Summary
The technique of choice in anterior hypospadias repair depends on the location of the hypospadic urethral meatus and the anatomy of the penis. The most commonly used techniques, MAGPI (meatal advancement and glanulaoplasty incorporated) and GAP (glans approximation procedure), and their modifications are explained in detail in this article. The advantages, complications and most known modifications of the methods are discussed. Although MAGPI is a simple method, it is one of the most difficult methods to learn and describe. The GAP procedure is a modified glanuloplasty method used in selected cases of glanular and coronal hypospadias with a wide urethral meatus and deep glanular groove.
Abstract
The technique chosen for the repair of anterior hypospadias will depend on localization of the hypospadic native meatus and anatomy of the penis. The most common accepted procedures are the MAGPI(meatal advancement and glanulaoplasty incorporated) and GAP (glans approximation procedure) and their modifications which presented in detail d below. Althoug it was described as a simple procedure the MAGPI procedure for hypospadias has been one of the more difficult techniques to describe and to teach. GAP procedure is a modified glanuloplasty for the selective repair of glanular and coronal hypospadias with deep glanular groove and wide urethral meatus.
Introduction
The aim in hypospadias surgery is to achieve the closest functional and cosmetic result to normal. In distal hypospadias cases, cosmetic appearance gains even more importance. A wide, elliptical, slit-like meatus, adequate glans closure from the inferior border of the meatus to the coronal sulcus, and an adequate mucosal collar (Firlit collar) ventrally under the coronal sulcus are the structures required for the closest appearance to normal anatomy when a normal cosmetic image is mentioned. . The success of all surgical methods used in anterior hypospadias repair is measured by the adequate creation of the anatomical structures described above.
My first training in the surgical repair of hypospadias was when I started my assistantship in Ege University Pediatric Surgery Department, my teacher Mr. prof. Dr. It started with the surgeries that Acun Gökdemir had patiently and explained. My teacher, Mr. Gökdemir, instilled in me and all the surgeons he trained the basic rules such as respect for tissue, the use of sensitive and fine surgical instruments, which are the basis of hypospadias surgery.
MAGPI( Meatal Advencement and Glanuloplasty Incorporated)
This surgical method was described by John W. Duckett in 1981.1 MAGPI (Metal Advancement and Glanuloplasty) method is a highly successful method that is frequently used in distal hypospadias repair. method. 2
My first encounter with the MAGPI method was in 1989 at Glasgow University, Yorkhill Children’s Hospital where I had the opportunity to work for 6 months with Mr. Thanks to Amir Azmy MD, FRCS. Azmy3 shared his experiences in hypospadias methods with me and many feelow who had the opportunity to work with him, and even shared these experiences with all his colleagues by taking part as an editor in a book describing hypospadias operation techniques. The MAGPI method became widespread in Turkey after the HYPOS’92 Workshop, which was held with the contribution of Cerrahpaşa pediatric surgery department and TÜBİTAK. The MAGPI method became widespread after Duckett, Snyder III, Turner-Warwick demonstrated in practice the MAGPI for distal cases and the Onlay and Duckett(Transverse Preputial Island flap) methods for proximal cases in a workshop in Istanbul.
MAGPI is known to be a method with low complication rates and no need for reoperation.1,2 It is a method with good cosmetic results in general and a high patient and surgeon satisfaction rate.4 In this method, the appearance of the meatus is the most concerned issue. 70% of all hypospadias cases are distal cases, and a significant part of these are coronal and subcoronal hypospadias cases. This method is a technique that can be applied in glandular, coronal and even subcoronal patient groups. Before the MAGPI method was described, these cases were usually circumcised, often leaving the meatus intact. The MAGPI method, apart from its cosmetic appearance, drew attention to the line-shaped meatus, meatal stenosis, and correction of the direction of the urine stream.
MAGPI procedure in hypospadias surgery is one of the most difficult methods to explain and learn. Although the method is described as very simple, it is not easy to apply it correctly without sufficient experience. The simple characterization of the method has resulted in many surgeons who have not gained sufficient experience in hypospadias surgery to start hypospadias operations with this method and gain experience with this method. Naturally, functional and cosmetic results have not been perfect in the hands of inexperienced surgeons. The MAGPI method can only be used successfully in cases with a sufficiently mobile meatus and distal urethra. This method should not be applied in cases where the meatus is fixed, periurethral spongy tissue is insufficient, the skin in front of the urethra is very thin and the skin seems to be attached to the urethra. As in the MIP (Megameatus Intact Prepuce) variant, cases with a very wide-mouth hypospadic native meatus are not suitable for this method. In order for this method to be used, the patient should not have any ventral fibrous cord and anterior curvature of the glans (glandular tilt) apart from the skin cord.
The most ideal cases for the MAGPI method should have a large glans, a sufficiently deep glandular groove, and a meatus that is not too wide. The most successful results are obtained in cases with dorsal web or skin bridge in the meatal area, which gives the impression of double urethral meatus.
Operation Method
The first steps of this operation are the same as in all other operations. A sling is placed vertically on the glans with a 5/0 or 4/0 suture. The hypospadic meatus is dilated with the help of bougies. During this dilatation, it should be checked once again whether the case is suitable for the MAGPI method. Mobility of the distal skin and urethra can be understood by pushing the skin and urethra towards the glans with the index finger, while the largest size (usually 8-10Fr) metal bougie that can enter the urethra is in the urethra. Again, while there is the largest metal dilator in the urethra, whether there is enough spongy tissue in front of the urethra can be understood by seeing the metal bougie in the urethra transparently, even through the skin. If it is decided to perform the MAGPI operation after these tests, the dorsal prepuce is pulled over the glans in such a way that the ventral defect is revealed, and the edges of the ventral prepuce are drawn with a pencil to prevent the mucous, which will form the Firlit 5 collar in the future, from being cut too short, and a sling suture is placed on the right and left with 5/0 (Fig. one). The penis is laid ventrally and drawn with a pencil, leaving 5-6 mm of mucosa all around from the glans between the sutures of the suspension (Figure 2) and the mucosa is cut in the marked area with an iris scalpel or a scalpel number 15, depending on the surgeon’s preference. With toothed thin Adson forceps and Tenetomy scissors, the preputium and the dorsal dartos tissue are left on the preputium side, and the penis is degloving in a glove-like manner. In order to complete the degloving process by cutting the skin all around in the ventral region, it is necessary to cut the skin in front of the meatus and urethra, from the right and left of the penis, from the lateral regions and from the proximal to the distal, between the urethra and the skin with scissors, leaving the ventral dartos tissue on the urethra side as much as possible this time. Cutting with scissors all around without leaving any dartos tissue under the skin ventrally will ensure that sufficient ventral dartos tissue remains for spongioplasty in front of the urethra after peeling. In my personal experience, I noticed that when the ventral skin is cut with a scalpel, more dartos tissue remains on the skin side, and much less ventral dartos remains on the skin side when it is cut with scissors. Previously I would have preferred to have a catheter in the urethra as it crossed the ventral skin. Since I see that it is more difficult to enter between the urethra and the skin when the catheter is left in the urethra, and the possibility of injury to the urethra is higher, I now complete the peeling process by inserting a scissors between the skin and the urethra without inserting a catheter into the urethra. In the MAGPI operation, I believe that instead of peeling the entire penis, peeling it up to the midpenile region is sufficient. The entire penis should be peeled off only in the presence of a prominent skin cord. However, in this case, postoperative edema will be high and a catheter should be inserted for 24-48 hours and the dressing should not be opened before 48 hours. After the peeling is done and it is determined that there is no ventral cordial and glandular tilt (forward tilt of the glans), it can be started to draw the MAGPI method. The incision areas to be made into the glans are determined by drawing the border where the glans ends and the base of the urethra begins on the right and left. Ventrally, a triangular mucosal area is drawn on both sides between the lines delineating the hypospadic meatus and the base of the glans urethra, and these triangles and glans wings are incised before starting the release phase (Figure 3).
Meatal advancement stage in MAGPI method
Meatal advancement
, which is an important step in MAGPI method, is provided with the classical dorsal vertical incision of the MAGPI method. The groove in the middle of the glans (groove) is cut from the dorsal to the midline dorsal from the meatus to the top of the glans (apex) at least 5mm, maximum 7mm (average 6mm) vertically and sutured transversely, and the meatal advancement is made by suturing and closing with the Heineke-Mikulicz principle. This vertical incision should not be made with scissors, but a deep incision should be made, preferably using the number 11 pointed scalpel. A deep incision is made by inserting the number 11 scalpel from the dorsal of the hypospadic meatus into the glans and advancing it up to the apex with a sawing motion. If there is a dorsal web or skin bridge that gives the impression of a double meatus in this area, it should be cut with scissors at this stage and the tissue edges should be smoothed. When removing the dorsal web or skin bridge, tissue should not be removed from the dorsal wall of the hypospadic meatus, and it should be noted that this tissue will form the dorsal wall of the urethra. It is very important that the classical vertical incision in the dorsal is deep. After the incision is made, bleeding of the glans tissue should be seen. Bleeding is a sign that the incision is deep enough. Bleeding should not be feared since it will stop spontaneously with the ligation of the suture of the dorsal vertical incision. In the Snodgrass method, care is taken not to cut the urethra floor as deeply as possible and not to bleed, while in the MAGPI method, this incision must be deep and the glans bleed. If the incision is made deep, when the glans apex and meatus are sutured from the midline, it contributes to the formation of a solid scar tissue in this area and prevents retraction of the meatus. The complication of meatal regression occurs due to the early loss of resistance of the suture placed in this region from the midline, its loosening and the incision not being made deep enough. Suture numbers preferred in surgical methods are usually given according to the ideal age. It should not be forgotten that the suture numbers should also change when the same surgery is performed at a time other than the ideal age. Likewise, one size larger suture should be preferred in secondary cases. The correct choice of the structure and number of the suture placed between the meatus and glans for meatal advancement in MAGPI surgery also directly affects the success of the surgery. Preferably 6/0 polyglactin multifilament sutures should be used in children up to one year of age, and 5/0 polyglactin multifilament sutures should be used between 1-3 years of age. This midline suture should not be crossed in one go. In the meatus, the suture should be passed through the dorsal wall of the urethra, the needle should be re-attached to the porthole, the dorsal glans incision should be re-entered from the midpoint for the second bite, the glans tissue should be removed fleshly and the end of the suture should be removed from the glans epithelium at 12 o’clock from the apex (Figure 4). In order not to loosen the midline suture, double knots are made and the ends are pulled to 12 and 6 o’clock positions and the knot is placed. It should be knotted at least 4-5 times, as it is very important that the knot is secure and not loosened. Knot security is higher with multifilament sutures. Therefore, multifilament polyglactin sutures should be preferred. If this suture can be passed through sufficiently fleshy and solid after ligation, the tied suture will cause the collapse of the apex of the glans and will enable the advancement of the meatus. When this suture is knotted, it causes dog-ear-like projections to the left and right of the glans tissue. Trimming of these dog ears should not be done at this stage, sutures should not be placed to the right and left of the midline suture in a way that will bury the dog’s ears at this stage. MAGPI is not just a meatal advancement surgery. Glanuloplasty is an important step of the surgery. At the stage of glanuloplasty, these dog-ear-like protrusions that seem excessive will disappear on their own or will need to be corrected differently later on. Closing the classical dorsal vertical incision for meatal advancement by suturing not with a single suture in the middle, but with two sutures from the right and left is the most important reason for not obtaining an elliptical meatus in the form of a line. Unfortunately, in many surgical atlases, including the drawings in which Duckett describes the original method, this suture is shown as 2 lines to the left and right of the midline in the MAGPI operation drawings. A single suture from the midline is sufficient. However, an elliptical and line-shaped meatus can be created by placing a single suture in the midline.
