Tubularized incised plate (TIP) hypospadias repair

Cumulative sum learning curve analysis of tubularized incised plate repair for hypospadias: a study of a single surgeon with a single surgical procedure

Purpose

To ascertain the quantity of instances by which a single surgeon achieves competency and proficiency in using tubularized incised plate (TIP) technique for the repair of distal and mid-shaft hypospadias using the cumulative sum (CUSUM) analysis.

Methods

We retrospectively evaluated patients with distal and mid-shaft hypospadias who were treated by a single surgeon between 2015 and 2021, using a single primary TIP technique with a de-epithelialized Byars flap. Data including type of hypospadias, age at surgery, curvature, operation time (OT), length of the reconstructed urethra, and postoperative outcomes were collected and assessed. CUSUM was used to assess the trends in OT and complication rate (CR) in order to generate the learning curve. The evolution of OT and CR can be divided into three phases: learning, competence, and proficiency.

Results

CUSUM identified three phases in the learning curves of all TIP repairs. The median OT decreased from 135 min [interquartile range (IQR) = 125-155] to 92 min (IQR = 80-100) (P < 0.001), CR decreased from 28 (28%) to 8 (5.3%) (P < 0.001), and reoperations decreased from 15 (15.2%) to 4 (2.6%) (P < 0.001). According to the CUSUM learning curve, technical competency plateaued after the 99th case, and both OT and CR entered a significantly declining proficiency phase after the 231st case. Further, when the neourethral length exceeded the total average, total complications, urethrocutaneous fistula, and reoperations increased (P = 0.013, P = 0.006, and P = 0.028, respectively).

Conclusions

Our study suggests that surgeons performing TIP repair may reach technical competency and achieve proficiency after operating on 99,231 cases, respectively. Moreover, the longer the neourethral length, the higher is the CR.

Comparing two surgical techniques in distal hypospadias repair: Urethral mobilization vs. urethral plate tubularization

OBJECTIVES

While numerous techniques have been described for hypospadias repair, the Tubularized Incised Plate (TIP) procedure is currently the most frequently used method. On the other hand, urethral mobilization techniques have less frequent preference. In this study, we aimed to compare the outcomes of these two techniques in patients with distal hypospadias, particularly those with the urethral meatus located at the coronal and subcoronal.

MATERIAL AND METHODS

A total of 75 patients with distal hypospadias underwent surgery. Patients with glanular and midpenile hypospadias whose meatus was not located at the coronal and subcoronal levels were excluded from the study. 43 patients underwent surgery performing the Eccentric Circummeatal-Based Flap with Limited Urethral Mobilization (ECMB) method, while the remaining 32 patients were treated with the TIP. We analyzed age at surgery, urethral meatus position, ventral or glanular curvature, catheterization duration, and complications.

RESULTS

The mean age at operation was 2.6 (±1.1) years. The position of the meatus was coronal in 48 patients (64%), and subcoronal in 27 (36%). Complications consist of fistula in two patients, meatal stenosis in seven patients, and preputial redundancy in two patients. No glans retraction, wound infection or glans dehiscence was observed in any patient. Complication rates were compared and no statistically significant difference was found between the two methods (P>0.05).

CONCLUSION

Mobilization techniques may be a preferable and safe option for young surgeons due to their relative ease of perform.

Effectiveness of penile ventral curvature correction and the trend of hypospadias repair: a prospective study of the national center in China

BACKGROUND

Hypospadias repair is a complex surgical procedure that involves correcting penile ventral curvature (VC) and performing urethroplasty. This study aims to evaluate the effectiveness of different strategies for VC correction and analyse the trends in hypospadias repair at a national centre in China.

METHODS

Prospective data collection was conducted from 2019 to 2020 for patients undergoing hypospadias repair. The effectiveness of VC correction was assessed based on the degree of VC change with different strategies. Furthermore, the choice of surgical techniques for different types of hypospadias repair was analysed.

RESULTS

A total of 434 patients were included, with a median preoperative VC degree of 50° (35°, 70°). All patients achieved a straight penis postoperatively, with 15.2% undergoing degloving, 28.6% undergoing degloving and dorsal plication (DP), 13.1% undergoing degloving and urethral plate transection (UPT), and 43.1% undergoing degloving, UPT and DP. Degloving alone was effective in correcting VC in 57.6% of patients with VC less than 30°. In our analysis, DP after UPT resulted in a higher degree of correction (25°) compared with DP after degloving alone (20°) (p<0.001). The study identified the current trends in hypospadias repair, with tubularised incised plate urethroplasty (TIP) being the most common technique used in distal hypospadias repair (70.6% of patients) and transverse preputial island flap urethroplasty (TPIFU) being preferred for proximal hypospadias repair (63.0%).

CONCLUSIONS

Degloving alone is effective for correcting VC less than 30°. The majority of patients in our centre underwent UPT, and DP after UPT yielded better results compared with DP after degloving alone. Distal hypospadias repair commonly used TIP, while TPIFU was favoured for proximal hypospadias repair.

TRIAL REGISTRATION NUMBER

ChiCTR1900023055.

One-stage repair of proximal hypospadias by in situ tubularization of the transverse preputial island flap

PURPOSE

This study aimed to compare the efficacy of modified transverse preputial island flap (TPIF) repair with the traditional TPIF procedure and Byar's two-stage procedure in proximal hypospadias repair, especially in the postoperative urethral stricture incidence rates.

MATERIALS AND METHODS

Patients admitted for proximal hypospadias treated with modified TPIF repair, the traditional TPIF procedure, or Byar's two-stage procedure at our institution from 2017 to 2021 were identified, and the incidence of postoperative complications among them was compared.

RESULTS

In total, 142 patients were included (modified TPIF group, 43; traditional TPIF group, 37; and Byar's two-stage group, 62). The length of the neourethra was 4.21 ± 0.63 cm in the modified TPIF group, 4.18 ± 0.71 cm in the traditional TPIF group, and 4.20 ± 0.68 cm in the Byar's two-stage group. The rate of urethral stricture in the modified TPIF group (two cases, 4.65%) was significantly lower than that in the traditional TPIF group (four cases, 10.81%) (P = 0.008). Seven (16.28%) cases of urethrocutaneous fistula occurred in the modified TPIF group, six (16.22%) in the traditional TPIF group, and eight (12.90%) in the two-stage group. Additionally, one case (2.33%) of urethral diverticulum occurred in the modified TPIF group, one (2.70%) in the traditional TPIF group, and three (4.84%) in Byar's two-stage group.

