Do patch procedures prevent complications of the Mathieu technique?

Hybrid Mathieu Urethroplasty: A Simple Modification Outcomes

Background

Distal hypospadias repair is one of the most frequent surgical interventions in the pediatric age group. Successful hypospadias repair should provide a functional penis and good cosmetic results. Mathieu urethroplasty is one of the most popular techniques used. The authors aimed at performing a modification that expanded the scope of indications and improved the final cosmetic results of classic Mathieu urethroplasty.

Methods

Forty-three patients with distal hypospadias were operated by hybrid Mathieu urethroplasty (HMU) during the period from March 2012 to December 2020. All cases had small size glans. Creation of the perimeatal-based flap was performed as Mathieu disrobed. This was followed by the development of glanular wings. The additional step was deep incision of the urethral plate. Then, urethroplasty was performed. The catheter was left in place for 1–3 days.

Results

The mean age was 1.5 years, and the mean operative time was 67 minutes (60–75 minutes). The mean size of glans was 12 mm (10–15 mm). Fistula developed in three cases. No stricture or meatal regression developed. Infection with disruption of repair occurred in one case.

Conclusion

Hybrid Mathieu urethroplasty represents a reliable and successful solution for the cases of distal penile hypospadias with small glans and shallow urethral plate. It increases the scope of candidates of the Mathieu procedure, improves the final cosmetic results and has a reasonable rate of complications.

Comparison of meatal-based flap (Mathieu) and tubularized incised-plate (TIP) urethroplasties for primary distal hypospadias: A systematic review and meta-analysis

PURPOSE

We conducted this meta-analysis to compare postoperative outcomes between meatal-based flap (Mathieu) and tubularized incised plate (TIP) techniques for distal hypospadias.

METHODS

A comprehensive literature search of PUBMED, Web of Science, EMBASE, and Cochrane Library was conducted. Outcomes evaluated in this review were fistula, meatal stenosis, wound dehiscence and flap necrosis. We calculated odds ratio (OR) with 95% confidential interval (CI) to compare postoperative outcomes between Mathieu and TIP after data extraction and literature identification. All data were analyzed using Review Manager 5.2. In order to find potential affective factors, meta-regression and subgroup analyses were applied.

RESULTS

16 studies, 1386 patients, including 762 patients receiving Mathieu and 624 individuals subjected to TIP met the inclusion criteria. The synthetic data suggested that Mathieu and TIP were comparable in terms of fistula (OR = 0.93; 95% CI: 0.65 to 1.33; P = 0.70, I² = 14%), wound dehiscence (OR = 0.89; 95% CI: 0.33 to 2.39; P = 0.81, I² = 11%), and flap necrosis (OR = 1.9; 95% CI: 0.51 to 7.09; P = 0.20, I² = 38%) without significant heterogeneity for each comparison group. Pooled estimates showed a significantly lower rate of meatal stenosis with Mathieu than with TIP (OR = 0.41; 95% CI: 0.24 to 0.73; P = 0.002, I² = 4%). Subgroup analyses showed that the difference between Mathieu and TIP was more obvious in the studies published before 2013 in meatal stenosis. The modified Mathieu technique and a running suture for urethroplasty might be relevant to a lower rate of meatal stenosis in the data, although no statistical significance in the present effects model overall was found. One-way sensitivity analysis showed that the results were stable. There was no publication bias detected using both funnel plot and Egger's test.

CONCLUSION

This meta-analysis suggested that Mathieu and TIP technique were equivalent for primary distal hypospadias in terms of fistula, wound dehiscence, and flap necrosis. Pooled estimates indicated that there was a lower rate of meatal stenosis with Mathieu rather than with TIP significantly. The modified Mathieu technique and a running suture for urethroplasty might be relevant to a lower rate of meatal stenosis.

TYPE OF STUDY

Meta-analysis.

LEVEL OF EVIDENCE

IV.

Evaluation of double-folded meatal-based flap (modified Mathieu) in redo circumcised distal penile hypospadias: a prospective multicenter study

Background

Sometimes it becomes a dilemma to repair a failed circumcised distal penile hypospadias with partial or complete wound dehiscence. In many of these cases, redo operations need a graft or a flap. The aim of this study is to evaluate the double-folded meatal-based flap in redo circumcised hypospadias with shallow urethral plate and a small glans penis.

