The Nigerian Experience with Hypospadias Repair

Abstract

In this issue (July-Sep 2024) of the Pediatric Surgery in Tropics, Dr. Ugwu et.al have reported their experience with hypospadias in Nigerian children.(1) It is commendable that they have improved the results of their hypospadias repairs over a few years. The authors have not mentioned certain details such as the width of the urethral plate, the width of the glans and the degree of chordee following penile degloving. Tubularized incised plate urethroplasty (TIPU) was employed in 51 of the 64 patients, including the 5 out of 7 penoscrotal hypospadias. TIPU is a versatile, reliable, cosmetic and functionally successful surgical method mainly used in distal hypospadias; but in recent times it is also used in some proximal varieties. Its main complications are urethro-cutaneous fistula, urethral meatus stenosis, glans dehiscence and urethral meatus dehiscence that the authors have noted in their series too. The urethro-cutaneous fistula and meatal stenosis rates have been reported as high as 12% and 15% respectively in a recent article.(2) Narrow urethral plate, flat glandular groove and small glans were found to be significantly associated with higher complication rates in TIPU. Further, Snodgrass advocated that a small glans (usually associated with proximal hypospadias) measuring less than 14 mm in width is not ideal for TIPU.(3) Some authors believe that TIPU should not be used if the urethral plate width (UPW) is less than 8 mm.(4,5), though Snodgrass denies the significance of this parameter.(6) Others believe that the functional outcome rather than cosmetic appearance of hypospadias repair is predicted by the UPW.(7) Mathieu’s urethroplasty is a good option for distal hypospadias with a narrow urethral plate and is recommended.(8) A hybrid technique of Mathieu’s urethroplasty incorporated with TIPU is also in vogue for distal penile hypospadias with small glans and shallow urethral plate.(9) Another point of controversy could be the use of a single-stage TIPU in patients with proximal hypospadias with significant chordee. There is no mention in the paper about the use of artificial erection test or the use of dorsal plication when single-stage urethroplasty was employed in such patients. Staged procedures should be more liberally performed in such cases as they tend to have better cosmetic and functional results.(10)