In the paediatric urology section this month, the papers describe studies on hypospadias repair and renal function after pyeloplasty.
To evaluate whether the V-incision sutured meatoplasty (VSM) is useful for configuring the constructed meatus after the onlay flap and the Mathieu flip-flap repair for hypospadias, as the transverse preputial onlay island urethroplasty is excellent for repairing anterior hypospadias with no chordee, and a slit-like normal meatus cannot be constructed in many patients who had the original onlay island-flap repair
PATIENTS AND METHODS
The configuration of the meatus which was repaired by the onlay island flap technique with VSM (group 2) was evaluated and compared with that of the original onlay technique (group 1). Group 1 consisted of 30 patients treated with only the classic onlay procedure as primary hypospadias repair (1999–2001). Group 2 consisted of 22 patients treated using the onlay procedure with VSM as primary hypospadias repair (2002–2004).
There were complications after surgery in four (18%) of 22 patients in group 1 and in five (17%) of 30 in group 2, with no significant difference. A slit-like meatus was achieved in eight (27%) of 30 in group 1 and in 12 (55%) of 22 in group 2. There was a significant difference between the groups in meatal configuration (P = 0.04).
The VSM is a useful technique to make a slit-like meatus for onlay island flap urethroplasty and flip-flap hypospadias repair, although the technique cannot always achieve the intended result.
V-incision sutured meatoplasty
tubularized incised plate.
The transverse preputial onlay island flap urethroplasty is excellent for repairing anterior hypospadias with no chordee [1,2]. Subsequently, the indication for the onlay island flap was extended to more proximal hypospadias with chordee, by applying the dorsal tunica albuginea plication technique [3,4].
Ghali  compared the onlay island flap with Mathieu flip-flap and tubularized island flap, and reported that the onlay island flap has a wider applicability in different types of hypospadias, including those with distal urethral hypoplasia or with severe chordee. Although the outcome was evaluated by assessing the cosmetic results and the occurrence of complications, meatal configuration was not referred to in that report.
Although the results with the onlay island flap technique for moderately severe hypospadias with and with no chordee have been quite acceptable, with a secondary repair rate of 5%, the originally described onlay procedure tends to produce a horizontal ‘bucket-handle’ meatus, which is cosmetically unacceptable. Currently, patients with hypospadias, and their parents, expect a circumcised penis with a normal appearance after repair. Thus the configuration of the meatus should also be considered with the overall appearance, mucosal collar and the location of the meatus.
Because a slit-like normal meatus could not be constructed in many patients who had the original onlay island flap repair, we applied a V-incision sutured meatoplasty (VSM), developed by Boddy and Samuel , to provide a natural vertical slit-like glanular meatus for the Mathieu flip-flaps, to our onlay urethroplasty. We evaluated whether the VSM is useful for configuring the constructed meatus for the onlay flap and the flip-flap.
PATIENTS AND METHODS
A ventral transverse preputial flap 10–12 mm wide is marked out and mobilized as an island flap, based on the axial blood supply. The onlay flap is rotated around to the ventrum of the penis. The onlay is approximated parallel to the urethral plate and the edges are sutured together with a running 6 or 7/0 polyglycolic acid suture. After the interrupted sutures are placed, a running inverting suture is used for the opposite edge of the flap (Fig. 1a).
The tip of the ventral side of the neourethra is excised in a V-shaped fashion with sharp scissors (Fig. 1b,c). Each side of the ‘V’ is sutured to the glanular wings using 6 or 7/0 polyglycolic acid sutures. The remaining glans wings are then re-approximated over the neourethra with no tension, resulting in a rounded glans with a mid-glanular meatus (Fig. 1d).
Penile ventral skin is approximated and sutured to the subglanular skin edge to cover the ventrum of the penis. A straight catheter within the urethra is secured distally to the glans with the traction suture. A compression dressing is applied and left in place for ≈7 days, as is the indwelling catheter.
The meatus was repaired using the onlay island flap technique with VSM (group 2; 22 patients; 2002–2004; median age 24.5 months, range 14–59) and evaluated and compared with that of the original onlay technique (group 1; 30 patients; 1999–2001; median age 29 months, range 10–132). The mean period of ‘dripping’ silicone catheterization was 7 days for both groups. The status of the urethral groove is shown in Table 1, with no differences between the groups in the urethral plate characteristics before surgery.
|Final meatal configuration||Urethral plate (n), deep/moderate/shallow|
|Group 1 (total)||Group 2 (total)|
|Slit-like||5/3/0 (8)||4/6/2 (12)|
|Not slit-like||2/9/6 (17)||0/3/3 (6)|
|Complication (glans dehiscence)||0/5/0 (5)||1/2/2 (5)|
|Total||7/17/6 (30)||5/11/7 (22)|
In the present study the configuration of the meatus was assessed critically by the authors, using the photographic appearance of the reconstructed penis at the outpatient clinic. The rates of complication were also compared between the groups, using the chi-square test to assess differences, considered statistically significant at P < 0.05.
