[Downloaded free from http://www.archintsurg.org on Thursday, August 17, 2023, IP: 182.3.5.

92]

Original Article

MAGPI technique for distal penile hypospadias;

modifications to improve outcome at a
single center
Arvind K. Shukla, Aditya P. Singh, Pramila Sharma, Jyotsna Shukla1
Departments of Pediatric Surgery and 1Physiology, SMS Medical College, Jaipur, Rajasthan, India

ABSTRACT
Background: Hypospadias is the most common congenital anomaly of urogenital organs in boys. We reviewed our experience with
modification in the meatal advancement and glanuloplasty incorporated (MAGPI) technique of hypospadias repair. We point out some
modifications and outcomes of this technique in this study.
Patients and Methods: We identified all patients who underwent modified MAGPI repair of the distal hypospadias by a single
surgeon over a 10‑year period. We performed a retrospective chart review by outdoor assessment postoperatively. We assessed
parents’ satisfaction with functional and cosmetic outcomes. Decision to undergo this type of repair was intraoperative, depending
on position and mobility of the meatus, and the quality of periurethral tissue. We made some modifications in the original technique
of the MAGPI including no trimming of the edge of the glans in granuloplasty, incorporation of the collar in the granuloplasty; leading
to glans augmentation and taking stay suture over the ventral wall of the urethra with some perimeatal tissue.
Results: Our study was a retrospective analysis. We collected data retrospectively and outcomes were assessed by the outpatient
department visits in follow‑up. We identified 150 patients, with a median age of 6 years (3–8 years). Position of meatus was glanular
90 (60%) or coronal 60 (40%). Chordee was minimal in our study and was corrected by only penile degloving. Urethral stenting was
required in all patients for 3–4 days. There was no case of fistula, meatal regression, stenosis, mucosal prolapse, or second procedure.
Cosmetic outcome was deemed satisfactory in 98% (147/150).
Conclusion: In selected cases, our modifications in the MAGPI hypospadias repair provide excellent functional and cosmetic outcomes
with minimal complications.

Key words: Distal hypospadias, hypospadias repair, meatal advancement and glanuloplasty incorporated

Introduction anomaly of urogenital organs in boys, with an incidence

of approximately 1 in 250 newborns.[1] Recently, case
Hypospadias is a condition in which the location of selection has been advised to avoid possible complications
the urethral meatus is on the ventral aspect of the and limitations. While the meatal advancement and
penis. Hypospadias is the most common congenital glanuloplasty incorporated (MAGPI) repair continues to give
satisfactory outcomes, its critics have noted its association
Address for correspondence: Dr. Aditya P. Singh, with meatal regression and meatal stenosis. Our aim was
Department of Pediatric Surgery, SMS Medical College, Jaipur,
to review our experience with some modifications in the
Rajasthan, India.
E‑mail: dr.adisms@gmail.com
This is an open access article distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
Access this article online License, which allows others to remix, tweak, and build upon the
Quick Response Code: work non‑commercially, as long as the author is credited and the
Website:
new creations are licensed under the identical terms.
www.archintsurg.org
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Shukla AK, Singh AP, Sharma P, Shukla J.
10.4103/ais.ais_37_16 MAGPI technique for distal penile hypospadias; modifications to improve
outcome at a single center. Arch Int Surg 2016;6:201-5.

© 2017 Archives of International Surgery | Published by Wolters Kluwer - Medknow 201

[Downloaded free from http://www.archintsurg.org on Thursday, August 17, 2023, IP: 182.3.5.92]
Shukla, et al.: Modified MAGPI technique to improve outcome
original MAGPI repair to reduce complications and improve
outcome.
Patients and Methods
We retrospectively reviewed all patients who underwent
MAGPI hypospadias repair in our department from 2005
to 2015 by one surgeon. This was followed by assessment
in the follow‑up clinic during interview with the parents or
patients. The decision to undertake this type of repair was
intraoperative, depending on the position and mobility of
the meatus as well as the quality of periurethral tissue and
quality of the urethra pxoximal to the meatus. We performed
MAGPI in the glanular, coronal (exclude subcoronal),
stenotic meatus, excluding cases with deep glanular groove,
wide urethral plate, and proximal urethra adherence to
the skin. To test its mobility, the meatus should be pulled
distally using a Micro‑Adson forceps. Surgical technique
was in accordance with the original MAGPI technique with
some modifications [Figure 1], including no trimming of the
edge of the glans in granduloplasty and incorporation of the
collar in the granduloplasty, leading to glans augmentation
and taking stay suture over the ventral wall of the urethra
with some perimeatal tissue. The mean outpatient follow‑up
period was 1 year. All patients were reviewed 5 times. We
analyzed adverse outcomes such as meatal stenosis,
meatal regression, fistula, persistent chordee, mucosal
prolapse, poor cosmesis, and the need for reoperation.
a b
c d
e f
Figure 1: (a-f) Pictorial diagram of the steps of surgical technique
202 Archives of International Surgery / Volume 6 / Issue 4 / October‑December 2016
The outdoor assessment consisted of assessing parental
satisfaction and complications. Outdoor assessment was
done by cosmetic appearance (conical shape glans, meatus,
scarring) and parent satisfaction.
Surgical technique
Surgery was performed under general anesthesia and
caudal block with infiltration with 1:100000 xylocaine and
adrenalin solution. Circumferential subcoronal incision was
made [Figure 2]. Degloving of the penis was done up to the
mid penile region leaving behind a 2 mm size “Firlit collars.”
A longitudinal incision was made in the stenotic meatus
2 mm proximally and calibrated with 10 Fr size silastic
NG tube. The meatal advancement was accomplished by a
Heineke–Mikulicz vertical incision and horizontal closure
using 6‑0 vicryl of the transverses septum just distal to the
meatus. Then, the stay suture was placed over the ventral
wall of the urethra with some perimeatal tissue and pulling
it forward. Glanduloplasty was done without dissection and
trimming of the glans. Vertical mattress sutures PGA 6‑0
were taken incorporating the collar. Dorsal prepuce was cut
in the midline to cover the penile shaft. Size 6‑Fr NG tube
was passed and left in situ. Simple penile dressing was
done. Catheter was removed after 3–4 days.
Results
The total number of patients who underwent this type
of repair during the study period was 150. The patients’
age at surgery ranged from 3 to 8 years, with a mean
age of 6 years. Ninety patients were aged 5–6 years. The
characteristics of the patients are shown in Table 1. Overall
outcome was deemed satisfactory in 98% (147/150) of the
cases. There were no urinary complaints in our study.
a b
c d
Figure 2: Preoperative (a), Intraoperative (b and c) and postoperative
view of our modified MAGPI technique (d) postoperative view of our
modified MAGPI technique
[Downloaded free from http://www.archintsurg.org on Thursday, August 17, 2023, IP: 182.3.5.92]

Shukla, et al.: Modified MAGPI technique to improve outcome

There was no persistent chordee and did not require any
dorsal plication to correct chordee in our study. There
was no case of urethral mucosal prolapse. There was
no case of fistula, meatal regression, or meatal stenosis.
None of the patients had a second procedure for a
complication [Table 2]. Good urinary stream and follow‑up
images are shown in Figure 3.
method in glandular type, whereas the tubularized incised
plate (TIP) repair is preferred for other cases of distal
hypospadias.[3] The MAGPI procedure allows the surgeon to
avoid an urethroplasty, and provides a reliable, reproducible
procedure for reconfiguring the glans and meatus without
the use of catheters and with a very low morbidity rate. The
MAGPI technique was devised by Duckett in 1981.[4]

Distal hypospadias is the most common variety accounting

Discussion for 70% of all cases.[4,5] Though the MAGPI technique offered
More than 300 surgical techniques for hypospadias repair improved cosmetic and functional results without the need
have been described.[2] The MAGPI repair is the preferred for formal urethroplasty, complications and limitations of
the procedure have been reported. The reported incidence
of complications following MAGPI repair, which required
Table 1: Characteristics of 150 patients with hypospadias
reoperation, ranges from 1.2 to 10%.[6,7] There was no
Variable Value reoperation in the present study. Meatal regression
Total number 150
and stenosis remain commonly cited problems. Meatal
Age range 3‑8 years (6 years)
regression occurs when the glanduloplasty does not hold.
Operative findings
Glanular 90 Proponents of the procedure have attributed high rates of
Coronal 60 meatal regression and stenosis to poor patient selection
Chordee Minimal chordee with those selected having a meatus located too far
Chordee require correction Nil proximal and those with severe chordee.[6] We included only
Stenting All
glandular and coronal hypospadias with minimal chordee
and excluded more proximal hypospadias in our study.
Table 2: Outcome of treatment in patients that had modified MAGPI Chordee was corrected by degloving only up to the mid
surgery shaft. It did not require any dorsal plication in our study.
Variable Value
We had no complication in our study because we followed
Total number 150 case selection criteria to repair hypospadias. Modifications
Overall satisfied 98% (147/150) to the initial description have been described to reduce
Dissatisfied 2% (3/150) the incidence of meatal regression by bringing glandular
Complications tissue together in a more solid ventral closure.[6] We had
Mucosal prolapse Nil
a modification in our study. We incorporated the collar in
Persistent chordee Nil
Fistula Nil
the glanduloplasty, which helped us in augmentation of the
Meatal regression Nil glans. An additional layer approximating deep glans tissue
Meatal stenosis Nil was added that replaced the vertical mattress stitches in
Second procedure Nil the initial description. Epithelial layer closure superficially
was also incorporated to secure closure. We repaired glans
with the collar in simple or vertical mattress sutures in
our study. Meatal stenosis occurs when the meatus is too
narrow; therefore, using the Heineke–Mikulicz procedure
of cutting vertically to open the dorsal aspect of the meatus
and suturing transversely can minimize this complication.[7]
There was no meatal stenosis in our study. We performed
a b adequate ventral meatotomy and calibration with a 10‑Fr
NG tube. Considering the complications or limitations of
the procedure, many alternative techniques are available.
The majority are based on neourethra formation, which is
usually associated with higher morbidity rate and perhaps
less satisfactory cosmetic results.[8,9]

c d In our study, we performed modified MAGPI up to the

Figure 3: (a) Good urinary stream and (b-d) follow-up images age of 8 years because later in age the glandular tissue

Archives of International Surgery / Volume 6 / Issue 4 / October‑December 2016 203

[Downloaded free from http://www.archintsurg.org on Thursday, August 17, 2023, IP: 182.3.5.92]
Shukla, et al.: Modified MAGPI technique to improve outcome
does not remain supple and causes complication related
to repair. Distal hypospadias has no functional problems
and is rarely associated with fibrous chordee. There
was minimal chordee in our study because we included
only glandular and coronal hypospadias. Patients’ main
concern is the deviation and splaying of urinary stream
in addition to unacceptable cosmetic appearance. Our
experience as well as that of other surgeons showed that,
though most of the cases achieved good cosmetic results,
the technique cannot be applied universally to all types
of distal hypospadias.[10] Most authors reported excellent
results with glandular hypospadias, however, in cases
of coronal and subcoronal hypospadias, complications
were constantly reported.[11] We only included coronal
hypospadias with shallow glandular groove and mobile
urethra in our study.
Variations of MAGPI procedure have been reported to
make this procedure amenable to borderline cases such
as coronal hypospadias, megameatus, and cases with
chordee. Somoza et al. described removing a triangular
segment of glandular tissue distal to the meatus, and
dissection of the dorsal and lateral urethral sides,
accomplishing the urethral advancement without any
tension. Strips of glandular epithelium are excised on
each side, and glans tissue is sutured above the ventral
urethral wall.[12] Another modification was not to dissect
and trim the glans for glanduloplasty with incorporation
of the collar leading to tensionless repair, so we did not
have any fistula, meatal regression, and meatal stenosis
in our study. While Duckett et al.[6] reported complication
rate as fistula (0.45%), meatal regression (0.6%), no meatal
stenosis, second surgery (1.2%), and residual chordee in
0.09%. Our results are more favorable than the original
MAGPI repair. The presences of distal chordee, glandular
tilt, fibrotic urethral meatus, or thin paraurethral skin
are important limiting factors for MAGPI. Case selection
has been advised to avoid the possible complications of
the meatal regression and stenosis.[13] We followed case
selection strictly in our study, and hence, we did not have
any complication with better functional and cosmetic
outcome in our study. The hypospadiac penis that is
amenable to the MAGPI is characterized by a dorsal web
of tissue within the glans that deflects the urine from either
a glandular or a slightly subcoronal meatus. The urethra
itself must have a normal ventral wall, without any thin or
atretic urethral spongiosum, and it must be mobile such
that it can be advanced into the glans.
The decision to undertake this type of repair was
intraoperative, depending on the position and mobility
of the meatus and the quality of periurethral tissue,
204 Archives of International Surgery / Volume 6 / Issue 4 / October‑December 2016
and the quality of the urethra pxoximal to the meatus.
We performed MAGPI in the glandular, coronal (exclude
subcoronal), and stenotic meatus, excluding cases with
deep glandular groove, wide urethral plate, and proximal
urethra adherent to the skin. In our study, there was no
mucosal prolapse. Some authors recommended mucosal
prolapse as a complication but in our study we did not find
any such problem and with no urinary complaints. There
was skin tag after glanduloplasty in our study, however,
it was not so problematic, and in follow‑up, it looks like a
frenulum after remodeling.
It is important not to stretch indications for MAGPI repair
such as selecting patients with a proximal meatus. Issa
and Gearhart reported 8 cases of meatal regression; 5
had meatal regression which was attributed to a technical
failure, and 3 had severe regression suggesting poor patient