Results

From September 2015 to August 2018, we prospectively studied the double-folded meatal-based flap in 56 failed circumcised distal hypospadias without penile curvature with shallow urethral plate and a small glans penis. Distally folded Mathieu flap was done. Forty-seven cases only had completed the study. We had 19 patients with distal penile hypospadias, 19 with sub-coronal hypospadias, and 9 with coronal hypospadias. Median operative time was 50 (range 40–80 min). The median length of the double-folded flap was 14 (range 10–18 mm). The median follow-up was 12 (range 1–33 months). The success of the operation means that there is an absence of any complications. Our success rate was 73%. We had 8 patients with meatal retraction, one fistula, and one patient with wound disruption. Only 3 patients (6.4%) needed re-operation: one case with meatal retraction, another with fistula, and a third with complete wound disruption.

Conclusion

Distally folded meatal-based flap is an additional option in redo circumcised hypospadias with shallow urethral plate, small glans penis, and pliable anterior penile skin with a considerable high percent of meatal recession.

Mathieu technique with incision of the urethral plate versus standard tubularised incised-plate urethroplasty in primary repair of distal hypospadias: A prospective randomised study

Objective

To compare outcomes of the Mathieu incised-plate (Mathieu-IP) technique vs the standard tubularised incised-plate (TIP) technique for primary management of distal hypospadias.

Patients and methods

Between April 2012 and August 2015, 66 patients (aged 15–60 months) with primary distal hypospadias were randomly allocated to two groups. Group 1 included 34 patients who underwent Mathieu-IP repair and Group 2 included 32 patients managed using the TIP technique for primary management of distal hypospadias. Postoperatively, all patients were examined weekly up to 1 month and then at 3 and 6 months. Perioperative data, complications and outcomes of both procedures were statistically analysed and compared.

Results

There were no statistically significant differences in patient demographics between the groups at baseline. There was no statistically significant difference in the mean (SD) operative time between Groups 1 and 2, at 95 (7.6) and 91.2 (8.1) min, respectively. There was no statistically significant difference in the shape of the urine stream at micturition or the neomeatus between the groups postoperatively. The rate of postoperative fistula was significantly higher in Group 2 (TIP) compared to Group 1 (Mathieu-IP), at 18.7% vs 2.9% (P = 0.004). There was no postoperative meatal stenosis in Group 1, which did occur in five patients (15.6%) in Group 2 (P = 0.002).

Conclusion

The Mathieu-IP technique appeared to be better than the standard TIP technique with regard to postoperative fistula formation and meatal stenosis, and with acceptable cosmesis.

A modified onlay island flap vs. Mathieu urethroplasty for distal hypospadias repair: A prospective randomised study

OBJECTIVE

To compare the outcome of a modified onlay island flap (MOIF) with that of the Mathieu urethroplasty for distal hypospadias repair.

PATIENTS AND METHODS

In a prospective randomised study, 60 patients with coronal, subcoronal and distal penile hypospadias, with a urethral plate width of ⩽6 mm, and minimal or no chordee, underwent either MOIF using a midline longitudinal outer preputial skin flap passed ventrally by penile buttonholing through dartos fascia incision, or a Mathieu urethroplasty. Closed envelopes were used for randomly selecting patients for each procedure. The operative duration, complications, cosmetic outcome, urinary stream and relatives' satisfaction were reported for each procedure.

RESULTS

Preoperative data (patients' age and site of urethral meatus) and operative duration were insignificantly different between the groups (P = 0.653, 0.786 and 0.710, respectively). There were no intraoperative complications in either group. The duration of follow-up was insignificantly different between the groups. Patients treated with the MOIF had a statistically significant lower complication rate (P = 0.036), and a better cosmetic outcome, urinary stream and relatives' satisfaction (P < 0.001 for all).

CONCLUSIONS

The MOIF urethroplasty seemed to be better than the Mathieu urethroplasty in patients with distal hypospadias and narrow urethral plates. Further studies including more patients, and a longer follow-up with an objective evaluation of functional outcome should be encouraged to confirm these early results.

Combined Use of the Mathieu and Incised Urethral Plate Techniques for Repair of Distal Penile Hypospadias

Though both the Mathieu and incised urethral plate techniques are individually described for single-stage repair of distal penile hypospadias, each has its own shortcomings. We describe the combination of the two techniques by taking their advantages and reducing their limitations. Thirteen patients belonging to the age group of 3-22 years with distal penile hypospadias and mild chordee were operated by this technique with a mean follow-up of 8 months. One patient had urethrocutaneous fistula, and another patient had partial skin necrosis which healed spontaneously without fistula. Both of these complications occurred in adult patients. None developed urethral stenosis, and the cosmesis of the glans was excellent in all cases. This technique is very helpful in patients having small flat glans and shallow urethral groove.