There were complications in five patients in group 1 (glanular dehiscence in five and urethrocutaneous fistula in three) and in four in group 2 (glanular dehiscence in all), with no significant difference between the groups in the rate of complications. A slit-like meatus was achieved in eight (27%) of the 30 children in group 1 (Fig. 2a,b) and in 12 (55%) of the 22 in group 2 (Fig. 3a,b), with a significant difference between the groups (P = 0.04;Table 1).
Five of the seven children in group 1 with a deep urethral groove had a slit-like meatus, while three of 17 with moderate groove and none of six with a shallow groove had slit-like meatus. However, of those in group 2, four of five with a deep groove, six of 11 with a moderate and two of seven with a shallow groove had a slit-like meatus.
The tubularized incised plate (TIP) urethroplasty has been mainly used for distal hypospadias. The TIP repair is useful for producing a vertically orientated, slit-like normal-looking meatus [8–10]. Furthermore, several authors noted that the TIP could be used for even proximal hypospadias, if the urethral plate is healthy and wide enough to tubularize . However, the indication for TIP is limited and the long-term results are unclear for proximal hypospadias. For moderately severe hypospadias the onlay island flap technique remains dominant because the calibre of the neourethra can be increased by taking a wider onlay flap when it is harvested from the prepuce.
Although the transverse preputial onlay island flap urethroplasty has been the mainstay for proximal hypospadias with no, mild or moderate penile curvature, since it was used in 1987 by Elder et al., Ververidis et al. reported that the onlay technique can produce a vertical meatus in only a third of the patients, whereas most of those treated using the TIP technique have a vertical meatus. As patients with hypospadias and their parents currently expect a circumcised penis with a normal appearance after repair, the configuration of the meatus should also be considered with the overall appearance, a mucosal collar, and the location of the meatus.
Boddy and Samuel  described a method of VSM as a modification of the Mathieu procedure, to avoid a horizontal ‘bucket handle’ meatus and to form a cosmetically acceptable natural vertical slit-like glanular meatus. We used the VSM in children who had moderately severe hypospadias repaired using the onlay island flap urethroplasty, because these two procedures used the same concept, i.e. the skin flap is laid on the urethral plate and sutured to the plate bilaterally. We evaluated the configuration of the meatus repaired by the onlay island flap technique with VSM and compared it with that repaired by the original onlay technique.
Yesildag et al. reported that a slit-like meatus was achieved in all 42 children who had a Mathieu procedure and a VSM, but in only 12 of 32 who were repaired with the original Mathieu procedure. In the present patients, 27% of those repaired with the original onlay technique had a slit-like meatus, vs 55% of those who also had a VSM resulting in a vertical slit-like meatus. Although we improved the appearance, we could not achieve a perfect appearance in the remaining 45% of the patients despite adapting the VSM. We consider that the present results were not satisfactory because the onlay repair was indicated for moderately severe hypospadias, which required a longer neourethra than for the flip-flap repair, and the configuration of the meatus was assessed critically using the photographic appearance of the reconstructed penis.
In 1989 Rich et al. described hinging the urethral plate, although the original technique was used as a complement to a Mathieu or onlay island flap procedure. In hypospadias with a shallow glanular groove the hinge technique allows a Thiersch-Duplay repair to be used when a Mathieu or onlay island flap repair would otherwise have been needed. In 1994 Snodgrass  developed the TIP urethroplasty, extending the concept of hinging the urethral plate, and created a neourethra of appropriate diameter and a vertical, normal-appearing meatus.
The vertical midline incision on the urethral plate could be effective for hinging the plate and producing a slit-like meatus, because the neourethra is constructed only with the plate in the TIP repair. However, because the neourethra of a Mathieu or onlay repair consists of the urethral plate and skin flap, managing the peripheral portion of the ventral skin flap would be an acceptable idea to obtain a slit-like meatus. In the present onlay repairs, hypospadiac patients with a deep urethral groove tended to have a slit-like meatus irrespective of the use of a VSM. However, those with a moderate or shallow glanular groove seldom had a slit-like meatus when the VSM was not used, while six of 11 of those with a moderate groove and two of seven with a shallow groove had a slit-like meatus by adding a VSM. The present results indicate that a VSM contributed to improved meatal configuration, at least in boys with a moderate and shallow groove in the onlay repair.
Tekant et al. had complete success with the Mathieu procedure using a VSM and noted that this technique created a reasonable meatal calibre, which is the most important factor to decrease the rate of complications such as meatal stenosis (which tends to induce fistula formations and diverticula). In the present study there were complications after repair in four (18%) of 22 patients in group 2 and five (17%) of 30 in group 1; the complication rates were similar in the two groups. While we had expected the VSM to improve the configuration of the meatus, we anticipated that the glanular adaptation might be fragile, because the glanular adaptation would be shorter than that in the original onlay procedure. The VSM contributed to the improvement in meatal configuration and did not affect the complication rates in group 2.
We conclude that the VSM is useful for making a slit-like meatus for onlay island flap urethroplasty and the flip-flap hypospadias repair, although the result is not always satisfactory.
CONFLICT OF INTEREST