Journal Pre-proof

TUBULARIZED RECONSTRUCTED PLATE URETHROPLASTY: AN

ALTERNATIVE TECHNIQUE FOR DISTAL HYPOSPADIAS REPAIR

Can Taneli , Halil Ibrahim Tanriverdi , Abdulkadir Genc ,

Aydin Sencan , Cuneyt Gunsar , Omer Yilmaz

PII: S0090-4295(20)31263-2
DOI: https://doi.org/10.1016/j.urology.2020.10.007
Reference: URL 22580

To appear in: Urology

Received date: 17 August 2020

Revised date: 2 October 2020
Accepted date: 5 October 2020

Please cite this article as: Can Taneli , Halil Ibrahim Tanriverdi , Abdulkadir Genc , Aydin Sencan ,
Cuneyt Gunsar , Omer Yilmaz , TUBULARIZED RECONSTRUCTED PLATE URETHROPLASTY:
AN ALTERNATIVE TECHNIQUE FOR DISTAL HYPOSPADIAS REPAIR, Urology (2020), doi:
https://doi.org/10.1016/j.urology.2020.10.007

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© 2020 Published by Elsevier Inc.

TUBULARIZED RECONSTRUCTED PLATE URETHROPLASTY: AN ALTERNATIVE

TECHNIQUE FOR DISTAL HYPOSPADIAS REPAIR

Can Taneli1, Halil Ibrahim Tanriverdi2, Abdulkadir Genc2, Aydin Sencan2, Cuneyt Gunsar2,

Omer Yilmaz2

1
Manisa Celal Bayar University, Department of Pediatric Surgery, Division of Pediatric

Urology, Manisa-Turkey

2
Manisa Celal Bayar University, Department of Pediatric Surgery, Manisa-Turkey

Running Title: Tubularized reconstructed plate urethroplasty

Key Words: Hypospadias; urologic surgical procedures; urethra; penis.

Corresponding author: Can Taneli MD, FEAPU, Professor of Pediatric Surgery

Director, Division of Pediatric Urology, Department of Pediatric Surgery, Manisa Celal Bayar

University, Faculty of Medicine, Uncubozkoy, Manisa, 45030,-Turkey

Telephone: +90 532 2926927,

E-mail: cantaneli@gmail.com

Word count for abstract: 249

Word count for text: 2739

Declaration of interest: All authors declare that there is no conflict of interest.

Author Disclosure Statement:

Disclosures/conflict of interest: All authors have nothing to disclosure

1
Ethical Standards: Informed consent was obtained pre-operatively from all our patients

which were included in our study.

Authors Contribution:

Can Taneli - Project development, Improvement of Surgical technique, Performance of

surgical operations, manuscript writing

Halil Ibrahim Tanriverdi- Data collection, follow-up examination

Abdulkadir Genc-Data collection, follow-up examination

Aydin Sencan-Data collection, follow-up examination

Cuneyt Gunsar-Data collection, follow-up examination

Omer Yilmaz-Data collection, follow-up examination, manuscript editing

Source of Founding: None

2
Abstract:

Objective: To report current results of a new surgical technique, tubularized reconstructed

plate urethroplasty (TRPU) in distal hypospadias repair which allows the tubularization of

urethral plate without incision or grafting.

Methods: This study is a prospective single surgeon series. Between January 2019-March

2020, total of 158 patients underwent hypospadias repair, and 29 selected patients had

TRPU procedure. Demographic data, duration of follow-up, complications were recorded. A

vertical incision is made starting from halfway up the glans. This incision creates a diamond

like defect which enables wedge removal of a segment of spongiosum tissue from the base

of urethral plate extending to the hypospadiac meatus. Vertical incision is closed horizontally.

The urethral plate is stretched and loosened from the base and re-secured into its bed using

quilting stitches. Reconstructed urethral plate ensures the required width to allow the

formation of neourethra of adequate circumference, followed by a formal glansplasty.

Results: Preoperative glans width was 13.4±0.9mm, urethral plate width was 6.1±0.9mm.

Mean postoperative follow-up period was 13.6 months. All patients had successful functional

outcome and cosmetically satisfying appearance. None of the patients required meatal

calibration. The total complication rate was 3.4%.

Conclusions: Native urethral plate itself is used as a natural flap to increase the surface

area of the urethral plate in this new perspective of urethroplasty method. We believe that

TRPU procedure provides an alternative approach for the formation of neourethra and it is a

successful and relatively simple procedure with low complication rates, good cosmetic results

and promising successful functional short-term outcome.

3
Introduction

Hypospadias is an improving field of reconstructive surgery with different techniques

being currently used. Even the most commonly used correction techniques continue

to challenge surgeons with post-operative complications such as meatal stenosis,

meatal retraction, urethral stricture, urethral fistula, glans dehiscence, hematoma,

infection etc. Successful outcomes depend mainly on the surgeon’s skills and

availability of adequate tissue. We developed an alternative technique by creation of

a neourethral plate for tubularization and named the procedure as reconstructed

plate urethroplasty. The procedure simulates fossa navicularis and additionally solve

the problem of meatal stenosis, which is the most common complication of

hypospadias surgery.

Thiersch-Duplay method originally described the creation of a neourethra by

tubularizing the penile skin to the meatus.1-3 Tubularization of the urethral plate is the

most frequently used approach; however, simple tubularization could result in

stenosis. Tubularized incised plate urethroplasty (TIPU) utilizes a midline relaxing

incision in the urethral plate.4 The incision results in denuded surface for delayed

epithelization, but it may not add the desired width. The exact healing mechanism of

the incised plate is still open for discussion. To improve healing of the neourethra

after TIPU, the grafting of the dorsal incised area using the inner prepuce and dorsal

inlay graft urethroplasty (DIGU) has been described.5 DIGU is an attractive procedure

for primary or secondary hypospadias cases.

4
The aim of the present study is to introduce an alternative method, tubularized

reconstructed plate urethroplasty (TRPU), in distal hypospadias repair. The TRPU

technique allows tubularization of urethral plate without relaxing incision or grafting.

We describe the steps of the TRPU technique on our initial series with successful

short-term outcome.

Materials and Methods

The TRPU method was performed in selected 29 patients between January 2019 and

March 2020 from a total of 158 patients that underwent hypospadias repair during

this inclusion period. The operation was performed consecutively to the patients that

met the inclusion criteria in a single center, by a single surgeon (CT), in a prospective

setting. The inclusion criteria for TRPU procedure is primary hypospadias repair with

shallow groove and flat glans where the relaxing midline incision is not ideal, but also

the groove is not narrow enough to require grafting. The indication for this technique

is well vascularized, thick, compliant, elastic plates, with urethral defect not longer

than 2-3 cm. Exclusion criteria are redo operations for hypospadias and preoperative

androgen stimulation. The major contraindication is fibrotic and scarred urethral plate.

TRPU surgery cannot be performed in cases with severe curvature and hypoplastic

urethra which are unable to preserve the urethral plate. TRPU technique could be

performed in mild-moderate glanular tilt, since it can be corrected by the removal of

spongium tissue excision. It is unnecessary to use TRPU technique in wide and very

deep-grooved plates where the tubularization could be easily performed.

Assessments of glans and urethral plate width measurements were performed

manually by compasses in all patients. Groove depth and surface area cannot be

measured objectively even with 3D technologies. Therefore, measurement of urethral

plate groove and surface before and after excision of subepithelial tissue at the base

5
of the plate cannot be assessed. The operation technique was chosen based on the

criteria above. Demographic data, duration of follow-up and complications were

recorded. Data are given as mean ± standard deviation and range. This study was

approved by our Institutional Review Board (IRB: 20.478.486/324). Written informed

parental consent was obtained from all patients. The assessment of the

complications and follow-up examination was made by third-party investigators blind

to the technique of the operation. Meatal size and necessity of dilatation was

determined by visual or video observation of voiding. We defined successful

functional outcome criteria as: straight urinary stream containing flare with a

translucent center, absence of voiding symptoms, additionally, the lack of meatal

regression, glans dehiscence, meatal stenosis, ventrally deflected or spraying urinary

stream. Cosmetically satisfying results are indicated as: conical shaped glans, slit-like

wide glanular meatus, ideal mucosal collar, aesthetically appearing skin covering and

normal cutaneous raphe.

Surgical Technique

After traction suture is placed through the tip of the glans, a vertical incision is made

beginning at the upper-half portion of the glans and extending distally to the apex.

Control of bleeding is provided by tourniquet. After the incision is deepened, two

traction sutures are placed at the edges of the incision (Fig. 1A). This incision creates

a diamond like defect which enables excision of a segment of glanular spongiosum

tissue, gaining adequate space for wide meatus (Fig.1B). Subsequently, longitudinal

wedge removal of a spongiosum tissue from the base of urethral plate extending to

the hypospadiac meatus (Fig. 1C). Thus, a wedge-shaped groove is carved out from

the posterior of the native urethral plate. Evacuation of spongiosum tissue is

performed while pulling the tissue with fine-toothed forceps, cutting the tissue with iris

6
scissors and then extirpating by curette. As long as the depth of spongiosum excision

is limited to corpus cavernosum there is no additional risk of excessive bleeding.

Sub-epithelial excision from the base of the native urethral plate thins and increases

the epithelialized surface area (additional video). The enlargement of the plate

resembles the stretchability of the graft by cleaning the fat tissue under the skin.

Vertical incision is closed horizontally by Heineke-Mikulicz principle, which also

widens the diameter of the narrow plate (Fig. 1D). Thinned, stretched and finally

enlarged native urethral plate is re-secured into its bed using quilting stiches to

reduce the risk of mobilization (Fig. 1E). Urethral plate itself is used as a natural flap

in this new perspective of our urethroplasty method. Wedge removal of spongiosum

tissue extending to the hypospadiac meatus creates a space for central embedding

of urethra. The cavity formed into the glans particularly simulates the fossa

navicularis. A U-shaped incision is done along the lateral margins of the urethral

plate. Reconstructed urethral plate ensures the required width to allow the

tubularization of neourethra of adequate circumference (Fig. 1F). Thiersh-Duplay

tubularization using double layer running subepithelial 7/0 polyglactin suture is

performed. Dartos tissue lays over the suture line as a second barrier for

waterproofing. Glans wings are brought together with interrupted 6/0 polyglactin

suture. Skin is closed with 7/0 PDS suture after circumcision. The operation stages of

the TRPU technique and postoperative results are illustrated in Figure 2. A silastic 8-

10 Fr catheter is used in all operated cases not only to maintain urinary diversion but

also to keep the reconstructed plate pushed back into its bed for 5-7 days. The

dressing is removed at the 2nd day. Outpatient clinic visits are scheduled at 1st week

and 1st, 3rd, 6th and 12th months for evaluation of postoperative outcome. All data

7
including age, meatus location, voiding pattern, and postoperative complications

such as meatal stenosis, fistula and cosmetic results were collected for all patients.

Results

The mean age of the patients at the time of surgery was 38.8±24.9 months (mean ±

standard deviation), and range was 6-120 months. Preoperative glans width was

13.4±0.9 mm (range 12-14 mm), urethral plate width was 6.1±0.9 mm (range 4-8

mm). External urethral meatus was located glanular in 2, coronal in 10, subcoronal in

15 and midshaft in 2 patients. There were no immediate or early postoperative

complications. The mean postoperative follow-up period was 13.6 months (range 6-

20 months). None of the patients need postoperative urethral calibration. At follow-up

visits one patient had a small fistula which was easily repaired 6 months later.

Another patient had anterior deflation of urine which was corrected spontaneously

within 3 months without any treatment. All patients had successful functional

outcomes. Straight urinary stream that contains flare with a translucent center were

observed in all cases at scheduled follow-up voiding controls. None of the patients

require meatal calibration since flare-like voiding pattern was achieved and confirmed

by voiding video records. All patients had cosmetically satisfying appearance with the

slit-like wide external meatus. Glans shape was conical compared to the preoperative

configuration. The total complication rate was 3.4%. The overall outcome of this

procedure seems to be attractive.

Comment

More than 300 procedures for hypospadias repair are available differing only in minor

details. High complication rates are a reported for hypospadias repair in the literature.

Tubularized incised plate urethroplasty procedure gained worldwide popularity since

8
it was published.4 However, some concerns about meatal stenosis and necessity for

regular urethral dilatations were reported.6 Nguyen et al7 suggested that meatal

stenosis is related to inadequate incision depth and tubularization of urethral plate

too far distally. Others reported that, neourethral stenosis is linked to plate

characteristics.8-9 Seleim et al10 stated that 4 mm width is the border line of clinical

relevance that defines poor urethral plate. Abbas and Salle11 proposed an objective

simple formula, measuring the ratio of the urethral plate before and after incision,

(urethra plate ratio =urethral plate pre incision/urethral plate after incision) to help

deciding to graft or not to graft the plate. They thought that if the ratio is less than 0.5,

a significant component of neourethra will be composed by raw tissue, therefore will

be vulnerable to stenosis.11

Urethroplasty technique is determined by ability to preserve the urethral plate. When

considering the optimal repair in hypospadias, the depth, width and characteristics of

the urethral plate should be assessed. Snodgrass12 reported that, the appearance of

the urethral plate varies according to the thickness of connective tissue between the

epithelial surface of the plate and underlying corpora cavernosa. TIPU repair varies

from a deep incision for a shallow groove to no incision for deep groove. 12 Since

most cases have a shallow or moderate groove, the incision of the plate should be

extended deep to corporal bodies. The major indications for grafting were flat glans

or inadequate urethral plate width. Grafting the incised plate decreased the incidence

of meatal stenosis but the procedure added graft-related problems. If the urethral

plate is inadequate, the surgeon could complete the repair with alternative or

modified methods. Urethral groove depth appears to influence neourethral caliber

after tubularization. Proper embedding of the neourethra is an important part of

optimization of the hypospadias repair procedures. In his original technique, Barcat13

9
embedded the neourethra with a small midline incision of the glans. Koff14 and

Barthold15 changed this approach and improved the embedding by making a larger

incision in attempt to reduce tissue pressure on the neourethra. In the original Barcat

technique and modifications, the entire urethral plate is mobilized and attached to a

meatal based skin flap obtained from adjacent shaft skin. Even after extensive

mobilization of urethral plate and substantial resection of glandular tissue during the

carving process in GRACE modification, no disturbance of glandular blood circulation

or sensitivity were observed.16 The TRPU technique is completely different from the

GRACE and Barcat modifications. TRPU technique is unique as it keeps the native

urethral plate intact in its original place and excises spongiosum tissue from the back

of the plate for reconstruction of the neourethra. Wedge excision of spongiosum

tissue creates a longitudinal deep groove extending to the hypospadiac meatus and

posterior resetting of the native urethral plate is done by using quilting stiches.

Distal urethroplasty and glanuloplasty (DUG) procedure represents a combination of

Heineke-Mikulicz and Thiesch-Duplay techniques described by Stock and Hanna.17

The DUG procedure is a reliable technique to widen the urethral plate. However,

DUG and TRPU have different approaches to widen the urethral plate. Unlike DUG

technique, with the TRPU technique the urethral plate is not only widened but also

thinned, stretched, mobilized, grooved and quilted; thus, entirely reconstructed.

We have been using glanular spongiosum excision successfully for more than a

decade as a modification of meatal advancement and glanuloplasty incorporated

(MAGPI) repair.18 We did not observe blood circulation, sensitivity and scar problems

in any patient operated with the modified MAGPI method. Later, in DIGU operations,

we started to place a preputial graft after spongiosum tissue excision. With the

experience gained from these operations, we realized that wedge excision of the

10
spongiosum tissue could be extended to the hypospadiac meatus by preserving the

integrity of urethral plate even in distal penile shaft hypospadias. This method

described in the present article is an intermediate solution between TIPU and DIGU

techniques. Native urethral plate itself is used as a natural flap to increase the

surface area of urethral plate in this new perspective of urethroplasty method. TRPU

method is based on the reconstruction of a re-grooved urethral plate with the

conservation of the epithelialized surface. Reconstructed native urethral plate,

particularly enlarged and grooved plates, ensures the required width for optimal

tubularization.

It is generally accepted that both the preputium and spongiosum tissue have a V-

shaped defect in the ventral part of the hypospadiac meatus.19 However, we also

believe that the spongiosum tissue is not completely missing. It is thicker in the dorsal

part of the urethral plate just like the dorsal collection of the hooded preputium. In our

opinion, the groove is shallow due to the spongiosum tissue collected in the dorsal

part of the urethral plate. Collection of dorsal spongiosum under the plate, allows the

midline relaxing incision in TIPU. Whereas the collection of spongiosum in the dorsal

part of the plate enables evacuating the spongiosum tissue under the epithelialized

surface in TRPU. Furthermore, the removal of the spongiosum creates a space for

the neourethra. Comparison of the schematic representation of cross sections of

TIPU and TRPU techniques in shallow groove hypospadias cases are illustrated in

figure 3.

The key step of the technique is to stretch the urethral plate by evacuating

spongiosum and removing the subepithelial tissue from the back of the plate to

expand the natural urethral plate. This maneuver also re-grooves the urethral plate,

creating a neourethra of appropriate diameter without leaving with a denuded surface

11
for re-epithelialization. In addition, spongiosum tissue removal creates a hinging

effect, facilitates glanular closure, embeds the neourethra further into the glans and

subsequently decreases glanular dehiscence.

Snodgrass and Bush20 stated that, the urethral meatus normally completely enclosed

by the glans which makes urine stream narrow and straight. Hypospadias repair

should restore natural anatomy creating a straight compact urinary stream. The new

TRPU technique imitates fossa navicularis in the normal anatomy of the urethra and

prevents meatal stenosis which is a common complication in distal hypospadias

repair. The TRPU procedure eases the embedding of the urethra further into the

glans, thus a slit-like wide meatus and straight urinary stream containing flare with a

translucent center is obtained (Fig. 4). The TRPU technique is applicable for all distal

hypospadias but has significant value in patients with shallow groove and relatively

narrow plate which are majority of the hypospadias cases. This new technique can

also be used specifically in the glanular section of proximal hypospadias.

In our presented series there were no immediate or early postoperative complications

except one small fistula which was easily repaired later. In addition, anterior deflation

of urine was detected in one patient which improved spontaneously at the

postoperative sixth month. We believe that anterior deflation of urine may occur due

to excessive excision of glanular spongiosum tissue. Therefore, excision of the

spongiosum tissue especially in the glanular part should not be exaggerated.

Although it is commonly stated that meatal stenosis or stricture may not become

apparent until toilet training, none of our toilet-trained patients needed urethral

calibration at the follow-up period. In this series, the TRPU method was applied to

patients in a wide age range of 6-120 months. It has shown that this new method can

be applied from the youngest age of 6 months to the old ages.

12
It has been well noted that boys with hypospadias show abnormal (subclinical) flow

patterns before and after surgery.21 However, until long term follow-up studies clarify

abnormal flow parameters, the significance of these studies remain uncertain. 22

Hence, we did not perform uroflow studies in toilet trained patients.

The limitations of this study were short term follow-up and absence of a comparison

control group of a standardized technique (TIPU, DIGU). Furthermore, the preference

of the surgical technique has not been applied in a randomized setting but by

surgeon’s judgement. Therefore, larger cohorts of patients and long-term follow-up

periods are still pending for further evaluation.

In conclusion, the new TRPU provides an alternative tool to the formation of urethra

in distal hypospadias. Native urethral plate itself is used as a natural flap to increase

the surface area of urethral plate in this new perspective of urethroplasty. We believe

that the TRPU is a relatively simple procedure with a low rate of complications, good

cosmetic appearance and promising successful functional outcome.

References

1.Thiersh C. On the origin and operative treatment of epispadias. Arch Heilk. 1869;

10: 20.

2.Duplay S. De I’hypospadias perineo-scrotal et de son traitement chirurgical Arch

Gen Med. 1874; 513:657.

3.Duplay S. Sur le traitement chirurgical de I’hypospadias et de I’epispadias. Arch

Gen Med. 1880;145:257.

4 Snodgrass W. Tubularized incised plate urethroplasty for distal hypospadias. J

Urol. 1994;151:464-465. https://doi.org/10.1016/s0022-5347(17)34991-1.

13
5. Kolon TF, Gonzales ET. The dorsal inlay graft for hypospadias repair. J Urol.

2000;63:1941-1943.

6. Elbakry A. Tubularized incised urethral plate: is regular dilatation necessary for

success. BJU Int. 1999;84:683-688. https://doi.org/10.1046/j.1464-

410x.1999.00207.x.

7. Nguyen MT, Snodgrass W, Zaontz MR, et al. Effect of plate characteristics on

tubularized incised plate urethroplasty. J Urol. 2004;171:1260-1262.

https://doi.org/10.1097/ 01.ju.0000110426.32005.91.

8. Holland AJ, Smith GH. Effect of depth and width of the urethral plate on

tubularized incised plate urethroplasty. J Urol. 2000;164:489-491.

9. Sarhan O, Saad M, Helmy T, et al. Effect of suturing technique and urethral plate

characteristics on complication rate following hypospadias repair: a prospective

randomized study. J Urol. 2009;182:682-686.

https://doi.org/10.1016/j.juro.2009.04.034.

