Elsevier

European Urology

Volume 44, Issue 6, December 2003, Pages 714-719
European Urology

Comprehensive Analysis of Six Years Experience in Tubularised Incised Plate Urethroplasty and its Extended Application in Primary and Secondary Hypospadias Repair

https://doi.org/10.1016/S0302-2838(03)00386-5Get rights and content

Abstract

Objective: We evaluated the potential of tubularised incised plate (TIP) urethroplasty in primary and secondary hypospadias repair focusing on the extended application of this procedure, the utility and handling of the urethral plate and operative results.

Methods: In this retrospective study, we analysed the medical records of 228 children with different levels of the hypospadiac meatus who underwent a TIP procedure between February 1997 and December 2002. The children were followed a mean of 42 months. Our medical records provided us with details about the location of the hypospadiac meatus, the width of the urethral plate before and after midline incision, primary versus secondary surgery, complications as well as notes on the extended application of the TIP procedure.

Results: The overall postoperative complication rate was 7.8%. The overall fistula rate was 5.7%, with 4.1% in primary distal, 9.6% in primary proximal and 7.5% in secondary repair respectively. We had one case of meatal stenosis (0.4%) and one of urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). Due to the encouraging results, the frequency of TIP procedure in hypospadias surgery increased from 33% in 1997 to 82% in 2002.

Conclusion: In our study the TIP procedure has emerged as the first-choice technique in primary hypospadias repair—irrespective of the level of the hypospadiac meatus and the width of the original urethral plate. This procedure has also proved to be favourable for many cases at secondary surgery.

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

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1

Present address: Department of Urology, University of Innsbruck, Austria.

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