Glanuloplasty phase in the MAGPI method
Glanuloplasty phase starts with making glans incisions on the line that was made before and defining the border of the glans and urethra floor. It is very important to pre-draw the borders of the glans before the midline suture is tied. After the midline suture is tied, the glans will deform, the apex will collapse and it will be difficult to determine these boundaries. The glans is fixed between the fingers with a dry pad with the left hand, and glans incisions are made with the right hand with the iris or the number 15 scalpel. These incisions should cut through the glans epithelium, but not too deep. While making glans incisions, a tunic can be applied to the penis at the midshaft level to control bleeding. Duckett recommends the administration of adrenaline for bleeding control in the original description of the MAGPI method. In the first 10 years of using this method (1990-2000), I injected 1/100,000 adrenaline-containing 2% lidocaine solution (jetocaine) around the glans and meatus ventrally with an insulin needle to prevent bleeding. Since 2000, I personally prefer to use a short-term tunic instead of adrenaline, since I have observed that adrenaline injection causes edema in the postoperative period.
The next step after making the incisions that define the glans borders is the release of the glans wings. Before the release of the glans wings, a sling suture is placed on the skin left in excess in front of the hypospadic meatus at the level of 6 o’clock from the midline with 5/0. This suture is drawn towards the apex and determined as the midpoint of the urethra and glans. Liberation of the glans wings should be started as lateral and proximal as possible. It should be started by performing spongioplasty on the corpus cavernosum and the correct plane should be found between the glans and the corpus without leaving any spongy tissue on the corpus. Once the right plane is found, the glans wings can be easily released without leaving any glandular tissue over the corpus cavernosum in the distal section. Caldomone et al. 6 starting from the lateral; He named the method of releasing the glans wings by performing spongioplasty over the corpus cavernosum of the glans from the proximal to the distal, the road to the glans. There are groups that both recommend and do not recommend applying a tunic while releasing the glans wings with this method. Personally, I find it more comfortable to release the glans wings without bleeding with the tunic. After the bilateral glans wings are released, I untie the tunic and control the bleeding with bipolar cautery. Those who do not apply a tunic prefer to move towards the glans by seeing the bleeding and controlling the bleeding with bipolar cautery. In the years when the use of bipolar cautery in the operating room was not common, bleeding control was provided with adrenaline injections and adrenaline tamponade. Later, battery powered hand cautery which made thermal heat coagulation started to be used. Battery-operated cautery has not been widely used in Turkey because it is expensive. We sterilized hand cautery with batteries, which were sold as disposable for a period, with ethylene oxide and used it without any problems. Today, bipolar cautery; It is the most ideal method of bleeding control when used with sensitive thin non-adhesive bipolar cautery tips. I think it is not appropriate to perform hypospadias surgery in operating rooms where bipolar cautery is not available. However, thermal hand cautery with batteries is an effective and sufficient method to control bleeding in the MAGPI method.
For glanuloplasty, the new shape of the glans is pulled upwards (apex) in the meatus that defines the midline, and the suspension sutures in the mucosa that will form the Firlite collar are pulled down (scototuma) and midline is controlled. One of the most critical aspects of MAGPI surgery is to release the glans wings enough for a tension-free closure. When the wings of the glans are insufficiently freed, it will not be possible to give the glans its new conical shape and the cosmetic results of the surgery will not be perfect. Azmy3 used to state that the glans had to be loose enough to open enough in the style of Sardine fillets (Mackerek fillets) to see if it was loose enough. There is no fishbone in the filleted fish, but the trace of the fishbone is evident in the midline. Azmy3 Mackerel Fillets definition was used to describe the situation where the glans was opened 180 degrees to both sides when the awn scar in the midline was accepted as the urethra. Another method to understand if the glans wings are sufficiently free is to place an 8 Fr catheter in the urethra, hold the glans wings at the same level with two toothed Adson forceps, bring them closer to each other in the midline and check whether they freely converge in front of the urethra with the 8 Fr probe inside. If the wings of the glans meet comfortably in front of the urethra without tension, the glans will close smoothly, the urethra, which is pulled up by embedding in the glans, will not be compressed and narrowed, and it will be easy to give the glans its new conical shape.
