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Kulle AE, Jürgensen M, Döhnert U, Malich L, Marshall L, Hiort O. Contexts of care for people with differences of sex development: Diversity is still missing in the laboratory routine. MED GENET-BERLIN 2023; 35:181-187. [PMID: 38840817 PMCID: PMC10842577 DOI: 10.1515/medgen-2023-2037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
The 2006 Chicago consensus statement of management of disorders/difference of sex development (DSD) has achieved advantages in clinical care and diagnosis for patients and families affect by DSD. This article provides a brief overview of contexts of care for physicians, and points out specific challenges in clinical practice that have arisen from the transformations of the sex/gender system in recent years. We focus on the impact of diagnosis and laboratory measurements. Both laboratory measurements and hormonal therapies still depend on the binary system. One problem is the lack of reference intervals for the different forms of DSD, which means that diversity is often neglected. In the following, we will give a brief insight into this complex topic.
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Affiliation(s)
- Alexandra E. Kulle
- Campus Kiel/Christian-Albrechts University of KielDivision of Pediatric Endocrinology and Diabetes, Department of children and adolescent medicine I, University Hospital of Schleswig-HolsteinRosalind-Franklin-Str 924105KielGermany
| | - Martina Jürgensen
- Campus Lübeck/University of LübeckDivision of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University-Hospital of Schleswig-HolsteinLübeckGermany
| | - Ulla Döhnert
- Campus Lübeck/University of LübeckDivision of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University-Hospital of Schleswig-HolsteinLübeckGermany
| | - Lisa Malich
- University of LübeckInstitute for the History of Medicine and Science StudiesLübeckGermany
| | - Louise Marshall
- Campus Lübeck/University of LübeckDivision of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University-Hospital of Schleswig-HolsteinLübeckGermany
| | - Olaf Hiort
- Campus Lübeck/University of LübeckDivision of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University-Hospital of Schleswig-HolsteinLübeckGermany
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De Clercq E, Starke G, Rost M. "Waking up" the sleeping metaphor of normality in connection to intersex or DSD: a scoping review of medical literature. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2022; 44:50. [PMID: 36282442 PMCID: PMC9596528 DOI: 10.1007/s40656-022-00533-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 08/31/2022] [Indexed: 06/16/2023]
Abstract
The aim of the study is to encourage a critical debate on the use of normality in the medical literature on DSD or intersex. For this purpose, a scoping review was conducted to identify and map the various ways in which "normal" is used in the medical literature on DSD between 2016 and 2020. We identified 75 studies, many of which were case studies highlighting rare cases of DSD, others, mainly retrospective observational studies, focused on improving diagnosis or treatment. The most common use of the adjective normal was in association with phenotypic sex. Overall, appearance was the most commonly cited criteria to evaluate the normality of sex organs. More than 1/3 of the studies included also medical photographs of sex organs. This persistent use of normality in reference to phenotypic sex is worrisome given the long-term medicalization of intersex bodies in the name of a "normal" appearance or leading a "normal" life. Healthcare professionals should be more careful about the ethical implications of using photographs in publications given that many intersex persons describe their experience with medical photography as dehumanizing.
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Affiliation(s)
- Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
- Institute of Biomedical Ethics and History of Medicine, University of Zürich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| | - Georg Starke
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
- College of Humanities, École Polytechnique Fédérale de Lausanne, Rte Cantonale, 1015 Lausanne, Switzerland
| | - Michael Rost
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
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Hosokawa T, Tanami Y, Sato Y, Hosokawa M, Oguma E. The role of ultrasound to evaluate the disorders of sex development: a pictorial essay. J Ultrasound 2022; 25:745-755. [PMID: 34988914 PMCID: PMC9402846 DOI: 10.1007/s40477-021-00632-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022] Open
Abstract
Ultrasonography is usually the first modality used to evaluate patients with disorders of sex development (DSD). To determine the sex in patients with DSD, the following four categories are carefully evaluated: chromosomal, gonadal, anatomical internal genitalia, and external genitalia. However, in the clinical setting, the only information that sonographers have prior to ultrasound examination is the appearance of the external genitalia. The following DSD presentations are commonly observed: (1) male external genitalia present at birth, without testis in the scrotum or with a small penis; (2) female external genitalia present at birth, with an inguinal hernia or clitoromegaly; (3) neonates with ambiguous genitalia at birth; and (4) female or male external genitalia without sexual maturity. In this retrospective study of several clinical cases, we demonstrated an ultrasound-based sex determination approach for these clinical presentations. We found that sonographers evaluated the external genitalia in relation to the distal urethra within the corpus spongiosum and corpus cavernosum and the presence or absence of follicles within the detected gonads to determine the sex of the patient.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Mayumi Hosokawa
