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ORIGINAL ARTICLE
Year : 2005  |  Volume : 21  |  Issue : 2  |  Page : 109-111
 

Tubularized incised plate urethroplasty (Snodgross procedure) for distal penile hypospadias - a regional centre experience


1 Division of Pediatric Surgery,Medical College Jammu,Jammu and Kashmir, India
2 Division of Urology,Medical College Jammu,Jammu and Kashmir, India
3 Division of Plastic Surgery,Medical College Jammu,Jammu and Kashmir, India

Correspondence Address:
N Singh
Department of Surgery, Medical College Jammu, H. No-28, Sec-9 Trikuta Nagar, Jammu - 180012,Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.19632

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   Abstract 

Tubularized incised plate (TIP) urethroplasty has rapidly become the procedure of choice for repair of distal penile hypospadias (DPH) at most of the centres throughout the world. Multiple series from major institutions have reported excellent cosmetic and functional results in conjunction with low complication rates. A retrospective review of 52 new cases of DPH where TIP urethroplasty was performed in Medical College Jammu has been analysed. Age range of the patients included in the study varied between 2 and 18 years with majority 47 (97.3%) below 5 years. Ten (19.9%) patients had chordee, which got corrected by degloving of the penis except 3 (5.7%) who required tunica albuginea plication. Neourethra was covered with vascularized pedicled dartos flap from the inner prepuce. Major complications occurred in 7 (13.4%) patients [urethrocutaneous fistula-5 (11.5%) patients, meatal stenosis-1 (1.9%) patient and complete breakdown-1 (1.9%) patient]. There were also minor complications like superficial skin necrosis in 10 (19.2%) patients and haematoma formation in 1 (1.9%) patient. Functional results as judged by the urinary stream, were good in 46 (88.8%) patients. Excellent cosmetic result was seen in 44 (84.6%) patients except 2 (3.8%) who had mild torsion of the shaft. Conclusion: Tubularized incised plate urethroplasty with dartos flap cover is a simple, single stage procedure for DPH with excellent cosmetic and functional results and is associated with minimal complications.


Keywords: Dartos flap; Distal penile hypospadias; Snodgross procedure; Tubularized incised plate urethroplasty


How to cite this article:
Singh N, Sharma E, Saraf R, Goswamy H L. Tubularized incised plate urethroplasty (Snodgross procedure) for distal penile hypospadias - a regional centre experience. Indian J Urol 2005;21:109-11

How to cite this URL:
Singh N, Sharma E, Saraf R, Goswamy H L. Tubularized incised plate urethroplasty (Snodgross procedure) for distal penile hypospadias - a regional centre experience. Indian J Urol [serial online] 2005 [cited 2019 Sep 20];21:109-11. Available from: http://www.indianjurol.com/text.asp?2005/21/2/109/19632



   Introduction Top


Hypospadias is a common condition with an incidence of 3.2 per 1000 live birth[1] and 50% of them being of distal penile type.[2] Principals of repair involve straightening of penis (orthoplasty), creating a slit like meatus at the tip of the penis (urethroplasty and meatoplasty), making the glans conical looking (glanuloplasty) and proper skin coverage. Many operative procedures have been devised for repair of the distal penile hypospadias (DPH) by different authors from time to time, all being time consuming and associated with complications. [3],[4],[5],[6] In 1994, WT Snodgross[7] described tubularized incised plate (TIP) urethroplasty for DPH, which is a simple technical innovation that has revolutionized the surgical management of hypospadias. The high success rate of the procedure is probably as a result of rich vascularity of the muscular urethral plate.[8],[9] Vascularized dartos flap cover of the neourethra decreases the fistula formation rate significantly.[10] The purpose of this study was to present our experience with TIP urethroplasty for DPH in terms of function, cosmesis and complications.