When the glanuloplasty stage is passed, upward traction is applied to the suspending suture placed in the native meatus. Depending on the size of the glans tissue, the glans wings should be brought closer to the midline with at least 2, if possible 3 6/0 multifilament polyglactin sutures. If the patient is between 1-3 years of age, 5/0 multifilament polyglactin sutures should be used. The sutures placed in the form of an inverted U-shaped horizontal matrix are tied while the glans wings are pulled down and the urethra is pulled upwards, and the glans is given its new shape. The horizontal matte suture should pass through the glandular tissue, but not too deeply at the epithelial level. When these sutures are passed too deep, closure of the glans becomes difficult and the tied suture may compress the urethra and cause fistula formation. When these sutures are passed too superficially or when the glans tissue cannot be penetrated sufficiently, it loosens and causes glans dehiscence. It is ideal to pass the glans approximation sutures in a horizontal matress style and approximately 3 mm below the skin level. First, the most distal suture of the glans is passed through, leaving enough stem to tie it, and suspended. Then the 2nd and, if possible, the 3rd suture is passed in the same way and the stems are suspended. Before these sutures are tied in order, the suspension suture, which was previously placed in the native meatus, is pulled upwards (apex of the glans) while the 1st suture for glanuloplasty is pulled down (proximal to the penis) this time, by pulling the glans wings down (proximal to the penis) by making a double knot and pulling the handles to 12 and 6 o’clock positions (Fig. 5). Likewise, the 2nd and 3rd sutures are tied and their stems are cut. Thus, the urethra is advanced to the apex and buried in the middle of the glans, giving the glans its new conical shape. The superficial epithelial layer of the glans should be closed with 6/0 PDS monofilament sutures as a second layer with 3-4 single sutures that do not aim to bring the glans wings closer, but only provide closure of the superficial tissue. It is also possible to place these sutures individually but subepidermally to provide a more cosmetic appearance.
It is very important to fix the urethra by suturing the glans after the glanuloplasty in MAGPI operation. While suturing between the urethra and the glans is not recommended after glanuloplasty in the Snodgras operation, suturing the urethra to the glans is a requirement in the MAGPI operation. Meatal retraction is inevitable if the urethra is not sutured to the glans. Before the 5/0 suspension suture in the meatus is cut and removed, the urethra is sutured to the glans at 5 and 7 o’clock with 8/0 or older children with 7/0 monofilament or multifilament sutures (Figure 6). After these sutures are removed, the suspension suture at the meatus can now be removed by cutting. If the stems of these sutures are not cut too short, the child will affect the direction of urination on the first day of urination and may cause messy, splashy urination. In order to close the vertical incision made in the dorsal for meatus advancement with the Heineke Mickulicz principle, the final state of the dog-ear-like protrusions formed on both sides of the suture is checked. It will be seen that these previously seen protrusions usually disappear spontaneously after the urethra, which has been reshaped and retracted distally, is completed with glanuloplasty. If still present, trim is done and additional superficial sutures can be placed if necessary.
It is controversial what should be the width of the urethral meatus and the closure length of the glans wings closed in the midline at the stage of glanuloplasty. There is only one study on the location of the external urethral meatus in adults and children. According to the study performed by Uygur et al. 7 in 1244 healthy adult men, the external urethral meatus is located in the distal 1/3 of the glans in 1198 men (96.3%), the middle 1/3 of the glans in 43 (3.5%) men, and the proximal 1/3 of the glans in 3 men (0.2%). . In the study performed by Genç et al. on 8 300 boys, the urethral meatus was located in the distal 1/3 of the glans in 282 (89%) children, in the middle 1/3 of the glans in 14 (4.6%) children, and in the proximal 1/3 of the glans in 2 (0.06%) children. . Hutton and Babu investigated the normal anatomy of the glans in 9 93 boys and determined that the upper junction of the line-shaped urethral meatus is A, the lower junction is B, and the point where the sulcus coronorius begins, where the glans ends, is C. Point A denotes the upper limit of the urethral meatus, point B the lower limit of the urethral meatus, point C the proximal limit of ventral glans closure. AB forms the vertical length of the meatus, BC forms the ventral glans closure distance (Figure 7). In this study, the mean vertical meatal length was 5.1+1mm, and the mean vertical glans closure distance was 4.7+1.2mm. Mean meatal length and glans closure distance have also been shown to increase with age. Snodgrass and Bush 10 stated that the glans closure distance for glansplasty in TIP operation should not be less than 2.3 mm and an average of 3 mm glans closure is sufficient for normal cosmetic appearance and urinary function, with the calculations they made by referencing this study. Although these ratios were not calculated in the Hutton and Babu 9 studies and attention was not drawn to this ratio, based on the highest and lowest values obtained from the study, the highest BC/AC, 4.7/10.1= 0.46 and the lowest BC/AC 3.5/7.1=0.44 values are found. . In my opinion, since the BC/AC values are less than 0.50 in both cases, care should be taken that the ventral glans closure distance is not more than the meatus length when adjusting the normal meatus length and glans closure distance. Since some meatal regression is expected in the postoperative period, especially in the MAGPI operation, it should be preferred that the ventral length of the glans equals the ventral length of the meatus during the operation. In the MAGPI operation, especially for the last 5 years, I prefer to close the dartos and spongy tissue remnants left ventrally with 7/0 sutures in the midline, starting from the most proximal and distally in front of the urethra, and perform a spongioplasty, even if partial, before starting the glanulloplasty phase for the last 5 years. For glanuloplasty, I tie the approximation sutures placed on the glans wings by burying the spongioplasty made urethra. Adding spongioplasty to the method does not make it difficult to close the glans wings in the midline. It eliminates the risk of fistula formation by directly pressing and cutting the urethra by reverse U sutures placed to bring the glans wings closer.
If the operation took less than 1 hour after the glansplasty procedure was completed and it is possible to dilate the urethral meatus with an 8 Fr metal bougie, that is, if the dilator can be passed easily, it is possible to terminate the operation without placing a drainage catheter in the bladder. If the operation lasted longer than 1 hour and glansplasty was possible only with excessive release of the glans wings, the urethral meatus is dilated with an 8Fr metal plug and then an 8Fr drainage catheter (feeding tube or silicone tube) should be placed into the bladder.
