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 Table of Contents  
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 339-343

Outcomes of mid-penile hypospadias repair using two different techniques

1 Department of Pediatric Surgery, Al-Azhar University, Cairo, Egypt
2 Department of Urology, Al-Azhar University, Cairo, Egypt
3 Pediatric Surgery Unit, South Valley University, Qena, Egypt
4 Pediatric Surgery Unit, Al-Azhar University of Assuit, Egypt

Date of Submission22-Jan-2019
Date of Decision02-Jun-2019
Date of Acceptance03-Nov-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Abdelaziz Yehya
Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, 11884
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_9_19

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Introduction Several techniques have been reported for mid-penile hypospadias repair, including Snodgrass tubularized incised plate (TIP) and onlay island flap (OIF) procedures, which are two popular procedures.
Aim of the work To compare the outcomes and complication rates for both TIP and OIF techniques.
Patients and methods A prospective randomized study was conducted on 140 boys (age range, 1–6 years) with primary mid-penile hypospadias who underwent repair from June 2011 to December 2016 at our university hospitals. The patients were prospectively randomly divided into two equal groups: group A (n=70), underwent Snodgrass TIP urethroplasty, and group B (n=70), underwent OIF. Inclusion criteria only males with fresh mid penile hypospadias without ventral chordee from 1 to 6years old. Exclusion criteria were recurrent cases, presence of ventral chordee, parental refusal or children more than 6years of age. Outcomes were assessed in terms of success rates, operative time complication rates, and cosmetic appearance during follow-up. All children were subjected to full history taking, thorough clinical examination, and routine laboratory investigations (CBC, BT, CT, FBS, urinalysis, liver and renal profile), results were compiled and compared statistically.
Results There were statistically significant differences between the two techniques regarding success rate, operative time incidence of complications and cosmetic results.
Conclusion Both techniques are reliable and feasible for treatment of mid-penile hypospadias, but there was a statistically significant difference regarding operative time, complications, and cosmetic outcome with TIP procedure. So, the authors preferred it if suitable urethral plate is present.

Keywords: mid-penile hypospadias, onlay flap, tubularized incised plate urethroplasty

How to cite this article:
Yehya A, Akl M, Abd-Alrazek M, ElSotohi I, Negm M, Aziz MA, Gamaan I, Othman A. Outcomes of mid-penile hypospadias repair using two different techniques. Al-Azhar Assiut Med J 2019;17:339-43

How to cite this URL:
Yehya A, Akl M, Abd-Alrazek M, ElSotohi I, Negm M, Aziz MA, Gamaan I, Othman A. Outcomes of mid-penile hypospadias repair using two different techniques. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Aug 10];17:339-43. Available from: http://www.azmj.eg.net/text.asp?2019/17/4/339/278403

  Introduction Top

Hypospadias was reported as one of the commonest congenital anomalies that had an incidence of one in every 150–250 male births [1]. The tubularization of the urethral plate facilitated by midline plate incision for hypospadias repair was described by Snodgrass [2]. In 1987, Duckett introduced onlay island flap (OIF) for hypospadias repair [3]. Many factors control the success rate of hypospadias repair, which include patients’ demographic and clinical data, such as type of hypospadias, age of the patient, chordee, and urethral plate width, and factors related to surgery, including technique of surgery, use of magnification, type of sutures, uses of intermediate layer between urethroplasty and skin, type and period of catheterization, and type of dressing [4],[5],[6]. The aim of this study was to compare the outcomes of both tubularized incised plate (TIP) urethroplasty and OIF techniques.

  Patients and methods Top

A prospective study was conducted on 140 patients, with age ranging from 1 to 6 years, who were admitted for surgical repair from June 2011 to December 2016 at our hospitals. Approval of our institutional ethical committee was obtained for the study, and written consents were obtained from all patients to be included in this study. Patients were randomly divided into two equal groups: group A (N=70), which underwent Snodgrass TIP urethroplasty, and group B (N=70), which underwent OIF. All had comparable mid-penile hypospadias without any ventral chordee or bending. Inclusion criteria: males with fresh mid penile hypospadias without ventral chordee from 1 to 6years old and completing the follow up for at least the first 6months postoperatively. Exclusion criteria: were recurrent cases, presence of ventral chordee, parental refusal or children more than 6years of age and patients lost to follow up the first 6months postoperatively.

