Trends in hypospadias surgery: results of a worldwide survey

Further analysis of the Glans-Urethral Meatus-Shaft (GMS) hypospadias score: correlation with postoperative complications

INTRODUCTION AND OBJECTIVE

The Glans-Urethral Meatus-Shaft (GMS) score is a concise and reproducible way to describe hypospadias severity. We classified boys undergoing primary hypospadias repair to determine the correlation between GMS score and postoperative complications.

STUDY DESIGN

Between February 2011 and August 2013, patients undergoing primary hypospadias repair were prospectively scored using the GMS classification. GMS scoring included a 1-4 scale for each component: G - glans size/urethral plate quality, M - meatal location, and S - degree of shaft curvature, with more unfavorable characteristics assigned higher scores [Figure]. Demographics, repair type, and complications (urethrocutaneous fistula, meatal stenosis, glans dehiscence, phimosis, recurrent chordee and stricture) were assessed. Total and individual component scores were tested in uni- and multivariate analysis.

RESULTS

Two-hundred and sixty-two boys (mean age 12.3 ± 13.7 months) undergoing primary hypospadias repair had a GMS score assigned. Mean GMS score was 7 ± 2.5 (G 2.1 ± 0.9, M 2.4 ± 1, S 2.4 ± 1). Mean clinical follow-up was 17.7 ± 9.3 months. Thirty-seven children (14.1%) had 45 complications. A significant relationship between the total GMS score and presence of any complication (p < 0.001) was observed; for every unit increase in GMS score the odds of any postoperative complication increased 1.44 times (95% CI, 1.24-1.68). Urethrocutaneuous fistula was the most common complication, occurring in 21 of 239 (8.8%) of single-stage repairs. Patients with mild hypospadias (GMS 3-6) had a 2.4% fistula rate vs. 11.1% for moderate (GMS 7-9) and 22.6% for severe (GMS 10-12) hypospadias (p < 0.001). Degree of chordee was an independent predictor of fistula on multivariate analysis; S4 (>60° ventral curvature) patients were 27 times more likely to develop a fistula than S1 (no curvature) boys (95% CI, 3.2-229).

DISCUSSION

The GMS score is based on anatomic features (i.e. glans size/urethral plate quality, location of meatus, and degree of chordee) felt to most likely impact functional and cosmetic outcomes following hypospadias repair. We demonstrated a statistically significant increase in the likelihood of any postoperative complication with every unit increase in total GMS score. The concept that factors aside from meatal location affect hypospadias repair and outcomes is not novel, and degree of ventral curvature and urethral plate quality are often cited as important factors. In our series, boys with greater than 60° of ventral curvature undergoing a single-stage repair were 27 times more likely to develop a fistula than those without chordee on multivariate analysis, making severe curvature an independent predictor of urethrocutaneous fistula formation. That meatal location did not retain significance on multivariate analysis highlights the importance of considering the entire hypospadias complex when determining severity, rather than just evaluating the position of the meatus. Our study has several limitations that warrant consideration. While GMS scores were assigned prospectively, the data was collected retrospectively, subjecting it to flaws inherent with such study design. Furthermore, type of repair is influenced by surgeon preference and subjective assessment of hypospadias characteristics not incorporated in our scoring system (i.e. tissue quality, urethral hypoplasia, penoscrotal transposition). Despite these limitations, our study demonstrates a strong correlation between the GMS classification and surgical complications, furthering supporting its potential as a tool to standardize hypospadias severity and gauge postoperative complications.

CONCLUSION

The Glans-Urethral Meatus-Shaft (GMS) classification provides a means by which hypospadias severity and reporting can be standardized, which may improve inter-study comparison of reconstructive outcomes. There is a strong correlation between complication risk and total GMS score. Degree of chordee (S score) is independently predictive of fistula rate.

Two-stage urethroplasty is a better choice for proximal hypospadias with severe chordee after urethral plate transection: a single-center experience

It is still debatable whether single- or two-stage urethroplasty is a more suitable technique for treating hypospadias with severe chordee after urethral plate transection. This retrospective study evaluated these two techniques. A total of 66 patients of proximal hypospadias with severe chordee were divided into two groups according to the techniques they underwent: 32 and 34 patients underwent single-stage (Duckett) or two-stage urethroplasty, respectively. Median ages at presentation were 7.5 years and 11.0 years in single-stage and two-stage repair groups, respectively. Median follow-ups were 28.5 months (20-60 months) and 35 months (18-60 months) in the single-stage and two-stage groups, respectively. The meatus of the neourethra was located at the top of the glans in all patients. No recurrence of chordee was found during follow-up, and all patients or parents were satisfied with the penile length and appearance. Complications were encountered in eight patients in both groups, with no statistically significant differences between the two techniques. The late complication rate of stricture was higher after the single-stage procedure (18.75% vs 0%). The complication rate after single-stage repairs was significantly lower in the prepubescent subgroup (10.52%) than in the postpubescent cohort (46.15%). These results indicate that the urethral plate transection effectively corrects severe chordee associated with proximal hypospadias during the intermediate follow-up period. Considering the higher rate of stricture after single-stage urethroplasty, two-stage urethroplasty is recommended for proximal hypospadias with severe chordee after urethral plate transection.

Disorders of sex development in a developing country: perspectives and outcome of surgical management of 39 cases

OBJECTIVE

Improvements in diagnostic testing and genital repair have significantly advanced the management of disorders of sex development (DSD). Challenges however, still exist in the management of DSD. This study evaluated the types, challenges of surgical management, and outcome of DSD in south-east Nigeria.

METHODS

Retrospective analysis of 39 children with DSD managed from January 2005 to December 2013 at the University of Nigeria Teaching Hospital, Enugu, Nigeria.

RESULTS

Types of DSD were: 46, XX DSD in 17 (43.6 %) cases; 46, XY DSD 16 (41 %); Ovotesticular DSD 5 (12.8 %); and one (2.6 %) 46, XY Ovotesticular DSD. Median age at definitive gender assignment was 3 years (range 2 months-14 years). Gender assignment was female for 20 (51.3 %; all 46, XX DSD, one each of 46, XY DSD, Ovotesticular DSD and 46, XY Ovotesticular DSD), and male for 19 (48.7 %; 15 of 46, XY DSD, 4 of Ovotesticular DSD). Eight cases reared as male before presentation required gender reassignment after evaluation and counselling. Genital repair was undertaken at mean age of 4.1 years (range 6 months-14 years). After average follow-up of 22.5 months (range 1 month-7 years), a total of eleven (28.2 %) developed procedure-related complications. Challenges were delayed diagnosis, inadequate diagnostic facilities, and need for gender reassignment.

CONCLUSION

There is a wide spectrum of DSD in our setting. Time to diagnosis, evaluation, and outcome may be improved by public enlightenment initiative, focused education of healthcare personnel and provision of relevant diagnostic facilities through enhanced funding and collaboration.

Byars two-stage procedure for hypospadias after urethral plate transection

OBJECTIVE

To report on the outcomes of primary hypospadias repaired with the Byars two-stage procedure.

MATERIALS AND METHODS

Primary hypospadias repairs with the Byars two-stage procedure, between 2009 and 2012, were retrospectively reviewed. Medical charts were reviewed and analyzed. Follow up was at two weeks, three months, six months and one year after surgery. Complications, which included fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum, recurrent penile curvature and others, were documented and analyzed.

RESULTS

One hundred and twenty-eight cases were included in the present study. The median follow up was 30 months (range 13-44 months). All flaps took successfully after the first stage. Overall complication rates were 11.8%. Complications included: seven cases of fistula; five glans dehiscence; two urethral strictures, which developed after fistula repair; and one concealed penis. No recurrent penile curvature was recorded.

CONCLUSIONS

The Byars two-stage procedure is an option for primary hypospadias when the urethral plate is transected. It had an 11.8% complication rate in this present study.

Survey of pediatric urologists on the preoperative use of testosterone in the surgical correction of hypospadias

OBJECTIVE

To better characterize the current state of testosterone use in the surgical correction of hypospadias among pediatric urologists.

METHODS

An email was sent via the pedsurology research listserv through the American Academy of Pediatrics, inviting members to participate in an anonymous survey regarding their use of preoperative testosterone in hypospadias correction.

