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Keywords:

  • hypospadias;
  • urethral plate;
  • meatus;
  • stenosis;
  • tubularized incised-plate;
  • urethroplasty;
  • urethrocutaneous fistula

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVE

To evaluate the results of tubularized incised-plate (TIP) urethroplasty for distal and midshaft hypospadias in adults, and to underline technical aspects to decrease complications.

PATIENT AND METHODS

From December 1999 to January 2004, 13 patients with hypospadias and aged 18–26 years had a TIP urethroplasty as a primary repair. Five had distal penile and eight had midshaft hypospadias. In all cases a TIP urethroplasty was used as described for children. Urinary drainage was by a urethral Nelaton catheter connected to a urine bag.

RESULTS

The catheter was removed after 10 days and the patients asked to attend a follow-up at 1, 3 and 6 months and then 6-monthly; the maximum follow-up was 3 years and the minimum was 3 months. One patient developed a fistula after the repair of distal penile hypospadias, which closed spontaneously after a month. All patients with a successful repair voided with a single straight urinary stream in a forward direction. They had a normally situated slit-like glanular meatus.

CONCLUSION

TIP repair in adults is associated good results. There is no difference in terms of wound healing, infection, complication rates and overall success between the TIP repair in children and adults. The cosmetic and functional outcome was comparable to that in children.


Abbreviation
TIP

tubularized incised-plate.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Hypospadias is a common congenital condition, with an incidence of 3.2 per 1000 live births [1]. Various surgical procedures have been described to correct this condition. The goal of hypospadias surgery is a penis that is both functionally and aesthetically normal. This requires a penis that is straight on erection, with a vertically orientated meatus at the tip of the glans, thus promoting a single, coherent urinary stream [2]. Since its introduction in 1994 by Snodgrass [3], the tubularized incised-plate (TIP) urethroplasty, a modification of the Thiersch-Duplay technique [4,5], has become a very popular repair for hypospadias; it is associated with very good functional and cosmetic results. Most of the studies of TIP repair are in children as such children with hypospadias in developed countries are usually treated before school age. However, in developing countries it is not uncommon for adults to present with hypospadias that has not been treated in childhood; herein I report experience of TIP repair in adults.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

TIP urethroplasty was undertaken in 13 adult patients (age range 18–26 years) from December 1999 to January 2004; five had distal penile hypospadias and eight midshaft hypospadias. The patients were selected for TIP urethroplasty only if they had a good urethral plate of reasonable width and had minimal chordee. The hypospadias was repaired under spinal anaesthesia.

The TIP repair was performed as previously described [3,6,7], the salient features being as follows. The penis was degloved and the ventral tethering tissues lateral to the corpus spongiosum and urethral plate excised. A successful urethroplasty was confirmed by an artificial erection, created by an injection with 0.9% saline into the corpora cavernosa of the penis. Tunica albuginea plication was not required in any of the patients. During degloving of the penis special care was taken to create a good gap between the hypospadiac meatus and the degloved skin. This helped in later covering the site of the original meatus completely and thoroughly with the vascularized pedicle.

After dividing the urethral plate in the midline, the neourethra was formed by tubularization of the urethral plates using 5/0 polyglactin on a round-bodied needle using a single-layer running suture. The process of tubularization started proximally from the site of the original meatus and proceeded distally. The following technical aspects were applied during the procedure in all patients: The urethral stent used was a 14 F Nelaton catheter; the urethral plate was tubularized only to the level of the midglans and not to the tip of the glans; the edges of the neomeatus were sutured to the edges of the glans wings using 4/0 chromic catgut; on completing the procedure a suture was taken at the dorsum of the glans and used to fix the stent, to prevent its inadvertent removal. A vascularized pedicle of subcutaneous tissue, harvested from the dorsal hooded prepuce, was brought ventrally to cover the neourethra. Special care was to taken to cover the site of the original meatus completely and thoroughly with the vascularized pedicle.

Antibiotic cover was given for 10 days after surgery, and bladder relaxants, either oxybutynin hydrochloride or tolterodine, were given to all patients for 5 days. The Nelaton catheter was maintained urethrally and connected to a urinary drainage bag, to provide a continuous closed system for drainage. The dressing and the urethral stent were removed after 10 days. No medications were given to any of the patients to prevent erections after surgery.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

All patients were assessed 10 days after removing the dressing and catheter. They were asked to attend a follow-up assessment at 1, 3 and 6 months, and the meatus was calibrated during these visits using a 16 F catheter. The patients were then asked to attend at 6-monthly intervals. The mean (range) follow-up was 0.5 (0.25–3) years.

