Hypospadias 3: MAGPI & snod grass (TIP) step by step operative urology series for more resources visit: uronotes2012.blogspot.com

1. Hypospadias repair - Part 3
(MAGPI, Thiersch duplay & Snod grass (TIP))
M.A.Wadood Aref

2. Hypospadias Options of ttt
according to site
Distal Hypo Middle Hypo Proximal Hypo
• MAGPI (glanular)  OIF (flap) 1 stage:
• Thiersch Duplay or •Thiersch Duplay or • OIF (flap)
TIP (tubularization) TIP (tubularization) • TPIF (flap)
• GAP • Thiersch Duplay or
• Mathieu TIP (tubularization)
• Pyramid (for MIP) 2 stage:
M.A.Wadood Aref

3. MAGPI (for glanular hypospadias)
• Meatal advancement: Longitudinal incision closed by 3 sutures in ts line
• Glanuloplasty: 2 stay sutures in midline & closure of lateral glanular wings in midline
M.A.Wadood Aref

4. Thiersch Duplay principle
• Simple tubularization
• The basic principle for all tubularization techniques
(including TIP = snod grass)
M.A.Wadood Aref

5. Snod grass (TIP procedure)
• Most common procedure performed for distal
hypospadias
• Some advocate for even more proximal defects
M.A.Wadood Aref

6. • 5–0 polypropylene suture in glans for • Degloving of penis
traction • 2 longitudinal incisions between
• artificial erection exclude curvature urethral plate & glanular wings
• Circumcising (subcoronal) incision
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7. • midline incision of the urethral plate.
• This manoeuvre is facilitated by counter-traction maintained by the surgeon and assistan
M.A.Wadood Aref

8. • the urethral plate is tubularized (as Thiersch duplay principle) beginning at
the neomeatus, using 6-0 or 7–0 polyglactin suture.
• The first suture is placed through the epithelium at a point just distal to
the midglans
• so that the meatus has an oval, not rounded, configuration
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9. • Dartos pedicle flap (2nd layer) is dissected from the preputial hood and dorsal
skin
• then either Rotated from side or button-holed and transposed ventrally to
cover the entire neourethra (2nd layer to prevent fistulation)
M.A.Wadood Aref

10. Glansplasty by:
• polyglactin suture through ventral lip of the meatus.
• sutures placed subepithelially to complete glansplasty
• No attempt is made to secure the glans to the underlying neourethra.
M.A.Wadood Aref

11. Skin closures
• also use subepithelial polyglactin sutures to minimize the risk of suture
tracks.
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12. Snod grass can be used also in more
proximal hypospadias
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13. • Initial circumcision & longitudinal incisions
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14. • Midline plate incision (main step)
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15. • Tubularization & dartos flap (2nd layer)
• Glansplasty & skin closure follows
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16. Snod grass in theatre
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17. Tubularized Incised Urethral Plate Repair (TIP)
M.A.Wadood Aref

18. • Initial circumcision & longitudinal incisions
M.A.Wadood Aref

19. • Initial circumcision & longitudinal incisions
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20. • Midline plate incision (main step)
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21. • tubularization
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22. • Dartos 2nd layer & skin closure
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23. Thank You
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