Tubularized Incised Plate Urethroplasty: 5 Years Experience

Transcription

1 European Urology European Urology 46 (2004) Tubularized Incised Plate Urethroplasty: 5 Years Experience Mehmet Eliçevik *,Gülay Tireli, Serdar Sander SSK Bakırköy Maternity and Children s Hospital, Clinic of Pediatric Surgery, Istanbul, Turkey Accepted 28 May 2004 Available online 25 June 2004 Abstract Objective: To evaluate the results of tubularized incised plate (TIP) urethroplasty in a series of primary hypospadias repairs. Patients and Method: The medical records of 360 children (Mean age: 4.3 years, range: 2 14 years) with primary hypospadias undergoing TIP urethroplasty repair and treatment of complications were reviewed. A good result is a direct urinary steam through a slit and vertically oriented meatus and mild angled urinary stream through a slightly regressed meatus is a satisfactory result. Results: The sum of good (74%) and satisfactory results (3%) was the overall success rate (77%) which was increased to 95% after a second surgical procedure for the treatment of complications. In 30 patients with single fistula (8%), fistula healed spontaneously in 2 patients and 20 patients had successful fistula closure. Redo TIP urethroplasty (n ¼ 30) was performed for dehiscence (n ¼ 15, 3%), neourethral stricture (n ¼ 3, 1%) and multiple fistula with meatal stenosis (n ¼ 12, 3%). The complication rate after redo TIP urethroplasty is 30%. Twenty-four (7%) patients underwent meatoplasty for meatal stenosis. Conclusion: TIP urethroplasty can be used to repair primary hypospadias. After a learning curve and attention to surgical details, cosmetic and functional outcome become excellent. Redo TIP urethroplasty can be performed in the treatment of complications. # 2004 Elsevier B.V. All rights reserved. Keywords: Hypospadias; Tubularized incised plate; Urethroplasty 1. Introduction * Corresponding author. Present adderss: Ataköy 9-10 Kısım, Karanfil Sokak, A8 Blok A Kapısı D: 3, 34750, Bakirköy, İstanbul, Turkey. Tel. þ address: melicevik@tnn.net (M. Eliçevik). The concept of incising the distal part of urethral plate for meatal configuration in hypospadias surgery was described previously [1]. Snodgrass incised the urethral plate in the midline from the hypospadic meatus to the distal end entirely and primarily tubularized these two well-vascularised strips and covered the neourethra by a dartos patch [2]. The observation of sufficient widening of urethral plate after midline incision for tubularization forms the basis of tubularized incised plate (TIP) urethroplasty repair. TIP urethroplasty is easily performed and has few complications. Cosmetic outcome is excellent and a vertically oriented slit-like meatus is achieved. TIP urethroplasty is first applicable to distal and middle hypospadias repairs but after several recent reports TIP urethroplasty is now being increasingly used to repair proximal hypospadias repairs and for reoperations also [3 15]. Herein we present our experiences with TIP urethroplasty for primary hypospadias repairs. We define the reasons of failures, technical errors encountered during the learning curve and treatment of postoperative complications after TIP urethroplasty. 2. Patients and method 2.1. Patients Among 514 patients with primary hypospadias the medical records of 360 patients undergoing TIP urethroplasty repair by seven pediatric surgeons between 1997 and 2002 were analyzed retro /$ see front matter # 2004 Elsevier B.V. All rights reserved. doi: /j.eururo

