Urethral advancement and glanuloplasty versus tubularized incised plate urethroplasty for distal hypospadias repair: a prospective randomized study

This prospective randomized comparative study was conducted at Al-Azhar University Hospitals from April 2022 to October 2022 to compare urethral advancement &glanuloplasty and TIP urethroplasty techniques for distal hypospadias repair. Preoperative inclusion criteria included primary cases and absence of severe chordee using eyeball assessment of curvature; intraoperative criteria included the absence of chordee after artificial erection test, while exclusion criteria were recurrent cases, cases with severe chordee, a proximal variant of hypospadias and cases with coagulation disorders. Any case with severe chordee (30 degrees of curvature or more) using eyeball assessment of curvature before the operation or after degloving of the penis and doing an artificial erection test that required any other surgical intervention for correction of chordee was excluded from the study. Only cases with mild chordee resolved entirely by degloving of the penis were included in the study. Fifty-seven cases with different types of hypospadias were assessed for eligibility. Among them, seven cases were excluded due to the presence of chordee (n = 3), proximal variant (n = 2), and recurrent cases of hypospadias (n = 2). Fifty cases were randomly divided into two groups using a 1:1 ratio (computer-generated randomization, single-blind). Twenty-five cases were subjected to urethral advancement and glanuloplasty; the rest were subjected to TIP urethroplasty (Fig. 1). The study protocol was approved by the Research ethics committee of the Faculty of medicine for Girls, Cairo, Al-Azhar University (FMG-IRB), Nasr City, Cairo, Egypt (approval number: 1323) and registered at the Pan African Clinical Trials Registry (number for the registry is: PACTR202211757905870). All procedures were performed under the Helsinki Declaration [12]. Informed consent was obtained from parents prior to the study. All patients’ medical history, physical examination results, and biochemical profiles (including complete urine analysis, coagulation profile, blood urea, and serum creatinine) were obtained. The sample size was calculated using Stata 17 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.) for the prevalence of hypospadias (1.4–3.3%) reported by Chul Kim et al. [13]. The minimum sample size required was calculated to be 50 using a confidence limit of 5% and power of 80%. Thus, 50 cases were allocated and randomly divided into two groups (25 cases per group).

Fig. 1figure 1

CONSORT flowchart of the study

Surgical techniques

The repair was performed in all patients under general anesthesia with a caudal nerve block in the supine position. First, a traction suture was placed at the glans, and then a silicone urethral catheter was passed (the caliber was selected according to the patient’s age and meatal size). After a circumcising incision, staying under the meatus in the ventral surface of the penis, complete degloving of the penis was done, releasing any tethered tissue causing chordee. Then, after a tourniquet was applied, an artificial erection test was done in all cases to detect the presence of any significant residual chordee. In the urethral advancement and glanuloplasty technique, we performed a meticulous periurethral dissection down to the corpora cavernosa on both sides (about 1–1.5 cm) using a magnifying Loupe (3.5×) and fine instruments. The urethra was then separated from the corpora cavernosa until an appropriate length of the urethra was achieved to reach the tip of the glans without tension. Then, glans wings were developed, and urethral advancement was done. The urethra was fixated in the new site to the glans at 11, 12, 1, 4, and 8 o’clock using a 6/0 polydioxanone suture (PDS) suture. The glans was closed using interrupted mattress sutures with 6/0 Vicryl. Then, the tourniquet was released. After skin closure, the excess foreskin was removed, and circumcision was performed (Fig. 2). A tight dressing was placed for 24 h postoperatively, and a traction suture was used to fix the catheter to the dorsal surface away from the suture line. TIP urethroplasty was performed using the classic technique described by Snodgrass [9]. A 1- to 2-mm incision was made proximal to the meatus, and two parallel longitudinal incisions along the urethral plate were made. Then, glandular wings were developed, and a midline incision of the plate was made down to the underlying corpora from the meatus up to the tip of the glans. Then, tubularization was done using a 6/0 PDS suture around the catheter. A loose vascularized dartos flap from the prepuce and/or the shaft was used as a second layer to cover the neourethra. Then, the glans, skin closure, and dressing were performed as described previously (Fig. 3). The urethral catheter was left 7 days postoperatively in both techniques for fear of glandular edema that happened postoperatively and compressed urethra, causing urinary complaining. except in one case who developed mild wound infection in which the stent was left for three additional days.

Fig. 2figure 2

Modified MAGPI: (a) before operation, (b) after degloving, (c) development of glans wings and urethral mobilization, and (d) final appearance after glans and skin closure

Fig. 3figure 3

TIP urethroplasty: (a) before operation, (b) U-shaped incision around the urethral plate, (c) after degloving, and (d) final appearance after glans and skin closure

Follow-up

Follow-up was done for all cases in the outpatient clinic at 3 days, 7 days, 3 weeks, and 2 months postoperatively to detect complications. All complications were recorded for analysis. The operators observed the voiding stream force and direction postoperatively to detect any abnormality, and meatal stenosis was confirmed if they failed to pass 6 French catheter through the meatus postoperatively. Success was defined in both groups functionally when the patient had a straight and good urine stream and cosmetically when the patient had glans with a normal conical appearance and orthotopic slit-like meatus.

Statistical analysis

The collected data were revised, coded, tabulated, and introduced to a personal computer using Statistical Package for Social Science (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Student’s t-test was used to assess the statistical significance of the difference between the two study group means. The Mann–Whitney U test was used to assess the comparison between two nonparametric groups. The chi-square test was used to examine the relationship between two qualitative variables. Statistical significance was considered at p < 0.05 and a 95% confidence interval.

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