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Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 212-217

Comparative study between tubularized incised plate urethroplasty with and without dorsal inlay graft

1 Department of Plastic Surgery, Faculty of Medicine, Menoufyia University, Shibin Al Kawm, Egypt
2 Department of Plastic Surgery, El-Obour Hospital, Kafr El-Sheikh, Egypt

Date of Submission19-Dec-2016
Date of Acceptance02-Mar-2017
Date of Web Publication14-Jun-2018

Correspondence Address:
Mohammad R Mansour
Department Plastic Surgery, El-Obour Hospital, Kafr El-Sheikh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_702_16

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The aim of this studywasto compare the results of two single-stage hypospadias repairs, namely, tubularized incised plate(TIP) repair with and without dorsal inlay preputial skin graft urethroplasty as regards meatal stenosis, urethral stricture, and cosmetic outcome.
The most commonly performed operation to repair distal hypospadias is the TIP repair. The key step is midline incision of the urethral plate, which widens a narrow plate and converts a flat groove into a deep plate groove, ensuring a vertical, slitneomeatus and a normal-caliber neourethra. At times in cases of distal hypospadias, the urethral plate is very narrow and needs to be augmented or substituted for further tubularization. We report our experience with primary single-stage dorsal inlay urethroplasty using inner preputial skin grafts.
Patients and methods
This study included 30patients less than 10years old who presented with primary distal types of hypospadias with narrow urethral plate at the Department of Plastic Surgery, Menoufia University Hospital and were divided into two groups: groupA included 14patients operated by TIP without dorsal inlay graft and groupB included 16patients operated by TIP with dorsal inlay graft. Patients who had undergone circumcision, previous hypospadias repair, or who had a deeply grooved urethral plate were excluded.
A total of 16 children underwent primary dorsal inlay preputial graft urethroplasty, of whom one(6.2%) child had partial wound dehiscence, two(12.5%) of the children had meatal stenosis, and one(6.2%) of these children developed urethral stricture; 14 children underwent TIP urethroplasty, of whom two(14.3%) children had wound dehiscence, four(28.6%) of the children had meatal stenosis, and four(28.6%) of these children developed urethral stricture.
Primary dorsal inlay inner preputial graft urethroplasty successfully fulfills all traditional hypospadias repair criteria. It offers a viable, safe, rapid, and easy option in the management of proximal hypospadias with a narrow urethral plate.

Keywords: hypospadias, meatal stenosis, preputial graft, urethral stricture

How to cite this article:
Kishk TF, Elsheikh YM, Elkashty SM, Mansour MR. Comparative study between tubularized incised plate urethroplasty with and without dorsal inlay graft. Menoufia Med J 2018;31:212-7

How to cite this URL:
Kishk TF, Elsheikh YM, Elkashty SM, Mansour MR. Comparative study between tubularized incised plate urethroplasty with and without dorsal inlay graft. Menoufia Med J [serial online] 2018 [cited 2022 Jan 18];31:212-7. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/212/234250

  Introduction Top

The aims of hypospadias surgery include the establishment of a straight penis with a urethral meatus at the glans tip, the establishment of a well-vascularized neourethra of adequate caliber with a solid, straight urinary stream, and the achievement of normal sexual function when the patient reaches maturity [1].

Tubularized incised plate(TIP) urethroplasty represents one of the most widely applied modern techniques for hypospadias repair. The procedure gained increasing popularity after its introduction by Snodgrass [1].

Satisfactory cosmesis with a normal slit-like urethral meatus can be reliably achieved by TIP repair because of the relative simplicity of the operative principle and its low complication rate [2]; the procedure has been progressively applied to more proximal defects [3].

Cosmesis and complications aside, several functional studies using uroflowmetry were reported with conflicting results. Gurdal etal. [4] reported that 18 of 19patients had a normal urinary flow rate when adjusting for the age of the analyzed group.

In contrast, an abnormal flow rate was noted in about 30% of patients by Marte etal. [5] and Hammouda etal. [6], who reported the initial experience with the TIP technique mainly for midshaft to distal defects.

A persistent concern is that, although a long defect corrected by TIP urethroplasty can be stricture free, the healing process may lead to an important increase in flow resistance on the basis of length-to-caliber ratio [7].

In 2000, Kolon and Gonzales reported a new technique of one-stage urethroplasty with a dorsal inlay graft using inner preputial skin. This technique involves incision from the native meatus to the end of the glans, not to the end of the urethral plate, with placement of a dorsal graft [8].

Dorsal inlay graft urethroplasty is an effective method for primary hypospadias repair and leads to a good cosmetic outcome with low risk of complications [9].

We report our experience in comparing the results of two single-stage hypospadias repairs, namely, TIP repair and dorsal inlay preputial skin graft urethroplasty(DIGU) as regards postoperative complications.

  Patients and Methods Top

All patients gave written informed consent before inclusion into the study. This study included 30patients who presented with distal penile hypospadias at the Department of Plastic Surgery, Menoufyia University Hospital(Shibin Al Kawm, Egypt). The cases were prospective from December 2014 until the end of the study and were divided into two groups:

GroupA: Included 14patients in whom TIPwithoutdorsal inlay graft repair was performed.

GroupB: Included 16patients in whom TIPwithdorsal inlay graft urethroplasty was performed.


Inclusion criteria

The inclusion criteria were as follows:

  • Primary hypospadias with narrow urethral plate
  • Distal types of hypospadias
  • Patients less than 10years old.

Exclusion criteria

  • Patients who had undergone circumcision or hypospadias repair previously
  • Deeply grooved urethral plate

  • Both groups were subjected to:

    1. Full history taking
    2. A detailed physical examination was carried out, and the penis was examined for length, chordee, urethral plate, and size
    3. Routine laboratory investigations such as completeblood count, urine culture and sensitivity, liver profile, kidney function test, prothrombin time and activity, international normalized ratio, fasting blood sugar, and hepatitis markers.

Operative technique

A circumferential incision was made below the corona and proximal to the hypospadiac urethral meatus [Figure1]. The penis was degloved and the chordee was corrected by dorsal plication of the corpora cavernosa if present. Incisions were made bilaterally along the urethral plate from the native urethral meatus to the glans tip. The glans wings were developed for closure over the neourethra. Asuitable size silicon catheter was placed to evaluate the urethral plate width for tabularization. Whenever the plate width was found to be insufficient, the urethral plate was incised longitudinally in the manner described by Snodgrass. Afree graft was then measured and harvested from the inner prepuce, and the graft was defatted and sutured onto the incised urethral plate. The neourethra was rolled into a tube over the catheter. This layer of closure was accomplished using 6-0 Vicryl (Mercedes Medical, 7590 Commerce Ct Sarasota, FL 34243). Avascularized dartos flap was developed and used as a second layer cover. The glans and corona were reapproximated and sutured. The wound was dressed, and the catheter was left in place for 7–10days.
Figure 1: Operative steps of tubularized incised plate with and without dorsal inlay graft: (a) preoperative; (b) traction suture, 8 fr catheter insertion and tourniquet application; (c) complete degloving and artificial erection test; (d) creation of glandular wings; (e) inner preputial graft harvest; (f) dorsal inlay graft suture fixation as an additional step; (g) dartos fascia flap; (h) fixation of dartos fascia; and (i) immediate postoperative.

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For all of our patients the following hospital data were obtained:

  • Operative details
  • Operative time
  • Operative complications such as wound infection, wound dehiscence, meatal stenosis, and persistent chordee.


All our patients were observed by routine clinical examination regarding the position and shape of meatus, urinary stream, urethrocutaneous fistula, and stricture formation.

Statistical analysis

All data were collected, tabulated, and statistically analyzed using SPSS 19.0 for windows(SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for windows (MedCalc Software BVBA, Ostend, Belgium).

Quantitative data were expressed as mean±SD and analyzed by applying Student's t-test for the comparison of two groups of normally distributed data, whereas for two groups of data that were not normally distributed the Mann–Whitney test was applied.

Qualitative data were expressed as n(%) and analyzed by applying χ2-test, and the 2×2 table and one cell had an expected number less than 5 when Fisher'sexact test was applied. P value at 0.05 was used to determine significance.

