The results were considered as acceptable or satisfactory when the meatal opening is present at the glans, but in a slightly different position from normal, with no other deviations from the objectives (Figs 4 and 5 and Table 4).
Our results also showed no significant association between the outcome of the operation and meatal location, previous repair, and the presence of chordee. It was found that the younger the age of the patients and the shorter the duration from the previous repair, the better the outcome of the operation (Table 4).
In modern hypospadias surgery, achievement of normal anatomy and esthetically satisfactory penile appearance has become as important as functional results 13,14.
TIP repair for hypospadias has become more popular as an easy single-stage hypospadias repair technique, with many studies in the literature showing good results not only in primary hypospadias repair but also in the treatment of those with previously failed or unsatisfactory hypospadias repair 1–3,5,6,8–10,15–17.
In this study conducted on the local population, TIP was performed on 30 patients ranging in age from 3 to 18 years as the hypospadias repair age is still high in our country, especially in rural areas with poorer resources. These data are in agreement with those of others who have reported on a series of older patients, wherein the oldest hypospadias patient was 20 years old. The advanced age may lead to psychological problems in addition to those of erection and the risk of infection, especially in patients older than 15 years of age 13,17. Moreover, some other researchers have reported data 18 in agreement with those of ours, wherein the oldest age of repaired hypospadias was also 18 years, in contrast to a report by Snodgrass 19, who, in 1994, reported that TIP was performed in 16 boys with primary hyposapadias ranging in age from 6 months to 11 years. However, the same author in another study 20 reported a maximum age of 15 years for reoperation in hypospadias repair.
Our study did not have patients younger than 3 years of age. This may be because of the fear of another repair failure among Egyptian parents. This may also explain the high cooperation by all patients and their families with the follow-up, although it may have been tough for them to attend the outpatient department very frequently postoperatively.
In our series, 10 patients with penoscrotal, proximal, and midshaft hypospadias had mild-type chordee that resolved with penile degloving and dissection of the ventral dartos.
It was reported in a published study of 15 patients that three patients required dorsal plication to correct the ventral curvature 21. Most of our patients had been operated upon previously by general surgeons: seven patients with coronal, 10 with distal penile, 10 with midshaft, two with proximal, and one with penoscrotal recurrent hypospadias. Of those, six patients had a previously failed MAGPI repair, one patient had failed TIP repair, three patients had failed Mathieu repair, and 20 patients presented after an unknown failed repair. This may have been because of an inadequate file system, and most parents were unaware of the complications of surgical repair in terms of the possibility of reoperation.
These data are comparable with those of another published report involving 15 patients in whom the meatus at reoperation was subcoronal or on the distal shaft in all, except one boy, who had a midshaft hypospadias; all the patients had previously undergone one attempt at hypospadias repair, except for one patient, who presented after two failed MAGPI procedures 21.
We calibrated the neourethra in all of our patients using a catheter with a calibration of 8 Fr or higher according to the patient’s age on the first postoperative follow-up visit. During the follow-up period, the calibration was increased to be 10 Fr or more according to the patient’s age and penile size. This calibration and dilatation may have led to a decrease in the fistulae rate as it reduces the incidence of meatal stenosis. Our results were similar to those of others 19, who reported using a neourethral calibration of 10 Fr or higher. Yet, two of our patients with meatal stenosis did show improvements with regular dilatation during the follow-up visit throughout the 24 weeks of follow-up.
Fistulae were reported in two of our patients (6.7%), who underwent surgical repairs. It has been hypothesized that the development of fistulae after TIP reoperation may be partly attributable to the relative lack of tissues available for coverage over the neourethra suture line 21. Other authors found that four of the five boys who developed fistulae in their series had no barrier layer interposed over the urethra, and recommended mobilization of a dartos or a tunica vaginalis flap to reduce the incidence of fistulae 17. Another report described the creation of a dartos flap from subcoronal shaft skin, with the development of a fistula only in one patient among 13 patients 22. We used dartos flaps from several locations, but fistulae developed when adjacent tissues were sutured over the neourethra, probably indicating the need for a flap to be developed that can be secured over the urethra using laterally based sutures; otherwise, sutures from the neourethra, barrier layer, and skin closures may overlap.
