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Simplifying the surgical approach to glanular and coronal hypospadias: Longitudinal urethral incision and glanuloplasty
Journal of Pediatric Urology (2007) 3, 453e456
Simplifying the surgical approach to glanular and coronal hypospadias: Longitudinal urethral incision and glanuloplasty Santiago Vallasciani a,*, Antonio Spagnoli a, Alessandro Borsellino a, Luisa Martini b, Fabio Ferro a a
Andrological and Gynecological Surgery Unit, Bambino Gesu` Pediatric Hospital e Research Institute, Piazza S. Onofrio 4, 00165 Rome, Italy b Anesthesiology Unit, Bambino Gesu` Pediatric Hospital e Research Institute, Piazza S. Onofrio 4, 00165 Rome, Italy Received 18 January 2007; accepted 4 June 2007 Available online 13 August 2007
KEYWORDS Glanduloplasty; Hypospadias; Penile surgery; Urethroplasty
Abstract Objective: Meatal advancement with glanuloplasty incorporated (MAGPI) is an appropriate approach for most glanular and coronal hypospadias. The very low incidence of complications with this technique (i.e., fistulas, meatal regression and stenosis) makes MAGPI very competitive if compared with other approaches proposed for similar anatomical defects. In certain cases, however, the MAGPI approach has led to an unsatisfactory neo meatus; instead of a natural slit-like appearance, the meatus can look too rounded and puckered. Methods: The last 84 patients referred to our unit with indications suitable for MAGPI (mean age 39 months) were operated on using a novel approach: the glanuloplasty was associated with a simple deep urethral plate incision, extending along the urethral channel, and left unsutured. Results: At minimum follow up of 12 months two meatal regressions to mid glans were recorded. No meatal stenosis was seen in this series. Conclusion: This approach allowed us to achieve a conical glans with a natural looking meatus, avoiding urethral sutures. ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: þ39 338 8004532; fax: þ39 06 6859 2207. E-mail address: [email protected] (S. Vallasciani).
In about 50% of patients with hypospadias, the meatus lies in a distal position with glanular and coronal percentages varying between different classifications and series. Within this spectrum, there are usually cases where the meatus
1477-5131/$30 ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2007.06.004
454 lies between the glans’ wings [1,2]. In such instances, the indication to correct the defect is based both on cosmetic and functional considerations. For this reason, the need for surgery to correct this kind of defect was controversial until it was recognized that a normal appearance of the penis is particularly relevant in adolescents. In addition, various authors have highlighted the fact that an abnormal aesthetic appearance of the penis is the greatest source of anxiety and complaint in adult hypospadias patients. It is very hard for a patient, especially an adolescent, to accept a curved penis with a divided prepuce, and an imperfectly shaped glans with a small, round and ectopic meatus [3e5]. Naturally, the correction of hypospadias for mainly aesthetic reasons should be performed with minimal incidence of complications and with concern for the psychological development of the patient. The right technical choice can reasonably provide such results. The meatal advancement with glanuloplasty incorporated (MAGPI) operation, introduced by Duckett in 1981 [2] and successively modified by the same author to avoid the risk of meatal retraction [6], seems to provide the answer. Complications following the Mathieu ‘flip-flap’ repair, urethral advancement according to Beck or the Mustarde ´e Hendren procedure is undoubtedly more frequent [2]. However, meatal advancement with the HeinekeeMikulicz tissue rearrangement, the focal point of MAGPI, can lead to an abnormal meatal configuration that, even in the terminal position, may appear round and abnormally puckered [5].
