Distal hypospadias repair with meatal-based flaps on an outpatient basis

Mathieu and Barcat repair with a V incision sutured meatoplasty for secondary hypospadias surgery

AIM

Today single-stage methods are more frequently selected for hypospadias repair than multistaged methods, but complications cannot always be avoided. We employed two kinds of meatal based flip-flap urethroplasty procedures for those with an unsuccessful primary hypospadias repair.

PATIENTS AND METHODS

From 1997 to 2005, a meatal based flip-flap urethroplasty was performed as a secondary hypospadias surgery on 17 patients. Basically we attempted the Mathieu repair, but when the wings of the glans were not generously widened and the urethral groove was not sufficiently deep we applied the Barcat procedure. While 11 patients were repaired with the Mathieu technique, six patients underwent the Barcat repair. The V incision sutured meatoplasty was added to obtain a natural ventral slit-like meatus.

RESULTS

Ten of the 11 patients who underwent the Mathieu repair had a good outcome, but one patient developed a urethrocutaneous fistula. None of the six patients repaired with the Barcat procedure encountered postoperative complications. Cosmetically, a vertical slit was constructed near the normal neomeatus with the Mathieu and V incision sutured (MAVIS) meatoplasty and the Barcat and V incision sutured (BAVIS) meatoplasty.

CONCLUSIONS

The Mathieu or the Barcat meatal based flip-flap urethroplasty procedure is feasible as a salvage surgery for those with relatively short urethral defects and adequate mobile ventral skin if an exact procedure is selected. Excellent cosmetic results could be obtained by adding the technique of V incision sutured meatoplasty.

Distal hypospadias: which repair?

OBJECTIVE

To compare the function, complications and cosmesis after a modified Thiersch-Duplay and Mathieu unstented urethroplasty.

PATIENTS AND METHODS

Over a 5-year period 381 consecutive patients (not randomized) with distal hypospadias were evaluated. A modified Thiersch-Duplay with dorsal incised urethral plate tubularization (group A) was undertaken in 170 (45%) and a parameatal based flip-flap Mathieu hypospadias repair (group B) in 211 (55%). No urinary diversion or stent was used in any of the 381 patients.

RESULTS

In both groups the mean (sd) follow-up was 3.1 (1.4) years. All 381 patients voided spontaneously after surgery and none developed urinary retention needing catheterization. In groups A and B, respectively, the overall late complications were 12 (7.1%) and 32 (15.2%) (P=0.001), with urethrocutaneous fistula in six (3.5%) and 26 (12.3%; P=0.001); secondary surgery for fistula repair was successful in all boys in A and 89% in B. The glanular meatus was a vertical slit in all in group A and 86% in B (P=0.02). In both groups, 71% of the children who are now toilet-trained and standing to void have a good calibre, single and straight urinary stream in a forward direction.

CONCLUSIONS

Stenting or urinary diversion is unnecessary after distal hypospadias surgery. The functional results were good in those standing to void. A more natural vertical slit-like glanular meatus was easily created using the modified Thiersch-Duplay urethroplasty, with a lower fistula rate.

Primary and salvage urethroplasty using Mathieu meatal-based flip-flap technique for distal hypospadias

BACKGROUND

Numerous surgical procedures have been attempted for correction of distal hypospadias. The Mathieu procedure was employed in this study for secondary cases as well as primary cases.

METHODS

The length of the skin flap is determined by measuring the distance from the meatus to the glans tip and then the ventral meatal-based skin flap is incised. The proximal skin flap is flipped and anastomosed to the distal urethral plate. Additionally, subcutaneous tissue of the flipped flap is sutured to cover the original suture lines completely.

RESULTS

The Mathieu urethroplasty was successful in one stage in 13 of the 16 primary repair cases (81%). Twelve of the 13 (92%) who underwent a secondary Mathieu procedure were successfully repaired with no problems. An overall success rate of 86% was achieved at the first operation for both primary and secondary cases. In the remaining 14% of the cases, success was achieved with only one additional procedure.

CONCLUSIONS

The Mathieu flip-flap procedure is feasible for relatively short urethral defects if the ventral penile skin demonstrates adequate mobility and there is no chordee. Even in patients who require revisional hypospadias surgery, the Mathieu procedure can give excellent functional and cosmetic results.

Comparison of the perimeatal-based flap (Mathieu) and the tubularized incised-plate urethroplasty (Snodgrass) in primary distal hypospadias

OBJECTIVES

To determine whether the perimeatal-based flap technique or the tubularized incised-plate repair is the more appropriate treatment for distal hypospadias in terms of fistula rate, cosmesis of the meatus and operative duration.

PATIENTS AND METHODS

Between July 1997 and August 1998, 60 children (none of whom had previously undergone a procedure for hypospadias) underwent primary distal hypospadias repair in a prospective randomized trial. Thirty patients were allocated to undergo a Mathieu repair (mean age 24.9 months, range 9-72) and 30 a Snodgrass procedure (mean age 23.1 months, range 7-19). The mean follow-up was 15.4 months.

RESULTS

The mean duration of surgery was significantly lower for the Snodgrass procedure than for the Mathieu repair (75 vs 115 min, P < 0.05). Three children undergoing a Mathieu repair had complications (two a urethrocutaneous fistula and one a meatal stenosis), compared with only one in the Snodgrass group (glanular dehiscence). The resultant meatus was slit-like in all patients undergoing the Snodgrass repair whereas those with a Mathieu repair had a rounded and horizontal meatus.

CONCLUSION

The overall complication rate was lower and the surgery significantly quicker with the Snodgrass urethroplasty, which also had a better cosmetic outcome. The Snodgrass technique is recommended as a primary treatment for distal hypospadias.

Hypospadias

The incidence of hypospadias is increasing. Decreased androgen sensitivity, 5alpha-reductase deficiency and chromosomal abnormalities are causes of the disease. Nonirritant suture material, coverage of the urethral reconstruction by additional tissue and perioperative care positively influence the outcome. Complication rates after repair of distal hypospadias are low. For severe hypospadias staged procedures provide good results. Buccal mucosa is promising for initial repair and repeat cases. Psychosocial function in patients with severe hypospadias is normal.