A small urinary leak occurred in one patient with distal penile hypospadias, at the site of the original hypospadiac meatus; it stopped spontaneously within a month. None of the patients had meatal stenosis. All the patients voided with a forward and straight urinary stream, and all had a normally situated vertical slit-like meatus. In four patients the meatus looked small but had a normal calibration. They had a good calibre forward urinary stream, with no straining. All the patients were satisfied with the cosmetic result.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Historically, > 200 procedures have been described for repairing hypospadias. The emphasis of all the modern repairs is not only on creating a neourethra, but also having a good cosmetic result with a normal looking penis. Bracka [8] reported that 72% of young adults felt that a normal appearance was as important a goal as normal function. In the last decade the TIP urethroplasty has gained rapid acceptance, is associated with minimum complications and achieves excellent results with a normal-looking penis and meatus [3,6,7]. Most of the published reports on hypospadias repair in adults address the psychosexual aspects of the problem [9–12]; very few have described the results of repairing adult hypospadias [13–16]. Li et al.[13] reported on 113 adults and adolescents in whom bladder mucosa was used for urethral repair. They had good success with a low complication rate. Secrest et al.[14] had a success rate of 94.4% in a series of 190 patients, with a mean age of 16 years. Temucin et al.[15] reported a complication rate of 10% in those undergoing primary repair; in contrast, Hensle et al.[16] reported complications in three of eight patients with no previous history of hypospadias surgery and who had a primary repair. This led them to conclude that although the techniques used to repair hypospadias in adults are similar to those used in children, there is a difference in terms of wound healing, infection and complications. The overall success is less in adults than in children. A closer analysis of the results of Hensle et al. shows that they had good success in primary repairs, and even when repeat cases are considered, their complication rate was only 18%, which is much less than their overall complication rates, if the native intact urethral plate was used (as in Mathieu, onlay island flap or Thiersch-Duplay repair). Temucin et al.[15] used the TIP repair primarily in five of their patients; they had good results with no complications. Thus repairs using the intact urethral plate are associated with good results even in adults. However, most of the published reports on TIP repair describe it only in children [3,6,7,17–19] and none stressed the results or use of TIP repair in adults.

In the present series TIP urethroplasty gave good results even in adults, but it is important to select the patients appropriately. To be suitable for TIP urethroplasty the hypospadias should basically satisfy two prerequisites, i.e. the presence of a good urethral plate of adequate width, and minimum chordee. The absence of a good urethral plate of adequate width and good vascularity is associated with failure. Snodgrass and Lorenzo [20] stated that the contraindications to TIP urethroplasty include previous resection of the urethral plate or obvious scarring of the plate. Thus patients with severe chordee and/or a poor urethral plate, where division or excision of the urethral plate is required, are not candidates for TIP urethroplasty.

Degloving the penis and excising the ventral tethering tissues lateral to the corpus spongiosum and urethral plate, without dividing or dissecting under the urethral plate, corrects the curvature of the penis in most cases. In the present study this was enough to correct chordee in all patients and tunica albuginea plication was not required in any.

Meatal stenosis is one of the complications after TIP urethroplasty, with an incidence of none [3] to 14%[21]. Meatal problems can be the cause of unsatisfactory cosmetic appearance and can cause fistula. In the series reported by Elbakry [22], four of the first seven patients had a fistula and it was associated with meatal stenosis in all. He advocated regular urethral calibration in all patients after TIP urethroplasty; Lorenzo and Snodgrass [23] disagreed with this and felt that regular calibration was not needed.

Adherence to particular technical points resulted in a normally situated vertical slit-like meatus in all the present patients. The tubularization of the urethral plates should end at the level of the midglans and not go to the tip of the glans. The appearance of a properly positioned meatus results more from the closure of the glans wings from the corona to the meatus than from tubularizing the neourethra too far distally; the latter can create obstruction even in the absence of scarring.

In all the present patients the edges of the neourethra were sutured to the edges of the glans wings. This prevents the insinuation of the epithelial edges of the glans wings inside the glans wound, and achieves primary healing between the epithelial edges. Thus, the suturing of the edges of the neomeatus to the edges of the glans wings helps not only to give an aesthetically good meatus, but also prevents meatal stenosis. Although there was no meatal stenosis in any of the present patients during the follow-up it is possible that it could develop later.

The urethral stent used was smaller than the neourethra; animal studies confirm that the midline incision through the dorsal aspect of the urethra heals with no fibrosis and by re-epithelialization [24]. The purpose of the stent is to provide urinary drainage; it does not serve as scaffolding around which epithelial growth occurs. This is corroborated in that although stents of 6 F were used in the series by Snodgrass [3], the size of the neourethra was > 10 F in all the patients. Steckler and Zaontz [4] also had a low incidence of meatal stenosis or stricture formation, despite using no stents.

The urethral stent was maintained for 10 days in all the present patients; by taking a suture on the dorsal aspect of the glans, the stent was fixed to it, thus preventing its inadvertent removal. As the small stent is held more dorsally it also prevents undue pressure on the ventrally approximated glans wings.

Urethrocutaneous fistula formation is another complication after repairing hypospadias, but TIP urethroplasty is associated with a low fistula rate. In the present study only one patient had a fistula at the site of the original distal penile hypospadiac meatus after removing the catheter. This closed spontaneously and there was no leak at the 1-month follow-up. One of the key reasons for the low fistula rate with TIP repair is the covering of the neourethra with a layer of the vascularized pedicle of subcutaneous tissue harvested from the dorsal prepuce [17]. The spongiosum around the hypospadiac meatus and for some distance proximal to it is very often thin and poorly vascularized. Hence in the patients undergoing onlay island flap or transverse preputial island flap repair, the recommendation is to slit the meatus up to the normal spongiosum [1]. As no such manoeuvre is recommended for TIP urethroplasty, it would be logical to provide good coverage of the area of the hypospadiac meatus with vascularized tissue after tubularizing the urethral plates. Hence, during orthoplasty the penile skin should be degloved to such an extent that the site of the hypospadiac meatus and the thin spongiosum proximal to it are completely exposed. This would help in covering this area with the vascularized pedicle thoroughly and completely.

In conclusion, TIP urethroplasty is associated with good results even in adults; there is no greater incidence of complications than in children. TIP repair uses the intact urethral plate, which has good vascularity and thus helps in achieving good healing, with no greater incidence of infection or fistula. The TIP repair is technically easy and the midline incision over the urethral plate allows tubularization irrespective of the glans configuration. It gives a normal-looking vertical slit-like meatus, so that patients are able to void with a coherent urinary stream. Strict adherence to technical aspects helps to decrease the incidence of meatal problems and fistula formation.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES