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Indian Journal of Plastic Surgery
Medknow Publications on behalf of Indian Journal of Plastic Surgery
ISSN: 0970-0358 EISSN: 1998-376x
Vol. 43, Num. 1, 2010, pp. 27-28

Indian Journal of Plastic Surgery, Vol. 43, No. 1, January-June, 2010, pp. 27-28

Commentary

Hypospadias algorithm: The way to propose

Wagih Mommtaz Ghnnam

Mansoura Faculty of Medicine, General Surgery Department, Mansoura University, Egypt

Correspondence Address: Dr. Wagih Mommtaz Ghnnam, Mansoura Faculty of Medicine, General Surgery Department, Mansoura University, Egypt, wghnnam@gmail.com

Code Number: pl10007

Tubularized incised plate repair is based on an old principle of urethral plate tubularization, also known as the Thiersch-Duplay procedure. Although a good concept, its main drawback was the limitation imposed by the width of the urethral plate. Snodgrass popularized the concept of urethral plate incision with subsequent tubularization and secondary dorsal healing for primary hypospadias repair. This relatively simple yet elegant and effective procedure has gained widespread acceptance, currently being recognized as the surgical technique of choice for distal and other types of hypospadias repair.^[1],[2],[3] In the present study, it is a good effort from the authors to propose the algorithm for hypospadias repair; however, to my mind, it cannot be postulated according to these small number of cases along with no comparison with different techniques and choices.

Decision making in hypospadias repair is no longer determined by meatal location, as in the past, but by severity of penile curvature and appearance of the incised urethral plate. Severe curvature, requiring plate transection or an "unhealthy" incised plate are uncommonly encountered.

A treatment Algorithm must consider the following:

Differentiation between functionally necessary and aesthetically feasible operative procedures
Establishing therapeutic objectives
Pre-operative hormonal treatment
Age at surgery
Penile curvature
Preservation of the well-vascularised urethral plate
Re-do hypospadias repairs
Urethral reconstruction
Urine drainage and wound dressing
Adolescent satisfaction with penis size
Rate of fistula formation

The second thing is the rate of fistulae. Although it is comparable to the literature, they do not favour use of a two-layer coverage and deny that Snodgrass has recommended two-layer neourethra closure to decrease fistula formation in all types of hypospadias defects. Several factors may influence fistula formation, such as surgical technique, delicate tissue handling, patient age, type of hypospadias defect, surgeon's experience, water-proof urethroplasty coverage and concomitant foreskin reconstruction.

The meatal stenosis rate varies from 0 to 17%, and Snodgrass has reported meatal stenosis rates below 1%. This has been a controversial topic and considered to be possibly related to the surgical technique. In the present study, meatal stenosis was high (8.8%), with no explanation for this high rate.

References

1.	Duplay S. On the surgical treatment of hypospadias in pispadias. Arch Gen Med 1880;145-9. Back to cited text no. 1
2.	Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464-5. Back to cited text no. 2 [PUBMED]
3.	Cook A, Khoury AE, Neville C, Bagli DJ, Farhat WA, Pippi Salle JL. A multicenter evaluation of technical preferences for primary hypospadias repair. J Urol 2005;174:2354-7, discussion 2357. Back to cited text no. 3 [PUBMED] [FULLTEXT]

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