Journal of Pediatric Urology (2008) 4, 359e363

Retrospective analysis of the results obtained

by using Mathieu and TIP urethroplasty
techniques in recurrent hypospadias repairs
Ayhan Karabulut, Melih Sunay*, Kazım Erdem, Levent Emir, Demokan Erol

Clinic of 1st Urology, Ministry of Health Ankara Teaching and Research Hospital, Cebeci, Ankara, Turkey

Received 14 November 2007; accepted 27 February 2008

Available online 14 April 2008

KEYWORDS
Hypospadias surgery;
Mathieu urethroplasty;
TIP urethroplasty
Abstract Objective: To determine the effect of Mathieu and tubularized incised plate (TIP)
urethroplasty techniques on the outcome of repair in recurrent hypospadias.
Material and methods: A total of 78 patients who had undergone surgical correction by either
Mathieu or TIP urethroplasty after unsuccessful hypospadias surgery were enrolled in this
study. Cases were divided into two groups according to the operation technique performed.
Surgical success rate of the techniques and the prognostic significance of age, type of diversion
used, caliber and length of new urethra, and the number of previous operations were analyzed
statistically.
Results: Mathieu and TIP urethroplasties were performed in 57 and 21 patients, respectively.
No statistically significant relation was found between the groups for age, length of new ure-
thra created, caliber of the urethra, urinary diversion used, mean operation success rates and
number of previous operations. From within-group analysis, Mathieu urethroplasty was found
to have a statistically significant relationship with the number of previous operations
(P Z 0.025, ManneWhitney U-test).
Conclusions: Age, length and caliber of new urethra, and diversion type used seem to have no
effect on the success rate of Mathieu and TIP urethroplasty in recurrent hypospadias restora-
tion. The success of the Mathieu operation diminished proportionally to the number of previous
failed surgeries.
ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Introduction

The principal aim of restoration of hypospadias is to bring

the urethral meatus into the tip of the glans, to eradicate
any existing curvature of the penis by straightening ven-
* Corresponding author. Tel.: þ90 312 4905344. trally, to give an esthetic penile appearance, to ensure
E-mail address: dr.m.sunay@gmail.com (M. Sunay). fertility in some cases, and to eliminate the negative

1477-5131/$34 ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpurol.2008.02.007
360
psychological effects on patients [1]. Given the current
modern conditions and knowledge about hypospadias
surgery, outcomes of restoration of hypospadias are satis-
factory, but some patients require multiple operations to
achieve full reconstruction.
In this study, the data of patients with distal hypospa-
dias, whose repeat restorations were performed by either
the Mathieu or Snodgrass technique, were compiled retro-
spectively. The association between success achieved with
each technique and the length of the tube created, caliber
of the tube, number of previous operations, and stent or
form of diversion used was investigated, and the compar-
ative effectiveness of the techniques was analyzed. This
study is unique in the English medical literature in com-
paring the results of reoperative Mathieu and TIP urethro-
plasty cases.
Patients and methods
A total of 78 patients who had previously undergone at least
one operation for hypospadias, and had been finally
operated at our hospital using either the Mathieu or
tubularized incised plate (TIP) urethroplasty technique
between 1993 and 2006 were included in the study. In
this time period, a total of 132 patients who had undergone
than one operation for hypospadias were admitted to our
clinic. Patients with a proximal penile meatus, scarred
penile skin and an unhealthy urethral plate were excluded,
and treated with other salvage procedures.
The Mathieu and TIP urethroplasty techniques were
performed in 57 and 21 patients, respectively. The Mathieu
technique was performed in 39 patients for fistula, 13 for
repair dehiscence, 3 for fistula þ meatal stenosis and 2
for meatal regression, while TIP was performed in 18 for
fistula þ meatal stenosis and 3 for repair dehiscence. Most
previous repairs had been performed in other medical cen-
ters. Only 10 patients had undergone prior failed hypospa-
dias surgery in our clinic and the previous operations
performed were Thiersch-Duplay urethroplasty technique
in five cases, Mathieu urethroplasty in three cases and TIP
in two cases. The gross appearance of the urethral plate
was healthy in all cases. The mean age of the patients
was 10.16  4.97 years (range 2e30 years) for the Mathieu
technique and 9.04  3.89 years (range 3e18 years) for
TIP. Techniques were applied in all cases at least 6 months
after the previous hypospadias repair. The final evaluation
of all patients was done in the operating room. Healthy,
elastic, well-vascularized and unscathed plates were con-
sidered appropriate for Mathieu or TIP. The Mathieu tech-
nique was preferred if the urethral plate was narrow
(7 mm width), and ventral skin was soft and had less scar-
ring. TIP was preferred if the width of the urethral plate
was at least 8 mm depending on the circumferential size
of the urethral stent used.
Cases were divided into two groups according to the
operation technique applied. The parameters of the study
were determined as age, type of diversion used, caliber and
length (in millimeters) of new urethra, and number of
previous operations. Caliber of the urethra was determined
by the number of the polyethylene feeding tube used; the
catheter size varied from 6 to 14 Fr for Mathieu and from 6
A. Karabulut et al.
to 12 Fr for TIP depending on the patients’ age and width of
meatus. Urethral stent (for 7 days), continued (through ep-
ithelium) suture technique with 6e0 or 7e0 polydioxanone
suture material depending on the patients’ age, and
a well-vascularized subcutaneous (dartos) tissue flap for
coverage of the neourethra were performed in all patients.
The glans wings were approximated with interrupted su-
tures without tension in two layers using 5e0 polydioxanone
suture material. A compression bandage was applied to all
patients. Percutaneous suprapubic diversion was performed
in 67 of the 78 patients. Mean operating time was
56.2  18.3 min. Bipolar cautery was used in all patients.
A broad-spectrum antibiotic (Cephalexin) was initiated 1
day before operation and continued until the urethral cath-
eter removed. Dressings were removed at the 4th day and
all patients were voided at the 7th day postoperatively.
All patients and/or their parents were interviewed after
operations. All patients were followed up at 1 month,
6 months and 12 months, and some up until 36 months.
Mean follow-up time was 18 (range 12e36) months.
All data were collected and the relation between
success rate of the repair and age, type of diversion used,
caliber and length of new urethra and number of previous
operations was evaluated. Statistical analyses were as-
sessed by ManneWhitney U-test and Fisher’s exact test
using SPSS (Statistical Package for the Social Sciences)
13.0 program. P value at 0.05 or lower was considered
statistically significant.
Results
Age, length of new urethra created and caliber of urethra
are shown for both groups of patients in Table 1. For these
parameters, there was no significant difference between
groups. Data about number of previous operations are
presented in Table 2; there was no statistical difference be-
tween groups (P Z 0.58). No significant difference was de-
termined between the results obtained by Mathieu and TIP
urethroplasty techniques performed to restore hypospadias
(P Z 0.74) (Tables 3 and 4). Patients were not evaluated
with uroflowmetry routinely. Uroflowmetry was performed
in only one patient with TIP urethroplasty referred to our
clinic for decreased projection at the 8th month postopera-
tively. After decreased urine flow rate had been determined
in this patient, urethral dilatation was applied. No complica-
tion was observed in further follow-up.
In nine unsuccessful cases of the Mathieu urethroplasty
group, dehiscence in four cases and urethrocutaneous
fistula in five cases developed. Buccal graft tube urethro-
plasty and Thiersch-Duplay urethroplasty were performed
in one and four patients with dehiscence, respectively,
and fistula repair was applied to four patients with
urethrocutaneous fistula. In the TIP urethroplasty group,
meatal stenosis was observed in one of four unsuccessful
cases, dehiscence in one and urethrocutaneous fistula
developed in two cases. Meatoplasty was performed in
one patient with meatal stenosis, redo Snodgrass tech-
nique in one patient with dehiscence and fistula repair in
two patients with urethrocutaneous fistula. All procedures
were done at least 6 months after the initial operation,
apart from meatoplasty which was performed within 3
Effect of Mathieu and TIP urethroplasty techniques 361

Table 1 Age of patients and length/diameter of new urethra

n Age (years) Length (mm) Diameter (Fra)
Min Max Mean  SD Min Max Mean  SD Min Max Mean  SD
Mathieu 57 2 30 10.16  4.97 5 35 15.9  7.19 6 14 8.07  1.67
TIP 21 3 18 9.04  3.89 5 35 18.84  8.71 6 12 7.80  1.53
P* 0.37 0.24 0.55
*P > 0.05, ManneWhitney U-test.
a
Polyethylene feeding tube used.

