|Year : 2004 | Volume
| Issue : 2 | Page : 15-18
Tubularized incised plate urethroplasty (TIP) for distal and midshaft hypospadias a preliminary experience
G R Sharma
Onkar Nilayam, 3/27 Samarth Nagar, North Sadar Bazar, Behind Civil Hospital, Solapur 413003, Maharashtra
| Abstract|| |
Objective: To describe the tubularized incised plate (TIP) urethroplasty for distal and midshaft hypospadias. To describe certain technical aspects to decrease the incidence of meatal stenosis and urethrocutaneous fistula.
Methods: TIP urethroplasty was undertaken in 35 patients in the last three years. The age ranged from two to 26 years. Nineteen cases were distal penile and 16 were midshaft hypospadias. Five cases had undergone a repair previously. Certain technical points were strictly adhered to during the TIP urethroplasty so as to achieve a normal slit like meatus and to decrease the incidence of meatal stenosis and urethrocutaneous fistula.
Results: The catheter was removed after 10 days. Average follow up was six months. There was complete dehiscence of the repair in one patient. One patient had superficial extravasation of urine. Meatal stenosis was seen in the first two cases. Fistula was seen in three patients. The patients with a successful repair voided with a single straight urinary stream in a forward direction and had a normally situated slit like glanular meatus.
Conclusions: TIP urethroplasty is a versatile, simple operation with good cosmetic results. Certain technical considerations if strictly adhered to help in preventing complications and achieve a satisfactory result.
Keywords: Hypospadias, Urethral plate, dorsal incision, meatus, tubularized incised-plate.
|How to cite this article:|
Sharma G R. Tubularized incised plate urethroplasty (TIP) for distal and midshaft hypospadias a preliminary experience. Indian J Urol 2004;20:15-8
|How to cite this URL:|
Sharma G R. Tubularized incised plate urethroplasty (TIP) for distal and midshaft hypospadias a preliminary experience. Indian J Urol [serial online] 2004 [cited 2013 Jun 20];20:15-8. Available from: http://www.indianjurol.com/text.asp?2004/20/2/15/37161
| Introduction|| |
Since its introduction in 1994 by Snodgrass  , the Tubularized Incised Plate (TIP) urethroplasty has become a very popular repair for hypospadias. Rich et al  first described an incision in the urethral plate to obtain a cosmetically acceptable vertical slit like meatus for the Mathieu repair. This was adopted for the entire length of the urethral plate as a complement to the Thiersch Duplay urethroplasty for distal hypospadias  . The dorsal relaxing incision over the urethral plate results in a neourethra of adequate caliber, with no structuring ,, . Incision of the urethral plate does not seem to compromise the blood supply and reepithelialization occurs without gross scarring due to the rich vascularity of the urethral plate ,
The purpose of the present article is to present my experience with the TIP urethroplasty for distal and midshaft hypospadias. It is also the objective of the article to describe certain technical points to minimize the complications in TIP urethroplasty
| Methods|| |
TIP urethroplasty was undertaken in 35 patients in the period from July 1999 to September 2003. The age of the patient ranged from two years to maximum of 26 years. The age distribution is given in [Table - 1].
Nineteen patients had distal penile and 16 had midshaft hypospadias. Out of the latter group five had failed, repair.
The patients were selected for TIP urethroplasty only if they had a good urethral plate of a reasonable width and had minimal chordee. The repair was done under general anesthesia in children, while in adults it was done under spinal anesthesia.
The TIP repair was performed as previously described by others , . The penis was degloved and the ventral tethering tissues lateral to the corpus spongiosum and urethral plate was excised. A successful orthoplasty was confirmed by artificial erection. Tunica albuginea plication was not required in any of the patients. During degloving of the penis special care was taken to achieve a good distance gap between the hypospadiac meatus and the degloved skin. This helped in covering the site of the original meatus completely and thoroughly with the vascularized pedicle later on.
After division of the urethral plate in the midline, the neourethra was formed by tubularization of the urethral plates using 5/0 vicryl on round body needle. The process of tubularization started proximally from the site of the original meatus and proceeded distally. The following technical aspects were adhered to during the procedure in all patients, except for the first seven cases.