RESULTS

Twenty-seven responses were obtained for a response rate of 53%. Almost all responders practiced in North America, had exclusively pediatric patients in their practice, and had been in practice for 30 years or less. 55% were classified as high-volume surgeons, completing >50 cases yearly, 87% of whom use preoperative androgen therapy currently, compared with 67% of low-volume surgeons. Testosterone was prescribed primarily for a small appearing penis, reduced glans circumference, reduced urethral plate width, and/or proximal hypospadias. The effect of testosterone was determined primarily by evaluating penile appearance (59%). However, the majority (56%) of physicians stopped giving testosterone when they completed a predetermined regimen.

CONCLUSIONS

While many pediatric urologists use testosterone prior to hypospadias repair, the practice patterns are variable. It appears that the use of testosterone is primarily limited to patients with proximal hypospadias, small appearing penis, reduced glans circumference or reduced urethral plate.

A modification of the TIP procedure for distal hypospadias: The burrowing technique

INTRODUCTION

The tubularized incised plate urethroplasty (TIP) hypospadias repair is a commonly performed procedure for hypospadias. Multiple series document excellent cosmetic outcome in conjunction with low complication rates. We describe a modification that we have named the "burrowing technique." We believe that this technique facilitates dissection of the glans, which improves mobility, decreases tension with closure, and potentially improves outcomes.

METHODS

A retrospective review was performed of 193 coronal or mid-shaft hypospadias repairs by a single surgeon. The first 98 were performed using the TIP procedure, then the burrowing technique was developed and a subsequent 95 were analyzed for outcomes using this modification. Urethral plate characteristics and glandular size did not influence the choice of surgical technique. Cases were selected to allow for a "learning curve," and were consecutively accrued. None of the boys had undergone prior hypospadias surgery. Proximal 2 stage repairs and distal (glanular) repairs were excluded.

RESULTS

A total of 193 boys underwent repair, 98 with the traditional TIP procedure and 95 using the burrowing modification. In total, 37 (19.2%) patients required re-operation for either fistulas or dehiscence; 23 (23.5%) in the non-burrowing group and 14 (14.7%) in the burrowing group, odds ratio 0.54 (p = 0.10).

CONCLUSIONS

The TIP procedure has revolutionized the management of distal hypospadias. The burrowing modification increases glandular mobility simplifying the procedure and demonstrates a non-statistically significant trend in reducing reoperation rates.

Digital photographic measurement in hypospadias: validation and comparison to intraoperative measurement

BACKGROUND

We propose a standardized method of photographing the hypospadias penis to capture penile dimensions that may be relevant for surgery. We also validate the use of digital imaging software for calculating penile dimensions as a substitute for intraoperative caliper-based measurements.

METHODS

Photographs were taken of hypospadias penises in four different views after placement of a traction stitch and retraction of the preputial hood. Intraoperative measurements were obtained with a caliper. Digital measurements were taken of the same parameters postoperatively. All measurements were obtained in triplicate by multiple participants, and averages were tested for equivalency by determining the correlation coefficient for each parameter. Inter-observer correlation was also calculated for each parameter.

RESULTS

180 intraoperative and 180 digital measurements were taken from 60 dimensions on 10 hypospadiac penises. Strong correlation existed between most digital and intraoperative measurements. Average inter-observer correlations ranged from 0.91 to 0.99 for each of the intraoperative measurements, and 0.90 to 1.00 for each of the digital measurements.

CONCLUSIONS

Standardized imaging is effective in capturing penile dimensions and measurements during hypospadias surgery. When compared with intraoperative measurements, digital measurements are reliable and precise; digital photography has the potential to both aid in surgical planning and improve documentation.

Hypospadias repair: a single centre experience

Objectives. To determine the demographics and analyze the management and factors influencing the postoperative complications of hypospadias repair. Settings. Hayatabad Medical Complex Peshawar, Pakistan, from January 2007 to December 2011. Material and Methods. All male patients presenting with hypospadias irrespective of their ages were included in the study. The data were acquired from the hospital's database and analyzed with Statistical Package for Social Sciences (SPSS). Results. A total of 428 patients with mean age of 8.12 ± 5.04 SD presented for hypospadias repair. Midpenile hypospadias were the most common. Chordee, meatal abnormalities, cryptorchidism, and inguinal hernias were observed in 74.3%, 9.6%, 2.8%, and 2.1% cases, respectively. Two-stage (Bracka) and TIP (tubularized incised urethral plate) repairs were performed in 76.2% and 20.8% of cases, respectively. The most common complications were edema and urethrocutaneous fistula (UCF). The complications were significantly lower in the hands of specialists than residents (P-value = 0.0086). The two-stage hypospadias repair resulted in higher complications frequency than single-stage repair (P value = 0.0001). Conclusion. Hypospadias surgery has a long learning curve because it requires a great deal of temperament, surgical skill and acquaintance with magnifications. Single-stage repair should be encouraged wherever applicable due to its lower postoperative complications.