Circumcision phase in the MAGPI method
After the meatal advancement and glanuloplasty phases in the MAGPI method are completed, the preputial skin must be adjusted and the excess skin removed. It is an important stage that affects the cosmetic results of the operation. It is suspended by cutting the prepuce skin from the dorsal midline and placing a suture on the mucous layer left around the skin and glans at the midline. Then the preputium is brought over the glans and the line of the glans sulcus coronorius is drawn on the preputium on both sides with a pencil. The anterior ventral skin is almost always short. The V-shaped front opening in the preputium skin needs to be sewn 1.5-2 cm. When these sutures are healed, the cosmetic appearance will not deteriorate as it will look like the anatomical structure that is the continuation of the scrotal raphe. The most common cosmetic mistake is leaving the preputium skin too much. Since the fistula formation rate is very low in the MAGPI method, it is not appropriate to leave extra preputium skin for future use. Excess preputium skin causes dissatisfaction of the patient and family.
MAGPI operation is not a simple operation as it is said when it is done properly such as meatal advancement (advancement), freeing the glans wings close to 180 degrees and reshaping the glans. When it is done in this way, it is necessary to place a urethral catheter for 24 sometimes 48 hours and not to open the dressing in the first 48 hours in order to prevent edema and urination difficulty. When the MAGPI method is performed properly with the method described above, successful results are obtained in coronal and subcoronal cases. 11 In some cases of glanular hypospadias, the MAGPI method may not need to be applied as described above. With a method that can be called minimal MAGPI, it is also possible to apply the method without a catheter and without dressing, without the need for excessive release of the glans wings. The MAGPI operation is a method that I have been using in appropriate cases for 25 years since 1990. I have always advocated that this method achieves uncomplicated and successful cosmetic results. The secret of uncomplicated cosmetic success with this method is the correct case selection. The application of the method to coronal and subcoronal cases without adequate glans wing release naturally causes complications and failure. Aynı şekilde yöntemin mobil olmayan üretra, periüretral spongioz dokunun ince olduğu ve üretra üzerindeki derinin çok ince ve yapışık olduğu olgularda kullanılması, subkoronal seviyeden daha proksimalde nativ meatusu bulunan olgulara yöntemi zorlayarak endikasyonunu genişletmeye çalışmak da kötü kozmetik görünüm ve komplikasyona neden olur.
MAGPI yönteminin Modifikasyonları
MAGPI yönteminin tarif edildiği günden bu yana pek çok modifikasyonu yayınlanmıştır. Bu makalede bütün modifikasyonları yerine en bilinen ve ülkemizden tariflenen modifikasyonları anlatılacaktır.
Arap Modifikasyonu
MAGPI yönteminin en bilinen fakat en az kullanılan modifikasyonudur. Arap modifikasyonu esas olarak yöntemi subkoronal seviyenin daha proksimalindeki olgulara uygulayabilmek için planlanmıştır. 12 Nativ hipospadik meatusun çevresindeki derinin fazla bırakılması ve bu fazla bırakılan derinin orta hatta birbirlerine sütüre edilip üretra uzatılarak galansa gömülmesinden ibarettir(Şekil 8). MAGPI yönteminin en büyük avantajı fistül komplikasyonun yok edenecek kadar az görülmemesidir. Bu yöntemde distal üretra orta hatta sütüre edilerek uzatıldığından fistül komplikasyonu görülme sıklığı diğer üretranın sütürle uztıldığı yöntemlerden daha az değildir. MAGPI yönteminin subkoronal seviyeden daha proksimalde meatusu olan olgularda zorlanarak uygulanmasının başarısızlıkla sonuçlandığı bilinmektedir. Genel olarak endikasyonun genişletilerek yöntemin zorlanması önerilmemektedir. Arap modifikasyonu bu yöntemin zorlanarak daha proksimal olgularda uygulanmasıdır. Her ne kadar Hoebeke 13 MAGPI ‘nin Arap modifikasyonunun başarılı bir yöntem olarak kullandığını bildirmişsede, kişisel olarak Arap modifikasyonunu uyguladığım subkoronal olguların komplikasyon oranı ve kozmetik sonuçlarından memnun kalmadığım için bu modifikasyonu artık kullanmıyorum.
Baran Modifikasyonu
Klasik MAGPI yönteminin standart vertikal insizyonunun en tepesine transvers bir insizyon yapılması ve T şeklindeki insizyonun iki yanında oluşan üçgenlerin tepesinin meatusun dorsaline dikilmesidir. Baran ve ark14 bu modifikasyonu meatusun balık ağzı şeklinde görünümünü düzeltmek, meatus darlığı ve meatal retraksiyona engel olmak amacıyla tarif etmişlerdir. Tariflenen modifikasyon yöntemiyle meatal darlığa ve engel olunduğu bildirilmiştir. Bana göre tariflenen bu modifikasyonla meatal darlık oluşmasada, eliptik ve çizgi şeklinde bir meatus elde edilememektedir.
