"Wide Skeletonization" Tubularised Incised Plate (TIP) Repair of Distal Penile Hypospadias with Narrow Urethral Plate.

The importance of an adequate caliber neo-meatus for success of any hypospadias repair cannot be overstated. TIP repair incorporates a midline relaxing incision thus enabling tubularization but ultimately may not result in adequate neourethral caliber to avoid fistulas or meatal stenosis when the plate was narrow or flat, respectively. Objectives of this study is to evaluate results of a modification of TIP - "wide skeletonization" tubularized incised plate (TIP) - for repair of distal penile hypospadias with narrow urethral plate (UP), with regard to meatal stenosis and urethrocutaneous fistula.

Methods: Total of 108 hypospadias patients were operated upon. 26 were found to have distal penile ypospadias with narrow UP (Narrow UP defined as any plate less than 6 mm width). 22 were selected for the study; All underwent "wide skeletonization" of the UP distally ("Wide Skeletonization" implies meatal based ventral "V" shaped incisions on outer margins of UP so as to incorporate generous portions of adjoining skin thereby allowing recruitment of penile and glandular skin lateral to the urethral plate to facilitate tubularization). Urethroplasty was fashioned over 10mm circumference of native UP with adjoining skin over a urethral stent. Repair was started with meatus first (calibrated over size 10-12F bougie). Meatal stitch was followed proximally with subepithelial tubularization of the neourethra; second layer comprising of spongiosal tissue. Barrier flaps were interposed between the neourethra and overlying glans and shaft skin closure, using inner prepucial mucosal flap.

Results: Two patients had urethrocutaneous fistulae; one child had superficial dehiscence of glans. All three children were managed conservatively with no child requiring further surgery. All children had a good sized meatus and good stream of urine without any splaying.

Conclusions: "Wide Skeletonization" of the urethral plate distally (in a "V" fashion rather than "U") gives an adequate caliber aesthetic neo-meatus especially in hypospadias children with narrow UP. It further helps in decreasing incidence of neourethral and/or meatal stenosis without increasing urethroplasty complication leading to an excellent functional outcome. Whether this leads to better long term functionality of neourethra remains to be seen.