Mathieu Repair Research Articles

Urinary function after Snodgrass repair of distal hypospadias: comparison with the Mathieu repair

To evaluate urinary function in patients with distal hypospadias undergoing repair by the tubularized incised-plate urethroplasty (TIP or Snodgrass), compare the results with those in patients treated by the Mathieu technique, and show the potential issues inherent to the evaluation of such results. A cross-sectional assessment was performed of uncomplicated distal hypospadias operated on during a 3-year period, already toilet trained, and able to void volitionally. Evaluation included clinical assessment urinary symptoms and urinary stream, and uroflowmetry. Out of 83 patients operated on during the study period, 10 (12%) developed complication and 32 were not toilet trained or refused to participate in the study. Median follow-up in the remaining 41 patients included in the study was 20 (3-36) months. None of these patients presented voiding symptoms or urinary stream abnormalities. Uroflowmetry was normal in 30 cases and obstructive in 11 (27%). An obstructive flow pattern was more common in patients undergoing TIP versus Mathieu repair, 8 of 19 (42%) versus 3 of 22 (14%), respectively (P = 0.07). Four TIP cases with an obstructive uroflow pattern were managed conservatively. Although both the TIP and the Mathieu repair allow good results in terms of urinary function after distal hypospadias repairs, the TIP technique seems more likely to be associated with urine flow pattern abnormalities. The actual clinical relevance of this finding remains ill defined.

Double-Cross Flap Protection: New Technique for Coverage of Neourethra in Hypospadias Repair

We analyzed a new urethra preserving approach, double-cross flap protection, during tubularized incised plate urethroplasty. We compared the results of 57 patients treated with this new procedure and 80 patients treated with 2 different techniques. We studied 137 patients with hypospadias between October 2002 and March 2008. Patients were divided into 3 groups. Group 1 consisted of 40 patients (mean age 50 months) undergoing tubularized incised plate urethroplasty. Group 2 included 40 patients (mean age 48 months) undergoing tubularized incised plate urethroplasty with dorsal subcutaneous flap. Group 3 consisted of 57 patients (mean age 39 months) undergoing tubularized incised plate urethroplasty with 2 de-epithelialized preputial flaps twisted ventrally and sutured individually over the neourethra. All patients were operated on by the same surgeons. Statistical analysis of postoperative complications was performed by ANOVA and chi-square test. In Group 1 fistula developed in 6 patients (15%) and was associated with stenosis of the neourethra in 4 (10%). In Group 2 fistula developed in 4 patients (10%). In Group 3 no fistula was observed, but mild stenosis of the neomeatus developed in 3 patients (5.3%), which was treated with dilation. Thus, the incidence of fistula in group 3 was significantly less (p = 0.015). Double-cross flap protection is safe and significantly reduces the incidence of postoperative fistula.

Dribbling Diversion in Y‐V Glanuloplasty Modified Mathieu Repair

Aim of the study was to determine the impact of an indwelling transurethral catheter on surgical outcome and postoperative micturation in Y-V glanuloplasty modified Mathieu repair for primary hypospadias. Fifty-nine consecutive boys underwent Y-V glanuloplasty modified Mathieu repair for primary distal hypospadias in our institution. The first 37 patients (group A) had catheterless repair. Due to significant painful postoperative urination, the next 22 children (group B) had an indwelling transurethral catheter (5 Fr feeding tube) for 24-48 hours. Adjunct caudal analgesia and penile block was given in both groups. Pain during postoperative voiding, urinary retention, meatal stenosis and fistula formation was statistically analysed with Wilcoxon's signed rank test. All patients in group A had distressing painful first micturation (p < 0.05). Eight children did not pass urine for more than 8 hours. Five (13.5 %) patients had urinary retention, 3 of whom required catheterisation (p < 0.05). Six (16 %) boys developed meatal stenosis and a further 5 (13.5 %) had urethrocutaneous fistula. In group B all patients had easy micturation after removal of the catheter. Only 1 boy developed a urethrocutaneous fistula and none of the boys in this group presented with meatal stenosis. An indwelling transurethral catheter obviates urinary retention and avoids distressing postoperative micturation. It minimises the chance of urethrocutaneous fistula and meatal stenosis in Y-V glanuloplasty modified Mathieu repair.