Taneli Modifikasyonu
Klasik MAGPI yöntemiyle meatal ilerletme için yapılan dorsal vertikal insizyon içinden dişli bir penset ile glans dokusunun dışarıya çekilerek bir miktar glans dokusunun eksize edilmesidir(Şekil 9 ). Yöntem glans kanatlarına aşırı mobilizasyon uygulanmadan üretranın glans içine gömülmesi kolaylaşmaktadır. Üretranın dorsalinde daha az glans dokusu kaldığı için üretra glans içinde daha derine (glansın ortasına) yerleştirilebilmekte ve daha anatomik bir onarım yapılabilmektedir. Üretranın dorsalinden vertikal insizyonun içinden bir miktar glans dokusu çıkarıldığı için burada oluşan boşluk (rooming) nedeniyle meatal darlık oluşması da engellenmektedir. Ayrıca çıkarılan bu glans dokusu sayesinde eliptik ve çizgi şeklinde (slit -like) bir meatus görünümü de elde edilir (Resim 1). Bu modifikasyonla normal anatomide var olan fossa navicularis yeniden oluşturularak idrar akış yönünün düzeltilmesi mümkün olmaktadır(Resim 2). Sonuç olarak; Taneli ve ark.15 nın modifikasyon tekniğinde üretranın glans içine daha derine yerleştirilmesiyle, geniş ve çizgi şeklinde bir meatus yapısı ve konik görünümlü kozmetik bir glans elde edilmektedir.
Yalçın Modifikasyonu
MAGPI yönteminde glans kanatlarının serbestleştirilmesi sırasında distal üretranın yanlardan arkasına doğru serbestleştirilerek parsiyel olarak mobilize edilmesidir. Yalçın ve ark 16 göre bu modifikasyon glandular oluğun derin olmadığı çevre dokuya fikse olduğu durumlarda meatal ilerletilmeyi kolaylaştırır. En distal kesimde üretra glanstan tamemen ayrılmadan klasik dorsal vertikal kesi yapılarak meatal ilerletme sağlanır.
MAGPI yöntemine benzer alternatif yöntemler
UAGP(Uretral Advancement and Glanuloplasty )
Yöntem 1981 yılında Urol Clin North Am dergisinde aymi ciltte MAGPI yönteminin yayınlandığı makalenin hemen arkasındaki makale olarak Waterhouse –Glassberg17 tarafından tariflenmiştir. Koff 18 da hemen hemen eş zamanlı olarak J Urol dergisinde aynı yöntemi tarif etmiştir. Üretral mobilizasyonun cerrahi bir yöntem olarak kabul görmesi fikri striktür onarımlarıyla başlamıştır. Üretranın etrafındaki spongioz tabakayla birlikte mobilizasyonu ile üretral striktürlerde 2cm’e kadar olan açıklığın(defektin) birleştirilmesinin mümkün olduğu gösterilmiştir. Waterhouse ve Glassberg17 önce hipospadias olmadan kordi olgularında sonra koronal hipospadias olgularında yöntemi başarıyla kullandıklarını bildirmişlerdir. Yöntem üretranın çevresindeki spongioz tabaka ile birlikte gerginlik oluşturmadan glansın apeksine kadar mobilize edilerek getirilmesi ve glans içine gömülerek tespit edildikten sonra glansa yeni şekil verilmesidir. Koff 18 anterior hipospadiaslı olgularda hatta hafif kordisi olan olgularda üretral mobilizasyon yöntemini başarıyla uyguladığını bildirmiştir. Ayni yöntem Türkiyeden 1995 de triangular glanular flap ilavesi ile Dindar ve ark 19 tarafından distal penil hipospadiasta başarılı bir yöntem olarak bildirilmiştir. 1999 da Türken ve Senocak 20 bu yöntemle distal hipospadiasta 2-2.5 cm lik bir üretral mobilizasyonun mümkün olduğunu ve fibröz kordi varlığında da bu yöntemin uygulanabildiğini bildirmiştir.
GRAP (Glanular reconstruction and preputioplasty)
Glipin ve ark21 1993 yılında distal hypospadias olgularında glanular rekonstrüksiyon ile birlikte prepisyumun korunduğu bir modifiye yöntem tarif etmişlerdir. Glanular, koronal ve subcoranal olgularda uygulanabilen bu yöntemle düşük komplikasyon oranı ile mükemmel fonksiyonel ve kozmetik sonuçların elde edilebildiğini bildirmişlerdir.22 Glanuloplasti ve preputioplastinin birlikte yapılması nedeniyle değerlidir. Prepisyum rekonstrüksiyonu 1990 yılında ilk kez Dewan23 tarafından Mathieu yönteminde kullanılmıştır. Kröpfl ve ark24 1992 yılında MAGPI yöntemiyle tam sünnet derisi rekonstrüksiyonunu ilk kez birlikte uygulamışlardır.
URAGPI (Uretral Advancement Glanuloplasty Preputioplasti Incorporated)
Keramidas 25 1995 yılında prepusyoplasti ile üretral mobilizasyon ve glanuloplasty tekniğini birlikte uygulamıştır. Yöntem künt diseksiyon ve mobilizasyonla üretranın gerginlik oluşturmadan glansın apeksine kadar çekilmesi ve glans içine gömülerek tespit edilmesine ilave olarak prepusyoplasti yapılmasıdır.Yöntemi glandular eğiklik(glandular tilt), hafif fibröz kordi, fibrotik immobil üretral meatus ve sekonder olgularda da başarıyla kullandığını bildirmiştir. Jawad 26 distal hipospadias olgularında özellikle glanular kordi ve eğiklik (chordee, tilt) ve immobik fibrotik üretral meatus durumunda MAGPI yönteminin sınırlarını zorlamak yerine UAGP veya URAGPI yöntemlerinin MAGPI yöntemine alternatif olarak kullanılabileceğini bildirmiştir.