Materials and methods In the period 2001e2005, 379 patients were treated for hypospadias in our unit; 259 (68%) were distal hypospadias (glandular, coronal, distal penile), 84 of them (22%) with the meatus in glandular or coronal position and limited spongiosum defect (glandular Z 43, 51%; coronal Z 41, 49%). Seventy-nine were primary cases and five were redo cases (previous correction by tubularized incised plate urethroplasty in three cases, classic MAGPI in two cases). Patients with megameatus, meatus in distal penile position or those with meatus in coronal or glandular position with extended spongiosum defect were dealt with by using other
S. Vallasciani et al. approaches (TIUP 147 cases, 84%; Beck 19 cases, 10%; Duplay nine cases, 6%) and excluded from this study. Examples of cases in whom this approach is indicated or contraindicated are shown in Fig. 2. Surgery was performed at a mean age of 39 months (min. 9.4emax. 143) under mask-assisted general anaesthesia plus a novel regional block, which is our alternative to caudal block. This block consists of inoculation with ropivacain 2 or 10 mg/ml (0.2 mg/kg) obtained by sliding the needle vertically along the internal surface of the left iliac crest until perceiving the vacuum sensation of the retroperitoneum. Once the penis has been degloved, an incision is made along the midline of the urethral plate with a scalpel. This incision is then lengthened and deepened for 4e5 mm behind the meatus and left unsutured. Any bleeding was staunched by fine-needle monopolar electrocautery. After that, rotation of the glanular wings (as in MAGPI procedure) is performed to produce the meatal advancement. Approximation of the glans wings was performed in two layers by deep stitches of polyglactin 5 or 6/0 and superficial sutures of 6/0 or 7/0 of rapid absorbable suture. A catheter (Foley or stent, 7 or 8 Ch, depending on age) was left in place for 3e5 days during which time antibiotic prophylaxis was maintained. The steps of the surgical procedure are summarized in Fig. 1.
Results Mean operating time was 59 min. After the penis was degloved, and the spongiosum defect evaluated was limited (usually <3 mm), persistent curvature less than 30 was corrected by dorsal plication in 14 cases. The immediate postoperative period was free of complications. Two patients presented persistent urethral bleeding which resolved spontaneously within 24 h. Hospital mean stay was 3 days; patients who were resident close to the hospital (less than 1 h distant) were treated on a day-case basis. All cases were recorded photographically before and after the procedure for follow up and aesthetic evaluation. At a mean follow up of 37.9 months (min. 12emax. 71), two meatal regressions to mid glans were recorded, both in the early postoperative period (1 month). These cases were
Figure 1 Details of surgical procedure with an example case (lateral). The sketch shows how the deep urethral incision allows a tension-free approximation of glans’ wings.
The surgical approach to glanular and coronal hypospadias
455
Figure 2 Examples of cases not suitable (top line: (a) spongiosum defect longer than 3 mm, yellow arrow line; (b) hypospadiac meatus proximal to bounds of the glans’ wings, yellow arrow line; (c) megameatus) or suitable (middle line) for this procedure, and postoperative aspect of suitable cases (bottom line) after 12 months’ minimum follow up. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
successfully repaired by dorsal inlay augmented urethroplasty 6 months later. Results are illustrated in Fig. 2.
Discussion After the first description by Duckett [2], MAGPI became the most utilized approach worldwide for most variants of glanular and coronal hypospadias. Its ready acceptance was logical after a comparison between the incidence of complications with this technique and with the procedures previously used to correct the same anatomical variants of hypospadias (Mathieu, Van der Meulen, Beck, Mustarde ´-
Hendren). The technique was not always completely satisfactory from a cosmetic point of view, which led Duckett to modify and refine it, advising that the original MAGPI was suitable for 50% of distal hypospadias [6]. Of the modifications suggested, the most important was a sturdier glanuloplasty [6]. There is general agreement that the principal cause of complications arising from MAGPI is an overindication on the part of surgeons. For this reason, patients with a urethral spongy defect longer than 3 mm, even with meatus in distal position, were excluded from this study; the hypoplastic urethra does not allow a safe ventral meatal advancement.