CONCLUSIONS

Modified TPIF repair can ensure a wedge anastomosis between the proximal urethral meatus and the neourethra, provide support and blood supply for the neourethra. Furthermore, it extended the urethral plate width at the anastomosis and urethral meatus, effectively reducing the incidence of urethral strictures.

A simple technique to repair distal and mid-shaft hypospadias using a de-epithelialized Byars' flap

OBJECTIVE

To describe standard and modified de-epithelialized Byars' flap techniques in tubularized incised plate urethroplasty and evaluate postoperative outcomes.

METHODS

We retrospectively evaluated data for 404 primary hypospadias repair patients who underwent standard (Group A) or modified (Group B) urethroplasty between January 2016 and 2021. Group B's data were analyzed to evaluate whether our modified technique was effective for all hypospadias types.

RESULTS

There was no difference in the ratio of different hypospadias types between Groups A (n = 145) and B (n = 259). Median follow-up duration was 35 months. Fistula occurred in 19 patients in Group A and 12 in Group B (statistically significant difference). The total complication rate was statistically significantly different between the groups. In Group B, 3/142 patients with distal hypospadias developed urethrocutaneous fistula vs 4/95 with mid-shaft hypospadias and 5/22 with proximal hypospadias. No difference was noted between the distal and mid-shaft groups. Significant differences were observed when comparing distal and mid-shaft groups with the proximal group; total complication rates were similar. Glans dehiscence and meatal stenosis rates were similar between Groups A and B, and among the hypospadias phenotypes.

CONCLUSION

Our modified procedure is simple to perform and yields excellent results in distal and mid-shaft hypospadias repair.

Autologous platelet gel improves outcomes in tubularized incised plate repair of hypospadias

BACKGROUND

hypospadias is one of the most widespread male congenital anomalies, occurring in 1:250 to 1:300 live births. Several repair techniques have been developing to improve the outcomes.

PURPOSE

a randomized prospective controlled study was adopted to evaluate effectiveness of autologous platelet gel in healing promotion and improving the outcomes of hypospadias repair.

METHODS

thirty children who aged between 6 months and 12 years were recruited and subdivided into two groups; group A had tubularized incised plate (TIP) repair with autologous platelet gel application and group B had TIP repair without autologous platelet gel.

RESULTS

there was no significant difference in duration of operation between both groups. All patients in groups A and B had slit-like meatus shape in the distal glans. While all those of group A had one urine stream, yet only 11 of group B had one. There were complications that happened exclusively in group B such as spray stream (27%) and fistula (20%). Whereas other complications occurred insignificantly more in group B than in A including meatal stenosis (53 versus 27%), glans dehiscence, (20 versus 7%), bleeding (33 versus 13%), infection (33 versus 27%), edema (27% versus13), respectively. The incidence of skin necrosis was equal in both groups.

CONCLUSION

autologous platelet gel usage in TIP hypospadias repair can be a reliable technique to promote wound healing, and to limit of postoperative surgical complications.

Outcomes of islanded scrotal raphe flap employment for skin shortage in complicated hypospadias repair

BACKGROUND

Ventral skin deficiency in complicated hypospadias is a difficult problem to treat. The aim of our study is to report our technique and outcomes of vascularized islanded scrotal raphe flap for ventral skin deficiency in complicated hypospadias.

METHODS

A retrospective review was conducted at Northwest General Hospital & Research Centre, Peshawar, from January 2012 to January 2019. Complicated hypospadias patients who underwent two-stage surgery employing islanded scrotal flap were identified. Patients underwent surgery in two stages: scar tissue removal, chordee correction and buccal mucosal graft in the first stage; neourethral tubularization, water proofing, and skin coverage with vascularized islanded scrotal raphe flap in the second stage. The primary outcome was 6-month flap survival rate. Secondary outcomes were 6-month complication rate (fistula, persistent chordee, distal stenosis) and end-of-follow-up patient self-reported satisfaction rate.

RESULTS

A total of 1845 patients underwent hypospadias surgery, of which 380 patients had complications. Scrotal raphe flap was used in 45 patients. Mean age was 14.09 (±8.02) years. Mean follow-up was 29.78 (±12.18) months. Mean number of previous surgeries was 4.31 (±2.59). The flap survived in all cases. Nine patients (20%) developed complications. One patient (2.2%) developed distal stenosis. Eight patients (17.8%) developed fistulas, one of whom additionally had persistent chordee. Five fistulas closed spontaneously within 3 months, while the rest were repaired surgically after 6 months. All patients self-reported satisfaction with results at end-of-follow-up.

CONCLUSIONS

Islanded Scrotal Raphé flap is a promising option for treating complicated hypospadias when there is significant ventral deficiency of skin, as it not only provides vascularized pliable skin but also fascia as a waterproofing layer.

Stentless hypospadias repair: The way forward

Background:

Stentless repair of hypospadias has been previously described in the literature for distal penile hypospadias repair. This was a prospective non-randomized study with the aim of assessing the efficacy of stentless repair in our health-care system.

Methods:

A total of 104 patients managed prospectively for hypospadias over a 30-month period who met the inclusion criteria were included in the study and underwent a stentless modified tubularized incised plate (TIP) urethroplasty repair (with a slight modification described subsequently) by three surgeons and were followed up for a minimum period of six months.

Results:

The median age at surgery was eight months. The site of meatus was glanular in 20 patients, coronal in 36 patients, sub-coronal in 38 patients and mid-penile in 10 patients. The median operative time was 47 minutes (range 32–76 minutes). The median time to first micturition was 140 minutes (range 10–300 minutes). Voiding difficulty was encountered in two patients, requiring catheterization. Three patients had superficial surgical site infections which were conservatively managed. All patients were discharged on the second postoperative day, except for the three patients with surgical site infection. On follow-up, two patients had a fistula.

Conclusion:

Stentless repair of hypospadias is the future and the new standard of care and should be used in every case where a modified TIP repair is feasible. This decreases complications from urethral stenting and decreases the duration of hospital stay. Both patient and parents are comfortable with this procedure. Level of evidence Level 2.

Cosmetic and functional outcome for the use of stitch by stitch technique in hypospadias surgery; results of 235 patients

INTRODUCTION

One of the essential goals of hypospadias surgery is to create a cosmetically and functionally accepted penis with a near-normal looking glans and external meatus.

AN OBJECTIVE

We developed our technique stitch by stitch to allow glans closure in a conical manner with centrally located external urethral meatus in hypospadias repair using onlay flap.

