Journal of Pediatric Urology

Pre-incision urethral plate width is not an independent risk factor for urethro-cutaneous

fistula following TIP urethroplasty: A single centre experience from a developing
country.
--Manuscript Draft--

Manuscript Number:

Article Type: Original Research

Keywords: Hypospadias; Urethral plate width; Tubularized incised plate urethroplasty; Urethro-
cutaneous fistula

Corresponding Author: Tanvir Kabir Chowdhury, MS (Pediatric Surgery)

Chittagong Medical College
Chattogram, BANGLADESH

First Author: Adnan Walid

Order of Authors: Adnan Walid

Md. Minhajuddin Sajid, MS

Rajib Khastagir, MS

Tanvir Kabir Chowdhury, MS (Pediatric Surgery)

Md Khurshid Alam Sarwar, MS

Md. Abdullah Al Farooq, MS, FCPS

Md Sharif Imam

Mohammad Zonaid Chowdhury

Abstract: Summary

Introduction

Tubularized incised plate (TIP) urethroplasty is the most commonly performed

operation for distal and mid shaft hypospadias. There is controversy in the previous
reports regarding the association between urethral plate width and complications in TIP
repair. The aim of this study was to compare the impact of urethral plate width in TIP
repair on the development of urethra-cutaneous (UC) fistula in the perspective of a
developing country.

Methods

It was a prospective comparative study carried out in the department of pediatric

surgery, Chittagong medical college Hospital, Bangladesh from December, 2017 to
March, 2019. Patients with distal and midshaft hypospadias were divided into 2 groups:
Group A-urethral plate less than 8 mm wide and Group B-urethral plate 8 mm or more
wide. Age at surgery, penile characteristics, pre-incision urethral plate width, per-
operative factors and development of UC fistula were analyzed. Follow up period was
6 months.

Results

A total of 43 patients (21 in group A, 22 in group B), with a mean age of 6.67±3.38
years under went TIP repair. Twenty-five (58%) patients had distal penile and 18 (42%)
had mid shaft hypospadias. Age correlated with glans size and urethral plate width ( P
= 0.019 and 0.003, respectively) but age was not different in patients with vs without
UC fistula. UC fistula developed in 16 (37.2%) patients but there was no significant
difference between groups (P 0.906). Other penile and per-operative factors were not
associated with UC fistula development.

Conclusion

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 Urethral plate width along with other penile and per-operative factors was not related to
this high rate of UC fistula development in these patients. Skill development and
improvement of other factors are necessary in the developing world to improve
outcome.

Suggested Reviewers: John M Hutson

University of Melbourne
john.hutson@rch.org.au
World expert in urology

Yves Heloury
Royal Children's Hospital, Melbourne
yves.heloury@rch.org.au
world expert in pediatric urology and hypospadias surgery

Tahmina Banu, MS, FRCS

Director, Chittagong Research Institute for Children Surgery
proftahmina@gmail.com
Pediatric urologist who is from same country and has vast knowledge about developing
country realities.

Ashish Minocha
Consultant, Norfolk and Norwich University Hospitals NHS Foundation Trust
ashish.minocha@nnuh.nhs.uk
Pediatric urologist with knowledge about developing world

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Cover Letter

12th May, 2020

To Editor in chief

Journal of pediatric urology

Subject: Publishing our manuscript in your valued journal

Title: Pre-incision urethral plate width is not an independent risk factor for urethro-cutaneous
fistula following TIP urethroplasty: A single center experience from a developing country.

Sir

It is my pleasure to submit our research work in your renowned journal. This manuscript compares
impact of urethral plate width in tubularised incised plate urethroplasty with narrow vs wide urethral
plate in distal and midshaft hypospadias in the context of a developing country. Although some studies
have been done previously about role of urethral plate width on hypospadias outcome, the results were
contradicting and few were from developing country. The study will help hypospadias surgeons to focus
on factors related to improving the outcome of hypospadias repair.

I hope you would be kind enough to publish it in your journal and oblige thereby.