456 Recent papers assessing patient satisfaction found that micturition appears to be less important than the meatal position, since the anatomical appearance of the penis is more important to patients than the strictly functional aspect [4,5,7]. Despite refinements to avoid a retrusive and stenotic meatus, the appearance of the neomeatus after MAGPI can still be abnormal. This problem could be related to the fact that the HeineckeeMikulicz manoeuvre performed in the urethral plate often distorts the glans by pulling the tip down proximally, producing a rounded and blunt meatus, because the mobility of the glans tip exceeds the elasticity of the urethral plate. In fact, Hodgson considered MAGPI to be an ‘‘illusion’’ because the glans is incorporated into the meatus and not the contrary [8]. In our previous experience with ‘classic MAGPI’ (74 patients operated between 1997 and 2000), in cases where the glandular urethral groove is too flat, or even absent, there is an increased risk of meatal stenosis in addition to the puckered described meatus when MAGPI is performed. The hinging of the urethral plate in flip-flap or onlay techniques has been shown to be capable of achieving a slit-like meatus [9]. Rapid and safe re-epithelialization of the urethral plate following a deep incision has been widely confirmed by the Snodgrass approach [10,11], and further investigated in animal models with stent-less urethral incised urethroplasties [12]. In our experience, no stenosis was observed in those cases of incised urethral plate urethroplasty in which the stent was accidentally removed before the scheduled time. Initially, this approach was limited to redo cases with meatal retraction after hypospadias repair with an insufficiently deep urethral plate, owing to the good results reported by Snodgrass for his urethral plate incision technique in redo cases [13]. Case selection was based on the absence of a grossly scarred urethral plate in addition to the meatal position. Previous urethral plate incisions were not a contraindication. The very good results prompted us to extend the indication for this approach to primary defects. One recognized advantage of MAGPI is that it can be performed on an outpatient basis without urinary diversion. While the use of a stent or catheter could be considered a disadvantage of the modification we have described, it has not been a source of complications or difficulties in managing the patient on an outpatient basis and, even though a stent-less Snodgrass procedure has been reported [12], we prefer to leave the catheter in to help urethral plate re-epithelialization and prevent bleeding associated with the incision. The deep plate incision is, in our opinion, the crucial manoeuvre, allowing optimal rotation of the glanular wings with the result of tension-free glanuloplasty. This rotation is possible only in selected cases: those with a limited spongiosum defect (cases with spongiosum defects longer
S. Vallasciani et al. than 3 mm were excluded from the present series) and hypospadiac meatus within the bounds of the glans wings. Patulous or stenotic meatus was not a contraindication for this procedure. In addition, persistent curvature (less than 30 ) after degloving, treated by dorsal plication in 14 cases, was not a contraindication when the spongiosum defect was limited and the meatus was in an optimal position. In both cases of this series where meatal retraction was seen, there had been an overindication of this technique with the meatus in the distal penile position. Fig. 2 illustrates cases where this procedure should or should not be applied. This complication was evident at 1 month postoperatively; patients with a longer follow up did not show meatal regression. Dorsal inlay augmentation with buccal mucosa or penile skin has been the surgical solution of choice. The present approach, inspired by all the cited techniques, has allowed us to achieve a conical glans with a natural looking meatus, avoiding urethral sutures.
References [1] Mieusset R, Soulie ´ M. Hypospadias: psychosocial, sexual, and reproductive consequences in adult life. J Androl 2005;26: 163e8. [2] Duckett JW. MAGPI (meatoplasty and glanuloplasty) a procedure for subcoronal hypospadias. Urol Clin North Am 1981;8: 513e9. [3] Mor Y, Ramon J, Jonas P. Is only meatoplasty a legitimate surgical solution for extreme distal hypospadias? A long term follow up after adolescence. BJU Int 2000;85:501. [4] Aho MO, Tammela OKT, Tammela TLJ. Aspects of adult satisfaction with the result of surgery for hypospadias performed in childhood. Eur Urol 1997;32:218e22. [5] Bracka A. Sexuality after hypospadias repair. Br J Urol 1999; 83:29e33. [6] Duckett JW, Snyder III H. The MAGPI hypospadias repair in 1111 patients. Ann Surg 1991;213:620e6. [7] Mureau MA, Slijper FM, Slob AK, Verhulst FC, Nijman RJ. Satisfaction with penile appearance after hypospadias surgery: the patient and surgeon view. J Urol 1996;155:703e6. [8] Hodgson. Editorial comment. J Urol 1984;131:98. [9] Rich MA, Keating MA, Snyder HM, Duckett JW. Hinging the urethral plate in hypospadias meatoplasty. J Urol 1989;142: 1551e3. [10] Snodgrass WT. Tubularized incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464e5. [11] Snodgrass W. Does tubularized incised plate urethroplasty hypospadias repair create neourethral strictures? J Urol 1999; 162:1159e61. [12] Hafez AT, Herz D, Bagli D, Smith CR, McLorie G, Khoury AE. Healing of unstented tubularized incised plate urethroplasty: an experimental study in a rabbit model. BJU Int 2003;91:84e8. [13] Nguyen MT, Snodgrass WT. Tubularized incised plate hypospadias reoperation. J Urol 2004;171:2404e6.
