Incised Plate Research Articles

Comparison of the efficacy and safety of dorsal inlay graft urethroplasty (DIGU) method with tubularized incised plate urethroplasty (TIPU) method in primary distal hypospadias repair: a systematic review and meta-analysis

Link of Video Abstract: https://youtu.be/r399GEt3guoIntroduction: Tubularized Incised Plate Urethroplasty (TIPU) is a technique that is widely used in distal hypospadias repair. The advantages possessed by this technique are better cosmetics, the meatus is at the tip of the penis, and the phallus is straight. Some researchers believe that a urethral plate with a size of less than 8 mm is unsuitable for the TIPU technique so augmentation with a graft using the dorsal inlay graft urethroplasty (DIGU) technique is needed. To date, there have been no systematic reviews and meta-analyses that have directly compared the efficacy and complications of DIGU and TIPU. Therefore, this study aimed to compare the effectiveness and complications of these two modalities for repair in primary distal hypospadias patients. Methods: This study is a systematic review study and meta-analysis. The protocol for conducting and compiling this study was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search was performed on six databases: PubMed, Scopus, Web of Science, ProQuest, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov. The risk of bias in the study will be analyzed using the Cochrane Risk of Bias Tools for Randomized Trials version 2 (RoB 2). Results: Six studies that met the inclusion criteria were included in the meta-analysis with a total of 381 samples. The success rates (OR 1.46, 95% CI 0.74-2.87, p = 0.28) and urine output (OR 2.54, 95% CI 0.63-10.20, p = 0.19) were not significantly different, while the mean operating time (MOT) (SMD 1.96, 95% CI 1.10-2.82, p < 0.0001) was significantly shorter in TIPU (P < 0.05). The incidence of meatal stenosis was significantly more in TIPU than DIGU significantly (OR 5.11, 95% CI 1.46-17.92, p = 0.01), while fistula (OR 2.93, 95% CI 0.92-9.35, p = 0.07) and dehiscence (OR 3.05, 95% CI 0.81-11.45, p = 0.10) was not significantly different between the two techniques. Conclusion: TIPU has the advantage of shorter operating time but a higher incidence of meatal stenosis than DIGU.

Dorsal Versus Ventral Dartos Flap to Prevent Fistula Formation in Tubularized Incised Plate Urethroplasty for Hypospadias.

The purpose of this study is to evaluate the results of two different flap procedures for prevention of urethrocutaneous fistula in hypospadias patients undergoing tubularized incised plate urethroplasty . We retrospectively reviewed 89 patients who underwent hypospadias repair. The standard technique of tubularized incised plate urethroplasty was used. There were 45 patients in Group 1 and 44 patients in Group 2, in which ventral and dorsal dartos flaps were used to cover the neourethra respectively. Surgical complications were assessed as the main outcomes. The results were analyzed with Chi-square and Mann-whitney u tests. There was no significiant difference between the groups in terms of age and meatus location. We observed postoperative surgical complications in 15 (33.3 %) patients in Group 1 and in 4 (9.1 %) patients in Group 2. The complications noted in the Group 1 were urethrocutaneous fistula in 10 patients ( 22.2 %) and meatal stenosis in 5 patients ( 11.1 %). In Group 2, fistula was observed in 2 patients (4.6 %) and stenosis in again 2 patients (4.6 %). Urethrocutaneous fistulas occurred statistically more frequently when ventral based dartos flaps were used (P < .05). Several flap procedures and their modifications have been suggested to avoid fistula formation. Within these procedures, dartos flaps are reported to be very useful for primary distal or proximal hypospadias repair and reoperations. In this study, we concluded that ; vascularized dorsal preputial dartos flap procedure is safe and more effective than ventral based flap in prevention of fistula formation.

Assessing the Effectiveness of Dorsal Flap in Surgical Repair of Hypospadias by Tubularized Incised Plate Urethroplasty

Background: Hypospadias is a congenital abnormality of the urethral meatus opening which is located anywhere along the length of the penis except the tip of the glans. The management of this congenital disease is surgical and comprises orthoplasty, urethroplasty, glanuloplasty and cosmetic correction. Urethroplasty is the key step of surgical correction of hypospadias. . Tubularized incision plate (TIP) urethroplasty by dorsal flap is frequently used for distal hypospadias. The reason for the preference is usually wide acceptability of low post-surgical complications and optimum cosmetic results. Other techniques include urethral plate augmentation and urethral plate replacement. Aims: The aim of this study is to assess the effectiveness of dorsal flap assisted TIP urethroplasty in patients with hypospadias of recruited population. The effectiveness will be measured against postoperative outcomes such as wound rupture, wound necrosis, meatal stenosis, and urethrocutaneous fistula formation. Methodology: This prospective study was conducted on 11 primary hypospadias cases undergoing TIPU in Dr Ziauddin Hospital, Karachi for the period of one year from November 2020 to October 2021. The inclusion criteria included infants with distal and midshaft hypospadias with sufficient width of the urethral plate. Whereas individuals with proximal hypospadias or other factors complicating the surgical procedure were excluded from the study population. Result: The total number of participants included was 11 children. The age of participants varied between 18 – and 28 months with a mean age of 24.2 ± 3.1 months. The meatus opening was seen at the distal end near the coronal sulcus in 8 participants whereas 3 participants showed preoperative meatus opening in the distal third of the shaft. An immediate follow up was done at 2 weeks intervals to assess wound health and situation. 1 out of 11 infants showed wound dehiscence which was immediately corrected. A late follow up was carried out after 2-3 years, no case presented with significant complications such as urethrocutaneous fistula or stenosis of the meatus. Conclusion: the study shows measured the post-operative complications followed by TIP urethroplasty using a dorsal flap. Immediate complications showed a single case of wound dehiscence. Whereas all long term follows up after 2-3 years showed no significant complications. After predisposing the clinical outcomes of this research against and in favour of pre-existing literature, it is concluded that dorsal flaps assisted TIP urethroplasty is a safe surgical procedure and is effective in terms of avoiding postoperative complications in individuals with hypospadias. Keywords: Dorsal flap, Hypospadias, Tubularized incised plate urethroplasty

Hybrid Mathieu Urethroplasty vs. Tubularized Incised Plate Urethroplasty for the Management of Distal Penile Hypospadias With a Small Glans.

IntroductionDistal hypospadias is a common anomaly. Different surgical techniques have evolved through the years to manage this anomaly. Several factors may affect the prognosis. One of them is glans size. We compared the hybrid Mathieu urethroplasty (HMU) and the tubularized incised plate urethroplasty (TIPU) for the management of distal hypospadias with a small glans.MethodsSixty-eight patients with distal hypospadias were included and categorized into two groups. Group A (n = 33) and group B (n = 35) patients were treated by HMU and TIPU, respectively. All patients had a small glans. In group A, the patients underwent Mathieu urethroplasty plus a deep incision of the urethral plate. In group B, the patients underwent TIPU. Urethral stents were used in all cases. Hypospadias objective score evaluation (HOSE) was used to assess the results.ResultsUrethrocutaneous fistulae developed in two cases in group A and six cases in group B. Meatal stenosis was significantly lower (one case in group A vs. eight cases in group B). Glanular dehiscence occurred in two cases in group A and five cases in group B. The small glans strongly correlated with the development of both urethrocutaneous fistulae and meatal stenosis where the odd ratios were 3.500 (1.383–7.879) and 9.481 (1.114–12.669), respectively.ConclusionBoth techniques showed efficacy during management of patients with a small glans. HMU had better outcomes, shorter duration of stent and lesser incidence of complications than TIPU. Small glans was significantly related to urethrocutaneous fistulae and meatal stenosis in group B.

Comparison of the use of graft augmented tubularized split (GATS) and tubularized incised plate urethroplasty (TIPU) techniques for hypospadias repair in patients with narrow plate and small glans

Background/Aim: Hundreds of repair techniques were described for hypospadias repair. It is still a problem to choose the right technique in hypospadias repair for patients with narrow plate and small glans, because the patients with narrow urethral plate and small glans usually suffer from complications. GATS (Glans Augmented Tubularized Split) is an alternative technique with different details from grafted TIPU (Tubularized Incised Plate Urethroplasty). The aim of this study is to compare the outcomes of TIPU and GATS procedures on these difficult cases. Methods: This retrospective cohort study consists of the analysis of patients who underwent GATS and TIPU procedures in our department between January 2017 and January 2020. Patients with distal and midpenile hypospadias and with shallow groove, glans smaller than 17 mm, and plate narrower than 8mm were included the study. Patient with follow-up shorter than 1 year or incomplete data and secondary cases were excluded. Patients were divided into two groups according to the technique performed, as 25 patients in TIPU group and 20 patients in GATS group. Results: The mean diameter of glans were 15.3 mm and 14.5 mm, mean width of plate were 5.2 mm and 4.1 mm in TIPU and GATS groups respectively. Complications were observed in 7 (28%) patients of TIPU group and in 2 (10%) patients of GATS group (P>0.05). Urethral stenosis in one patient, urethral fistula in two patients, urethral dehiscence in two and urethral stenosis and diverticula in one patient, urethral stenosis and fistula in one patient were detected in TIPU group. Urethral fistula in one patient and urethral dehiscence in one patient were observed in GATS group. Conclusion: GATS procedure is an alternative method for difficult cases with narrow urethral plate and small glans with less complications than TIPU technique.

The Histopathological Effect of Aloe Vera on the Wound Healing Process in a Surgically Created Tubularized Incised Plate Urethroplasty Model on Rats

Background Hypospadias is a common congenital anomaly which is determined as an abnormal urethral opening on the ventral face of penis. The purpose of this rat model study was to research the effect of topically applied Aloe vera after a tubularized incised plate urethroplasty (TIPU). Methods The TIPU model was applied to male Wistar albino rats. A total of 30 rats were randomly grouped into 3 groups of 10. Group I was assigned as the control group, treated with 0.9% saline only twice a day for 15 days. Group II received topical Aloe vera gel once a day and Group III received Aloe vera gel twice a day. Spongiofibrosis was graded as 0: none, 1+:≤10% tissues involved, 2+:10%-49% tissues involved, 3+: ≥ 50% tissues involved. Results A higher degree of fibrosis and inflammation was determined in the Group I subjects than in Groups II and III. Fibrosis of grade 3+ was observed in 33% of the control group and not in any of the two Aloe groups (p = 0.043). Inflammation of grade 3+ was seen in 66.7% of the control group, in 10% of Group II, and in 33% of Group III (p = 0.02). Conclusions The topical application of Aloe vera to a surgically created tubularized incised plate urethroplasty model decreased inflammation and fibrosis that may affect the success rates of this operation.

Dressing or Not after Tubularized Incised Plate Urethroplasty

Background: Many surgical techniques, as well as dressing models, were identified in the treatment of hypospadias. There are many publications in the literature that are the result of the effort to find the ideal dressing after hypospadias surgery. The dressing has some benefits; however, it has some adverse effects. The present study aimed to discuss outcomes of the patients who have been operated through the tubularized incised plate urethroplasty (TIPU) method and followed with and without dressing postoperatively. Methods: Patients operated on through the TIPU method between March 2015 and August 2019 were reviewed retrospectively. The patients were divided into two groups, dressing and undressing. Preoperative hypospadias severity was evaluated according to the Glans-Urethral Meatus-Shaft (GMS) scoring method. The care results of the patients were recorded. Postoperative outcomes were compared according to the Hypospadias Objective Scoring Evaluation (HOSE) scale, and statistical analyses were conducted. The results of both groups were compared statistically. Results: One hundred and nineteen patients were divided into two groups: dressing (n = 56) and nondressing (n = 63). The patients’ average age was 3.54 ± 2.97 years in group 1 and 3.50 ± 3.01 years in group 2 (p = 0.940). There was not any statistically significant difference between the two groups for demographic data. Minimal bleeding had stopped in three patients in the nondressing group spontaneously before discharging. No severe edema or hematoma, which might have concerned the parents, appeared. Two (3.5%) and 3 (4.7%) patients underwent a maximum of three urethral dilation sessions in dressing and nondressing groups, respectively (p = 0.556). We found no significant difference between groups in the comparison of preoperative GMS and postoperative HOSE scoring. Discussion: The most important limitation of the study is that it is retrospective. Pre- and postoperative scoring systems are objective. The data obtained in the literature show that surgeons prefer to apply dressings commonly after the TIPU technique. Advantages and disadvantages of dressing are mentioned in the literature. Even if the paradigm is dressing in hypospadias surgery, according to the results of our study, dressing may not affect the functional and cosmetic results of TIPU repair. Conclusion: Postoperative functional and cosmetic results of TIPU in hypospadias appear to be independent of dressing. However, the results must be supported by further research.

Comparison of Urethrocutaneous Fistula Rate After Single Dartos and Double Dartos Tubularized Incised Plate Urethroplasty in Pediatric Hypospadias.

Background and objectiveTubularized incised plate (TIP) urethroplasty is an easy and popular technique for repairing hypospadias, however urethrocutaneous fistula (UCF) is a frequently reported complication. Different techniques are used to reduce this complication. We aimed to compare the rate of UCF after single dartos and double dartos TIP urethroplasty in children with distal and mid penile hypospadias.MethodsA randomized controlled trial (NCT 04699318) was conducted in the Department of Pediatric Surgery, Mayo Hospital, Pakistan from August 2017 to February 2018, after ethical approval. After informed consent, a total of 60 patients with distal and mid penile hypospadias who were uncircumcised, had no chordee, and/or previous surgery, were randomly allocated in two groups using computer generated table numbers. Group A underwent single dartos TIP urethroplasty and Group B underwent double dartos TIP urethroplasty. Catheter was removed on day 10 post-operatively in both groups and primary outcome (UCF) was noted after a week of catheter removal. Rate of UCF was compared using chi square and p-value of <0.05 was taken as significant. Data was stratified to check for effect modifiers.ResultsOut of 60 children, eight (13.3%) developed UCF. In Group A, seven (23.3%) developed UCF and in Group B, one (3.3%) developed UCF (p-value 0.02). In both groups, no patient (0%) had urethral disruption, penile torsion, skin necrosis or meatal stenosis.ConclusionAdditional covering of neo-urethra by a double dartos layer significantly reduces fistula rate after tubularized incised plate urethroplasty in both primary distal and mid penile hypospadias.

Using prepucial mucous to cover neourethra in TIP urethroplasty: 4 years experience in a tertiary paediatric hospital of Bangladesh

Background. Hypospadias has a wide spectrum of penile abnormality requiring surgical correction. Most of the cases are of anterior variety and the surgical technique depends on constructing a neo urethra. Snodgrass or Tubularized Incised Plate (TIP) urethroplasty is one of the most popular techniques of urethroplasty which depends on the existing healthy, adequate and intact urethral plate. Different tissues have been described to cover the neourethra as second layer in literature. In this study we modified the TIP urethroplasty by covering the neourethra with 2 layers of pedicled prepucial mucosa or Dartos flap. Objective. To see the outcome of modified Snodgrass or TIP urethroplasty in anterior mid and proximal penile hypospadias. Materials and method. Total 88 patients were operated by modified Snodgrass technique or modified TIP urethroplasty from January 2012 to July 2016. Coronal, subcoronal, distal penile, mid penile and proximal penile hypospadias were included in the study. Every patient underwent modified TIP urethroplasty and outcomes were assessed. Results. The mean age of the patients were 28.34±14.98 months, ranges from 6.5 to 65 months. 9 (10.2%) patients of our series develop urethrocutaneous fistula, 5 (5.68%) patients develop meatal stenosis and 1 (1.1%) patient developed neourethral stricture. Conclusion. TIP urethroplasty is a versatile method to correct penile hypospadias. Covering of the neourethra with prepucial mucosa secure the neourethral anastomosis. The author declares that there is no conflict of interest. Key words: Hypospadias, TIP urethroplasty, Prepucial mucosa.

Comparative Study Between Outcomes of Tubularized Incised Plate Urethroplasty and Modified Tubularized Incised Plate Urethroplasty in the Management of Distal Hypospadias

Objective: To compare the outcomes of tubularized incised plate urethroplasty and modified tubularized incised plate urethroplasty in the primary management of distal hypospadias Materials and Methods: Total 70 patients of age group 2 to 10 years with distal hypospadias were selected for this study from January 2008 to December 2010. They were divided into Group-A (n=35) treated by the tubularized incised plate urethroplasty and Group-B (n=35) treated by the modified tubularized incised plate urethroplasty.The modification was performed by using inner preputial skin on the incised plate before tubularization. All patients were followed up immediately and at 4th, 8th and 12th weeks after operation. Results: The satisfactory cosmetic and functional outcomes were observed in 29 patients (82.85%) of Group-A and all families of Group-B were happy with aesthetic and functional outcomes. Urethrocutaneous fistula developed in 5 patients (14.70%) patients of Group- A and 1 (2.94%) patient in Group-B. Three patients (8.82%) in group-A and one patient (2.94%) in group-B were found to develop meatal stenosis. One patient (2.94%) developed stricture urethra in group A but no patient in group-B developed urethral stricture. Overall complications occurred in 10 patients (29.41%) in Group-A and 2 patients (5.88%) in Group-B. Conclusions: This study demonstrates that modified tubularized incised plate urethroplasty had excellent cosmetic and functional outcomes and fewer complications than that of tubularized incised plate urethroplasty in the primary management of distal hypospadias. Bangladesh Journal of Urology, Vol. 17, No. 2, July 2014 p.75-81

Competency in Tubularized Incised Plate Repair for Distal Hypospadias: Cumulative Sum Learning Curve Analysis of a Single Surgeon Experience.

We sought to determine the number of cases to achieve competency and proficiency in tubularized incised plate technique for distal hypospadias repair using cumulative sum analysis. From 2001 to 2015 we reviewed all distal tubularized incised plate repairs performed by a single surgeon since independent practice. Data for 450 consecutive cases included age, meatal location, presence of curvature, operative time, occurrence of complications and followup duration. A cumulative sum analysis cohort chart was used to determine trends in complication rate and operative time during the evaluation period. In order to account for surgical experience with time, the highest peak, plateau, and down trends in operative time and complication rate were identified on the plot and set as the transition points between learning (phase 1), competence (phase 2) and proficiency (phase 3). Based on the cumulative sum analysis learning curve, the competence phase with plateau of operative time and complication rate commences beyond the 127th case, and the proficiency phase with notable decline in operative time and complication rate was noted beyond the 234th case. When comparing case characteristics and surgical outcomes between phases and learning curve, the proficiency phase involved younger patients and more severe degree of distal hypospadias being repaired using the tubularized incised plate approach with fewer complications related to meatal stenosis and fewer cosmetic complications. In our study competency in distal hypospadias tubularized incised plate repair was reached beyond the 127th case, while proficiency was attained beyond the 234th case.

Flap Method is Better Than the Tubularized Incised Plate Method for the Surgical Treatment of Distal Hypospadias

BACKGROUND: Urethroplasty techniques generally can be divided into two methods, the flap method (Mathieu and Onlay Flap) and no flap with tubularized incised plate (TIP) urethroplasty method. Complications are common after urethral reconstructioninclude urethrocutaneous fistulae and cosmetic appearance, which is usually measured by Hypospadias Objective Penile Evaluation (HOPE) scoring system.&#x0D; AIM: The aim of this study was to determine whether there are differences in the outcome of flap method compare to TIP method in distal hypospadias patients who underwent urethroplasty.&#x0D; PATIENTS AND METHOD: The subjects of this study were patients with distal hypospadias who underwent urethroplasty in Sanglah General Hospital from September 2017 to December 2017. Thirty-six samples were selected by consecutive sampling.&#x0D; RESULTS: The results showed a significant difference in the incidence of meatal stenosis (p = 0.05) and urinary stream disturbances(p = 0.05) between two methods. No significant differences were found in the incidence of urethrocutaneous fistulae (p = 0.500) and the unsatisfactory HOPE score (p = 0.169).&#x0D; CONCLUSION: This research showed that meatal stenosis andthe maximum urinary stream were better in flap method compared to TIP method in distal hypospadias patients underwent urethroplasty.