  Results Top

Preoperatively, in the DIGU group, the urethral meatus was at the distal shaft in three, coronal in 12, and glandular in one. In the TIP group, the urethral meatus was at the distal shaft in five, coronal in six, and glanular in three[Table1]. The chordee was successfully released by skin release if present. The mean operating time was 90.8±6.5 in the dorsal inlay graft(range: 80–100min) and 79.1±6.1 in TIP(range: 70–90min). One(6.2%) child had a breakdown of the ventral shaft skin[Table2] in DIGU and two(14.3%) in TIP. The urethral tube was fine, and the skin wound healed by secondary intention. Two(12.5%) children had meatal stenosis[Table2][Figure2] in DIGU, in which the children responded well to frequent dilatation, and four(28.6%) in the TIP procedure[Figure3]; as regards urethral stricture,[Table3] one(6.2%) child had stricture in DIGU and four(28.6%) childrenin TIP, with nonsignificant decrease of postoperative urethral stricture in DIGU(P>0.05).
Table 1: Preoperative site of urethral meatus in the studied patients

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Table 2: Postoperative complications in the studied patients

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Figure 2: A 3-year-old boy with coronal hypospadias operated by dorsal inlay graft surgical technique: (a) Preoperative; (b) Intraoperative; (c) inner preputial graft; (d) 1 month postoperatively; (e) Postoperative voiding; (f) retrograde urethrogram (normal caliber); (g) 3 months postoperatively before completion of circumcision.

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Figure 3: A 4-year-old boy with coronal hypospadias operated by Snodgrass surgical technique: (a) Preoperative; (b) Intraoperative; (c) postoperative; (d) postoperative urethrogram showing urethral stricture; (e) Postoperative voiding. (narrow urinary stream); (f) meatomy was performed; (g): postmeatomy final appearance.

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Table 3: Incidence of urethral stricture in the studied groups

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  Discussion Top

Hypospadias is defined as an incomplete virilization of the genital tubercle, leading to an ectopic opening of the urethra on the ventral aspect of the penis, anywhere from the glans to the perineum. Its incidence is about 1/300 in live male infant births. Surgical repair is the mainstream of therapy and one of the most common procedures performed by pediatric urologists. The aim of hypospadias repair is to achieve normal urinary and sexual function with good esthetic result and self-confidence of the child [10].

The results of this study using TIP with dorsal inlay graft technique in the repair of distal penile hypospadias has emphasized its efficacy, as there was one out of 16(6.2%) cases with partial wound dehiscence and two out of 14(14.3%) cases in Snodgrass technique, explained by decreased pressure on the neourethra.

Urethrocutaneous fistula is the most common and serious complication of the surgical technique of hypospadias repair, and its incidence can be used to judge the success of hypospadias repair [11]. The incidence of fistula is less in urethral plate preservation procedures like TIP and onlay flap as compared with inner preputial flap and tube urethroplasty [12].

In this study, urethrocutaneous fistula occurred in three cases(21.4%) of the Snodgrass group as compared with two(12.5%) cases of the dorsal inlay graft group. However, statistical analysis shows that there is no significant difference between them(P>0.05). The high incidence of fistula in the Snodgrass group compared with the dorsal inlay graft group may be attributable to the resultant urethral stricture and meatal stenosis caused by secondary intention healing of the back cut, which increases the risk of developing urethrocutaneous fistula.

Meatal stenosis generally occurs in up to 7% of patients after hypospadias repair [2]. Early dilatation of the neourethra after hypospadias repair is a useful method for the early disclosure and treatment of meatal stenosis [13]. Meatal stenosis occurred in four(28.6%) cases of the Snodgrass group and two(12.5%) cases in the dorsal inlay graft group treated with periodic gradual urethral dilatation over6weeks.

Asanuma etal. [9], in their study, have reported on their results of the dorsal inlay graft procedure performed on 28patients with no deep groove and no severe curvature. At a mean of 22months of follow-up, an urethrocutaneous fistula developed in only one(3.6%) patient, requiring repair surgery 6months after urethroplasty. No patient had meatal stenosis, neourethral stricture, or urethral diverticulum along the inlay graft.

This technique, although initially described for primary repair, has also been used for hypospadias reoperations. Ye etal. [14] have reported on their experience with single-stage dorsal inlay buccal mucosal grafts using the Snodgrass technique for complex redo cases in 53patients aged 3–34years. After a follow-up of 14–30months(mean: 22.6months), the total complication rate was 15.1%, with five cases of fistula and three cases of stricture. The authors opined that this approach represented an effective, simple, and safe option for reoperations.