Best Regards

Dr Tanvir Kabir Chowdhury

MBBS, BCS, MS (Pediatric Surgery), FACS

Rowan Nicks Fellow, Royal Australian College of Surgeons
Former, Urology Fellow, Royal Children's Hospital, Melbourne, Australia
Member, British Association of Pediatric Surgeons (BAPS)
Assistant Professor
Department of Pediatric Surgery
Chittagong Medical College & Hospital
Chattogram, Bangladesh
Email: ivan_tanvir@yahoo.com
tanvir.pedsurg@gmail.com
Web mail: tanvir.chowdhury@paedsurgcmch.org.bd
Phone: +8801771477766
Address: Room 908, Ward-84
Department of Pediatric Surgery
Chittagong Medical College & Hospital
1, KB Fazlul Kader Road
Chattogram, 4203, Bangladesh
Title Page (including authors and addresses)

Pre-incision urethral plate width is not an independent risk factor for urethro-cutaneous

fistula following TIP urethroplasty: A single center experience from a developing country.

Adnan Walid, Md. Minhajuddin Sajid, Rajib Khastagir, Tanvir Kabir Chowdhury, Md Khurshid

Alam Sarwar, Md. Abdullah Al Farooq, Md Sharif Imam, Mohammad Zonaid Chowdhury.

Department of Pediatric Surgery, Chittagong Medical College and Hospital, Chattogram,

Bangladesh

Word count: 2171

Article type: Original research

Corresponding Author:

Tanvir Kabir Chowdhury

Mobile: +8801771477766

1, KB Fazlul Kader road, Chattogram 4203, Bangladesh

e-mail: ivan_tanvir@yahoo.com

No conflict of interest

Disclosure: This study was part of a thesis work of the principle author for Masters of Surgery under
Bangabandhu Sheikh Mujib Medical University, Bangladesh.
Manuscript (excluding author details) Click here to view linked References

Pre-incision urethral plate width is not an independent risk factor for urethro-

cutaneous fistula following TIP urethroplasty: A single center experience from a

developing country.

Summary

Introduction: Tubularized incised plate (TIP) urethroplasty is the most commonly

performed operation for distal and mid shaft hypospadias. There is controversy in the
previous reports regarding the association between urethral plate width and
complications in TIP repair. The aim of this study was to compare the impact of urethral
plate width in TIP repair on the development of urethra-cutaneous (UC) fistula in the
perspective of a developing country.

Methods: It was a prospective comparative study carried out in the department of

pediatric surgery, Chittagong medical college Hospital, Bangladesh from December,
2017 to March, 2019. Patients with distal and midshaft hypospadias were divided into
2 groups: Group A-urethral plate less than 8 mm wide and Group B-urethral plate 8
mm or more wide. Age at surgery, penile characteristics, pre-incision urethral plate
width, per-operative factors and development of UC fistula were analyzed. Follow up
period was 6 months.

Results: A total of 43 patients (21 in group A, 22 in group B), with a mean age of
6.67±3.38 years under went TIP repair. Twenty-five (58%) patients had distal penile
and 18 (42%) had mid shaft hypospadias. Age correlated with glans size and urethral
plate width (P= 0.019 and 0.003, respectively) but age was not different in patients
with vs without UC fistula. UC fistula developed in 16 (37.2%) patients but there was
no significant difference between groups (P 0.906). Other penile and per-operative
factors were not associated with UC fistula development.

Conclusion: Urethral plate width along with other penile and per-operative factors was
not related to this high rate of UC fistula development in these patients. Skill

i
development and improvement of other factors are necessary in the developing world
to improve outcome.

Key Words: Hypospadias, Urethral plate width, Tubularized incised plate

urethroplasty, Urethro-cutaneous fistula.

ii
Introduction

Tubularized incised plate (TIP) urethroplasty has become an attractive method worldwide for

hypospadias repair since its introduction in 1994 for distal hypospadias and 1998 for mid

shaft and proximal hypospadias [1]. Although reports from developed world shows excellent

outcome of this procedure, the description from many developing countries still shows more

fistula rates and other complications [2–6]. Moreover, there is still debate about the ultimate

outcome of incising a urethral plate and the application of TIP where the urethral plate is

narrow. There has been concern among surgeons that urethra-cutaneous (UC) fistula in TIP

urethroplasty is more related to the width of the plates than other factors and some surgeons

still prefer other methods such as combining with a Mathieu procedure or other modifications

for narrow urethral plate [7–12]. This article addressed the issue of urethral plate in TIP

urethroplasty for distal and mid shaft hypospadias from the perspective of a tertiary pediatric

surgical center from a developing country.

Method: This prospective comparative study was performed in the department of pediatric

surgery, Chittagong medical college Hospital, Bangladesh from December, 2017 to March,

2019. Patients with distal and midshaft hypospadias were divided into 2 groups: Group A-

Narrow Urethral plate (less than 8 mm wide) and Group B-Wide urethral plate (8 mm or

more width). Patients with previous history of hypospadias repair and patients with proximal

hypospadias were excluded. Since urethral calibration under anesthesia was not performed

and all the patients who had other complications such as meatal stenosis, wound infection,

partial dehiscence also developed UC fistula, those were not analyzed for the study. Age at

surgery, glans width, glans configuration, pre-incision urethral plate width, duration of

3
tourniquets, catheter size, layers of repair were recorded during surgery and post-operative

complications and development of urethra-cutaneous fistula were recorded. Surgeries were

performed by multiple general pediatric surgeons all more than 45 years of age. It was

hypothesized that narrow urethral plate width would adversely affect fistula rate. Patients

were followed up for 6 months and follow up schedule was 7 days, 15 days, 3 months and 6

months. Data were collected using a predesigned case record form and analysis was done

with Student’s t test and Chi-square test using SPSS version 23. P value of <0.05 was

considered significant. This study was approved by the ethical review board of Chittagong

Medical College (ERB memo no-CMC/PG/2017/355).

Results:

There was a total of 43 patients; 21 patients (48.8%) in Group A, with urethral plate width

less than 8 mm and 22 patients (51.2%) in Group B with urethral plate width more than 8

mm. The overall mean age was 6.69±0.52 years with a range of 1-12 years. Patients with

narrow urethral plate were younger than the patients with wide urethral plate (Table-1, p =

0.0025). Twenty-five (58%) patients had distal hypospadias and 18 (42%) patients had mid

shaft hypospadias. Mid shaft hypospadias was more in Group B than Group A, however the

difference was not significant (p=0.084).

4
Table 1: Age distribution between groups and types of hypospadias patients (n=43)

Groups Type of hypospadias Age in years P value

Mid penile Distal penile Mean (±SD) Range

Group A (< 8 mm)

(n=21, 48.8%) 6 15 5.13±3.15 1-12

Group B (> 8 mm) 0.0025

(n=22, 51.2%) 12 10 8.19±3.04 2-12

Total 18 (42%) 25 (58%) 6.69±0.52 1-12

Both pre-incision urethral plate width and glans width were significantly more in group B than

group A. (Table 2). The mean pre-incision urethral plate width was 7.16±0.99 for distal penile,

7.5±0.93 for mid penile hypospadias with an overall mean of 7.3±0.96 for the entire cohort.

Mean glans width was 17.84± 4.2 in entire cohort, 15.95±2.69 in group A and 19.64±4.69 in

group B (p=0.003). However, there was no significant difference of glans width between distal

(mean 17.6±3.88 mm) and mid shaft hypospadias (mean 18.17±4.77 mm), p=0.67. Glans

configurations were significantly flatter in group A and more clefted in group B. However,

there was no significant difference in glans configuration between distal and midshaft

hypospadias (Table-2). Use of testosterone to enlarge the size of penis, penile length before

and after degloving were also similar between groups and types of hypospadias (Table 2).