Systematic review and meta-analysis of studies comparing the perimeatal-based flap and tubularized incised-plate techniques for primary hypospadias repair

PURPOSE

To conduct a systematic review and meta-analysis of studies comparing the perimeatal-based flap (PBF) and tubularized incised-plate (TIP) techniques for primary hypospadias repair and determine whether the two techniques had similar reported outcomes.

METHODS

The PubMed, Embase and Cochrane databases were searched using the terms: hypospadias, Snodgrass, TIP*, tubularized incised plate, tubularized incised-plate, Mathieu*, perimeatal-based flap, perimeatal flap, meatal-based flap and meatal based flap. No other limits were used. Inclusion criteria included: primary hypospadias repair only; both including the PBF and TIP techniques; at least one of the quantitative outcomes obtainable from study; comparative studies.

RESULTS

Twelve studies fulfilled the inclusion criteria and were included in the final analysis. Meta-analysis showed that there were no significant differences between the two techniques when comparing fistula (OR = 1.47; 95 % CI: 0.82-2.63; P = 0.20), meatal stenosis (OR = 0.53; 95 % CI: 0.24-1.16; P = 0.11), and wound dehiscence (OR = 0.82; 95 % CI: 0.24-2.84; P = 0.76). Both the studies which assessed cosmesis objectively showed a consistent better cosmetic result of the TIP technique (P < 0.05).

CONCLUSION

There were no significant differences of complication rates between the two techniques, and the TIP technique was usually of better cosmesis. Given the large clinical heterogeneity among studies, future more well-designed studies with full data and uniform criterion were awaited.

Prepuce preserving versus conventional Mathieu urethroplasty for distal hypospadias - a prospective randomized study

OBJECTIVES

To evaluate the impact of prepuce preservation during Mathieu repair for distal hypospadias.

METHODS

This prospective randomized comparative study, carried out in Assiut University Hospital, between 2006 and 2009, included 200 patients with distal penile or coronal hypospadias. They underwent either Mathieu repair with prepuce preservation (group I, n = 100) or traditional Mathieu repair with circumcision (group II, n = 100). Follow up was at 2 weeks, and 1 and 3 months postoperatively, which only 153 patients completed (I: n = 86 and II: n = 67).

RESULTS

The mean operative time was 64.5 min in group I and 121.7 min in group II (p < 0.001). All patients in group I developed postoperative preputial edema. Patients from group I who had a successful operation underwent circumcision at least 3 months later. Urethrocutaneous fistulae developed in 7 and 6 patients in group I and II respectively (p = 0.967). Fistula closure was done at least 3 months postoperatively, and there was no significant difference in success between the two groups. Two cases of glanular dehiscence were detected (one in each group); the patient from group I had a successful onlay island flap repair.

CONCLUSIONS

Preputial preservation during Mathieu repair is a time-saving procedure with similar complication rate to traditional repair. Valuable local tissue is preserved to deal with complications that may occur.

Use of double pigtail stent in hypospadias surgery

OBJECTIVE

Various types and materials of stents have been used for urinary diversion in hypospadias surgery. We evaluated whether double pigtail stents are superior to straight silicone stents.

METHODS

We conducted a retrospective chart review of all patients who underwent hypospadias surgery with straight silicone or double pigtail stents between November 1997 and October 2005. Comparisons were made between the two groups specifically with regard to the complication rates.

RESULTS

A total of 86 patients were included. The complication rates in patients who received double pigtail stents were significantly reduced as compared with those who received straight silicon stents. There was less wound disruption associated with early stent dislodgement in the double pigtail group compared with the straight silicone group (3.2%vs. 17.4%, p< 0.05). The rate of urethrocutaneous fistula was also lower in the double pigtail stent group (12.7%vs. 30.4%). Subjectively, there was also improved patient comfort and parent anxiety in the double pigtail stent group.

CONCLUSION

Double pigtail stent is a suitable material for urinary diversion in hypospadias surgery. It not only reduces patient discomfort, but also decreases complication rates in hypospadias surgery.

