Hypospadias is one of the most common congenital genital anomalies. There are a number of available techniques of surgical correction of hypospadias; still, there is controversy over the ideal technique. Distal hypospadias is currently treated with acceptable success rates using one-stage repair methods, e.g., meatal advancement and glanuloplasty, tubularized incised plate (TIP), Thiersch-Duplay, Mustarde, and Mathieu urethroplasty. The overall reported success rate for hypospadias repair ranges from 85% to 90% in proximal hypospadias to over 98% in glanular hypospadias.
As TIP remains the most popular technique in distal hypospadias, a consensus is yet to reach in cases with small glans with shallow groove. Even with the 97%–98% success rate of TIP procedure, these groups of children experience complications such as glans dehiscence, meatal stenosis, and fistula formation. We introduce a modification of glans augmentation with the locally available inner prepuce flap with good cosmetic and functional results. We hypothesize that with this modification of the TIP procedure, there will be no fistula formation and no meatal narrowing, and a child will have a good cosmetic appearance.
Materials and Methods
This was a prospective interventional study conducted over a period of 1 year from July 1, 2021, to June 31, 2022, at the Department of Pediatric Surgery, SMS Medical College and attached SPINPH, Jaipur. Institutional ethical clearance was taken (475/MC/EC/2022). All distal penile hypospadias patients with small glans and shallow groove were included in the study. Patients with failed repairs and having associated congenital conditions were excluded. Children having small phallic length were given hormonal treatment with injection testosterone propionate 25 mg intramuscular (IM) for one or two doses. All the included patients underwent hypospadias repair by the standard TIP technique, and a modification was added to augment the glans by inner preputial flap.
The glans augmentation technique
After all the preoperative preparation under general anesthesia, traction suture over the glans is placed. Urethral plate and meatus are marked. Perimeatal incision is placed including the urethral plate and extended up to the glans. Circumcoronal incision is placed, and degloving is done. Glans wings are raised. Urethral plate tubularization is performed as the standard TIP procedure after incising the plate up to the coronal sulcus over 7 or 8 Fr stent. Inner preputial flap is prepared of size 5 mm larger than the required urethral plate at glans. The flap is manipulated on the ventral side as shown in Figure 1 and sutured over the glans wings on each side as a second layer by 6-0 polyglactin interrupted sutures. The rest of the urethral tube was covered by a layer of Dartos fascia. Skin was closed with polyglactin 5-0 interrupted sutures using Byar’s flap technique. Dressing was done as per institutional protocols [Figure 1].
Standard postoperative care was given as intravenous antibiotics for 48 h and then oral antibiotics for next 8 days along with anticholinergics (oxybutynin 0.2 mg/kg/day) and laxatives. Dressing was changed on the seventh postoperative day (POD) except in cases of soakage. Catheter was removed on the 10th POD [Figure 2]. Regular follow-up was done monthly to observe the incidence of glans dehiscence and fistula formation along with cosmetic appearance till 6 months [Figure 2]. After that, follow-up was done every 3 months for the next 6 months.
There were 25 patients, who qualified for the inclusion criteria. Median age was 3 years. There were 14 (56%) patients with subcoronal hypospadias followed by distal penile (n = 7; 28%) and coronal (n = 4; 16%) hypospadias [Table 1]. There were no immediate postoperative complications such as hematoma, skin necrosis, wound dehiscence, or bleeding. The follow-up period was ranging from 6 months to 12 months. There were no any late complications such as urethra cutaneous fistula and meatal stenosis. The chordae was present in three (12%), which was corrected after degloving. The mean width of the inner preputial flap was 15 mm (range: 12–18 mm). All the patients had dressing changed on the seventh POD, and the catheter was removed on the 10th POD. All patients had a good single straight stream directing forward with good caliber meatus. After 6 months of follow-up, all patients had a good glans shape with no color difference with the flap, good satisfactory cosmetic appearance, wide meatus, and straight stream. The overall success rate of this procedure is 100%.
Distal hypospadias being the most common variety and having nearly 98% successful results still has some technical issues in children with small glans. These children face complications of meatal stenosis, urethrocutaneous fistula, and glans dehiscence. Since the original description of TIP procedure by Snodgrass, a lot of modifications were described to augment the glans in children with distal penile hypospadias and small glans with variable success rates.[2,4] However, the hunt for the ideal procedure for glans augmentation is still going on. This study describes a modification of the existing technique for distal penile hypospadias using inner preputial flap with a vascular pedicle to cover the ventral surface of the glans over the urethral tube. This flap reduces the tension over the glans wings and meatal narrowing. Nezami et al. described a modification of the Mathieu perimeatal flap procedure by a double-faced Mathieu technique with acceptable complication rate. Similarly, Brannen (1976) used penile flap reconstruction technique for urethral strictures involving both fossa navicularis and meatus and described an inverted U-shaped vertical penile flap to reconstruct the glanular urethra. In the present study, we have used a pedicled inner preputial flap and manipulated it ventrally to cover the glans, and the glanular surface of the inner prepuce remains on the external surface, thus giving a normal skin-colored appearance. This procedure is incorporated with the existing TIP procedure, and the complication rates are very less or nil. Cosmetic appearance in terms of color, texture, and scar is also satisfactory (based on the patient’s review). Although Snodgrass’s TIP procedure with deep urethral groove incision is a good technique in children with shallow groove, there are difference of opinions about the efficacy and outcomes of this procedure in case of small glans. Snodgrass has provided technical details to avoid stricture formation in cases of small glans and shallow groove by deep urethral plate incision and avoiding the tubularization too far distally. We have added this modification, which is easy to perform and gives assured results without any fistula formation or glans disfigurements. It also avoids meatal stenosis. As these children with a small glans and shallow urethral groove with hypospadias pose a great challenge to the surgeons, there have been a few other techniques of glans augmentation that have been described.[1,7,8] Before augmentation, these children should receive hormonal stimulation; in our institute, we have used injection testosterone propionate (25 mg, IM) in all children one or two times before surgery.
In the TIP technique with deep urethral plate incision, tension-free closure of the glans wings is usually difficult to achieve and also technically demanding in situations of very small glans and older children. In our technique, we used inner prepuce as a bridge between glans wings and as a second layer over the urethral plate, which reduces the undue tension over the glans wings, keeps the urethral meatus wide to avoid stenosis, increases the glans circumference, and maintains the skin color of the glans. As we have observed no complications with this technique in the 6-month follow-up period, we are continuing our study and will publish the subsequent results after 2–3 years and recommend more randomized trials with a larger sample size.
With the incorporation of a modification of TIP procedure with glans augmentation by inner preputial flap, it is feasible to provide good results to the children with hypospadias having small glans and shallow groove in terms of meatal caliber, urethrocutaneous fistula, glans color, and cosmetic appearance.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
All the authors were involved in patient care (establishing clinical diagnosis, planning investigations, management, and follow-up) and writing the article.
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