Simplifying the surgical approach to glanular and coronal hypospadias: Longitudinal urethral incision and glanuloplasty Santiago Vallasciani a,*, Antonio Spagnoli a, Alessandro Borsellino a, Luisa Martini b, Fabio Ferro a a
Andrological and Gynecological Surgery Unit, Bambino Gesu` Pediatric Hospital e Research Institute, Piazza S. Onofrio 4, 00165 Rome, Italy b Anesthesiology Unit, Bambino Gesu` Pediatric Hospital e Research Institute, Piazza S. Onofrio 4, 00165 Rome, Italy Received 18 January 2007; accepted 4 June 2007 Available online 13 August 2007
KEYWORDS Glanduloplasty; Hypospadias; Penile surgery; Urethroplasty
Abstract Objective: Meatal advancement with glanuloplasty incorporated (MAGPI) is an appropriate approach for most glanular and coronal hypospadias. The very low incidence of complications with this technique (i.e., fistulas, meatal regression and stenosis) makes MAGPI very competitive if compared with other approaches proposed for similar anatomical defects. In certain cases, however, the MAGPI approach has led to an unsatisfactory neo meatus; instead of a natural slit-like appearance, the meatus can look too rounded and puckered. Methods: The last 84 patients referred to our unit with indications suitable for MAGPI (mean age 39 months) were operated on using a novel approach: the glanuloplasty was associated with a simple deep urethral plate incision, extending along the urethral channel, and left unsutured. Results: At minimum follow up of 12 months two meatal regressions to mid glans were recorded. No meatal stenosis was seen in this series. Conclusion: This approach allowed us to achieve a conical glans with a natural looking meatus, avoiding urethral sutures. ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: þ39 338 8004532; fax: þ39 06 6859 2207. E-mail address: [email protected] (S. Vallasciani).
In about 50% of patients with hypospadias, the meatus lies in a distal position with glanular and coronal percentages varying between different classifications and series. Within this spectrum, there are usually cases where the meatus
1477-5131/$30 ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2007.06.004
454 lies between the glans’ wings [1,2]. In such instances, the indication to correct the defect is based both on cosmetic and functional considerations. For this reason, the need for surgery to correct this kind of defect was controversial until it was recognized that a normal appearance of the penis is particularly relevant in adolescents. In addition, various authors have highlighted the fact that an abnormal aesthetic appearance of the penis is the greatest source of anxiety and complaint in adult hypospadias patients. It is very hard for a patient, especially an adolescent, to accept a curved penis with a divided prepuce, and an imperfectly shaped glans with a small, round and ectopic meatus [3e5]. Naturally, the correction of hypospadias for mainly aesthetic reasons should be performed with minimal incidence of complications and with concern for the psychological development of the patient. The right technical choice can reasonably provide such results. The meatal advancement with glanuloplasty incorporated (MAGPI) operation, introduced by Duckett in 1981 [2] and successively modified by the same author to avoid the risk of meatal retraction [6], seems to provide the answer. Complications following the Mathieu ‘flip-flap’ repair, urethral advancement according to Beck or the Mustarde ´e Hendren procedure is undoubtedly more frequent [2]. However, meatal advancement with the HeinekeeMikulicz tissue rearrangement, the focal point of MAGPI, can lead to an abnormal meatal configuration that, even in the terminal position, may appear round and abnormally puckered [5].
