Usefulness of tubularized incised plate technique in posterior hypospadias

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1 ORIGINAL ARTICLE Usefulness of tubularized incised plate technique in posterior hypospadias Landa-Juárez S, 1 Huacuz-Herrera LM, 2 Hernández-Aguilar G, 1 Miguel-Gómez RD, 1 Andraca-Dumit R, 3 Meneses- Juárez JH. 4 ABSTRACT RESUMEN Tubularized incised plate (TIP) technique is a method that has been used in distal hypospadias repair. Objective: To report the authors experience with this technique in proximal hypospadias repair. Materials and methods: A retrospective study on patients with proximal hypospadias who underwent correction using the TIP technique over a 5-year period was carried out. Lateral corpus spongiosum tissue was tubularized to the open urethral plate and urethral tube suture was covered by the tunica vaginalis. Results: Only 6 (9.3%) out of 64 patients operated on with this technique presented with complications. Three (4.6%) developed fistula with associated meatal stenosis and 3 (4.6%) developed isolated meatal stenosis. Conclusions: This technique is recommended for the correction of proximal hypospadias in patients with a well-developed urethral plate in whom curvature is not severe. The tubularization of corpus spongiosum tissue stabilizes the urethra even more and the tunica vaginalis cover eliminates the necessity of using foreskin, which could endanger the vascularity of the cutaneous covering and result in fistula formation. La técnica de plato incidido y tubularizado (PIT) se ha practicado en la reparación de los hipospadias distales. Objetivo: Notificar la experiencia de los autores en la aplicación de este método para hipospadias proximales. Material y métodos: Se realizó un estudio retrospectivo de los pacientes con hipospadias proximales sometidos a corrección con la técnica de PIT en un periodo de cinco años. En todos los pacientes se tubularizó el tejido esponjoso lateral al plato uretral abierto y se cubrió la sutura del tubo uretral con túnica vaginal testicular. Resultados: De 64 pacientes operados con esta técnica sólo seis (9.3%) presentaron complicaciones, tres (4.6%) desarrollaron fístula con estenosis meatal y tres (4.6%) estenosis meatal aislada. Conclusiones: Es recomendable la utilización de esta técnica para la corrección de los hipospadias proximales en los pacientes que poseen un plato uretral bien desarrollado y cuya incurvación no sea muy acusada. La tubularización del tejido esponjoso estabiliza aún más a la uretra y la cobertura con túnica vaginal hace innecesario tomar dartos de prepucio, lo cual podría poner en riesgo la vascularidad de la cubierta cutánea y dar lugar a la formación de fístulas. 1 Pediatric Surgeon. Urologic Pediatric Surgery Service, Hospital General CMN La Raza, IMSS. Mexico City. 2 Pediatric Surgery Resident. Urologic Pediatric Surgery Service, Hospital General CMN La Raza, IMSS. Mexico City. 3 Staff Physician, Department of Pedia- trics, Hospital Médica Sur, Mexico City. 4 Urology Service. Hospital Colonia, IMSS. Mexico City. Corresponding author: Dr. Sergio Landa Juárez. Puente de Piedra (Torre 1). Toriello Guerra. México, D.F. Hospital Medica Sur. Telephone: milanda@prodigy.net.mx 206 Rev Mex Urol 2009;69(5):

