Ali Cift

Alper Gok

Can Benlioglu

Haci Polat

Mehmet Ozgur Yucel

Ugur Lok

Umut Gulacti

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Polat et al. SpringerPlus  (2016) 5:689 
DOI 10.1186/s40064-016-2316-0
RESEARCH
The success of tubularized-incised plate 
urethroplasty in adults and children
Haci Polat1*, Umut Gulacti2, Alper Gok1, Mehmet Ozgur Yucel1, Ali Cift1, Ugur Lok2 and Can Benlioglu1
Abstract 
Purpose: Hypospadias repair is rarely performed in adults. It is believed that the success rate is lower in adulthood. 
We aimed to compare the success rate of primary hypospadias repair with tubularized-incised plate (TIP) urethro-
plasty in adults and children.
Patients and methods: The databases of consecutive boys and adults who were treated with TIP urethroplasty for 
primary hypospadias between 2012 and 2015 were evaluated. All operations in the boys and adult patients were 
performed by a single surgeon. We considered urethroplasty complications to include a urethrocutaneous fistula, 
neourethral stricture, meatal stenosis, diverticulum, and glans dehiscence. Urine flow was also evaluated using 
uroflowmetry.
Results: Seventy-seven consecutive patients underwent surgery by a single surgeon in the last 3 years for hypospa-
dias repair. Nineteen of these patients were adults. Urethrocutaneous fistulae developed in 2 of the 19 (10.5 %) adults, 
and 3 of the 58 (5.2 %) boys. In addition, there were urinary tract infections in 2 (3.4 %) children, meatal stenosis in 1 
(1.7 %) child, and glans dehiscence in 1 (5.3 %) adult. Uroflowmetry was normal in all patients. There was no difference 
in outcomes between boys and adults.
Conclusion: Our data showed that the success rate of hypospadias repair with TIP urethroplasty is similar in adults 
and children. TIP urethroplasty is associated with good results in adults and boys.
Keywords: Adult, Child, Hypospadias, Reconstructive surgical procedures, Urethra
© 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License 
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, 
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, 
and indicate if changes were made.
Background
Hypospadias repair is usually performed during pre-
school age. It is rarely performed in adults in developed 
countries. Hypospadias repair is widely believed to have 
a greater complication rate in adults than in children 
(Snodgrass et al. 2014). However, to our knowledge, there 
are only two studies in the literature that compare the 
success of hypospadias repair in adults and children. In 
the study of Snodgrass et al. with a small series of adult 
patients (six adult patients) who underwent primary dis-
tal tubularized-incised plate (TIP) urethroplasty, com-
plication rates were similar to those reported in children 
(Snodgrass et al. 2014). In another study, Hensle reported 
that hypospadias repair in adults, performed using the 
same techniques as in children, had a higher compli-
cation rate (Hensle 2013); however, various flaps or 
1-stage tubularized grafts were used as opposed to TIP 
urethroplasty.
We have performed TIP urethroplasty for primary 
hypospadias repair in 77 consecutive patients over the 
last 3 years. Nineteen of these patients were adults. We 
evaluated the success rate and complications of TIP ure-
throplasty in adult and pediatric patients in the largest 
adult patient series to date.
Patients and methods
We retrospectively evaluated the medical records of 
consecutive boys and adults treated with primary hypo-
spadias repair for distal or mid-penile hypospadias 
from 2012 to 2015. One surgeon (HP) performed the 
operation for all boys and adult patients. The records of 
patients were entered into databases including patient 
Open Access
*Correspondence:  dr.polat@hotmail.com 
1 Department of Urology, Faculty of Medicine, Adiyaman University, 
Adiyaman, Turkey
Full list of author information is available at the end of the article
Page 2 of 4Polat et al. SpringerPlus  (2016) 5:689 
age, pubertal stage, meatal location, existence of penile 
chordee, glansplasty suture used, and urethroplasty 
complications, such as urethrocutaneous fistula, meatal 
stenosis, neourethral stricture, glans dehiscence, and 
diverticulum.
TIP urethroplasty was performed in all patients, by 
which the neourethra was translocated to the tip of the 
glans to create an orthotopic neomeatus. For the repair, 
4/0 or 5/0 polyglactin sutures were used in children 
and 3/0 or 4/0 polyglactin sutures were used in adults. 
Patients were catheterized with a latex Foley catheter and 
were discharged after its removal on the second or third 
postoperative day.
For this study, glans dehiscence was defined as “com-
plete separation of the glans wings.” Meatal stenosis was 
defined as “meatal calibration <8 Fr in symptomatic boys 
and <12  Fr in symptomatic men with stranguria, pro-
longed voiding, and/or urinary retention.” Diverticulum 
