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Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 489-493

A comparative study between Snodgrass versus Mathieu with dartos flap urethroplasty for distal hypospadias repair

1 Department of Surgery, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
2 Kafr El-Sheikh General Hospital, Kafr El-Sheikh, Egypt

Date of Submission20-Aug-2017
Date of Acceptance08-Oct-2017
Date of Web Publication25-Jun-2019

Correspondence Address:
Allam SS Gamea
Kafr El-Sheikh General Hospital, Kafr El-Sheikh 33735
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_578_17

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The aim of this study was to compare between Snodgrass and modified Mathieu procedures regarding the complications rates and the operative time.
Hypospadias is the presence of abnormal meatal opening along the ventral aspect of the penile shaft or into the perineum. Surgical management of hypospadias abnormality has challenged and perplexed surgeons.
Patients and methods
From April 2015 to December 2016, eligible boys were randomly assigned with equal probability to undergo one of the two techniques of hypospadias repair. The study included 40 children experiencing anterior distal shaft hypospadias. Surgeries were performed by a single surgeon. Patients were followed up after discharge.
Mean age for the patients was 23 months, and the mean operative time varied from 70 min for Snodgrass to 100 min for Mathieu (P = 0.170). Success rate was 17 (85%) of 20 for the Snodgrass and 18 (90%) of 20 for modified Mathieu (P = 0.072). Complication rates in the form of urethrocutaneous fistula and meatal stenosis were the commonest, being 15% in Snodgrass and 10% in modified Mathieu repair. No statistically significant difference was found between tubularized incised plate and modified Mathieu procedure regarding complications (P = 0.721).
Snodgrass and modified Mathieu repair were safe, and the choice of one of the techniques will depend on the surgeon's decision.

Keywords: child, hypospadias, operative time, penis, perineum, surgical flaps, urethra

How to cite this article:
Badr ML, Loulah MA, Eltatawy AG, Gamea AS. A comparative study between Snodgrass versus Mathieu with dartos flap urethroplasty for distal hypospadias repair. Menoufia Med J 2019;32:489-93

How to cite this URL:
Badr ML, Loulah MA, Eltatawy AG, Gamea AS. A comparative study between Snodgrass versus Mathieu with dartos flap urethroplasty for distal hypospadias repair. Menoufia Med J [serial online] 2019 [cited 2020 May 27];32:489-93. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/489/260900

  Introduction Top

Hypospadias is a congenital condition characterized by tissue hypoplasia of the ventral aspect of the penis, with incidence of one (0.3%) in 300 males. There is an increase incidence in those with first-degree relatives having hypospadias to about 13 times more than those without family history[1].

Hypospadias is characterized by the following anomalies: abnormal location of urethral opening, presence of chordee, and deficient prepuce ventrally[2],[3],[4]. Surgery aims at achieving both a good function and shape of the penis[1],[3],[5].

Owing to complexity of the condition, more than 200 surgical techniques are described, but none of them is universally accepted[4],[5],[6]. One-stage and two-stage procedures are described, where one-stage repair is currently preferred[5],[7],[8],[9],[10].

The most commonly used one-stage procedures are Snodgrass or tubularized incised plate (TIP) and the modified Mathieu procedure (MMP)[6],[11],[12],[13]. There is controversy about which one is better as regarding success and complication rates[13],[14],[15],[16]. The commonest procedure used by pediatric surgeons is Snodgrass procedure[8],[16],[17],[18],[19],[20]. The aim of the study was to compare between Snodgrass and MMPs.

  Patients and Methods Top

The study was conducted at Department of Surgery, Menoufia University Hospital, from April 2015 to December 2016. After approval of the study protocol by the local ethical committee and obtaining fully informed parents' written consents, 40 children with distal shaft hypospadias, with good prepuce, mild or no chordee, and wide urethral plate, were included in the study. Children were randomly divided into two equal groups according to the surgical technique used, either MMP group or TIP urethroplasty group. All children underwent complete physical examination, preoperative laboratory tests, and abdominal ultrasonography. Those with previous repair, circumcised, narrow urethral plate, moderate to severe chordee, and proximal hypospadias were excluded from our study. All procedures were performed by one surgeon using general anesthesia. Antibiotics were given with induction in a dose of 50 mg/kg, continued for 72 h postoperatively, and replaced by oral antibiotics till removal of urinary catheter at 5–7 days.

Surgical techniques

A tourniquet was applied at the base of the penis to maintain a bloodless field; traction suture (proline 4/0) was applied at the glans to facilitate traction and fixation of the catheter at the end of the procedure.

For TIP urethroplasty, a U-shaped incision was made along the edge of the urethral plate up to the glans and the healthy skin 2 mm proximal to the ectopic meatus; the penile shaft skin was degloved [Figure 1]. The penis was evaluated for curvature by saline injection into corpus spongiosum[19],[20].
Figure 1: U-shaped incision, degloving of the penis, incision of uretral plate, and dissection of glans wings.

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Incision of the urethral plate was done in the midline from the native meatus up to the glans, and tubularization was done by continuous subcuticular sutures over an 8–10 Fr catheter using 5–6/0 polyglactin sutures [Figure 2]. The new urethra was covered with vascularized dorsal dartos flap[3],[6],[8],[14]. Dartos flap was taken from the prepuce, preserving the vascular pedicle, and transferred from the dorsum to the ventrum through a button hole in the dartos tissue and used to cover the new urethra and secured with 6-0 polyglactin sutures to buck's fascia [Figure 3]. At the end of the procedure, skin of the penile shaft was reconstructed[14],[16],[17].
Figure 2: Tubularization urethroplasty.

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Figure 3: Prepucial dorsal flap transferred from dorsum to ventrum through button hole technique.

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For MMP, repair was started by marking the urethral plate and perimeatal-based flap [Figure 4], taking into consideration that the distance of the perimeatal- based flap proximally is about 1.5–2 times the distance from the ectopic meatus to the glans tip, and width of 7.5 mm measured from the proximal flap, tapered to 5.5 mm at the distal extent of the flap for placement at the glans. The flip flap was mobilized off the urethra in a proximal to distal direction with the aid of fine stay sutures and tenotomy scissor, taking into consideration the vascularity of the flap, and folded over the native meatus up to the tip of the glans; the penile shaft skin was degloved, and the penis was evaluated for curvature by saline injection into corpus spongiosum[5],[6],[7],[14].
Figure 4: Perimeatal-based flap created and dissected from proximal to distal.

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The flap was sutured by bilateral longitudinal running subcuticular continuous sutures that approximate this flap to the lateral aspect of the urethral plate, thereby creating a neourethra over an 8–10 Fr catheter using fine polyglactin sutures (5–6/0) [Figure 5].
Figure 5: Flip flap sutured to urethral plate creating neourethra.

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Glandular wings were created by deep dissection under glans away from marked urethral plate, and the meatus created at the tip of the glans with single interrupted fine absorbable sutures, a second layer coverage provided by dorsal dartos preputial flap transposed from dorsum to ventrum, adding more protection and reducing the complications. The glans wings were approximated without tension in two layers, and skin reconstruction completed[14],[19].

Simple gauze dressing was applied. The dressing was removed on the third postoperative day, and the patient was discharged with instructions to follow-up weekly in the first month, then monthly in the first year. The following postoperative problems were assessed in both groups on follow-up: meatal stenosis, penile torsion, wound breakdown, urethrocutaneous fistula, and meatal opening configuration[1],[2],[14],[17].

Statistical analysis

It was done by SPSS software package (version 24; IBM Corp., Armonk, New York, USA) used for data input and analysis. Discrete variables were presented as numbers (counts) and percentage. Continuous variables were presented as mean and SD. Student's t-test was used for two independent samples and was used to test the significance of difference between two different variables. Findings with P value less than 0.05 were considered significant.