2 Key words: posterior hypospadias, repair, tubularized incised plate technique, Mexico. Palabras clave: hipospadias posterior, reparación, técnica de plato incidido tubularizado, México. INTRODUCTION The term hypospadias refers to the lack of embryologic development of the urethra in which the meatus can open at any place on the ventral part of the penis up to the perineum. It can present with ventral curvature with a deficiency of skin at the site and redundant dorsal foreskin. It is a common malformation affecting 1 out of every 300 live births and the urethral opening in approximately 20% of cases is at the proximal penis. 1 Hypospadias classification is determined by the location of the meatus once chordee is corrected. The most commonly used is the Barcat classification. 2 Objectives in successful hypospadias repair include straightening of the penis (orthoplasty), functional urethral tube creation (urethroplasty), vertical alignment of the meatus with the conic gland (meatoplasty with glanuloplasty), transposition of the penis (scrotoplasty) and cosmetic cutaneous covering. 1,3,4 Proximal hypospadias correction is complex and laborious techniques using local flaps or grafts from buccal, bladder or cutaneous mucosa have traditionally been employed. Complications arising from these techniques have been reported to range from 30-70%. 3 In the pediatric surgery service of the Centro Médico Nacional La Raza an average of 58 hypospadias procedures are performed annually and 20-25% of them are proximal hypospadias. Local island flaps and grafts have been used in their correction and in the last 5 years tubularized incised plate (TIP) urethroplasty has been employed. This technique was initially introduced in distal hypospadias repair. 5, 6 Thanks to advances made in TIP, it can now be used in medial and proximal hypospadias correction. 7 OBJECTIVE The objective of the present study was to analyze the results of proximal hypospadias repair with the TIP technique that was performed on patients at the pediatric surgery service of the Centro Médico Nacional La Raza between January 2000 and March MATERIALS AND METHODS The case records in the hospital archive of patients presenting with proximal hypospadias that underwent surgical repair with the TIP technique at the pediatric urological surgery service of the Hospital General Centro Médico Nacional La Raza of the IMSS between January 2000 and March 2006 were reviewed. All patients admitted to the hospital with proximal hypospadias diagnosis that had not received prior surgical treatment were included in the study. Cases of proximal hypospadias in which there was welldeveloped urethral plate and in which ventral curvature correction spared the plate were selected. Patients having undergone previous penile surgery, those who presented with curvature greater than 30 or those who required more than 2 medial dorsal corporal plications once the foreskin was degloved from the penis were excluded from the study. Surgery was performed under general anesthesia or caudal block (Image 1). First the urethral plate was marked from the meatal opening to the glanular tubules. The mucosal collar was also marked. Incisions were made over the marked lines and proximal circumferential cut was made 2 mm from the meatus (Image 2). Once the cutaneous covering was degloved from the penis, ventral curvature correction was verified by means of artificial erection (Image 3). Only if curvature persisted, were up to 2 dorsal plications done at the midline with 2 inverted 4-0 nylon sutures where the curvature was greatest (Image 4). An incision was made on the urethral plate at the midline to centrally broaden and tubularize it without tension over a 6-8 F silicon catheter (Image 5). Urethroplasty was performed on 2 planes with 6-0 PDS suture material with running suture on the first plane and separate sutures on the second. The corpus spongiosum remnant was separated from the tunica albuginea at each side of the urethral plate and the remnant was used to add an extra layer to the neourethra as described by Yerkes. 8 The neourethra was then completely covered lengthwise with the tunica vaginalis (Image 6) and glanuloplasty was performed moving the mucosal collar toward the Rev Mex Urol 2009;69(3):

3 Landa-Juárez S et al. Usefulness of tubularized incised plate technique in posterior hypospadias Image 1. Marking of the urethral plate from the meatal opening to the tubules including the mucosal collar Image 4. Persistent curvature requires up to 2 dorsal plications on the midline site of greatest chordee with inverted vascular nylon suture Image 2. Outline of incisions on the marked lines and circumferential proximal cut 2 mm from the meatus Image 5. Tension-free central tubularization over a 6-8 F silicon catheter Image 3. Degloving the cutaneous cover of the penis and verifying ventral curvature correction Image 6. The entire length of the neourethra is covered with tunica vaginalis midline. Finally, the penis was covered with Byars flaps or their variations, forming penile raphe when possible (Images 8 and 9). The penis was dressed 208 Rev Mex Urol 2009;69(5): with gauze and tegaderm that was kept in place for 5-7 days and transurethral catheter was kept in place for days.name, hospital identification number,

