Tubularized incised-plate urethroplasty for secondary hypospadias surgery

Evaluation of surgical procedures of mouse urethra by visualization and the formation of fistula

Visualization of the surgically operated tissues is vital to improve surgical model animals including mouse. Urological surgeries for urethra include series of fine manipulations to treat the increasing number of birth defects such as hypospadias. Hence visualization of the urethral status is vital. Inappropriate urethral surgical procedure often leads to the incomplete wound healing and subsequent formation of urethro-cutaneous fistula or urethral stricture. Application of indocyanine green mediated visualization of the urethra was first performed in the current study. Indocyanine green revealed the bladder but not the urethral status in mouse. Antegrade injection of contrast agent into the bladder enabled to detect the urethral status in vivo. The visualization of the leakage of contrast agent from the operated region was shown as the state of urethral fistula in the current hypospadias mouse model and urethral stricture was also revealed. A second trial for contrast agent was performed after the initial operation and a tendency of accelerated urethral stricture was observed. Thus, assessment of post-surgical conditions of urogenital tissues can be improved by the current analyses on the urethral status.

Tubularized incised plate urethroplasty for distal and midpenile hypospadias reoperation: A single institute experience

Objective:

Our study aimed to evaluate our experience in tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation.

Patients and methods:

This was a retrospective study in which we reviewed the medical records of 56 patients who underwent tubularized incised plate urethroplasty in distal and midpenile hypospadias reoperation. Tubularized incised plate urethroplasty was performed using a surgical technique like the primary tubularized incised plate repair based on the Snodgrass’s method. We recorded complications and functional outcomes of redo procedures.

Results:

We reviewed 56 patients who ranged in age from 2–16 years (mean 7.02±3.8 years). The overall complication rate was 33.9% ( n=19). Eight patients (14.3%) had fistula, six had meatal stenosis (10.7%), four had dehiscence (7.1%), and one had neourethral stenosis (1.8%). The complications occurred in 13 of mid-penile cases representing 50% of mid-penile cases but occurred in six cases of distal-penile cases (20%). The success rate of tubularized incised plate urethroplasty reoperation was 94.6% after repair of fistula and meatal stenosis by simple closure of fistula and meatoplasty.

Conclusion:

Tubularized incised plate urethroplasty is a safe and effective alternative procedure for hypospadias reoperations. The outcome is favorable if the urethral plate has no scars and with distal meatal location. The complication rate increases if the third redo is done and with midpenile meatal location.

Meta-analysis of complication rates of the tubularized incised plate (TIP) repair

OBJECTIVE

To determine overall complication rates of the tubularized incised plate (TIP) repair and assess the effects of technical modifications, length of follow-up and geographical location of reported results.

MATERIALS AND METHODS

A systematic literature search was undertaken, using Medline and Pubmed, in order to identify relevant articles. Random effects models were used to estimate pooled complication rates. Meta-regression was performed for each outcome by using mixed effects models with type of hypospadias (primary distal, primary proximal and secondary) as predictors.

RESULTS

Of the 189 articles that were identified, 49 studies (4675 patients) were included in the analysis. Fistula and re-operation rates were significantly higher in secondary repairs (15.5% and 23.3%) compared to primary proximal (10.3% and 12.2%) and primary distal (5.7% and 4.5%) (P = 0.045 and P < 0.001, respectively). Technical modifications reduced fistula rates from 10.3% to 3.3% (P = 0.003) and re-operation rates from 13.6% to 2.8% (P = 0.001). The rate of meatal stenosis was highest in the secondary repairs, with follow-up >1 year (12.7%). Comparison of geographical location showed that complication rates for all but one variable were significantly lower in North America when compared to Europe and the rest of the world. Mean meatal stenosis rates were 1.8% in North America, 3.4% in Europe and 8.2% in the rest of the world (P = 0.002). This remained significant in a multivariable model incorporating repair technique and length of follow-up (P = 0.046). Mean rates of urethral stricture, fistula and re-operation followed a similar pattern (P = 0.045, P = 0.009 and P < 0.001, respectively). Mean follow-up was shortest in the North American group, at 11.9 months, compared to Europe, at 17.8 months, and the rest of the world, at 18.9 months.

