European Urology 44 (2003)

Transcription

1 European Urology European Urology 44 (2003) Comprehensive Analysis of SixYears Experience in Tubularised Incised Plate Urethroplasty and its Extended Application in Primary and Secondary Hypospadias Repair Marcus Riccabona *, Josef Oswald 1, Mark Koen, Goedele Beckers, Anton Schrey, Lukas Lusuardi Department of Paediatric Urology, Krankenhaus Barmherzige Schwestern, Seilerstätte 4, A-4010 Linz, Austria First published online 26 August 2003 Abstract Objective: We evaluated the potential of tubularised incised plate (TIP) urethroplasty in primary and secondary hypospadias repair focusing on the extended application of this procedure, the utility and handling of the urethral plate and operative results. Methods: In this retrospective study, we analysed the medical records of 228 children with different levels of the hypospadiac meatus who underwent a TIP procedure between February 1997 and December The children were followed a mean of 42 months. Our medical records provided us with details about the location of the hypospadiac meatus, the width of the urethral plate before and after midline incision, primary versus secondary surgery, complications as well as notes on the extended application of the TIP procedure. Results: The overall postoperative complication rate was 7.8%. The overall fistula rate was 5.7%, with 4.1% in primary distal, 9.6% in primary proximal and 7.5% in secondary repair respectively. We had one case of meatal stenosis (0.4%) and one of urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). Due to the encouraging results, the frequency of TIP procedure in hypospadias surgery increased from 33% in 1997 to 82% in Conclusion: In our study the TIP procedure has emerged as the first-choice technique in primary hypospadias repair irrespective of the level of the hypospadiac meatus and the width of the original urethral plate. This procedure has also proved to be favourable for many cases at secondary surgery. # 2003 Elsevier B.V. All rights reserved. Keywords: Hypospadias; Tubularised incised plate; Snodgrass; Urethral plate; Complications; Outcome 1.Introduction * Corresponding author. Tel. þ ; Fax: þ address: marcus.riccabona@bhs.at (M. Riccabona). 1 Present address: Department of Urology, University of Innsbruck, Austria. Recent data show that the prevalence of hypospadias has nearly doubled over the past 30 years [1,2].Hypospadias therefore continues to be a challenging problem for paediatric urologists. The current operative concept in hypospadias surgery is based on a perfect singlestage repair of the malformation and should result in functional excellence and a cosmetically normal looking penis. A successful hypospadias repair includes a vertical slit-like glandular meatus, a conically shaped glans, a straight penis during erection, good skin coverage and a normal position of the scrotum in relation to the penis. These parameters reflect the expected standard in current hypospadias surgery [3]. Over the last 5 8 years hypospadias surgery has changed, especially since the identification of the urethral plate as an anatomical entity, which has considerably simplified surgery. Today, two principles which can be used for more than 90% of all repairs enjoy widespread popularity. The first is the preservation of the urethral plate whenever possible; the second is the in situ tubularisation of the plate, with or without dorsal longitudinal midline incision /$ see front matter # 2003 Elsevier B.V. All rights reserved. doi: /s (03)

