; (c) early postoperative picture with edema of the flap|
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|Figure 3: Clinical photographs showing (a) postoperative photograph before the removal of stent; (b) patient passing urine in good stream during follow-up; (c) Soft tissue on the penile ventrum lifting the glans|
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| Results|| |
The tubularized incised plate repair with asymmetrical division of the dorsal prepuce and use of dartos flap to cover the neourethra resulted in good conical glans and a slit-like meatus in all cases. Follow-up of patients in the study ranged from 6 months to 2 years. Three (8.57%) patients developed a fistula at the coronal level, of which one closed spontaneously within 3 months of repair whereas two healed after a surgical repair. There was retraction of the meatus in 1 patient. All the remaining patients had good cosmetic and functional outcome. None of the cases had penile torsion consequent upon asymmetrical division of the prepucial flap.
| Discussion|| |
The Snodgrass or TIP repair is a well-established procedure for patients of hypospadias without chordee. This procedure is essentially a tubularization of the divided virgin urethral plate. The inherent advantages of this procedure include the in-situ tubularization of the native urethral plate with a final outcome of a slit-like meatus and a conical glans.,, Other procedures for such cases of hypospadias are MAGPI (meatal advancement and glanuloplasty), Mathieu's flip flap technique, or onlay flap procedure., These repairs have also been proven to be good alternatives in patients of hypospadias without chordee, however, TIP procedure is now being preferred due to low complication rate, good cosmetic outcome, and being a simple surgical technique., However, the neourethra created needs to be covered by a barrier layer (flap) under the skin as an attempt to prevent urethrocutaneous fistula formation. The most commonly used flap for this purpose is the one taken from the dorsal preputial layer. This flap is transposed ventrally from one side of the penile shaft as a whole or divided into two flaps or is buttonholed for ventral transposition. Snodgrass also described an additional layer of cover for the neourethra by subcutaneous tissue dissected from the dorsal prepucial layer after performing the dissection between two layers of prepuce and the outer skin was used to cover the penile shaft. However, this dissection between the two layers of prepuce requires skill, and in addition, the vascularity of the outer skin layer may be compromised. To avoid this dissection between the two layers of prepuce, the authors have devised a variation of this technique where the dorsal prepuce is divided into two unequal halves (one-third and two-third) and a flap is taken from inner layer of one-third portion of the asymmetrically divided prepuce a result of soft tissue of prepucial flap [Figure 3]c. This variation of the technique avoids the overlapping of suture lines of neourethra and outer skin. The advantage of this method is the ease of dissection and absence of risk of loss of blood supply to the dorsal skin. However, the cosmesis is not optimal because of the soft tissue of the prepucial layers on the ventrum of penile shaft.
There are various studies where vascularized flaps have been used to cover the neourethra in Snodgrass repair with good functional and cosmetic outcome,,, and in the present study also a vascularized flap has been used but with asymmetrical prepucial flaps. Despite the use of flaps in the repair of hypospadias, the urethrocutaneous fistulae continue to occur in 5–16% of the cases., In the present study, the fistula rate was 8.57%, which is comparable to the various reported series., However, the fistula repair in cases operated by the described technique is likely to be relatively easier because of availability of enough soft tissue on the ventrum of penile shaft as a result of the double-layered prepucial flap used in the initial repair. Another advantage of this flap is that it takes care of glanular tilt because of the cushioning effect of the soft tissue. However, the cosmetic outcome with this technique may not be comparable to those using techniques where the prepuce is divided symmetrically. The authors believe that the proposed technique would be most beneficial to the select group of patients of hypospadias having good dorsal prepuce and in whom a long neourethra is created in the more proximal virgin hypospadias cases.
| Conclusion|| |
The TIP repair with suggested modification of asymmetrical division of dorsal prepuce and use of dartos flap to cover the neourethra is a valuable option in select patients of hypospadias without chordee. The advantage is that there is no overlapping of suture lines of the neourethra and skin. Moreover, it takes care of glanular tilt which is commonly seen in hypospadias. However, the cosmesis is a reason for concern because of the asymmetrical division of prepucial flaps.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baskin LS, Ebbers MB. Hypospadias: Anatomy, etiology, and technique. J Pediatr Surg 2006;41:463-72.
Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5.
Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair for proximal hypospadias. J Urol 1998;159:2129-31.
Jayanthi VR. The modified Snodgrass hypospadias repair: Reducing the risk of fistula and meatal stenosis. J Urol 2003;170:1603-5.
Alsharbaini R, Almaramhy H. Snodgrass urethroplasty for hypospadias repair: A retrospective comparison of two variations of the technique. J Taibah Univ Med Sci 2014;9:69-73.
Guralnick ML, al-Shammari A, Williot PE, Leonard MP. Outcome of hypospadias repair using the tubularised incised plate urethroplasty. Can J Urol 2000;7:986-9.
Cheng EY, Vemulapalli SN, Kropp BP, Pope JC 4th
, Furness PD 3rd
, Kaplan WE, et al
. Snodgrass hypospadias repair with vascularized dartos flap: The perfect repair for virgin cases of hypospadias? J Urol 2002;168:1723-6.
Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair: Results of a multicenter experience. J Urol 1996;156:839-41.
Al-Hunayan AA, Kehinde EO, Elsalam MA, Al-Mukhtar RS. Tubularized incised plate uretheroplasty: Modification and outcome. Int Urol Nephrol 2003;35:47-52.
El-Kassaby AW, Al-Kandari AM, El-Zayat T, Shokeir AA. Modified tubularized incised plate urethroplasty for hypospadias repair: A long-term result of 764 patients. J Urol 2008;71:611-5.
Snodgrass W, Bush N. Primary hypospadias repair techniques: A review of the evidence. Urol Ann 2016;8:403-8.
] [Full text]
Ducket JW. MAGPI (meatoplasty and glanuloplasty): A procedure for subcoronal hypospadias. Urol Clin North Am 1981;8:513-9.
Hueber PA, Antczak C, Abdo A, Franc-Guimond J, Barrieras D, Houle AM. Long-term functional outcomes of distal hypospadias: Comparison with the Mathieu repair. Pediatr Surg Int 2010;26:519-22.
Djordjevic ML, Perovic SV, Slavkovic Z, Djakovic N. Longitudinal dorsal dartos flap for prevention of fistula after a Snodgrass hypospadias procedure. Eur Urol 2006;50:53-7.
Kolon TF, Gonzales ET Jr. The dorsal inlay graft for hypospadias repair. J Urol 2000;163:1941-3.
Shoeib MA. Snodgrass Repair of Hypospadias (10 years Experience of a Modified Technique). Anaplastology 2015;5:155.
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.
[Figure 1], [Figure 2], [Figure 3]