Total preputial flap: a reliable and versatile technique for urethral and penile reconstruction

We revisit the technique of total preputial flap (TPF) and its application for urethroplasty, penile skin coverage of both and present our results in 43 patients (41 hypospadias, 2 epispadias). There were no instances of flap necrosis. In patients without prior attempts at reconstruction (n = 36), we observed four urethrocutaneous fistulas. TPF allowed the repair of cases of proximal hypospadias in one stage with an acceptable complication rate.

Assessment of outcome in hypospadias surgery - a review

Hypospadias is a challenging field of urogenital reconstructive surgery with different techniques being currently used. Modern surgery claims that it is possible to create a functionally and cosmetically normal penis. Continuous re-evaluation and assessment of outcome may have a major impact on future clinical practice. Assessment of outcome includes: complication rate, cosmetic appearance of the penis, functional outcome (micturition, sexuality), and psychological factors such as quality of life and psychosexual life. This article briefly reviews current strategies of outcome assessment. Somehow in the future, we will be able to give an accurate estimation of the long-term consequences of being born with hypospadias.

Current practice in paediatric hypospadias surgery; a specialist survey

AIM

To undertake an online survey of current hypospadias surgery practice among those specialists attending the IVth World Congress of the International Society for Hypospadias and Disorders of Sex Development (ISHID), 2011.

MATERIALS AND METHODS

An online survey covering 22 separate questions relating to proximal and distal hypospadias surgery was set up, and all delegates registered for the conference were invited to complete this questionnaire anonymously. The data was analysed by three of the authors.

RESULTS

A total of 162 delegates registered for the conference of whom 74% were paediatric surgeons, paediatric urologists, plastic surgeons and adult/adolescent urologists. 93 delegates completed the online survey, and most of them (57%) were from Europe. The majority of surgeons see over 20 new patients/year (90%) and perform primary hypospadias surgery in over 20 patients/year (76%). The tubularized incised plate (TIP) repair is the most frequent technique used for the management of distal hypospadias (59%); other techniques used included Mathieu, onlay and TIP with graft. A variety of techniques are used for proximal hypospadias, but nearly half of the respondents (49%) preferred a staged approach. Self reported complication rates for distal hypospadias surgery are favourable (less than 10%) for 78% of the respondents. However, proximal hypospadias complication rates are higher.

CONCLUSIONS

With a majority of paediatric urologists and European delegates responding to our survey, the results suggest that there are differences in the management of proximal and distal hypospadias between surgeons, yet no differences were observed according to the region of their practice. Variations in long-term outcomes appear to be in keeping with the current literature.

Age of patient is a risk factor for urethrocutaneous fistula in hypospadias surgery

OBJECTIVE

There is still much debate regarding the effect that age at hypospadias operation has on the rate of complications. The aim of this study was to evaluate whether patient age is a risk factor for surgical complications when using the tubularized incised plate (TIP) urethroplasty technique.

METHODS

Between 2005 and 2011, 307 pediatric patients with distal or mid-penile hypospadias underwent the TIP procedure. Demographic and surgical data were evaluated.

RESULTS

The complications recorded across all age groups were: fistula, meatal stenosis, glans dehiscence and urethral stenosis. Fistula was the most frequent complication in 10-14 year olds compared to the younger patient groups, and this difference was statistically significant.

CONCLUSION

Age and surgical technique should be taken into consideration when planning hypospadias surgery, since the complication rate increases with patient age. The TIP technique is a safe procedure with a low rate of fistula formation in distal and mid-penile hypospadias repair for patients of any age during the prepubertal period.

Comparative outcomes of the tubularized incised plate and transverse island flap onlay techniques for the repair of proximal hypospadias

PURPOSE

The optimal management of proximal hypospadias remains uncertain. In this study, the surgical outcomes of tubularized incised plate repair (TIP) and transverse island flap (TVIF) onlay urethroplasty in boys with hypospadias were compared.

