The Y-V modified Mathieu procedure
The meatal-based flap technique of Mathieu is the most popular technique for distal hypospadias repair and has withstood the test of time. However, the major drawback of the original Mathieu technique is the final appearance of the meatus (a smiling meatus that is not very terminal). The Y-V glanuloplasty helps to employ the Mathieu operation in all forms of distal hypospadias and gives a terminal, slit like meatus. This will include about 70 to 80 % of patients with hypospadias. The only contraindication is the presence of severe chordee distal to the hypospadiac meatus.
Steps of Y-V glanuloplasty modified Mathieu technique: a) Y Incision; b) The three flaps elevated and coring to make a space for the neo-urethra; c) Y sutured as V with preservation of dog-ears; d) The dog-ears opened; e) U shaped flap; f) urethroplasty; g) A small dog-ear is excised near the meatus; h) A small V is excised from the neourethra; i, ,j) Meatoplasty and glanuloplasty (from Hadidi A; Y-V modified Mathieu in Hadidi A and Azmy A (eds.) Hypospadias Surgery, Art and Science. Heidelberg, Springer Verlag, 2004).
A Y-shaped incision is outlined on the glans with the centre of the Y where the tip of the neo-meatus will be located. Each limb of the Y is 0.5 cm long (Fig. 8 a). The Y-shaped incision is made deep and the three flaps are elevated and a core of soft tissue is excised from the bed of each flap to create a space for the neo-urethra (Fig. 8 b). The Y-shaped gap is sutured as a V making sure to keep the dog- ears at the upper ends of V suture lines (Fig. 8 c). These dog-ears will enlarge the circumference of the tip of glanular wings 1 cm at least (Fig. 8 d).
A U-shaped incision is made slightly longer than the distance between the meatus and the designed tip of the neo-meatus. The longitudinal incisions should diverge away from the hypospadiac meatus to allow for adequate blood supply to the flap. The U-shaped incision will open wide the dog- ears (Fig. 8 e).
A continuous subcuticular running VicrylŽ 6-0 on a cutting needle is used for neo-urethra reconstruction. The subcuticular suture is continued until the tip of the glans, then goes back with the same stitch in a running stitch approximating the flap fascia to the depth of the glans and the shaft of the penis (double breasting). Thus, one will have one knot only for the whole two layers (Fig. 8 f).
A small V is excised from the apex of the parameatal flap and the meatus is reconstructed (Fig. 8 g). The glanular wings are approximated using transverse mattress interrupted sutures (Fig 8 h).
The preputial skin is left intact. The prepuce may be reconstructed if parents desire after 6 months when everything has healed well or circumcision performed. Usually, it is not recommended to perform circumcision during urethroplasty, in case complications occur and the preputial skin becomes important.
Fistula occurs in 2 - 5 % of patients