2 656 M. Eliçevik et al. / European Urology 46 (2004) spectively. The mean age was 4.3 years (range: 2 14 years). The median age was 4 years. The data in regard to location of meatus, postoperative results and treatment of complications were noted Technique A circumcision incision and degloving of skin is done. The urethral plate is separated from the glans by longitudinal parallel incisions and from the meatus by a U-shaped incision. An artificial erection test is performed and if detected, chordee was corrected by dorsal plication described by Nesbit and TIP urethroplasty was performed. However, if resection of urethral plate for chordee release was mandatory, tubularized preputial island flap repair was performed. The surgical technique of TIP urethroplasty was based on the principles described by Snodgrass [2]. The urethral plate is deeply incised in the midline and tubularization by one layer of continuous 6/0 Polyglactin 910 (Vicryl-R) suture over Fr urethral catheters is done. A well-vascularised subcutaneous tissue flap from the dorsal preputium is used to cover the neourethra as a barrier in all of the patients. The meatus is secured to the glans at the 4, 6 and 8 o clock positions with 7/0 Polyglactin 910 (Vicryl-R) sutures. The coronal margins of glanular wings are approximated by a 6/0 Polyglactin 910 (Vicryl-R) suture. Next the skin edges of glans are closed by mattressed separate 6/0 Polyglactin 910 (Vicryl-R) sutures and the glansplasty is completed. The surgery is performed on two days-stay basis and patients are discharged home after removal of elastic bandage. The size of the urethral stent is 2 Fr smaller than the width of the neourethra and remains indwelling for 7 10 days. A slit and vertically oriented oval meatus and conical glanular configuration with direct urinary stream are the criteria for good results (Fig. 1A). A slightly regressed meatus and/or partial glanular dehiscence with mild angled urinary streams defines satisfactory results (Fig. 1B). The follow-up patients range between 6 months to 5 years. Fischer ki square test was used for statistical analysis. 3.Results Table 1 The complications encountered after TIP urethroplasty Complications Distal (n ¼ 324) Middle (n ¼ 32) Proximal (n ¼ 4) Total (n ¼ 360) Single fistula (8%) Multiple fistula and (3%) meatal stenosis Meatal stenosis (7%) Dehiscence (4%) Neourethral stricture 3 3 (1%) Total complication rate 75 (23%) 9 (28%) 84 (23%) In regard to the learning curve the complication rate was initially higher (35%). Attention to above mentioned points; first to incise the urethral plate deeply in the midline through the epithelium near the underlying corpus cavernousum to the level of the tunica albugenia and to limit the incision to the urethral plate, secondly to put the first stitch of neourethral tube at the middle glanular level and to put only one stitch beyond that level during closure of glanular rings and sewing of meatus at 6 o clock position (Fig. 2A) and finally, to create an oval neomeatus not a circular one (Fig. 2B), decreased the complication rate to 15% in the last 160 patients (Fig. 3). The improvement was statistically significant (p < 0.05). Treatment of complications: 30 patients had a single fistula; fistula healed spontaneously in 2 patients, 20 patients had successful fistula closure (72%) and 8 patients were candidates for re-fistula closure. Together with other 12 patients with multiple fistula who had Excluding 54 patients undergoing MAGPI repair and 40 patients undergoing resection of urethral plate and tubularized preputial island flap repair, TIP urethroplasty (n ¼ 360) comprised 86% of all other primary hypospadias repairs (n ¼ 420). Dorsal plication was performed in 10 patients. The complications encountered after TIP urethroplasty for repair of primary hypospadias were summarized in Table 1. There was a not statistically significant difference between the type of hypospadias and complication rate (p > 0.05). Fig. 1. (A) Anterior view of a good result: A slit and vertically oriented oval meatus with conical glanular configuration. (B) A satisfactory result: A slightly regressed meatus and/or partial glanular dehiscence. Fig. 2. (A) Glanuloplasty: Notice that the first stitch of neourethral tube begins at the middle glanular level and there is only one stitch beyond that level during closure of glanular rings and seeing of meatus at 6 o clock position. (B) Postoperative view after TIP urethroplasty: The meatus is sewn to the glans at 4, 6, 8 o clock and an oval slit like meatus is created.