- Department of Pediatrics, Saitama City Hospital, 2460 Mimuro Midori-Ku Saitama, Saitama, 336-8522 Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
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Cai J, Zhu G, Tian H, Yuan J, Gao H, Sun L, Dong G, Ru W, Wu D, Tang D, Gao W, Fu J, Yang R. Mental health status of children with disorders of sexual development and their correlates. Front Public Health 2022; 10:756382. [PMID: 35968443 PMCID: PMC9363791 DOI: 10.3389/fpubh.2022.756382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Disorders of sexual development (DSD) refer to the congenital abnormalities of chromosomes, gonads, or gender anatomy. Children with DSD usually experience more stress. The present study aims to evaluate the mental health status of children with DSD, and to explore the potential relevant factors. We included 30 children with DSD and 30 age- and gender-matched children without DSD as the control group. All the children and their parents completed the scales of the Hamilton Anxiety Scale (HAMA). Children over 8 years old (n = 22) completed the Screen Scale for Child Anxiety Related Emotional Disorders (SCARED), the Depression Self-rating Scale for Children (DSRSC), and the Egna Minnen av Barndoms Uppfostran-own memories of parental rearing practices in childhood. DSD children had significantly higher somatic anxiety, mental anxiety, and total anxiety scores than the control group (p < 0.001). The scores of the SCARED, anxiety, and depression subscales of DSD children were higher than those of control children (p < 0.05 and p < 0.001, respectively). The correlation analysis showed that the score of generalized anxiety was positively related to age and entertainment. The regression analysis showed that age was a major factor that affected generalized anxiety in DSD children, and neuroticism was a major factor of anxiety disorder and separation anxiety in DSD children. Children with DSD have obvious anxiety problems, which are associated with family environmental factors (entertainment, success, and conflicts) and age. It is important to focus emphasis on emotional stability in children with DSD for detecting anxiety-related emotional disorders early.
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Affiliation(s)
- Jingjing Cai
- Department of Child Psychology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Guochun Zhu
- Department of Child Psychology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongjuan Tian
- Department of Urology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinna Yuan
- Department of Endocrinology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Huihui Gao
- Department of Pediatrics and Adolescent Gynecology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Liying Sun
- Department of Pediatrics and Adolescent Gynecology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Guanping Dong
- Department of Endocrinology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Ru
- Department of Urology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Dehua Wu
- Department of Urology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Daxing Tang
- Department of Urology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Weijia Gao
- Department of Child Psychology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Junfen Fu
- Department of Endocrinology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Junfen Fu
| | - Rongwang Yang
- Department of Child Psychology, Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, China
- Rongwang Yang
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Ekenze SO, Chikani U, Ezomike UO, Adiri CO, Onuh A. Clinical profile and management challenges of disorders of sex development in Africa: a systematic review. J Pediatr Endocrinol Metab 2022; 35:139-146. [PMID: 34670035 DOI: 10.1515/jpem-2021-0510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/04/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To review the published literature regarding disorders of sex development (DSD) in Africa which will highlight clinical characteristics, and challenges of evaluation and treatment of DSD. CONTENT We performed systematic review of articles published on DSD in Africa between January 2001 and December 2020. SUMMARY Eighteen studies involving 1980 patients from nine countries were analyzed. Overall mean age at presentation was 9.3 years (range 1 day-33 years) with 52.5 and 45.1% reared as females and males, respectively, prior to presentation. Following evaluation however, 64% were assigned female sex, 32.1% were assigned male sex, and 21.8% of the cases required sex reassignment. Only 7 (38.9%) of the publications reported medical treatment of DSD, 4 (22.2%) reported on psychosocial management and 5 (27.8%) documented multidisciplinary team management. Barring regional variations, the documented challenges of management include delayed presentation, loss to follow up, financial challenges, and lack of facilities for care of DSD. Comparison of the cases managed in the last decade (2011-2020) with those managed in the earlier decade (2001-2010) showed a trend towards earlier presentation and reduced rate of sex reassignment in the last decade. However, the challenges persisted. OUTLOOK Barring regional differences, a high proportion of DSD in Africa may have delayed presentation with inappropriate sex of rearing, inadequate evaluation and need for sex reassignment. Specific efforts to improve time to diagnosis, patient evaluation, improvement of healthcare funding, and collaboration with more developed countries may improve the care of patients with DSD in Africa.