STUDY DESIGN (PATIENT AND METHODS)

A total of 235 hypospadias male patients (0.5-30 years old) were included in the study. All of them treated by flap urethroplasty techniques and meatoglanuloplasty using stitch by stitch technique. Operative technique (described in details by illustrations); starts with penile degloving, preparation of the flap (Site of hypospadic meatus is determined after degloving). Creation of a narrow strip of the urethral plate with wide glanular wings is done using bilateral incisions which are extended to the tip of the glans. The width of the urethral plate is about 3 mm then we suture the flap to the narrow urethral plate in two layers in continuous manner using vicryl 6/0 over a suitable plastic catheter. Triangular (V shape) area of the distal part of the flap is excised at the midline. After this we anastomose the flap to the tip of the glans. The glans appears opened in the midline as inverted V shape. Closure of the glans is finished in the midline using three mattress interrupted sutures with another three simple stitches are used in between.

RESULTS

From February 2007 to December 2016; 235 hypospadias patients fulfilled criteria and were included in our prospective cohort study table (1).

DISCUSSION

The meatoplasty technique and stitch-by-stitch glans closure were used in all patients. Excellent results were achieved with an overall degree of satisfaction of 87% in patients older than six years (based on the Pediatric Penile Perception Score), and 84% in patients younger than six years. The complication rate was low at 8.5% and was related to a failure of the flap technique. Many surgical techniques have been described for glans closure and meatoplasty with variable outcomes, but none of them fits all patients with hypospadias; each procedure has its limitations and demands specific selection criteria. Limitations of this study come from a relatively short follow-up, and a single surgeon experience that needs to be reproduced by other surgeons.

CONCLUSION

Meatoglanuloplasty using stitch-by-stitch technique provides satisfactory cosmetic and functional results in hypospadias patients.

[Urethral reconstruction in patients with failed hypospadia repair]

BACKGROUND

The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.

OBJECTIVES

To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.

MATERIALS AND METHODS

The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.

RESULTS

The general rules of reconstruction that should be applied in each particular situation are described.

CONCLUSIONS

Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

Choosing an ideal vascular cover for Snodgrass repair

AIM

The aim of this study is to compare tunica vaginalis (TV), dorsal dartos, and ventral dartos flap as a second layer vascular cover during Snodgrass repair.

MATERIALS AND METHODS

Data of 83 patients who underwent primary hypospadias repair with Snodgrass technique (age range: 1.6-12 years) were retrospectively collected and compared. They were divided into three groups. Group A (26 patients) included cases using TV flap, Group B (36 patients) included those where dorsal dartos from prepuce was used as second cover, and Group C (21 patients) included those with ventral dartos as cover.

RESULTS

In Group A, no complications recorded. Mild scrotal edema was present in 5 patients which was conservatively managed. In Group B, there were 8 fistulas, 2 glans breakdown, and 1 meatal stenosis. In Group C, there were 3 fistulas and 1 glans breakdown.

CONCLUSION

TV flap is better than dorsal dartos and ventral dartos as vascular cover for primary hypospadias repair with Snodgrass technique.

Grafted tubularised incised-plate urethroplasty: An objective assessment of outcome with lessons learnt from surgical experience with 263 cases

Objective

Snodgrass urethroplasty remains the preferred technique in primary distal hypospadias but development of meatal stenosis often limits distal extension of the midline incision of the urethral plate (MIUP), which remains a limiting factor in reconstructing an apical neomeatus (NM). We here-in assess the cosmetic and functional outcome with distal extension of the MIUP in grafted tubularised incised-plate urethroplasty (G-TIP) repair.

Patients and methods

This prospective study included the surgical experience of 263 cases of primary hypospadias operated upon between 2012 and 2015. The G-TIP technique included standard steps of Snodgrass urethroplasty, including degloving and harvesting of glans wings, followed by MIUP that was extended distally beyond the margins of the urethral plate (UP) into the glans. The incised bed was grafted with a free preputial skin graft and fixed to the bed with polydioxanone 7-0 suture. The UP was tubularised and the suture line reinforced with a Dartos flap. The urethral catheter was removed at 7–10 days after the repair and the outcome was assessed at follow-up using the Hypospadias Objective Scoring Evaluation (HOSE) system.

Results

An apical NM was achieved in 96% of the patients with a 3.7% incidence of urethrocutaneous fistula. The presence of suture tracks and graft at the margins of the NM were seen in the initial 4% and 5% of cases, respectively. Acceptable cosmetic results, with objective HOSE scores of >14, were achieved in 96% of cases.

Conclusion

The G-TIP repair is a straightforward and feasible technique facilitating reconstruction of an apical NM, with an optimum outcome based on HOSE scoring. However, multicentre data are needed for undertaking comparative analysis and to assess the universal applicability of this technique in primary hypospadias.

A novel technique for repair of mid-penile hypospadias using a preputial skin flap: results of 110 patients

BACKGROUND

Several techniques have been used to repair mid-penile hypospadias; however, high failure rates and major complications have been reported. In this study, we describe a novel technique using a well-vascularized flap of the inner and outer preputial skin.

METHODS

A total of 110 male children with hypospadias underwent repair by our technique between 2008 and 2015. The inclusion criteria were children with mid-penile or slightly more proximal hypospadias, with or without ventral chordae, and an intact prepuce of the cobra eyes variety. Recurrent cases, patients with other preputial types, and circumcised children were excluded from this study. The prepared flap was sutured in its natural longitudinal orientation to the created urethral plate strip to form a neo-urethra over a urethral catheter. Outcome measures included surgical success without the formation of a urethra-cutaneous fistula, no ischaemia of the flaps, glans dehiscence or infection and functional outcome and cosmetic appearance.

RESULTS

The median follow-up duration was 3.3 years. There were 63 cases of mid-penile hypospadias (57.3 %), and in 47 cases (42.7 %), the meatus was slightly more proximal. The age of the patients ranged from 1.1 to 8.0 years, with a mean age of 4.6 ± 1.2 years. Surgery was successful in 106 (96.4 %) cases. Minor complications occurred in 11 patients (10 %) and included oedema of glans in ten patients and bluish discoloration on the ventral aspect of the glans close to the suture line in three patients. All patients improved within 2 weeks after surgery. Long-term follow-up revealed a properly functioning urethra with a forward, projectile, single, compact, and rifled urinary stream of adequate calibre and cosmetically acceptable repair. No cases of meatal retraction, meatal stenosis, urethral stricture, or acquired urethral diverticulum occurred.

