Tubularized incised plate technique (tips) for recurrent hypospadias: A local experience

Tubularized incised plate technique (tips) for recurrent hypospadias: A local experience

Ossama M Zakaria,a MD; Magdi Loulah,h MD; Tamer A Sultan,b MD

a) Department of Surgery, Divisions of Pediatric and Plastic Surgery, Suez Canal

University, Egypt.

b) Department of Surgery, Menoufyia University, Egypt.

Co"espondence:e-mail: ossamaz2004@yahoo.com

Abstract

Background:  Tubularized incised-plate (TIP) repair has been well described for the use in salvage hypospadias repairs with good results.

Aim: To evaluate our local experience of TIP repair (Snodgrass method) in the management of recurrent hypospadias.

Patients and methods: This prospective, descriptive study was conducted over a period of 5 years from December 2003 to December 2008. The study included 30 patients, all of them had previously undergone hypospadias repair, and the indication for surgery was complete failure of the previous repair.  Classic TIP repair was performed although tissues for barrier layers between  the   neourethra  and   skin  closures  were  not    as   readily  available.

Results:  Secondary  TIP repair was successful  in 29 patients  (96%)  while one case (4%)

showed a complete failure. Postoperative follow-up was 2.1 years with a range of2- 8.2 years.

Conclusion: Our local experience coincide with data of the literature that TIP is an excellent option in treatment of recurrent hypospadias when the primary techniques results are unsatisfactory.

Key words: Recurrent hypospadias, TIP, salvage hypospadias.

Introduction:

Although modem hypospadias repairs have low complication rates, inevitably there are occasional failures that require reoperation. Primary hypospadias repairs are associated with failure rates of 5-20%  depending upon the type of procedure performed, location of original meatus and quality of tissue available for the initial repair.l-6

The  principles of  reoperation remain identical to those of the primary operation. The challenges of performing a secondary hypospadias repair include lack of healthy or adequate amount of local tissue to create flaps for both replacement and coverage of the defective urethra and, resurfacing the penile shaft.7

These secondary procedures are often more difficult than the original surgery because there is less skin available to create flaps, and the vascularity of previously operated tissues may

be  suboptimal, resulting in  further complications.2,s  Potential  advantages of tubularized incised plate (TIP) urethroplasty in these circumstances include creation of the neourethra with no need for skin flaps, and the opportunity to achieve good cosmetic results despite previous surgery.5,6,8-10

Our study aimed to evaluate our local experience with tubularized incised-plate (TIP) urethroplasty in the management of recurrent hypospadias.

Patients and methods:

This prospective, descriptive study was conducted over a period of 5 years from December 2004 to December 2008 with a follow-up period of 2 years or more post surgery. The study included 30 patients, all of them had previously undergone different types of hypospadias repair, and the indication for surgery was complete failure of the previous

repair. All patients were subjected to a thorough history taking  stressing upon  the  parietal consanguinity, associated congenital anomalies and  clinical examination with  a  special emphasis on the number(s) and type(s) of the previous  original  primary operations if available.

Thorough local examination to assess the

state of the urethral  plate, preputial skin if present, site  of  hypospadias, presence of chordee and the scrotum for a possible scrotal transposition. TIP was performed with a surgical technique similar to the primary TIP repair,12 except that tissues for barrier layers between the neourethra and skin closures were not as readily available.

Follow-up was  performed through outpatients' clinic  visits. These  visits were arranged to be in the first week post surgery, followed  by a session  every 2 weeks in the first month then monthly for the period of at least  two   years  period  post  surgery.

Functional results were  measured via uretheral calibration after 2 months of surgery and uroflowmetry, while cosmetic results were evaluated by genital examination and family satisfaction about the function and appearance of the  penis. These  measurements were performed weekly in the 1st month then every

2 weeks in the next months. After the second month, assessment of the neourethra by urethral calibration via a urethral catheter was performed  in every visit. Patients  of meatal stenosis were treated via urethral dilatation while patients with fistula were treated with fistula  repair  after  failure of  spontaneous closure.

The  urinary  flow  pattern, maximum (Q

(max)) and average flow rate (Q (ave)) were measured; the  results were  expressed as percentiles and compared to the Toguri values from normal  children. The Q (max)  and Q (ave) were considered normal if they were in

>25th percentile, equivocally obstructed in the

5-25th percentile and  obstructed if  <5th percentile. The flow pattern was classified as bell  ring  shape,  plateau or intermittent. II

Results:

A total of 30 patients suffering of recurrent hypospadias were enrolled in the study. Their

preoperative characteristics data are shown in

Table(l).

The  most  commonly reported type  of previous repair  was  MAGPI  in  6 patients (20%). One patient who had been subjected to TIPS presented after 1 year of the previous repair. The rest of patients presented after a mean  duration of  4.9  ±3.1  years  from  the previous repair Table(2).

On preoperative assessment of the status of urethral plate,  the  presence or absence of foreskin because  of circumcision results are shown in Table(3). Only one patient in our series  has  shown  complete failure of  the procedure.This patient presented with disturbed urethral plate which was markedly scarred. A statistically  significant  difference  was noted between patients with disturbed urethral plate and patients  with undisturbed urethral  plate regarding reported compilations Table(3).

Postoperative urethral calibration was equal or more than 8 fr, in cases of successful repair without meatal stenosis according to patient's age; 8 to 10 fr were used on those above 3 years till 10 years, 10-12 fr from 10 to 15 years and    12-14  fr   for    15   years  or   more.

