|Year : 2017 | Volume
| Issue : 2 | Page : 52-55
Experience with tubularized incised plate urethroplasty in distal and mid penile hypospadias
Tausif A Khan1, Reyaz Ahmad2, Shehtaj Khan1, Rajendra S Chana3
1 Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Paediatric Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
3 Department of Paediatric Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||4-Apr-2018|
Dr. Reyaz Ahmad
Department of Paediatric Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Whilst hypospadias is a common congenital defect in boys its aetiology largely remains unknown. The objective of this study was to evaluate the results of tubularized incised plate (TIP) urethroplasty in distal and mid-penile hypospadias repair.
Patients and Methods: This was a prospective clinical study conducted in the Department of Pediatric Surgery over a period of 42 months (January 2012 to June 2015). All patients with distal and mid shaft hypospadias who underwent TIP urethroplasty in our department were studied. The patients were followed up for a period of 1 year after surgery.
Results: Fifty eight patients (N = 58) with hypospadias (29 distal and 29 mid penile) were included in the study. The mean age at presentation was 4.5 years (range 3–7 years). The mean operative time was 70 min (range 55–90 min). The mean duration of postoperative stay was 11 days (range: 10–14 days). Overall 15 patients (25.86%) developed complications. Urethrocutaneous fistula (UCF) developed in 10 (17.24%) patients. Meatal stenosis occurred in six (10.34%) patients. Five patients (8.62%) developed flap necrosis and dehiscence of glans occurred in two patients (3.44%). The difference in complication rate between different types of hypospadias was not statistically significant (P > 0.05). There was no statistically significant difference in cosmetic and functional outcome between two groups operated by TIP urethroplasty.
Conclusion: TIP urethroplasty is a simple and effective technique of repair for distal and mid-penile hypospadias in properly selected patients. It offers good functional and cosmetic results.
Keywords: Hypospadias, tubularized incised plate, urethrocutaneous fistula, urethroplasty
|How to cite this article:|
Khan TA, Ahmad R, Khan S, Chana RS. Experience with tubularized incised plate urethroplasty in distal and mid penile hypospadias. Arch Int Surg 2017;7:52-5
|How to cite this URL:|
Khan TA, Ahmad R, Khan S, Chana RS. Experience with tubularized incised plate urethroplasty in distal and mid penile hypospadias. Arch Int Surg [serial online] 2017 [cited 2018 Nov 19];7:52-5. Available from: http://www.archintsurg.org/text.asp?2017/7/2/52/229188
| Introduction|| |
Despite being one of the most common congenital defects in boys, the etiology of hypospadias largely remains unknown. The child with hypospadias presents a difficult surgical challenge. There are over 200 procedures described in literature for hypospadias repair. In 1994, Snodgrass popularized the concept of deep incision of urethral plate up to the corporal bodies with subsequent Thiersch-Duplay tubularization and secondary dorsal healing for primary hypospadias repair. This relatively simple and effective procedure has gained widespread acceptance over the years. The tubularized incised plate (TIP) urethroplasty is currently being recognized as the surgical technique of choice for distal hypospadias.
The spectrum of TIP urethroplasty has also been extended to proximal hypospadias, scientifically proven in a multicenter experience., Snodgrass and Yucel have reported success of the TIP urethroplasty for mid-shaft and selected patients with proximal penile hypospadias with significantly improved outcome, but noted that results of mid shaft versus proximal hypospadias repairs are significantly different and should be reported separately.
Therefore, the purpose of this study was to evaluate the results of TIP urethroplasty in distal and mid-penile hypospadias repair.
| Patients and Methods|| |
This was a prospective clinical study conducted in the Department of Pediatric Surgery over a period of 42 months from January 2012 to June 2015. All patients admitted with distal and mid penile hypospadias were included in the study. The patients with previous failed surgery, presence of ventral chordee more than 30°, circumcised patients and patients not giving informed consent were excluded from the study.
An institutional ethical approval was obtained and informed consent was taken from parents/guardians. The patients were admitted after routine work up and anesthetic consultation, a day before surgery. All patients received intravenous antibiotics before induction of anesthesia. All patients were operated under general anesthesia with endotracheal intubation and caudal block for postoperative analgesia.
A stay suture was placed in glans to aid in traction of the phallus. The penis was degloved with a circumscribing incision carried ventrally to 1–2 mm proximal to urethral meatus, preserving the urethral plate. An artificial erection test was performed to demonstrate chordee, which if present, was corrected by dorsal midline plication. A deep midline incision was given in the urethral plate from meatus to its most distal extent. The plate was tubularized with 6-0 polyglactin using continuous subcuticular suture in a single layer. In all cases, dartos flap was applied as second layer. The closure of glans wing was done with 5-0 polyglactin suture. No spongioplasty or mobilization of urethral plate was performed. All repairs were stented with 6 Fr. Nelaton's catheter which drained into urine collecting bag. A mild compressive dressing was applied. All patients received intravenous antibiotics for 2 days, followed by oral antibiotic and were monitored regularly for complications. The dressing was removed on postoperative day 3 and catheter on day 10. The patients were discharged after they passed urine. Postoperative results were assessed on the basis of complications like bleeding, flap necrosis, glans dehiscence, urethrocutaneous fistula (UCF), meatal stenosis, neourethral stricture, and residual chordee. The urethral calibration was not routinely performed unless patient complained of poor urinary stream. The cosmetic and functional results were also noted.
Each patient was assessed during admission, after removal of catheter, 2 weeks after discharge from hospital and three monthly for 1 year. A proforma was used to record the observations.
The statistical analysis was done using MedCalc® 188.8.131.52 version. Chi-square test was used for testing the association between types of hypospadias, outcome of surgery as well as incidence of complications. Fischer's exact probability test was calculated to test the association of different type of complications with the type of hypospadias. A P< 0.05 was considered statistically significant.
| Results|| |
Fifty eight patients with hypospadias (29 distal penile and 29 mid-penile) were included in the study. The mean age of presentation was 4.5 years (range 3–7 years). The mean operative time was 70 min (range 50–80 minutes). The mean duration of postoperative stay was 11 days (range 10–14 days).
Overall, 10 patients (17.24%) developed UCF. All patients with UCF required reoperation after 6 months, all fistulas healed after repair. Six patients (10.34%) in the present study developed meatal stenosis, out of which two patients developed both meatal stenosis and UCF, which required reoperation. Four patients with meatal stenosis were managed successfully by serial meatal dilatation. [Table 1] depicts the incidence of each of the complications, that is, UCF, meatal stenosis, flap necrosis, and glans dehiscence vis-a-vis the clinical type of hypospadias.
|Table 1: Incidence of different complications following TIP urethroplasty among the two groups of hypospadias|
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Overall, fifteen (25.86%) patients had developed complications following TIP repair. However, the proportion of complication between distal and mid-penile hypospadias did not assume statistical significance (P > 0.05) [Table 2].
|Table 2: Proportion of patients with complication vis-a-vis those without complication among the two groups of hypospadias|
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The cosmetic outcome as reported by parents, was good in 26 (89.65%) and 23 (79.31%) patients undergoing TIP repair for distal and mid-penile hypospadias respectively. The functional outcome, as judged by urinary stream, was good in 26 (89.65%) and 22 (75.86%) patients undergoing TIP repair for distal and mid-penile hypospadias respectively. The difference in outcome between the two groups was not statistically significant (P > 0.05).
The significant bleeding/hematoma formation, penile torsion, urethral stricture, residual chordee, delayed fistula, and urethral diverticulum were not found in the present study.
| Discussion|| |
The ultimate goal of hypospadias repair is a penis that is not only functionally normal, but also achieves cosmesis. The urethral plate in hypospadias is a vascularized tissue with extensive muscular and connective tissue backing, rich in nerve supply and with gland forming capability. The TIP repair takes the advantage of this extensive blood supply under the urethral plate, seems to respond to primary incision and secondary healing without scarring, resulting in adequate caliber neourethra and vertical slit like configuration of neomeatus. This single stage procedure gives excellent functional and cosmetic result and can be done in circumcised patients as it doesn't require prepuce for urethroplasty.,
Although, several modifications and refinements have been made, UCF still remains the main postoperative complication. Braga et al. in their review of 54 studies related to distal hypospadias operated by TIP urethroplasty, reported a median fistula rate of 5%, ranging from 0% to 16%. Snodgrass et al. reported overall complication rate of 25% and fistula incidence of 10% after TIP repair for proximal hypospadias.
Several factors may influence fistula formation: surgical technique, delicate tissue handling, patient's age, type of hypospadias defect, surgeon's experience, waterproofing urethroplasty coverage, and concomitant preputioplasty. However, one study suggests that only the type of hypospadias has a statistically significant impact on development of UCF, whereas type of hypospadias repair, suture materials, and technique has no significant effect on the outcome.
In the present study, three patients (10.34%) and seven patients (24.13%) developed fistula following TIP repair in distal and mid-penile hypospadias respectively. However, there was no significant difference in the development of UCF between the two groups [Table 1]. Further refinement of surgical technique with the use of finer suture material, two layered neourethral closure, younger patients, and dedicated team for hypospadias repair may further improve the results.