“Limited” double dorsal dartos flap coverage. An effective alternative to conventional flap coverage of the neourethra following Mathieu repair for subcoronal hypospadias

Double dorsal dartos flap coverage of the neourethra has been reported to be superior to single flap coverage for the prevention of urethrocutaneous fistula following hypospadias surgery. Conventional flap coverage involves covering the entire neourethra with vascularised flap. We describe a "limited" double dorsal dartos flap coverage of the neourethra following Mathieu repair for subcoronal hypospadias. In a prospective study conducted between Feb 2003 and Feb 2007, 31 patients with primary subcoronal hypospadias who had a flat and narrow urethral plate with a healthy urethral meatus and minimal or no chordee underwent Mathieu hypospadias repair. A "limited" double dorsal dartos flap coverage of the neourethra was done in all patients. This involved covering only that portion of the neourethra which remained exposed after glans closure, i.e. the proximal neourethra. Primary surgical outcome assessed was the development of urethrocutaneous fistula following surgery. The mean age at the time of repair was seven years and mean follow up was eight months. There was no flap loss, urethrocutaneous fistula formation, or glanular dehiscence in any of the 31 patients. One patient developed meatal stenosis which was managed by dilatation. One patient developed superficial sloughing of the penile skin. Overall complication rate was 6.45%. "Limited" double dorsal dartos flap coverage of the neourethra seems to be an effective method to reduce the fistulous complication rate following Mathieu repair for subcoronal hypospadias. A larger comparative study needs to be done to evaluate conventional neourethral coverage with "limited" neourethral coverage.

Short hospital stay versus day-care Mathieu hypospadias repair

This study compared the outcome of Mathieu repair between patients who went home within 24 hours on catheter and dressing and patients who were managed in hospital for 48 hours and had their catheters and dressings removed before going home. A retrospective study of Mathieu hypospadias repair performed by the same surgeon for 11 years. Outcome measures were catheter and dressing related problems/complications. Sixty five patients were included in the study; 43(66.2%) were managed in-hospital for the first 48 hours (Group A), while 22(33.8%) were managed as day-care cases (Group B). Complication rate was 6(14.0%) and 3(13.6%) respectively, with fistula rate of 2(4.7%) in Group A and 1(4.5%) in Group B. Day care Mathieu repair of hypospadias does not increase the occurrence of complications.

Mathieu and Barcat repair with a V incision sutured meatoplasty for secondary hypospadias surgery

Today single-stage methods are more frequently selected for hypospadias repair than multistaged methods, but complications cannot always be avoided. We employed two kinds of meatal based flip-flap urethroplasty procedures for those with an unsuccessful primary hypospadias repair. From 1997 to 2005, a meatal based flip-flap urethroplasty was performed as a secondary hypospadias surgery on 17 patients. Basically we attempted the Mathieu repair, but when the wings of the glans were not generously widened and the urethral groove was not sufficiently deep we applied the Barcat procedure. While 11 patients were repaired with the Mathieu technique, six patients underwent the Barcat repair. The V incision sutured meatoplasty was added to obtain a natural ventral slit-like meatus. Ten of the 11 patients who underwent the Mathieu repair had a good outcome, but one patient developed a urethrocutaneous fistula. None of the six patients repaired with the Barcat procedure encountered postoperative complications. Cosmetically, a vertical slit was constructed near the normal neomeatus with the Mathieu and V incision sutured (MAVIS) meatoplasty and the Barcat and V incision sutured (BAVIS) meatoplasty. The Mathieu or the Barcat meatal based flip-flap urethroplasty procedure is feasible as a salvage surgery for those with relatively short urethral defects and adequate mobile ventral skin if an exact procedure is selected. Excellent cosmetic results could be obtained by adding the technique of V incision sutured meatoplasty.