The patient who had dehiscence and complete breakdown had previously undergone partial excision of the urethral plate during an unknown procedure for midshaft hypospadias; gross inspection showed supple tissues extending from a coronal meatus that were incised and tubularized.
Contraindications to TIP urethroplasty for hypospadias reoperations may therefore include previous resection of the urethral plate or obvious scarring of the plate after a previous surgery. We were reluctant to incise skin that had been used to replace the urethral plate, as we expected re-epithelialization to occur, although it has been reported previously to succeed in six reoperations with satisfactory results 23.
It is unclear how many midline incisions can be made into the urethral plate with a reasonable expectation of a successful urethroplasty. Only one patient had undergone more than one previous operation; the TIP repair resulted in a neourethra with no meatal stenosis or stricture.
Other options for a one-stage reoperation include skin flaps and grafts. However, previous surgery often limits the availability of skin for urethroplasty, and even one operation can impair the blood supply to skin, increasing the risk of complications, including strictures and meatal stenosis. Accordingly, the complication rates for secondary flip-flaps, onlay, and tubularized flaps range from 14 to 56% in a large series 24. Others have similarly concluded that these risks are too high and instead recommend onlay or tubularized buccal grafts 25. One-stage buccal repairs in which the ventral urethra is reconstructed with a graft still rely on the variable blood supply of previously operated dartos and skin layers, and therefore, not surprisingly, complications occur in over half the patients 26. This has been replaced by the two-stage Bracka’s repair with a buccal mucosal graft as it is currently considered the best tool for complicated reoperative cases known as hypospadias cripples. Currently, the one-stage buccal mucosal graft is not favored 27,28.
We found no significant association between the outcome of the operation and meatal location, previous repair, and the presence of chordee. It was found that the younger the age of the patients and the shorter the duration since the previous repair, the better the outcome of the operation. However, the results of uroflowmetry showed that the flow pattern was normal bell-shaped for all the patients, except one, with Qmax below the 25th percentile according to the Toguri nomogram.
This was an unexpected result because the reconstructed urethras lack the expansile properties of a native urethra. This may have been because of the long follow-up period, which may have led to a better spontaneous improvement in the uroflowmetry pattern, in agreement with recently published data 29.
For recurrent hypospadias, TIP is an excellent treatment option, with some restrictions of its use in patients with a disturbed uretheral plate with an apparent scarring of the plate as it may result in an excellent cosmetic appearance of the penis. It should be considered as the first reoperation option when the results of primary techniques are unsatisfactory. This work represents a regional experience from a developing country and provides some practical points for pediatric surgeons, especially those interested in hypospadias surgery.
Further meta-analytic and data-based evidence may be required to overcome the limitations of our study, which included the following: the small number and variability in the patient population, and the subjective assessment of the urethral plate and the cosmetic outcomes of the procedure.
Conflicts of interest
There are no conflicts of interest.
