Review articleMeta-analysis of complication rates of the tubularized incised plate (TIP) repair
Introduction
Over 300 methods of surgical repair have been described for the correction of hypospadias, with no one procedure accepted as the gold standard for each degree of hypospadias. First described in 1994 by Snodgrass [1], the tubularized incised plate (TIP) urethroplasty has become the most popular technique for distal hypospadias [2], [3]. Originally described for correction of distal hypospadias, it has also been applied to more severe proximal forms.
There is a wide discrepancy between published complication rates for different repair types [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16] and a poor evidence base for the current management of hypospadias. Due to the popularity of the TIP repair technique, a large number of papers giving outcomes and complication rates have been published. As there is a paucity of randomised, controlled trials, a meta-analysis of the outcomes of the TIP repair was performed with a view to:
- 1.
Assessing the appropriateness of its application to all degrees of hypospadias.
- 2.
Evaluating the long-term results by analysing the pooled complication rates to accurately determine representative complication rates for this technique.
- 3.
Reviewing the effects of technical modifications, length of follow-up and geographical location of these complications.
Section snippets
Data collection
Medline and Pubmed were searched in order to identify articles published between 1994 and 2012. The search terms ‘tubularized incised plate urethroplasty/Snodgrass repair/technique ± outcomes/complications ± follow-up/long term follow-up’ were used. The following data were extracted independently from each article by two reviewers (K.P and P.C): study size; degree of hypospadias (classified by meatal location: distal – midshaft distally, proximal – proximal shaft proximally); primary or
Overall complication rates
Fistula rates were significantly higher in secondary repairs (mean 15.5%, range 12.1–19.6%) compared to primary proximal (mean 10.3%, range 6.3–16.3%) and primary distal (mean 5.7%, range 4.0–8.2%) (P = 0.005). Re-operation rates were significantly higher in the secondary repairs (mean 23.3%, range 18.5–28.9%) compared to primary proximal (mean 12.2%, range 7.7–18.6%) and primary distal repairs (mean 4.5%, range 2.7–7.5%) (P < 0.001). Meatal stenosis rates were higher in secondary repairs (mean
Discussion
This meta-analysis shows the lowest complication rates for the TIP repair when it is applied to primary distal hypospadias, with mean rates of meatal stenosis at 3.6% (range 1.7–7.4%), urethral stricture at 1.3% (range 0.8–2.2%), fistula at 5.7% (range 4.0–8.2%) and re-operation at 4.5% (range 2.7–7.5%). The fistula rate is higher than the re-operation rate as one paper reports spontaneous healing of three fistulae [24]. Several studies, including the review paper by Wilkinson et al. [66]
Conclusions
Experience so far with the TIP repair has shown that modifications have reduced the complications. The wide reporting of modifications suggests that surgeons have found that the initial technique was in need of changing. Lack of standardised outcome measure reporting has significantly reduced the available papers for the present study, which limited the power of the analysis. It is suggested that outcome measures become established as criteria for acceptance for publication. The minimum
Ethics approval
Ethics approval was not required.
Conflict of interest/Funding statement
None of the authors have any conflicts of interest or funding to declare.
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