Vertical Meatus Research Articles

Extended Ulaanbaatar Procedure with Preputial Skin Graft for Proximal Hypospadias.

Two stage urethroplasty for proximal penile hypospadias is time consuming, expensive and; traumatic both for parents and phallus. On the other hand, single stage procedure technically demanding. We would like to describe Extended Ulaanbaatar Procedure (EUP) which is not a two stage procedure. Rather, might be called as 'extended single stage' procedure. In EUP we have done orthoplasty along with urethroplasty with preputial skin graft at same sitting as primary procedure keeping urination diverted through proximal hypospadiac meatus as "controlled fistula" which was closed after six months as secondary procedure. We operated on 35 patients of proximal penile hypospadias with moderate to severe chordee. Chordee was excised till correction of curvature. Two distracted cut ends of native plate was bridged with preputial skin graft (PSG) in between. Following that, silastic tube was placed over glandular plate as scaffold, on both cut ends of native plate and PSG. All the urethral plates and PSG were buried with tunica vaginalis flap before glanuloplasty. After six months, proximal "controlled fistula" was closed with scrotal dartos fascia and skin to join distal to proximal urethra. Vertical meatus in glans was found in 32 patients. One patient had glans dehiscence, two patients had medium sized fistula, another two patients had stenosis in neourethra and six had suture track fistula. Twenty-nine patients had satisfactory curve with good flow in uroflowmetry as per nomogram at sixth month of follow up. In classic Ulaanbaatar procedure authors do distal urethroplasty and glanuloplsaty in 1st stage following orthoplasty to avoid repeat trauma in glans in repeat procedures. Left over urethroplasty in classic Ulaanbaatar was done in 2nd stage. However, in EUP; we did urethroplasty for full length following orthoplasty as primary procedure. This procedure is less invasive than two staged as we avoided repeat degloving and repeat dissection on operated tissues. Urethroplasty done as primary procedure shunned the need of repeat degloving, decreased the period of morbidity, stay, and cost of surgery. We also avoided problems of urination through not matured, long, neo-urethra. Similarly complications i.e disruption, stenosis in neo-urethra can be managed utilizing the advantages of urinary diversion.

Assessment of the effect of urethral plate width on outcome of hypospadias repair

The paradigm for hypospadias repair is a straight penis with a vertical meatus at the tip of the glans that provides satisfactory urination and is cosmetically acceptable to the parents of the patient. To determine the cosmetic and functional outcomes of hypospadias repair in relation to the width of the urethral plate. This study was a prospective evaluation of patients operated for hypospadias. The urethral plate width (UPW) of the patients were measured preoperatively using vernier calipers. The patients were categorized into groups A and B. Group A patients have a UPW <8mm, whereas group B patients have a UPW ≥8mm. The width of the urethral plate was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of hypospadias repair. Overall, 47 patients had their hypospadias repaired during the study period. But, only 42 patients who had their distal hypospadias repaired using tubularized incised plateurethroplasty were evaluated. There were 20 patients (47.6%) in group A and 22 patients (52.4%) in group B, with a mean urethral plate of 7.3mm±0.50 SD. The mean UPW in group A was 5.6mm±1.22 SD and the mean UPW in group B was 8.8mm±0.88 SD. Overall, mean HOPEscore was 40.0±6.83 SD. Group A patients had a mean HOPE score of 38.7±7.49 SD, whereas Group B patients had a mean HOPE score of 41.2±6.08 SD. P-value was 0.725, which is not statistically significant. Relating good urinary stream (15 in group A and 20 in group B) with the width of the urethral plate statistically (using Spearman correlation technique) gave a P-value of 0.03 (P<0.05), which is statistically significant. Our findings indicate that the cosmetic outcome of hypospadias repair may not be determined by UPW, but the functional outcome may be predicted by the width of the urethral plate.

Objective outcome assessment of the modified Bretteville Technique

The paradigm for hypospadias repair is a straight, erect penis, with a vertical meatus at the tip of the glans that provides satisfactory urination and is cosmetically acceptable to the patient. We provide objective outcome data on 40 cases of hypospadias repaired using the modified Bretteville technique. The 'HOSE' questionnaire, flowmetry, wetted pad and spray pattern analysis in combination with other questionnaire data were obtained to evaluate the long-term results of the modified Bretteville technique. The average HOSE score was 15/16. Cosmesis is good, with average scores of 7.1/10 (patient) and 7.6/10 (doctor). HOSE assessment is good, with 85% of patients scoring 14 or over. Uroflow rates are very good for a hypospadiac population with 82.5% of the patients within normal limits for their age group. Wetted pad and spray pattern analysis showed 56% of patients sprayed more than 3g of urine compared to 11% in a junior football team acting as control, although there was little correlation between this objective assessment and the patients' perceived symptoms as assessed by the questionnaire. The modified Bretteville hypospadias repair provides a reliable epithelialized repair of consistent dimensions with good patient-reported cosmesis and excellent functional outcomes.

T-incision technique in distal hypospadias: a modification of meatal advancement and glanuloplasty.

Hypospadias is among the most common of the congenital anomalies. Distal hypospadias refers to an orifice in the distal third of the penile shaft. Correction of distal hypospadias requires different techniques, depending on the location of the meatus. Simple advancement techniques can be used for most distal hypospadias, whereas hypospadias with chordee requires reconstruction of a urethra. The meatoplasty and glanuloplasty procedures developed by Duckett have become standard operations to correct these lesions. Complications such as meatal stenosis, meatal retraction, and fish mouth-like meatus can be seen after meatal advancement and glanuloplasty ("MAGPI"), though it usually yields good results. In an attempt to avoid the complications associated with the meatal advancement and glanuloplasty procedure, the authors added a modification to the procedure for those hypospadias cases located in the coronal sulcus or its distal part. As an addition to conventional meatal advancement and glanuloplasty, a transverse incision on top of the vertical incision was made so that the urethra was supported by lateral triangle flaps created on the glans. Lateral triangle flaps of the glans were sutured to the dorsal aspect of the urethra advanced from the previous position. Thus, stress on the urethra was lessened and meatal retraction was prevented. When closure was performed with a T incision, an M-shaped, zigzag incision line was placed instead of a circular incision line. Therefore, stenosis was prevented and a vertical meatus with good cosmetic appearance was obtained. Fifty-three boys aged 4 to 7 years were operated on with this technique and were followed for 2.4 years. Good functional and cosmetic results were achieved in most of the cases.