Leslie etal. [15] analyzed the histological and functional characteristics of the TIP versus dorsal inlay graft urethroplasty in an experimental rabbit model. Atotal of 24 NewZealand male rabbits were randomly allocated into four groups, including sham operation, urethroplasty, TIP urethroplasty, and dorsal inlay graft urethroplasty. In the urethroplasty group the anterior urethral wall was half excised, and the dorsal aspect was tubularized. In the TIP group, the same steps were followed but tubularization followed a longitudinal midline incision in the dorsal wall. In the dorsal inlay graft group, the defect created by the dorsal incision was covered with an inner preputial graft. The animals were killed at 4 and 8weeks, respectively. The grafts were examined in all the animals. The TIP defect was bridged by the urothelium, whereas in the dorsal inlay graft group the preputial graft kept its original histological characteristics. In this short-term rabbit model, dorsal inlay graft urethroplasty was feasible with good graft take and integration. Simple tubularization of a reduced urethral plate led to a significantly decreased flow.

  Conclusion Top

Primary dorsal inlay inner preputial graft urethroplasty successfully fulfills all traditional hypospadias repair criteria. It offers a viable, safe, rapid, and easy option in the management of proximal hypospadias with a narrow urethral plate.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

SnodgrassWT. Tubularized incised plate urethroplasty for distal hypospadias. JUrol 1994; 151:464–465.  Back to cited text no. 1
SnodgrassW, KoyleM, ManzoniG, HurwitzR, CaldamoneA, EhrlichR. Tubularized incised plate hypospadias repair: results of a multicenter experience. JUrol 1996; 156(Pt 2):839–841.  Back to cited text no. 2
ChengEY, VemulapalliSN, KroppBP, PopeJC, FurnessIII PD, KaplanWE, etal. Snodgrass hypospadias repair with vascularized dartos flap: the perfect repair for virgin cases of hypospadias J Urol 2002; 168:1723.  Back to cited text no. 3
GurdalM, TekinA, KirecciS, SengorF. Intermediate-term functional and cosmetic results of the Snodgrass procedure in distal and midpenile hypospadias. Pediatr Surg Int 2004; 20:197.  Back to cited text no. 4
MarteA, Di IorioG, De PasqualeM, CotrufoAM, Di MeglioD. Functional evaluation of tubularized-incised plate repair of midshaft-proximal hypospadias using uroflowmetry. BJU Int 2001; 87:540–543.  Back to cited text no. 5
HammoudaHM, El-GhoneimiA, BagliDJ, McLorieGA, KhouryAE. Tubularized incised plate repair: functional outcome after intermediate follow up. JUrol 2003; 169:331–333.  Back to cited text no. 6
SpagnoliA, ZaccaraA, FerroF. Snodgrass urethroplasty: grafting the incised plate. Presented at annual meeting of American Academy of Pediatrics, Section on Urology, San Francisco, California, 17–19October 1998. p.141  Back to cited text no. 7
KolonTF, GonzalesET. The dorsal inlay graft for hypospadias repair. JUrol 2000; 163:1941.  Back to cited text no. 8
AsanumaH, SatohH, ShishidoS. Dorsal inlay graft urethroplasty for primary hypospadiac repair. Int J Urol 2007; 14:43–47.  Back to cited text no. 9
BaillargeonE, DuanK, BrzezinskiA, JednakR, El SherbinyM. The role of preoperative prophylactic antibiotics in hypospadias repair. Can Urol Assoc J 2014; 8:236–240.  Back to cited text no. 10
RetikAB, KeatingM, MandellJ. Complications of hypospadias repair. Urol Clin North Am1988; 15:223–236.  Back to cited text no. 11
UygurMC, UnalD, TanMO, GermiyanogluC, ErolD. Factors affecting outcome of one-stage anterior hypospadias repair: analysis of 422cases. Pediatr Surg Int 2002; 18:142–146.  Back to cited text no. 12
RadojicicZI, PerovicSV, StojanoskiKD. Calibration and dilatation with topical corticosteroid in the treatment of stenosis of neourethral meatus after hypospadias repair. BJU Int 2006; 97:166–168.  Back to cited text no. 13
YeWJ, PingP, LiuYD, LiZ, HuangYR. Single stage dorsal inlay buccal mucosal graft with tubularized incised urethral plate technique for hypospadias reoperations. Asian J Androl 2008; 10:682–686.  Back to cited text no. 14
LeslieB, JesusLE, El-HoutY, MooreK, FarhatWA, Bägli DJ. Comparative histological and functional controlled analysis of tubularized incised plate urethroplasty with and without dorsal inlay graft: a preliminary experimental study in rabbits. JUrol 2011; 186:1631–1637.  Back to cited text no. 15


  [Figure1], [Figure2], [Figure3]

  [Table1], [Table2], [Table3]


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