modified tubularized incised plate urethroplasty

7/28/2019 Modified Tubularized Incised Plate Urethroplasty

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Modified tubularized

incised plateurethroplastyShivaji Mane, Jamir Arlikar, Nitin DhendeJournal of Indian Association of Pediatric Surgeons

Year : 2013 | Volume : 18 | Issue : 2 | Page : 62-65


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INTRODUCTION


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Snodgrass urethroplasty

For distal hypospadias : common procedure

Accepted worldwide.

Lowest reported urethral fistula & meatal

stenosis

Gives circumcised penis.


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Modified tubularized incised plate

urethroplasty

Single surgeon personal series from 2004 to

2009

To address the increased demand of preserving

prepuce in India: preputioplasty along withtubularized incised plate urethroplasty.


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Modified tubularized incised plate

urethroplasty

Main technical modifications from original

Snodgrass procedure:

Spongioplasty

Preputioplasty

Dorsal slit when inability to retract prepuce

during surgery


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MATERIALS AND METHODS


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n=100

Distal hypospadias

Hypospadias repair with preputioplasty

Period : 2004 to 2009.

Mean age = 2.7 years (range 1 - 5 yr)


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Selection criteria

Good urethral plate

w/o chordee & torsion (needing complete

degloving)

Only those patients whose parents demanded

preputioplasty considered for the preputioplasty


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SURGICAL TECHNIQUE


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Operative steps

GA & caudal block

catheterized with an infant feeding tube

Tourniquet applied at the base of penis

vertical stay suture on tip of glans withprolene 50.

2 stay sutures : edge of the prepuce - lateralmost part.

Incision: "U"-shaped incision around themeatal opening -> extended on either sidealong the edge of the prepuce


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Ventral dartos fascia dissected

Ventral skin dissectedproximally till normalspongiosum.

urethra-thin and

hypoplastic: cut tillnormal urethra withcorpus spongiosum.

ventral dartos fascia

was dissected onlateral aspect from theBuck's fascia and leftwith the outer skin


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Splayed corpus spongiosum on

either side dissected laterally from

the Buck's fascia to get

easy approximation of

the corpus spongiosum

in the midline.

Keeping close to the

margin of the urethral

plate, glans wings were

raised distally till the

midglans level


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Stay taken on urethral plate ~ 5 mm

proximal to distal end of urethral plate

stretches urethral plateon either side

a marker for distallimit to constructurethral tube.

midline incision istaken on the urethralplate.

Care taken not to

extend this incision upto tip of urethradistally.


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Spongioplasty by avoiding to go

through the edges of urethral plate Corpus spongiosum

approximated in midlinewith 6-0 continuous andlocking sutures

From few mm prox tourethral meatus to 5 mmprox to distal end ofurethral plate

Going through the edges

of urethral plate avoided Last suture at urethral

plate kept long aftertying .


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Glansplasty

In two layers.

Initially distal stitch taken and its knot tied with

left over suture of urethral plate to fix the glans

over the newly created urethral meatus. Second layer :vertical mattress sutures 60 PGA.

Proximally raised glans wings fixed from inside

laterally on either side with corporal body while taking this stitch, ventral dartos fascia put

within the proximal glans.

avoid retraction of glans & bleeding


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Dorsal midline incision

sutured transversely Inner prepuce : subcuticular

continuous

Outer prepuce approximated in

midline

Ventral dartos fascia sutured in

the midline to cover the urethral

repair

Ventral skin sutured in midline

In difficulty in retracting

reconstructed prepuce dorsal

midline vertical skin incision

sutured transversely


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Mean operating time ~ 45 minutes

Compression dressing for 10 d

Dressing and catheter removed on POD 10


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Prepuce after 6 m of

preputioplasty

Preputial edema more 1st

week

Subsides by 2nd week.

Parents advised to retract

the prepuce slowly after

edema subsides Over the period of time

gives appearance of

normal, uncircumcised

prepuce


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RESULTS


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N=100

follow-up period : b/w 3-48 m.(avg 23 months).

Period 2004-2009

Complete dehiscence of prepuce - 1 pt

Fistula 7 pts (sub glanular-1, sub coronal-3,

mid penile-3) who required operative closure.


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Retraction of prepuce not possible in 3 pts in

P.O., required circumcision.

These cases done in earlier period of the

experience, when the dorsal slit incision notmade

Intraoperatively 7 pts required dorsal slit.

