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Hypospadias with Intact Prepuce: Evolving Morphology and Current Surgical Techniques

Ramaswamy Rajendran*

A comprehensive research-report on the anatomy of hitherto designated Megameatus with Intact Prepuce (MIP) was recently published in early 2024. “Hypospadias with Intact Prepuce (HIP)” as the umbrella-term to contain cases with megameatus and all other cases of hypospadias with entire prepuce was proposed along with their current surgical techniques. The incidence of MIP is 3% to 6% among hypospadias. Presence of median raphe anomalies or long redundant prepuce may be pointer to the occult MIP. Cases may present post-circumcision in which case, iatrogenic hypospadias should be clinically excluded. Unlike popular belief, MIP can be associated with dorsal or ventral chordee. Glans-penis may have wide, spatulated or conical shape. MIP usually is distal hypospadias, but rarely midshaft hypospadias too. There is wide variation in the size of External Urethral Meatus (EUM) from normal to wide or enormously wide. Thus the conventional nomenclature “MIP” is inappropriate to some. On the other hand, HIP suits to all such cases irrespective of having megameatus or not. Urethral Plate (UP) may be wide and deeply clefted or not. Distal transverse septum in UP is rare. Associated distal urethral dilation is not omnipresent. Distal megalourethra associated with 8.33% of HIP had serious internal urinary anomalies. Thus a spectrum of anomalies of penile curvature, median raphe anomalies, long redundant prepuce, anomalous glans, EUM, UP and distal native urethra can be clubbed together under the umbrella-term “HIP”. Duckett and Keating employed ‘Pyramid Procedure’ which involved wedge-excision of distal urethra and urethroplasty. Suture-lines overlapping and lack of necessity to excise distal urethra caused disfavour of this technique. Glanular HIP can be repaired by Glans Approximation Procedure (GAP), Tabularized Urethral Plate Urethroplasty (TUPU) or Meatal Advancement and Glanuloplasty Incorporated (MAGPI) depending upon the morphology. Coronal and subcoronal varieties can be corrected by MAGPI, Mathieu’s, TUPU or Tubularised Incised Plate Urethroplasty (TIPU) where as penile shaft varieties can be repaired by TUPU or TIPU.