Combined Mathieu and Snodgrass urethroplasty for hypospadias repair: a prospective randomized study

OBJECTIVES

To evaluate the outcomes of combined Mathieu and Snodgrass urethroplasty for distal hypospadias repair and to compare them with the two techniques separately.

METHODS

Between January 2006 and February 2009, patients with distal hypospadias were prospectively randomized to undergo one of the three following urethroplasty techniques: Mathieu urethroplasty, Snodgrass urethroplasty or a combination of the two. Operative time, intraoperative, early and late postoperative complications were reported for each procedure.

RESULTS

101 patients were included in this study. The Mathieu technique was used for 30 patients, Snodgrass repair was carried out in 37 patients and 34 patients underwent the combined technique. Operative time ranged from 43 to 120 min. Eight patients developed urethrocutaneous fistulae. Meatal stenosis was encountered in five cases. Thirty-seven patients had rounded meatus, while a slit-like urethral opening was found in 64 cases.

CONCLUSIONS

In our hands, the combined Mathieu and Snodgrass urethroplasty technique provided a better cosmetic outcome than the Mathieu technique with no incidence of meatal stenosis as seen with the Snodgrass technique.

Dartos flap coverage of the neourethra following repair for primary hypospadias, reoperative hypospadias and urethrocutaneous fistulas: it is a safe approach

PURPOSE: Urethrocutaneous fistula and neourethral dehiscence are frequently seen complications of hypospadias surgery requiring reoperation. In this study we report the experience of one surgeon with dartos flap coverage in primary hypospadias, reoperative hypospadias and urethrocutaneous fistulas repair. METHODS: A total of 23 patients underwent hypospadias and urethrocutaneous fistulas repair from January 2006 to May 2009. Fourteen patients were operated on for primary hypospadias repair at our institution and 9 patients were admitted for hypospadias complications such as failed hypospadias repair and urethrocutaneous fistula. In all the patients, the dartos flap was dissected and transposed to cover the neourethra. Operative results were recorded. RESULTS: The primary surgical procedure was a one-stage repair in 61% (n = 14); tubularised incised plate (TIP) urethroplasty in 43% (n = 6) and a Mathieu procedure in 57% (n = 8). Urethrocutaneous fistulas complicating the previous initial hypospadias repair were anterior in 33% (n = 2), middle in 33% (n = 2) and proximal in 33% (n = 2). Repair of the fistula was successful on the first attempt in all patients. The reason for redo surgery in 3 patients was complete dehiscence and the patients had distal shaft hypospadias. CONCLUSION: Dartos flap coverage of the neourethra seems to be an effective method of reducing the fistulous complication rate following primary and secondary hypospadias repair.

Hypospadias repair and glans augmentation using a modified Mathieu technique

PURPOSE

To describe a modification in Mathieu (perimeatal-based flap urethroplasty) technique that incorporates glans augmentation into the procedure and is applicable for hypospadias patients with small glans and shallow urethral grooves.

PATIENTS AND METHODS

Fifty-four children with primary hypospadias and small glans underwent either the new double-faced Mathieu (DF-Mathieu) technique (33 patients) or tubularized incised plate (TIP) procedure (21 patients). DF-Mathieu perimeatal-based skin flap was meant to cover the distance from urethral orifice to the tip of the glans and flip back to fill the gap between glans wings. Patients were followed up for 20 months (12-30). TIP group underwent the conventional procedure.

RESULTS

The mean age in DF-Mathieu and TIP group was 43.1 and 39.8 months, respectively. Post-operative results in DF-Mathieu group revealed one urethral fistula and no urethral break down or necrosis. In TIP group, there were one glans fistula (4.7%) and one meatal stenosis (4.7%). Overall success rate was 97% in DF-Mathieu and 90.5% in TIP operation. After 6 months, all DF-Mathieu patients had slit-like meatus and their cosmetic results were satisfactory.

CONCLUSION

Double-faced Mathieu technique seems applicable in patients with shallow urethral grooves when TIP procedure may increase the risk of complications. Unlike its predecessor, this technique eliminates the tension on glans wing sutures and the risk of subsequent neo-urethral break down.

Combined use of Mathieu procedure with plate incision for hypospadias repair: a randomized clinical trial

OBJECTIVES

To introduce a simple and effective technique for urethroplasty of distal hypospadias, using the advantages of both standard techniques of Snodgrass and Mathieu to reduce or eliminate the shortcomings of each.

