Plate Incision Research Articles

Treatment of 52 Cases of Hypospadias by Longitudinal Section of Urethral Plate and Coiled Tube Urethroplasty

Objective: To investigate the indications and some problems in the treatment of hypospadias by longitudinal section of urethral plate and coiled tube urethroplasty. Methods: All the children were treated with longitudinal urethral plate section and coiled tube urethroplasty. Results: The penis of all the children showed the appearance after circumcision, with normal erectile function, urethral opening in the right position of the head of the penis, postoperative urethral fistula in 4 cases, urethral stenosis in 3 cases, ventral swollen penis in 5 cases, slight torsion of the penis in 2 cases, and slight downward curvature of the penis in 1 case. Discussion: For distal and middle types of hypospadias with low penile flexion and well-developed urethral plates, longitudinal section urethral plate incision urethral tube urethroplasty has good surgical effect, short operation time and fewer postoperative complications. It is a commonly used surgical method at present.

Efficacy comparison between Mathieu combined urethral plate incision and onlay island flap urethroplasty for distal hypospadias in patients with urethral plate stenosis.

The aim of the study was to compare the efficacy of Mathieu combined urethral plate incision (Mathieu-IP) versus onlay island flap urethroplasty in patients with distal hypospadias complicated by urethral stenosis. The clinical data of 70 patients with distal hypospadias complicated by urethral plate stenosis treated in the Department of Urology, Anhui Provincial Children's Hospital (Hefei, China), from May 2019 to May 2022, were retrospectively analyzed. Thirty-eight patients underwent Mathieu-IP (Mathieu-IP group) and 32 underwent onlay island flap urethroplasty (Onlay group). Follow-ups at 1 month, 6 months, and 12 months postoperatively assessed operative time, complications, urethral meatus morphology, and family satisfaction. The Mathieu-IP group had significantly shorter operative time (mean ± standard deviation [s.d.]: 81.58 ± 5.18 min) versus the Onlay group (mean ± s.d.: 110.75 ± 6.05 min; P < 0.05). Surgical success rates were 78.9% (Mathieu-IP group) and 75.0% (Onlay group), with no significant difference ( P > 0.05). Complications were comparable between the groups. The Mathieu-IP group resulted in a vertical slit-shaped urethral meatus in 89.5% versus 13.8% in the Onlay group ( P < 0.05). Family satisfaction with general penile appearance and skin shape showed no significant differences, but the Mathieu-IP group had higher satisfaction with meatal position ( P < 0.05). Mathieu-IP offers simplicity, safety, and shorter operative time compared to Onlay. Both the techniques effectively treat urethral plate stenosis in distal hypospadias, with reduced postoperative complications compared to tubularized incised plate urethroplasty. Mathieu-IP results in a vertical slit-shaped urethral meatus which enhances urinary stream, indicating its potential for broader adoption.

Postoperative complications of Mathieu incised plate versus standard tubularized incised plate urethroplasty for distal hypospadias: a systematic review and meta-analysis

Introduction: Surgical reconstruction is the mainstay treatment for distal hypospadias. A range of urethroplasty techniques is available with their benefits and disadvantages. We conducted a study to investigate the postoperative complications of Mathieu with plate incision technique relative to standard tubularized incised plate (TIP) technique in patients with distal hypospadias. Materials and Methods: The course of the study was referred to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Designated articles were clinical trials comparing postoperative complications of Mathieu with plate incision and standard TIP technique for distal hypospadias, systematically searched through PubMed and ScienceDirect databases. Pooled studies were analyzed in qualitative and quantitative methods. The protocol of this study was registered on PROSPERO (CRD42022341745). Results: Meta-analysis of the included studies yielded a significant difference in the postoperative incidence of meatal stenosis, narrow stream, and fistula formation of distal hypospadias patients in favor of Mathieu with plate incision compared to standard TIP technique, with Mantel-Haenszel test result of OR: 0.08 CI 0.01-0.41 (p = 0.003) for meatal stenosis; OR: 0.09 CI 0.02-0.49 (p = 0.006) for narrow stream; and OR: 0.28 CI 0.08-0.96 (p = 0.04) for fistula formation. All outcomes presented insignificant heterogeneity across studies (p &gt; 0.05). Conclusion: The incidence of meatal stenosis, narrow stream, and fistula formation is lower in patients with distal hypospadias who underwent Mathieu with plate incision procedure than the standard TIP urethroplasty.