Uroflowmetery results showed that the flow pattern was normal bell-shaped  for all of the patients, except 1, with Q (max) below the 25th percentile according to the Toguri nomogram. He had a plateau flow pattern and was found to have an asymptomatic meatal stenosis, which improved with urethral dilatation.

Considering meatal  stenosis  and fistulae rate,  and  a  functional neourethra with  a cosmetically nonnal slit-like meatus our success rate was 86.7%.

Twenty six patients showed no postoperative complications and had a slit like meatus and a forward directed urinary  stream  without branching with their parent's satisfaction with the repair results.

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 estimated 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).

Table (1): Preoperative patient characteristics.

Table (2): Distribution  of the studkd patients according to the type of previous repair.

Table (3): Distribution of the studied patients according tothe preoperative state of the urethral plate, and complications according to the state of urethral plate.

NS: No significant difference.

*Statistically significant difference (p-value < 0.05)

NS: No statistically significant difference (p-value > 0.05)

Discussion:

In modem hypospadias surgery, achieving normal anatomy and aesthetically satisfactory penile appearance has become as important as functional results.13,14

TIP repair for hypospadias has gained more popularity as an easy single stage hypospadias repair  technique with  many  literatures supporting its good results not only in primary hypospadias repair but also for treating those with previously failed  or unsatisfactory hypospadias repair.1-3,5,6,8-10,15-17

In this local study, TIP was performed on

30 patients whose age ranged from 3 to 18 years as the hypospadias repair age is still high in our country especially in rural areas with poorer resources.

This data coincides with others who reported

series of more advanced age that the eldest hypospadias patient was 20 years old. The advanced age brings about psychological problems in addition to those of erection and infection especially inthose older than 15 years of age_l3,17

Some other reported data18 coincided with us where  the highest age of repaired hypospadias was also 18 years, contrary to a

report by Snodgrass,l9 who in 1994 reported that TIPS was performed in 16 boys with primary hyposapadias with age from 6 months to 11 years. However, the same author in another study20 reported a maximum age of

15 years for reoperation in hypospadias repair.

We observed that no patients less than 3 years were involved. This may due to fear of Egyptian  parents of another repair failure.

The hereditary factors were clearly confrrmed in our study as there were 8 boys with positive history of consanguinity and 1 of them had a family history of hypospadias in his elder brother.

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 that involved 15 patients that 3 patients required dorsal plication to correct the ventral curvature.21 Most of our patients were previously performed by general surgeons; they included 7 patients with coronal, 10 with distal penile, 10 with mid shaft, 2 with proximal, and 1 with peno-scrotal recurrent hypospadias. Out of those, 6 had a previously

failed MAGPI repair; one patient had failed

TIP repair, 3 with failed Mathieu repair, and

20 patients  presented after  unknown failed repair.  This  may be due  to deficient files' system and most parents were unaware by the complications of surgical repair regarding the possibility of reoperation.

This   data   can  be  compared to  other

published report involving 15 patients where the meatus at reoperation was subcoronal  or on the distal shaft in all but one boy, who had a midshaft  hypospadias, all had previously undergone one attempt at hypospadias repair, except for one patient  presenting after  two failed MGPI procedure.21

We  calibrated the  neourethra with  8 fr catheter  or more according  to patient's age; on  the  first  postoperative follow-up visit. During  the follow-up period the calibration increased to be 10 fr or more according to patient's age and the penile size. Our results were similar to those of others19 who reported a neourethral calibration to be 10 fr or more. Yet, our 2 patients  with meatal stenosis  did improve by regular dilatation during the follow up visit throughout  24 weeks of follow- up.

Fistulae were reported in 2 of our patients (6.7%) who were surgically repaired. It has been  hypothesized that  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 noted 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 tunica vaginalis flap to reduce fistulae's incidence.17 Another report described the creation of a dartos flap from subcoronal shaft skin with only one fistula among 13 patients.22 We used dartos flaps from several locations, but that the fistulae occurred when adjacent tissues were sutured over the neourethra  probably  illustrating  the need for a flap to be developed which can be secured over the urethra by laterally based sutures; otherwise sutures from the neourethra, barrier layer and skin closures may overlap.

That patient who suffered dehiscence  and complete breakdown had previously undergone partial excision of  urethral plate  during 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 previous surgery. We were reluctant to incise skin that has been used to replace the urethral plate, expecting re-epithelialization to occur, although, it  was  previously published 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. There was only one patient who 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 skinflaps 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, complication

rates  for secondary flip-flaps, onlay  and tubularized  flaps range from 14% to 56% in large series.24 Others have similarly concluded that these risks are too high and instead advocate onlay or tubularized buccal grafts.25

Unfortunately, one-stage buccal  repairs  in which the ventral urethra is reconstructed with a graft still rely upon the variable blood supply of previously operated dartos and skin layers, and so, not surprisingly, complications occur in over half the patients.26

We  showed no  significant association between  the outcome of the operation and meatal location, previous repair and the presence of chordee.It was estimated that the younger the age of the patients and the shorter the duration since the previous repair the better may   be  the  outcome of  the  operation.

In conclusion, for recurrent  hypospadias,

TIP is an excellent treatment option with some restrictions of its use in patients with disturbed uretheral plate with an apparent scarring of the plate as it may give  an excellent cosmetic appearance of the penis. It should be considered

as the first re-operation option when the primary techniques  results  are   unsatisfactory No financial relationship: The  authors declare that they have no conflict of interest.

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