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Affiliation(s)
- Sebastian O Ekenze
- Sub-Department of Paediatric Surgery, Faculty of Medical Sciences, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Ugo Chikani
- Department of Paediatrics, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Uchechukwu O Ezomike
- Sub-Department of Paediatric Surgery, Faculty of Medical Sciences, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Charles O Adiri
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Augustine Onuh
- Department of Radiation Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu, Nigeria
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Délot EC, Vilain E. Towards improved genetic diagnosis of human differences of sex development. Nat Rev Genet 2021; 22:588-602. [PMID: 34083777 PMCID: PMC10598994 DOI: 10.1038/s41576-021-00365-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 02/05/2023]
Abstract
Despite being collectively among the most frequent congenital developmental conditions worldwide, differences of sex development (DSD) lack recognition and research funding. As a result, what constitutes optimal management remains uncertain. Identification of the individual conditions under the DSD umbrella is challenging and molecular genetic diagnosis is frequently not achieved, which has psychosocial and health-related repercussions for patients and their families. New genomic approaches have the potential to resolve this impasse through better detection of protein-coding variants and ascertainment of under-recognized aetiology, such as mosaic, structural, non-coding or epigenetic variants. Ultimately, it is hoped that better outcomes data, improved understanding of the molecular causes and greater public awareness will bring an end to the stigma often associated with DSD.
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Affiliation(s)
- Emmanuèle C Délot
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Hospital, Washington, DC, USA
- Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Eric Vilain
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Hospital, Washington, DC, USA.
- Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA.
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Estermann MA, Smith CA. Applying Single-Cell Analysis to Gonadogenesis and DSDs (Disorders/Differences of Sex Development). Int J Mol Sci 2020; 21:E6614. [PMID: 32927658 PMCID: PMC7555471 DOI: 10.3390/ijms21186614] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 12/20/2022] Open
Abstract
The gonads are unique among the body's organs in having a developmental choice: testis or ovary formation. Gonadal sex differentiation involves common progenitor cells that form either Sertoli and Leydig cells in the testis or granulosa and thecal cells in the ovary. Single-cell analysis is now shedding new light on how these cell lineages are specified and how they interact with the germline. Such studies are also providing new information on gonadal maturation, ageing and the somatic-germ cell niche. Furthermore, they have the potential to improve our understanding and diagnosis of Disorders/Differences of Sex Development (DSDs). DSDs occur when chromosomal, gonadal or anatomical sex are atypical. Despite major advances in recent years, most cases of DSD still cannot be explained at the molecular level. This presents a major pediatric concern. The emergence of single-cell genomics and transcriptomics now presents a novel avenue for DSD analysis, for both diagnosis and for understanding the molecular genetic etiology. Such -omics datasets have the potential to enhance our understanding of the cellular origins and pathogenesis of DSDs, as well as infertility and gonadal diseases such as cancer.
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Affiliation(s)
| | - Craig A. Smith
- Department of Anatomy and Developmental Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton 3800, Victoria, Australia;
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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Incidence and diagnoses of disorders of sex development in proximal hypospadias. J Pediatr Surg 2018; 53:2498-2501. [PMID: 30224237 DOI: 10.1016/j.jpedsurg.2018.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/25/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Evidence-based guidelines on evaluation of boys with proximal hypospadias for the possibility of a disorder of sex development (DSD) have yet to be developed. We aimed to investigate the incidence and diagnoses of DSD in patients with proximal hypospadias. METHODS We retrospectively reviewed the records of consecutive boys who underwent proximal hypospadias repairs from 2006 to Sept 2017. Data collected included scrotal anomaly, testes position/palpability, micropenis, DSD investigations, and surgical techniques. RESULTS 165 patients were eligible for the study. 14 (8.5%) were diagnosed to have DSD. The diagnoses were 46,XX testicular DSD [n = 1], 46,XY DSD [n = 7; partial gonadal dysgenesis (PGD) = 3; 5α-reductase type 2 deficiency = 3; 17α-hydroxylase deficiency = 1], Sex Chromosome DSD [n = 6; 45,X/46,XY PGD = 4; Klinefelter = 2]. 3/7 (43%) patients with PGD had gonadal germ cell neoplasms. Of the DSD patients, 6/14 (43%), 11/14 (79%) and 11/14 (79%) had undescended/impalpable testes, micropenis and penoscrotal transposition/bifid scrotum, respectively, significantly higher prevalence rates than those without DSD diagnosis (p-values <0.05). 10/14 (71.4%) DSD patients underwent 2-stage repair compared with 57/151 (37.7%) of others without DSD diagnosis (p = 0.01). CONCLUSIONS Patients presenting with proximal hypospadias and one or more of the coexisting anomalies of micropenis, undescended/impalpable testes, and penoscrotal transposition/bifid scrotum should warrant DSD evaluation. Presence of bilaterally descended testes in scrotum does not preclude the possibility of DSD. LEVEL OF EVIDENCE IV.
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Morozumi K, Ainoya K, Takemoto J, Sakai K. Newly Identified t(2;17)(p15;q24.2) Chromosomal Translocation Is Associated with Dysgenetic Gonads and Multiple Somatic Anomalies. TOHOKU J EXP MED 2018; 245:187-191. [DOI: 10.1620/tjem.245.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kento Morozumi
- Department of Urology, Yamagata Prefectural Central Hospital
| | - Keiko Ainoya
- Department of Urology, Miyagi Children’s Hospital
| | - Jun Takemoto
- Department of Urology, Miyagi Children’s Hospital
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