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The effect of pre-incision urethral plate width and glanular width on the outcome of Tubularized Incised Urethral plate repair surgery in distal penile Hypospadias, A prospective study

To determine the cosmetic and functional outcomes of hypospadias repair in relation to the width of the urethral plate in addition The study was a prospective evaluation of patients operated for hypospadias after approval of ethical committee a formal consent were taken from parents. The urethral plate width (UPW) and glans width (GW) of the patients were measured preoperatively using standard calipers. The width of the urethral plate was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of hypospadias repair. All patients were managed via the same technique using Snodgrass tubularized incised plate repair (TIP). All operations were performed by a single surgeon. All intaoperative data were recorded. All patients were followed up for 1 year. Success was de ﬁ ned as slit shaped meatus at the tip of the glans with no stenosis, ﬁ stula or diverticulum.


Introduction
Dating the nal 2 decades, tabularized incised plate procedure (TIP) for repair of distal penile hypospadias is the foremost common method at numerous institutions. In any case, a few downsides counting meatal and/or neourethral stenosis and the require for standard urethral dilatation have been recorded (1). The preservation of the urethral plate and the increase in the surface area with healthy epithelium give better outcome (2) TIP is a procedure that is more dependent on urethral plate quality in comparison with other surgical procedures. The plate quality is generally regarded as one of the intrinsic risk factors in uencing the outcomes of hypospadias repairs. However, there is currently no clear agreement on the evaluation of the urethral plate (5).
The urethral plate width was classi ed based on an arbitrary 8-mm cut-off value, while groove depth was graded as deep, moderate and shallow. However, is the arbitrary value of 8 mm suitable for all penis sizes? (3).
Generally, urethral plate width increases with penis size, as the patient grows. It might be more appropriate to evaluate urethral plate quality with a parameter scaled with penis size. In recent years, Glans-Urethral Meatus-Shaft score was proposed to classify the severity of hypospadias, providing a concise method for evaluating urethral plate quality (4,5).
There is a debate regarding the effect of UPW and GW on the postoperative complications post TIP surgery. Some reports have found that urethral plate (UP) widths <8 mm before TIP incision increased urethroplasty complications (6). While, The UP width before incision did not increase urethroplasty complications (7)(8)(9).
Glans size does not correlate with age in patients with hypospadias between 3 and 24 months old, supporting the decision to operate as early as 3 months in some centers (10). Small glans size, de ned as width <14 mm, is an independent risk factor for urethrocutanous stula (8).
To address this void, we aimed to answer a question, Is the UPW and GW are a controlling factors for hypospadias outcome as regard the functional and cosmetic outcome?

Materials And Methods
After approval from Institutional Review Board, we conducted a prospective study that was carried out in Urology department in kafr el Sheikh University, between November 2018 and November 2019. A total of 60 children diagnosed with distal penile hypospadias were included.
Inclusion criteria were, distal penile hypospadias, primary, uncircumcised, and no or mild chordee (less than 30°), aged < 10 years, No associated syndromes and boys able and willing to comply with follow up schedule.
We excluded boys who were recurrent, circumcised, with severe chordee. Written consent with detailed description of the operation and expected complications was explained and signed from the parents.
All operations were performed by single pediatric urologist. Preoperative IV antibiotic prophylaxis was given. A circumferential subcoronal incision is made proximal to the hypospadiac urethral meatus. The penis is degloved. A bilateral longitudinal incision was made along the urethral plate to prepare the glanular wings. The ap was obtained from the inner dartos muscle and sutured overlying the incision line with 6/0 vicryl.
The ap width and length were differing in every case according to the location of the meatus, urethral plate characteristics and depth of the midline incision. Urethroplasty was performed using 6/0 Vicryl continuous subcuticular then interrupted sutures and 2nd layer cover using dartos fascia flap. Glanular approximation was done with 6/0 Vicryl. 8F stent was kept for 7-10 days.
All patients were routinely followed up for cosmetic and functional results at 3 months intervals. By routine examination of the external genitalia, evaluation of the voiding symptoms, uroflowmetery study was performed if possible and it was repeated when the voided volume was insufficient or when the result was inconsistent with the physical examination and history.
Overall acceptable cosmetic appearance of the penis was decided according to the slit like appearance of the neo-meatus, the straight position of the penis and this cosmetic aspect was judged by an independent blinded observer. Hypospadias Objective Penile Evaluation (HOPE) is considered a valuable tool for assessing the outcome (11) All methods were carried out in accordance with relevant guidelines and regulations.
Informed consent was obtained from all subjects or, if subjects are under 18, from a parent and/or legal guardian.

Statistical analysis
Statistical analysis was performed with IBM Statistical Package for Social Sciences. IBM SPSS Statistics for Windows (version 22.0. Armonk, NY) was used to evaluate multiple steps. Signi cance level was set to p < 0.05. Internal consistency reliability was tested using Cronbach's α, and test-retest reliability was assessed with the Wilcoxon signed rank test. For concurrent external validity, Spearman rank correlation was used. For values > 0.70, it was assumed that there was su cient consistency and reliability.