  Results Top

Mean age for the patients was 23 months, ranging from 10 to 36 months [Table 1]. The mean operative time varied from 70 min (55–85 min) for TIP to 100 min (85-115 min) for MMP (P = 0.170). Moreover, the location of the ectopic meatus varied among the patients as shown in [Table 2].
Table 1: Distribution of patients according to age group

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Table 2: Location of meatus in all patients and operative time

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Success rate is defined as those patients who were free of complications after surgery; it was 17 (85%) of 20 for TIP and 18 (90%) of 20 for MMP (P = 0.071) [Table 3].
Table 3: Comparison of complications between tubularized incised plate and modified Mathieu procedure

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Complication rate in Snodgrass was 15% in the form of urethrocutaneous fistula in two patients and one patient with meatal stenosis, whereas in modified Mathieu repair, it was 10% in the form of one patient with urethrocutaneous fistula and one patient with meatal stenosis (P = 0.712) [Table 3].

In Snodgrass group, two patients with fistula were rescheduled for redo surgery, whereas in MMP group, one patient with fistula was booked for reoperation. Patients with meatal stenosis were managed by frequent dilatation until improved completely within 3–6 months. In both groups, there were losses to follow-up: three patients in Snodgrass group and two patients in MMP group.

  Discussion Top

Hypospadias is defined as a common congenital anomaly of the urethra and phallus, which needs a safe and proper surgical management to prevent further disabilities and psychological problems in the affected children[1]. Hypospadias repair can result in complications ranging from urethrocutaneous fistula to complete disruption of the repair requiring further redo surgery[17].

The demographic characteristics from this study did not show any statistical significance. The age of the patients may play a critical role in the outcome of the operation related to the size of the penis: the smaller the penile size, the more difficult is the tissue handling during the urethral reconstruction[8].

The difference between the two groups, regarding location of the ectopic urethral meatus, was not significantly different, and it shows the same outcome when age of the patient is considered.

The mean operative time was shorter in the group of children operated with the Snodgrass procedure, 70 min (55–85 min) versus 100 min (85–115 min) for MMP. This was also seen in reports of Moradi et al.[6]. The shorter operative time in Snodgrass procedure favors this technique, as it exposes the patients to lesser anesthetic time and potential iatrogenic complications[13]. In both techniques, wound dehiscence was not observed, and when comparing the proportions of patients who developed complications following the two techniques, we found no significant difference[6].

Complication rate differences between the two groups were not statistically significant: 15% for Snodgrass versus 10% for MMP[3]. It was found that urethrocutaneous fistula and meatal stenosis are the most common complications reported, and they are like those reported by Matumba regarding TIP group and MMP group[13] and like those reported by Hasson[19].

Follow-up losses represented in this study were because of either a long distance between patient's residence and university hospital or parents satisfied at first visits and found no reason to come back to the hospital for follow-up or unsatisfied about the results and seeked advice at other center.

Meatal stenosis in TIP was 5% in our study, and this is comparable to 8% in the study by Hasoon[19]. The urethrocutanous fistula incidence was 10% in this study, and this is very close to the results of Matumba et al.[13], being 9.75%.

Urethral stenosis in MMP was 0% in our study, and this is better than 3.12% reported by Saleem et al.[3]. Regaring shape, the meatal opening configuration was superior in Snodgrass (vertical or oval) than MMP (rounded), and this raises the question of which is the best technique for the patient[6].

