Few days (around 1 month) after TIP urethroplasty, the newly created external urethral meatus gradually become narrow if dilatation was not done. Even though I start urethroplasty from midglans level and meatus looks oval, slit like in immediate post operative period but gradually stenosed.Meatal dilatation is troublesome in toddler age. What is the technical problem which causes stenosis?
Certain tricks that were told to us during our curriculum are as follows (I fully agree that they may not work all the time)
The midline incision that divides the urethral plate should stop short of the neo-meatus by atleast 2-3 mm. If it runs into the neomeatus there is a very high chance of stenosis.
I have seen that some surgeons take the glans stay just at the prospective neo-meatus; I think the small raw area created by the needle is sufficient to invite fibrosis.
Some surgeons do not fix the margins (especially ventral) by means of radial sutures adequately to the glans. According to me this leads to the overriding of raw edges of glans over the neomeatus as it heals.
I certainly agree that these are some of the probable causes according to me.
Dr. Dhananjay Vaze
http://pedsurgeon.wordpress.com/
More important trick is to close the tubularized plate until one or 2 sutures only distal to the mid-glans. If the surgeon continues his sutures till the end of the plate the stenosis will be very likely
You have to begin anastomoses from distal side and made neouretra like V shaped. If you begin to anastomoses from proksimal, meatal stenosis is performed.
Beginning frm distal end as modified by snodgrass is nice to avoid stenosis but it makes the closure of the most proximal part of the tube more difficult. Improper suturing of the proximal end of the tube increases risk of urethrocutaneous fistula
Rather than start from the meatal end, I tend to put a single stitch at neomeatus site and calibrate the neomeatus with a bougie (depending on age of patient - min 3.5 Fr metal dilator or 7.5Fr - 10.5 stent). With the neomeatus well oriented one may then proceed with the urethroplasty. Glanuloplasty carried out after triangularization; unfortunately i am face with submeatal retraction in upto 5% of my patients. This is a bigger problem than fistula or meatal stenosis, as it is very difficult to manage; sometimes I just slit the glans open to relieve the distal obstruction to stream of urine and then address the issue at later date.
Try this, don't suture till the neomeatus is snugged around the catheter/stent. Let it loose/gaped a bit.
The TIP procedure is based on the erroneous assumption that the incision of a narrow urethral plate will ultimately result in a normal caliber urethra. In fact, more than 20 % of pateints who underwent TIP urethroplasty have an obstructive flow. This probably represents the percentage of children with distaal hypospadias with narrow plates. On the other hand, if the plate is wide, the incision is not necessary and a simple Thiersch Duplay tubularization suffices. That is why I said the TIP technique should not be used. If the plate is narrow, it should be augmented. Those who are happy with the TIP have not followed the patients long enough.
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