• distal hypospadias;
  • Thiersch-Duplay;
  • incised plate urethroplasty;
  • Mathieu parameatal flip-flap;
  • abnormalities


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion

Objective  To compare the function, complications and cosmesis after a modified Thiersch-Duplay and Mathieu unstented urethroplasty.

Patients and methods  Over a 5-year period 381 consecutive patients (not randomized) with distal hypospadias were evaluated. A modified Thiersch-Duplay with dorsal incised urethral plate tubularization (group A) was undertaken in 170 (45%) and a parameatal based flip-flap Mathieu hypospadias repair (group B) in 211 (55%). No urinary diversion or stent was used in any of the 381 patients.

Results  In both groups the mean ( sd ) follow-up was 3.1 (1.4) years. All 381 patients voided spontaneously after surgery and none developed urinary retention needing catheterization. In groups A and B, respectively, the overall late complications were 12 (7.1%) and 32 (15.2%) ( P =0.001), with urethrocutaneous fistula in six (3.5%) and 26 (12.3%; P =0.001); secondary surgery for fistula repair was successful in all boys in A and 89% in B. The glanular meatus was a vertical slit in all in group A and 86% in B ( P =0.02). In both groups, 71% of the children who are now toilet-trained and standing to void have a good calibre, single and straight urinary stream in a forward direction.

Conclusions  Stenting or urinary diversion is unnecessary after distal hypospadias surgery. The functional results were good in those standing to void. A more natural vertical slit-like glanular meatus was easily created using the modified Thiersch-Duplay urethroplasty, with a lower fistula rate.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion

Surgical techniques for repairing common distal hypospadias have been continuously developed as modifications have been devised to seek ways of minimizing complications and improving cosmesis. Of all hypospadias, 65–70% are distal lesions; established procedures to correct this problem are the Thiersch-Duplay, Mathieu, Mustardé, meatal advancement and glanuloplasty and tubularized incised plate (TIP) urethroplasty (Snodgrass manoeuvre) [1–7]. A technique with more universal applicability in most variants of distal hypospadias would be appealing. A vertically orientated slit-like meatus in the normal position on the glans is most consistently achieved with the modified Thiersch-Duplay urethroplasty and Snodgrass manoeuvre, which we have used in the past 5 years at our institution. However, in cases with a shallow glanular groove or flattened glans we have adopted the Mathieu parameatal based flip-flap urethroplasty. We have also undertaken all distal hypospadias repairs, irrespective of the operative technique, with no stenting. The purpose of this report was to compare, in a large series of boys with a long-term follow-up, the unstented modified Thiersch-Duplay urethroplasty and Mathieu repair for distal hypospadias. We assessed the operative technique and the duration, function, complications and cosmesis of the repair.

Patients and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion

Consecutive boys (381, not randomized) with distal hypospadias underwent the one of the following two urethroplasties over the past 5 years; group A (170, 45%) who had a good glanular groove and an adequate urethral plate, underwent a modified Thiersch-Duplay hypospadias repair (Snodgrass manoeuvre); group B (the other 211, 55%), who had a flattened glans with a shallow groove and a poor inadequate urethral plate, underwent a Mathieu parameatal based flip-flap repair.

The hypospadias was coronal in 66%, subcoronal in 30% and mid-shaft in 4%; this was the first attempt at hypospadias repair in all children. Penile torsion was present in 31 (8%) and none required correction of chordee by dorsal plication. The defect was repaired under general anaesthesia with perioperative caudal analgesia. A 7/0 polydioxanone monofilament absorbable suture was used in both groups for the urethroplasty. In group A, a dorsal midline incision was made in the urethral plate to obtain a tension-free tubularization around an 8/10 F silicon catheter. The remainder of the repair was undertaken as described previously [1,2,6,7]. In group B the Mathieu urethroplasty was undertaken using a flap with a mean width of 8 mm and a glanular urethra of 16 mm circumference [3,8]. Hemi-circumcision and a penile compressive conforming foam dressing (Cavi-Care®, Smith and Nephew, Hull, UK) completed the urethroplasty in both groups. No urinary diversion or stent was used in any of the 381 boys. The dressing was removed 24 h after surgery and the patients were discharged after an overnight stay. The duration of the operation, length of the repair, functional and voiding results, complications and cosmesis were analysed in the two groups.

An anova was used to compare the results, with P<0.05 considered to indicate statistical significance. Student's t-test was used with a one- or two-tailed distribution for paired or two-sample equal variance (homoscedastic) or two-sample unequal variance (heteroscedastic), and Dunn's test for more than two variables. The results are presented as the mean (sd).


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion

In groups A and B, respectively, the mean age at surgery was 19.2 (3.1) and 18.5 (3.4) months (P=0.2), and the mean operative duration 66.6 (9.6) and 89.7 (1.8) min (P=0.53). There was a good correlation between the groups for age at surgery and duration (r=0.88). The mean length of the urethroplasty was 9.7 (1.3) and 11.4 (1.9) mm (P=0.3). In group B the mean length of the Mathieu flap was 15 (1.1) mm in 29 boys and 10.9 (1.5) mm in the other 182. In both groups the mean follow-up was 3.1 (1.4) years; all 381 patients were assessed at 3 and 6 months after surgery.