5
Table 2: Penile characteristics between groups and types of hypospadias patients (n=43)

Groups P Type of Hypospadias P

Value Value

Group A Group B Distal Mid shaft

Hypospadias Hypospadias

Mean urethral plate 6.43 ±0.51 8.14±0.35 0.000 7.16±0.99 7.50±0.92 0.254

width (mm)

Glans Width (mm) 15.95±2.69 19.64±4.69 0.003 17.60±3.88 18.17±4.77 0.670

Preoperative

Testosterone

 Yes 5 6 7 4 0.668

 No 16 16 0.795 18 14

Glans Configuration

 Flat 3 (14.29%) 0 (0.00%) 1 (4%) 2 (11.11%)

 Incompletely 17 7 (31.82%) 17 (68%) 7 (38.89%)

cleft (80.95%) 0.000 0.157

 Cleft 1 (4.76%) 15 7 (28%) 9 (50%)

(68.18%)

Penile length before 43±9.43 35±7.46 0.006 38.68±9.15 39.83±9.49 0.692

degloving

Penile length after 44±9.48 36.77±7.48 0.008 39.76±9.04 41.06±9.59 0.653

degloving

Sixteen patients (37.21%) developed UC fistula but there was no significant difference between

groups with 8 patients in each group (38.1% in group A and 36.36% in group B; p=0.907).

There was also no significant difference in fistula rate between distal and mid shaft hypospadias

(8 in each type; p=0.405). Age at surgery correlated with glans size and pre-incision urethral

plate width (Spearman’s correlation P= 0.019 and 0.003, respectively) but age was not different

in patients with or without UC fistula (Figure 1 and Table 3).

6
 Figure1: Scatter diagram of correlation of age(years) with urethral plate width (mm)

There were no differences in glans size and pre-incision urethral plate width between patients

with or without UC fistula (Table 3). Glans configuration, penile length before and after

degloving and use of testosterone were not significantly different between patients with or

without fistula (P= 0.280, 0.753, 0.853 and 0.946 respectively). Tourniquet duration, size of

stent used, layers of repair, duration of dressing and catheter also were not significantly

different between patients with vs without fistula (Table 3). Multiple logistic regression

analysis also showed that none of the factors were significantly associated with UC fistula

development.

Table 3: Comparison of factors in patients with vs without UC fistula.

Factors No UC Fistula UC Fistula P-value

Mean Age, years 6.31±3.38 7.28 ±3.40 0.37

Mean glans width, mm 17.59 ±3.91 18.25 ±4.82 0.63

7
 Mean urethral plate width, mm 7.37 ±0.84 7.19 ±1.17 0.59

Tourniquet duration, min 40.93±15.48 40.50±14.26 0.929

Catheter size, Fr 7.19±0.96 6.69±0.95 0.107

Repair layer, No. 1.89±0.51 2.0±0.37 0.448

Dressing duration, days 3.30±0.67 3.31±0.70 0.940

Catheter duration, days 8.0±2.59 7.44±3.09 0.526

DISCUSSION:

The present study was carried out with an objective to observing whether urethral plate width

in TIP urethroplasty had any impact on UC fistula. However, it was found that urethral plate

width, and other parameters such as penile characteristics, duration of catheter and dressing

were not significantly related to fistula development in TIP repair. As has been suggested

earlier, the result of hypospadias surgery depends on a constellation of many other factors such

as surgical technique, delicate tissue handling, patient age, type of hypospadias defect and

surgeon experience [13].

Fistula rate of TIP repair varies from center to center. Snodgrass reported only 6% complication

after repair of all types of hypospadias. [14] A recent meta-analysis of 49 studies showed that

the overall complication rate following TIP repair is only 4-8.2% with more complication in

parts of the world other than USA and Europe [15]. However, Braga et al reported in their

literature review that complication of TIP repair may vary from 0-50% with an overall

8
complication rate of 33% [3]. Chukwubuike et al. (2019) reported a 31% complication rate for

distal and mid shaft hypospadias in Nigeria [2]. Chrzan et al. (2007) reported that complication

rate after mid penile hypospadias repair with the TIP technique was 66% compared to 35%

after distal penile repair. A report from Ghana showed 28% complication rate for TIP repair

and another report from Nigeria showed 33.1% fistula rate [6,16].