GAP( Glans Approximation Procedure)
1989 yılında Zaontz 27 tarafından geniş bir meatus ve derin glanular oluk (groove) varlığında glanular ve koronal hipospadias olgularında kullanılabilecek bir yöntem olarak tarif edilmiştir. Aslında 1869-1880 yıllarında rapor edilen Thierch-Duplay tubularizasyon prensiplerinin yeni bir uygulamasıdır. Geniş üretral meatus çevresine yapılan U şeklindeki kesinin önde sütüre edilerek kapatılmasıyla üretra uzatılır ve glanuloplasti yapılarak yeni üretra glansa gömülür(Şekil 10 ). 1989 yılında Duckett ve Keating 28 yine J Urol dergisinde çok benzer bir yöntemi Pyramid prosedürü olarak yayınlamışlardır. Pyramid prosedürü geniş üretral meatus çevresine GAP yönteminde tarif edilen U şeklindeki kesi yerine tenis raketi şeklinde insizyon yapılıp sütüre edilerek üretranın uzatılıp glansa gömülmesidir. Pyramid yönteminin özellikle MIF varyantında kullanılması önerilmiştir. Hemen hemen aynı yöntem olan GAP ve PYRAMID yöntemlerinden GAP daha önce yayınlanmıştır. Meatusun geniş ancak glanular oluğun yeterince derin olmadığı olgularda Zaontz 27 oluğu derinleştirmek için insize ederek sekonder iyileşmeye bıraktığını böylece üretranın önde gerginlik oluşturmadan kapatılabildiğini de belirtmiştir. GAP yöntemi bu tarzda yapıldığında adına kısaca SNODGAP de denilebilir.
SNODPI
Snodgrass ve MAGPI operasyonlarının her ikisinin bir karışımı olan bu yöntem birçok cerrah tarafından ameliyat sırasında dorsal vertikal kesi yapıldıktan sonra bazı uygun olgularda kesinin sütüre edilmeden bırakılabileceğinin farkedilmesiyle ortaya çıkmıştır. Modifikasyon sonradan SNODPI olarak isimlendirilmiştir.29 Bu yöntemde MAGPI ve Snodgrass operasyonlarının her ikisinde de mevcut olan dorsal vertikal kesi yapılmakta ancak MAGPI yöntemindeki gibi sütüre edilerek Heineke-Mickulicz prensibiyle kapatılmamakta, Snodgrass yöntemindeki gibi sütüre edilmeden bırakılmaktadır. SNODPI yöntemi bana göre; yanlızca glandular groove’u çok derin olan olgularda kullanılmalıdır. Ayrıca bu yöntemde dorsal kesi, bistüri ile değil makas ile yapılmalı ve üretra tabanını kanatmamaya yani çok derin kesmemeye dikkat edilmelidir. Dorsal kesi çok derin yapıldığında skar ile iyileşmekte ve meatus darlığına neden olmaktadır.
SNODPI veya SNODGAP gibi kısaltmalar yöntemlerin tarif edilmesini kolaylaştırmakla birlikte doğru bir isimlendirme değildir. Çünkü üretra tabanının vertikal olarak orta hattan insizyonu Snodgrassdan önce bir çok cerrah tarafından uygulanılan bir tekniktir. Tubularized incised plate (TIP)yöntemi Snodgrass30 tarafından 1994 yılında 16 olguluk bir hasta serisinde yayınlanmıştır. Snodgrass’dan önce üretra tabanın orta hattan insizyonunu ilk kez Reddy 31 1975 yılında rapor etmiştir. Reddy31 orta hat insizyonunu kordiye neden olduğunu düşündüğü fibröz yapıları keserek kordiyi düzeltmek için uygulamıştır. Daha sonra Orkiszewski 32 üretra tabanının longitudinal insizyon adını verdiği kesiyi yaparak üretranın gerginlik olmadan kapatılmasını sağlamış ve 1989 yılında Polonya Üroloji dergisinde yayınlamıştır. Orkiszewski 33 editöre mektup olarak yayınlanan bir yazısında teyzesinin; eşinin ölümünden sonra avcı ceketi ile tabuta konulmasını istemesi nedeniyle artık küçük gelen ceketin arka bölümünün kesilerek önde rahatça düğmelerinin kapatılması ile yöntemin fikrinin oluştuğunu belirtmiştir. Midline longitudinal insizyon için Ölü Adam Ceketi ( Dead Man’s Jacket) esinlenmesini kullanmıştır. Aynı yıl (1989) Rich ve Keating34 vertikal çizgi şeklinde üretral meatus oluşturmak için üretra tabanının distalinin orta hattan longitudinal insizyonunu önermişler ve yapılan işleme Menteşeleme (Hinge- Hinging ) adını vermişlerdir. Bütün bu modifikasyonların bir sentezi sonucunda TIP(Tubularized Incised Plate )veya SNODGRASS yöntemi ortaya çıkmıştır.
Sonuç olarak, 1981 yılında tariflenen MAGPI ve UAGP, 1989 yılında tariflenen GAP gibi temel yöntemler öğrenildiğinde; yani meatal ilerletme, üretral mobilizasyon, glansplasti ve glans yaklaştırılması gibi tekniklere hakim olunduğunda distal hipospadias olgularının cerrahi onarımında amaç olan fonksiyonel ve kozmetik sonuçlara ulaşmak mümkün olacaktır.
Kaynaklar
1.Duclett JW. MAGPI (Meatoplasty and glanuloplasty) a procedure for subcoronal hypospadias Urol Clin North Am 1981;8(3) 513-9.
2.Ducket JW Snyder HMIII. The MAGPI hypospadias repair in 1111 patients. Ann Surg 1991;213 (6): 620-5.