3 M. Eliçevik et al. / European Urology 46 (2004) by TIP urethroplasty and after a second surgical procedure either a fistula closure, meatoplasty or redo TIP urethroplasty for the treatment of complications. Patients with satisfactory results required no further surgery. 4. Discussion Fig. 3. Decrease of complication rate in relation with learning curve. also meatal stenosis, 15 patients with dehiscence and three patients with neourethral stricture underwent redo TIP urethroplasty (n ¼ 30). During redo TIP urethroplasty the appearance of the previously incised urethral plate was healthy without any obvious scar and the width of the plate was sufficient even for primary tubularization in half of the patients. After redo TIP urethroplasty fistula formation had occurred in 5 patients (16%), 3 patients had meatal stenosis (10%) and last patient had neourethral stricture (3%). The complication rate is higher in redo TIP urethroplasty (30%) than primary repairs (23%). A total number of 39 (11%) patients had an observation or history of weak urinary steam without a fistula at the end of first month. Urethral calibration revealed stenosis of meatus in 24 (7%) patients and stenosis of whole neourethra in 3 (1%) patients. In other 12 (3%) patients there was not stenosis and one course of urethral calibration was sufficient to improve the urinary steam. Patients with meatal stenosis (n ¼ 24) were initially managed by frequent urethral dilatations under general anesthesia for 3 6 times/2 3 weeks. A urethral stent was left for 5 days and daily urethral dilatations were performed by members of family. But finally all of these patients underwent a meatoplasty procedure. Postoperatively there was mild regression of meatus and acceptable angled urinary steams. The overall success rate was 77% and this rate increased to 95% after treatment of complications. Table 2 summarized the rate of good, satisfactory and total success results after primary repair of hypospadias Table 2 The postoperative results after TIP urethroplasty and treatment of complications Results After TIP urethroplasty (%) Good Satisfactory 3 13 Total After treatment of complications (%) Since its first description in 1994, TIP urethroplasty has become a popular technique for repair of primary hypospadias [3 15]. The key step in TIP urethroplasty is the midline incision of urethral plate to widen the urethral plate for tubularization and our data supports this thesis that the urethral plate can be easily widened to create a neourethra greater than Fr regardless of the glans configuration. The length of the neourethra affects the rate of success [15]. In our experience, the difference between the level of hypospadias and complication rate was not statistically significant. Excluding MAGPI repair since it is not generally applicable to all forms of distal hypospadias repairs and had its limited indication depending on surgeons preference, recently we have been performing TIP urethroplasty in all patients with a native urethral plate for repair of primary hypospadias. The only contraindication was a significant chordee requiring resection of urethral plate and in these cases tubularized preputial island flap repair was done. The most encountered complications in the learning curve were a higher rate of meatal stenosis with or without fistula(s) formation, neourethral stricture and dehiscence. Initially we put the first neourethral tube stitch distal to the middle glanular level. This technique error increased the incidence of meatal stenosis. Attention to put not more than one stitch beyond middle glanular level avoids meatal stenosis and fisula [10] and this is our first lesson to learn besides to incise the urethral plate deeply towards the underlying corpus cavernous to prevent stenosis and dehiscence. Thirdly, efforts to create a circular neomeatus resulted in meatal stenosis and the neomeatus should be oval. The reflection of the importance of these above mentioned three problems and solutions was a statistically significant reduction of complication rate from 35% to 15% finally in our series. The published results of 328 patients undergoing TIP urethroplasty for primary hypospadias repair were summarized and the overall complication rate was 5.5% [2 6,8,10]. The reported rate of fistula formation varies between 0% and 10% [2 14]. Meatal stenosis occurred in 3% (0 14%) of 779 patients [2 16]. After all, still the most common problems were fistulas (8%), meatal stenosis and fistulas (3%) and