Management of Distal Penile Hypospadias by Tubularized Incised Plate Urethroplasty: Study Of 30 Cases

Background: Hypospadias is the result of failure of fusion of the urethral folds on the ventral aspect of the penis.It usually occur 1 in every 300 male children.Reconstruction of urethra in childhood is the only hope of cure. The aim of this study is to find out the out.come of tubularized incised plate urethroplasty for distal penile hypospadias and to -~~ow that this procedure will end up in a better cosmetic appearance.&#x0D; Methods: This prospective study was conducted in a private medical college hospital, Comilla between July 2011 to June 2012 on 30 patients using Snodgrass technique of hypospadlas surgery. All cases were consecutively selected. Data were processed and analysed· using software SPSS (Statistical Package for social Sciences) version 11.5 and the test· statistics used to analyse the data were descriptive statistics and Z-test for proportion. The variables studied were age, socioeconomic condition, post-operative complications, such as infection rate, urethrocutaneous fistula, meatal stenosis, wound dehiscence etc. &amp;cosmatic outcome such as size of the meatus, shape of the glans studied.&#x0D; Results: Satisfactory results were obtained in 21 (70%) patients and only 8 (26.67%) had urethrocutaneous fistula, 1(3.33%) had retrusive meatus and 7 (23.33%) had wound infection. The final outcome was evaluated based on urethrocutaneous fistula and cosmesis. Out of 30 patients, 21(70%) did not have urtethrocutaneous fistula and were cosmetically acceptable. Binomial test based on Z-approximation reveals that observed proportion of patients with satisfactory- outcome was statistically significant (p = 0.05).&#x0D; Conclusion: This study concludes that Snodgrass urethroplasty has better cosmetic outcome. Thus we recommended it as the primary treatment for the children with distal hypospadias.&#x0D; Journal of Surgical Sciences (2014) Vol. 18 (1) : 9-14

Outcome of Snodgrass (Tabularized Incised Plate) in Repair of Primary Distal Hypospadias with Narrow Urethral Plate

AbstractBackground: Options for urethroplasty in children with hypospadias can be classified as tubularizations of the urethral plate, skin flaps and grafts. Throughout the history of surgery for this condition flaps have been most commonly used, but in the past 10 years incision and tubularization of the urethral plate (tubularized incised-plate, TIP) has rapidly gained popularity for correcting distal, proximal and re-operative hypospadias. TIP potentially simplifies both decision-making and surgical technique, and has a low complication rate with better cosmetic results. However, careful attention to surgical details and awareness of contraindications to the procedure are needed to achieve optimal results.Aim of Study: Outcome of Snodgrass (Tabularized Incised Plate) in repair of primary distal hypospadias with narrow urethral plate.Patients and Methods: Twenty patients with primary distal and midpenile hypospadias were enrolled for repair with Snodgrass technique.Demographic data, hereditary relationship, urethral plate length and width, glans width, and intraoperative time were recorded and post-operative early and late complications were observed for parents and surgeon satisfaction.Results: Between the 20 patients, only three patients developed post-operative complication one was urethrocuta-neous fistula and two showed meatal stenosis with success rate 85%.Conclusion: Tubularized incised plate in repair of primary distal and midpenile hypospadias successfully fulfils all traditional hypospadias repair criteria. It offers a viable option in the management of primary hypospadias with a narrow urethral plate.

Use of a Stent in Distal Hypospadias Repaired by Tubularized Incised Plate Urethroplasty: A Comparative Study

Purpose: We present our experience of stented and unstented distal hypospadias repaired by tubularized incised plate urethroplasty (TIPU). Patients and Methods: Data of 84 patients who were operated by TIPU method in 2 hospitals were retrospectively analyzed, and they were invited to be included in the study. Sixty-six patients agreed to participate in the study and were divided into 2 groups. Group 1 consisted of 38 boys operated in Sütçü İmam University Hospital on using a stent between 2015 and 2017. Group 2 consisted of 28 boys operated in Private Hospital of Megapark on without a stent between 2016 and 2017. The hypospadias objective scoring evaluation (HOSE) scale was used to compare the groups. Results: The median age was 2.81 years in group 1 and 1.95 years in group 2 (p = 0.243). The mean follow-up duration was 25.74 ± 4.62 and 24.5 ± 4.19 months in groups 1 and 2 respectively (p = 0.268). The HOSE scores were similar in both groups with comparable results (p = 0.622). Conclusions: No difference was observed between the groups in this study, regarding functional and cosmetic outcomes according to the HOSE score. However, the results should be supported by prospective studies with a sufficient number of patients.