  Conclusion Top

Snodgrass and modified Mathieu repair are safe. Many surgeons think that the gold standard for distal hypospadias repair has not yet been determined and that the two techniques are as effective as each other. At this point, our study cannot yet finalize the debate about the superiority of one technique to the other. A bigger sample will be needed before we can reach safe recommendations. The choice of one of the techniques will depend on the surgeon's choice.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair: results of a multicenter experience. J Urol 1996; 156 (Pt 2):839–841.  Back to cited text no. 1
Bilici S, Sekmenli T, Gunes M, Gecit I, Bakan V, Isik D. Comparison of dartos flap and dartos flap plus spongioplasty to prevent the formation of fistulae in the Snodgrass technique. Int Urol Nephrol 2011; 43:943–948.  Back to cited text no. 2
Saleem MS, Rasool M, Pansota MS, Tabassum SA. Comparative study between tubularized incised plate uretroplasty (Snodgrass) and reverse flap (Mathieu) repair in distal hypospadias. Ann Pak Inst Med Sci 2012; 8:96–100.  Back to cited text no. 3
Daher P, Khoury A, Riachy E, Atallah B. Three-week or one-week bladder catheterization for hypospadias repair? A retrospective–prospective observational study of 189 patients. J Pediatr Surg 2015; 50:1063–1066.  Back to cited text no. 4
Abdulghafoor B, Aldabbagh H. Primary distal hypospadias repair: tubularized incised plate urethroplasty (Snodgrass) versus the perimeatal based flap (Mathieu). Iraqi J Med 2009; 23:1.  Back to cited text no. 5
Moradi M, Moradi A, Ghaderpanah F. Comparison of Snodgrass and Mathieu surgical techniques in anterior distal shaft hypospadias repair. Urol J 2005; 2:28–31.  Back to cited text no. 6
Oswald J, Korner I, Riccabona M. Comparison of the perimeatal-based flap (Mathieu) and the tubularized incised plate urethroplasty (Snodgrass) in the distal hypospadias. BJU Int 2000; 85:725–727.  Back to cited text no. 7
Snodgrass W, Bush N. Primary hypospadias repair techniques: a review of the evidence. Urol Ann 2016; 8:403–408.  Back to cited text no. 8
Rasool M, Sheikh A.H, Tabassum SA, Amin M. Hypospadias repair Professional Med J 2007; 14:677–684.  Back to cited text no. 9
Bleustein CB, Esposito MP, Soslow RA, Felsen D, Poppas DP. Mechanism of healing following the Snodgrass repair. J Urol 2001; 165:277–279.  Back to cited text no. 10
Hassib AH. Comparative study between the meatal-based flap 'Mathieu' technique and tubularized incised plate 'Snodgrass' urethroplasty in treatment of distal hypospadias. Egypt J Plast Reconstr Surg 2005; 29:141–148.  Back to cited text no. 11
El-Kassaby AW, Al-Kandari AM, El-Zayat T, Shokeir AA. Modified tubularized incised plate urethroplasty for hypospadias repair. long term results of 764 patients. J Urol 2008; 71:611–615.  Back to cited text no. 12
Matumba CK. Distal hypospadias repair: comparison of Snodgrass versus modified mathieu procedures: a randomized clinical trial [thesis]. Harare, Zimbabwe: University of Zimbabwe; 2013.  Back to cited text no. 13
Hombalkar N, Guray P. Dhandor P, Parmar R. Snodgrass procedure – Aversatile technique for various type of hypospadias repair. J Krishna Inst Med Sci Uni 2013; 2:116–122.  Back to cited text no. 14
Abd El-Mageed M, Husein A, El-Moez W. Randomised comparative study between Mathieu flip-flap and Snodgrass technique for the repair of distal hypospadias. Egypt J Plast Reconstr Surg 2007; 31:157–165.  Back to cited text no. 15
Aslam R, Cambell K, Wharton S, Baracka A. Medium to long term results following single stage Snodgrass hypospadias repair. J Plast Reconstr Aesthet Surg 2013; 66:1591–1595.  Back to cited text no. 16
Winberg H, Westbacke G, Ekmark A N, Anderberg M, Arnbjornosson E. The complication rate after hyposoadias repair and correlated preoperative symptoms. Open J Urol 2014; 4:155–162.  Back to cited text no. 17
Snodgrass W, Bush N. Recent advances in understanding/management of hypospadias. F100Prime Rep 2014; 6:101.  Back to cited text no. 18
Hasoon MA. Comparative study in anterior distal hypospadias reconstruction utilizing different techniques (Mathieu and Snodgrass): outcome, complictions and failure rate. IOSR J Pharm 2013; 3:53–59.  Back to cited text no. 19
Keays MA, Dave S. Current hypospadias management: diagnosis, surgical management, and long-term patient-centred outcomes. Can Urol Assoc J 2017; 11(Suppl 1):S48–S53.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3]


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