2 M. Riccabona et al. / European Urology 44 (2003) The tubularisation was originally described by Thiersch and Duplay 130 years ago and later proposed by the French school (Monfort) with elevation of the plate and in situ by the American school (Kass). The idea of hinging the plate was initially proposed by the Philadelphia group (Rich) in order to achieve a slit-like meatus with a meatal-based or an onlay repair. Snodgrass has largely contributed to further popularizing the TIP procedure [4 9]. It has become the preferred technique in primary and secondary hypospadias repair in many paediatric urology centres worldwide. Advantages of the modified Snodgrass technique include the use of native urethral mucosa to reconstruct the urethra, a single urethral suture line and a vascularised subcutaneous flap for coverage of the neourethra to minimize the risk of urethrocutaneous fistulae. Several authors have reported excellent functional and cosmetic results with a low complication rate [10 12]. We started to perform this procedure in early 1997 and can now report about our 6 years experience focusing on the utility and handling of the urethral plate, the expanding indication for a TIP procedure as well as on the results and complications in primary and secondary repair. 2. Material and methods Between January 1992 and December 2002, 775 patients underwent a hypospadias repair at our institution. We used different operative techniques depending on the child s anatomy, the location of the hypospadiac meatus and the chordee. We have retrospectively analysed our medical records of a total of 228 boys who underwent a tubularised incised plate (TIP) procedure between 1997 and Patient age ranged from 6 months to 17 years (average age 21 months); the majority was younger than 16 months (76%). While 188 cases were primary repairs, 40 children underwent TIP repair as a secondary procedure. At first we used this technique in coronal and subcoronal hypospadias repair, then extended it to proximal and secondary hypospadias surgery and are currently applying it to virtually all forms of hypospadias repair. The various levels of hypospadiac defect and the indications for secondary TIP urethroplasty are listed in Table 1. We have never administered any testosterone or dehydrotestosterone preoperatively. All procedures were either performed or supervised by at least one of the three senior surgeons (M.R., J.O., L.L.) following identical surgical steps. All hypospadias surgery was carried out using micro instruments and 2.5 to 4.0 optical magnification. After placing a 5-0 Prolene 1 traction suture, we marked a U-shaped incision line from the hypospadiac meatus to the coronal margin (Figs. 1 and 2). With a round ophthalmic microsurgery knife (Sharptome Crescent Knife 1, Alcon/Grieshaber AG) we made a superficial midline incision of the mucosa of the urethral plate from the hypospadiac meatus to the glans tip to widen the plate (Fig. 3). We performed the U-shaped incision circumferentially along the marked line. We degloved the penis and created an artificial erection to assess any residual chordee. We either placed dorsal median sutures (Baskin) or bilateral tunica albuginea plication Table 1 Level of the hypospadiac meatus (after orthoplasty)/indication for TIP procedure in operations between 1997 and 2002 Indication Total Primary repair (n ¼ 188) Megameatus Coronal Penile Penoscrotal Scrotal Perineal Secondary repair (n ¼ 40) Fistulae Recurrence Total sutures (Schroeder Esset) according to the location and the degree of the curvature. Corporal disproportion was noted and corrected in 47 children (20.6%). Tourniquet placement provided optimum conditions to carry out further critical steps. This was followed by parallel longitudinal glandular incisions (microsurgery knife 1 Grieshaber Ultrasharp 1 ) down to the level of the corpora cavernosa in order to define the glandular urethral plate, to mobilise the glans wings and to allow for a tension-free tubularisation. The urethral plate was tubularised over an 8 Fr dripping stent (Tarkington 1 ) with a subcuticular 7-0 polyglactin 910 running suture starting at the caudal point of the elliptically shaped neomeatus (Fig. 4). The suture line was covered with the remaining tissue of the corpus spongiosum. A subcutaneous and ventrally rotated flap was dissected from the preputial and the shaft skin. The glandular tissue was approximated over the neourethra with 3 4 interrupted absorbable monofilament 6-0 polyclecaprone 25 sutures; the urethral mucosa and glandular epithelium were sutured with 7-0 polyglactin Fig. 1. Scrotal hypospadias and partial penoscrotal transposition: preoperative situs.

3 716 M. Riccabona et al. / European Urology 44 (2003) Fig. 2. Snodgrass manoeuvre. rapid. Skin coverage was performed with either rotational dorsal flaps or ventral shaft skin, redundant skin was excised. The correction of penoscrotal transposition was done during the same sessions, if necessary (Fig. 5). Surgery was completed by applying Benzoin 1 and a Mepithel 1 Tegaderm 1 dressing. The dripping stent drained into a double nappy, and the meatus was kept moist with antibiotic ointment. In re-operative cases in which no preputial skin was left a tunica vaginalis flap was used and repositioned over the neourethra. The bio-occlusive dressing and the dripping stent were removed between day 6 and 10 after surgery depending on the extent of the repair and the healing process. All patients were placed on antimicrobials (trimethoprim/sulfamethoxazole 2 mg/kg per day) until stent removal. Follow-up checks for early and late results as well as for any complications were performed on all children at 3-week, 3-month, 1-year and 5-year intervals. Those examinations included history, observation of the urinary stream whenever possible, thorough inspection of the penis, urinalysis and a sonographic post-void residual check. In patients aged 5 or above uroflowmetry was obligatory in all controls. Careful assessment, including uroflow, is recommended in complex and re-operative cases. Neourethral calibration and follow-up endoscopy were carried out in rare individual cases, however not routinely. 3. Results Fig. 4. Tubularisation of the urethral plate. Patients were followed a mean of 42 months (range 5 71). 210/228 (92.1%) patients were operated in a single-stage repair without any complications. The overall (primary and secondary surgery) complication Fig. 3. The width of the original urethral plate is doubled. Fig. 5. Scrotal hypospadias and partial penoscrotal transposition: postoperative situs.