DISCUSSION

Our technique is different from the split prepuce in situ technique. We create a narrow strip of the urethral plate that facilitates glanular closure, and we use the inner and adjacent outer skin in a vertical manner to preserve excess skin for penile coverage. Prepuce is split at midline to preserve more preputial skin with favourable dartos tissue for penile skin coverage. The glans is closed using a stitch-by-stitch method that has not been described previously.

CONCLUSION

This study presents a novel technique for mid-penile hypospadias repair using a preputial skin flap with excellent results in terms of short- and long-term outcomes.

Comparison of tubularized incised plate urethroplasty combined with a meatus-based ventral dartos flap or dorsal dartos flap in hypospadias

PURPOSE

Tubularized incised plate urethroplasty (TIPU) is the preferred surgical option for distal and mid-shaft hypospadias repair. Neourethra dartos flap coverage is routinely used as a protective layer with good results. We modified meatus-based ventral dartos flap (MBVDF) to TIPU by dissecting the proximal mid-ventral dartos attached urethra and leaving the subcutaneous fascia connecting the meatus, and retrospectively compared the outcomes of using MBVDF with single dorsal dartos flap (DDF) on the complication rates of TIPU.

METHODS

We present 2 surgeons' experiences with 356 patients with distal and mid-shaft hypospadias between January 2010 and December 2014. Patients were divided into two groups. Group DDF included 185 patients (mean age 29 months) underwent TIPU with DDF rotated laterally covering the suture lines of the neourethra. Group MBVDF included 171 patients (mean age 26 months) underwent TIPU with MBVDF covering the suture lines of the neourethra. Statistical analysis of patient basic information and complications was performed by two independent sample t test and Chi square test or Fisher's exact test.

RESULTS

There were no statistical differences in age, type of hypospadias, and follow-up time between the two groups. The mean operative time in the group MBVDF (68.93 ± 8.32 min) was significantly shorter than in the group DDF (73.60 ± 9.06 min). Ventral skin necrosis (2.7%) and penile rotation (3.8%) in group DDF was significantly higher than group MBVDF which did not occur. The differences in other complication rates including fistula rate (2.7 vs 2.9%) between the groups were not statistically significant.

CONCLUSION

DDF and MBVDF with TIPU are similarly effective methods for decreasing fistula in hypospadias repair. MBVDF with TIPU may be an easier method and can avoid ventral skin necrosis and penile rotation.

Is combined inner preputial inlay graft with tubularized incised plate in hypospadias repair worth doing?

BACKGROUND

It has been noted that after tubularized incised plate urethroplasty (TIP) repair, the final meatal position is glanular but not at the optimum position. Inner preputial inlay graft combined with tubularized incised plate (G-TIP) has been proposed for redo urethroplasty. We extended this indication to be the standard technique for primary hypospadias repair. We conduct this prospective study to obtain a wide, slit-like appearance neomeatus at the optimum position in the glans proper and to judge if hypospadias repair complications differ from TIP repair in the published data in the literature.

PATIENTS AND METHODS

This prospective study included 230 consecutive patients who underwent this technique. The study was conducted from November 2011 to August 2014 for all hypospadias cases to be repaired in a single stage regardless of the width and depth of urethral plate or the glans size and shape. Localization of the meatus was glanular in 13 patients, coronal in 75, distal penile in 112, mid penile in 25 and proximal in five. The urethral plate was incised deeply and extended distally beyond the end of the plate by 3 mm in glans proper. The mucosal graft was harvested from the inner prepuce, inlayed and quilted in the incised urethral plate. The neourethra was created over a urethral catheter in two layers. The vascular dartos flap was mobilized dorsally and moved ventrally to cover the neourethral suture line as a barrier.

RESULTS

The follow-up period ranged from 5 to 36 months. Excellent cosmetic and functional results were achieved in 221 of 230 patients (96.09%). Neither meatal stenosis nor urethral diverticulum were encountered. An excellent glanular position of a wide slit-like neomeatus was achieved using this technique. Nine patients (3.91%) developed urethrocutaneous fistula. Excellent urinary stream was reported by parents.

CONCLUSIONS

Combined inner preputial graft with TIP urethroplasty secures the optimal glanular position of a wide slit-like neomeatus because of extension of the incision beyond the end of the plate, thus optimizing functional and cosmetic outcome with no meatal stenosis.

The effect of dorsal dartos flaps on complication rates in hypospadias repair: a randomised prospective study

AIM

This study prospectively analysed the effect of using a dartos flap on the complication rates of TIPU (tubularised incised plate urethroplasty) in hypospadias repair.

MATERIAL AND METHODS

Patients having TIPU repair for hypospadias at our university hospital between January 2010 and August 2013 were prospectively divided into two groups. Group 1 had TIPU repair with dorsal dartos flap, whereas group 2 had flapless repair. At the end of the follow-up period (mean 23.3 m, median 20.2), complication rates were compared between two groups.

RESULTS

There were 107 patients in each group. The overall complication rate was 9.3%. The complication rates were 12.1% in group 1 (6 glans dehiscence and 7 fistula) and 6.5% in group 2 (2 glans dehiscence and 5 fistula). The differences between complication rates and fistula were statistically insignificant (p = 0.2511 and p = 0.7710, respectively).

CONCLUSION

Our prospective and randomised study found that the use of dartos flaps in hypospadias offers no statistically significant advantage over flapless repair for complication rates.

Urethroplasty by use of turnover flaps (modified mathieu procedure) for distal hypospadias repair in adolescents: comparison with the tubularized incised plate procedure

PURPOSE

The purpose of this study was to examine whether urethroplasty with a turnover flap, as an alternative method of distal hypospadias repair in adolescents, improves the outcome of surgery.

MATERIALS AND METHODS

Between January 2004 and December 2013, a total of 38 adolescents (aged 11-17 years) underwent distal hypospadias repair with either the tubularized incised plate (TIP) procedure (n=25) or the turnover flap procedure (n=13). The turnover flap procedure was performed with a proximal, ventral penile flap that was turned over to cover the urethral plate. Patient demographics, perioperative outcomes, complications, and postoperative uroflowmetry in each surgical group were analyzed retrospectively.