was defined as “visible sacculation of the urethra during 
voiding and/or urethrogram.”
Patients who were Tanner stages 4 and 5 were defined 
as adults. Only patients who underwent primary repair 
at our facility were enrolled in the study. Patients with 
<6 months of follow-up were excluded from the study.
Patients were contacted and invited back to our clinic 
for follow-up after an average of 15 postoperative months 
(range 6–38  months). These patients underwent free 
uroflowmetry using a digital uroflowmeter (Solar Silver, 
Medical Measurement System, The Netherlands); urine 
flow was observed, and a picture was taken at that time.
Data analysis was performed using SPSS for Windows, 
version 11.5 (SPSS Inc., Chicago, IL, USA). Continu-
ous data are presented as mean  ±  standard deviation 
(SD) and/or median (minimum to maximum). Differ-
ences in continuous variables between the two groups 
were determined by a Mann–Whitney U test. Categori-
cal variables were summarized as numbers and per-
centages and compared with the Chi square or Fisher’s 
exact test. A p value of <0.05 was considered statistically 
significant.
Results
We performed 81 consecutive primary hypospadias 
repairs using TIP urethroplasty over the last 3  years. 
Seventy-seven patients with a regular follow-up were 
enrolled in the study. The demographic characteristics 
of the patients are listed in Table  1. Fifty-eight children 
with a median age of 2 years (mean ± SD 3.45 ± 2.939; 
range 1–14 years) and 19 adults with a median age of 20 
(mean  ±  SD 23.74  ±  9.786; range 16–54  years) under-
went surgery. In all patients, primary TIP urethro-
plasty was performed, and a neomeatus was created in 
the normal location at the tip of the glans (Fig.  1). Five 
(8.6 %) children and two (10.5 %) adult patients with mid-
penile hypospadias had mild penile chordae. After penile 
degloving, it was determined that the clinically significant 
curvature did not require additional corrective surgery.
Perioperative outcomes, postoperative complications, 
and uroflowmetry findings are given in Table 2. Periopera-
tive outcomes such as operation time, duration of urethral 
catheterization, and duration of postoperative hospital 
stay were similar in children and adult patients (p > 0.05). 
Regarding postoperative complications, urethrocutane-
ous fistulae developed in three (5.2 %) children, who fully 
recovered after fistula repair. Urethrocutaneous fistulae 
also developed in two (10.5  %) adults. Fistula repair was 
performed in one of these patients, and the patient fully 
recovered. The other patient has been scheduled for fistula 
repair. Glans dehiscence developed in one (5.3  %) adult; 
secondary TIP urethroplasty was performed in this patient, 
however, urethrocutaneous fistulae developed after this 
session, which were successfully repaired during a third 
surgery (Fig. 2).  
The uroflowmetry peak flow rate (Qmax) was measured; 
the mean was 17 mL/s (min–max 14–28) in the pediat-
ric patients and 20 mL/s (min–max 16–29) in the adults. 
The flow pattern of all patients was normally shaped dur-
ing uroflowmetry measurements.
No adult patients reported sexual dysfunction or dis-
ability after surgery. In addition, a patient aged 54 years 
with mid-penile hypospadias whose main issue was infer-
tility fathered a child 1 year postoperatively.
There was no statistically significant difference between 
pediatric and adult patients in terms of meatus location 
on the penis and complications, such as urethrocutane-
ous fistula, glans dehiscence, urinary tract infection, and 
meatal stenosis (p > 0.05).
Table 1 Demographic characteristics of patients
SD standard deviation
Children Adults p value
Number of patients 58 19
Age, years
 Mean ± SD 3.45 ± 2.939 23.74 ± 9.786 <0.001
 Median (min–max) 2.00 (1–14) 20.00 (16–54)
Meatal location, n (%) 0.483
 Distal 41 (70.7) 15 (78.9)
 Mid-shaft 17 (29.3) 4 (21.1)
Existence of chordae, n (%) 5 (8.6) 2 (10.5) 1.000
Follow-up period, months
 Mean ± SD 16.76 ± 9.312 16.58 ± 9.495 0.957
 Median (min–max) 14.00 (6–38) 14.00 (6–38)
Page 3 of 4Polat et al. SpringerPlus  (2016) 5:689 
Discussion
Many studies in the literature focus on pediatric 
patients who undergo primary hypospadias repair with 
TIP urethroplasty and modifications thereof (Tavak-
koli Tabassi and Mohammadi 2010; Karakus et  al. 
2014; Acimi 2011). To our knowledge, there is only one 
publication related to the comparative success rates of 
TIP urethroplasty in adult and pediatric patients. In 
that study, Snodgrass et al. published the results of six 
adult patients who underwent primary repair with TIP 
urethroplasty for distal hypospadias (Snodgrass et  al. 
2014). Urethroplasty complications were not observed 
in these patients. The authors stated that there was no 
difference in the urethral complication rate in adults 
and children.
In a study somewhat similar to the present study, 
