Find best premium and Free Joomla templates at GetJoomlaTemplatesFree.com

Review of Cases Operated with Snodgrass Technique

H.Gozar¹, V.Gliga², A. Borda², M. Turcu²

¹ Tg. Mures County Emergency Clinical Hospital

² U.M.F. Tg. Mures, Romania

 

 

Correspondence

Horea Gozar
Tg. Mures County Emergency Clinical Hospital
Gheorghe Marinescu, 50, Tg. Mures, Romania

Tel: 0040740070534 

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Aim: To report our experience of using the tubularized incised plate (TIP) urethroplasty.

Material and Methods: The TIP urethroplasty was undertaken in 70 boys (mean age 5.54 years) within the last 2 years. We had 27 small patients (0-3 years), 36 mid age children (4-11 years) and 7 pubertal children (12- 17 years). There was the first operation for 44 children and a redo operation for 26 children. There were 27 cases of distal hypospadias, 33 cases of mid shaft hypospadias and 10 cases of proximal hypospadias. The patients were followed up at 2 weeks, 4 weeks, 3 months, 6 months, 1 year.

Results: Overall complications were encountered in 18.57% of cases. The succesful rate in small children was 92.59%, in mid age children 77.78% and in prepubertal children 57.14%. We had 84.09% of succesful operations as a first operation and 76.92% as a redo operation. Distal and mid shaft hypospadias had similar rate of success (88.88% and 81.81%). Proximal hypospadias had a succesful rate of 60%.

Conclusions:The TIP urethroplasty is a versatile operation for all types of hypospadias. It became the first choice for repairing this malformation. The operation in early ages became our option.

Key words: hypospadias, Snodgrass, urethroplasty

  

Introduction

In 1994, Snodgrass described the tubularized incised plate (TIP) urethroplasty [13]. He proposed a midline incision of the urethral plate, distal to the level of hypospadiac meatus, but continued also proximally, in the shallow urethra. The aim of this incision is to extend the urethral plate and make possible a correct size for a tailored neourethra [13]. Applying this procedure to hypospadias has the advantage of reconstructing the new urethra solely from urethral plate, without additional skin flaps.

Fistula is the most common complication of this technique [9]. To prevent this complication, we use a vascularized flap, put to cover the neourethra [1,2]. In fact, Snodgrass operation is a modification of Duplay operation, but with better results.

At first, TIP operation was described for distal hypospadias, but now, the use of this technique was extended to mid penile and even penoscrotal hypospadias [10]. It is used also in primary and reoperative hypospadias [8,14]. This technique became the most commonly used procedure for this type of malformations [14].  The aim of this report is a retrospectively review of our experience with TIP urethroplasty.

Materials and Methods

From March 2007 to April 2009, we performed 70 operations for hypospadias using the TIP procedure. The operations were performed to all types of hypospadias: distal, mid-shaft and proximal. The patients` ages raged from 10 months to 16 years. The mean age was 5.54 years. We had 27 small children (0-3 years), 36 mid age children (4-11years) and 7 pubertal children (12-17years). The location of the meatus was distal in 27 cases, mid shaft in 33 cases, proximal shaft or penoscrotal in 10 cases. Before operation, 55 patients had a chordee and 15 had not. It was the first operation for 44 children and a reoperation for 26 children. The urethral plate was good for reconstruction in 46 cases and altereted in 24 cases. The foreskin was present in 61 cases, 9 children had circumcision. The meatus was stenotic in 53 cases and large enough in 17 cases. We found 9 children with associated anomalies: 4 with inguinal hernia, 3 with cryptorchidism and 2 with intersex.

Briefly, the technique begins with a longitudinal midline incision of the urethral plate, from the hypospadiac meatus, to the tip of the glans (Snodgrass incision). Then, we make a `U` shape incision, who marks the limits of the urethral plate laterally, circumscribing the hypospadiac meatus. We prepare the lateral flaps for the future neourethra. A circumferential incision at 2 mm proximal to the coronal margin is extended from each lateral branches of `U` incision. Then, we make the degloving (fig. 1) and cut the chordee. The urethral plate is tubularized over a 6, 8 or 10 Fr catheter, with a running subcuticular polyglyconate monofilament 5-0 or 6-0 suture (fig. 2). A vascularized flap is prepared from the foreskin after de-epithelisation (fig. 3). This intermediary layer covers the neourethra (fig. 4). The glans wings are then approximated (fig. 5). We finish the procedure with skin sutures and securisation of the catheter to the glans (figure 6). A compression bandage is put. The averrage time for this operation is about 75 minutes. All patients were followed up at 2 weeks, 4 weeks, 3 months, 6 months, 1 year.

Table 1. Ages of patients

Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
No. 1 13 7 6 5 7 5 4 7 3 4 1 2 2 1 0 2 0

Table 2.  Succesfull operations- groups of ages

Groups Numbers of patients Number of succesfull operations
0-3 years 27 25 (92.59%)
4-11 years 36 28 (77.78%)
12-17 years 7 4 (57.14%)
snodgrass 1 snodgrass 2
 Figure 1. Degloving  Figure 2. Urethroplasty
snodgrass 3 snodgrass 4
Figure 3. Intermediary layer preparation Figure 4. Intermediary layer fixation

Table 3: Succesfull operations after chriteria: first or redo 

type of operation numbers of patients number of succesfull operations
first operation 44 37 (84.09%)
redo operation 26 20 (76.92%)

Table 4: Succesfull operations after the morphological type of hypospadias 

type of hypospadias numbers of patients number of succesfull operations
distal  27 24 (88.88%)
mid shaft  33 27 (81.81%)
proximal  10  6 (60%)
snodgrass 5 snodgrass 6
Figure 5. Glanuloplasty Figure 6. Skin closure

Results

There were 13 complications. Glanular dehiscence developed in one case, one child developed a meatal stenosis and 11 children had fistulae. Each of them required a secondary surgery. The locations of the fistulae were: 4 at coronal level, 4 at former hypospadiac meatus and 3 between the coronal sulcus and the former hypospadiac meatus.