4 M. Riccabona et al. / European Urology 44 (2003) Table 2 Incidence of complications in primary vs. secondary repairs Complication rate was 7.8% (18/228): 13/228 boys developed fistulae (5.7%); we observed one case of meatal stenosis which required a simple meatotomy (0.4%), one urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). In 2 of the 3 cases of complete wound dehiscence allergic reactions to antiseptic material (Octenisept 1 )wereconfirmed. We encountered no cases of diverticulum formation or retrusive meatus. No meatal stenoses or neourethral strictures occurred in primary repairs. Complications in primary versus secondary repairs are listed in Table 2. Complications after secondary surgery are shown in Table 3. Analysis of fistula formation revealed a fistula rate of 4.1% in primary distal and 9.6% in primary proximal hypospadias repair and 7.5% in secondary repairs. In 12 patients the fistula was successfully closed in a single-stage procedure, one child needed two additional procedures. In all except three boys (3/228) the TIP procedure resulted in a cosmetically normal looking penis with a slit-like vertical glandular meatus and a conically shaped glans similar to a circumcised penis. The same successful result was also achieved in primary penile and scrotal repairs as well as in all secondary procedures. 4. Discussion Primary repair (n ¼ 188) Secondary repair (n ¼ 40) Fistulae 10 (5.3%) 3 (7.5%) Meatal stenosis 0 (0.0%) 1 (2.5%) Urethral stricture 0 (0.0%) 1 (2.5%) Glandular dehiscence 3 (1.5%) 0 (0.0%) Diverticulum formation 0 (0.0%) 0 (0.0%) Retrusive meatus 0 (0.0%) 0 (0.0%) Overall complications 13 (6.9%) 5 (12.5%) Table 3 Incidence of complications after secondary TIP procedure Author Complications Cases Percentage Shanberg et al. [16] Borer et al. [14] Snodgrass et al. [15] Riccabona et al Over 300 different surgical methods and several modified approaches have been published in the past, demonstrating that an ideal and universally applicable technique for hypospadias repair has not yet been found. However, the identification of the urethral plate as an anatomical entity has fundamentally changed hypospadias surgery, which in fact has revolutionised and considerably simplified this surgery. Before, the Mathieu procedure had been our most frequently performed technique for many years. In a prospective randomised trial, a forerunner to this present study, we already compared the perimeatal-based flap technique with the TIP procedure in 60 children who underwent primary distal hypospadias repair [13]. Upon completion of that trial the TIP procedure emerged as the preferred technique for distal hypospadias repair at our department. The positive results encouraged us and others to apply this technique successively to proximal and secondary repairs [14 19]. The preparation of the urethral plate is an important step of the TIP procedure: We start with a superficial midline incision incising only the thin mucosa strip from the hypospadiac meatus to the tip of the glans. We then pull the urethral mucosa slightly laterally to widen the plate and to allow for a ventral tubularisation over an 8 Fr stent (we use 10 Fr stents for children of 5 years of age and above). There is no need for skin or preputial flaps. With additional parallel superficial relaxing incisions the width of the original urethral plate can be more than doubled. In 32 boys the width of the urethral plate was measured before and after the additional relaxing incisions: The average width was 4.3 mm (range 2 7 mm) before and 8.2 mm (range 7 13 mm) after the incisions. This technique enables us to transform an elastic narrow 3 5 mm mucosa strip into an 8 10 Fr neourethra in an infant boy. In the last two years we never saw the need to perform an onlay urethroplasty in primary repairs. According to our experience there is rarely a need for a deep incision, unless the shape of the glans is very flat. For the Snodgrass manoeuvre we use a specially rounded knife to perform very fine and superficial parallel longitudinal incisions distally and proximally into the connective tissue underlying the urethral plate. We tubularise the plate starting distally and create a wide elliptical neomeatus before continuing the suture in proximal direction. In order to prevent a meatal stenosis it is important not to carry the suture too far distally when sewing the ventral aspect of the glandular tissue. Ellsworth et al. studied the healing characteristics in animal models. Migration of epithelial cells into the dorsal urethral defect occurred two days after surgery, with complete re-epithelialisation after 5 days. After 21 days there was complete healing of the dorsal incision [22]. Snodgrass et al. observed epithelialisation over