In cases of difficulty in retracting prepuce,application of steroid ointment, helped in

retracting the prepuce (n=38)


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Meatal stenosis(n= 1)

Thin urinary stream : meatal calibration with the

infant feeding tube a size less than used for

urethral tubularization(n = 32 ) Pts with dorsal slit after 6 m follow up:

Visualized as a minor cleft dorsally in the

prepuce Glans was well covered by prepuce all over

giving an appearance of normal prepuce

covering glans.


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DISCUSSION


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Snodgrass technique &

modification

Introduced in 1994

Widely done in distal penile hypospadias.

Modifications to address the issue of meatal

stenosis and to have uncircumcised prepuce.

When planning for preputioplasty, patient

selection very important.

Better to avoid preputioplasty for patientshaving significant penile torsion, which needs

degloving and after degloving, difficult to do

preputioplasty

Snodgrass technique with


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Snodgrass technique with

urethroplasty & other

modifications Snodgrass : no increase in incidence of fistulawith preputioplasty.

Meatal stenosis reported where midline urethral

plate incision extended up to the tip of urethralplate.

Nguyen addressed this problem by making the

TIP incision first ,not extended up to the meatus

Jayanti tubularized urethra from distal to

proximal.


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Modified Snodgrass:

preputioplasty

Preputioplasty has been done 3-4 layers

Sutured prepuce in 2 layers with vicryl 6-0.

Difficulty in retracting: dorsal slit & sutured

transversely.

Application of steroid-based ointment in all

patients after 2 weeks to reduce edema and

advocated retraction of prepuce after 3 weeks

Overall preputioplasty gives an uncircumcised

normal looking penis


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Meatal stenosis

Meatal stenosis can be reduced by:

not extending the midline urethral plate incision

up to the distal end of urethral plate,

not going across urethral plate on to the distalglans.

While converting urethral plate into the tube,

stop at least 5 mm proximal from the tip


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Suturing corpus spongiosum alone without

taking edges of urethral plate is enough to roll

urethral plate into a tube.

Fistula rate comparable to series reported bySnodgrass where he used dorsal dartos fascia to

cover urethral repair.


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CONCLUSIONS


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Midline approximation of corpus spongiosum

enough to convert urethral plate into a tube,

without taking actual sutures through the edges

of urethral plate. Modified tubularized incised plate urethroplasty

with preputioplasty effectively gives cosmetically

normal looking penis with low complications.

Long-term follow-up and double blind trial

needed to establish the results.


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REFERENCES


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Foreskin preservation in penile surgery.Snodgrass WT, Koyle MA, Baskin LS, Caldamone AA.

J Urol. 2006 Aug;176(2):711-4

CONCLUSIONS: Foreskin reconstruction in

association with penile surgery safe

low complication in appropriately selected pts.

Higher risk of complications:

more proximal hypospadias

requiring complete degloving of the penile shaft

Of the reconstructions resulting in phimosismost can be salvaged with the application of

steroids


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Results of preputial reconstruction in 77 boys with distal

hypospadias.Klijn AJ, Dik P, de Jong TP.

J Urol. 2001 Apr;165(4):1255-7

CONCLUSIONS:

preputial repair combined with hypospadias

repair may lead to anatomically correct

reconstruction of the penis at the cost of 33%complication rate.


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Preputial reconstruction with distal hypospadias repair.Bhatti AZ, Naveed M, Adeniran A, Ingelfield CJ.

J Pediatr Urol. 2007 Apr;3(2):132-4.

evaluated 35 boys during 1 year

CONCLUSIONS: Preputial repair combined with

hypospadias repair lead to anatomically correct

reconstruction of the penis at the cost of an8.25% complication rate

Eff f h l l h i i b l i d


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Effect of urethral plate characteristics on tubularized

incised plate urethroplasty.Nguyen MT, Snodgrass WT, Zaontz MR.

J Urol. 2004 Mar;171(3):1260-2

CONCLUSIONS: tubularized incised plate

urethroplasty for distal hypospadias repair: low

complication rate regardless of urethral plate

configuration or width potentially applicable in all cases of primary

distal hypospadias

Th difi d S d h di i


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The modified Snodgrass hypospadias repair:

reducing the risk of fistula and meatal stenosis.Jayanthi VR.

J Urol. 2003 Oct;170(4 Pt 2):1603-5

Incorporated several modifications in relatively

narrow urethral plates (


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modified tubularized incised plate urethroplasty

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