It is well accepted that type of hypospadias is an independent risk factor for fistula development

with more proximal hypospadias having more fistulas. Although in this study fistula rate was

more in midshaft than distal hypospadias, it was not statistically significant. Elicevik et al.

(2004) also found no differences in the complication rate after TIP for mid and distal

hypospadias, with an overall complication rate of 23% [17]. There is no convincing evidence

that penile anthropometry has clinical utility in distal hypospadias cases. It was suggested that

glans shape, urethral plate length, prepuce vascularization and penile size do not significantly

affect the complication rate of TIP repair in distal hypospadias [18]. Bush et al. reported that

Glans size is an independent risk factor for urethroplasty complications after hypospadias

repair. Mean glans size of their patients were 15mm (mean age of their patients was 1.5 years

) and in this study it was 17.8 mm (mean age 6.69 years) [19]. On the other hand, Faasse et al.,

reported that glans width was not a risk factor for complications after hypospadias repair [20].

Glans configuration was not associated with complications in this study and also in other

studies [21–23]. Holland and Smith (2000) first reported a series of 48 distal TIP cases and

urethral fistula developed in 6 patients with a urethral plate of less than 8 mm width (P = 0.001)

suggesting that urethral fistula was exclusively associated with a maximal urethral plate width

of less than 8 mm and cautioned that surgeons might consider alternative techniques to repair

the subgroup with a narrow UP [23]. Subsequently, Sarhan et al., (2009) also found that a pre-

incision width <8 mm correlated with increased urethroplasty complications in boys

9
undergoing distal and midshaft TIP [24]. Aboutaleb (2014) reported similar finding in their

100 patients of distal hypospadias in whom 26 patients had less than 8 mm urethral plate [21].

However, Bush and Snodgrass (2017) later reported that pre-incision urethral plate width was

not an independent risk factor for urethroplasty complications [14]. Earlier, a multicenter study

of 159 prepubertal boys who underwent TIP repair for primary distal hypospadias, in whom

urethral plate was less than 8mm in 30 cases, conducted by Nguyen and Snodgrass (2004)

found that only 3(2%) patients developed UC fistula [22]. It has been suggested by Snodgrass

that midline incision of the urethral plate should be enough to create a neourethra with adequate

width around catheters so that the urethral plate makes a tension free anastomosis.

The mean age of patients in this study was 6.69 years which is far beyond the current

recommended age for hypospadias repair. This is also a reality of developing world where

many patients present late. Age was not related with outcome in this study and there are

conflicting reports of impact of age on outcome [25][26]. Only 4 (9.3%) patients were within

recommended age of 2 years and one of them developed UC fistula who developed soaked

dressing and peri catheter leakage very early suggesting technical failure rather than anatomy

of the defect. Perlmutter et al. reported better outcome in early surgery, mean age of their

patients without complications was 18.5 months compared with 26.5 months for patients

developing complications [25]. Age was a significant risk factors for UC fistula after

hypospadias repair in Indonesia and about 60% of their patients were more than 4 years old

[27]. However, Weber et al. (2009) did not find evidence to support recommendations

concerning the ideal age for hypospadias repair [28]. Types and duration of catheter or stent,

suturing types and technique, type and duration of dressing produced variable results and none

was an independent risk factor. These were not also related to UC fistula in this study. Although

10
some studies reported good outcome with different types of additional layers, comparative

studies did not show benefit of one over another.

While developed world has reduced the complications following hypospadias repair, it is

evident that developing countries, where most hypospadias surgeries are still done by general

pediatric surgeons, still have unacceptable complication rates. Surgeries were done by multiple

pediatric surgeons in this study, who, although experienced, are not dedicated pediatric

urologists. Moreover, most of the surgeons did not use loupe during hypospadias surgery,

which is a very essential component for successful outcome of hypospadias repair. UC fistula

rate also varied among surgeons. Meticulous tissue dissection and proper hemostasis have been

said to be key factors for best outcome in hypospadias surgery and the application of these

varied greatly among surgeons. It emphasizes the fact that hypospadias surgeries are better

performed by pediatric urologists and developing countries should give emphasis on

developing independent pediatric urology departments.

