Objective To evaluate the combination of the tubularized incised urethral plate (TIUP) urethroplasty after Snodgradd and the glans approximation procedure (GAP) after Zaontz with the aim of simplifying TIUP.
Patients and Methods Twenty-three patients with distal hypospadias were included in the study. Eight boys had had previously failed repairs and three boys were circumcised. In all boys a combination of TIUP and GAP was applied to prospectively evaluate the procedure in primary and previously failed distal hypospadias to facilitate future TIUP.
Results All cases ended by a vertically positioned, normal-shaped external urethral

meatus. None of the patients developed fistula, however, complete disruption of repair occurred in one patient. The operation was easy to perform and less time-consuming than the original Snod-grass procedure.
Conclusion The best results of the procedure can be achieved in redo and circumcised cases. A larger series is needed to prove its feasibility.
Key Words hypospadias, gap procedure, tabularized incised urethral plate urethroplasty

INTRODUCTION

In 1994, Snodgrass described a repair for distal hypospadias by tubularized incised urethral plate urethroplasty (TIUP)1. Satis-factory functional and cosmetic results of this technique were confirmed in a multicenter study carried out two years later claiming that the procedure outcome was superior to other popular techniques2. Since then, many authors including those of the present study have supported the operation due to its simplicity and excellent functional and cosmetic re-sults3,4,5. Furthermore, the operation proved to be excellent in redo cases6.7. In 1989, Zaontz described the GAP (Glans Approximation Procedure) for selective cases to easily repair glandular and coronal hypospadias. He stated that the procedure should be limited to boys with a wide, deep glanular groove and a non- compliant urethra8.

In this study, we combined both techniques to prospectively evaluate the procedure in primary and previously failed distal hypo-spadias to facilitate future TIUP.

PATIENTS AND METHODS

Twenty-three patients with distal hypo-spadias were included in the study. The age ranged from 2 to 16 years. Eight boys had had previously failed repairs and three boys were circumcised.

Operative technique:

A circumscribing incision was made 1 to 2 mm proximal to the hypospadiac meatus. The penis was degloved down to the penoscrotal junction in all but one patient (Fig. 1A). Artificial erection was performed to test for chordee. Mild persistent chordee was corrected by dorsal plication to preserve the urethral plate. The glans was infiltrated with 1:100.000 epinephrine along the lateral borders of the urethral plate. Parallel longitudinal incisions approximately 8 to 10 mm apart defined the urethral plate. Another lateral incision was taken laterally to the urethral plate on both sides. The epithelium between the urethral plate and the later incision covering the glans was removed leaving a row area (Fig. 1B). The

plate was undermined and incised in the midline from the meatus to the tip of the glans. The incision was carried deeply dividing all transverse webs and exposing the underlying corporeal bodies (Fig. 1C). When the meatus was stenosed, the midline incision was extended by 2 to 3 mm proximally to dilate the meatus. The incision was extended beyond the newly located external meatus to increase the distance between the edges of the incision at the new meatus site and, thus, to prevent future stenosis.5 Deepening of the groove is very important to yield a capacious future urethra. The urethral plate was tubularized over a silicon catheter 8-12 Fr. with a con-tinuous 6/0 vicryl suture (Fig. 1D). This appro-ximated both row areas together and they were closed forming a layer between the urethra and the glanular skin. The glans was finally closed using 6/0 vicryl sutures (Fig. 1E). The catheter was removed after a week. The patients were followed up for at least 6 months.

RESULTS

All cases ended by a vertically positioned, normal-shaped external urethral meatus. None of the cases developed fistula (Fig. 6), however complete disruption of the repair oc-curred in one case. This was the patient where we did not apply penile skin degloving.

DISCUSSION

When Zaontz described the GAP pro-edure, he stated that it should be limited to boys with a wide, deep glanular groove and a
postoperative day. (b) Regions of increased fibroblastic activity were observed in the sub-epithelial stroma below the incised area on the third postoperative day. Early collagen depo-sition was noted in these areas. (c) These areas appeared to organize by the 21st postoperative day. There was little evidence of increased fibroblastic activity or excess colla-gen deposition. They concluded that urethral healing after incision and tubularization over a catheter occurred through normal re-epithe-lialization without excess collagen deposition or scarring11.

