Recent technique to correct the most frequent anomaly of male genitalia: hypospadias

1. Distal /Mid-shaft Hypospadias : How we do it
Antonio Marte

2. Tubularized incised plate (TIP)has gained worldwide
acceptance for hypospadias repair due to its
low complication rate,
good cosmetic result
technical simplicity.
Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol.
1994;151(2):464-465
• 2016 Feb;12(1):28.e1-7.
doi: 10.1016/j.jpurol.2015.06.011. Epub 2015 Aug 4.
Proximal Hypospadias: A Persistent Challenge. Single Institution Outcome Analysis of
Three Surgical Techniques Over a 10-year Period
J L Pippi Salle 1, S Sayed 2, A Salle 3, D Bagli 4, W Farhat 5, M Koyle 6, A J Lorenzo 7

3. Goals
 Wide meatus
 Create a functional/homogenous urethra
 Create a normal appearing glans and a slit-like meatus
 Straight penis/Correction of chordee
 Achieve cosmetically acceptable skin coverage

4. T
I
P
Main steps

5. The leading step of TIP: widening of
urethral plate
Before U Plate incision
After

7. Experience
432 primary hypospadias (age range 7Mts-4.4 yrs- Mean
age 2 yrs)
226 Distal Hyp (60,7)
372 TIP
146 Midshaft (37.9)
60 prox/ scrot Hyp.(13,8%)

8. Contraindications to Snodgrass
Veiled urethra/accentuated curvature

9. Technique
 Traces/ tourniquet
Catheter
Degloving
Correction of the curvature (removal of the dysplastic
ventral tissue and / or with the Baskin Tec.
Tubularization (subcuticular Interrupted 7/0 stitches
Second layer if possible
Coverage with dartos fascia
Circumcision

10. Methods
Tubularization of
the neouretra
was performed
by microsurgical
technique using
Maxon 7 and 6/0

11. Why Maxon
Maxon, synthetic suture, monofilament, (copolymer of glycolic acid and
trimethylene carbonate) has a double resorption time compared to
dexon.
Has a higher tensile strength than other resorbable, synthetic sutures
and is easier to handle.
Easy handling and good knot holding.
Maxon sutures have a tensile strength of approximately 75% of the
initial one two weeks after

12. Urethroplasty Coverage
Subcutaneous flap
Dartos fascia
Lateral abnormal spongiosum
Pedicle of island flap
De-epithelialized skin flap
Tunica vaginalis

13. preference in set
up dorsal flap
anatomical
arrangement of
the dorsal
foreskin

14. After the first
experiences we prefer to
use the left portion of
dorsal flap to cover the
neo urethra
anatomical
arrangement of
the dorsal
foreskin

15. Midshaft Hypospadias

16. Snodgrass W, Elmore J. Initial experience with staged
buccal graft (Bracka) hypospadias re-operations. J
Urol. 2004;172:1720–4. [PubMed] [Google Scholar]

17. Drain
we don’t use catheterless technique
• Urethra is oversized
• Always drip stent with double diaper
• Drain with Foley catheter undersized 6 CH

18. Follow up: Uroflowmetry
pz >3 aa. Volitional voiding
Still uncertain value
The more proxymal native meatus /the flatter the flow
Is this a stenosis? : not in our experience
More reliable clinic symptoms
Scarpa MG, Castagnetti M, Berrettini A, Rigamonti W, Musi L. Urinary function after snodgrass repair of distal hypospadias:
Comparison with the mathieu repair. Pediatr Surg Int. 2010;26:519–22.
Marte A, Di Iorio G, De Pasquale M, Cotrufo AM, Di Meglio D. Functional evaluation of tubularized-incised plate repair of
midshaft-proximal hypospadias using uroflowmetry. BJU Int. 2001;87:540–3.

19. Follow up: Uroflowmetry
These results are consistent with previous work showing frequently reduced
Qmax after hypospadias surgery with great potential for improvement at puberty.T
The gradual normalization of flow rates was suggested to result from the
postoperative softening of tissues
J Pediatr Urol. 2016 Aug;12(4):Long-term functional outcomes after penoscrotal hypospadias repair: A
retrospective comparative study of proximal TIP, Onlay, and Duckett.
Hueber PA1, Salgado Diaz M1, Chaussy Y1, Franc-Guimond J1, Barrieras D1, Houle AM2.
Eassa W, Brzezinski A, Capolicchio JP, Jednak R, El-Sherbiny M. How do asymptomatic toilet-trained children void
following tubularized incised-plate hypospadias repair? Can Urol Assoc J. 2012;6:238–42.

20. Results
Good cosmetic appearance pts. 350/372; 94%,
Qmax: urinary flow > the fiftieth percentile, pts. 321/372; 86%
Transient meatal stenosis (just one dilatation) 28 pts ,7.5%
 True stenosis (reoperation) 3 pts ,0.8%
 Fistula 12 pts, 3.2%
Recurvatum 3 pts 0.8%

21. Prox. Hypospadias Two-stage repair
Bracka A. A long-term view of hypospadias. Br J Plast
Surg. 1989;42:251–5. [PubMed] [Google Scholar]

22. Conclusion
Age : the smaller the patient, the better the results
limited incision of the urethral plate without deepening it to the
corpora cavernosa;
The incision /healing of urethral plate in children is quite
different from healing of urethrotomy of adult patients
Oxybutinin plays a pivotal role more than painkillers

23. Conclusion 2
In our experience, TIP remains a versatile, safe and
effective intervention with excellent aesthetic results, but
it cannot be considered the panacea for all cases of
hypospadias.

24. Prof. Barry O’ Donnel (1926-2019)
Three statements I never believed in my life:
•Of course I love you, darling;
•The cheque is in the mail;
•I never had a complication or a fistula after hypospadias
repair!

25. Thanks for the attention