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

The Anatomical Repair Technique to Correct Penile Hypospadias Provides Excellent Long-term Function with Low Complications

<i>Introduction</i> There are various techniques described for repair of penile hypospadias. <i>Objective</i> To present the anatomical repair technique and to discuss the lessons learned from this technique over 18 years. <i>Methods</i> All consecutive patients with penile hypospadias who underwent anatomical repair of urethra, spongiosum, bucks and dartos fascia and foreskin by the 3^rd author, with a minimum of 1 year follow up from January 2003 to March 2020 at the Royal Manchester Children's Hospital, United Kingdom, were included in the study. No formal ethics approval taken as this study was done as a service evaluation. Perioperative and follow up data were recorded prospectively in the departmental database. SIPP 21 was used for statistical analysis. Fisher’s Exact Test used for sub-group analysis. Findings were considered statistically significant at p<0.05. <i>Results</i> 368 patients had surgery at a median age of 18 months. 94.6% had no complications, 4.1% had minor and 1.3% had significant complications. 77.5% had a distal ectopic meatus. The mean length of urethroplasty was 8mm. To widen the urethral plate, a meatoplasty (M) was performed in 34% and urethral plate incision (UPI) in 14%. Catheters were used in 71% for a median duration of 7 days, and 40% had a 6F catheter. Regards to meatal stenosis the only statistically significant causative factor was UPI with 6fr catheter. P value=0.02. <i>Conclusions</i> Anatomical repair provides a completely normal penis with minimal complications. Meatoplasty widens the urethral-plate and reduces the risk for meatal stenosis.

Extended TIP vs. Standard TIP for primary distal hypospadias repair: randomized study for comparing functional and cosmetic outcomes

Objectives The aim of this study was to critically evaluate distal extension of the midline urethral plate incision, extended tubularized incised plate (e-TIP) technique, with the standard TIP and investigating predictors of functional and cosmetic success. Methods In a prospective study, consecutive patients with primary distal hypospadias presented for repair were randomized to undergo either extended TIP (e-TIP) or standard TIP (s-TIP) technique. Cosmetic outcome was evaluated postoperatively using Hypospadias-Objective-Penile-Evaluation (HOPE) score and measurement of ventral-glans-closure-length (VGCL) and meatal length (ML). Functional outcome was evaluated by maximal flow rate (Qmax), average flow rate (Qave), and postvoid residual urine (PVR). The effect of preoperative parameters on the outcome was assessed with regression analysis. Results In all 94 cases, out of 110 randomized, were available for analysis. Forty-six in e-TIP group and 48 cases in s-TIP group with comparable preoperative demographics. Median (inter-quartile range) of postoperative total HOPE-score was 57(45–60) vs. 55(44–60) for e-TIP and s-TIP (p < 0.001), respectively. The mean (SD) ratio of VGCL/ML was 87% (26) versus 46% (12) for e-TIP vs. s-TIP, respectively (p < 0.001). Both complications and functional outcomes were comparable. Urethral plate (UP) width and the use of e-TIP technique were significant predictors of successful cosmetic outcome in regression analysis (p = 0.019 and p = 0.001), respectively. Conclusion Extension of midline urethral plate can potentially create a vertical slit-like meatus located at the glans tip without compromising the functional outcome, thus providing better cosmetic outcome compared with the standard technique. The UP width was a significant predictor of superior cosmetic outcome.

