Distal extension of the midline urethral-plate incision in the Snodgrass hypospadias repair: An objective assessment of the functional and cosmetic outcomes

Abstract

ObjectivesTo objectively assess the functional and cosmetic outcomes of a modified tubularised incised-plate (TIP) urethroplasty (Snodgrass) technique, with particular attention to the uroflowmetry study and Hypospadias Objective Scoring Evaluation (HOSE) score.Patients and methodsIn a prospective case-series study, 43 consecutive patients with primary distal hypospadias were evaluated. The modified Snodgrass technique included an extension of the midline relaxing incision of the urethral plate from within the hypospadiac meatus to the very tip of the glans. The neourethra was tubularised starting at the neomeatus and proceeding proximally. The neourethra was covered with either a single or double dartos flap. In toilet-trained boys, at least 3 months after surgery, the flow pattern, maximum (Qmax), and mean urinary flow rate (Qave) were recorded, and the results plotted against a recently published flow-rate nomogram from normal children. The postvoid residual urine volume was measured using ultrasonography. The cosmetic outcome was assessed using the HOSE system.ResultsThe native meatus was coronal in 11 (26%), subcoronal in 23 (53%) and distal penile in nine (21%) of the patients. The median (range) age was 4.2 (0.5–14) years. The neourethra was covered by a single dorsal dartos flap in 25 and a double dartos flap in 18 patients. At a median (range) follow-up of 6 (3–24) months, the uroflowmetry findings in 26 uncomplicated toilet-trained boys with a median (range) age of 5.2 (3.3–14) years showed an abnormal Qmax below the fifth percentile in four (15%), with the Qave above the fifth percentile in all. The flow pattern was bell-shaped in nine boys (35%), interrupted/intermittent in five (19%), slightly flattened in 10 (39%) and a plateau in two (8%). A vertical slit-like meatus located at the distal glans was created in 39 (91%) boys, and at the proximal glans in four (9%). The urinary stream was single and straight in 39 and angled in four patients. A straight erection was observed in 42 (98%) boys. Four patients had preoperative mild penile torsion of <45°, that was corrected by surgery. The mean (SD, range) HOSE score was 15.8 (0.6, 13–16). Two patients had a small, single subcoronal fistula.ConclusionExtending the midline urethral plate-incision in the modified Snodgrass repair to the apical part of the glans can be done safely with a high rate of locating the neomeatus at the glans tip, with no resultant meatal stenosis. The functional and cosmetic results of the procedure are good, but long-term data and comparative studies are required to confirm these results.

Grafted tubularised incised-plate urethroplasty: An objective assessment of outcome with lessons learnt from surgical experience with 263 cases

“…Hypospadias repair should be evaluated both in terms of cosmetic and functional outcomes [19], [20]. Holland et al [19] proposed an objective assessment scoring system (HOSE) designed to reflect the traditional weighting given to a satisfactory functional outcome, e.g.…”

“…As the score can be measured by clinical observation it is simple to use, with good agreement between parents and medically trained assessors. A total HOSE score of 14 has been recommended as an acceptable outcome in the present era of hypospadias repair [19], [20]. Al-Adl et al [20] objectively assessed the functional and cosmetic outcomes in 43 patients undergoing TIP with distal extension of the MIUP without grafting and achieved a HOSE score of ⩾14 in 98% of the patients.…”

“…A total HOSE score of 14 has been recommended as an acceptable outcome in the present era of hypospadias repair [19], [20]. Al-Adl et al [20] objectively assessed the functional and cosmetic outcomes in 43 patients undergoing TIP with distal extension of the MIUP without grafting and achieved a HOSE score of ⩾14 in 98% of the patients. In the present study, a functional and cosmetic outcome based on meatal shape, location, penile angulation, UCF and urine steam as per the HOSE score showed that a score of ⩾14 was achieved in 96% of patients, thus suggesting that G-TIP is associated with a good overall objective outcome.…”

Prospective Randomized Comparison of Distal Extension of Midline Urethral plate Incision and Standard Tubularized Incised Plate Urethroplasty – Do Anatomical Penile Measurements Influence the Outcomes?

“…In brief, first measurements of the UP width and length, and maximal transverse glans diameter (TGD max ) were taken (Figure 1, a, b). Adopting the previously described e-TIP technique [4,5], starting from within the hypospadiac meatus and extended up to the apical part of the glans tip, the UP vertical midline incision was made and tubularization initiated from the distal end ensuring adequate diameter of the future neomeatus using a 7/0 polyglactin suture ( Figure 1 c-e). This technique enabled more distal sewing of the glans and more distal location of the neomeatus to the very tip of the glans.…”

“…In the standard TIP (s-TIP) by Snodgrass, the urethral plate (UP) incision shouldn't extend to the apical part of the glans for fear of meatal stenosis. Therefore, the meatus won't reach the glans tip [3].To improve the cosmetic outcome and bring the meatus at the tip of the penis mimicking the normal position, distal extension of the urethral plate midline incision was described with promising early results regarding the cosmetic and functional outcomes [4]. In the present study, we objectively compared functional and cosmetic outcomes between the extended tabularized incised plate (e-TIP) and standard TIP (s-TIP) techniques and assessed the impact of preoperative penile biometrics on these outcomes.…”