METHODS

A total of 176 patients with proximal hypospadias underwent TIP (n = 83) or TVIF onlay repairs (n = 93) by a single surgeon and were evaluated retrospectively. No patient received a testosterone injection prior to surgery. A retrospective review of their medical records collected data regarding age at surgery, chordee, dorsal plication, hypospadias site, penoscrotal transposition, bifid scrotum, congenital hernia, undescended testis and any postoperative complications, including fistula, recurrent curvature, dehiscence, diverticulum, meatal stenosis and urethral stricture. The pediatric penile perception score (PPPS) was completed by parents to evaluate their perception of cosmetic outcomes.

RESULTS

There was no statistical difference in age or any of the anatomical and clinical features of hypospadias. The median follow-up duration was 22 months (range 12-48 months) and 25 months (14-51 months) for the TIP and TVIF onlay groups, respectively. The overall complication rate in the TVIF onlay group was 21.5% (20/93), which was higher than 18.1% (15/83) in the TIP group, but the difference was not statistically significant (P = 0.569). The most common complication was urethrocutaneous fistula, occurring in 9.6% (8/83) of the TIP group and 10.8% (10/93) of the TVIF onlay group. There were no significant differences in the rate of any complication and the overall PPPS between the two groups.

CONCLUSION

TIP and TVIF onlay are clinically equivalent for the repair of proximal hypospadias.

Failed hypospadias in paediatric patients

Failed hypospadias refers to any hypospadias repair that leads to complications or causes patient dissatisfaction. The complication rate after hypospadias repairs ranges from 5-70%, but the actual incidence of failed hypospadias is unknown as complications can become apparent many years after surgery and series with lifelong follow-up data do not exist. Moreover, little is known about uncomplicated repairs that fail in terms of patient satisfaction. Risk factors for complications include factors related to the hypospadias (severity of the condition and characteristics of the urethral plate), the patient (age at surgery, endocrine environment, and wound healing impairment), the surgeon (technique selection and surgeon expertise), and the procedure (technical details and postoperative management). The most important factors for preventing complications are surgeon expertise (number of cases treated per year), interposition of a barrier layer between the urethroplasty and the skin, and postoperative urinary drainage. Major complications associated with failed hypospadias include residual curvature, healing complications (preputial dehiscence, glans dehiscence, fistula formation, and urethral breakdown), urethral obstruction (meatal stenosis, urethral stricture, and functional obstruction), urethral diverticula, hairy urethra, and penile skin deficiency.

Key discussions from the Working Party on Disorders of Sex Development (DSD) evaluation, Foundation Merieux, Annecy, France, March 14-17, 2012

Four topics from the DSD Working Party, a meeting to provide information regarding future studies, reported here are the complexities of hypospadias, surgical treatment of virilized genitalia of 46,XX DSD individuals, advances in phalloplasty and psychological, social and sexual outcomes.

Split dorsal dartos flap transposed ventrally as a bed for preputial skin graft in primary staged hypospadias repair

OBJECTIVE

To describe a modification of the 2-stage repair using a dorsal split dartos fascia flap, as a well vascularized bed for the graft in the first stage.The 2-stage repair is a commonly used technique in proximal hypospadias or in hypospadias with severe chordee, or in cases with urethral plate of poor or dubious quality.

METHODS

Between 2006 and 2009, 32 patients underwent a staged hypospadias repair: 8 (25.0%) midshaft with chordee and/or poor urethral plate, 14 (43.8%) proximal penile, 7 (21.9%) peno-scrotal, and 3 (9.4%) perineal hypospadias. Plication was necessary in 27 (84.4%). All cases received a preputial skin graft. Median age at the first stage was 21 months (range 15-26); median follow-up was 35 months (range 20-55) and the median time between the 2 stages was 8 months (range 6-12).

RESULTS

Graft take was 100% after the first stage. Follow-up after second-stage repair showed 31 of 32 (96.8%) had a successful functional outcome (straight erection; good, single urine stream; voiding in a standing position) and cosmetic outcome (slitlike meatus positioned at the tip of the glans, "normal looking circumcised penis"); one fistula occurred. One patient has mild residual ventral curvature.

CONCLUSION

Using a vascularized dorsal split dartos flap ventrally underneath and laterally of the skin graft in the first stage offers the advantages of an excellent graft take and the provision of versatile dartos tissue for a waterproofed and secured urethroplasty.