Factors Associated with Short Term Outcomes of Hypospadias Repair at the University Teaching Hospitals-Lusaka, Zambia

The study aimed to establish whether age at the time of surgery, glans size, urethral plate width, suture material, urethral catheter blockage/dislodgement and haemoglobin level influence short term outcomes of hypospadias surgery at the University Teaching Hospitals (UTH), Lusaka Zambia. This was a consecutive (total enumerative) observational cohort study done at D-block and Clinic 7 at UTH Lusaka over nine months. A total of 41 patients were enrolled, and their demographic data, haemoglobin, maximum glans width size and urethral plate size before creating glans wing or midline plate incision were noted and measured. Logistic regression assessed urethroplasty complications on urethral plate size, glans size, haemoglobin, suture material and catheter problems. The average age of participants was 34 months. Distal hypospadias was the most common type at 61%, while middle hypospadias was 27% and proximal hypospadias 12%. The complication rate was 34%. The most common complication seen was urethrocutaneous fistula at 53%. The other complications seen included 11.8% glanular dehiscence, 11.8% infections, 6% persistent chordee and 6% penile torsion. The risk factors for postoperative complications included the location of the urethral opening. The more proximal the site of the hypospadias, the higher the complication rate. Complications were strongly associated with haemoglobin levels of less than 11.5g/dl (p=0.001) and catheter blockage or dislodgment (p=0.008). There was no association of complications with Socioeconomic status, age at the time of repair, glans width size or suture material. Contrary to the finding of many authors, a wider urethral plate in this study was associated with a higher complication rate.

Duct Division in Pure Laparoscopic Donor Hepatectomy: DELHI Technique

Background: Pure laparoscopic donor hepatectomy (PLDH) has become accepted surgical procedure in living donor liver transplantation (LDLT). This study aimed to report our technique of duct division in PLDH: Duct division by Extraglissonian Looping after Hilar plate Incision (DELHI).

Comparison of three internal fixation methods for distal femoral fractures of Müller types C2 and C3

Objective To compare 3 internal fixation methods for the treatment of distal femoral fractures of Muller types C2 and C3. Methods The clinical data of 58 patients were retrospectively analyzed who had been treated for distal femoral fractures of Muller types C2 and C3 at Department of Orthopaedic Trauma, Ningbo No. 6 Hospital from February 2013 to February 2017. They were divided into 3 groups according to the internal fixation method they had used. In the single incision locking plate group (group A) of 21 cases, there were 13 males and 8 females with an age of 50.6 years±12.9 years. In the double-incision locking plate combined with reconstruction plate group (group B) of 18 cases, there were 11 males and 7 females with an age of 53.5 years±13.0 years. In the single incision locking plate combined with reconstruction plate group(group C) of 19 cases, there were 10 males and 9 females with an age of 48.1 years±12.2 years. The 3 groups were compared in terms of operation time, intraoperative blood loss, intraoperative C-arm fluoroscopy, fracture healing time, incidence of postoperative complications, range of motion of the knee and knee functional recovery. Results The 3 groups were compatible because there were no significant differences between them in their preoperative general data (P>0.05). There were no significant differences between groups in the frequency of C-arm fluoroscopy, follow-up time, or incidence of postoperative complications (P>0.05). The operation time in groups A and C (96.7 min±16.4 min and 101.9 min±16.5 min) and intraoperative blood loss for groups A and C (237.8 mL±47.5 mL and 253.6 mL±46.6 mL) were significantly less than in group B (114.9 min±20.1 min and 290.1 mL±60.9 mL) (P<0.05); the fracture healing time for groups B and C (6.9 months±1.6 months and 6.6 months±1.7 months) was significantly shorter than for group A (8.4 months±1.9 months) (P<0.05); the ranges of knee motion 12 months after operation in groups B and C (91.7°±16.7° and 90.9°±14.4°) were significantly larger than that in group A (78.8°±14.4°) (P<0.05); the excellent and good rates of knee function 12 months after operation in groups B and C [77.8% (14/18) and 73.7% (14/19)] were significantly higher than that in group A [57.1%(12/21)] (P<0.05). Conclusion In the treatment of distal femoral fractures of Muller types C2 and C3, application of lateral locking plate and additional anterior locking reconstruction plate via the anterolateral incision at the distal femur can achieve rigid fixation without much damage to the surrounding soft tissues and lead to fine functional recovery of the knee joint because it has the advantages of single incision locking plate and double incision medial and lateral locking plates. Key words: Femoral fractures; Fracture fixation, internal; Bone plates; Surgical approach