Surgical techniques

TIP procedure was done according to the technique described by Snodgrass [2]. Preoperative intravenous antibiotic (amoxicillin–clavulanic acid) was administered routinely in all patients with induction of general anesthesia, and caudal analgesia in all patients to decrease the postoperative pain. U-shaped incision extended along the edges of the urethral plate to healthy skin 2 mm proximal to the meatus and then de-gloving of the penile shaft was done, followed by excising of tethering tissue lateral to the urethral plate. An artificial erection was performed in all cases to ensure straight penis to detect any residual chordee. The flaps were mobilized for a tension-free repair. Then an incision in urethral plate was added from native meatus up to glans, and a tube was made of local flaps created of urethral plate over 6–12-Fr nelaton catheter. TIP urethroplasty was done with subcuticular vicryl 6/0 sutures in two layers. The glandular wings were dissected laterally and re-approximated in the midline with two layers. Neo-urethra was then covered with a vascularized dartos flap harvested either from subcutaneous tissue of dorsal preputial skin or the penile shaft, and ventral skin closure was achieved by Byars’ flaps in all cases ([Figure 1]).
Figure 1 TIP technique with Snodgrass modification: diagram, intraoperative photographs for main steps. TIP, tubularized incised plate.

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OIF repair was described by Duckett [3], in which after performing the basic steps as in TIP, a flap of appropriate width and length was then made on the dorsal inner preputial skin and rotated on ventral side. The flap was then stitched with the urethral plate over 6–10-Fr nelaton catheter with a running inverting stitch of vicryl 6/0 sutures in all layers. Glanuloplasty and ventral skin closure was done the same way as TIP. All operations were done by the first four authors with the same perioperative and operative principles for hypospadias repair ([Figure 2]).
Figure 2 Onlay island flap: diagram of main steps intraoperatively.

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The phallus was placed between two gauze pieces and placed over anterior abdominal wall with compression tapes applied over gauze used, which was removed after 7 days postoperatively unless indicated. Postoperative intravenous antibiotic in the form of amoxicillin–clavulanic acid injections for 1 week was used.


The wounds were examined at the time of catheter removal 7th postoperative day, and then assessed at out-patients clinic every week for 1 month then every month for the first 6 months then every 6 months, then yearly follow-up visit were planned with mean follow-up of 23.5±8 months (15–44 months) and 26.4±7 months (18–48 months) for TIP group and OIF group, respectively. Outcomes were assessed by the last four authors in both groups regarding operative time, success rate postoperative complications, and cosmetic results. The incidence and type of complications such as fistula, meatal stenosis, glandular dehiscence, or recurrence were recorded and followed up.

Statistical analysis

Sample size justification

MedCalc, version program (Ostend, Belgium) was used for the calculation of sample size. Using the statistical calculator based on 95% confidence interval and power of the study 80% with α error 5%, a minimal samples size of 50 cases was required in each group.

The collected data were tabulated and statistically analyzed using statistical package for social sciences program software, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Inferential analyses were done for qualitative data using χ2 test for independent groups. The level of significance was taken at P value less than 0.050 as significant, otherwise not significant. The P value is a statistical measure for the probability that the results observed in a study could have occurred by chance.

  Results Top

One hundred and forty patients were included and 133 of them had completed the 15-months of follow-up period. However, 7 patients with successful repair (3 from group A and 4 from group B) stopped to follow after completing the minimum follow up period (first 6months postoperatively). Their ages ranged between 1 and 6 years at the time of operation, with a mean of 38.5±24.44 months for TIP group and 42.1±19.94 months for OIF group (P=0.6128).

Operative time

Mean operative time was 82.75±7.518 min for group A (TIP urethroplasty) and 103±11.17 min for group B (OIF repair) (P<0.01); this difference was statistically significant.

The success rate was reported in 114 (81.5%) patients. Complications were observed in 42 patients, 15(21.5%) in group A and 27(39%) in group B, which was significantly different (P=0.040) ([Table 1]).
Table 1 Complications and cosmetic results of both groups

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In group A, 15 (21.5%) developed complications: urethrocutaneous fistula in seven (10%), meatal stenosis in five (7%), glandular dehiscence in one (1.5%), and superficial wound infection in two (3%).

In group B, 27 (39%) patients developed complications: fistula in 14 (20%), meatal stenosis in three (4.3%), glandular dehiscence in four (5.7%), and superficial wound infection in six (9%).

Seven cases were lost to follow-up after 6 months without complications: three cases in group A and four cases in group B.

Urethrocutaneous fistula was the commonest early complication that occurred in 21 patients (seven in group A and 14 in group B), with significant difference between the groups (P=0.028). These patients needed repair after 6 months.

Partial glans dehiscence was seen one case in group A and four cases in group B (P=0.346). Glanuloplasty was done after 6 months.

