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COMBINED INNER PREPUTIAL INLAY GRAFT WITH TUBULARIZED INCISED PLATE IN HYPOSPADIAS REPAIR: WORTH DOING ?
Mamdouh A. Ahmed, Sr., MD, Abdulnaser Alsaid, Sr., Canadian Board.
Ibn Sina Hospital, Kuwait, Kuwait.

COMBINED INNER PREPUTIAL INLAY GRAFT WITH TUBULARIZED INCISED PLATE IN HYPOSPADIAS REPAIR: WORTH DOING ?
Background
Inner preputial inlay graft combined with tubularized incised plate has been proposed for redo urethroplasty. We extended its indication to be the standard technique for primary hypospadias repair. We conduct this prospective study to clarify whether the combined inner preputial inlay graft with tubularized incised plate technique is the optimal procedure to minimize the hypospadias repair complications and to get excellent cosmetic result especially for meatal position.
Patients and methods
This prospective study included consecutive 185 patients who underwent combined inner preputial inlay graft with tubularized incised plate for primary hypospadias repair from November 2011 to December 2013. Age ranged between 11months to 10 years (mean: 3.4 years). Localization of the meatus was glanular in 10 patients, coronal in 62, distal in 92, midpenile in 18 and proximal in three. Fourteen patients received hormonal therapy (Dihydrotestosterone cream / Testosterone IM injection) due to extremely small glanular size. In all patients, the urethral plate was incised deeply and extended distally beyond the end of the plate (entering the glans by 3 mm). The mucosal graft harvested from the inner prepuce, inlayed and quilted in the incised urethral plate. Neourethra was created over urethral catheter using 7.0 polyglactin sutures in 2 layers. Vascular dartos flap was mobilized dorsally and moved ventrally to cover the neourethral suture line as a barrier.
Results:
Follow up period ranged from 5 to 31 months. Excellent cosmetic and functional results were achieved in 180 of 185 patients (97.3%). Neither meatal stenosis nor urethral diverticulum has been encountered. Excellent glanular position of a wide slit like neomeatus was achieved by this technique. Five patients (2.7%) developed urethrocutaneous fistula that occurred in one patient very early (5 days) post operatively. Excellent urinary stream was reported by parents.
Conclusions:
Combined inner preputial inlay graft with tubularized incised plate significantly reduces the incidence of urethrocutaneous fistula as the inlay graft plays a major role in minimising the postoperative scarring of incised urethral plate that might occur in original tubularized incised plate urethroplasty. Furthermore, it secures optimal glanular position of a wide slit like neomeatus due to extension of the incision beyond the end of the plate, thus optimising functional and cosmetic outcome particularly in patients with small glanular size.Further uroflowmetry study will be conducted to assess the longterm urinary flow.
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