Combined Use of Mathieu and Incised Plate Technique for Repair of Distal Hypospadias

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1 Original Article Annals of Pediatric Surgery Vol 5, No 2, April 2009, PP Combined Use of Mathieu and Incised Plate Technique for Repair of Distal Hypospadias Hisahm Fayad Aly Pediatric Surgery Unit, Tanta University, Tanta, Egypt Purpose: Both perimeatal-based flap (Mathieu technique) as well as tubularized incised plate (Snodgrass technique) have been used successfully in the repair of distal hypospadias. However, some complications were reported following each technique. This study was undertaken to evaluate the results of combined use of Mathieu and incised plate technique for repair of distal penile hypospadias Materials & Methods: twenty two boys with distal penile hypospadias were operated by using perimeatal-based flap (Mathieu technique) combined with a deep urethral plate incision ( the key step of Snodgrass techniques). Each patient was evaluated as regard to age, position of the native urethral opening, presence and degrees of associated chordee, operative details, postoperative results. All patients were followed up at least 6 months after surgery. Results: The patient's ages ranged from 6 to 30 months. Two patients developed postoperative meatal stenosis that was treated successfully by simple dilatation after a follow up period of 6-18 months. Urethrocutaneous fistula developed in 2 patients, one healed spontaneously, the other required repair after 6 months from the initial repair. None of the patients developed urethral stenosis, the configuration and position of the new meatus was excellent in all cases. Conclusion: Combining Mathieu procedure with incised plate technique is a promising combination to achieve a natural looking meatus and to reduce the rate of meatal related complications. The rate of complication is acceptable and the cosmetic outcome is excellent Index Word: Hypospadias, Mathieu, tubularized incised plate, complications. M INTRODUCTION any surgical techniques have been reported for the repair of distal hypospadias aiming to maximize the cosmetic results and the functional outcomes 1-2 Mathieu procedure is one of these popular techniques. It is based on preparation of a perimeatal-based flap to construct the urethra. The flap usually creates a horizontal and round meatus, which is cosmetically less acceptable than a normal vertical slit-like. 3-4 Tubularized incised plate (TIP) urethroplasty was first described in 1994 for correction of distal hypospadias. 5 This procedure lead to good functional and cosmetic results that is superior to many other techniques. The advantage of this procedure is that it provides a mobile plate to form a neourethra with a vertical slit-like meatus. 6, 7 On the other hand; some authors reported as high as 12 to 33% incidence of meatal stenosis and or urethrocutaneous fistula after TIP technique Correspondence to: Hisham Fayad M.D, Department of Pediatric Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt

2 The purpose of this study was to study the initial results of a simple modified technique for urethroplasty of distal hypospadias by combining Mathieu technique and incised plate to achieve the best cosmetic and functional results. PATIENTS AND METHODS During the period from 2006 to 2009, 22 boys (age ranges from 6 to 30 months) with subcoronal and distal penile hypospadias were enrolled into this study. All of them were primary cases. Patients with severe chordee, those with previous urethroplasty, or mega meatus were excluded from this study. All patients underwent repair with Mathieu technique with incising the urethral plate. The postoperative results and complications were studied and analyzed Surgical technique Following standard preparation and draping of the operative field, a traction stay suture was inserted at the glans. The distance between the site of native meatus and the tip of the glans was measured. A U- shaped perimeatal-based skin flap was created. The width of the distal end of the flap was made narrower than the base. The two lateral incisions distal to the native urethral opening were made less wide than in conventional Mathieu procedure especially at the glanular part. A midline incision was applied to the urethral plate from the native urethral meatus to the glans tip, involving the epithelial and subepithelial layers. Then, urethroplasty was completed by onlay of the perimeatal-based skin flap over an 8F urethral catheter using polyglycolic acid 6-0 suture in a running subcuticular manner. The neourethra was covered by an inner preputial layer that had been dissected from the prepuce and rotated ventrally. Then the glanular wings were closed symmetrically over the neourethra with 6-0 polyglycolic acid suture in two layers, and the penile shaft was covered by the available penile skin. (Figures 1-6( Dressing was applied, and patients received antibiotics until the stent was removed. The patients were discharged with oral antibiotics at the same day. The dressing was removed 4 days after surgery, and the urethral catheter was kept in place for 4 to 7 days. All patients were assessed 5 days after urethral catheter removal and every 1 week for 3 weeks, then every 3 months for one year. On follow-up evaluation, parents were asked about the quality of urine stream, its caliber, and the presence of any voiding difficulty. Urethral calibration was applied to those complaining of such symptoms. RESULTS Operative time ranged from 50 to 80 minutes. All patients were discharged the same day. The follow up period ranged from 6-18 months. The postoperative period was uneventful; for all patients. Urethrocutaneous fistula developed in 2 patients, one of them closed spontaneously, the other required repair 6 months after the initial repair. None of the patients developed urethral stenosis, the configuration and position of the neomeatus was excellent in all cases Annals of Pediatric Surgery 142

3 Fig 1. Distal penile hypospadias Fig 2. Creation of the perimeatal-based flap and the deep plate incision Fig 3. Urethroplasty Fig 4. Completed urethroplasty Fig 5. Glanuloplasty, and closure of penile incision Fig 6. Immediate postoperative lateral view 143 Vol 5, No 2, April 2009