selection.[11] On the other hand, Gibbons has suggested that
cases with subcoronal meatus or possible chordee are
suitable for MAGPI with some modification to the technique.
He described a creation of a vascularized meatal‑based
flap, which provides excellent flexibility.[14] One of the few
disadvantages of the MAGPI repair is the unsatisfactory
look of the meatus, and some surgeons would argue that
a nice slit‑like meatus could hardly be fashioned by a
nonmodified MAGPI repair. In our experience, this has not
been a commonly encountered issue. The key of success
in our study is proper intraoperative selection criteria for
MAGPI.
This careful selection resulted in excellent outcomes
from the modified MAGPI procedure with no meatal
stenosis or meatal regression. On the other hand, we
could be criticized for choosing a case of megameatus
for MAGPI repair, as it was advised that this type of
hypospadias would best be repaired using the pyramid
or Mathieu procedure.[6] Nevertheless, other reports have
suggested that megameatus intact prepuce (MIP) variant
of hypospadias is not an absolute contraindication for this
type of repair, with published satisfactory success rates.[15]
Corpus spongiosum advancement is a new technique
ideal for distal hypospadias repair. This procedure has
several advantages over many other procedures currently
employed for repair of distal hypospadias.[16]
Conclusions
Excellent surgical results are determined by meticulous
surgical technique and careful case selection. Our aim of
study is to show the importance of the case selection and
some modifications in the original MAGPI technique to
improve the results in term of complications, functionality,
[Downloaded free from http://www.archintsurg.org on Thursday, August 17, 2023, IP: 182.3.5.92]
Shukla, et al.: Modified MAGPI technique to improve outcome
and cosmetics. Surgical procedure for hypospadias should
be decided after case selection intraoperatively.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Baskin LS, Himes K, Colborn T. Hypospadias and endocrine
disruption: Is there a connection? Environ Health Perspect
2001;109:1175‑83.
2. Germiyanoglu C, Nuhoglu B, Ayyildiz A, Akgul KT.
Investigation of factors affecting result of distal hypospadias
repair: Comparison of two techniques. Urology 2006;68:182‑5.
3. Springer A, Krois W, Horcher E. Trends in hypospadias surgery:
Results of a worldwide survey. Eur Urol 2011;60:1184‑9.
4. Duckett JW. MAGPI (meatoplasty and glanuloplasty):
A procedure for subcoronal hypospadias. Urol Clin North
Am 1981;8:513‑9.
5. Sweet RA, Schrott HG, Kurland R, Culp OS. Study of the
incidence of hypospadias in Rochester Minnesota, 1940‑1970
and case control comparison of possible etiologic factors.
Mayo Clin Proc 1974;49:52.
Archives of International Surgery / Volume 6 / Issue 4 / October‑December 2016 205
6. Duckett JW, Snyder HM. The MAGPI hypospadias repair in
1111 patients. Ann Surg 1991;213:620‑5.
7. Ghali AM, el‑Malik EM, al‑Malki T, Ibrahim AH. One‑stage
hypospadias repair. Experience with 544 cases. Eur Urol
1999;36:436‑42.
8. Devine CJ Jr, Horton CE. Hypospadias repair. J Urol
1977;118:188.
9. King LR. Cutaneous chordee and its implication in
hypospadias repair. Urol Clin North Am 1981;8:397.
10. Ozen HA, Whitaker RH. Scope and limitations of the MAGPI
hypospadias repair. Br J Urol 1987;59:81.
11. Issa MM, Gearhart JP. The failed MAGPI: Management and
prevention. Br J Urol 1989;64:169‑71.
12. Somoza I, Liras J, Abuin AS, Mendez R, Tellado MG, Rios J,
et al. New Modern Magpi. Cir Pediatr 2004;17:76‑9.
13. Duckett JW, Snyder HM. Meatal advancement and
glanuloplasty hypospadias repair after 1000 cases:
Avoidance of meatal stenosis and regression. J Urol
1992;147:665.
14. Gibbons MD. Nuances of distal hypospadias. Urol Clin North
Am 1985;12:169‑74.
15. Bar‑Yosef Y, Binyamini J, Mullerad M, Matzkin H,
Ben‑Chaim J. Megameatus intact prepuce hypospadias
variant: Application of tubularized incised plate
urethroplasty. Urology 2005;66:861‑4.
16. Dutta HK. Meatal and corpus spongiosum advancement:
A better technique for distal hypospadias repair. Pediatr
Surg Int 2013;29:633‑8.