Regarding the ages, in the first group of small children (0-3 years), we had 25 succesful operations (from 27), in the second group of children (4-11 years), we had 28 succesful operations (from 36) and in the third group (12-17 years), we had 4 succesful operations (from 7), (table ll). All the succesful operations were cosmeticaly good. No one had residual chordee.

There were 37 good results for first operations (from 44) and 20 reoperations (from 26) as shown in table lll. We had 3 complicated cases of distal hypospadias (from 27), 6 complicated cases of mid shaft hypospadias (from 33) and 4 complicated cases of proximal hypospadias (from 10). These results are in table lll.

Discussion

Tubularized incised plate urethroplasty provides excellent results in repairing of hypospadias. Before TIP procedure, we used mostly the Thiersch-Duplay procedure or the Mathieu procedure. Snodgrass operation is, in fact a modification of Thiersch-Duplay urethroplasty, but with better results because the tubularization is tension free. The functional and cosmetic results are good. There were one-stage repairs in all cases and this was another advantage. In Thiersch-Duplay operations we used 2-stages or even 3-stages for repairing.

The complication rate was 18.57%. These results are similar with other statistics [3, 5, 11]. At the beginning, our complication rate was higher, now is lower. In groups of ages, we had better results in small children. In pubertal patients we had more complications. After the criteria first or redo operation, we had 84.09% success rate at first operation and 76.92% success at reoperations. This is also similar with other statistics [4,6,7].

Our best results were in distal and mid shaft hypospadias. Also in proximal hypospadias the results were good.

The TIP repair has the advantage of technical simplicity. Every case is an interesting operation on border of pediatric surgery, urology and plastic surgery. It is not a simple urethroplasty, it is a reconstruction of the malformated penis. We have to make a good degloving for a good orthoplasty and to prepare a vascularized tissue, as an intermediary layer between the neourethra and the skin or glans. We harvested tissue from the dorsal hooded prepuce or from ventral dartos as a coverage layer for the tubularized urethra. A catheter was let in every case, for 7-10 days. Periodic neourethral calibrations were performed in 4 cases.

Conclusions

The TIP urethroplasty is a versatile single-stage operation. This technique may be used successfuly for repair all types of hypospadias: distal, mid shaft, proximal; as a first operation or redo operation. We prefer to perform this surgery in children under one and a half years. The aesthetic appearance is good. The function of the penis is also good. Now, we considere this procedure the best technique for repairing of hypospadias. The complication rate is lower than with other operations.

 

 

REFERENCES

1. Amukele SA, Weiser AC, Stock JA,: Results of 265 consecutive proximal hypospadias repairs using the Thiersch-Duplay principle, J Urol, 2004; 172(6Pt1): 2382-2383

2. Bakan V, Yldiz A: Dorsal double-layer dartos flap for preventing fistulae formation in the Snodgrass technique, Urol Int, 2007; 78(3): 241-244

3. Beuke M, Fisch M: Salvage strategies after complications of hypospadias repair, Urologe A, 2007; 46(12): 1670-1675

4. Cakan M, Yalcinkaya F, Demirel F: The midtermsucces rates of tubularized incised plate urethroplasty in reoperative patients with distal or midpenile hypospadis, Pediatr Surg Int, 2005; 21(12): 973-976

5. Elbakry A: Further experience with the tubularized incised urethral plate technique for hypospadias repair, BJU Int, 2002; 89: 291-294

6. Elicevik M, Tireli G, Demirali O: Tubularized incised plate urethroplasty for hypospadias reoperations in 100 patients, Int Urol Nephrol, 2007; 39(3): 823-827

7. El-Kassaby AW, Al-Kandry AM, Elzayat T: Modified tubularized incised plate urethroplasty for hypospadias repair: a long-term results of 764 patients, Urology, 2008; 71(4): 611-615

8. El-Sherbiny MT, Hafez AT, Dawaba MS: Comprehensive analysis of tubularized incised-plate urethroplasty in primary and re-operative hypospadias, BJU Int, 2004; 93: 1057-1061

9. Horowitz M, Salzhauer E: The `learning curve` in hypospadias surgery, BJU Int, 2006; 97(3): 593-596

10. Samuel M, Wilcox DT: Tubularized incised- plate urethroplasty for distal and proximal hypospadias, BJU Int, 2003; 92: 783-785

11. Serrano Durba A, Pacheco Bru JJ, Dominguez Hinarejos C: Hypospadias repair using the Snodgrass technique, Actas Urol Esp, 2007; 31(5): 528-531

12. Singh N, Sharma E, Saraf R: Tubularized incised plate urethroplasty (Snodgrass procedure) for distal penile hypospadias- a single centre experience, Indian J Urol, 2005; 21(2): 109-111

13. Snodgrass WT: Tubularized incised plate urethroplasty for distal hypospadias, J Urol, 1994; 151: 464-465

14. Ziada AM, Morsi H, Aref A: Tubularized incised plate (TIP) in previously operated (redo) hypospadias, J Pediatr Urol, 2006; 2: 409-414