4 658 M. Eliçevik et al. / European Urology 46 (2004) meatal stenosis (7%) in this series. We think in order to reduce the rate of fistula formation use of Y to I closure of the corpus spongiosum besides a dartos pedicle may be considered. Originally Snodgrass et al. did not sew the glans to the meatus but on their final reviews, they had mentioned that the meatus should be secured to the glans at 5 and 7 o clock to improve cosmetic results [2]. In these study surgeons preference was to secure the meatus to the glans by a 4, 6 and 8 o clock sutures in all of the cases. This added third suture may be the reason of a higher rate of meatal stenosis and may be canceled, but still this point was questionable. Our findings suggest that meatal stenosis after TIP urethroplasty could not be treated by regular urethral dilatations and a meatoplasty procedure is required. The consequences of meatoplasty were regression of the meatus at an acceptable glanular level and angled urinary steam. To our knowledge, including our three cases (1%) only four cases of neourethral stricture have been reported [17,18]. Neourethral stenosis and dehiscence should be interpreted as a failure of surgeons and not TIP urethroplasty technique. There is controversy especially over urethral dilatation [16 19]. Periodic neourethral calibration and urethroscopy revealed that dorsal relaxing incision did not result in stricture [16]. In contrast spontaneous closure of fistula and improvement in uroflowmetry by postoperative regular urethral dilatations was reported and routine urethral calibration was advised [17,19]. Inour point of view, routine urethral calibration is not necessary unless there is an observation or a history of weak urinary stream, as only 11% of our patients required urethral calibration. Stenosis of meatus (7%) and neourethra (1%) was diagnosed. There were only 3% of patients who had weak urinary steam but calibration of urethra revealed no stenosis and further regular urethral dilatations was not required. We also think that in the follow-up of these patients uroflowmetry must be done to detect sub clinical obstruction [18]. Our experiences with TIP urethroplasty provide additional evidence that postoperative complications can be easily managed by simple fistula closure, meatoplasty and redo TIP urethroplasty. Fistula closure and meatoplasty was effective in 72% and 100% patients respectively. Redo TIP urethroplasty was performed in 30 patients for multiple fistula and meatal stenosis, neourethral stricture and complete dehiscence. The complication rate was 30%. Our preference for redo TIP urethroplasty is based on the observation that the previously incised urethral plate appeared normal without any obvious scar after failure of TIP urethroplasty and the diameter of the neourethra was sufficient even for primary tubularization in half of the cases. Additionally no problem was encountered in the secondary midline urethral plate incision and re-tubularization. Redo TIP urethroplasty mainly did not vary significantly from primary repairs except for subcutaneous coverage flap which can be created from lateral based de-epithelialized skin flaps instead of preputium [10,20]. The reported complication rate for redo TIP urethroplasty was 20% [20]. A slit and vertically oriented meatus with conical glanular shape with direct urinary steam is the final good result and is present in 74% of our patients. A slightly regressed meatus and mild angled urinary steam is observed in patients with partial glanular dehiscence and in patients after meatoplasty. These findings are satisfactory and further operation is not considered [3]. A second surgical intervention for the management of complications increased the success rate from 77% to 95%. 5. Conclusion TIP urethroplasty is a versatile technique that can be easily learned and applied. The glanular shape and level of meatus did not affect outcome. The success of the operation depends firstly on an effective dorsal relaxing incision over a healthy urethral plate. Secondly the first stitch of neourethral tube should be at the middle glanular level and to prevent meatal stenosis more than one stitch beyond that point must not be used during the sewing of meatus. Thirdly an oval meatus should be constructed. The cosmetic outcome is excellent. Treatment of complications is simple. Redo TIP urethroplasty can be safely performed after failure of primary repairs. References [1] Rich MA, Keating MA, Synder HM. Hinging the urethral plate in hypospadias meatoplasty. J Urol 1989;142: [2] Snodgrass W. Tubularized incised plate urethroplasty for distal hypospadias. J Urol 1994;151: [3] 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: [4] Ross JH, Kay R. Use of a de-epithelialized local skin flap in hypospadias repairs accomplished by tubularization of the incised urethral plate. Urology 1997;50: [5] Steckler RE, Zaontz MR. Stent free Thiersh Duplay hypospadias repair with the Snodgrass modification. J Urol 1997;158: [6] Retik AB, Borer JG. Primary and reoperative hypospadias repair with the Snodgrass technique. World J Urol 1998;16:

5 M. Eliçevik et al. / European Urology 46 (2004) [7] Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate urethroplasty repair for proximal hypospadias. J Urol 1998;159: [8] Sugarman ID, Trevett J, Malone PS. Tubularization of the incised urethral plate (Snodgrass procedure) for primary hypospadias surgery. BJU Int 1999;83: [9] Decter RM, Franzoni DF. Distal hypospadias repair by the modified Thiersch-Duplay technique with or without hinging the urethral plate: a near ideal way to correct hypospadias. J Urol 1999;162: [10] Snodgrass W. Tubularized incised plate hypospadias repair: indications. Urology 1999;54:6 11. [11] Holland AJ, Smith GH, Cass DT. Clinical review of the Snodgrass hypospadias repair. Aust NZ J Surg 2000;70: [12] Dayanç M, Tan MO, Gokalp A, Yıldırım L, Peker AF. Tubularized incised plate urethroplasty for distal and mid- hypospadias. Eur Urol 2000;37: [13] Borer JG, Bauer SB, Peters CA, Diamond DA, Atala A, Cılento BG, et al. Tubularized incised plate urethroplasty: expanded use in primary and repeat surgery for hypospadias. J Urol 2001;165: [14] Snodgrass W, Lorenzo A. Tubularized incised plate urethroplasty for proximal hypospadias. BJU Int 2002;89:90 3. [15] Riccabono M, Oswald J, Koen M, Beckers G, Schrey A, Lusuardi L. Comprehensive analysis of six years experience in tubularized incised plate urethroplasty and its extended application in primary and secondary hypospadias repair. Eur Urol 2003;44: [16] Snodgrass W. Does tubularized incised plate hypospadias repair create neourethral strictures. J Urol 1999;162: [17] Elbakryl A. Tubularized incised plate urethroplasty: Is regular dilatation necessary for success? BJU Int 1999;84: [18] Lorenzo AJ, Snodgrass WT. Regular dilatation is unnecessary after tubularized-incised plate hypospadias repair. BJU Int 2002;89:94 7. [19] Elbakryl A. Further experience with the tubularized-incised urethral plate technique for hypospadias repair. BJU Int 2002;89: [20] Snodgrass WT, Nguyen MT. Current technique of tubularized incised plate hypospadias repair. Urology 2002;60: Editorial Comment H.M. Snyder III, Philadelphia, PA, USA snyderh@ .chop.edu This five-year experience with tubularized incised plate urethroplasty (Snodgrass repair) is an excellent and frank review of this increasingly popular procedure. The technique is quite simple and it is becoming clear that it is becoming a commonly applied technique. The lessons learned in this experience make worthwhile reading. In my personal practice as originally proposed by Snodgrass [1], I use the incision of the dorsal urethral plate left open for secondary epithelization to facilitate executing a good glans plasty. It had been our hinging of the plate to achieve this that had been the impetus for the development of this Snodgrass technique [1]. For more major hypospadias requiring a substitution urethroplasty of the urethra, I have continued to use and advocate the island onlay technique. If one must harvest a dorsal interpreputial soft tissue flap to cover a Snodgrass repair, it would seem a small step further to transfer the required epithelium of the interprepuce ventrally. The advantage of not having to mobilize the corpus spongiosum tissue is that it is less likely to be damaged and one avoids a dorsal suture line. My personal fistula rate for major hypospadias repair continues to be lower than any of the published rates to date for a Snodgrass repair when applied to the urethra (refer to Cooper s paper [2]). However, it is clear that this repair is here to stay and this paper provides a useful review. References [1] Snodgrass W. Tubularized incised plate urethroplasty for distal hypospadias. J Urol 1994;151: [2] Cooper CS, Noh PH, Snyder III HM. Preservation of urethral plate spongiosum: technique to reduce hypospadias fistulas. Urology 2001; 57:351 4.