   Materials and methods Top


Tubularized incised plate urethroplasty was undertaken in 52 patients between 2 and 18 years of age over a period of 2 years from January 2002 to December 2004. Majority 47 (97.3%) patients were below 5 years of age. All the cases included in the study were of distal penile variety (coronal-4, subcoronal-16 and distal shaft-32), and underwent repair for the first time. Surgery was performed under general anesthesia with tourniquet application and infiltration with 1 : 1 00 000-adrenaline solution. Operative procedure essentially involved - degloving of the penis with preservation of urethral plate, adequate mobilization of glans wings, midline incision of the urethral plate followed by tubularization and subsequent covering of repair with vascularized dartos flap mobilized from inner prepuce. Urethral tubularization was performed with 6-0 polydiaxanone continuous suture. Infant feeding tube no. 6-8 was used as splint and for urinary diversion. The dressing was removed on fourth postoperative day and wound left exposed. All patients were discharged on tenth postoperative day after catheter removal and called in the follow up clinic 1 week later for urethral calibration. Regular follow up and urethral calibration with an appropriate size feeding tube continued up to 3 months, initially weekly and then fortnightly. Assessment of the patient was done at the time of dressing removal, catheter removal and in the follow up clinic.


   Results Top


The average operating time in our study was 75 min. Three (5.7%) patients required tunica albuginea plication for correction of chordee. The commonest early complication noticed in the series was superficial skin necrosis of some part seen in 10 (19.9%) patients. Most of this occurred in the initial period of the study and all of them settled conservatively and did not have any implication in the final outcome of the repair. One (1.9%) patient had haematoma on second postoperative day for which no intervention was needed and final outcome of the repair was satisfactory. Overall 7 (13.4%) patients had major complications and 6 (10.1%) of them needed a second operation. Small urethrocutaneous fistula developed in 5 (9.6%) patients. The site of fistula was at the hypospadic meatus in 3 (5.7%) and subcoronal in 2 (3.8%) patients. One (1.9%) patient with subcoronal fistula settled after dilatation but 4 (7.6%) needed closure. One (1.9%) patient with severe meatal stenosis required surgical correction. One (1.9%) patient had total disruption of the repair and is waiting for surgery. All the remaining 46 (88.4%) patients with successful repair had good urinary flow and void with a single stream in forward direction. All of them had normally situated slit like meatus and excellent cosmetic appearance except 2 (3.8%) in whom mild torsion of the shaft was noticed.


   Discussion Top


Snodgross TIP urethroplasty basically combines the modification of the previously described techniques of urethral plate incision[11] and tubularization.[12] The main advantages of TIP urethroplasty are- decision making is greatly simplified, incision of the urethral plate enables tubularization of neourethra irrespective of the glanular configuration and previous attempts at repair or circumcision does not limit the procedure.[13] Most of the studies[7],[14],[15],[16],[17] have reported encouraging results in terms of short operative time, overall low complication rate and good functional and cosmetic result. We found the procedure quick to perform and average time taken in our study was 75 min. Moreover, being a single stage procedure patient does not require multiple anesthesia exposure. Our major complication rates were also favourable as compared with the other studies.[7],[15],[17],[18] The urethrocutaneous fistula occurred in 5 (9.6%) patients as compared to 0-7% reported by other studies.[7],[15],[16],[17],[19] The overall re-operation rate in the present series was 10.1%, which is well comparable to other series.[10] Meatal stenosis in one patient could possibly be explained by inadequate mobilization of glans wings and closure under tension. One patient in whom total disruption occurred had ischemia probably due to tight dressing, which was removed on second postoperative day. We do agree that 19.9% incidence of the superficial skin necrosis is quite high in our series and other authors have not encountered this problem. But most of it occurred in the initial period of the study when we were leaving too much redundant skin and once we started excising the extra skin this problem has been overcome. There was no megalourethra or diverticulae in our series as has been reported by other authors,[10] which can be explained by the use of native urethral plate in TIP urethroplasty instead of skin flap or tubes.. All four patients with urethrocutaneous fistula who needed closure had normal looking meatus. The penile appearance was normal in all the boys with successful repair except two, who had mild torsion, which can be attributed to the dartos flap rotation. This problem was overcome by adequate mobilization of the dartos flap. Urethral calibration was carried out in all patients and we recommend it for, prevention of fistula formation and meatal stenosis.[20] The TIP urethroplasty has virtually replaced all other procedures for repair of DPH in our institution and we have started using it for proximal type of hypospadias also.


   Conclusion Top


Tubularized incised plate urethroplasty is a simple, quick, single stage procedure for DPH. It provides excellent functional neourethra, cosmetically normal looking glans and meatus and is associated with few complications. We think combined with dartos flap cover, TIP urethroplasty is the ideal operation for DPH.