5 718 M. Riccabona et al. / European Urology 44 (2003) connective tissue without fibrosis or dysplastic tissue development in the incision area of virgin urethral plates [20]. These histological findings make the effort of preserving the urethral plate worthwhile even in penoscrotal and scrotal hypospadias repairs with severe chordee. Several reports about the application of the Snodgrass TIP procedure in distal hypospadias repair have been published, but much less has been reported about this technique when used in proximal hypospadias repair. We extended the application of the Snodgrass procedure step by step and are now using it also in penoscrotal and scrotal hypospadias repairs. In cases of 90 degree or other severe chordee we preserve the plate, mobilise the bulbar urethra and corpus spongiosum similar to a urethroplasty in the case of a traumatic stricture and correct the corporal disproportion by dorsal plication. In our experience the urethral plate has never been the cause for a ventral curvature. We no longer see any indication for a staged procedure in a primary repair, irrespective of the level of the hypospadiac meatus. In our group of 52 children with midshaft to scrotal hypospadias we achieved equal functional and cosmetic results. Therefore, the TIP procedure has replaced both the Mathieu and the transverse island onlay technique at our institution. Urethral calibration and urethroscopy are obligatory before all secondary surgery. Secondary TIP procedure was undertaken as described for primary surgery, with the exception of neourethral covering for which either a vascularised scrotal tunica dartos or a tunica albuginea flap was used. In the secondary hypospadias repair group 11 fistulas were coronal and 3 subcoronal with a thin glandular tissue bridge. 26 boys had previously undergone one or more hypospadias procedures including operations with previous midline incision. With an overall complication rate of 12.5%, the percentage in secondary hypospadias procedures was nearly twice as high as in primary surgery (6.9%). This percentage, however, is still lower compared to other reports (Table 3) [14 16,21]. If the urethral plate has been resected in previous operations or if it is severely scarred, we recommend a two-stage repair using lip or buccal mucosa following Bracka s approach [23]. Regular follow-up checks on these patients are mandatory, but according to our experience there is no need for routine neourethral calibration or follow-up endoscopy. 5. Conclusions Tubularised incised plate urethroplasty has indeed revolutionised and considerably simplified hypospadias repair. The TIP procedure provides satisfactory functional as well as excellent cosmetic results in many different cases of distal and proximal primary hypospadias repair. Except for distal glandular forms, it has finally been successfully applied to virtually all forms of single-stage primary hypospadias repair, irrespective of the level of the hypospadiac meatus and the width of the urethral plate. This technique can even be recommended for re-operative hypospadias repair. References [1] Dold H. Rise in prevalence of hypospadias. Lancet 1998;351: [2] Borer JG, Retik AB. Current trends in hypospadias repair. Urol Clin North Am 1999;26: [3] Cooper CS, Snyder HM. Pediatric reconstructive surgery. Curr Opin Urol 2000;10: [4] Thiersch C. On the origin and operative treatment of epispadias. Arch Heilkunde 1869;10:20 3. [5] Duplay S. De l hypospadias perineo-scrotal et de son traitement chirurgical. Arch Gen Med 1874;1: [6] Monfort G, et al. Posterior hypospadias repair: a new technical approach. Mobilisation of the urethral plate and Duplay urethroplasty. Eu Urol 1992;22: [7] Van Horn AC, Kass EJ. Glanduloplasty and in situ tubularisation of the urethral plate: a simple reliable technique for the majority of boys with hypospadias. J Urol 1995;154:1505. [8] Rich MA, et al. Hinging the urethral plate in hypospadia meatoplasty. J Urol 1989;142: [9] Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151: [10] Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair: results of a multicenter experience. J Urol 1996;156: [11] Snodgrass WT. Tubularized incised plate (TIP) hypospadias repair. Urol Clin North Am 2002;29(2): [12] De Filippo RE, Bauer SB. New surgical techniques in pediatric urology. Curr Opin Urol 2001;11: [13] Oswald J, Körner I, Riccabona M. Comparison of the perimeatalbased flap (Mathieu) and the tubularized incised-plate urethroplasty (Snodgrass) in primary distal hypospadias. BJU Int 2000;85: [14] Borer JG, Bauer S, Peters G, Diamond DA, Atala A, Cilento B, et al. Tubularized incised plate urethroplasty: expanded use in primary and repeat surgery for hypospadias. J Urol 2001;165: [15] Snodgrass WT, Lorenzo A. Tubularized incised-plate urethroplasty for hypospadias reoperation. BJU Int 2002;89: [16] Shanberg AM, Sanderson K, Duel B. Re-operative repair using the Snodgrass incised plate urethroplasty. BJU Int 2001;87: [17] Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair for proximal hypospadias. J Urol 1998;159:

6 M. Riccabona et al. / European Urology 44 (2003) [18] Chen SC, Yang SS, Hsieh CH, Chen YT. Tubularized incised plate urethroplasty for proximal hypospadias. BJU Int 2000;86: [19] Luo CC, Lin JN. Repair of hypospadias complications using the tubularized, incised plate urethroplasty. J Pediatr Surg 1999;34: [20] Snodgrass W, Patterson K, Plaire JC, Grady R, Mitchell M. Histology of the urethral plate: implications for hypospadias repair. J Urol 2000;164: [21] Elbakry A. Further experience with the tubularized-incised urethral plate technique for hypospadias repair. BJU Int 2002;89: [22] Ellsworth P, Lopes J, Schned A, Cendron M. Evaluation of the healing characteristics of the dorsal incision and ventral anastomosis in an animal model of tubularized incised plate urethroplasty. BJU Int 2002;89(Suppl 2):74 5. [23] Bracka A. Hypospadias repair: the two stage alternative. BJU Int 1995;76(Suppl 3):31 41.