4 DISCUSSION Hypospadias is a common anomaly for which many surgical procedures have been described. Although distal hypospadias is a mild degree in the spectrum of hypospadias, still It is usually hard for any patient especially adults to accept an abnormal shaped ectopic meatus. 11 In 1932 Mathieu first described his technique for reconstruction of distal hypospadias using perimeatal-based penile skin flap. Since then, it has remained one of the most reliable procedures for repair of those cases. The complication rate of Mathieu procedure is variable in different series ranging from 4 % to 15%.12 However, One of the most common drawbacks of this procedure is malshaped neomeatus. 2 Boddy and Samuel13 proposed a technique called MAVIS (Mathieu and V Incision Sutures) to achieve a natural slit like meatus in Mathieu urethroplasty. They incorporated the removal of a V from the apical part of the flap and suturing the V handles to the glans but this technique is difficult. 12 In 1994, a new method for distal hypospadias repair was described by Snodgrass in which tubularization of the urethral plate without skin flaps was facilitated by midline plate incision TIP urethroplasty has gained widespread acceptance for urethroplasty of both distal and proximal hypospadias. The deep plate incision is a crucial maneuver, allowing optimal rotation of the glanular wings with the result of tension-free glanuloplasty. The technique is simple and provides good cosmetic results. The technique simplified decision making in distal hypospadias surgery because the operation was successful regardless of various meatal and urethral plate configurations encountered. 12 Some concerns have been always raised regarding meatal and neourethral complications (ie, meatal stenosis and fistula formation) and the need for regular urethral dilation after TIP procedure; these complications would be potentially more prominent in patients with a flat and narrow urethral plate. 14,15 In the current study, the incised urethral plate step was added to Mathieu techniques to facilitate glanuloplasty. Few other modifications were added to the Mathieu technique including less lateral position of the incision at the glans as the glanular part of the urethra is formed by both the perimeatal flap as well as the incision of the plate, this will facilitate closure of the glanular wings, and eliminate the incidence of glanular dehiscence. The current modification maximizes the functional and aesethic results by adding the TIP principles to the standard Mathieu procedure appear to be a helpful measure to reshape the urethral meatus in a slit pyramidal shape and give a better cosmetic result. 16 On the other hand, it seems to decrease the incidence of meatal stenosis and fistula formation. 12 CONCLUSION Combining Mathieu with incised urethral plate procedures could reduce the incidence of fistula and meatal stenosis which is sometimes associated with TIP procedure and improve the cosmetic results of Mathieu procedure. The technique is quite feasible and promising alternative approach to urethroplasty of distal primary hypospadias. REFERENCES. ١ Vallasciani S, Spagnoli A, Borsellino A, et al. Simplifying the surgical approach to glanular and coronal hypospadias: Longitudinal urethral incision and glanuloplasty. J Pediatr Urology 3: , ٢ Samuel M, Capps S, and Worthy A. Distal hypospadias: which repair? BJU Int 90: 88-91, ٣ Oswald J, Korner I, and Riccabona M. Comparison of the perimeatal-based flap (Mathieu) and the tubularized incised-plate urethroplasty (Snodgrass) in primary distal hypospadias. BJU Int 85: , ٤. Yesildag E, Tekant G, Sarimurat N, et al. Do patch procedures prevent complications of the Mathieu technique? J Urol 171: , Annals of Pediatric Surgery 144

5 . ٥ Snodgrass W: Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 151: , ٦ Snodgrass W, Koyle M, Manzoni G et al. Tubularized incised plate repair: results of a multicenter experience. J Urol 156: , ٧ Kiss A, Nyirady P, Pirot L, et al. Combined use of perimeatal-based flap urethroplasty (Mathieu) with midline incision or urethral plate in hypospadias repair. Eur J Pediatr Surg 13: , ٨ Chen SC, Yang SSD, Hsieh CH, et al. Tubularized incised plate urethroplasty for proximal hypospadias. BJU Int 86: , ٩ Elbakry A. Further experience with the tubularized-incised urethral plate technique for hypospadias repair. BJU Int 89: , ١٠ Marte A, de Iorio G, de Pasquale M, et al. Functional evaluation of tubularized-incised plate repair of midshaftproximal hypospadias using uroflowmetry. BJU Int 87: , ١١ Mor Y, Ramon J, Jonas P. Is only meatoplasty a legitimate surgical solution for extreme distal hypospadias? A long term follow up after adolescence. BJU Int 85: , ١٢.Aminsharifi A, Taddayun A, Assadolahpoor A, et al. Combined Use of Mathieu Procedure with Plate Incision for Hypospadias Repair: A Randomized Clinical Trial J Urology 72:305-8, ١٣ Boddy S, and Samuel M: A natural glanular meatus after Mathieu and a V incision sutured : MAVIS. BJU Int 86: , ١٤ Snodgrass WT, Koyle M, Manzoni G, et al. Tubularized, incised plate hypospadias repair: Results of a multicenter experience. J Urol 156: , 1996-١٥Sozubir S, Snodgrass W. A New Algorithm for Primary Hypospadias Repair Based On Tip Urethroplasty. J Pediatr Surg, 38: , 2003 ١٦ - Ververidis M, Dickson AP, Gough DC. : An objective assessment of the results of hypospadias surgery. BJU Int. 96: 135-9, Vol 5, No 2, April 2009