1. Dolatzas T, Chiotopoulos D, Antipas S, Demetriades D, Ipsilantis S. Hypospadias repair in children: review of 250 cases. Pediatr Surg Int. 1994;9:383–386
2. Gürdal M, Tekin A, Kireççi S, Şengör F. Intermediate-term functional and cosmetic results of the Snodgrass procedure in distal and midpenile hypospadias. Pediatr Surg Int. 2004;20:197–199
3. Coplen DE. Reoperative hypospadias surgery and management of complications. In: Brandes SB, editor. Urethral reconstructive surgery
. NewYork, USA: Humana Press; 2008. pp. 285–295
4. Hinderer UT. Functional and aesthetic results in hypospadias repair with Hinderer’s techniques. Aesthetic Plast Surg. 2000;24:323–343
5. Çakan M, Yalçinkaya F, Demirel F, Aldemir M, Altuǧ U. The midterm success rates of tubularized incised plate urethroplasty in reoperative patients with distal or midpenile hypospadias. Pediatr Surg Int. 2005;21:973–976
6. Mouriquand P, Mure P, Zeidan SHadidi AT, Azmy AF. Management of failed hypospadias repairs. Hypospadias surgery. 20041st ed New York Springer
7. Eliçevik M, Tireli G, Demirali O, Ünal M, Sander S. Tubularized incised plate urethroplasty for hypospadias reoperations in 100 patients. Int Urol Nephrol. 2007;39:823–827
8. Mustafa M, Wadie BS, Abol Enein H. Standard Snodgrass technique in conjunction with double-layer covering of the neourethra with dorsal dartos flap is the therapy of first choice for hypospadias. Int Urol Nephrol. 2008;40:573–576
9. Pieretti RV, Pieretti A, Pieretti Vanmarcke R. Circumcised hypospadias. Pediatr Surg Int. 2009;25:53–55
10. Mustafa M. The concept of tubularized incised plate hypospadias repair for different types of hypospadias. Int Urol Nephrol. 2005;37:89–91
11. Lorenzo AJ, Snodgrass WT. Regular dilatation is unnecessary after tubularized incised-plate hypospadias repair. BJU Int. 2002;89:94–97
12. Kaya C, Kucuk E, Ilktac A, Ozturk M, Karaman MI. Value of urinary flow patterns in the follow-up of children who underwent Snodgrass operation. Urol Int. 2007;78:245–248
13. Fuse H, Akashi T, Yasuda K, Mizuno I. Tubularized incised plate urethroplasty for distal hypospadia, using overlapping dorsal subcutaneous flaps. Int Urol Nephrol. 2002;34:535–537
14. Elder JS, Duckett JW. Urethral reconstruction following an unsuccessful one-stage hypospadias repair. World J Urol. 1987;5:19–24
15. Al Hunayan AA, Kehinde EO, Elsalam MA, Al Mukhtar RS. Tubularized incised plate urethroplasty: modification and outcome. Int Urol Nephrol. 2003;35:47–52
16. Baccala AA Jr., Ross J, Detore N, Kay R. Modified tubularized incised plate urethroplasty (Snodgrass) procedure for hypospadias repair. Urology. 2005;66:1305–1306
17. Borer JG, Bauer SB, Peters CA, Diamond DA, Atala A, Cilento BG Jr, et al. Tubularized incised plate urethroplasty: expanded use in primary and repeat surgery for hypospadias. J Urol. 2001;165:581–585
18. Elbakry A. Tubularized-incised urethral plate urethroplasty: Is regular dilatation necessary for success? BJU Int. 1999;84:683–688
19. Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol. 1994;151:464–465
20. Snodgrass WT, Lorenzo A. Tubularized incised-plate urethroplasty for hypospadias reoperation. BJU Int. 2002;89:98–100
21. Snodgrass WT, Lorenzo A. Tubularized incised-plate urethroplasty for proximal hypospadias. BJU Int. 2002;89:90–93
22. Shanberg AM, Sanderson K, Duel B. Re-operative hypospadias repair using the Snodgrass incised plate urethroplasty. BJU Int. 2001;87:544–547
23. Luo CC, Lin JN. Repair of hypospadias complications using the tubularized, incised plate urethroplasty. J Pediatr Surg. 1999;34:1665–1667
24. Simmons GR, Cain MP, Casale AJ, Keating MA, Adams MC, Rink RC. Repair of hypospadias complications using the previously utilized urethral plate. Urology. 1999;54:724–726
25. Baskin LS, Duckett JW, Ueoka K, Seibold J, Snyder HM III. Changing concepts of hypospadias curvature lead to more onlay island flap procedures. J Urol. 1994;151:191–196
26. Metro MJ, Wu HY, Snyder HM III, Zderic SA, Canning DA. Buccal mucosal grafts: lessons learned from an 8-year experience. J Urol. 2001;166:1459–1461
27. Bracka A. A versatile two-stage hypospadias repair. Br J Plast Surg. 1995;48:345–352
28. Bhattacharya S. A modified tubularised incised plate urethroplasty technique and a revised hypospadias algorithm. Indian J Plast Surg. 2010;43:21–27
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29. Andersson M, Doroszkiewicz M, Arfwidsson C, Abrahamsson K, Holmdahl G. Hypospadias repair with tubularized incised plate: does the obstructive flow pattern resolve spontaneously? J Pediatr Urol. 2011;7:441–445