Hypospadias with Intact Prepuce (HIP): Morphological Variations and Advances in Surgical Treatment

Background: Subsequent to the maiden description of megameatus with intact prepuce (MIP), and the invention of the ‘pyramid technique’ as its surgical solution, other researchers published discordant anatomical features in MIP. Other surgical techniques are proved more appropriate.

Objectives: To perform a detailed analysis of the clinical characteristics of MIP and to audit our results of reconstructive surgeries on MIP.

Methods: Design: Retrospective analysis. Setting: Pediatric surgery departments of 2 tertiary-care centres. Periods of simultaneous research: 9y, 10y 9mo. Age, size of the penis, circumcision status, chordee, glans-penis, external urethral meatus (EUM), urethral plate (UP), distal native urethra, reconstructive surgery and its complications were analyzed. The postoperative result was objectively assessed by Hypospadias Objective Scoring Evaluation (HOSE).

Key Findings: A total of 20 patients showed the incidence of MIP as 2.72%. Their mean age was 45.75 months (range = 12–120 mo). 3 patients were pre-circumcised. Ventral chordee was present in 3(15%). Glans-penis was wide, shovel-like in 15(75%) cases, but conical shape in 5. The types of MIP were Coronal(10), Subcoronal(6) and Glanular(4). The size of EUM was wide in 14(70%) but normal in 6. UP was wide in the majority (13 = 65%), but others were of moderate-width or narrow. In two cases of wide deep UP, the distal transverse septum was present. The distal native urethra was nondilated in all but 1, which had megalourethra. Tubularised urethral plate urethroplasty (TUPU) of Thiersch-Duplay was the technique of reconstruction in 9 cases including 3 pre-circumcised ones. Snodgrass tubularised incised plate urethroplasty (TIPU) was employed in 9 cases including the HIP-megalourethra case. HIP- megalourethra underwent partial excision of megalourethra and TIPU. Incision of distal UP-septum was performed in two cases prior to UP-tubularisation. Glans approximation Procedure (GAP) was the method of repair in 2 glanular-MIP. In three cases, intraoperative injury to native distal urethra/UP occurred. The mean follow-up period was 4.79 months (range=1–12mo). Five postoperative complications occurred in 4 cases and 3 required re-operation. HOSE-score
14 was achieved in 17 out of 20 cases, which is a very satisfactory outcome.

Discussion: The incidence of HIP is 3%-6% among hypospadias. Congenital HIP should be distinguished from iatrogenic-hypospadias before circumcision, to avert false allegation. The dorsal chordee and ventral chordee are found associated with HIP. The shape of the glans-penis is not uniform, and EUM is not always distal, but recently midpenile HIP has also been diagnosed. EUM may have variable sizes. UP may be wide to narrow. The distal native urethra is undilated in the vast majority. Thus, a spectrum of anomalies is found in previously grouped cases of MIP. The term MIP is unsuitable for some such cases, HIP is suitable for all. Associated genitourinary anomalies are possible with HIP. The pyramid procedure is only rarely adopted by hypospadologists to reconstruct HIP. TIPU, TUPU, GAP, Mathieu’s perimeatal flap, and MAGPI are commonly adopted corrective surgeries in suitable cases of HIP.

Conclusion: Hypospadias with intact prepuce is a rare variant of hypospadias. Some such cases have no megameatus and hence cannot be termed MIP, contrary to convention. All cases of hypospadias having intact prepuce can be covered by the umbrella term “HIP”. HIP has a spectrum of anomalies of penile curvature, glans-penis, EUM, and UP. Significant dilatation of the distal urethra (megalourethra) is an occasional association with HIP. MIP is a large subgroup under HIP. Reconstruction of the HIP by tubularisation of UP without or with a midline incision and superimposition layer or with MAGPI or perimeatal flap in selected cases gives excellent results.