Prospective Randomised Study Of Stented Versus Unstented Mathieu Repair Of Hypospadias

Aim: To undertake a prospective randomised study comparing outcome of Mathieu hypospadias repair in patients with and without stents Methods: Patients suitable for Mathieu repair of hypospadias constituted our patient population. Patients were randomised into the group with stent (group1) and the group without a stent(group2). Surgical procedure was the same in both where repair was carried out over a stent. The surgeon was unaware of the randomisation till the end of the operation. Those randomised to group 1 had the stent with dressing for 48hours.In group2, stent was removed in theatre, and no dressing was applied. Both groups received the same antibiotic cover. All were reviewed at 6weeks and 1 year. Duration of hospital stay,and results of surgery were assessed. Results:20 patients were entered in the study. 10 randomised into each group.2 children in group 1(stented) had immediate post-operative problems related to the stent. None in either group had postoperative bleeding or urinary retention. No long term problems in terms of fistula, stricture or meatal stenosis were noted in either group. Duration of hospital stay however was significantly different. Duration in hospital for those in group 1 exceeded that for ones in group 2 by an average of 31 hours

An objective assessment of the results of hypospadias surgery

To compare the cosmetic result of tubularized incised-plate urethroplasty (Snodgrass method) with that of two established techniques, the meatal-based flap and onlay island flap repair. Photographs of the penis after hypospadias repair in 32 boys were assessed by a panel of five independent health professionals, including four surgeons with variable paediatric urological experience and a urology nurse. Twenty patients had a distal and 12 a proximal meatus. The Snodgrass technique was applied by one paediatric urologist for either distal (10) or proximal (six) hypospadias. A Mathieu repair was used for distal hypospadias (10) and an onlay preputial island flap for proximal hypospadias (six) by a second paediatric urologist. The panel was asked to grade cosmesis as poor, unsatisfactory, satisfactory or very good (points 1-4) for each of the following aspects of penile appearance: meatus, glans, shaft and overall appearance. Photographs were taken in a standard way, with a standard distance, lighting and two views, one of the dorsal surface and one ventral, for each patient. Signed written consent for the study was obtained from each family. The mean assessment score for any aspect of cosmesis was significantly higher for the Snodgrass technique (P < 0.05). The mean score (95% confidence interval) for the meatus was 0.76 (0.4-1.1) points higher for the patients with a Snodgrass repair than those with a Mathieu or onlay island flap repair (P = 0.002). Correspondingly, the values for the glans were 0.67 (0.38-0.97) (P = 0.003), shaft 0.42 (0.16-0.69) (P = 0.01) and overall appearance 0.62 (0.24-1.0) (P = 0.01) points higher for the Snodgrass repair. The Snodgrass technique was more effective in producing a vertically orientated meatus (87.5%) than the Mathieu and Duckett onlay repairs (37.5%; P = 0.009). The Snodgrass technique, as assessed by this panel, had a better cosmetic outcome than the Mathieu and Duckett onlay island flap repairs. The assessment of cosmesis in hypospadias surgery is potentially more objective when several health professionals, not involved in the surgery, compared the various methods of repair.

DO PATCH PROCEDURES PREVENT COMPLICATIONS OF THE MATHIEU TECHNIQUE?

The effects of V-incision sutured (MAVIS) and dartos patch reinforcement techniques in reducing side effects and complications of the Mathieu procedure and improving the appearance of the meatus are evaluated. A total of 74 patients with distal shaft hypospadias without chordee or with minimal chordee were operated on by a single surgeon using Mathieu's technique. While only the classic Mathieu repair was performed in group 1, MAVIS and dorsal dartos patch reinforcement was included with the procedure in group 2. A silicone urethral catheter and foam silicone dressing were used in both patient groups. There were 32 cases in group 1 and 42 in group 2. Median patient age at operation was 3.2 and 3.4 years in groups 1 and 2, respectively. Mean postoperative period for the silicone catheter was 4.9 days in both groups. Followup ranged from 52 to 128 months (mean 76) for group 1 and 13 to 43 months (25.4) for group 2. Five fistulas and 1 meatal stricture developed in group 1 and all the children in this group required meatal calibration with dilatation in some. Neither fistula nor stricture occurred in group 2 and there was no need for calibration. A slit-like meatus was achieved in all children in group 2 but in only 12 in group 1. The MAVIS technique and dorsal dartos patch reinforcement may prevent complications of the classic Mathieu procedure. A slit-like meatus was obtained in all cases with this approach.

Combined use of perimeatal-based flap urethroplasty (Mathieu) with midline incision or urethral plate in hypospadias repair.