RESULTS

The patient demographics were similar in the two groups. There were no significant differences in perioperative outcomes between the groups, including mean operative time, duration of hospital stay, and urethral catheterization. The number of patients with at least one complication, including wound dehiscence, urethrocutaneous fistula, meatal stenosis, and urethral stricture, was lower in the turnover flap group (1/13, 7.7%) than in the TIP group (11/25, 44%, p=0.030). The incidence of meatal stenosis was lower in the turnover flap group (0/12, 0%) than in the TIP group (6/25, 24%). In postoperative uroflowmetry, the plateau-shaped curve rate was lower in the turnover flap group (1/12, 8.3%) than in the TIP group (5/19, 26.3%); the peak flow was higher (p=0.030).

CONCLUSIONS

The turnover flap procedure is clinically useful for repairing adolescent distal hypospadias because it offers lower complication rates and better functional outcomes than TIP.

Coverage of urethroplasty in pediatric hypospadias: randomized comparison between different flaps

OBJECTIVES

The use of covering urethroplasty with flaps in hypospadias surgery has been well recommended. Various techniques have been described for flap harvesting. The aim of the present study was to compare the outcome and complication rate of dorsal preputial flaps and ventral dartos flaps.

METHODS

A total of 130 patients were prospectively evaluated from January 2008 to December 2011. Using the tubularized incised plate urethroplasty procedure, urethroplasty was carried out by a single surgeon. Patients were randomly divided in two groups: group A (57 patients), in which a preputial flap was carried out using three different techniques; and group B (73 patients), in which a single or a double ventral dartos flap was used.

RESULTS

A total of 41 complications occurred in 24 patients. Urethrocutaneous fistulas were observed in 14.9%, quite equally distributed between groups A and B. There was only one urethrocutaneous fistula in a patient treated with the double ventral dartos flaps. Five cases (3.8%) of glans dehiscence were observed: four after single ventral dartos flap and one after dorsal preputial flap. Six patients in group A and seven in group B experienced meatal stenosis. In three cases of iatrogenic torsion of the penis, a dorsal preputial flap was laterally transposed. Finally, a lower complication rate was observed for double ventral dartos flap versus the other techniques.

CONCLUSIONS

The use of a double ventral dartos flap should represent the first-line technique for coverage of distal urethroplasty.

The glandular resection and central embedding modification (GRACE) in Duckett and Barcat hypospadias repair

INTRODUCTION

We recently reported a novel modification of the Barcat technique termed glandular resection and central embedding (GRACE). Here, we report results from a large patient population and apply this modification also to Duckett hypospadias repair.

PATIENTS AND METHODS

We retrospectively evaluated 488 patients who had undergone primary or secondary hypospadias repair by Barcat or Duckett using the GRACE modification.

RESULTS

For all GRACE repairs, cosmetic appearance was favorable regarding meatal position, shape and overall appearance. Maximum and average flow were above the 5th percentile in at least 95%. In Barcat and Duckett repairs, urethrocutaneous fistulas occurred in 5 and 30.7%, urethral strictures in 3 and 20.8%, and meatal strictures in 5 and 25.3%, respectively.

CONCLUSIONS

The initially reported favorable cosmetic and functional results were confirmed both for Duckett and Barcat repair using the GRACE modification. Complication rates were favorably low for Barcat and higher, but consistent with published results, for Duckett repair.

Hypospadias repair: an overview of the actual techniques

Hypospadias is one of the most common congenital genital anomalies for which surgery early in life is indicated. The surgical treatment is changing progressively, often by repeating treatment strategies that have been used decades ago. Indeed, historically two-stage procedures were replaced by one-stage procedures and nowadays two-stage procedures gain new interest. The same for reconstructions using the urethral plate, which decades ago were based on the Thiersch Duplay principle. In the 1980s, preputial onlay flaps were most often used and today we see a new interest in the use of the urethral plate. The actual surgical approach to hypospadias is described and technical details are given.

Multicentric experience on double dartos flap protection in tubularized incised plate urethroplasty for distal and midpenile hypospadias

PURPOSE

We report a multicenter experience using double dartos flap to protect the neourethra in TIP urethroplasty for distal and midpenile hypospadias.

METHODS

A total of 394 patients underwent tubularized incised plate urethroplasty for primary distal and midpenile hypospadias using double dartos flap protection by ten pediatric surgeons and urologists at five different institutions.

RESULTS

Tubularized incised plate urethroplasty protected by a double dartos flap was simple to perform and flaps were easy to obtain. Complications occurred in 23 patients (5.83%): fistulas 1.01% (4 cases), stenosis 0.25% (1 case), mild stenosis 2.53% (10 cases), dehiscence of ventral cutis 0.50% (2 cases) and penile torsion 1.26% (5 cases). All fistulae had a spontaneous resolution.

CONCLUSION

Double dartos flap to protect tubularized incised plate urethroplasty is safe with a low complication rate. The neourethra is covered entirely with a double layer of vascularized tissue and the double coverage appears a good choice for preventing urethrocutaneous fistula formation.

Tubularized incised plate urethroplasty with dorsal inlay graft prevents meatal/neourethral stenosis: a single surgeon's experience

BACKGROUND/PURPOSE

Snodgrass tubularized incised plate urethroplasty (SUP) is versatile and has good cosmesis. However, postoperative meatal/neourethral stenosis (M/N-S) is common enough for some surgeons to add a dorsal inlay graft (DIG) harvested from the inner prepuce and sutured to cover the longitudinal midline incision of the urethral plate. This is the first formal assessment of the effectiveness of DIG for preventing M/N-S.

METHODS

We reviewed the medical records of 100 consecutive SUP cases performed by a single surgeon between 2003 and 2010 comparing SUP + DIG (S + D group, n = 50) with SUP - DIG (S - D group, n = 50). Mean follow-up was 3.6 years. Data were analyzed statistically using the χ(2), 2-way ANOVA, and Mann-Whitney tests, with P < .05 considered significant.

RESULTS

Severity of hypospadias and type of SUP were similar. Mean age at SUP was 3.3 years in S + D and 3.6 years in S-D (P = NS). There were 4 complications in the S + D group: urethrocutaneous fistula (n = 3) and neourethral stenosis without diverticulum (n = 1). There were 15 complications in the S-D group : meatal stenosis (n = 2), neourethral stenosis with or without diverticulum (n = 6), urethrocutaneous fistula (n = 7) (P < .01). M/N-S was significantly less in the S + D group (1 vs 8; P < .05).

CONCLUSIONS

We strongly recommend that DIG be performed routinely during SUP.

Nonstented tubularized incised plate urethroplasty with Y-to-I spongioplasty in non-toilet trained children

INTRODUCTION

This study was designed to evaluate the supportive role of spongioplasty during tubularized incised plate (TIP) urethroplasty repair of hypospadias.

