Question

Describe the surgical steps of Tabularized Incised Plate Urethroplasty for a mid-penile hypospadias with minimal chordee.

Hint:

The Tabularized Incised Plate Urethroplasty (Snodgrass procedure) is effective for mid-penile hypospadias with minimal chordee, providing a straightened penis and a functional neourethra.

Answer 1

Tabularized Incised Plate (TIP) Urethroplasty, also known as the Snodgrass procedure, is a commonly used technique for the surgical correction of hypospadias, especially for cases of mid-penile hypospadias with minimal chordee. This procedure is designed to correct the abnormal urethral meatus and straighten the penis while maintaining the integrity of the urethral plate.
Step 1: Preoperative Assessment and Marking:
- Examine the Chordee: Before beginning the surgery, assess the degree of chordee (ventral curvature of the penis). In cases with minimal chordee, correction is performed during the procedure.
- Mark the Surgical Site: The location of the meatus is marked, and the shape of the urethral plate is carefully delineated. The surgery is performed under general anesthesia.
Step 2: Incision of the Urethral Plate:
- Incision of the Plate: A longitudinal incision is made along the urethral plate, starting at the meatus and extending proximally. The urethral plate is then incised along its midline to allow it to be tubularized into a neourethra.
- Mobilizing the Urethral Plate: The urethral plate is carefully mobilized to free it from surrounding tissue, such as the corpora cavernosa, to facilitate the reconstruction.
Step 3: Straightening the Penis (Chordee Correction):
- Chordee Release: If there is any chordee, the corpora cavernosa are gently released from any fibrous bands or tissue causing the curvature. The degree of chordee is minimized by releasing these adhesions and straightening the penis.
- Correction of Curvature: Minimal chordee often requires limited release, and the penis is straightened without the need for extensive dissection.
Step 4: Tubularization of the Urethral Plate:
- Forming the Neourethra: The incised urethral plate is then tubularized to form the new urethra. The edges of the plate are carefully sutured together using fine absorbable sutures. The tubularization creates a new channel for urine flow, and the neourethra is aligned with the normal anatomical axis of the penis.
- Ensuring Patency: The surgeon ensures that the new urethra is patent and free of any stenosis or narrowing. A catheter is typically placed in the neourethra to allow for urinary drainage during the postoperative period.
Step 5: Closure of the Surgical Site:
- Skin Closure: The skin is closed with fine sutures, ensuring a functional and aesthetically pleasing result. The penis is straightened, and the meatus is positioned at the tip of the glans penis.
- Postoperative Care: The patient is typically managed with a urinary catheter for a period of time (usually 7-10 days) to prevent any tension on the newly constructed urethra. Antibiotics and pain management are given as necessary.
Step 6: Follow-Up and Long-Term Care:
- Monitor for Complications: After surgery, the patient is monitored for signs of infection, wound dehiscence, or any issues with the newly constructed urethra, such as stenosis or fistula formation.
- Long-Term Follow-Up: Regular follow-up visits are scheduled to assess the function and appearance of the neourethra, ensuring that the surgery has been successful and that the child is voiding normally.