A modification of the MAGPI procedure

A M o d i f i c a t i o n of the M A G P I Procedure By Michael Dimler, M. David Gibbons, and Anthony Haley Johnson City, Tennessee 9 Since its description in 1981, t h e MAGPI p r o c e dure has rapidly assumed a major :role in t h e repair o f coronal and subcoronal hypospadias w i t h o u t chordee. Success w i t h this p r o c e d u r e depends upon careful a t t e n t i o n t o detail and p r o p e r patient selection. Despite heeding t h e s e caveats the authors have noted occasional p a t i e n t s w h o , following completion of a MAGPI. have a disturbing " ' f i s h m o u t h " quality to the meatus. Herein is described a simple modification t h a t seems t o improve the c o s m e t i c results w h e n this s i t u a t i o n is encountered. INDEX WORDS: Hypospadias; MAGPI procedure.

N 1981 Duckett I reported on a surgical proce-

I dure for patients with distal hypospadias, not associated with chordee, calling it the MAGPI procedure for meatal advancement and glanuloplasty. The advantages of this technique are an improved cosmetic appearance without need for urinary diversion and a very low complication rate. Because of these features, the procedure requires minimal hospitalization and is even suit-

incision line

MATERIALS AND METHODS Modification Technique V-shaped incisions are placed in the lateral recesses on each side of the "fishmouthed" meatus (Fig 1A). Note the elongated ventral lip of the meatus that contributes to the "fishmouth" appearance. Each incision can then be thought of as consisting of four lines: B'-A, B'-A', A-B, and A'-B (Fig 1B). Beginning at point B', lines B'-A and B'-A' are approximated with a running chromic 6-0 catgut suture. This same suture is then continued laterally, thereby approximating lines A-B and A'-B (Fig 1C). This maneuver is then repeated on the opposite side (Fig 1D), thus eliminating the "fishmouth" and producing a more satisfactory appearing meatus. (Fig 1E). DISCUSSION

S C

able for "same-day" surgical facilities. Acceptance of this new technique has been rapid, and several reports have already appeared in the literature attesting to the favorable results that can be attained with minimal complications.2'3 Patient selection is important to the success of the MAGPI, and the presence of certain meatal varients, namely patulous, fibrotic and hypoplastic,4 or the presence of fibrous chordee should sway the surgeon from the use of this technique. Although aware of these pitfalls, we have on occasion been faced with an unsatisfactory "fishmouth" appearance to the meatus at the completion of the MAGPI (Fig 1A) and propose this modification for correction.

D

Fig 1. (A) The completed MAGPI demonstrates the wide fishmouth m e a t u s and elongated ventral lip. The incision sites are shown. (B) Close up of incisions with lines B'-A, B'-A', A-B, and A'-B. (C) Beginning at point B', lines B'-A and B'-A' have been approximated to each other as have lines A - B and A'-B on the right side of the meatus. The left side will be similarly closed. (D) Both sides have been approximated eliminating the ventral lip and reducing the excessive meatal size. (E) The completed MAGPI with modification. The phallic skin is ready for approximation with the coronal skin. Journal of Pediatric Surgery, Vol. 19, No. 6 (December), 1984

Meatal advancement with glanuloplasty has quickly become an important procedure in the treatment of hypospadius without chordee. Relative contraindications to its use are the presence

From the Department of Surgery, Division of Pediatric Surgery, Quillen-Dishner College of Medicine, East Tennessee State University, and the Department of Urology, Division of Pediatric Urology, Georgetown University School of Medicine. Presented before the 15th Annual Meeting of the American Pediatric Surgical Association, Marco Beach, Florida, May 9-12, 1984. Address reprint requests to Dr Michael Dimler, Box 19750A ETSU, College of Medicine, Johnson City, TN 37614. 9 1984 by Grune & Stratton, Inc. 0022-3468/84/1906~900 2503.00/0 627

628

DIMLER, GIBBONS, AND HALEY

of a wide patulous meatus; a fibrotic, noncompliant meatus; or a hypoplastic meatus with deficient perimeatal spongiosum. 4 The M A G P I technique allows hypospadias repair to be performed with minimal complications, no urinary diversion and in short-stay surgical facilities thus reducing medical costs. We believe that our modification can improve the appearance of a "fishmouthed" meatus that occasionally is seen following completion of this procedure. In one case it allowed satisfactory repair in a child who

had inadvertently undergone neonatal circumcision, thus eliminating some of the other available surgical options. As with the original procedure, the modification requires no urinary diversion and therefore is consistent with same-day surgery. This modification will not replace careful attention to surgical details and proper patient selection that are the hallmarks of all hypospadias repairs but may allow further application of the M A G P I technique that we have found so satisfying.

REFERENCES

1. DuckettJW: MAGPI (meatoplastyandglanuloplasty) a procedure for subcoronal hypospasias. Urol Clin N Am 8:513-519, 1981 2. Belman AB, Kass EJ: Hypospadias repair in children less than one year old. J Urol 128:1273-1274, 1982

3. Livne PM, Gibbons MD, Gonzales ET: Meatal advancementand glanuloplasty: An operation for distal hypospadias. J Urol 131:95-98, 1984 4. Gibbons MD, Gonzales, ET: The subcoronal meatus. J Urol 130:739-742, 1983