3. Hadidi AT, Azmy AF Hypospadias Surgery , An Illustrated Guide . Heidelberg: Springer –Verlag ;2004
4.Baskin L Hypospadias : a critical analysis of cosmetic outcomes using photography. BJU Int 2001;87(6):534-9.
5. Firlit CF The mucosal colar in hypospadias surgery J Urol 1987;137(1) :80-2.
6.Snodgrass W1, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularized incised plate hypospadias repair for proximal hypospadias. J Urol 1998;159(6);2129-31.
7. Uygur MC, Ersoy E, Erol D. Analysisi of meatal location in 1244 heathy men Definition of the normal site justified the need for meatal advancenent ain all pediatric anterior hypospadias cases Pediatr Surg Int 1999;15 :119-20.
8.Genç A, Taneli C, Oksel F, Balkan C, Bilgi Y. Analysisi of meatal location in 300 boys Int urol Nephrol 2001; 33:663-4.
9. Hutton KAR, Babu R. Normal anatomy of the external urethral meatus in boys : implications for hypospadias repair. BJU Int 2007;100;161-3.
10.Snodgrass W, Busch N. Glansplasty In: Hypospadiology Eds: Snodgrass W, Busch N 1 st edition 2015, Texas, Operation Happenis, p58-9, p106-7.
11. Abdelrahman MA, O Connor KM, Kiely EA. MAGPI hypospadias repair: factors determined outcome Ir J Med Sci 2013; 182(4):585-8.
12.Arap S, Mitre AI, De Goes GM. Modified meatal advancement and glanuloplasty repair of distsl hypospadias J Urol 1984; 131:1140-1141.
13.Hoebeke P, De Sy W The Arap modification of MAGPI: experience in 72 patients Ann Urol (paris) 1996; 30(4):170-3.
14. Baran CN, Sungur N, Kılınç H, Özdemir R, Sensöz OT incision technique in distal hypospadias : a modification of meatal advancement and glanuloplasty. Plast Reconstr Surg 2002 109(3):1018-24.
15.Taneli C, Genç A, Günsar C, Sencan A, Arslan OA, Dağlar Z, Mir E Modification of meatal advancement and glanuloplasty for correction of distal hypospadias Scand J urol Nephrol 2004;38(2):122-4.
16. Yalçın M, Karadağ ÇA, Yıldız A, Kaba Mk, Baskın D, Demir M, Dokucu Aİ .Results of modified MAGPI operation with mobilizations of ventral glanular urethra. ASPU&WOFSPU, 2010 27 -29 October 2010 İstanbul, Turkey
17. Waterhouse K, Glassberg KI Mobilization of anterior uretra as an aid in the one –stage repair of hypospadias. Urol Clin North Am 1981;8(3), 521-5.
18. Koff SA Mobilization of the urethra in the surgical treatment of hypospadias J Urol 1981;125(3):394-7.
19. Dindar H, Çakmak M, Yücesan S, Barlas M. Distal penile hypospadias repair in children with complete mobilization of pendulous urethra and triangular flap. Br J Urol 1995 ;75(1):94-5.
20. Turken A, Senocak ME, Büyükpamukçu N, Hiçsönmez A. The use of eccentric circummeatal based flap with combined limited urethral mobilization technique for distal hypospadias repair. Plast Reconstr Surg 1999;103(2):525-30.
21. Glipin D, Clements WD, Boston VE GRAP repair : single –stage reconstruction of hypospadias as an outpatient procedure Br J urol 1993;71(2):226-9.
22. Gray J, Boston VE. Glanular reconstruction and preputioplasty repair for distal hypospadias: a unique day-case method to avoid urethral stenting and preserve the prepuce. BJU Int 2003;91(3): 268-70.
23.Dewan PA. Mathieu urethroplasty with preputial reconstruction and urethral stent urine drainage. Aust NZJ Surg 1990;60(10):787-90.
24. Kröpfl D, Schardt M, Fey S. Modified meatal advancement and glanduloplasty with complete foreskin reconstruction. Eur Urol 1992; 22(1):57-61.
25. Keremidas DC, Soutis ME. Urethral advancement ,glandulopasty and preputioplasty in distal hypospadias Eur J Pediatr Surg 1995 ,5(6) 348-51.
26. Jawad AJ Urethral advancement and glanuloplasty UAGP vs MAGPI for distal hypospadias repair. Int Urol Nephrol 1997;29(6):681-6.
27. Zaontz MR The GAP(glans approximation procedure) for glanular/coronal hypospadias J Urol 1989 ;141(2):359-61.
28. Duckett JW, Keating MA Technical challenge of the megameatus intact prepuce hypospadias variant :the pyramid procedure. J Urol 141(6):1407-9
29. Repair of anterior hypospadias In Pediatric Urology Web Book 2014 2nd edition Eds: Subramanıan R, Hoebeke P, Kocvara R, pp 238.
30.Snodgrass W Tubularized incised plate urethroplasty for distal hypospadias J Urol 1994 151;464-6.
31. Reddy LN. One- stage repair of hypospadias . Urology 1975;5(4) :475-8.
32. Orkiszewski M. Urethral reconstruction in skin deficit Polish Urology 1987; 40:12-5.
33. Orkiszewski M. Midterm success rate of tubularized incised plate urethroplasty an observation. Pediatr Surg Int 2006;22:302
34. Rich MA, Keating MA, Snyder HM, Duckett JW. Hinging the urtehral plate in hypospadias meatoplasty. J Urol 1989 142(6):1551-3.