METHODS

All non-toilet trained children who underwent TIP repair for primary hypospadias by 1 surgeon over a 30-month period were included in our study. The divergent spongiosa was mobilized off the corpora cavernosa and was rotated toward the midline to wrap the neourethra. A dartos flap was used to cover the neourethra. The neourethra was calibrated immediately after surgery in all patients. A urethral stent was left in place only when difficult calibration was encountered. Complications and cosmetic appearance were documented at last follow-up.

RESULTS

Thirty-two consecutive patients with a mean age of 18 (standard deviation [SD] 6) months were included in the study. The defects were distal and mid-shaft in 26 patients (81.3%) and proximal-shaft in 6 (18.8%). No intraoperative catheterization difficulties were encountered and all repairs were nonstented. Antibiotics and anticholinergics were not required. Mean follow-up was 9 (SD 6) months. Urinary extravasation developed in 1 patient (3.1%) on the second postoperative day. A urethral catheter was easily inserted and left indwelling for 5 days. One patient presented 6 days postoperatively with suspected voiding difficulty. Urethral calibration was easily performed excluding any mechanical obstruction. There were no urinary fistulae and reoperation was not required. An excellent cosmetic appearance was achieved in all patients.

CONCLUSION

TIP urethroplasty is a versatile operation that can be performed in almost all cases of penile hypospadias. A nonstented technique for hypospadias repair simplifies postoperative care and obviates the need for antibiotics and anticholinergics. We believe that spongioplasty provides good support to the neourethra and the hypoplastic distal urethra that may facilitate catheterization in the immediate and early postoperative periods, if required. Future controlled study is warranted to further evaluate the role of spongioplasty.

Tubularized incised plate hypospadias repair for distal hypospadias

PURPOSE

We report surgical technique and outcomes in consecutive patients with primary distal hypospadias.

MATERIALS AND METHODS

A prospectively maintained database of all patients operated by WS in 2000-2008 was reviewed for pertinent data in consecutive patients.

RESULTS

A total of 551 consecutive patients of mean age 17 months underwent distal tubularized incised plate hypospadias repair by urethral plate tubularization with (459) or without (92) midline incision. Follow up occurred for 426 (77%) at a mean of 8.2 months. Calibration and/or uroflowmetry were obtained in 279 (65%). Complications developed in 19 (4%), including nine fistulas, nine glans dehiscences and one delayed meatal stenosis from balanitis xerotica obliterans. These complications could not be attributed to meatal location, urethral plate configuration or incision, suture materials or methods for urethroplasty and glansplasty, or to use or not of a dartos flap barrier layer.

CONCLUSIONS

No contraindication to urethral plate tubularization with or without incision was found in 551 consecutive patients operated for distal hypospadias. Reliability of the procedure was confirmed by the low complication rate and success using varied suture materials and methods.

Assessment of urethral plate appearance through digital photography: do pediatric urologists agree in their visual impressions of the urethral plate in children with hypospadias?

OBJECTIVE

There is a paucity of literature on a definition or set criteria evaluating urethral plate (UP) quality. We sought to determine whether pediatric urologists are in agreement in their assessment of UP quality.

MATERIALS AND METHODS

A cohort of 21 pediatric urologists attending a national annual meeting were surveyed with a questionnaire inquiring about practice patterns and perceived impressions of UP quality. Nineteen sequentially projected, standardized, digital photographs, depicting plates with variable meatal locations, were presented. Intra- and inter-rater agreement among pediatric urologists was estimated by calculating the Kappa statistic (kappa).

RESULTS

Thirty percent of respondents had more than 15years of practice and one-third repair 10 or more hypospadias per month. Measurement of level of agreement in the impression of UP quality of the 18 projected photographs revealed poor inter-rater agreement (kappa=0.06, P=0.0003), which was not improved by focusing on particular meatal locations or surgeon experience.

CONCLUSIONS

Despite the inherent shortcomings of digital photography, this study highlights the potential subjectivity and lack of agreement on UP quality. Disagreement seems to be present irrespective of level of the defect or surgeon experience. Setting standards and improving agreement is likely to enhance reporting and interpretation of data in hypospadias studies.

Factors predicting success in hypospadias repair using preputial flap with limited pedicle mobilization (Asopa procedure)

OBJECTIVES

To analyze the objective factors determining success in hypospadias repair by the Asopa technique of limited preputial pedicle mobilization.

METHODS

This was a prospective study involving a cohort of 48 patients (age range 1-19 years) who underwent hypospadias repair in a tertiary care teaching institution, with a follow-up of 20-58 months. Patient inclusion criteria were absence of past history of any local surgery with urethral plate less than 6 mm and hooded prepuce.

RESULTS

At a median follow-up of 33.5 months, the overall complication and fistula rates were 22.9% and 16.7%. Complication and fistula rates were 40% and 30% with tube repairs vs. 18.4% and 13.2% with onlay repairs.

CONCLUSIONS

In patients unsuitable for Snodgrass repair, the Asopa technique of transverse preputial flap repair provides reasonably good results. Patients with proximal hypospadias, conical glans configuration, tube repairs, and more advanced age had higher complication rates with transverse preputial flap repair.

A modified tubularised incised plate urethroplasty technique and a revised hypospadias algorithm

To simplify and standardize surgical management of hypospadias, a modified tubularised incised plate (TIP) urethroplasty (Snodgrass) technique has been described and a revised hypospadias management algorithm has been formulated. The study aims to evaluate the viability of the described procedure in different types of hypospadias and tests the validity of the algorithm. The modification described is recruitment of penile and glandular skin lateral to the urethral plate to facilitate tubularisation. The algorithm starts with penile degloving with preservation of urethral plate. Snodgrass repair was done in cases with no chordee and where skin chordee resolved by skin take down. Modified Snodgrass repair was done in cases where urethral plate was narrow. Another modification proposed by us is single layer penile skin closure instead of an added dartos flap, which was done in both classical and modified Snodgrass repair. Cases of severe chordee not resolved by skin take down were repaired by transverse preputial island flap (TPIF) and Bracka's technique. Dorsal plication was not used as an orthoplasty modality. It was possible to repair 68.89% of the cases by Snodgrass repair. These patients either had no chordee or had superficial skin tethering (skin chordee) which resolved on degolving. All these cases were coronal, distal and mid penile hypospadias. Remaining cases were mid, proximal and penoscrotal with true fibrous chordee and were repaired by TPIF or Bracka's technique. The Snodgrass technique had a fistula rate of 9.67%. Acceptably, low fistula rate and simple execution make the proposed modification of classical Snodgrass repair a viable option. The proposed algorithm proves to be a useful tool for standardised and logical preoperative decision making. It also defines indications of the three techniques vis-à-vis the type of hypospadias.

