Tubularized Incised Plate Urethroplasty (TIP)

The Tubularized Incised Plate repair (Snodgrass 1994) is based on the assumption that midline incision into the urethral plate may widen it sufficiently for urethroplasty without stricture. Many centres report excellent results with this technique. There are two important criteria to achieve good results: the urethral plate should not be less than 1 cm wide and there should be no distal deep chordee. The technique has gained popularity because it is easily performed, with few complications and results in a slit-like meatus. The importance of regular dilatation is still controversial.

Operative Steps

• A traction suture is placed in the glans just beyond the anticipated dorsal lip of the neomeatus. A circumscribing skin incision is made 1–2 mm proximal to the meatus and the shaft skin is degloved to the penoscrotal junction.
• The urethral plate is separated from the glans wings by parallel incisions. The glans wings are mobilized carefully.
• A relaxing incision is made in the midline of the urethral plate without reaching the glans tip. A 6 Fr stent is secured, and tubularization is completed with a two-layer running subepithelial closure using 7-0 polyglactin.
• Dartos tissue is used to cover the neourethra, and a dorsal dartos pedicle is transposed ventrally for additional protection.
• The glans and skin are closed using 6-0 polyglactin and 7-0 chromic catgut sutures.
• Byars’ flaps are created from preputial skin to mimic the median raphe. Tegaderm dressing is applied. Stent is removed after about one week.

Complications: Occurs in 5–35% for distal hypospadias and up to 65% in proximal hypospadias, including meatal stenosis, persistent fistula, obstruction, and persistent chordee.

Transverse Preputial Island Flap

Operative Steps

• Deep Y-shaped incision on the glans, excision of chordee or fibrous tissue. Meatus is assessed and widened if needed.
• Penile and preputial skin are degloved preserving pedicle arteries.
• A 1.5 cm wide rectangular flap is prepared, tubularized around a 10 Fr catheter, and sutured to the meatus.
• The pedicle is separated from the outer preputial skin down to the root of the penis.
• Glanular wings are rotated medially around the neourethra, with transverse mattress sutures applied. De-epithelialization is performed for protection.

Complications: Fistula, wound disruption, diverticulum, and rotation occur in 10–30% of patients.

MAGPI (Meatal Advancement and Glanuloplasty Incorporated)

This technique may be used for glanular hypospadias with a mobile urethral meatus that can be pushed to the tip. If the meatus is immobile, outcomes are less satisfactory.

Operative Steps

• Meatal advancement by cutting the dorsal lip longitudinally and, in classical MAGPI, closing transversely.
• Glanuloplasty by rotating flattened glanular wings ventrally into a conical shape and two-layered glans tissue reapproximation.

Complications: Meatal regression may occur if the technique is used in cases with immobile meatus. Precision is required to achieve a conical glans.

Onlay Island Flap

The Onlay Island Flap is ideal for proximal hypospadias without deep chordee. If chordee is less than 30°, dorsal placation can be preferred instead of excision.

Operative Steps

• Midline vertical incision is made on the glans, creating a wide glanular groove for the meatus.
• Subcoronal incision is made around the glans, extending along the urethral plate and glanular groove.
• Degloving of the skin, preservation of pedicle arteries, and flap preparation from the inner prepuce.
• The Onlay flap is sutured into place with a running 7-0 polyglactin suture. Glans wings are rotated medially around the neourethra.

Complications: Fistula, wound disruption, rotation, and recurrent curvature occur in 10–20% of patients.