- The urethral stent used was at least two to four Fr. smaller than the size of the neourethra.
- The tubularization of the urethral plate was done only till the level of the midglans and not till the tip of the glans.
- The edges of the neomeatus were sutured to the edges of the glans wings using 5/0 chromic catgut.
- At the completion of the procedure a stitch was taken at the dorsum of the glans to fix the stent and prevent its inadvertent removal.
- A vascularized pedicle of subcutaneous tissue, harvested from the dorsal hooded prepuce was brought ventrally to cover the neourethra. Special care was taken to cover the site of the original meatus completely and thoroughly with the vascularized pedicle. This step was not done in all the five cases repaired in past as the prepuce was not available.
Post operatively antibiotics were given for 10 days. Bladder relaxants, either oxybutynin hydrochloride or tolterodine, were given to all patients for five days. The dressing and the urethral stentwere removed after 10 days.
| Results|| |
All the 35 patients were assessed on the 10 th postoperative day after removal of dressing and the catheter. They were followed up at one, three and six months. Meatus was calibrated at one, three and at six months. The calibration was in accordance with the age of the patients. It varied from 10 Fr in smaller boys to 16 Fr in patients above the age of 15 years. The patients were then asked to follow up at six monthly intervals. The maximum follow up has been three years and the minimum follow up has been three months. The average follow up has been of six months duration.
Early complications were seen in two patients. In one boy aged seven years there was complete dehiscence of the repair. He underwent a repeat TIP urethroplasty after six months with good results. In another boy aged twelve years, who had undergone a repair in the past (three years back - which had failed), there was no fistula or any problem with wound healing after removal of the catheter on the 10 th post operative day. He passed urine satisfactorily initially but after 6 hours developed superficial extravasation of urine. Per urethral catheterization was successful. It was kept for 14 days. After removal of catheter the boy passed urine with a good stream. With a follow up of two and half years he is fine with a normal looking penis and no fistula stricture or meatal stenosis.
The first two cases developed meatal stenosis, which needed correction. All other patients where the technical nuances described above were adhered to did not develop any meatal problems.
Urethrocutaneous fistula was seen in three patients, one in distal penile and two in those with midshaft hypospadias. In all the cases the fistula was at the site of the original hypospadiac meatus. Out of these three patients, two were lost for follow up after three months while one with distal penile hypospadias underwent successful fistula repair, six months after the primary repair. None of the patients with urethrocutaneous fistula had meatal stenosis.
All the patients had a normally situated vertical slit like meatus and voided with a coherent urinary stream.
| Discussion|| |
The goal of hypospadias surgery is a penis that is both functionally and aesthetically normal. This requires a penis that is straight on erection with a vertically oriented slit like meatus at the tip of the plans, thus promoting a single, coherent urinary stream  . Bracka showed that 72% of young adults felt that normal appearance was as important a goal as normal function.  . TIP urethroplasty is associated with minimum complications and achieves satisfactory results with a normal looking penis and meatus ,
The main advantages of the TIP urethroplasty are
- It is technically easy.
- It gives a normal looking vertical slit like meatus.
- As skin flaps are not used for reconstructing the neourethra, it can be done even in those where previous attempts at hypospadias repair had failed , However for a particular type of hypospadias to be suitable for TIP urethroplasty, the presence of a good urethral plate of adequate width and minimal chordee are the two prerequisites.
Absence of a good urethral plate of adequate width and good vascularity is associated with failure. The contraindications to TIP urethroplasty include previous resection of the urethral plate or obvious scarring of the palte  . Thus patients with severe chordee and/or poor urethral plate, where division or excision of the urethral plate is required, are not candidates for the TIP urethroplasty.
A recent trend in hypospadias repair has been to preserve the urethral plate. This is the result of two observations
- Incorporation of plate into the urethral reconstruction may reduce complications , .
- The urethral plate is usually not the cause of ventral curvature and so its resection often does not correct chordee ,
Hence degloving the penis, without division or dissection under the urethral plate corrects the curvature of the penis in most of the cases. In this study this was enough to correct chordee in all the cases. Tunica albuginea plication was not needed in any of the cases.
