Comprehensive Analysis of Six Years Experience in Tubularised Incised Plate Urethroplasty and its Extended Application in Primary and Secondary Hypospadias Repair
Introduction
Recent data show that the prevalence of hypospadias has nearly doubled over the past 30 years [1], [2]. Hypospadias therefore continues to be a challenging problem for paediatric urologists. The current operative concept in hypospadias surgery is based on a perfect single-stage repair of the malformation and should result in functional excellence and a cosmetically normal looking penis. A successful hypospadias repair includes a vertical slit-like glandular meatus, a conically shaped glans, a straight penis during erection, good skin coverage and a normal position of the scrotum in relation to the penis. These parameters reflect the expected standard in current hypospadias surgery [3].
Over the last 5–8 years hypospadias surgery has changed, especially since the identification of the urethral plate as an anatomical entity, which has considerably simplified surgery. Today, two principles which can be used for more than 90% of all repairs enjoy widespread popularity. The first is the preservation of the urethral plate whenever possible; the second is the in situ tubularisation of the plate, with or without dorsal longitudinal midline incision.
The tubularisation was originally described by Thiersch and Duplay 130 years ago and later proposed by the French school (Monfort) with elevation of the plate and “in situ” by the American school (Kass). The idea of hinging the plate was initially proposed by the Philadelphia group (Rich) in order to achieve a slit-like meatus with a meatal-based or an onlay repair. Snodgrass has largely contributed to further popularizing the TIP procedure [4], [5], [6], [7], [8], [9]. It has become the preferred technique in primary and secondary hypospadias repair in many paediatric urology centres worldwide. Advantages of the modified Snodgrass technique include the use of native urethral mucosa to reconstruct the urethra, a single urethral suture line and a vascularised subcutaneous flap for coverage of the neourethra to minimize the risk of urethrocutaneous fistulae. Several authors have reported excellent functional and cosmetic results with a low complication rate [10], [11], [12].
We started to perform this procedure in early 1997 and can now report about our 6 years experience focusing on the utility and handling of the urethral plate, the expanding indication for a TIP procedure as well as on the results and complications in primary and secondary repair.
Section snippets
Material and methods
Between January 1992 and December 2002, 775 patients underwent a hypospadias repair at our institution. We used different operative techniques depending on the child’s anatomy, the location of the hypospadiac meatus and the chordee. We have retrospectively analysed our medical records of a total of 228 boys who underwent a tubularised incised plate (TIP) procedure between 1997 and 2002. Patient age ranged from 6 months to 17 years (average age 21 months); the majority was younger than 16 months
Results
Patients were followed a mean of 42 months (range 5–71). 210/228 (92.1%) patients were operated in a single-stage repair without any complications. The overall (primary and secondary surgery) complication rate was 7.8% (18/228): 13/228 boys developed fistulae (5.7%); we observed one case of meatal stenosis which required a simple meatotomy (0.4%), one urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). In 2 of the 3 cases of complete wound dehiscence allergic reactions to
Discussion
Over 300 different surgical methods and several modified approaches have been published in the past, demonstrating that an ideal and universally applicable technique for hypospadias repair has not yet been found. However, the identification of the urethral plate as an anatomical entity has fundamentally changed hypospadias surgery, which in fact has revolutionised and considerably simplified this surgery.
Before, the Mathieu procedure had been our most frequently performed technique for many
Conclusions
Tubularised incised plate urethroplasty has indeed revolutionised and considerably simplified hypospadias repair. The TIP procedure provides satisfactory functional as well as excellent cosmetic results in many different cases of distal and proximal primary hypospadias repair. Except for distal glandular forms, it has finally been successfully applied to virtually all forms of single-stage primary hypospadias repair, irrespective of the level of the hypospadiac meatus and the width of the
References (23)
- et al.
Current trends in hypospadias repair
Urol. Clin. North Am.
(1999) - et al.
Glanduloplasty and in situ tubularisation of the urethral plate: a simple reliable technique for the majority of boys with hypospadias
J. Urol.
(1995) Hinging the urethral plate in hypospadia meatoplasty
J. Urol.
(1989)Tubularized, incised plate urethroplasty for distal hypospadias
J. Urol.
(1994)- et al.
Tubularized incised plate hypospadias repair: results of a multicenter experience
J. Urol.
(1996) Tubularized incised plate (TIP) hypospadias repair
Urol. Clin. North Am.
(2002)- et al.
Tubularized incised plate urethroplasty: expanded use in primary and repeat surgery for hypospadias
J. Urol.
(2001) - et al.
Tubularized incised plate hypospadias repair for proximal hypospadias
J. Urol.
(1998) - et al.
Repair of hypospadias complications using the tubularized, incised plate urethroplasty
J. Pediatr. Surg.
(1999) - et al.
Histology of the urethral plate: implications for hypospadias repair
J. Urol.
(2000)
Rise in prevalence of hypospadias
Lancet
Cited by (19)
Meta-analysis of complication rates of the tubularized incised plate (TIP) repair
2015, Journal of Pediatric UrologyCitation Excerpt :Where studies contained distal and proximal repairs and/or modified and standard techniques and/or primary and secondary repairs, the data were entered only if these were separable. Of the 189 studies identified, only 49 (4675 patients) [14,17–64] fulfilled the inclusion criteria, as detailed below: Complications given for at least one of those under consideration
Analysis of risk factors for glans dehiscence after tubularized incised plate hypospadias repair
2011, Journal of UrologyCitation Excerpt :Furthermore, similar rates of GD among the first 113 cases with chromic suture compared to the subsequent 528 cases suggest that a learning curve or unmeasured cointerventions such as changes in nursing care did not contribute significantly to GD. Table 4 summarizes published GD and overall complication rates following TIP hypospadias repair.1–13 We noted GD after primary distal or mid shaft TIP hypospadias repair in about 3% of cases, which agrees with other reports indicating a 0% to 4% occurrence despite a wide range of total complications (3% to 22%).
The efficacy of dihydrotestosterone transdermal gel before primary hypospadias surgery: A prospective, controlled, randomized study
2008, Journal of UrologyCitation Excerpt :All the patients from both groups underwent hypospadias repair using TIP urethroplasty with or without chordee correction. The procedure was performed using micro-instruments with 2.5 to 4 times optical magnification in a standardized manner, as described previously.10 After degloving the penis an artificial erection was achieved to assess any deviation.
Tubularized incised plate urethroplasty: 5 Years' experience
2004, European UrologyComparative outcomes of the tubularized incised plate and transverse island flap onlay techniques for the repair of proximal hypospadias
2014, International Urology and Nephrology
- 1
Present address: Department of Urology, University of Innsbruck, Austria.