Cases of meatal stenosis resolved with repeated dilation for 2–3 months.

All cases with superficial wound infection were improved with conservative treatment without fistula occurrence.

No cases of urethral stricture or diverticulum were encountered in both groups. Moreover, no cases of complete repair disruption were encountered in both groups.

Regarding the shape of the external urethral meatus, after TIP urethroplasty, vertically positioned and rounded external urethral meatus was seen in 65/70 (93%) and 5/70 (7%) patients, respectively. On the contrary, it was vertically positioned in 11/70 (16%) patients and round in 59/70 (84%) patients in OIF group.

  Discussion Top

The aim of hypospadias repair is to construct a straight penis with normal looking shape and location of the external meatus which may not interfere with normal coitus and forward directed stream [7]. Hypospadias repair must be accomplished by the time a boy reaches school or may be by the age of 2 years. The selection and outcome of the repair procedure does not change with age [8].

Although patients presented with a wide age range from 1 to 14 years, we included only patients with 1–6 years of age (mean, 38.5±24.44 and 42.1±19.94 months for group A and group B, respectively) in this study.

The type of urinary diversion after hypospadias surgery is still a controversial issue. We used transurethral urinary diversion with 6–10-Fr nelaton catheter for 7 days.

Osifo and Azeez [9] reported shorter hospital stay in transurethral catheterization compared with suprapubic urinary diversion. Sigumonrong et al. [10] reported that the type of urinary diversion after hypospadias surgery did not affect surgical outcome.

Excellent results with stent-free TIP urethroplasty were reported by Almodhen et al. [11]. The ideal dressing for hypospadias repair remains elusive.

In this study, sandwiched dressings were used in all cases and then removed 7 days postoperatively.

The advantages of dressing following the hypospadias repair are good hemostasis by gentle compression and wound immobilization, whereas infection and pain during removal are some of the disadvantages. No major difference was seen in outcome of comparative study between dressed and nondressed hypospadias repair [12].

In the present study, the mean operative time was 82.75±7.518 min for group A and 103±11.17 min for group B, which was much shorter for TIP urethroplasty compared with OIF repair as reported in many previous studies.

Sujijantararat and Chaiyaprasithi [13] observed urethra-cutaneous fistula in 14.7% patients after TIP urethroplasty and 23.8% after OIF repair. Moreover, meatal stenosis was reported as 0–6% after TIP urethroplasty and 3–9% after OIF repair in many series. Sujijantararat and Chaiyaprasithi observed complete repair disruption in 5.9% for TIP urethroplasty and 0% for OIF repair.

Braga et al. [14] reported incidence of complete repair disruption as 8.6% for TIP urethroplasty and 5.0% for OIF repair.

In this study, urethra-cutaneous fistula was observed in 10% in TIP urethroplasty and 20% in OIF repair. Meatal stenosis was found in 7 and 4.3% patients, respectively. No cases of complete wound disruption were seen in both groups.

A large study in 641 consecutive patients after primary distal and proximal and reoperative TIP reported glans dehiscence in 4% after distal and 15% after proximal and reoperative surgeries [15].

In this study, 1.5 and 4.7% of the patients had glans dehiscence in TIP urethroplasty and OIF repair, respectively.Vallasciani et al. [16] observed urethral diverticulum in 7% of cases; all occurred after preputial flaps, with no distal stenosis, and all occurred before puberty.

In this study, with maximum follow-up period, no cases of diverticulum were detected.

Symptomatic meatal stricture was reported in 17% with urethral plate dissection in cases of release of ventral chordee compared with nonurethral mobilization [17].

In the present study, no cases of urethral stricture were detected.

Xiao et al. [18] observed in a meta-analysis study comparing onlay flap and TIP repair for primary proximal hypospadias that complication rate ranged from 14.04 to 47.06% and 13.54 to 60.00% for onlay and TIP, respectively.

Braga et al. [14] observed in a retrospective review comparing proximal TIP with onlay preputial flap repairs in children with a mean age of 17 months (9–91 months) that at a mean follow-up of ∼3 years, there were urethroplasty complications in 60% with TIP and 45% with onlay.

In this study, the complication rate was 21.5% for TIP and 39% for onlay, with low complications with TIP than with OIF for mid-penile hypospadias repair.

Criteria for success of any hypospadias repair is tip meatus, forward directed single stream, and absence of chordae [7].

We had also come across satisfactory cosmetic results with the TIP urethroplasty compared with OIF repair. Regarding the shape of the external urethral meatus, after TIP urethroplasty, 93% patients had external urethral meatus that resembled the normal urethral meatus.