This study disapproves the assumption of Holland and Smith that incising the urethral plate has no role in increasing the final urethral diameter. They believe that the preoperative depth of the urethral plate is crucial, as a shallow preoperative plate will lead to fistula formation12. According to Lopes et al. re-epithelialization was shown and the justification of an indwelling catheter for more than 5 days until complete epithelialization of the plate was proven11.

The only case with glandular disruption in our study was due to ignoring degloving of the penile skin that alleviates tension from suture lines. Therefore, we recommend strongly not to ignore this step.

The operation was easy to perform and less time consuming than the original Snodgrass. The best results can be achieved when the procedure is applied in redo and in circumcised cases. A larger series is needed to further prove its feasibility.

REFERENCES

1. Snodgrass W. Tubularized incised urethral plate urethroplasty. J Urol 1994, 151:464.
All correspondence to be sent to:

M.O. Badreldin, M.D.
Urology Department
Menofeya University
Egypt

Phone: 010-1413411

non-compliant urethra. We decided to combine the GAP and the TIUP procedures because it is easier to close the glans and then dissect the glandular wings. Moreover, the midline incision of the urethral plate turned it deep and wide and it, thus, became suitable for the Zaontz glanuloplasty. The closure of the glans in 2 layers gave support to the glans and sepa-rated the skin from the tubularized plate. Con-sequently, the use of a dartos flap to cover the urethral plate, as described in the original Snodgrass procedure, in order to decrease the fistula rate is not necessary any more. The criticism of the Snodgrass procedure was directed towards the use of a dorsal sub-cutaneous flap to prevent fistula formation, as this could lead to torsion of the penis and compromise vascularity of the dorsal skin9 and a regular dilatation to prevent distal stenosis10. Applying our modification in the form of combining the GAP procedure and extending the midline incision above the level of the new external meatus renders such criticism irrele-vant. Also, discarding the use of a dartos flap reduced the operation time considerably. Ex-cellent results were obtained in the recurrent cases. This finding was supported by Borer et al.6 and Hayashi et al7. We believe that the procedure will alleviate the fear from those cases, especially during the early learning curve of the surgeon.

In an animal study done by Lopes et al. in 2001, they did a midline incision in the urethral plate and tubularized it around a catheter. They showed that: (a) migration of the epi-thelial cells was evident on the second post-operative day with an apparent complete re-epithelialization around the catheter by the 5th
2. Snodgrass W, Koyle M, Manzoni B, Hurwitz R, Caldamone A, Erlich R. Tubularized incised urethral plate repair for proximal hypospadius. J Urol 1996, 159:2129.

3. Lorenzo AG, Snodgrass WT. Regular dilatation is unnecessary after tabularized incised plate hypospadias repair. BJU Int 2002, 89:94-97.

4. Guralnick ML, Al-Shammari A, Williot PE, Leonard MP. Outcome of hypospadius repair using tabularized incised plate urethroplasty. Can J Urol 2000, 7:986-991.

5. Kheirallah M, Badreldin MO. Distal hypospadius repair with tabularized incised urethral plate: Results, complications and management. Men Med J 2000, 12:146-150.

6. Borer SG, Bauer SB, Peters CA, Diamond DA, Attala A, Cilento BG Jr., Retik AB. Tubularized incised plate urethroplasty. Expanded use in primary and repeat surgery for hypospadias. J Urol 2001, 165:581-585.

7. Hayashi Y, Kojima Y, Mizuno K et al. Tubularized incised plate urethroplasty for secondary hypo-spadias surgery. Int J Urol 2001, 8:444-448.

8. Zaontz MR. The GAP (Glans Approximation Procedure) for glanular/coronal hypospadias. J Urol 1989, 141:359-361.

9. Ross JH, Kay R. Use of deepithelialized local skin flap in hypospadius repair accomplished by tubu-larization of the incised plate. Urology 1997, 50:110.

10. Elbakrey A. Tubularized incised urethral plate urethroplasty: is regular dilatation necessary for success? BJU Int 1999, 84:78.

11. Lopes JF, Schned A, Ellsworth PI, Cendron M. Histological analysis of urethral healing after tubularized incised plate urethroplasty. J Urol 2001, 166:633.

12. Holland AJ, Smith GH. Effect of depth and width of the urethral plate on tabularized incised plate urethroplasty. J Urol 2000, 164:489-491.