Our expirience in distal hipospadias and tip urethroplasty

PURPOSE: We began performing the Snodgrass procedure in 2012 /tabularized incised plate urethroplasty, described by Orkiszewski in 1987/ and improved and popularized by Warren Snodgrass in 1994 (1). METHODS: Snodgrass TIP urethroplasty was performed between January 2013- January 2020 for distal hypospadias in 12 boys aged 8 months to 12 years were included, with data on the demography of the patients, type of hypospadias, extent of urethral plate incision, type of flap, used to cover the urethroplasty, the surgical outcome and follow-up for meatal stenosis. RESULTS: We reviewed the boys with hypospadias repair of Snodgrass TIP urethroplasty, who is performed between January 2013-January 2020 in the Pediatric Surgery Department of University hospital–Stara Zagora. Cases of proximal hypospadias with severe chordae and those who had undergone previous urethroplasty were excluded. CONCLUSION: On the basis of our experience we feel that the Snodgrass considered not only for primary but also for reoperative repair of distal hypospadias.

Distal hypospadias repair using the needle point bipolar cutting–coagulation forceps

To determine the outcome of distal hypospadias repairs performed using bipolar diathermy (BD) for all the dissection. Retrospective review of 310 patients undergoing distal hypospadias (264 subcoronal/distal penile and 46 coronal/glanular) over a 11-year period. Median age at surgery was 2.0 years (range 9 months-15 years). Caudal anesthesia was performed in all patients. All children underwent an in situ tubularization of the urethral plate, which was combined with midline incision of the plate in 30 (10%). Preputial reconstruction was performed in 303 (98%) patients. BD forceps was used for coagulation and for all the dissection including skin incision, elevation of glans wings, separation of the corpus spongiosum from the corpora cavernosa, and urethral plate incision, when deemed appropriate. The authors assessed surgical complications and cosmetic results. The latter using the hypospadias objective score (HOSE), with a score≥14 considered as acceptable. The average operative time was 70min. There was no postoperative bleeding or hematomas that required surgical intervention. There were no wound infections or necrosis. Complications occurred in 37 patients (11.9%). Urethral fistula formation was the commonest (n=18). Postoperative persistent preputial swelling occurred in 3.5% of cases. Two hundred twelve patients (90.6%) had a HOSE score≥14, and no patient required revision surgery for skin problems after a median follow-up of 8.1 (range 1.2-13.1) years. The study is limited by its retrospective nature and by the fact that a number of other pre-operative, intra-operative, and postoperative variables can affect outcome. Bipolar diathermy can be safely used for distal hypospadias repairs. It allowed careful control of intra-operative bleeding and also clear visualization of tissue planes. Complication rate overall compares favorably with the literature, and cosmetic results were satisfactory.

Tubularized Incised plate(Snodgrass)urethroplasty as the Surgical Technique of Choice for Repair of Distal and Midshaft Hypospadias in Tikrit Teaching Hospital

Background: The Snodgrass technique is a widely accepted method for hypospadias repair. Snodgrass has a urethroplasty of tubularized incised plate (TIP) type for repair of distal penile hypospadias. It was with encouraging results and also applied to hypospadias of proximal type. Objective:To evaluate Conducting surgical techniques performed to repair the submicillator. Patients and Methods: In this study, we follow the patient post operatively within three months after performing this technique and notice its final outcome with respect to postoperative complications and outcome, with emphasis on meatal stenosis, fistula formation, residual chordee and penile torsion. Results: We reviewed the results of 60 cases treated by Snodgrass urethroplasty between March 2012 and February 2014at the urological department in Tikrit Teaching Hospital. In this study, performed Snodgrass technique on 60 cases for primary hypospadias , The boys age at time of operation ranged from 18 months to 14 years. The mean age of the children was 5 years. Complications occurred in 8 patients (13.3%). Aurethrocutaneous fistula occurred in 6 patients (10%). three (5%) of these patients with u.c.fistula associated with meatal stenosis . one patient develop meatal stenosis only and Penile torsion was recorded postoperatively in one patient also. Conclusion: A shorter urethral plate incision, use of a lateral and preputial dartos flap to cover the neourethra and more extensive skin degloving in Snodgrass urethroplasty reduce the rate of complications.