 
   References Top

1.Sweet RA, Schrott HG, Kurland R. Study of incidence of hypospadias in Rochester Minnesota 1940-70 and a case control comparison of etiological factors. Mayo clin proc 1974;49:52-8.  Back to cited text no. 1    
2.Duckett JW. Hypospadias In Walsh PC, Retik AB, Vaughan Ed Jr, Wein AJ (eds): Campbells Urology, vol. 2 Philadelphia WB Saunders, 1998;2093-119.  Back to cited text no. 2    
3.Mathieu P. Treatment en un temps de I'hypospadias balanique U juxtabalanique. J chir 1932;39,481-4.  Back to cited text no. 3    
4.King LR. Hypospadias: A one-stage repair without skin graft based on new principle; chordee is sometimes produced by skin alone. J Urol 1970;103:660-2.  Back to cited text no. 4  [PUBMED]  
5.Arap S, Mitre AL, De Goes GM. Modified meatal advancement and glanuloplasty repair of distal hypospadias. J Urol 1984;131:1140-1.  Back to cited text no. 5    
6.Elder JS, Duckett JW, Snyder HM. Only island flap in the repair of mid and distal penile hypospadias without chordee. J Urol 1987; 138:376-9.  Back to cited text no. 6  [PUBMED]  
7.Snodgross W. Tubularized incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5.  Back to cited text no. 7    
8.Baskin LS, Erol A, Ying WL, Cunha GR. Anatomic studies of hypospadias. J Urol 1998;160:1108-15.  Back to cited text no. 8    
9.Erol A, Baskin LS, Li YW, Liu WA, Anotomic studies of urethral plate; why preservation of the urethral plate is important in hypospadias repair. BJU Int 2000;85:728-34.  Back to cited text no. 9    
10.Samuel M, Wilcox DT. Tubularized incised plate urethroplasty for distal and proximal hypospadias. BJU Int 2003;92:783-5.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Rich MA, Keating MA, Snyder HM. "Hinging" the urethral plate in hypospadias meatoplasty. J Urol 1989;142:1551-53.  Back to cited text no. 11    
12.Thiersch C. Uber die Entstehungsweise und operative Behandlung der epispadie Arh Heitkunde 1869;10;20.  Back to cited text no. 12    
13.Borer JG, Bauer SB, Peters CA, Diamond DA, Atala A, Cilento BG. Tubularized incised plate urethroplasty, expanded use in proximal and repeat surgery for hypospadias. J urol 2001;165,581-5.  Back to cited text no. 13    
14.Snodgross WT, Lorenzo A. Tubularized incised plate urethroplasty for proximal hypospadias. BJU Int 2002;89:90-3.  Back to cited text no. 14    
15.Oswald J, Korner I, Riccabona M. Comparison of perimeatal based flap (Methieu) and primary incised plate urethroplasty (Snodgross) in primary distal hypospadias. BJU Int 2000;85;725-27.  Back to cited text no. 15    
16.Sugarman ID, Trevett J, Malene PS. Tubularization of the incised urethral plate (Snodgross procedure) for primary hypospadias surgery. BJU Int 1999;83;88-90.  Back to cited text no. 16    
17.Snodgross W, Koyle M, Manzoni G. Tubularized incised plate hypospadias repair: result of a multicentre experience. J Urol 1996;156,839-41.  Back to cited text no. 17    
18.Dayane M, Tan MO, Gokalp A. Tubularized incised plate urethroplasty for distal and mid penile hypospadias. Eur Urol 2000;37;102-5.  Back to cited text no. 18    
19.Decter RM, Franzoni DF. Distal hypospadias repair by modified Thiersch Duplay technique with or without hinging the urethral plate; a near ideal way to correct distal hypospadias. J Urol 1999;162:1156-8.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Elbarky A, Further experience with tabularized- incised urethral plate technique for hypospadias repair. BJU Int 2002;;89:291-4.  Back to cited text no. 20    



This article has been cited by
1 Comparative Study of Snodgrass and Mathieuís Procedure for Primary Hypospadias Repair
Raashid Hamid,Aejaz A. Baba,Altaf H. Shera
ISRN Urology. 2014; 2014: 1
[Pubmed] | [DOI]



 

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    Results
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