Perimeatal-based flap urethroplasty is commonly used for the primary correction of distal hypospadias. The Mathieu repair provides excellent function and satisfactory cosmetic results, but the risk of devascularisation of the neourethral flap is an inherent problem of this technique. The midline incision of the urethral plate is part of the Snodgrass method, which offers good urethral calibre and tension-free closure. Our aim was to test the effectiveness of the use of the perimeatal-based flap combined with a midline incision of the urethral plate in hypospadias repair. 19 boys, aged 20 months to 5 years, with distal hypospadias, underwent a one-stage repair using the above-described modification of the Mathieu technique. The meatal-based flap with a midline incision of the urethral plate was similar in all cases. The hypospadias repair was successful in all patients, only one boy developed a urethrocutaneous fistula which required subsequent operation. There was no postoperative scarring, chordee or urethral stricture during follow-up. Hypospadias repair using a perimeatal-based skin flap and combined with an incision of the urethral plate reduces complication rates and offers good cosmetic results.

MATHIEU HYPOSPADIAS REPAIR: EXPERIENCE IN 202 PATIENTS

The complication rate after Mathieu hypospadias repair was recently reported to be 3.6% in unstented cases. We reviewed our experience and results of the Mathieu repair performed at our institution during the last 5 years. We performed 197 primary and 5 secondary repairs in 202 patients. Reconstruction of the neourethra was done with a 2-layer anastomosis using optical magnification. Urethral stents were placed for postoperative drainage in all but 1 patient. Followup was up to 54 months. There were no incidences of stent migration or symptomatic urinary tract infection while the stent was in place and all patients voided spontaneously after stent removal. Excellent cosmetic results were obtained in 201 cases. In 1 patient meatal retraction required subsequent meatoplasty with meatal advancement. In 2 patients pinpoint urethrocutaneous fistulas were successfully repaired. The total rate of reoperation was 1.5% in our series. There was no report of urethral stricture during followup. The well established Mathieu repair provides excellent cosmetic and functional results. The overall complication rate is minimal and compares favorably with stentless repair. A 2-layer neourethral anastomosis performed under sufficient optical magnification produces a watertight closure with minimal risk of fistula formation. Postoperative urethral stenting decreases this risk even further, while adding only minimal morbidity. We believe that in the era of newly reported techniques the well established Mathieu procedure should be the standard by which distal repair is judged.

Tubularized-incised urethral plate urethroplasty: is regular dilatation necessary for success?

To report the results of the tubularized-incised urethral plate repair of hypospadias. Twenty-seven patients (mean age 8 years, range 6-18) had their hypospadias corrected using the tubularized-incised urethral plate technique. Five patients had glanular, 16 had coronal, and two had recurrent hypospadias after a failed Mathieu repair, and four patients required a second-stage repair. The urethral plate was incised in the midline and tubularized over a suitably sized stent. In patients who required second-stage repair a Thiersch-Duplay neourethra was constructed from the hypospadiac orifice to the corona and the glanular urethra was constructed by tubularization of the incised urethral plate. The functional and cosmetic results were excellent. Of the first seven patients, four had a small fistula associated with meatal stenosis. By regular dilatation of the glanular urethra, all fistulae resolved spontaneously. Dilatation was instituted in all the remaining patients and no fistula or meatal stenosis occurred. Other complications included haematoma formation in one patient, urinary tract infection in another and frequent bladder spasm in two. The tubularized-incised urethral plate urethroplasty is a simple and versatile technique that provides an excellent cosmetic appearance of the glans. It can be applied not only for the primary repair of distal hypospadias, but also for re-operation of recurrent hypospadias. The technique is ideal for constructing a glanular urethra when the Thiersch-Duplay operation is used to repair posterior hypospadias. Regular urethral dilatation is important in preventing adhesions between both sides of the incised plate, which can result in meatal stenosis and fistula.

Hypospadias repair by skin flaps: a comparison of onlay preputial island flaps with either Mathieu's meatal-based or Duckett's tubularized preputial flaps.