DISCUSSION

The present meta-analysis has shown that the lowest complication rates for the TIP repair are when it is applied to primary distal hypospadias. Complication rates are higher for all variables when the TIP repair is used for primary proximal hypospadias. Lower complication rates than those reported in this TIP review have been documented in some studies using a staged repair for correction of primary proximal or secondary hypospadias [11,12,68], implying that a staged approach may be superior to the TIP repair in these settings. Documentation of follow-up duration was limited, making assessment of the impact of length of follow-up difficult. Geographical location had a noticeable effect on outcome, with all but one complication being lower in the North American than the other groups. Mean follow-up was shortest in North America and it is suggested that the short follow-up in the North American studies may have led to under-reporting of late complications.

CONCLUSION

The TIP repair has evolved to incorporate modifications that have significantly lowered complications. Higher complication rates are seen with secondary and proximal repairs; however, limited, published long-term data impair a true assessment of outcome.

Tubularized incised plate urethroplasty for the treatment of penile fistulas after hypospadias repair

OBJECTIVE

Urethrocutaneous fistula is the most common complication of hypospadias repair. Tubularized incised plate urethroplasty (TIPU) has been used for the management of distal fistulas. This study reports the usage of TIPU in the treatment of large penile fistulas.

MATERIALS AND METHODS

Between April 2002 and September 2012, 15 patients with large penile fistulas who were managed with TIPU were included in the study. The fistulas were sited along the penile shaft from proximal to distal penile localization. Glanular and coronal fistulas were excluded. The surgical technique was completed according to the standard TIPU technique. The surrounding scar tissue of the fistula was circumferentially excised, and the urethral plate at the level of the fistula was incised to provide performance of loose urethral tubularization. A urethral stent was kept for 5-7 days.

RESULTS

The mean age of the patients was 7.3 ± 3.1 years. Primary operation of these patients was tubularized preputial island flap (n = 6), on-lay preputial island flap (n = 4), and TIPU (n = 5). The sites of the hypospadias fistulas were as follows; penoscrotal (three), mid-penile (eight) and subcoronal (four). Fistulas recurred in two patients after fistula repair. The postoperative follow up of the patients was 12.4 ± 7.7 months.

CONCLUSION

TIPU may be used safely for the treatment of fistulas after hypospadias repair.

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.

Tubularized incised plate urethroplasty for hypospadias reoperations in 100 patients

OBJECTIVES

To determine the key points for a successful redo hypospadias procedure using tubularized incised plate urethroplasty operation.

METHODS

A retrospective chart review of a cohort of 100 patients (Mean age: 4.5 years, range: 2-12) who had undergone a redo tubularized incised plate urethroplasty operation was performed. Fischer exact and Chi square tests were used for statistical analysis.

RESULTS

The incidence of complications of tubularized incised plate urethroplasty reoperation after failed repairs of meatal advancement and glanuloplasty procedure (n: 14), meatal based flap (n: 36), and tubularized incised plate urethroplasty (n: 50) were 29% (n: 4), 22% (n: 8) and, 28% (n: 14) respectively (P > 0.05). The overall complication rate was 26% (n: 26). Eighteen patients (18%) had fistula, five had meatal stenosis (5%), two had dehiscence (2%) and one had neourethral stenosis (1%). Postoperatively, fistula was closed in 18 patients and 5 underwent meatoplasty. Two patients with dehiscence and one with neourethral stenosis underwent an unsuccessful third redo tubularized incised plate urethroplasty reoperation and they were candidates for a complex hypospadias repair (3%). The ultimate success rate of tubularized incised plate urethroplasty reoperation after treatment of complications was 97%.

CONCLUSION

Tubularized incised plate urethroplasty is a safe and efficacious alternative procedure for hypospadias reoperations if the urethral plate has no scars and outcome is favourable if the first failed hypospadias repair is a meatal based flap procedure. The complication rate increases if the urethral plate has been previously incised in the midline and a redo third redo must be avoided.

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.