There were no acute or early complications, e.g. bleeding, haematoma, complete or partial dehiscence, and urinary retention requiring catheterization. Overall, there were 12 (7.1%) late complications in group A and 32 (15.2%) in group B (P=0.001). Urethrocutaneous fistula occurred in six boys (3.5%) in A and 26 (12.3%) in B (P=0.001). The incidence of urethrocutaneous fistula in relation to the length of the Mathieu flip-flap was eight (3.8%) of 7–13 mm long flaps and 18 (8.5%) of 14–17 mm (P=0.01). Secondary surgery for fistula repair was successful in all in A and 89% in B. In two patients in group B a second attempt at simple fistula repair was successful. Other complications in both groups were: (i) meatal stenosis requiring meatal dilatation in four (2.4%) in A; (ii) a nodular hypertrophied graft needing refashioning in one patient in group B; (iii) balanitis xerotica obliterans in both groups, i.e. two (1.2%) in A and five (2.4%) in B.

All 381 patients voided spontaneously after surgery and none developed urinary retention needing catheterization. In both groups, 71% of the children who are now toilet-trained and standing to void have a good calibre single straight urinary stream in a forward direction, and all 381 patients have a normally situated glanular meatus. The glanular meatus was vertical and slit-like in all boys in A and 86% in B (P=0.02); the glanular meatus was a horizontal slit in 14% of those with the Mathieu repair.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion

The incidence of hypospadias is estimated as 0.8–8.2 per 1000 live male births [9,10]. Hypospadias is commonly associated with a dystopic urethral meatus (located at any position on the ventral aspect of the penis), atretic corpus spongiosum, absent frenular artery, ventrally deficient hooded foreskin and abnormal ventral curvature of the penis (chordee). Chordee and a dorsal hooded foreskin are common although not constant, and distal atresia of the corpora cavernosa can occur in rare cases. Barcat's classification, based on the position of the ectopic urethral meatus, may be unsatisfactory, as a significant proportion of hypospadias is associated with varying degrees of hypoplasia of the distal urethra [11]. Although in the present cohort of patients hypospadias was classified according to the meatal location, a clinical classification based on the level of division of the corpus spongiosum may be more appropriate.

TIP urethroplasty. Hypospadias surgery involves constructing a functionally and cosmetically appealing penis. Tubularization of the urethral plate for distal hypospadias was popularized by several authors after its first description by Thiersch in 1869 [ 1,12,13 ]. In 1989, Rich et al. [ 14 ] first described an incision in the glanular urethral plate to obtain a cosmetically acceptable vertical slit meatus for Mathieu repair, and this was subsequently adopted for the entire length of the urethral plate as a complement to the Thiersch-Duplay urethroplasty for distal hypospadias, by Snodgrass in 1994 [ 6 ]. The urethral plate is a well-vascularized tissue with a rich nerve supply, and an extensive muscular and connective tissue backing [ 15 ]. The TIP urethroplasty takes advantage of this extensive blood supply under the urethral plate and this probably explains the success of the procedure, as shown by the low fistula rate in the present series (3.5%) and previously (0–7%) [ 6,7,16,17 ]. The dorsal midline incision into the urethral plate provides good mobility and a tension-free tubularization. However, an over-zealous incision would result in troublesome bleeding and healing may not be the same as an incision limited to the plate, and stricture formation might result. Urethral stenting is not essential after a modified Thiersch-Duplay repair. On reviewing previous reports there was no increased incidence of complications between a stented (0–7%) or an unstented (0–5.9%) modified Thiersch-Duplay urethroplasty [ 6,7,17–20 ].

Parameatal-based flip-flap urethroplasty. An impaired blood supply to the distal-based flaps may be the cause of urethrocutaneous fistula in a Mathieu repair. The length of the flap was detrimental, causing fistula formation, and a flap length of >14 mm increases the possibility of a decreased blood supply to the distal-based flap, resulting in a higher incidence of fistula. However, the occurrence of fistula is not dependent on stenting or not of the neourethra, as the reported overall complication rate for the unstented Mathieu repair was 3.6–18.9%, vs 2.6–21% for stented repairs [ 8,21–27 ]. Although the Mathieu repair produces good functional results it is criticised for its poor cosmesis of the meatal configuration, which is often not ideal. Meticulous care at meatoplasty or the adoption of a shallow midline incision before meatoplasty, or the MAVIS manoeuvre, will produce a natural vertical slit-like glanular meatus [ 8,14,28 ].

Other techniques for distal hypospadias. Distal hypospadias with a well-defined glanular groove is suitable for the glans approximation procedure, or for urethroplasty, glanuloplasty and preputioplasty [ 29,30 ]. The reported complication rate for these two methods is low, at 0–1.2% [ 29–31 ]. Reconstructing the foreskin is deemed aesthetically desirable in European society and the foreskin can be reconstructed after the Snodgrass manoeuvre or the Mathieu urethroplasty [ 32 ]. The present patients were circumcised; if the foreskin is reconstructed it is important that it is retractile and supple, so as not to hamper sexual activity at adolescence. In some cases the hypospadiac urethra can be mobilized circumferentially in the proximal direction to such a degree that it reaches the tip of the penis without inducing chordee. The reported fistula rate after Koff's procedure is 1–16.7% [ 33,34 ].

In conclusion, the modified Thiersch-Duplay urethroplasty is a versatile and simple operation which provides a good functional penis with a natural looking glanular meatus, and with minimal complications. Urinary diversion or stenting is unnecessary in distal hypospadias repair, and penile dressing is only necessary in the first 24 h after surgery, to prevent oedema.


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tubularized incised plate.

M. Samuel, 29 Brookhill Way, Rushmere St Andrews, Ipswich IP4 5UL, UK. e-mail: