The Nigerian Experience with Hypospadias Repair

Yogesh Kumar Sarin [1,2]

[1] Department of Pediatric surgery, Lady Hardinge Medical College, New Delhi, India.

[2] Editor, Pediatric Surgery in Tropics.

In this issue (July-Sep 2024) of the Pediatric Surgery in Tropics, Dr. Ugwu et.al have reported their experience with hypospadias in Nigerian children.(1) It is commendable that they have improved the results of their hypospadias repairs over a few years. The authors have not mentioned certain details such as the width of the urethral plate, the width of the glans and the degree of chordee following penile degloving. Tubularized incised plate urethroplasty (TIPU) was employed in 51 of the 64 patients, including the 5 out of 7 penoscrotal hypospadias. TIPU is a versatile, reliable, cosmetic and functionally successful surgical method mainly used in distal hypospadias; but in recent times it is also used in some proximal varieties. Its main complications are urethro-cutaneous fistula, urethral meatus stenosis, glans dehiscence and urethral meatus dehiscence that the authors have noted in their series too. The urethro-cutaneous fistula and meatal stenosis rates have been reported as high as 12% and 15% respectively in a recent article.(2) Narrow urethral plate, flat glandular groove and small glans were found to be significantly associated with higher complication rates in TIPU. Further, Snodgrass advocated that a small glans (usually associated with proximal hypospadias) measuring less than 14 mm in width is not ideal for TIPU.(3) Some authors believe that TIPU should not be used if the urethral plate width (UPW) is less than 8 mm.(4,5), though Snodgrass denies the significance of this parameter.(6) Others believe that the functional outcome rather than cosmetic appearance of hypospadias repair is predicted by the UPW.(7)

Mathieu’s urethroplasty is a good option for distal hypospadias with a narrow urethral plate and is recommended.(8) A hybrid technique of  Mathieu’s urethroplasty incorporated with TIPU is also in vogue for distal penile hypospadias with small glans and shallow urethral plate.(9) 

Another point of controversy could be the use of a single-stage TIPU in patients with proximal hypospadias with significant chordee. There is no mention in the paper about the use of artificial erection test or the use of dorsal plication when single-stage urethroplasty was employed in such patients. Staged procedures should be more liberally performed in such cases as they tend to have better cosmetic and functional results.(10)

REFERENCES

1. Ugwu JO, Ekwunife OH, Modekwe VI, Mbaeri TU, Osuigwe AN. Hypospadias repair: A single-centre experi-ence with clinical presentations, operative techniques and outcome. Pediatr Surg Trop 2024 July-Sep; 1(3): 141-147

2. Guler Y. TIPU outcomes for hypospadias treatment and predictive factors causing urethrocutaneous fistula and external urethral meatus stenosis in TIPU: Clinical study. Andrologia. 2020 Oct; 52(9): e13668. 

3. Bush NC, Villanueva C, Snodgrass W. Glans size is an independent risk factor for urethroplasty complications after hypospadias repair. J Pediatr Urol. 2015 Dec; 11(6): 355.e1-5.

4. Holland AJ, Smith GH. Effect of the depth and width of the urethral plate on tubularized incised plate urethroplasty. J Urol. 2000 Aug; 164(2): 489-91. 

5. Aboutaleb H. Role of the urethral plate characters in the success of tubularized incised plate urethroplasty. Indian J Plast Surg. 2014 May; 47(2): 227-31.

6. Bush NC, Snodgrass W. Pre-incision urethral plate width does not impact short-term Tubularized Incised Plate urethroplasty outcomes. J Pediatr Urol. 2017 Dec; 13(6): 625.e1-625.e6.

7. Chukwubuike KE, Obianyo NEN, Ekenze SO, Ezomike UO. Assessment of the effect of urethral plate width on outcome of hypospadias repair. J Pediatr Urol. 2019 Dec; 15(6): 627.e1-627.e6.

8. Salako AA, Olajide AO, Sowande AO, Olajide FO.  Retro-spective analysis of Mathieu’s urethroplasty for anterior hypospadias repair in circumcised children: A single center experience. Afr J Urol. 2011; 17: 11-4.

9. Khirallah M, El-Dossuky N. Hybrid Mathieu Urethro-plasty: A Simple Modification Outcomes. Res Rep Urol. 2021 Jul 5; 13: 473-478.

10. Zheng DC, Yao HJ, Cai ZK, Da J, Chen Q, Chen YB, Zhang K, Xu MX, Lu MJ, Wang Z. Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience. Asian J Androl. 2015 Jan-Feb; 17(1): 94-7.