Can Grafted Tubularized Incised Plate Urethroplasty be Used to Repair Narrow Urethral Plate Hypospadias? Its Functional Evaluation Using Uroflowmetry.

Aim:Using uroflowmetry, the aim of this study is to determine the functional results of the grafted tubularized incised plate (GTIP) urethroplasty used to repair poor urethral plate hypospadias.Settings and Design:Seventy-one patients (mean age: 5.7 years, follow-up: 1–5.5 years) were selected from those who underwent surgery using the GTIP technique from 2013 to 2015 at our institution.Methods:Patients included were able to void voluntarily and had no fistula. The flow pattern, maximum urinary flow rate (Qmax), voided volume (vv), average flow rate, and voiding time were measured. The results were expressed as percentiles and interpreted according to Siroky nomogram. The Qmax was considered normal if >25th percentile, as equivocally obstructed when in the 5th–25th percentile, and obstructed if <5th percentile.Results:Hypospadias was distal in 45, mid penile in 17 and proximal penile in 9. The uroflow curve was bell-shaped in 24 (30%), interrupted in 9 (14%), slightly flattened in 31 (46%), and a plateau in 7 (10%). Flow rate nomograms revealed that 49 (68%) were above the 25th percentile, 9 (17%) were below the 5th percentile, and 13 (15%) were between these ranges. Eleven patients showed improvement in the flow curve and maximum urinary flow rate (Qmax) in follow-up uroflowmetry.Conclusion:GTIP repair provides satisfactory functional results. A long-term follow-up is needed to confirm these results.

A Critical Analysis of Stented and Unstented Tubularized Incised Plate Urethroplasty Through a Prospective Randomized Study and Assessment of Factors Influencing the Functional and Cosmetic Outcomes

To compare, functionally and aesthetically, stented and unstented tubularized incised plate urethroplasty (TIPU). In addition, predictors of repair success were investigated. One hundred ten children with distal hypospadias were included in this study. The length and width of the urethral plate (UP) and transverse glans diameter (TGD) were measured. Patients were randomized into two groups: stented and unstented TIPU. Postoperative assessment of pain was done using Face, Legs, Activity, Cry, Consolability (FLACC) scale, and cosmetic outcome was evaluated using hypospadias objective scoring evaluation. Uroflow was assessed at 6 months in toilet-trained boys. Complications were graded by the Clavien classification system. In 93 cases, Face, Legs, Activity, Cry, Consolability score, hospital stay, and dressing time were in favor of the unstented group, whereas hypospadias objective scoring evaluation score and uroflow parameters were comparable. TGD and UP width varied significantly between successful and failed cases. Cutoff values of 13.5 mm and 8.5 mm for TGD and UP width, respectively, are required for successful outcome. Acute urinary retention was 12.8% after unstented repair. Detrusor spasm was 47.8% after stented and 8.5% after unstented repair. In both groups, urethrocutaneous fistula of 5.4%, glanular dehiscence of 1.1%, and meatal stenosis of 5.4% were found in cases with small TGD and narrow UP. Unstented TIPU evades the associated drawbacks of the stent along with lower postoperative pain, hospital stay, and dressing time. Even without a postoperative stent, the complication rate in infants with distal hypospadias is low, and short-term functional and aesthetic outcomes were not compromised.

A Simple Method for Closure of Urethrocutaneous Fistula after Tubularized Incised Plate Repair: Preliminary Results