Materials and methods In the period 2001e2005, 379 patients were treated for hypospadias in our unit; 259 (68%) were distal hypospadias (glandular, coronal, distal penile), 84 of them (22%) with the meatus in glandular or coronal position and limited spongiosum defect (glandular Z 43, 51%; coronal Z 41, 49%). Seventy-nine were primary cases and five were redo cases (previous correction by tubularized incised plate urethroplasty in three cases, classic MAGPI in two cases). Patients with megameatus, meatus in distal penile position or those with meatus in coronal or glandular position with extended spongiosum defect were dealt with by using other
S. Vallasciani et al. approaches (TIUP 147 cases, 84%; Beck 19 cases, 10%; Duplay nine cases, 6%) and excluded from this study. Examples of cases in whom this approach is indicated or contraindicated are shown in Fig. 2. Surgery was performed at a mean age of 39 months (min. 9.4emax. 143) under mask-assisted general anaesthesia plus a novel regional block, which is our alternative to caudal block. This block consists of inoculation with ropivacain 2 or 10 mg/ml (0.2 mg/kg) obtained by sliding the needle vertically along the internal surface of the left iliac crest until perceiving the vacuum sensation of the retroperitoneum. Once the penis has been degloved, an incision is made along the midline of the urethral plate with a scalpel. This incision is then lengthened and deepened for 4e5 mm behind the meatus and left unsutured. Any bleeding was staunched by fine-needle monopolar electrocautery. After that, rotation of the glanular wings (as in MAGPI procedure) is performed to produce the meatal advancement. Approximation of the glans wings was performed in two layers by deep stitches of polyglactin 5 or 6/0 and superficial sutures of 6/0 or 7/0 of rapid absorbable suture. A catheter (Foley or stent, 7 or 8 Ch, depending on age) was left in place for 3e5 days during which time antibiotic prophylaxis was maintained. The steps of the surgical procedure are summarized in Fig. 1.
Results Mean operating time was 59 min. After the penis was degloved, and the spongiosum defect evaluated was limited (usually <3 mm), persistent curvature less than 30 was corrected by dorsal plication in 14 cases. The immediate postoperative period was free of complications. Two patients presented persistent urethral bleeding which resolved spontaneously within 24 h. Hospital mean stay was 3 days; patients who were resident close to the hospital (less than 1 h distant) were treated on a day-case basis. All cases were recorded photographically before and after the procedure for follow up and aesthetic evaluation. At a mean follow up of 37.9 months (min. 12emax. 71), two meatal regressions to mid glans were recorded, both in the early postoperative period (1 month). These cases were
Figure 1 Details of surgical procedure with an example case (lateral). The sketch shows how the deep urethral incision allows a tension-free approximation of glans’ wings.
The surgical approach to glanular and coronal hypospadias
455
Figure 2 Examples of cases not suitable (top line: (a) spongiosum defect longer than 3 mm, yellow arrow line; (b) hypospadiac meatus proximal to bounds of the glans’ wings, yellow arrow line; (c) megameatus) or suitable (middle line) for this procedure, and postoperative aspect of suitable cases (bottom line) after 12 months’ minimum follow up. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
successfully repaired by dorsal inlay augmented urethroplasty 6 months later. Results are illustrated in Fig. 2.
Discussion After the first description by Duckett [2], MAGPI became the most utilized approach worldwide for most variants of glanular and coronal hypospadias. Its ready acceptance was logical after a comparison between the incidence of complications with this technique and with the procedures previously used to correct the same anatomical variants of hypospadias (Mathieu, Van der Meulen, Beck, Mustarde ´-
Hendren). The technique was not always completely satisfactory from a cosmetic point of view, which led Duckett to modify and refine it, advising that the original MAGPI was suitable for 50% of distal hypospadias [6]. Of the modifications suggested, the most important was a sturdier glanuloplasty [6]. There is general agreement that the principal cause of complications arising from MAGPI is an overindication on the part of surgeons. For this reason, patients with a urethral spongy defect longer than 3 mm, even with meatus in distal position, were excluded from this study; the hypoplastic urethra does not allow a safe ventral meatal advancement.