Braga et al. in their review noted meatal stenosis rate of 2.1%, ranging from 0% to 17% in 53 studies. Meatal stenosis is considered to be related to faulty surgical technique and occurs when urethral plate incision is extended beyond the urethral plate far too distally. In the present study, six patients (10.34%) developed meatal stenosis. Four patients with meatal stenosis were managed with dilatation and two patients who also had UCF required surgical correction. The incidence of meatal stenosis was higher in patients operated in early part of the study and we felt that limiting the dorsal midline incision just up to the urethral plate and not extending beyond it resulted in fewer stenosis.
No patient in the present study developed symptomatic urethral stricture. Snodgrass demonstrated with calibration and urethroscopy that the neourethra lumen after TIP repair is adequate as healing of the incised urethral plate occurs without fibrosis. However, 17% patients with proximal hypospadias in his series undergoing TIP repair with urethral plate elevation and proximal urethral mobilization developed symptomatic stricture. There is an extensive network of blood vessels and large vascular sinuses supplying the urethral plate which seems to respond to secondary healing without scarring. The urethral plate elevation defeats the purpose of urethral plate preservation by violating this intricate blood supply leading to stricture.
Additional coverage of neourethra by vascularized dartos flap was performed in the present study. This dissection requires skill and there are chances that vascularity of the skin cover may get compromised resulting in subsequent dermal necrosis. Other causes include hematoma, infection, vascular spasm, and tight dressing. In one series, the incidence of penile skin flap necrosis was reported to be 6%. In the present study, flap necrosis developed in five (8.62%) patients.
In the present study, two (3.45%) patients developed glans dehiscence. A study reported the incidence of glans dehiscence to be 5% in patients undergoing TIP repair. Age at repair, preoperative hormonal stimulation, and type of suture used for glansplasty did not impact the risk of glans dehiscence. However, odds of glans dehiscence were 3.6 times higher in patients with proximal versus distal meatal location and 4.7 folds higher in patients undergoing reoperative versus primary TIP repair.
| Conclusion|| |
TIP urethroplasty is a simple and elegant technique of repair for distal and mid-penile hypospadias in properly selected patients. It gives good functional as well as cosmetic result with low rate of complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brouwers MM, van der Zanden LF, de Gier RP, Barten EJ, Zielhuis GA, Feitz WF, et al
. Hypospadias: Risk factor patterns and different phenotypes. BJU Int 2010;105:254-62.
Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5.
Cook A, Khoury AE, Neville C, Bagli DJ, Farhat WA, Pippi Salle JL. A multicenter evaluation of technical preferences for primary hypospadias repair. J Urol 2005;174:2354-7.
Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair: Results of a multicentre experience. J Urol 1996;156:839-41.
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.
Snodgrass W, Yucel S. Tubularized incised plate for mid shaft and proximal hypospadias repair. J Urol 2007;177:698-702.
Erol A, Baskin LS, Li YW, Liu WH. Anatomical studies of the urethral plate: Why preserving the urethral plate is important in hypospadias repair. BJU Int 2000;85:728-34.
Baskin LS, Ebbers MB. Hypospadias: Anatomy, etiology, and technique. J Pediatr Surg 2006;41:463-72.
Snodgrass WT. Utilization of urethral plate in hypospadias surgery. Indian J Urol 2008;24:195-9.
] [Full text]
Braga LH, Lorenzo AJ, Salle JL. Tubularized incised plate urethroplasty for distal hypospadias: A literature review. Indian J Urol 2008;24:219-25.
] [Full text]
Snodgrass WT. Tubularized incised plate (TIP) hypospadias repair. Urol Clin North Am 2002;29:285-90.
Chung JW, Choi SH, Kim BS, Chung SK. Risk Factors for the development of urethrocutaneous fistula after hypospadias repair: A retrospective study. Korean J Urol 2012;53:711-5.
Snodgrass W. Does tubularized incised plate hypospadias repair create neourethral strictures? J Urol 1999;162:1159-61.
Snodgrass WT, Granberg C, Bush NC. Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair. J Pediatr Urol. 2013;9:990-4.
Baskin LS, Erol A, Li YW, Cunha GR. Anatomical studies of hypospadias. J Urol. 1998;160:1108-15.
Bhat A, Mandal AK. Acute postoperative complications of hypospadias repair. Indian J Urol. 2008;24:241-8.
Bakal Ü, Abeş M, Sarac M. Necrosis of ventral penile skin flap: A complication of hypospadias surgery in children. Adv Urol 2015;2015:452870.
Snodgrass W, Cost N, Nakonenzy PA, Bush N. Analysis of risk factors for glans dehiscence after tubularized incised plate hypospadias repair. J Urol 2011;185:1845-9.
[Table 1], [Table 2]