|Year : 2017 | Volume
| Issue : 1 | Page : 12-17
Modified Mathieu’s surgical procedure for distal penile hypospadias—our institutional experience
Aditya P Singh, Arvind K Shukla, Ramendra Shukla, Jyotsna Shukla
Department of Pediatric Surgery, SMS Medical College Jaipur, Jaipur, Rajasthan, India
|Date of Web Publication||16-Aug-2017|
Aditya P Singh
Near The Mali Hostel, Main Bali Road, Falna, Dist-Pali, Rajasthan, India; Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Aims and Objective: This study was carried out to show modified Mathieu’s procedure to reduce the rate of complications of Mathieu’s procedure for the repair of primary distal hypospadias.
Settings and Design: Prospective study.
Materials and Methods: This study was carried out in the Department of Paediatric Surgery from March 2012 to March 2016. Children between 3 and 12 years were included in the study. We managed 40 patients with primary distal hypospadias. Those who had previous repair, chordee were excluded from the study. After a detailed history, local examination was performed with reference to the site and shape of meatus, glandular groove, penile size, and presence of chordee. Modified Mathieu’s was performed in 40 patients. On follow-up, the patients were examined for the position and the shape of the meatus, urinary stream, urethrocutaneous fistula, and stricture formation.
Statistical Analysis Used: Done.
Results: The mean age of the presentation was 7.5 ± 2.68 years (range 3–12 years). The mean operative time was 52.37 ± 5.42 min in modified Mathieu’s repair. Complications after surgery were urethrocutaneous fistula in one (2.5%), glandular disruption in 2 (5%), meatal stenosis in zero, wound infection in zero cases in modified Mathieu’s repair. The shape of meatus was near to rounded in all patients who had undergone modified Mathieu’s repair, which was accepted by parents cosmetically and with urinary stream in our study.
Conclusion: The modified Mathieu’s repair is significantly faster with less complication in spite of having round-shaped meatus, which was cosmetically and with good urinary stream accepted by parents in our study.
Keywords: Hypospadias, mathieu, modified, urethroplasty
|How to cite this article:|
Singh AP, Shukla AK, Shukla R, Shukla J. Modified Mathieu’s surgical procedure for distal penile hypospadias—our institutional experience. Nigerian J Plast Surg 2017;13:12-7
|How to cite this URL:|
Singh AP, Shukla AK, Shukla R, Shukla J. Modified Mathieu’s surgical procedure for distal penile hypospadias—our institutional experience. Nigerian J Plast Surg [serial online] 2017 [cited 2018 Jan 16];13:12-7. Available from: http://www.njps.org/text.asp?2017/13/1/12/213028
| Introduction|| |
Hypospadias is a congenital defect due to incomplete tubularization or fusion of the urethral plate, leading to abnormal location of the meatus anywhere along the ventral aspect of penile shaft and down on to the perineum. Hypospadias are classified into anterior (distal), middle, and posterior (proximal) according to site of native meatus. The incidence of anterior hypospadias is 71%, middle 16%, and posterior 13%.
Procedures established to correct distal penile hypospadias are the tubularized incised plate urethroplasty (TIP repair), Thiersch–Duplay, Mathieu’s repair, Mustarde, Onlay flap, and meatal advancement and glanduloplasty (MAGPI). Of these procedures, Mathieu’s and TIP urethroplasty (Snodgrass repair) have been widely practiced.
The study aims to show that our modification of Mathieu’s procedure reduces the rate of complications for the repair of primary anterior hypospadias typically associated with the traditional Mathieu’s procedure.