Metal stenosis is one of the complications seen with the TIP urethroplasty. The incidence has ranged from 0%  to 14%  . Meatal problems can be the cause of unsatisfactory cosmetic appearance and can also cause fistula. In the series by Elbarky, four of the first seven patients had a fistula and it was associated with meatal stenosis in all the cases. He advocated regular urethral calibration in all the patients after the TIP urethroplasty  Lorenzo and Snodgrass disagreed with this and felt that regular calibration was not needed  .
In the present study meatal stenosis was seen in the first two cases (5.7%). But after the first seven cases, certain technical aspects were strictly adhered to; this, I feel, resulted in a normal meatus in all the remaining cases.
For the meatus to be termed as normal it should fulfill the following criteria
- Location atthetipoftheglans.
- Shape vertical slit like.
- No meatal stenosis
- Good stream lineflow of urine
To achieve a normal slit like meatus it is imperative that the tubularization of the urethral plates should end at the level of the midglans and not till the tip of the glans. The appearance of a properly positioned meatus results more from the closure of the glans wings from the corona to the meatus than from tubularizing the neourethra too far distally. Tubularizing the urethral plate too far distally can create obstruction even in the absence of scarring.
In all the patients in this study the edges of the neourethra were sutured to the edges of the glans wings.
This helps in preventing the insinuation of the epithelial edges of the glans wings inside the glans wound. It also achieves primary healing between the two epithelial edges. Also it prevents the edges of the neomeatus from getting buried beneath the glans wings when they are approximated and sutured ventrally. Thus, the suturing of the edges of the neomeatus helps not only in achieving an aesthetically good meatus but also prevents meatal stenosis.
Another technical consideration in this study has been to use a urethral stent, which is smaller than the size of the neourethra. Animal studies have proved that the midline incision through the dorsal aspect of the urethra heals without fibrosis by reepitheliaIization  . The purpose of the stent is to have urinary drainage It does not serve as scaffolding around which epithelial growth occurs. This fact is borne out from the fact that though the stent size used in the series by Warren Snodgrass in 1994 was 6 Fr, the size of the neourethra was greater than 10 Fr in all the patients  . In the series by Steckler and Zaontz there was no high incidence of meatal stenosis or stricture formation despite not using a stent  .
By taking a stitch at the dorsal aspect of the glans the stent was fixed to it to prevent its inadvertent removal. As the small sized stent gets held more dorsally; it also prevents undue pressure on the ventrally approximated glans wings.
Urethrocutaneous fistula formation is another complication, which afflicts repair of hypospadias. TIP urethroplasty is associated with a low fistula rate. Number of series on this repair have described a fistula rate ranging from 0-21% ,,, . In the present study three patients (8.8%) had urethrocutaneous fistula. Out of these one had distal penile while the other two had midshaft hypospadias. One of the key reasons for this low fistulae rate is the coverage of the neourethra with a layer of the vascularized pedicle of subcutaneous tissue harvested from the dorsal prepuce  . In the present study all the fistulae were at the site of the original hypospadiac meatus. None of the patients who had undergone a repair previously (five cases) had a fistula. The urethra around the hypospadiac meatus and for some distance proximal to it is very often thin and poorly vascularized due to paucity of spongiosum over it. Hence in the patients undergoing Onlay Island flap or Transverse Preputial Island flap repair, the recommendation is to slit the meatus till the normal spongiosum  . As no such maneuver is recommended for the TIP urethroplasty, it would be but logical to provide good coverage of the area of the hypospadiac meatus with a vascularized tissue after the tubularization of the urethral plates. The possible reason of the redo cases doing well, despite no coverage by a vascularized pedicle„could be due to the fact that the previous repairs had (probably) slit the meatus to the normal spongiosum and thus the vascularity of the urethra around the hypospadiac meatus was better.
| Conclusion|| |
In conclusion, TIP urethroplasty is a single stage, technically simple operation with good cosmetic results. The author recommends the use of certain technical aspects to decrease the incidence of meatal problems and fistula formation.
| References|| |
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[Table - 1]