456 Recent papers assessing patient satisfaction found that micturition appears to be less important than the meatal position, since the anatomical appearance of the penis is more important to patients than the strictly functional aspect [4,5,7]. Despite refinements to avoid a retrusive and stenotic meatus, the appearance of the neomeatus after MAGPI can still be abnormal. This problem could be related to the fact that the HeineckeeMikulicz manoeuvre performed in the urethral plate often distorts the glans by pulling the tip down proximally, producing a rounded and blunt meatus, because the mobility of the glans tip exceeds the elasticity of the urethral plate. In fact, Hodgson considered MAGPI to be an ‘‘illusion’’ because the glans is incorporated into the meatus and not the contrary [8]. In our previous experience with ‘classic MAGPI’ (74 patients operated between 1997 and 2000), in cases where the glandular urethral groove is too flat, or even absent, there is an increased risk of meatal stenosis in addition to the puckered described meatus when MAGPI is performed. The hinging of the urethral plate in flip-flap or onlay techniques has been shown to be capable of achieving a slit-like meatus [9]. Rapid and safe re-epithelialization of the urethral plate following a deep incision has been widely confirmed by the Snodgrass approach [10,11], and further investigated in animal models with stent-less urethral incised urethroplasties [12]. In our experience, no stenosis was observed in those cases of incised urethral plate urethroplasty in which the stent was accidentally removed before the scheduled time. Initially, this approach was limited to redo cases with meatal retraction after hypospadias repair with an insufficiently deep urethral plate, owing to the good results reported by Snodgrass for his urethral plate incision technique in redo cases [13]. Case selection was based on the absence of a grossly scarred urethral plate in addition to the meatal position. Previous urethral plate incisions were not a contraindication. The very good results prompted us to extend the indication for this approach to primary defects. One recognized advantage of MAGPI is that it can be performed on an outpatient basis without urinary diversion. While the use of a stent or catheter could be considered a disadvantage of the modification we have described, it has not been a source of complications or difficulties in managing the patient on an outpatient basis and, even though a stent-less Snodgrass procedure has been reported [12], we prefer to leave the catheter in to help urethral plate re-epithelialization and prevent bleeding associated with the incision. The deep plate incision is, in our opinion, the crucial manoeuvre, allowing optimal rotation of the glanular wings with the result of tension-free glanuloplasty. This rotation is possible only in selected cases: those with a limited spongiosum defect (cases with spongiosum defects longer
S. Vallasciani et al. than 3 mm were excluded from the present series) and hypospadiac meatus within the bounds of the glans wings. Patulous or stenotic meatus was not a contraindication for this procedure. In addition, persistent curvature (less than 30 ) after degloving, treated by dorsal plication in 14 cases, was not a contraindication when the spongiosum defect was limited and the meatus was in an optimal position. In both cases of this series where meatal retraction was seen, there had been an overindication of this technique with the meatus in the distal penile position. Fig. 2 illustrates cases where this procedure should or should not be applied. This complication was evident at 1 month postoperatively; patients with a longer follow up did not show meatal regression. Dorsal inlay augmentation with buccal mucosa or penile skin has been the surgical solution of choice. The present approach, inspired by all the cited techniques, has allowed us to achieve a conical glans with a natural looking meatus, avoiding urethral sutures.
References [1] Mieusset R, Soulie ´ M. Hypospadias: psychosocial, sexual, and reproductive consequences in adult life. J Androl 2005;26: 163e8. [2] Duckett JW. MAGPI (meatoplasty and glanuloplasty) a procedure for subcoronal hypospadias. Urol Clin North Am 1981;8: 513e9. [3] Mor Y, Ramon J, Jonas P. Is only meatoplasty a legitimate surgical solution for extreme distal hypospadias? A long term follow up after adolescence. BJU Int 2000;85:501. [4] Aho MO, Tammela OKT, Tammela TLJ. Aspects of adult satisfaction with the result of surgery for hypospadias performed in childhood. Eur Urol 1997;32:218e22. [5] Bracka A. Sexuality after hypospadias repair. Br J Urol 1999; 83:29e33. [6] Duckett JW, Snyder III H. The MAGPI hypospadias repair in 1111 patients. Ann Surg 1991;213:620e6. [7] Mureau MA, Slijper FM, Slob AK, Verhulst FC, Nijman RJ. Satisfaction with penile appearance after hypospadias surgery: the patient and surgeon view. J Urol 1996;155:703e6. [8] Hodgson. Editorial comment. J Urol 1984;131:98. [9] Rich MA, Keating MA, Snyder HM, Duckett JW. Hinging the urethral plate in hypospadias meatoplasty. J Urol 1989;142: 1551e3. [10] Snodgrass WT. Tubularized incised plate urethroplasty for distal hypospadias. J Urol 1994;151:464e5. [11] Snodgrass W. Does tubularized incised plate urethroplasty hypospadias repair create neourethral strictures? J Urol 1999; 162:1159e61. [12] Hafez AT, Herz D, Bagli D, Smith CR, McLorie G, Khoury AE. Healing of unstented tubularized incised plate urethroplasty: an experimental study in a rabbit model. BJU Int 2003;91:84e8. [13] Nguyen MT, Snodgrass WT. Tubularized incised plate hypospadias reoperation. J Urol 2004;171:2404e6.