  Conclusion Top

Both techniques are reliable and feasible for treatment of mid-penile hypospadias with respect to operative time, complications, and cosmetic outcome. TIP procedure had a statistically significant difference with respect to operative time, complications, and cosmetic outcome. So, the authors prefer it if suitable urethral plate is present. Randomized studies with larger sample sizes are required to support this conclusion.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Koyle MA. Hypospadias: a 30-year personal journey. Scand J Surg 2011; 100:250–255.  Back to cited text no. 1
Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994; 151:464.  Back to cited text no. 2
Elder JE, Duckett JW, Snyder HM. Onlay island flap in the repair of mid and distal penile hypospadias without chordee. J Urol 1987; 138:376–379.  Back to cited text no. 3
Kanaroglou N, Wehbi E, Alotay A, Bagli DJ, Koyle MA, Lorenzo AJ et al. Is there a role for prophylactic antibiotics after stented hypospadias repair? J Urol 2013; 190:1535–1539.  Back to cited text no. 4
Sarhan OM, El-Hefnawy AS, Hafez AT, Elsherbiny MT, Dawaba AM, Ghali AM. Factors affecting outcome of tubularized incised plate (TIP) urethroplasty: single-center experience with 500 cases. J Pediatr Urol 2009; 5:378–382.  Back to cited text no. 5
Snodgrass WT, Lorenzo A. Tubularized incised-plate urethroplasty for proximal hypospadias. Br J Urol Int 2002; 89:90–93.  Back to cited text no. 6
Al-Saied G, Gamal A. Versatility of tubularized incised plate urethroplasty. Afr J Paediatr Surg 2009; 6:88–92.  Back to cited text no. 7
[PUBMED]  [Full text]  
Djakovic N, Nayarangi-Dix J, Özturk A, Hohenfellner M. Hypospadias. Adv Urol 2008; 6:501–535.  Back to cited text no. 8
Osifo OD, Azeez AL. Outcome of transurethral and suprapubic urinary diversion following hypospadias repair in children. Pak J Med Scien 2010; 26:329–334.  Back to cited text no. 9
Sigumonrong YH, Santoso A, Djojodimedjo T, Widodo JP. Difference in event rates urethrocutaneous fistula on the use of urethral catheter and suprapubic catheter with stents after hypospadias surgery. Indonesian J of Urol 2011.  Back to cited text no. 10
Almodhen F, Alzahrani A, Jednak R, Capolicchio JP, El Sherbiny MT. MTEI. Nonstented tubularized incised plate urethroplasty with Y-to-I spongioplasty in non-toilet trained children. Can Urol Assoc J 2008; 2:110–114.  Back to cited text no. 11
Van Savage JG, Palanca LG, Slaughenhoupt BL. A prospective randomized trial of dressings versus no dressings for hypospadias repair. J Urol 2000; 164(3 part 2):981–983.  Back to cited text no. 12
Sujijantararat P, Chaiyaprasithi B. Comparative outcome between transverse island flap onlay and tubularized incised plate for primary hypospadias repair. Asian J Surg 2009; 32:229–233.  Back to cited text no. 13
Braga HP, Pippi Salle JL, Lorenzo AJ, Skeldon S, Dave S, Farhat WA et al. Comparative analysis of tubularized incised plate versus onlay island flap urethroplasty for penoscrotal hypospadias. J Urol 2007; 178(4 part 1):1451–1456.  Back to cited text no. 14
Snodgrass W, Cost N, Nakonezny PA, Bush N. Analysis of risk factors for glans dehiscence after tubularized incised plate hypospadias repair. J Urol 2011; 185:1845–1849.  Back to cited text no. 15
Vallasciani S, Berrettini A, Nanni L, Manzoni G, Marrocco G. Observational retrospective study on acquired megalourethra after primary proximal hypospadias repair and its recurrence after tapering. J Pediatr Urol 2013; 9:364–367.  Back to cited text no. 16
Snodgrass W, Villanueva C, Bush N. Outcomes of reoperations for glans dehiscence in prepubertal boys with hypospadias. New Orleans, LA: American Academy of Pediatrics National Conference and Exhibition; 2012.  Back to cited text no. 17
Xiao D, Nie X, Wang W, Zhou J, Zhang M, Zhou Z et al. Comparison of transverse island flap onlay and tubularized incised-plate urethroplasties for primary proximal hypospadias: a systematic review and meta-analysis. PLoS ONE 2014; 9:9.  Back to cited text no. 18


  [Figure 1], [Figure 2]

  [Table 1]


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