months. All patients with complications were successfully
cured.
Forms of urinary diversion applied in all patients are
listed in Table 5. There was no difference between groups
(P Z 0.70). When correlation between forms of urinary
diversion used in patients and surgery outcomes was ana-
lyzed, it was found that utilizing urethral catheter or stent
and cystostomy made no difference with regard to success
(P Z 0.33) (Table 6).
After within-group analysis for age, length of urethra
created, caliber of urethra and number of previous oper-
ations, and correlation of these parameters with surgical
success, it was concluded that the success achieved with
the Mathieu urethroplasty had a statistically significant
relationship with the number of previous operations
(P Z 0.025, ManneWhitney U-test).
Discussion
Hypospadias is one of the most commonly seen congenital
anomalies [2]. Treatment consists of surgical restoration of
the anatomic defect. Restoration is a procedure that a sur-
geon experienced in the technique performed could carry
out at one session and through day surgery. Rarely, patients
may need to undergo operation that requires another more
intensive surgical procedure.
In cases of distal hypospadias, there are many tech-
niques described for treatment. Since 1932, the year it was
first described, the Mathieu urethroplasty technique [3] has
been used many times and its outcomes have been dis-
cussed, being performed not only in primary hypospadias
cases, but also in reoperative cases.
It is undeniable that the Mathieu technique is one of the
distinguished restoration methods in primary distal penile
hypospadias. Successful applicability of the technique in
reoperative cases and the extent to which a successful
restoration can be achieved with a flap on a scarred
operation field, the base of which has previously undergone
surgery, are still controversial issues. Secrest and col-
leagues [4] reported that complication rates could increase
in meatus-based flap techniques repeated due to a dartos
Table 2 Number of previous operations
Min Max Mean  SD
Mathieu 1 6 1.59  1.03
TIPU 1 4 1.66  0.96
P* 0.58
*P > 0.05, ManneWhitney U-test.
layer with impaired vascularization from previous hypospa-
dias restoration. In their series, they stated that they suc-
ceeded 53% of 34 patients in whom they carried out
salvation urethroplasty using a meatus-based flap, while
they achieved 71% success in 35 patients with salvation ure-
throplasty using an island flap. Additionally, they men-
tioned disadvantages, such as difficulty in dissection while
raising the prepared meatus-based flap over suture scars
due to early surgery and risk of injury to the underlying ure-
thra. In contrast, Wheeler and Malone [5] and Keramidas
and Soutis [6] reported that meatus-based flaps could be
used as a salvation operation with high success rates,
83.3% and 100%, respectively, stating that meatus-based
flaps in secondary urethroplasties were applicable choices
irrespective of the first type of operation. Bar-Yosef and
colleagues [7] reported that they achieved 74% success in
their series of 34 patients reoperated using the Mathieu
technique. Our success rate was 84.2% in the group consist-
ing of 57 patients who were reoperated using the Mathieu
technique. When this rate is compared with the examples
mentioned above, this seems to be one of the most success-
ful series. We may consider not only the experience ac-
quired by frequent use of the Mathieu technique in our
clinic but also fastidiousness in choosing reoperative cases
in whom this technique is applicable as the reason for
this success. The sensitivity in case selection for this tech-
nique is that the urethral plate is narrow, ventral skin is soft
and has less scarring, and the skin around the meatus is soft
and unscathed. Additionally, the number of previous oper-
ations should be taken into consideration. It is reasonable
not to insist on the Mathieu technique in cases with ade-
quate preputium and scarred and hard ventral penile
skin, and to choose restoration with island flaps on-lay style
instead.
Localization of meatus, quality of penile skin and
whether there is preputium and ventral curvature should
be considered in the selection of intervention technique. In
57 cases reviewed in this study whose restorations were
performed using a meatus-based flap, the distance
Table 3 Surgical outcomes of the groups
Successful, Unsuccessful, Total,
n (%) n (%) n (%)
Mathieu 48 (84.2) 9 (15.8) 57 (100)
TIPU 17 (81.0) 4 (19.0) 21 (100)
Total 65 (83.3) 13 (16.7) 78 (100)
P* 0.74
*P > 0.05, Fisher’s exact test.
362 A. Karabulut et al.

Table 4 Success rates with respect to number of previous operations

Outcome No. of previous operations
1 2 3 4 6
n % n % n % n % n %
Mathieu
Successful 34 91.9 9 75 2 50 3 100 0 0
Unsuccessful 3 8.1 3 25 2 50 0 0 1 100
Total 37 100 12 100 2 100 3 100 1 100

TIPU
Successful 10 83.3 5 83.3 1 100 1 50
Unsuccessful 2 16.7 1 16.7 0 0 1 50
Total 12 100 6 100 1 100 2 100