BackgroundUrethrocutaneous fistula (UCF) is the most prevalent complication after hypospadias repair surgery. Many methods have been developed for UCF correction, and the best technique for UCF repair is determined based on the size, location, and number of fistulas, as well as the status of the surrounding skin.ObjectivesIn this study, we introduced and evaluated a simple method for UCF correction after tubularized incised plate (TIP) repair.MethodsThis clinical study was conducted on children with UCFs ≤ 4 mm that developed after TIP surgery for hypospadias repair. The skin was incised around the fistula and the tract was released from the surrounding tissues and the dartos fascia, then ligated with 5 - 0 polydioxanone (PDS) sutures. The dartos fascia, as the second layer, was covered on the fistula tract with PDS thread (gauge 5 - 0) by the continuous suture method. The skin was closed with 6 - 0 Vicryl sutures. After six months of follow-up, surgical outcomes were evaluated based on fistula relapse and other complications.ResultsAfter six months, relapse occurred in only one patient, a six-year-old boy with a single 4-mm distal opening, who had undergone no previous fistula repairs. Therefore, in 97.5% of the cases, relapse was non-existent. Other complications, such as urethral stenosis, intraurethral obstruction, and epidermal inclusion cysts, were not seen in the other patients during the six-month follow-up period.ConclusionsThis repair method, which is simple, rapid, and easily learned, is highly applicable, with a high success rate for the closure of UCFs measuring up to 4 mm in any location.

Advantages of Reduced Prophylaxis after Tubularized Incised Plate Repair of Hypospadias

Concerns about antibiotic resistance, adverse drug reactions and questionable medical benefits have led to changes in prophylactic antibiotic management in hypospadias repair at our clinic. In March 2010 our guidelines were changed from continuous prophylaxis for 14 days to 1 dose preoperatively and another at removal of the stent. We analyze the effects of this new regimen. We performed a prospective journal cohort study of all our hypospadias operations from June 2008 to December 2011. We collected data from consecutive patients undergoing primary tubularized incised plate repair and postoperative stent. Patients operated on before March 2010 were compared to those operated on later. End points were postoperative infection requiring antibiotics and any complication that required redo surgery. The study included 113 primary tubularized incised plate repairs with postoperative stents. Patient distribution was the same in both groups. Of 58 patients in the group receiving continuous antibiotic prophylaxis 17 had a complication and/or infection, compared to 9 of 55 patients receiving 2-dose prophylaxis. The infection rate was 5% in the continuous prophylaxis group and 4% in the 2-dose group. In contrast to our expectations, a lower complication rate was observed in the group with lower antibiotic dose without an increased risk of infection. There is little documented evidence concerning benefits of antibiotic prophylaxis for postoperative complications, which gives rise to large variations in clinical practice. In our study lower antibiotic dose did not increase the number of infections, but rather decreased complication rates. We advocate antibiotic prophylaxis with only a 2-dose regimen.

A Comparative Study to Evaluate the Outcome of Double Dartos Flap in Tubularized Incised Plate Urethroplasty for Distal Hypospadias Repair

Background/purpose: The tubularized incised plate urethroplasty (Snodgrass technique) presents the procedure of choice for distal hypospadias repair. Fistula formation is the most common complication with various rates. Avoiding overlap of suture lines in the Snodgrass repair is critical to minimize fistula formation through second-layer coverage of the neourethra. We compared the outcome of double- layer dartos flaps to flapless procedure in the tubularized incised plate urethroplasty for distal hypospadias repair to assess the effectiveness of dartos flap in this method.Methods: Our study included 28 patients aged upto 12 years who were treated with tubularized incised plate urethroplasty for distal hypospadias in Shaheed Suhrawardy Medical College Hospital from April 2010 to December 2011. They were divided into two groups. Group A (14 patients) had double dartos flap coverings. Group B (14 patients) had no dartos flap covering. The dissected dorsal dartos flap was bisected vertically to form two pedicle wings. Each wing was rotated laterally from either side of the glans to cover the neourethra ventrally in a double-layer fashion.Result: Mean follow up period was 9 months. In Group A, one patient (7%) developed fistula and one (7%) superficial skin necrosis. On the other hand three (21%) patients developed fistula and one patient (7%) meatal stenosis in group B, who were treated with Snodgrass procedure without using dartos flap. All successful repaired hypospadias patients of both groups had a cosmetically normal looking circumcised penis with ventrally slit meatus.Conclusions : Double dartos flaps covering of the neourethra is a simple procedure and could be effective for the prevention of urethrocutaneous fistula after tubularized incised plate urethroplasty.J. Paediatr. Surg. Bangladesh 3(2): 65-70, 2012 (July)