10. Seleim HM, ElSheemy MS, Abdalazeem Y, et al. Comprehensive evaluation of

grafting the preservable narrow plates with consideration of native plate width at

primary hypospadias surgery. J Pediatr Urol. 2019;15:345.e1-345 e7.

https://doi.org/10.1016/j.jpurol.2019.05.002

11. Abbas TO, Pippi Salle JL. When to graft the incised plate during TIP repair? A

suggested algorithm that may help in the decision-making process. Front Pediatr

2018;6:326-328. https://doi.org/10.3389/fped.2018.00326. eCollection 2018.

14
12. Snodgrass WT. Tubularized incised plate hypospadias repair; indications,

technique and complications. Urology 1999;54:6-11. https://doi.org/10.1016/s0090-

4295(99)00144-2.

13. Barcat J. Les hypospadias. III. Les uretroplasties, les resultates – les

complications. Ann Chir Infant. 1969;10:310-376.

14. Koff SA, Brinkman J, Ulrich J et al. Extensive mobilization of the urethral plate

and urethra for repair of hypospadias: the modified Barcat technique. J Urol.

1994;151:466-469.doi: 10.1016/s0022-5347(17)34992-3.

15. Barthold JS, Teer TL, Rodman JF. Modified Barcat balanic groove technique for

hypospadias repair: experience with 295 cases. J Urol. 1996;155:1735-1737.

16. Ardelt PU, Glaser T, Schoenthaler M, erharz EW, Frankenschmidt A. Glandular

resection and central embedding in hypospadias repair-a novel modification of the

Barcat technique. J Ped Surg. 2012;47:1032-1037.

doi:10.1016/j.jpedsurg.2011.12.013.

17. Stock JA, Hanna MK. Distal urethroplasty and glanuloplasty procedure: results of

512 repairs. Urology. 1997;49(3):449-451. doi:10.1016/S0090-4295(96)00441-4.

18. Taneli C, Genc A, Günsar C, et al. Modification of meatal advancement and

glanuloplasty for correction of distal hypospadias. Scand J Urol Nephrol.

2004;38:122-124. https://doi.org/10.1080/00365590310020042.

19. Baskin LS Ebbers MB. Hypospadias: anatomy, etiology, and technique Journal

Pediatr Surg 2006;41:463-472. doi: 10.1016/j.jpedsurg.2005.11.059.

20. Snodgrass W, Bush N. Is distal hypospadias repair mostly a cosmetic operation?

J Pediatr Urol. 2018;14:339-340. https://doi.org/10.1016/j.jpurol.2018.06.004.

15
21. Wolffenbuttel KP, Wondergem N, Hoefnagels JJ, et al. Abnormal urine flow in

boys with distal hypospadias before and after correction. J Urol. 2006;176(4 Pt

2):1733-1737. doi:10.1016/S0022-5347(06)00614-8.

22. González R, Ludwikowski BM. Importance of urinary flow studies after

hypospadias repair: a systematic review. Int J Urol. 2011;18(11):757-761.

doi:10.1111/j.1442-2042.2011.02839.x.

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Figure Legends

Figure 1. The TRPU technique. A, A vertical incision is made beginning at the upper-half of

the glans and extending distally to the apex. B, Glanular spongiosum tissue is excised with

iris scissors in order to deepen the groove of the urethral plate C, Cleaning the tissue under

the epithelialized surface of the plate widens the native urethral plate. D, Vertical incision and

horizontal closure (Heineke-Mikulicz). E, Thinned, stretched and enlarged urethral plate is

secured into the glans using quilting stitches. F, U-shaped incision is done along the lateral

margins of the urethral plate.

Figure 2: A, Spongiosum tissue excision. B, Expanded plate is re-secured into the glans. C,

U-shaped incision. D, Tubularization of reconstructed urethral plate. E, Dartos tissue is laid

over the suture line. F, Postoperative appearance.

Figure 3: Comparison of cross sections of TIPU and TRPU techniques.

Figure 4: A, Narrow glanular neourethra without fossa navicularis causes a string type

urinary stream. B, TRPU procedure provides a wide meatus and straight urinary stream that

contains flare with a translucent center.

Video Legend

Video showing sub-epithelial excision from the base of the native urethral plate thins and

increases the epithelialized surface area. The resulting enlargement of the plate resembles

the stretching ability of the graft after extirpating the fat tissue under the skin.

17
Figure 1

18
Figure 2

19
Figure 3

20
Figure 4

21