| Materials and Methods|| |
This prospective study was conducted between March 2012 and March 2016. A total of 40 patients with primary distal hypospadias were included in the study. Modified Mathieu’s repair was performed in every case. The previously operated cases of distal penile hypospadias with extensive scarring, severe chordee, patients with micropenis with poorly developed urethral plate, and glandular groove were excluded from the study. We did modified Mathieu’s repair only in patients with deep glandular groove, adequate glans size, and without stenotic meatus or had fish mouth meatus. Repair of hypospadias was done under general anesthesia, caudal block, and endotracheal intubation. In modified Mathieu’s repair, the urethral plate and perimeatal-based flap were marked. Typically, the width of 6 to 10 mm was measured for the proximal flap. Tourniquet was applied over the base of penis. Urethral plate and proximal shaft skin were incised about 6 to 10 mm wide and the penis was not degloved. Glandular wings were developed by deep dissection under glans to perform tension-free glanuloplasty. Two stay sutures were applied at the end of the flap. A fine scissor introduced and spread under the flap to separate it from underlying tissue. It maintained the vascularity and evenness of the flap. Proximal shaft skin flap was mobilized and transposed toward the urethral plate. This flap was folded over the urethral meatus and neourethra formed over 8 or 10 Fr silastic nasogastric (NG) tube with continuous 6-0 polyglactin subcuticular on the both sides of the flap. Neourethra was covered with additional layer of dartos tissue with three to four interrupted sutures after continuous layer closure. Additional two U-shaped sutures were taken on the either side of flap proximally at the junction. Two sutures were taken at 4 and 8 o’clock position over the meatus. Glanuloplasty and midline skin closure in two layers with polyglactin 6-0 sutures completed the procedure. Then 6 Fr silastic NG tube was put in all cases after removal of the 8/10 Fr silastic NG tube. Tourniquet was released after 30 min intermittently and removed completely after applying the first layer of the dressing. Appearance was with hooded prepuce which manages after 6 months with circumcision.
Dressing of the penis was first opened 7 days after surgery and dressing was done. The catheter was removed 10 days postoperatively in every case; patients were discharged home. All patients were maintained on antibiotic prophylaxis. Patients were followed for 6 months to 1 year. We did not routine calibration or dilatation postoperatively. Stricture formation was only diagnosed by urinary complaints and urinary stream.
These are some modifications of the technique.
- Only ventral dissection and prepuce remain intact, penis was not degloved completely.
- Mobilization of the flap by introducing the blades of the scissor under the flap and by spreading the blades.
- Two U-shaped sutures on the either side of flap proximally at the junction.
- Two sutures were taken at 4 and 8 o’clock position over the meatus.
- Urethroplasty in two layers, first continuous and second interrupted.
- Skin closure midline in two layers.
| Results|| |
A total of 40 patients were studied, who were underwent modified Mathieu’s repair. Age ranged between 3 and 12 years with the mean of 7.5 years. Age of the patients is shown in [Table 1]. Majority of the patients (25/40) were between 6 and 12 years of age.
Classification of the patients according to type of hypospadias is shown in [Table 2]. Subcoronal was present in 30 (75%) and coronal in 10 (25%) patients.
Duration of the surgery is shown in [Table 3]. Operative time ranged from 45 to 60 min (mean = 50 min for modified Mathieu’s repair).
The postoperative complications among studied groups are shown in [Table 4]. After modified Mathieu’s urethroplasty, there were only three (7.5%) patients who developed postoperative complications, that is, one (2.5%) had postoperative urethrocutaneous fistula, glandular disruption two (5%), no meatal stenosis, proximal stricture, and complete repair disruption [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11].
|Figure 3: Showing technique to produce proximal flap with spreading of blades of scissor after introduces it under the flap|
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|Figure 6: Showing U-shaped sutures proximally at the junction on both sides|
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The shape of the external urethral meatus was in between the round and slit like in all patients in our study. Regarding shape of the external urethral meatus, it was near to round in all patients. Moreover, the cosmetic results were also excellent with modified Mathieu’s technique as glans shape and urinary stream. There were no urinary complaints and urinary stream was adequate.
| Discussion|| |
Hypospadias is a common clinical problem with an incidence of 0.8 to 8.2 per 1000 live male birth. In the majority of cases, abnormal meatus is situated in the glanular, coronal, or in the distal part of the shaft. The goal of repair is a functionally and cosmetically normal penis. Even in the hands of most experienced surgeons, hypospadias repair is associated with a number of complications ranging from urethrocutaneous fistula to the complete breakdown of neourethra requiring further reconstruction. The TIP urethroplasty and Mathieu’s repair have been widely practiced. Final cosmetic results and normal penile functioning are two important considerations in hypospadias surgery.
Mathieu’s perimeatal-based flap repair was first described in 1932; it is usually applied for correcting coronal and subcoronal defects. Native urethral plate is use in the Mathieu technique.
