Two-flip Mathieu's technique in distal hypospadias with small glans

Abstract

Introduction: Hypospadias repair can be complicated, especially with poorly developed glans. This study evaluates the outcomes of the Two-Flip Mathieu (TFM) procedure, which aims to reinforce the glans and reduce dehiscence in patients with small glans, comparing it to conventional Mathieu's repair.

Methods: This retrospective study analyzed case records of patients with distal hypospadias and minimal ventral curvature. Preoperative evaluations included assessments of meatal location, glans and urethral plate width, perimeatal skin quality, and presence of chordee. Patients with small glans (<14 mm) received hormonal stimulation using intramuscular testosterone. Surgical choices were based on urethral plate and glans morphology: patients with good urethral plates and glans underwent TIP repair (excluded), those with poor urethral plates and good glans widths underwent conventional Mathieu repair (Group 1), and those with both poor urethral plates and glans widths received TFM repair (Group 2). Postoperative assessments focused on meatal position, fistula formation, glans dehiscence at regular intervals, and patient satisfaction, which was measured using a 5-point Likert scale covering meatal appearance, glans aesthetics, urinary stream, and overall cosmetic satisfaction at 6 month follow-ups.

Results: During the two-year study period (2021-2023), 73 patients with distal hypospadias were treated. After excluding 22 patients who underwent TIP repair, 51 were divided into two groups. Group 1 (20 patients) underwent conventional Mathieu repair, while Group 2 (28 patients) received TFM repair. In the TFM group, 2 patients (7.1 %) developed urethrocutaneous fistulas, with one requiring surgery. Three patients (10.7 %) experienced superficial necrosis, managed conservatively. TFM had no cases of glans dehiscence, whereas conventional Mathieu repair showed significant dehiscence (p = 0.0343). Re-operation rates were lower in TFM (p = 0.0148). Patient satisfaction was significantly higher in TFM for glans aesthetics and overall appearance.

Discussion: Glans size and urethral plate quality are key factors in hypospadias repair. The TFM technique addresses limitations in conventional Mathieu repair by reinforcing the glans, reducing tension on the neo-urethra, and improving outcomes. Though initial color mismatch between the V-flap and glans is a limitation, cosmetic satisfaction was excellent at 6 month follow-up. TFM is unsuitable for patients with distal urethral hypoplasia and thin perimeatal skin but enhances the versatility of Mathieu repair in cases with poor glans quality.

Keywords: Glans augmentation; Hypospadias; Mathieu's procedure; Outcomes; Poor glans.