Short term outcomes of snodgrass urethroplasty in distal and mid penile hypospadias

Background: Hypospadias is common congenital condition. First attempted hypospadias surgery was done during first century A.D. Since then more than 300 techniques have been explained in the surgery for Hypospadias. The goal of surgery is focused on functional and cosmetic outcomes. In 1994 Snodgrass popularized the technique of urethral plate incision, tubularization and secondary dorsal healing for hypospadias repair. Aim of the study was to evaluate the short term outcomes of Snodgrass urethroplasty.Methods: This was a retrospective study conducted by the department of Pediatric Surgery, Kempegowda Institute of medical sciences (KIMS) hospital, Bangalore from 2014 to 2017. Children with mid penile and distal hypospadias who had undergone Snodgrass urethroplasty were enrolled in the study. Children with previous surgery were excluded. The demographic data, duration of surgery, post operative requirement of anticholinergics, duration of catheterization and post operative stay were tabulated. Children were followed up for duration of 6 months to 3 years. Post operative complications were tabulated. Results: 40 children were included in the study. Age ranges of children were between 9 months to 14 years. In most of the children hypospadias was diagnosed at birth. The mean duration of surgery was 97.25 minutes. The mean duration of hospitalization was12.2 day. The overall complications rate was 20%. The most common complication was urethrocutaneous fistula. Out of the 40 children included in the study 4(10%) children required resurgery (urethrocutaneous fistula closure).Conclusions: Snodgrass urethroplasty is a simple and effective technique. It is easy to learn and can be applied as a single stage procedure. The most common complications are urethrocutaneous fistula and meatal stenosis.

Pre-incision urethral plate width does not impact short-term Tubularized Incised Plate urethroplasty outcomes

Two reports have found that urethral plate (UP) widths <8mm before tubularized incised plate (TIP) incision increased urethroplasty complications. The present study measured pre-incision UP width in consecutive boys undergoing TIP to determine if it affected outcomes. The present study followed the method previously used by Holland and Smith, and Sarhan etal. to measure UP width before creating glans wings or performing midline plate incision in consecutive patients with primary hypospadias and ventral curvature <30°, who all underwent TIP repair (Summary Fig.). Glans width at its widest point was also measured. Multiple logistic regression assessed urethroplasty complications (fistula, glans dehiscence, meatal stenosis/urethral stricture, diverticulum) based on pre-incision UP width, glans width, patient age, and meatal location. The UP widths were determined in 224 consecutive primary TIP repairs during 2012-2015: 200 distal, 11 midshaft, and 13 proximal. The UP width was <8mm in 192/224 (86%) patients. Mean pre-incision width was 6.1mm (SD 1.5, range 2-11), without difference in UP widths according to meatal location (P=0.06). Mean post-incision UP width was 12mm (SD 2.2, range 10-16). Mean change in width after incision (delta/original UP width) was 116% (SD 63, range 20-250). There was follow-up in 186 patients for a mean of 6 months. Urethroplasty complications (five fistulas, six glans dehiscence) were diagnosed in 11 (6%): 9/165 distal, 1/9 midshaft, and 1/12 proximal repairs. There was no difference in those <8 vs ≥8mm (11/160 vs 0/26, P=0.17). Similarly, UP width was not different between patients with and without urethroplasty complications. Multiple logistic regression in these 186 patients - including meatal location, UP width, glans width, and age - found only glans width <14mm was associated with increased odds of urethroplasty complications (OR 19.2, 95% CI 3.5-106, AUC=0.799). The data show that pre-incision UP width is not an independent risk factor for urethroplasty complications. However, it is possible that technical factors, such as how deeply the dorsal incision is made or size of the urethral stent, might contribute to this finding by other authors. After watching the TIP repair, Smith stated that the plate incision was deeper than he made. Sarhan etal. reported a mean change of 57% in UP width after incision, whereas the present one was double at 116% (i.e. from 6mm pre-incision to 12mm post incision), and they used an 8-Fr catheter. While they stated that they incised the plate deeply, the lower percentage increase in width suggests that it was not as deep as was recommended. The UP width before incision did not increase urethroplasty complications. Surgeons do not need to measure or categorize the UP to determine suitability for TIP repair, as long as the plate incision is made deeply to the corpora.