between the meatus and penoscrotal border being longer
than the distance between the meatus and tip of the glans
was considered a general rule of our clinical practice. In all
cases, great care was taken to check whether there was
adequate penile skin, to conserve the relationship between
meatal base and flap length, and not to have a thick scar
over the flap line to be raised. Although the opinion that
soft scars over the flap line could be problematic is
theoretically right, whereby it is possible to prepare the
flap obliquely, we observed no negative outcome from using
areas without these scars. Some authors may prefer to use
an island flap instead of Mathieu urethroplasty, but a meatus-
based flap technique is carried out in a shorter time and
with less difficulty than the salvation surgery performed
using an island flap.
Utilization of successful TIP urethroplasty in reoperative
hypospadias cases was first published by Snodgrass and
colleagues [8]. In another publication, Nguyen and Snod-
grass [9] carried out TIP urethroplasty as reoperation tech-
nique in 31 previously operated patients with a mean
number of operations of 1.1. They reported a success rate
of 90%, and concluded that TIP urethroplasty could be
used as reoperation technique in hypospadias cases where
the urethral plaque was neither excised nor vastly scarred.
Çakan and colleagues [10] reported a mean success rate of
78.4% in their series of 37 patients who were reoperated
using TIP. Our success rate in the series of 21 cases of res-
toration with TIP was 81%. Because the transition of
a department accustomed to utilize the Mathieu technique
in primary hypospadias cases successfully for many years to
TIP took some time, and also due to a short delay in em-
ployability of the technique in reoperative cases, the pa-
tient number in this group is low. The numbers in the two
series of surgery are statistically comparable. No difference
was observed between the two groups when surgical suc-
cess was compared. As there is adequate tissue for TIP ure-
throplasty in most cases, the urethral plaque has a rich
vascularization and the technique is relatively simple,
both surgical success and preference of the surgeons for
the technique increases. No difference in success between
the groups can be interpreted as a reflection of the known
success of both groups in primary hypospadias cases and re-
operative cases. The most important factor for success in ei-
ther primary or reoperative cases is deciding on the most
appropriate technique for restoration and carrying out this
technique in the best way. When the groups were analyzed
internally, considering patient’s age, length of urethra cre-
ated, caliber of urethra, form of diversion used, and number
of previous operations and success rates achieved, a statisti-
cally significant association was found between number of
previous operations and surgical success in the Mathieu
group. As the number of previous operations increases, the
success rate decreases in this group. We interpret this finding
as a cumulative and inevitable effect of scars from previous
operations and defects of vascularization. While scarred
areas of early surgery can be eliminated by adjusting the

Table 5 Urinary diversion types of the Mathieu and TIP Table 6 Relationship between diversion types and surgi-
urethroplasty groups cal success rates
Diversion type Diversion type
Urethral Stent and Total, P* Urethral Stent and Total, P*
catheter, cystostomy, n (%) catheter, cystostomy, n (%)
n (%) n (%) n (%) n (%)
Mathieu 6 (10.9) 49 (89.1) 55 (100) 0.70 Successful 9 (14.1) 55 (85.9) 64 (100) 0.33
TIPU 3 (14.3) 18 (85.7) 21 (100) Unsuccessful 0 (0) 12 (100) 12 (100)
Total 9 (11.8) 67 (88.2) 76a (100) Total 9 (11.8) 67 (88.2) 76a (100)
*P > 0.05, Fisher’s exact test. *P > 0.05, Fisher’s exact test.
a a
Two of the 78 patients were not included in statistical eval- Two of the 78 patients were not included in statistical
uation because we could not obtain their data. evaluation because we could not obtain their data.
Effect of Mathieu and TIP urethroplasty techniques
direction of the flap to be prepared around the urethral me-
atus, there is no such maneuver for scars in the area where
the base of the flap is to be prepared. It would be proper to
accept scars in this area as a warning signal not to carry out
the Mathieu urethroplasty technique.
With regard to the form of urinary diversion used, our
current clinical approach is to use a urethral catheter for
6 days after operation, allowing the patient to void on
the 7th day postoperatively, rather than the diversion
method via urethral stent and suprapubic cystoscopy that
was often used before. By inserting a permanent stent,
the risk of development of urinary retention by exposure
of newly created urethra to compression caused by edema
that could occur in the glans postoperatively, and thus the
risk of possible development of fistula, is eliminated.
In this study the two techniques had similarly high
complication rates in reoperative cases compared to primary
hypospadias cases in the literature. This result may be
interpreted as previously operated tissues not healing as
well as virgin tissues. Urethrocutaneous fistula is one of the
most frequently seen complications of surgery requiring
reoperation. The frequency of urethrocutaneous fistula
formation after hypospadias surgery has decreased as a result
of coverage of the operation area with well-vascularized
tissue (a dartos flap) [11]. In reoperative hypospadias cases,
preparation of an adequate dartos flap may be of difficulty to
most surgeons. In many cases only palpation of the skin cov-
ering the penile shaft (thick and loose skin) may predict the
underlying available dartos tissue. Naturally, this dartos
flap is not as well-vascularized as the virgin tissue.
Conclusions
In patients undergoing reoperative hypospadias surgery,
age, length and caliber of the new urethra created, and the
diversion method used have no significant effect on
the success of both the TIP and Mathieu techniques. As
363
the number of previous hypospadias operations increases,
the success of the Mathieu urethroplasty operation de-
creases. From the small number of cases in this study, it
appears that TIP urethroplasty is preferable to the Mathieu
technique in patients with several previous hypospadias
surgeries. Further studies involving a greater number of
reoperative hypospadias patients would be valuable to
confirm these results.
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