To evaluate the success of different skin flaps in the one-stage correction of primary hypospadias, with particular emphasis on comparing onlay preputial island flaps with Mathieu's meatal-based and Duckett's preputial tubularized flaps. During a 12-year period, 418 patients underwent single-stage primary hypospadias repair using skin flaps, carried out by one surgeon. The surgical techniques used included Mathieu's repair in 216 (52%), Duckett's in 148 (35%), onlay preputial flaps in 42 (10%) and the Mustarde flap procedure in 12 (3%). The surgical results were reviewed, assessing complications and the functional and cosmetic outcome. At a mean follow-up of 23 months the initial overall complication rate for flap procedures was 22%; however, after a mean of 1.4 procedures, the final success rate was 95%. The complication rate was significantly (P<0.05) higher in patients with a proximal urethral meatus, with severe chordee or in repairs involving transection of the urethral plate. However, the complication rates were not significantly different when the patients underwent repair when aged <2 years or >2 years. Despite no significant difference in overall complication rates, onlay procedures tended to be used in more severe hypospadias than was Mathieu's repair. Duckett's repair caused a significantly higher overall complication rate as fistulae, strictures, meatal stenoses and tubular abnormalities than did onlay procedures. The use of double-faced preputial island flaps resulted in an inferior cosmetic appearance than the use of single-faced flaps, but the overall complication rates did not differ significantly between these techniques. Hypospadias repair using skin flaps offered a reliable and durable outcome. However, complication rates were greater in patients with severe hypospadias and with techniques requiring transection of the urethral plate. The onlay preputial island-flap technique was more widely applicable than was Mathieu's repair and had a lower complication rate than Duckett's procedure.

Distal hypospadias repair with meatal-based flaps on an outpatient basis.

We report the results of primary repairs that were performed on 52 consecutive patients with distal hypospadias as an outpatient procedure. A modified Mathieu repair with meatal-based vascularized flap was performed under 2.5 optical magnification using Scottring retractors, traction sutures, micro instruments and fine suture material. A total of 3 patients had complications that required reoperation (5.8%). One of these 3 complications was a urethrocutaneous fistula (1.9%). We found that the repair of distal hypospadias was successful with meatal-based flap using contemporary finer approaches and equipment.

Outcome Analysis of the Modified Mathieu Hypospadias Repair: Comparison of Stented and Unstented Repairs

Purpose We compared surgical outcomes of stented and unstented Mathieu repairs in boys with primary distal hypospadias, and evaluated the efficacy and safety of caudal analgesia relative to other forms of analgesia (penile block and epidural analgesia). Materials and Methods We retrospectively reviewed the records of 336 consecutive boys who underwent the modified Mathieu repair for primary distal hypospadias. A urethral stent was placed in 114 patients and nonstented repair was performed in 222. Adjunct caudal analgesia was given in 136 cases, a penile block in 158 and continuous epidural analgesia in 42. Results None of the unstented cases had urinary retention. Analysis of surgical outcomes revealed no difference in fistula formation between patients with and without stents (2.63 versus 2.70 percent, respectively, p greater than 0.999). Overall complication rates in the stented and unstented groups were not significantly different (2.63 versus 3.60 percent, respectively, p = 0.756). The fistula rate in patients who received adjunct caudal analgesia was no different than in those who received other forms of adjunct analgesia (2.21 versus 3.0 percent, respectively, p greater than 0.999). Conclusions These data suggest that successful Mathieu hypospadias repair is independent of the use of a stent. Caudal analgesia, a penile block and epidural analgesia provided effective postoperative pain control with no difference in complication rates. To our knowledge our report represents the largest observational study reported to date comparing stented and unstented repairs. However, because of the small number of complications in each group, a much larger study is required to determine statistically significant differences among these groups.

Distal Hypospadias Repair Without Stents: Is It Better?