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias.

Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias. All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty. Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52%) children required a tunica albuginea plication for chordee correction. In total, 16 (17%) patients developed 24 complications and 11 children (12%) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus. Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.

Hypospadias and concomitant undescended testis: Comparison of no skin incision with inguinal and scrotal skin incision orchiopexy

BackgroundTo present the feasibility of no skin incision orchiopexy in children with concomitant hypospadias and undescended testis (UDT) by a single subcoronal incision technique. To introduce the creation of subdartos muscle scrotal pouch with no scrotal skin incision. MethodsFrom one thousand and twenty-one children with hypospadias, 61 patients presented with concomitant palpable UDT and hypospadias. In group I (N = 34) single subcoronal incision with no scrotal skin incision was applied. In group II (N = 27), multi-incision technique was applied for classical orchiopexy and hypospadias surgery. For hypospadias reconstruction, all patients had classical subcoronal and para urethral plate incision with penile skin degloving according to the location of urethral meatus. Early and late complications, surgical time, hospital stay, and cosmetic results were recorded. ResultsChildren with unilateral UDT and hypospadias had one incision in group I and three skin incisions in group II. Patients with bilateral UDT had one incision in group I and five skin incisions in group II. The operation time was significantly shorter in group I (93 ± 11 min) compared with group II (138 ± 17 min) (P = 0.03). Both groups were operated as day care basis; however, the hospital stay was slightly longer in group II (group I = 12 ± 2 h, vs group II = 16 ± 3 h) (P = 0.07). All testes were satisfactorily positioned into the bottom of the scrotum without development of any testicular atrophy. ConclusionSingle subcoronal penile skin incision is a feasible, safe, and cosmetically satisfactory technique in patients with hypospadias and concomitant UDT. Reduced postoperative pain, better objective cosmetic results, shorter operative time and comfortable post-operative period are the most significant advantages of this approach.

Individualized reconstruction plate for treatment of calcaneal fractures via tarsal sinus incision

Objective To investigate the clinical efficacy of individualized reconstruction plate in the treatment of calcaneal fractures through the tarsal sinus incision. Methods From May 2010 to September 2012, we treated 46 cases of calcaneal fracture (51 feet) involving talocalcaneal joint. They were 35 males and 11 females, 17 to 65 years of age (average, 35 years). The injury affected the left foot in 24 cases, the right foot in 17, and both feet in 5. By the Sander's classification, 30 feet were type Ⅱ and 21 type Ⅲ. The fractures were reduced through the tarsal sinus incision before internal fixation with individualized reconstruction according to the morphology of fracture. When necessary, fixation with hollow screws was added. The Bohler and Gissane angles were compared between preoperation and postoperation. The clinical efficacy was evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) system. Results The patients were followed up for 8 to 14 months (average, 12 months). No such complications as incision infection, skin necrosis, plate loosening or exposure occurred in this group. There were significant differences in the Bohler and Gissane angles between preoperation and postoperation [(31.70°±5.50° and 122.10°±6.79° at 3 days postoperation) and (30.95°±3.47° and 122.49°±4.83° at 6 months postoper-ation) versus (6.14°±1.58° and 91.63°±4.76° at preoperation)] (P 0.05). All the patients obtained bony union at 6 months postoperation. According to the AOFAS scores, 38 feet were ex-cellent, 9 feet good and 4 feet fair, giving an excellent to good rate of 92.2% . Conclusion In the treatment of intra-articular calcaneal fractures through the tarsal sinus incision, application of individualized reconstruction plate can lead to fine fracture reduction, rigid internal fixation, early exercise, and decreased incision-related complications. Key words: Calcaneal fracture; Fracture fixation, internal; Bone plates

Dorsal inlay buccal mucosal graft (Asopa) urethroplasty for anterior urethral stricture.

