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

Abstract

To the Editor, We read the article by Shimotakahara et al [1] with great interest. In this article, the authors are evaluating of the effectiveness of dorsal inlay graft (DIG) urethroplasty for preventing meatal/neourethral stenosis (M/N-S) after hypospadias repair. For this purpose, they have compared the outcomes of snodgrass urethroplasty (SUP) and SUP plus DIG. Finally, they reported that using DIG during SUP is significantly decreasing the M/N-S, and therefore, they strongly recommend the routine use of this technique. However, there are some limitations of the study that need to be clarified. The main drawback of the study is the use of DIG in cases with shallow groove as indicated in the “Methods” section. Although the authors are using this technique in only select cases, it is not wise to strongly recommend the routine use of DIG during every SUP. If the indication of this technique is limited to the patients with narrow or shallow glans, unless randomized studies have been conducted in hypospadiac patients, the suggestion of the routine use of DIG should be avoided. The other technical factor when considering the routine use of DIG from the inner preputial skin is perhaps the severity of the hypospadias. The safe use of DIG in distally located primary hypospadias cases have been previously reported [2,3]. However, in the present study, the meatus of the penis is proximally located in almost half of the children preoperatively. Especially in this group of patients, the preputial skin is generally saved and is used to cover the corpora of the penis, which is exposed and lengthened after the degloving and chordectomy phases. Therefore, sometimes it might be technically difficult to sacrifice a large portion of the inner preputial skin to cover the incised urethra. In that special group of cases, we suggest that harvesting a buccal mucosa for the preparation of the inlay graft would be a better choice of treatment instead of using an inner preputial skin. We also have an experience of using DIG prepared from the inner prepuce in 15 primary distal hypospadias cases at our institution. After a mean follow-up of 9.1