The limitations of the study were that the sample size was small, outcome was assessed by the

principle author and surgeries were performed by multiple surgeons.

Conclusion:

This study showed pre-incisional urethral plate width was not an independent risk factor for

urethroplasty complications. Other penile and per-operative factors were not also associated

with complications. Improvement of surgical skill and development of dedicated pediatric

urology centers might be considered to attain good surgical outcomes which has already been

availed by the developed world.

Conflicts of Interest

11
None.

Funding

None.

Ethics Approval

Institutional approval obtained. This study is a part of thesis of the principle author under

Bangabandhu Sheikh Mujib Medical University, Bangladesh.

Acknowledgements

The authors like to acknowledge Dr. Farid Uddin Ahmed, MPH for his support in statistical

analysis.

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[27] Duarsa GWK, Tirtayasa PMW, Daryanto B, Nurhadi P, Renaldo J, Tarmono, et al.

Risk factors for urethrocutaneous fistula following hypospadias repair surgery in

Indonesia. J Pediatr Urol 2020. https://doi.org/10.1016/j.jpurol.2020.04.011.

[28] Weber DM, Schonbucher VB, Gobet R, Gerber A, Landolt MA. Is there an ideal age

for hypospadias repair? A pilot study. J Pediatr Urol 2009;5:345–50.

15
Figure 1 Click here to access/download;Figure(s);Figure 1 JPG.png
Figure 1 Legend

Figure1: Scatter diagram of correlation of age(years) with urethral plate width (mm)
Table 1

Table 1: Age distribution between groups and types of hypospadias patients (n=43)

Groups Type of hypospadias Age in years P value

Mid penile Distal penile Mean (±SD) Range

Group A (< 8 mm)

(n=21, 48.8%) 6 15 5.13±3.15 1-12

Group B (> 8 mm) 0.0025

(n=22, 51.2%) 12 10 8.19±3.04 2-12

Total 18 (42%) 25 (58%) 6.69±0.52 1-12

Table 2

Table 2: Penile characteristics between groups and types of hypospadias patients (n=43)

Groups P Type of Hypospadias P

Value Value

Group A Group B Distal Mid shaft

Hypospadias Hypospadias

Mean urethral plate width 6.43 ±0.51 8.14±0.35 0.000 7.16±0.99 7.50±0.92 0.254

(mm)

Glans Width (mm) 15.95±2.69 19.64±4.69 0.003 17.60±3.88 18.17±4.77 0.670

Preoperative Testosterone

 Yes 5 6 7 4 0.668

 No 16 16 0.795 18 14

Glans Configuration

 Flat 3 (14.29%) 0 (0.00%) 1 (4%) 2 (11.11%)

 Incompletely 17 7 (31.82%) 17 (68%) 7 (38.89%)

cleft (80.95%) 0.000 0.157

 Cleft 1 (4.76%) 15 7 (28%) 9 (50%)

(68.18%)

Penile length before 43±9.43 35±7.46 0.006 38.68±9.15 39.83±9.49 0.692

degloving

Penile length after 44±9.48 36.77±7.48 0.008 39.76±9.04 41.06±9.59 0.653

degloving
Table 3

Table 3: Comparison of factors in patients with vs without UC fistula.

Factors No UC Fistula UC Fistula P-value

Mean Age, years 6.31±3.38 7.28 ±3.40 0.37

Mean glans width, mm 17.59 ±3.91 18.25 ±4.82 0.63

Mean urethral plate width, mm 7.37 ±0.84 7.19 ±1.17 0.59

Tourniquet duration, min 40.93±15.48 40.50±14.26 0.929

Catheter size, Fr 7.19±0.96 6.69±0.95 0.107

Repair layer, No. 1.89±0.51 2.0±0.37 0.448

Dressing duration, days 3.30±0.67 3.31±0.70 0.940

Catheter duration, days 8.0±2.59 7.44±3.09 0.526