Asopa described the inlay of a graft into Snodgrass’s longitudinal urethral plate incision using a ventral sagittal urethrotomy approach in 2001. He claimed that this technique was easier to perform and led to less tissue ischemia due to no need for mobilization of the urethra. This approach has subsequently been popularized among reconstructive urologists as the dorsal inlay urethroplasty or Asopa technique. Depending on the location of the stricture, either a subcoronal circumferential incision is made for penile strictures, or a midline perineal incision is made for bulbar strictures. Other approaches for penile urethral strictures include the non-circumferential penile incisional approach and a penoscrotal approach. We generally prefer the circumferential degloving approach for penile urethral strictures. The penis is de-gloved and the urethra is split ventrally to exposure the stricture. It is then deepened to include the full thickness of the dorsal urethra. The dorsal surface is made raw and grafts are fixed on the urethral surface. Quilting sutures are placed to further anchor the graft. A Foley catheter is placed and the urethra is retubularized in two layers with special attention to the staggering of suture lines. The skin incision is then closed in layers. We have found that it is best to perform an Asopa urethroplasty when the urethral plate is ≥1 cm in width. The key to when to use the dorsal inlay technique all depends on the width of the urethral plate once the urethrotomy is performed, stricture etiology, and stricture location (penile vs. bulb).

Snodgrass urethroplasty for hypospadias repair: A retrospective comparison of two variations of the technique

The Snodgrass technique is a widely accepted method for hypospadias repair. In this paper, we compare two methods of performing this technique with respect to postoperative complications and outcome, with emphasis on meatal stenosis, fistula formation, residual chordee and penile torsion. We reviewed the results of 320 cases treated by Snodgrass urethroplasty between March 2007 and February 2012 at the maternity and children’s hospital of Almadinah Almunawwarah, Kingdom of Saudi Arabia. The two methods differed in the extent of urethral plate incision, the type of flap used and the degree of degloving of the penile skin. In group A (115 boys), the urethral incisions and the sagittal deep longitudinal incision were extended from the posterior edge of the hypospadiac meatus to the tip of glans, and the neourethra was covered by a dorsal preputual flap. In group B (205 boys), the urethral incisions and the deep longitudinal incision extended to the mid-glans, and the neourethra was covered by a lateral dartos flap. After tubularization of the urethral plate and a circumferential incision proximal to the coronal sulcus from each edge of the urethral plate, the penile skin was degloved from 1 cm proximal to the hypospadiac meatus in group A and to the penoscrotal junction in group B. The mean age of the children was 1.5 years. Complications occurred in 45 patients (14.1%). A urethrocutaneous fistula occurred in 8 patients (2.5%), with 6 in group A (5.2%) and 2 in group B (0.98%). Ten patients (3.1%) developed meatal stenosis, with 7 in group A and 3 in group B. Penile torsion was recorded postoperatively in 13 patients (total rate, 4.1%), with 9 cases in group A (7.8%) and 4 in group B (2.0%). The differences between the two groups were statistically significant. A shorter urethral plate incision, use of a lateral dartos flap to cover the neourethra and more extensive skin degloving in Snodgrass urethroplasty reduce the rate of complications.

Applications of triangular glanular flap in hypospadias repairs for different purposes

Hypospadias is a congenital anomaly of the penis with an ectopic, ventrally-placed meatus due to insufficient development of the anterior urethra. Tubularisation of glanular flaps without plate incision is performed with addition of a triangular flap in order to move the meatus more distally and avoid meatal stenosis. Subcoronally, mid-shaft, and coronally placed 41 hypospadias cases were treated with the tubularisation of the glanular flaps without incision of the urethral plate, a technique similar to TIP technique. Triangular flaps were added at the most distal end of one of the glanular flaps in all cases for different purposes. A medially-based triangular flap was elevated at the distal end of the right-sided longitudinal flap to carry the last suture more distally. The flap increased meatal diameter and carried the last suture more distally. No meatal stenosis was observed for an average of 18.02 (12–30) months. The final localisation of the meatus was satisfactory in all patients. Meatal stenosis, demonstrated after hypospadias repair, is a challenge for both the surgeon and the patient. A distal triangular glanular flap is planned to avoid this challenge. Besides, it helps to carry the meatus more distally. Promising results support the use of the glanular flap while longer follow-up is required for better evaluation.