Tubularized incised plate urethroplasty for distal hypospadias: A literature review

The tubularized incised plate (TIP) urethroplasty or Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair due to its low complication rate, good cosmetic result, and technical simplicity. As a result, several articles have been published concerning various aspects and subtle variations of this procedure. The aim of this review is to critically and systematically analyze the published complication rates of TIP repair for distal hypospadias in children. We also reviewed the surgical modifications that have been introduced to the original technique and discussed the potential impact on the final outcome of the Snodgrass procedure.

[Correction of hypospadias by the Snodgrass method. Indications and results]

Tubularisation of the urethral plate with a medial incision was popularized by Snodgrass in the late 1990s. Since then this procedure has emerged throughout the world as the method of choice for correction of primary hypospadias. The procedure is applied as the technique of choice for primary correction of hypospadias, regardless of the level of the hypospadic meatus and the width of the original urethral plate, and is also used in various situations for secondary hypospadias surgery.. The complication rate is about 5-10 % in primary cases and between 10% and 20% in revision surgery for hypospadias repair.

[Hypospadias repair with Snodgrass' technique]

Retrospective study of 124 patients (average age: 3.8 years) with midpenile hypospadias: 48.3% (60 children), distal penile: 45.9% (57) and coronal 5.6% (7), of which the 25.8% (16) presented ventral curvature and the 4.8% (6) resulting from the complication of another previous technique. All of them were operated according to Snodgrass' technique, removing the catheter between the 6th and 7th day in most of them. The global rate of complications was of 12%: 9 fistulae (7.2%) and 6 meatal stenosis (4.8%). Aesthetic result was satisfactory in all cases, getting glans covered by foreskin in 57.3%.

Comparative Analysis of Tubularized Incised Plate Versus Onlay Island Flap Urethroplasty for Penoscrotal Hypospadias

PURPOSE

Despite being the dominant technique for repair of distal hypospadias, application of the tubularized incised plate approach for penoscrotal hypospadias remains controversial. We report our experience with severe hypospadias, comparing tubularized incised plate to transverse island flap onlay urethroplasty.

MATERIALS AND METHODS

We retrospectively reviewed consecutive patients with penoscrotal hypospadias presenting between 1998 and 2006. Based on surgeon preference 35 children underwent tubularized incised plate and 40 underwent onlay urethroplasty. Penoscrotal transposition and degree of ventral curvature, type of ventral curvature repair, complication rate, postoperative uroflowmetry pattern in toilet trained patients and number of reoperations were compared between the 2 groups.

RESULTS

Mean patient age at surgery was 17 months (range 9 to 91) for tubularized incised plate urethroplasty and 17.8 months (10 to 58) for the onlay procedure. Urethroplasty was performed over an 8Fr catheter in all patients. With mean followups of 30 months (range 6 to 74) and 38.8 months (16 to 80) the overall complication rates were 60% and 45% for the tubularized incised plate and onlay procedures, respectively. Fistula occurred in 15 patients and repair breakdown in 3 patients (total 51.4%) treated with tubularized incised plate repair, compared to 8 and 2 patients, respectively (25%), treated with onlay repair (p = 0.01). Fistula location also differed significantly between the 2 groups, with proximal fistulas occurring in 11 of 15 tubularized incised plate repairs (73.3%) vs 2 of 8 onlay repairs (25%, p = 0.02). Recurrent ventral curvature was more frequent after onlay urethroplasty (5.7% vs 12.5%, not significant). At a mean age of 5.1 years a plateau uroflow curve (vs normal bell curve) was observed in 16 of 24 children (66.7%) who underwent tubularized incised plate repair and in 7 of 21 (33.3%) who underwent onlay repair (p <0.01).

CONCLUSIONS

In this series the overall complication rate was similar for tubularized incised plate and onlay urethroplasty. Despite similar urethroplasty calibers, the uroflow curves and fistula positions in patients undergoing tubularized incised plate repair suggest that the neourethra distal to the fistula may be relatively narrow, creating flow resistance and leading to proximal fistula. Longer followup and close monitoring are needed before embracing one approach over the other.

Extended urethral mobilization in incised plate urethroplasty for severe hypospadias: a variation in technique to improve chordee correction

PURPOSE

The feasibility of tubularized incised plate urethroplasty in proximal hypospadias with severe chordee was studied after correction of chordee by extended urethral mobilization.

MATERIALS AND METHODS

Boys with severe hypospadias who underwent tubularized incised plate urethroplasty were included. A total of 34 patients (28 with proximal penile/penoscrotal hypospadias and 6 with scrotal hypospadias) 18 months to 13 years old (mean 5 years) with severe hypospadias underwent tubularized incised plate urethroplasty between January 1999 and March 2006. A Gittes test was performed to assess the chordee after penile degloving and preservation of the urethral plate. Subsequently, the urethral plate with divergent corpus spongiosum and proximal healthy urethra were mobilized up to the bulbar urethra. Glanular chordee was corrected by mobilizing the urethral plate into the glans. The urethral plate was tubularized with or without incision and spongioplasty to complete the urethroplasty.

RESULTS

Chordee correction was possible by mobilization of the urethral plate with corpus spongiosum from the meatus to the glans and the proximal urethra up to the bulbar region in 88% of the cases. Mean followup was 23 months (range 6 months to 3 years). Overall complication rate was 12% (fistula in 3 patients, meatal stenosis in 1). Two patients (6%) required dorsal plication, and in 2 (6%) the urethral plate had to be divided to correct the chordee. No patient had residual chordee during followup.

CONCLUSIONS

The technique of chordee correction by mobilization of the urethral plate and proximal urethra with preservation of the urethral plate is simple and effective, and enlarges the scope of tubularized incised plate urethroplasty in severe hypospadias.