METHODS

Forty patients with primary distal hypospadias were randomized between two groups (20 in each). Patients in group I underwent standard Snodgrass urethroplasty, whereas those in group II were operated with our novel technique, Mathieu-Incised Plate (Mathieu-IP), comprising preparation of a parameatal-based skin flap as in the Mathieu procedure together with modifications (adopted from Snodgrass urethroplasty) such as a complete longitudinal incision on the urethral plate as well as coverage of the neourethra with an inner preputial flap. Operative data and outcomes of both procedures were analyzed prospectively after 1 year of follow-up.

RESULTS

Both groups were age matched (group I: 7.05 +/- 4.85 years; group II: 7.31 +/- 2.17 years), and there were no significant differences in mean operative time (95 minutes versus 100 min in groups I and II, respectively). There were significant differences between the two groups in terms of complications. Whereas 3 cases of posturethroplasty meatal stenosis and 2 of urethrocutaneous fistula (5 complications, 25%) were detected in the Snodgrass group, neither of these complications occurred in the Mathieu-IP group. All 40 patients benefited from a slit-like meatus.

CONCLUSIONS

Combining the Mathieu procedure with plate incision could be considered a promising simple technique to achieve a normally shaped meatus and to reduce the rate of meatal-related complications, the major concern with the Snodgrass procedure.

Can a slit-like meatus be achieved with the V-incision sutured meatoplasty for onlay island flap hypospadias repair?

OBJECTIVES

To evaluate whether the V-incision sutured meatoplasty (VSM) is useful for configuring the constructed meatus after the onlay flap and the Mathieu flip-flap repair for hypospadias, as the transverse preputial onlay island urethroplasty is excellent for repairing anterior hypospadias with no chordee, and a slit-like normal meatus cannot be constructed in many patients who had the original onlay island-flap repair

PATIENTS AND METHODS

The configuration of the meatus which was repaired by the onlay island flap technique with VSM (group 2) was evaluated and compared with that of the original onlay technique (group 1). Group 1 consisted of 30 patients treated with only the classic onlay procedure as primary hypospadias repair (1999-2001). Group 2 consisted of 22 patients treated using the onlay procedure with VSM as primary hypospadias repair (2002-2004).

RESULTS

There were complications after surgery in four (18%) of 22 patients in group 1 and in five (17%) of 30 in group 2, with no significant difference. A slit-like meatus was achieved in eight (27%) of 30 in group 1 and in 12 (55%) of 22 in group 2. There was a significant difference between the groups in meatal configuration (P = 0.04).

CONCLUSION

The VSM is a useful technique to make a slit-like meatus for onlay island flap urethroplasty and flip-flap hypospadias repair, although the technique cannot always achieve the intended result.

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.

Emotional effects of hypospadias surgery on Turkish boys

PURPOSE

The aim of this study is to investigate in Turkish boys the emotional effects of hypospadias repair before and after the optimal age for repair.

MATERIALS AND METHODS

Forty hypospadias patients treated in our department were included in this study. Group 1 consisted of 13 patients operated on at less than 30 months of age. Group 2 consisted of 27 patients operated on at over 30 months of age. Age at time of study, severity of hypospadias, age at repair and number of operations were evaluated for both groups retrospectively. Socio-economic and socio-demographic characteristics of these patients including place of residence, educational level of their parents and parental occupations were determined. The Turkish versions of the Children's Depression Inventory and the State-Trait Anxiety Inventory for Children A-State scale were used to evaluate the emotional effects of hypospadias surgery. For statistical analysis, the Mann-Whitney U test, Student's t test and Chi-squared test were used.

RESULTS

There was a significant difference in the age at repair between Groups 1 and 2. No significant differences existed in severity of hypospadias and number of operations between the two groups. All 40 patients had the same socio-economic and socio-demographic characteristics. Group 1 did not significantly differ from Group 2 in regard to the educational level of their parents and parental occupations. Age at repair, which was the only difference between the two groups, did not affect the level of depression and anxiety-state symptoms.

CONCLUSIONS

There is a close relationship between emotional effect of hypospadias surgery and age at repair. Possibility of depression and anxiety, which were dominating emotional symptoms among boys operated on for hypospadias, was found not to be high after the recommended age. It is concluded that, as hypospadias surgery creates a circumcised penis, the degree of emotional trauma is lower in Turkish boys than in other nationalities.