Results
All 30 patients were evaluated at 1 year of follow up. Mean age at surgery was 4.5 ± 2.1 years.
Overall, the mean ± SD of UPW was 10.92 ± 1.24 mm. a 24 patients (61.5 %) (Group A) had a urethral plate width of less than 8 mm while 14 patients (35.9 %) (Group B) had a urethral plate width greater or equal to 8 mm. the mean ± SD of GW was 9.52 ± 1.56 mm.
A 20 (83.3 %) patients in group A have good urinary stream while 12 patients (85.7%) in group B have good urinary stream.
There was a signi cant correlation between good urinary stream with the mean UPW of the 2 groups (p<0.05).

Post-operative complications
Two patients (6.3%) developed urethrocutanous stula, three patients (10 %) developed glanular dehiscence. However, no statistical signi cance found in relation of the complications to the mean UPW or GW of the two groups of patients (p = 0.5).

Cosmetic outcome
The cosmetic outcome was assessed using Hypospadias Objective Penile Evaluation (HOPE), as shown in Table 2.
Overall, mean ± SD hypospadias objective penile evaluation (HOPE) score was 39.1 ± 8.83. Group a patients had a mean HOPE score of 37.2 ± 6.4 SD while Group B patients had a mean HOPE score of 42.4 ± 6.1 SD.
A signi cant correlation found between the cosmetic outcome of the two groups and HOPE score (p = 0.06).

Discussion
Hypospadias is an extremely common anomaly. There are different procedures that have been described for the adjustment of hypospadias since of the presence of various hypospadias presentations. Be that as it may, no single technique had 100% satisfactory result (12). The goals of hypospadias surgery include development of a urethra of su cient caliber and length, orthotopic meatus at the tip of the glans permitting the patient to void in a straight stream without maddening spreading.
Moreover, obtaining a conical glans and rearrangement of the dorsal skin provides a uniform ventral skin cover and correction of penile curvature just to achieve proper sexual intercourse and effectively inseminate (13).
Hypospadias surgery is continuously evolving, since its description by Galen in the rst and second centuries AD, to improve a suboptimal functional and cosmetic results. The aim of hypospadias surgery is the creation of a straight penis with a slit-like meatus at the tip of the glans 7.
In spite of the recognition of the urethral plate as the tissue distinct from the glans and penile skin that would have formed the urethra and as having a well vascularized connective tissue and its incorporation in hypospadias repair, an objective way of assessing the impact of urethral plate on outcome is yet to be established.
Snodgrass in 1994 reported his own technique of tubularized incised plate urethroplasty (TIP) repair for distal hypospadias that gained a widespread use for its perceived simplicity and good cosmetic outcomes in the majority of cases [11]. However, unfortunately, when the urethral plate is narrow the rate of urethrocutaneous fistula, meatal/neo-urethral stenosis is increased [12].
In the current study, we evaluated the effect of width of the urethral plate and glanular width on outcome of hypospadias repair.
Most of our patients had coronal and midpenile hypospadias (38.5 %%), the same ndings by Prat et al (14). The reason for this is not clear but might be explained by the geographical location.
Hypospadias Objective Penile Evaluation (HOPE) which assessed the cosmetic outcome, there was a statistical signi cance correlation (p = 0.06). This nding agrees with the result from some previous studies (15). However, Aboutaleb et al (6)

in their study
We used 8 mm in the present study because urethral plate width 8mm or greater is essential for creation of adequate neourethra and successful hypospadias repair (16), while, Da Silva et al1 (15) in their study had 41.9% of their patients in the narrow urethral plate group and 58.1% in the wide urethral plate group.
Comparing both studies, the slight difference in percentages may be explained by the fact that Da Silva used 10 mm as the dividing line between narrow and wide urethral plates while we used 8 mm in the current study. Nguyen et al (9) and Aboutaleb et al (6) in their studies also used 8 mm as the dividing line. Urethral plate of more than 8 mm is associated with good cosmetic outcome (16,17) On the assessment of the functional outcome, 20 (83.3 %) patients in group A had good urinary stream while twenty patients 12 (85.7%) in group B had good urinary stream. Statistical analysis showed that there is a statistically signi cant difference between the 2 groups (p value of 0.05). This agrees with ndings of some other studies that concluded that narrow urethral plate is associated with poor functional outcome such as poor urinary stream and complications such as meatal stenosis and urethrocutanous stula (17)(18)(19).
However, Nguyen et al8 and Da Silva et al (15) in their study concluded that width of urethral plate do not affect the functional outcome of hypospadias repair. This is related to the fact that there were confounding variables in their study such as penile size, glans shape and vascularity of the prepuce which were not separately analyzed. We did not assess penile size, glans shape and vascularity of the prepuce in the current study.
There are a diversity in the complications following hypospadias repair. It ranges from 6-30% (20, 21). The most common complication we recorded was urethrocutanous stula. These differences in complication rates may be explained by the differences in surgical expertise due to low volume of hypospadias repairs done per year in our setting. The rate of urethrocutanous stula in our study is not correlated with narrow urethral plate, a similar to (20). While, Aboutaleb reported higher incidence in stula in patients with narrow urethral plates when compared to those with wide urethral plate (6,21).
Though this study was a prospective study, it was limited by a small sample size that hindered the signi cant statistical difference detection in complications. Moreover, single surgeon series cannot be generalized as the outcome of repair, including complications, may be related to the skill of the surgeon.

Conclusion
The pre-incision urethral plate width and glanular width was not correlated with the TIP outcome. A better HOPE score is associated with wide urethral plate. However, the width of the urethral plate and glanular width may predict the functional outcome (urinary stream).