Value of Urinary Flow Patterns in the Follow-Up of Children Who Underwent Snodgrass Operation

The urinary flow patterns and the Toguri nomogram were compared in the intermediate functional results of the tubularized-incised plate urethroplasty (TIPU) to repair distal and midpenile hypospadias by using uroflowmetry. 28 children who were toilet trained, were able to void volitionally, and had no fistulas following hypospadias repair were eligible for the study. The study did not include children who had persistent fistula, meatal stenosis or urethral stricture, and did not return for follow-up. The mean age was 8.4 years and the mean follow-up period was 18 months. The urinary flow pattern, maximum (Q(max)) and average flow rate (Q(ave)) were measured; the results were expressed as percentiles and compared to the Toguri values from normal children. The Q(max) and Q(ave) were considered normal if they were in >25th percentile, equivocally obstructed in the 5-25th percentile and obstructed if <5th percentile. The flow pattern was classified as bell ring shape, plateau or intermittent. According to the Toguri nomogram, 22 of 28 patients (78.5%) were considered normal, 4 patients (14.2%) as equivocally obstructed, and 2 patients (7.1%) as obstructed group. A normal bell-shaped flow curve was obtained in 23 (82.1%) of the children. 4 patients (14.2%) had a plateau flow pattern. Only 1 of the patients had an intermittent shape flow curve. The flow pattern was normal bell-shaped for all of the patients, except 1, with Q(max) above the 25th percentile according to the Toguri nomogram. Of children with Q(max) below the 5th percentile, both of them had a plateau flow pattern and were found to have an asymptomatic meatal stenosis, which was improved with urethral dilatation. However, of the 4 patients with Q(max) between 5 and 25 percentiles, 2 had a plateau flow pattern and the others had a bell-shaped flow pattern. The flow patterns of the 2 patients determined as obstructive by the Toguri nomogram were plateau-shaped. TIPU provides satisfactory functional results for distal and midpenile hypospadias; uroflowmetry is an important noninvasive tool to evaluate this technique. There are no studies in the literature which only used flow patterns for the evaluation of urination for follow-up after the hypospadias repair. Our study showed that the evaluation of obstruction according to the Toguri nomogram may not be necessary in patients with a normal bell-shaped flow pattern in uroflowmetry.

Technique for repair of minimal distal balanitic hypospadias

OBJECTIVES

Although not pernicious, minimal distal hypospadias is frequently obvious to parents, whose concern that their child be completely normal prompts their request for repair. A simple technique for the repair of this anomaly that results in an elliptical meatus is presented.

METHODS

A total of 28 boys ranging in age from 3 to 100 months (mean 21.8) underwent a surgical technique in which the distal urethral plate was excised, followed by advancement of the meatus into the defect thus created. Only 5 boys (17.8%) underwent hypospadias repair as an isolated procedure. Other concomitantly repaired anomalies included hooded prepuce, phimosis, redundant prepuce after neonatal circumcision, ventral penile curvature, inguinal hernia, undescended testis, penile torsion, and meatal stenosis.

RESULTS

All patients had healed well at a follow-up of 3 to 4 months (mean 3.2) and uniformly had an excellent cosmetic appearance with an elliptical meatus.

CONCLUSIONS

We recommend a technique for the repair of minimal distal hypospadias, consisting of excision of the distal urethral plate with advancement of the dorsal lip of the meatus into the created defect, for its simplicity and resultant elliptical meatus.

The midterm success rates of tubularized incised plate urethroplasty in reoperative patients with distal or midpenile hypospadias

To review the midterm results of tubularized incised plate (TIP) urethroplasty (Snodgrass method) in reoperative patients with distal or midpenile hypospadias. The results of TIP urethroplasty in 37 patients who had previously failed hypospadias repair were reviewed. Of the patients, 21 (56.8%) had coronal, 11 (29.7%) had subcoronal, and 5 (13.5%) had midpenile hypospadias. The mean age was 4.1 (2-16) years. Twenty-three patients had one operation and 14 patients had two operations previously. Of all the patients, 14 did not have a foreskin because of circumcision. The urethral plate had been disturbed in 6 patients, but there was not apparent scarring of the plate. Postoperative follow-up was 2.3 years with a range of 1.1-3.9 years. Genital examination, urethral calibration, and uroflowmetry were performed in control. Satisfaction of the families about the function and appearance of penis was also evaluated. Successful functional and cosmetic results were achieved in 29 patients (78.4%). All the families were happy with penile aesthetic appearance. The urethral plate seemed healthy at the operation in nine patients who had undergone TIP urethroplasty before and the outcomes were successful in eight of them. The operation was successful in 19/23 (82.6%) patients who had undergone one operation before and in 10/14 (71.4%) patients with two operations as well (P < 0.05). In addition, sufficient outcomes were obtained in also 11 of the 14 patients with circumcision. The success rate was higher in patients <5 years (P < 0.05). The rate was also higher during the recent period (2001-2003) since the experience we had increased (P < 0.05). TIP urethroplasty was unsatisfied in four of the six patients who had had disturbed urethral plate before and in five of eight patients who did not have sufficient amount of dartos tissue for flap to cover neourethra. Complication was observed in eight patients (21.6%): four had a pinpoint fistula, two had wound dehiscence, one had meatal stenosis, and one had mild meatal regression and a short neourethral stricture. All of these complications were repaired successfully at a later date. The mean hospital stay was 4.6 days. TIP urethroplasty provides good functional and cosmetic midterm outcomes in most of the reoperative patients with distal or midpenile hypospadias unless contraindicated by previous resection or gross scarring of the urethral plate. This procedure seems not to disturb the urethral plate and, therefore, it can be applied on reoperative patients who had undergone TIP urethroplasty before. It can also be used in a circumcised patient when there is a lack of foreskin.

Double dartos flaps in tubularized incised plate hypospadias repair

OBJECTIVES

To compare the single dartos flap with double dartos flap coverage. Two overlapping layers of dartos flap were fashioned and fixed in front of the neourethra after tubularized incised plate hypospadias repair to prevent urethrocutaneous fistula and glanular torsion.

METHODS

A total of 96 boys with distal hypospadias were treated with tubularized incised plate urethroplasty. They were divided into two groups. Group 1 (54 patients) had a single dartos flap covering. Group 2 (42 patients) had double dartos flap coverings. The dissected dorsal dartos flap was bisected vertically to form two pedicled wings. Each wing was rotated laterally from either side of the glans to cover the neourethra ventrally in a double-layer fashion.

RESULTS

In group 1, 2 patients (3.7%) developed fistula, 49 (90.7%) had mild glanular torsion, and 5 (9.3%) had moderate glanular torsion. None of group 2 developed fistula or glanular torsion postoperatively.

CONCLUSIONS

Double dartos flaps covering of the neourethra is a simple procedure that was superior to single flap covering for the prevention of urethrocutaneous fistula after tubularized incised plate urethroplasty. Glanular torsion did not occur when double dartos flaps were used.