Hensle reported complications in three (37  %) of eight 
patients who underwent a primary repair (Hensle 2013). 
Fig. 1 a–d A 35-year-old patient’s preoperative, intraoperative, and postoperative images
Table 2 Perioperative and  postoperative outcomes 
and complications
SD standard deviation
Children Adults p value
Perioperative outcomes
 Operation time, min
  Mean ± SD 34.40 ± 8.938 34.21 ± 6.511 0.347
  Median (min–max) 30.00 (25–60) 35.00 (25–50)
 Duration of urethral catheterization, h
  Mean ± SD 40.90 ± 7.878 36.89 ± 8.089 0.139
  Median (min–max) 48.00 (24–48) 36.00 (26–52)
 Duration of hospital stay postoperatively, h
  Mean ± SD 43.31 ± 7.762 40.0 ± 7.824 0.181
  Median (min–max) 48.00 (26–54) 38.00 (30–55)
Postoperative complications
 Glans dehiscence, n (%) 0 1 (5.3) 0.237
 Urethrocutaneous fistula, n (%) 3 (5.2) 2 (10.5) 0.587
 Meatal stenosis, n (%) 1 (1.7) 0 1.000
 Urinary tract infection, n (%) 2 (3.4) 0 1.000
Uroflowmetry findings
 Peak flow rate (mL/s)
  Mean ± SD 17.1 ± 2.998 20.42 ± 3.322 <0.0001
  Median (min–max) 16.00 (14–28) 20.00 (16–29)
Fig. 2 Images of some patients in postoperative different time
Page 4 of 4Polat et al. SpringerPlus  (2016) 5:689 
However, other hypospadias repair techniques were used 
in Hensle’s study, including various flaps and 1-stage 
tubed grafts. Hensle stated that these results clearly dif-
fered from those achieved in childhood repairs.
In addition, to our knowledge, three studies in the lit-
erature included only adult patients. Sharma published a 
series of 13 patients aged 18–26 years (Sharma 2005). A 
urethrocutaneous fistula developed in one patient in this 
series; no other complications were reported. Hatipoglu 
et  al. performed a study on 27 men who were treated 
with primary distal (n =  19) or mid-shaft TIP urethro-
plasty (Hatipoglu et  al. 2013). Complications developed 
in 5 (19 %) men, including 2 fistulae and 3 meatal sten-
oses. Adayener and Akyol described 12 men with distal 
hypospadias who underwent TIP urethroplasty (Aday-
ener and Akyol 2006). A urethrocutaneous fistula devel-
oped in 1 of the 12 men (8 %) as a complication.
In this study, we shared the results of 77 consecutive 
patients who underwent primary hypospadias repair 
with TIP urethroplasty. Nineteen of these patients were 
adults. Our series showed that the success rate of adult 
hypospadias repair with TIP urethroplasty is good and 
equal to the success rate seen in boys who undergo the 
same surgery.
In our routine practice, we follow several basic steps 
that may differ from other surgeons who perform hypo-
spadias repair. First, we only use TIP urethroplasty in 
distal hypospadias repair. We use 3/0 or 4/0 polyglactin 
sutures in adults and 4/0 or 5/0 polyglactin sutures in 
children. We prefer 8 or 10 F latex Foley catheters in chil-
dren and 14 F latex Foley catheters in adults. We remove 
the catheter two or three days postoperatively, because 
we believe that early catheter removal reduces cuff for-
mation (Polat et al. 2015).
There are two potential limitations of our study. First, 
only the results of patients who underwent primary 
repair for distal or mid-shaft hypospadias were analyzed. 
Second, the mean follow-up was 16  months; additional 
complications may be diagnosed after a longer follow-up.
Conclusion
To our knowledge, this is the second study in the lit-
erature to compare hypospadias repair in children and 
adults. TIP urethroplasty for primary hypospadias repair 
was successful in both boys and adults, with a low com-
plication rate. The success rates of TIP urethroplasty 
were the same in adults and children.
Abbreviation
TIP urethroplasty: tubularized-incised plate urethroplasty.
Authors’ contributions
HP carried out the surgery of patients and organized this study. AG partici-
pated in data collection and regulation. MOY participated in data collection 
and regulation. AC participated in data collection and regulation. UG made 
statistical process. UL contributed to the statistical process. CB contributed to 
writing the manuscript. All authors read and approved the final manuscript.
Author details
1 Department of Urology, Faculty of Medicine, Adiyaman University, Adiyaman, 
Turkey. 2 Department of Emergency, Faculty of Medicine, Adiyaman University, 
Adiyaman, Turkey. 
Competing interests
The authors declare that they have no competing interests.
Ethical approval
All procedures performed in studies were in accordance with the ethical 
standards of the institutional and/or national research committee and with 
the 1964 Helsinki Declaration and its later amendments or comparable ethical 
standards.
Informed consent
Informed consent was obtained from all individual participants included in 
the study.
Received: 4 March 2016   Accepted: 10 May 2016
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The success of tubularized-incised plate urethroplasty in adults and children

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