The mean age (7.5 ± 2.68 years) of the patients in our study was higher compared to the age reported by other authors.,, This may be due to lack of awareness and education on the part of parents and delayed referral from rural healthcare centers.
The meatal-based flap is commonly used urethroplasty for distal penile hypospadias; the reported complication of Mathieu’s urethroplasty is between 5 and 21% for distal penile hypospadias. But in our study, we had lower complication rate (7.5%). There is also an increased risk of meatal stenosis because there is reduced blood flow to the distal part of the flap. In our study with modified Mathieu’s technique, we had no meatal stenosis. We created the even thickness flap to maintain the vascularity of the flap by mobilizing the flap by spreading the blades of the scissor under the flap. Another potential problem of Mathieu’s technique was cosmetically undesirable and rounded meatus that was not so problematic in our patients and was accepted by the parents in our study. We used two sutures at the 4 and 8 o’clock position over the meatus, which leads to cosmetically accepted meatus and without any stenosis.
In modified Mathieu’s careful preservation of the vascularity of the flap and the additional second layer of neourethra with interrupted sutures produced a watertight closure with minimal risk of postoperative fistula formation. We did only local ventral dissection without degloving of the penis.
In our series, complications were seen in three (7.5%) patients. Complications do occur after every hypospadias repair. Currently, there is expected complication rate of 5 to 10% mostly fistulas in one-stage urethroplasy. In our study, urethrocutaneous fistula rate was only 2.5% as a complication. In our series, excellent cosmesis was achieved in 40 (100%) patients.
Reported incidence of urethrocutaneous fistula by Haq et al. is 7.7% in Mathieu’s repair. Ali et al. reported this as 14.3%, and we had come across this as 2.5% in modified Mathieu’s repair. Incidence of meatal stenosis is 3 to 9% for Mathieu’s repair in many studies.,, Although in our study meatal stenosis did not occur, proximal urethral stricture observed in different studies range from 3 to 6% for Mathieu’s repair,,,, whereas in our study, it was zero.
Oswald et al. observed complete repair disruption 6.66% for Mathieu’s repair and Samore et al. reported 10%. Although in our study, complete disruption occurred 0.0%, but glandular disruption was 5.0%. The overall complication rate is 7.5% for modified Mathieu’s repair, which is comparably less than many previous studies.,,,, Our study therefore shows that there is a significantly lower rate of complications with modified Mathieu’s procedure than with Mathieu’s repair. The mean duration (50 min) of surgery was found significantly lower for modified Mathieu’s procedure than for Mathieu’s repair. We applied tourniquet during surgery with no minimal blood loss.
In our study, functional and cosmetic results were highly satisfactory with modified Mathieu’s urethroplasty when compared with Mathieu’s repair. Another advantage of the modified Mathieu’s is, it saves dorsal preputial tissue which can be used in redo surgery. But it has a disadvantage as more anesthetic exposure for circumcision and preputial edema. Preputial edema gets regress in 3 to 4 weeks, so it is not so problematic. Modified Mathieu’s technique produces a cosmetically good penis with a good urinary stream. Cosmetic outcome in our study was better because there was minimal scarring, meatus opening at tip of penis. Other factors were, it looks like a circumcised penis and shape of meatus was appeared to be near rounded and accepted by parents in our study.
Case selection has been advised to avoid the possible complications of the meatal regression and stenosis by Duckett and Snyder. We usually follow case selection strictly in the hypospadias repair, and hence, we have better functional and cosmetic outcome with minimal complications. We did modified Mathieu’s repair only in patients with deep glandular groove, adequate glans size, and without stenotic meatus or had fish mouth meatus. We excluded the cases including the previously operated cases of distal penile hypospadias with extensive scarring, severe chordee, patients with micropenis with poorly developed urethral plate and glandular groove in our study.
| Conclusion|| |
The modified Mathieu’s repair is significantly faster with less complication. In spite of having round-shaped meatus, it was cosmetically and with good urinary stream accepted by parents in our study. Therefore, we recommend this repair as a primary treatment for distal penile hypospadias.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
[Table 1], [Table 2], [Table 3], [Table 4]