4 Image 7. Glanuloplasty bringing the mucosa collar to the midline Image 9. Completion of surgery; transurethral catheter and gauze and tegaderm penile dressing are put in place Mean hospital stay was 5 days. Generally, penile dressing was removed before the patient was released from the hospital and transurethral catheter was removed at a scheduled out-patient consultation. Only one patient required cystostomy due to accidental dislodgement of the transurethral catheter 24 hours after surgery. From the total of 64 patients, 6 presented with complications postoperatively at a mean time of 6 months. Three developed meatal stenosis and fistula that were repaired by urethral dilatation, meatoplasty and fistula closure and the other three developed meatal stenosis alone that was repaired by urethral dilatation. Image 8. Penis covered with Byars flaps or their variants to form the penile raphe age of patient at time of surgery, findings and followup care were registered and complications were evaluated in the out-patient service. RESULTS A total of 64 patients diagnosed with proximal hypospadias underwent corrective surgery with the TIP technique. Patient age ranged from 6 months to 5 years (60 months) with a mean age of 14 months. Ventral curvature presented in 100% of patients, of which 23 cases (36%) required correction by means of medial dorsal plication and the others were corrected simply through foreskin degloving (64%). DISCUSSION Tubularized incised plate (TIP) urethroplasty can be used for proximal hypospadias correction in well-selected cases. They should be cases in which there is sufficient urethral plate for performing tubularization of the neourethra without tension once the relaxing incision has been made. Ventral curvature should initially be corrected by means of cutaneous degloving of the penis and only if there is persistent chordee, should correction be carried out by a maximum of 2 corporal plications at the dorsal midline of the penis. 8 If more than 2 dorsal plication sutures are used to correct chordee the surgeon should be aware of the necessity to cut the urethral plate and correct ventral corpus cavernosum disproportion by means of grafts. In such cases a different technique for correcting urethral deficiency should be chosen. 9 Corpus spongiosum remnant tubularization at each side of the urethral plate provides additional stability Rev Mex Urol 2009;69(3):

5 to the urethroplasty. In addition, when suture lines are covered with testicular tunica vaginalis in proximal hypospadias there is no need to take preputial dartos. The authors feel that subcutaneous foreskin tissue dissection is an aggressive procedure, since the obtained flap must be large enough to cover the entire length of the urethral tube, possibly jeopardizing vascularity of the final cutaneous covering. By using the tunica vaginalis, overlapping sutures between the neourethra and skin are avoided and a well-vascularized foreskin that is able to cover the penis results in adequate fistulafree cicatrization and a better cosmetic appearance. International reports on proximal hypospadias repair refer to complication rates of up to 58% for buccal mucosa, 20% for island flaps and 37% for bladder mucosa tubes. These complications include urethral stricture, fistula, balanitis xerotica obliterans and urethral diverticula. 3,10 Complication percentage in the present study (9.3%) showed a 40% improvement when compared with international studies. In conclusion, many cases of proximal hypospadias can be repaired while at the same time preserving the urethral plate. Severe ventral curvature is the main contraindication for TIP technique because in those cases the urethral plate must be transected in order to straighten the penis. BIBLIOGRAPHY 1. O Neill J, Rowe. Pediatric surgery. Fifth Edition. St Louis Missouri. Mosby Year Book, 1998; p Barcat J: Current concepts of treatment. In: Horton CE, ed. Plastic and reconstructive surgery of the genital area. Boston: Little, Browm & Co, Amukele SA, Stock JA, Hana MK. Management and Outcome of Complex Hypospadias Repairs. J Urol 2005;174(4 Pt 2): Yucel S, Sanli A, Kukul E, et al. Midline dorsal plication to repair recurrent chordee at reoperation for hypospadias surgery complication. J Urol 2006;175(2): Snodgrass W. Tubularized Incised plate urethroplasty for distal hypospadias. J Urol 1994;151(4): Landa JS, Soto GI, Hernández AG, Galicia SR, Clemente RL, Canché DD. Hipospadias con Snodgrass: utilidad del colgajo perimeatal y de tejido fibrograso escrotal o tunica vaginalis para cubrir la neouretra. Rev Mex Urol 2002; 62 (2): Sozubir S, Snodgrass W. A New algorithm for primary hypospadias repair based on TIP urethroplasty. J Pediatr Surg 2003;38(8): Yerkes EB, Adams MC, Miller DA, Pope JC 4th, Rink RC. Use of the distal spongiosum for hypospadias repair. J Urol 2000;163(5): Baskin,LS, Duckett JW. Dorsal tunica albuginea placation for hypospadias curvature. J Urol 1994;151(6): Nuininga JE, DE Gier RP, Verschuren R, Feitz WF. Long-term outcome of diferent types of 1-stage hipospadias repair. J Urol 2005;174(4 Pt 2): Rev Mex Urol 2009;69(5):