This paper by one of the current international leaders in hypospadias surgery looks at the outcome of over 1800 consecutive hypospadias repairs using the tubularised incised plate (TIP) repair, beginning from the first original operation through to sequential modifications over the years. These modifications attempted to address known hypospadias complications, especially meatal stenosis, glans breakdown and fistula formation. The paper’s strengths include the fact it is a series with large numbers, one practitioner’s experience and a prospective database. Its weaknesses are that there is no control or comparative series and that modifications occurred over 20 or more years. Additionally, these modifications were introduced in a non-comparative, non-randomised way. It is not clear what is meant by an ‘indicator operation’ but the assumption is that it should be used as a gold standard in hypospadias surgery and that, as the authors state in the paper, correct learning of the technique is a more reliable indicator of outcome than mere regular numbers of procedures. What are the salient conclusions of the authors? Changing from chromic catgut to polyglactin and from epithelial to sub-epithelial sutures did not significantly change complications. Preoperative testosterone is not the solution to glans dehiscence but preoperative glans width of ≤14mm increases this complication. Increasing the extension laterally of glans dissection reduces glans dehiscence. Initial dorsal plate width of less than or more than 8mm made no difference to the outcome. If there is ventral curvature of 30 degrees or more after gloving, then dividing the plate completely and resorting to a two-stage repair is better than elevating the plate and performing a dorsal placating procedure for chordee. The authors conclude that what they term the three P’s (prospective data collection, periodic outcomes, practice changes) is a powerful mechanism in improving practice and they believe they have demonstrated this with their series. They state that their hypospadias practice is now limited to two procedures – the TIP or, when the anatomical situation is contraindicated (as judged by their findings above), a two-stage grafting procedure. 

TIP hypospadias repair: a pediatric urology indicator operation.
Snodgrass W, Bush N.
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Henrik Steinbrecher

Southampton University Hospital NHS Trust

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