We previously reported the results of the meatal based flap urethroplasty (Mathieu) for distal hypospadias repair. Of 49 patients in whom stents were left indwelling for 2 to 5 days meatal stenosis developed in 1 and there were no fistulas. In view of these good results and to decrease postoperative discomfort from bladder spasms, we performed 37 consecutive meatal based flap repairs without stents. Seven patients (19%) had urinary retention requiring catheterization several hours after surgery, of whom 3 had had a caudal block and 4 a penile block with 0.25% bupivacaine for postoperative pain control. In 5 patients (14%) a urethrocutaneous fistula developed, which required surgical repair. Of the patients with a fistula 2 were also among those who presented with urinary retention and 1 had concomitant meatal stenosis. One child had meatal stenosis only, requiring a meatoplasty after failed dilations. Subsequently, of another 16 children who underwent the Mathieu repair with stents a urethrocutaneous fistula and meatal stenosis developed in 1 (6.2%) and 15 patients had no complications.Overall of 65 patients in whom a stent was used 3 (4.6%) had complications, in contrast with a complication rate of 18.9% in the unstented group, representing a statistically significant difference (p <0.05). The stent obviates urinary retention, which was unrelated to the type of anesthetic block used, and minimizes the incidence of fistula and stenosis. We conclude that the use of a multiper-forated silicone urethral stent is advantageous for the outcome of this operation.

Improved Mathieu Repair for Coronal and Distal Shaft Hypospadias with Moderate Chordee

A modified Mathieu "flip-flap" technique is described for coronal and distal shaft hypospadias with moderate chordee. The first improvement is the creation of a well vascularised skin flap by leaving the dartos tunica attached to the mobilised skin, thus making it possible to bridge urethral defects up to 2.5 cm. The second improvement is the correction of congenital curvature by partial chordectomy and dorsal plication of the tunica albuginea without the need for circumcision. Preputial reconstruction is possible if required. Twenty patients underwent the procedure with a follow-up of at least 2.5 years; 96 patients had a shorter follow-up. Complications in the group of 20 patients consisted of 1 fistula, 2 meatal stenoses and 1 glanular dehiscence due to severe wound infection. There were no late complications.

The Role of the Mathieu Repair as a Salvage Procedure

Conceived as a primary single-stage procedure for coronal and subcoronal hypospadias, the Mathieu repair has not been previously described as a salvage operation in situations where other forms of hypospadias surgery have failed to give an adequate functional or cosmetic result. We describe the use of the operation as a planned salvage procedure.

Outpatient catheterless Mathieu repair: how to cover ventral penile skin defect.

A modification of the Mathieu repair eliminating stenting has been described by Rabinowitz which makes the method more convenient for outpatient performance. We report on our experience with this modification with special emphasis on coverage of ventral penile skin defect. To cover the raw area formed on the ventral aspect of penis with the creation of meatal based flap Rabinowitz used Byar's flap. Two different flaps prepared from prepuce were used in this series. In some patients an island flap was used. In others the prepuce was incised transversally on its dorsal aspect and transferred to the ventral surface as a bipedicle visor flap, as described by Ombrédanne and popularized by Nesbit. Twenty-two patients ranging in age from one to twelve years (mean +/- 1SD = 6 +/- 3.28) were operated on using the technique. The meatus was glandular in two, coronal in twelve and distal penile in eight patients. Preputial flap was not used in one patient because the defect was small. Island flap was used in three and Ombrédanne-Nesbit's flap in 18 patients. Complete disruption of the repair occurred in one of the patients in whom an island flap was used. Among 18 patients in whom Ombrédanne-Nesbit's flap was used, one partial necrosis of the preputial flap was encountered which required revision and two urethrocutaneus fistulae occurred which healed spontaneously. The use of the present technique yields a good cosmetic result, a high success rate with minimal complications, and eliminates catheterization; hence, hospitalization is recommended.

Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair

We studied 24 boys who were randomized to receive caudal epidural anesthesia with 0.33ml. kg.-1 0.25% bupivacaine either before (group A) or after (group B) Mathieu repair of distal hypospadias. The 2 groups did not differ in regard to age or weight, and all boys received a standardized anesthetic with halothane and nitrous oxide in oxygen. Intraoperative blood loss was measured with sponge weights and microcalibrated suction canisters. Halothane requirements were reduced in group A (0.5 versus 1.1 plus or minus 0.1%, p <0.001). Measured blood loss was reduced in group A (16 plus or minus 10ml. versus 31 plus or minus 17ml., p <0.01). Operating time was reduced in group A (92 plus or minus 13 minutes versus 103 plus or minus 14 minutes, p <0.05). There was no apparent difference in postoperative pain relief between the 2 groups. We conclude that caudal epidural anesthesia can reduce blood loss and improve surgical conditions during hypospadias repair.