Cosmotic Outcome of Distal Penile Hypospidias Repair Using Stitch by Stitch Glanuloplasty Versus TIP
Condition: Distal Penile Hypospadias
MeSH terms: Hypospadias
Study type: Interventional

Summary: 
      Hypospadias is generally defined as the combination of three anatomic anomalies of penis,
      which are an abnormal ventral opening of the urethral orifice, ventral curvature of the
      penis, and abnormal distribution of the foreskin around the glans with a ventrally deficient
      hooded foreskin . It is estimated that about 1 in every 200 babies is born with hypospadias
      in the United States, making it one of the most common birth defects.

      In newborn males, hypospadias is the second most common congenital anomaly after undescended
      testis. Due to incomplete closure of the penile structures during embryogenesis, the urethral
      opening is displaced along the ventral side of the penis . Most hypospadias occur as an
      isolated condition, but associated anomalies include uni/bilateral cryptorchidism and
      micropenis .

      Duckett proposed the most commonly used classification; i.e., nearly 70% of hypospadias are
      either glanular or distally located on the penis and are considered a mild form, whereas the
      remainder is more severe and complex The main goal for hypospadias repair is to achieve both
      cosmetic and functional normality. Reasons for treating hypospadias include spraying of
      urinary stream, inability to urinate in standing position, curvature leading to difficulties
      during intercourse, fertility issues because of difficulty with sperm deposition, and
      decreased satisfaction with genital appearance. Current guidelines consider optimal age for
      hypospadias repair somewhere between 6 and 18 months, depending on the severity and the need
      for multiple procedures .

      Penile biometrical parameters, like a small glans width and narrow urethral plate, are some
      of the anatomical factors associated with increased postoperative complications and form a
      technical challenge . Functional outcome was considered satisfactory when the patient could
      micturate an ideal stream of urine (single, compact, rifled, non-dispersed urinary stream of
      adequate caliber) without straining. Cosmetic outcome was considered satisfactory when a
      straight penis was obtained with a vertical slit like, wide, smooth external meatus at the
      tip of a conical glans .

      The normal meatus is a vertical slit with smooth and sharp edges that is centrally located
      within the glans penis . The literature lacks standardization of techniques for hypospadias
      repair and uniform definitions of complications and outcome assessment .

      Many surgical techniques have been described for glans closure and meatoplasty with variable
      outcomes, but none of them fits all patients with hypospadias; each procedure has its
      limitations and demands specific selection criteria.

      Duckett described the "meatal advancement and glanuloplasty incorporated" (MAGPI) procedure.
      The two essential elements of MAGPI are meatoplasty and glanuloplasty. However, many
      researchers reported a high incidence of partial meatal regression in their patients
      following the MAGPI procedure.

      In 1928, Mathieu described a single-stage, meatal based flap technique to repair the distal
      forms of hypospadias but results in flat meatus. In 2000 Boddy and Samuel reported the
      "V-incision" sutured MAVIS technique to provide a cosmetically acceptable natural slit-like
      meatus in Mathieu cases Rich et al. in 1989 described a urethral plate incision (hinging) as
      a modification of the Mathieu repair to improve the cosmetic outcome of the neo-meatus. It
      helps in achieving a slit-like vertical meatus. Nevertheless, a healthy wide urethral plate
      with no scarring is essential for a successful outcome Snodgrass extended the concept of
      urethral plate hinging by incising the whole urethral plate in the midline from the
      hypospadias meatus distally. It helps in the tabularization of the plate with a good cosmetic
      outcome.

      -stitch by stitch technique: Operative technique :starts with penile degloving, preparation
      of the flap (Site of hypospadic meatus is determined after degloving). Creation of a narrow
      strip of the urethral plate with wide glanular wings is done using bilateral incisions which
      are extended to the tip of the glans. The width of the urethral plate is about 3 mm then we
      suture the flap to the narrow urethral plate in two layers in continuous manner using vicryl
      6/0 over a suitable plastic catheter. Triangular (Vshape) area of the distal part of the flap
      is excised a the midline. After this we anastomose the flap to thetip of the glans. The glans
      appears opened in the midline as inverted V shape. Closure of the glans is finished in the
      midline using three mattress interrupted sutures with another three simple stitches are used
      in between
    


Intervention name(s): TIP; STITCH BY STITCH
Intervention type(s): Procedure; Procedure
Intervention description(s): TIP An 8F straight sound is passed into the hypospadiac meatus to assess skin coverage over the urethra., a circumscribing incision is made 2 mm proximal to the meatus, a U-shaped incision is extended proximally to healthy skin The key step in the operation is a midline relaxing incision made from within the meatus to the distal extent of the plate. This incision extends through the epithelial surface of the plate deeply into underlying connective tissues down to the corpora cavernosaNext, a 6F stent is passed into the bladder for postoperative urinary diversion. Then the urethral plate is tubularized. , stitches are ever taken further distally to ensure the neomeatus has a generous oval openingticular closures. .; SBS in brief Operative technique :starts with penile degloving, preparation of the flap (Site of hypospadic meatus is determined after degloving). Creation of a narrow strip of the urethral plate with wide glanular wings is done using bilateral incisions which are extended to the tip of the glans. The width of the urethral plate is about 3 mm then we suture the flap to the narrow urethral plate in two layers in continuous manner using vicryl 6/0 over a suitable plastic catheter. Triangular (Vshape) area of the distal part of the flap is excised a the midline. After this we anastomose the flap to thetip of the glans. The glans appears opened in the midline as inverted V shape. Closure of the glans is finished in the midline using three mattress interrupted sutures with another three simple stitches are used in between
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment