Long-term outcome of penile appearance and sexual function after hypospadias repairs: situation and relation

Application of the modified Byars staged procedure for severe hypospadias repair

This study aimed to introduce a modified Byars staged procedure and investigate its application value in patients with severe hypospadias. We retrospectively analyzed the clinical data of patients with severe hypospadias admitted to the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between October 2012 and October 2022. In total, 31 patients underwent the conventional Byars procedure (conventional group), and 45 patients underwent the modified Byars staged procedure (modified group). Our modified strategy was built upon the standard Byars procedure by incorporating glansplasty during the first stage and employing a Y-shaped flap in conjunction with a glandular tunnel for urethroplasty during the second stage. Notably, there were no statistically significant differences in the preoperative baseline characteristics, duration of surgery, amount of blood loss, or occurrence of postoperative complications, including urethral fistula, stricture and diverticulum, or penile curvature, between the conventional and modified groups. However, there was a significantly lower incidence of coronal sulcus fistula (0 vs 16.1%, P = 0.02) and glans dehiscence (0 vs 12.9%, P = 0.02) in the surgical group than that in the conventional group. In addition, the modified group exhibited a notably greater rate of normotopic urethral opening (100.0% vs 83.9%, P = 0.01) and a higher mean score on the Hypospadias Objective Penile Evaluation (HOPE; mean ± standard error of mean: 8.6 ± 0.2 vs 7.9 ± 0.3, P = 0.02) than did the conventional group. In conclusion, the modified Byars staged procedure significantly reduced the risks of glans dehiscence and coronal sulcus fistula. Consequently, it offers a promising approach for achieving favorable penile esthetics, thereby providing a reliable therapeutic option for severe hypospadias.

Adulthood cosmetic and sexual outcomes of the patients who underwent hypospadias repair in childhood

This study aimed to assess the cosmetic and sexual outcomes of childhood hypospadias repair after puberty. Among 672 patients who underwent hypospadias repair between 2001 and 2017, 243 sexually active patients were included in the study. At their last visit, cosmetic and sexual evaluation were done through the Penile Perception Score, the Hypospadias Objective Scoring Evaluation, IIEF, MSHQ-EjD. The levels of erectile dysfunction(ED) severity were determined according to erectile function domain of IIEF. The median follow-up after the last surgery was 16 [IQR (13-18)] years, and median patient age at the time of study was 19.67 [IQR(18-22)] years. Patients were divided into two subgroups as follows: Group I; Repairs using grafts (n = 120, 49.4%) and Group II; Graft-free repairs (n = 123, 50.6%). The rate of dissatisfaction with penile appearance was higher in Group I (16.7% vs. 4.9%, p = 0.003). Mild ED was more frequent in Group I (14.2% vs. 3.3%, p = 0.007); while none of the patients had either moderate or severe ED. Other domains of sexual function were observed to be similar in both groups. The need for unwanted interventions due to complications, and surgeries requiring grafts were found to be risk factors for ED development and dissatisfaction with penile appearance in adulthood. Those who underwent graft-free hypospadias repair experience better cosmetic and sexual outcomes when compared to grafted repairs, yet, satisfactory results were achieved in almost 90% of the grafted repairs.

Outcomes Assessment of Hypospadias Repair

INTRODUCTION

Hypospadias is a congenital malformation, which involves the displacement of the urethral orifice on the underside of the penis. The mainstay treatment of hypospadias is surgery. Currently, there is no literature broadly assessing hypospadias repair outcomes in the Kingdom of Bahrain. This study aims to provide descriptive data on cosmetic, functional, and surgical outcomes of hypospadias repair at a single medical institute in the Kingdom of Bahrain.

METHOD

Data on patients who underwent hypospadias repair from January 2012 to December 2020 by a single surgeon were reviewed. Parents of patients were contacted via telephone for consent. All consenting participants returned for an outpatient assessment of functional and cosmetic outcomes using an original questionnaire and the Pediatric Penile Perception Score, respectively. All responses were recorded using a four-point Likert scale. Surgical outcomes were assessed by reviewing postoperative notes. All collected data were anonymized. The study was approved by the King Hamad University Hospital institutional review board.

RESULTS

Of the 29 patients who underwent surgical repair for hypospadias, 15 patients consented to participate. The mean age of the study population was 2.466 (SD = 0.496). Both parent and physician cosmetic assessments had similar results with the majority of participants very satisfied with all cosmetic parameters. Physician assessment reported higher satisfaction compared to parents. There were no reported cases of poor satisfaction. In terms of functional outcomes, there were no reported cases of straining on initiation, and a smooth and continuous urinary stream was reported in 80%. Only four patients reported post-void dribbling. When assessing surgical outcomes, 53.30% had coronally located urethra with no cases of postoperative complications. More than half of our patients were discharged after one day.

CONCLUSION

Our study noted overall high satisfaction in terms of surgical, cosmetic, and functional outcomes. Physicians reported better cosmetic outcomes when compared to parents. Further analysis with a larger sample size across various medical institutes will be required to better assess post-repair outcomes.

Sexual dysfunction in patients with late complications of hypospadias surgery

Most hypospadias cases are successfully treated in childhood. Still, patients with sequelae of failed hypospadias repair and sexual dysfunction may be encountered. We evaluated 112 patients with a history of failed hypospadias repair, defined as the presence of voiding symptoms or cosmetic problems remaining despite previous surgery or caused by it. Patients' median age was 29.5 years (range: 18-62). There were no intersex cases. Only 9.8% (11/112) underwent single attempt at surgical reconstruction, the median number of attempts was 3.5 (range: 1-9). Patients with IIEF-EF score ≤25 were considered to have erectile dysfunction; those with IIEF-EF ≤16 underwent penile doppler ultrasound, penile electromyography and endocrine assessment. About 64.2% of patients (72/112) were dissatisfied with penile appearance, 40.2% (45/112) had ED, 71.4% (80/112) had ejaculation disorders. Psychogenic ED was diagnosed in 21 patients with preserved non-coital erections and no evidence of organic ED. Median IIEF-EF in ED patients was 20 (range: 8-25). Asthenic ejaculation, delayed ejaculation and anejaculation were present in 63.4% (71/112), 7.1% (8/112) and 3.5% (4/112) patients respectively. Premature ejaculation was present in 28.6% (32/112) patients, but its association with hypospadias or previous surgery is unlikely.

At The Forefront of Penile Surgical Reconstruction: A Bibliometric Study of the 100 Most-Cited Articles

PURPOSE

The citation count of a scientific article is considered as the recognition it received from this field. The purpose of this bibliometric analysis was to identify the top 100 most-cited scientific articles in penile surgical reconstruction.

METHODS

The Web of Science database was used to extract the top 100 most-cited articles. Individual articles were reviewed to identify the authorship, published journal, journal impact factor (IF), primary disease, article type, institution and country of origin, and year of publication.

RESULTS

The top 100 most-cited articles were published between 1947 and 2013. The number of citations ranged from 23 to 233. Journal of Urology contributed the most articles (n = 36). Articles with a high level of evidence like prospective analysis (n = 5), systematic review and meta-analysis (n = 2), and guideline (n = 1) were all published after 2000. The average citation per year of articles published in high-IF journals was significantly higher than that of other articles (p = 0.0129). There was a positive linear correlation between citation count per year and publication year (r² = 0.26, p < 0.001). Among the top 100 articles, 74 articles were interlinked via citation of each other. The major topic of co-citation network was the application of flaps in penile reconstruction.

CONCLUSIONS

The analysis of top 100 most-cited articles facilitates the comprehensive recognition of current focus in the field of penile surgical reconstruction, which is the exploration of flaps and development of new techniques in penile reconstruction. In the future, more attention should be paid to evidence-based medicine to provide high-level evidence for research.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hypospadias: clinical approach, surgical technique and long-term outcome

Background

Hypospadias is one of the most common congenital abnormalities in male newborn. There is no universal approach to hypospadias surgical repair, with more than 300 corrective procedures described in current literature. The reoperation rate within 6–12 months of the initial surgery is most frequently used as an outcome measure. These short-term outcomes may not reflect those encountered in adolescence and adult life. This study aims to identify the long-term cosmetic, functional and psychosexual outcomes.

Methods

Medical records of boys who had undergone surgical repair of hypospadias by a single surgical team led by the same surgeon at a single centre between August 2001 and December 2017 were reviewed. Families were contacted by telephone and invited to participate. Surgical outcome was assessed by combination of clinical examination, a life-related interview and 3 validated questionnaires (the Penile Perception Score-PPS, the Hypospadias Objective Score Evaluation-HOSE, the International Index of Erectile Function-5-IIEF5). Outcomes were compared according to age, severity of hypospadias, and respondent (child, parent and surgeon).

Results

187 children and their families agreed to participate in the study. 46 patients (24.6%) presented at least one complication after the repair, with a median elapsed time of 11.5 months (6.5–22.5). Longitudinal differences in surgical corrective procedures (p < 0.01), clinical approach (p < 0.01), hospitalisation after surgery (p < 0.01) were found. Cosmetic data from the PPS were similar among children and parents, with no significant differences in child’s age or the type of hypospadias: 83% of children and 87% of parents were satisfied with the cosmetic result. A significant difference in functional outcome related to the type of hypospadias was reflected responses to HOSE amongst all groups of respondents: children (p < 0.001), parents (p=0.02) and surgeon (p < 0.01). The child’s HOSE total score was consistently lower than the surgeon (p < 0.01). The HOSE satisfaction rate on functional outcome was 89% for child and 92% for parent respondents.

Conclusion

Surgeons and clinicians should be cognizant of the long-term outcomes following hypospadias surgical repair and this should be reflected in a demand for a standardised approach to repair and follow-up.

Long-Term Undesirable Consequences of Penile Skin Island Flap to Correct Penoescrotal Transposition: A Case Report and Review of Literature

Hypospadias is a congenital malformation of the male lower urinary tract, consisting of a ventral urethral opening proximal to the glans penis. This condition is corrected surgically in the paediatric age, with a great variety of techniques available. Traditionally, a tubularized genital skin was used for one- or two-stage repairs. Nowadays, the tendency is to use preputial or oral mucosa grafts, dorsally located, to avoid diverticula formation and prevent hair growth in the neourethra. We present a case of a patient born with proximal hypospadias with penoscrotal transposition, surgically corrected in his childhood, using dorsal penile skin island flap. The patient is referred to urology consultation in his adulthood for a weak urinary stream, recurrent infections, and a large amount of hair exiting through the urethral meatus.

Sexual functions and fertility outcomes after hypospadias repair

Hypospadias is a common abnormality of the urogenital tract with a wide range of variety in its presentation and severity. The primary aim to correct hypospadias is to restore normal penile function and appearance. Although it can be corrected at any age, early correction between the 6 and 18 months of life is recommended. The functional and cosmetic outcomes have been very-well presented in the literature, although the aspects of sexuality and fertility of hypospadias repair in the long term are vague. In this narrative review, we aimed to gather the data around the sexuality and fertility outcomes of hypospadias repair and acknowledge urologists and parents of boys with hypospadias who will have a correction surgery about future sexual and fertility concerns.

Urological results and patient satisfaction in adolescents after surgery for proximal hypospadias in childhood

BACKGROUND

Proximal hypospadias repair is associated with a considerable complication risk. Long-term follow-up is required to present realistic expectations in pre-operative counseling.

OBJECTIVE

To investigate adolescents after childhood surgery for proximal hypospadias in a prospective cohort study describing the urological outcome, complication rates and patient satisfaction with penile appearance.

STUDY DESIGN

39 adolescents ≥14 years with penoscrotal to perineal hypospadias and primary urethroplasty (tubularized incised plate (TIP), preputial flap as Onlay or tubularized (Duckett)) from 1996 to 2005 at a single center were evaluated. The clinical assessment, at Md 16.5 years (14-25), included voiding history, genital examination including the Hypospadias Objective Scoring Evaluation (HOSE), uroflowmetry plus chart data from previous urinary flows and evaluation of patient satisfaction using the Penile Perception Score (PPS).

RESULTS

Twenty-nine patients with penoscrotal and 10 with scrotal/perineal hypospadias underwent surgery with TIP (N = 14), Onlay (N = 14) and Duckett (N = 11). Uroflows improved significantly compared with prepubertal maximal flows. Impaired flow rate (<10 mL/s) was found in 14% (5/36). Fifty-one percent (20/39) required reoperations, 29% (4/14) of TIP, 50% (7/14) of Onlay and 82% (9/11) of Duckett (p = 0.0062). Median penile length in adolescence was 8.7 cm (4.0-11.0). Forty-four percent (12/27) of patients were dissatisfied with penile length. Patients were 'satisfied' or 'very satisfied' with meatal position and shape despite HOSE for meatal position being 11% (4/38) distal, 76% (29/38) proximal glanular and 13% (5/38) coronal. TIP patients had more curvature at puberty than Duckett (p = 0.0062). Patients that had a decurvature procedure had shorter penile length (p = 0.019).

DISCUSSION

A high complication rate is previously described, predominantly within the first years. Our study shows 50% of reoperations were performed after >3 years, illustrating the need for long-term follow-up. Patient satisfaction with a deviant meatal position is rarely reported [1,2]. Our results support a conservative approach to an asymptomatic retracted meatus. Limitations of this descriptive study are the non-comparable groups and the retrospective data for correlation, impeding evaluation of prognostic outcome-factors. The shorter penile length found in patients after plication, and increased curvature after TIP, is therefore merely descriptive. However, the findings are in line with earlier publications suggesting limited use of TIP, and plication (recommending ventral lengthening instead) to avoid penile shortening and curvature in these cases [3-5].

CONCLUSIONS

The urological long-term outcome after proximal hypospadias repair is good, although late reoperations are common. In adolescence, patients were dissatisfied with the short penile length but satisfied with meatal position, indicating that in proximal hypospadias, preserving penile length and correcting curvature are prioritized over a distal meatus.

Psychosexual Functioning Outcome Testing after Hypospadias Repair

Self-confidence plays an important role in both genders’ sexual functioning. Lack of genital self-esteem may have negative effects on psychosexual development, especially in males, where deviations from a standardized normal penile appearance can lead to inhibitions in entering into sexual relationships. The aim of our study was to evaluate the informativeness of studied domains of the Global Sexual Functioning (GSF) questionnaire and sexual functioning of patients surgically treated in childhood for different types of hypospadias. We evaluated 63 males with hypospadias and 60 healthy age- and gender-matched controls. The GSF questionnaire was used to estimate psychosexual function as a long-term follow-up after the surgical correction of hypospadias in the patient and control groups. Sexual activity (p = 0.017), arousal (p = 0.033) and orgasmic abilities (p = 0.002) values were significantly increased in patients. Strong correlation was noticed between sexual activity and sexual desire (R = 0.872); arousal and sexual desire (R = 0.753), as well as orgasmic and erectile abilities (R = 0.769). Different domains of psychosexual functioning in the patient group correlated with each other to various degrees, resulting in a heterogeneous expression of psychosexual dysfunctions, implicating the necessity of a personalized treatment approach.

Proximal hypospadias treated with a transverse preputial island tube: long-term functional, sexual, and cosmetic outcomes

OBJECTIVE

To study long-term urinary and sexual function, and cosmetic outcomes in adult patients who underwent single-stage transverse preputial island tube (TPIT) for proximal hypospadias repair in childhood. Long-term data on outcomes of patients with proximal hypospadias with severe coexisting curvature and insufficient urethral plate are scarce, but are necessary to decide which repair technique is most beneficial.

PATIENTS, SUBJECTS AND METHODS

Patients with proximal hypospadias operated with TPIT (TPIT Group) were compared to patients with distal hypospadias repair (Distal Group) and to a control group of male medical students (Control Group). Participants completed the International Prostate Symptom Score, the International Index of Erectile Function (IIEF-15), additional non-validated questions, and performed uroflowmetry. Cosmesis was assessed in the patients with hypospadias using the Pediatric Penile Perception Score (PPPS); stretched penile length was also measured.

RESULTS

Of the 121 eligible patients with hypospadias, 54 with either TPIT or distal hypospadias repairs participated. The TPIT Group comprised 12 patients (median age of 20.0 years) and the Distal Group comprised 42 patients (median age of 19.6 years). The complication rates were similar, at 8 of the 12 patients in the TPIT Group vs 26/42 (62%) in the Distal Group (P = 0.76). Urinary outcomes were similar in the TPIT, Distal, and the Control (comprised of 148 medical students with a median age of 21.0 years) groups. The TPIT Group had a lower maximum urinary flow rate compared to the Control Group, at 24.1 vs 28.6 mL/s (P < 0.05). IIEF-15 scores were similar in the TPIT, Distal and Control groups, except for 'Orgasmic Function' (7.5 vs 10.0 vs 10.0, respectively; P < 0.01). Although the TPIT Group had a smaller penile length compared to the Distal Group (10.1 vs 12.9 cm, P < 0.01), PPPS outcomes were similar.

CONCLUSION

In these TPIT patients, long-term urinary, sexual and cosmetic outcomes were similar to those in patients with distal hypospadias repairs and controls.

The SIGHT questionnaire: A novel assessment tool for Satisfaction In Genital Hypospadias Treatment

PURPOSE

Psychosexual development is currently underrepresented in hypospadias outcome research. The aim of this study was to develop and validate a questionnaire addressing psychosexual long-term satisfaction, specifically of adolescent patients, after hypospadias repair.

MATERIALS AND METHODS

In a multistep participative design we identified key interests of adolescent patients with hypospadias. Next, a questionnaire addressing specifically the psychosexual satisfaction of adolescents after hypospadias repair was established. A population of 109 former patients with hypospadias was then assessed using this questionnaire. Furthermore, functional and cosmetic aspects, behavioural anomalies, and sexual activity were investigated. Age-matched patients undergoing circumcision served as control patients. Possible influence factors on patient satisfaction were investigated. Clinical trial registry site: German Registry of Clinical Trials DRKS, Freiburg, Germany (Reference: DRKS00003432).

RESULTS

Key interests of adolescent patients were "normal appearance of the penis", "normal function of the penis regarding voiding and sexual activity", "no limitations regarding cosmetic appearance to others", "no limitations to sexual activity", and an "unimpaired masculine identity". The "Satisfaction In Genital Hypospadias Treatment" (SIGHT) questionnaire was developed using these items and using previously published evaluation systems. Nine questions address psychosexual aspects and two additional questions address current sexual activity. Internal consistency was high and retest reliability acceptable. The patient population showed a normal strength and difficulties score (SDQ). Overall satisfaction was high and similar to that of the control group. In a Spearman correlation a high SDQ value, erectile problems, and complications correlated negatively with satisfaction.

CONCLUSION

To date, few studies have examined patients' satisfaction and psychosexuality. To our knowledge, the SIGHT questionnaire is the first to be developed participatively and in a stepwise fashion in collaboration with a paediatric psychologist and an open approach to determine items specifically important for adolescents. The SIGHT questionnaire can thus offer a relevant assessment of patients' psychosexual satisfaction. It is most suitable to supplement current strategies that so far mostly neglect the impact on psychosexual wellbeing.

Hypospadias repair during adulthood: Case series

Purpose

We report our complications and success rate in adult hypospadias repair.

Patients and Methods

This was a retrospective study of patients aged ≥17 years who underwent hypospadias repair during 2006-2014. We analyzed two groups, one with primary repair and the other that had secondary repair after failed childhood hypospadias surgery. Outcome was compared between the two groups and among different surgical procedures. Descriptive statistics and Fisher's exact test were used and significance level was set at P < 0.05.

Results

Forty patients were included, of which 26 presented for a secondary repair and 14 for primary repair. The meatus was distal in 15 patients, mid-penile in 16, and penoscrotal in 9. The median age of patients at the time of surgery was 21 years (standard deviation [SD] =4, range 17-30). The median follow-up period was 37 months (SD = 8, range 5-75). In the primary repair group, the success rate was 71% (10/14), whereas in the secondary repair group, the success rate was 55% (14/26). The overall complication rate was 60%. Following a subsequent repair, the overall success rate reached 95% (38/40). There was no significant difference in success or complications between patients who presented with primary or secondary hypospadias or between methods of repair.

Conclusion

Delayed hypospadias repair in adults is associated with a high success rate of 95% with no difference between primary and secondary repair. Secondary repair however may require more than one procedure most of the time.

Patient-reported long-term outcome after primary hypospadias repair

PURPOSE

Long-term evaluation of the surgical outcome after puberty, particularly patient reported outcome is rare in the literature. The aims of this study were to investigation the patients' satisfaction with the long-term results and their views and memories of their childhood surgery and follow-up.

METHODS

A modified version of previously used questionnaire was sent to 134 patients ages 18 years or older previously primarily repaired due to hypospadias by one of the authors (HS) between 1989 -2009.

RESULTS

Thirty-nine patients responded. Eighty-two per cent were satisfied with the appearance of their penis, 87% were satisfied with their ability to urinate and their sexual function and 92% were satisfied with the overall surgical results. Ninety per cent of patients were positive to the current duration of our post-pubertal follow-up program or would have preferred an even longer follow-up.

CONCLUSIONS

The majority of patients were satisfied with the long-term surgical results and the duration of follow-up. Despite having problems patients does not always contact the health care system spontaneously, which warrants long-term follow-up.

Reconstructive surgery for hypospadias: A systematic review of long-term patient satisfaction with cosmetic outcomes

INTRODUCTION

Research on long-term results of hypospadias has focused on surgical techniques and functional outcomes, and it is only recently that patient satisfaction with appearance and psychosocial outcomes have been considered. The aim of this study was to provide an evidence-based systematic review of adolescent and adult patient perceptions of cosmetic outcomes following childhood surgery for hypospadias.

METHODS

A systematic review was performed in accordance with the PRISMA and PICO guidelines, and studies assessed using the Oxford Centre for Evidence-Based Medicine system. MEDLINE, PsycInfo, EMBASE, and CINAHL databases were searched from 1974 to 2014 for clinical studies containing patient perceptions of appearance, deformity, and social embarrassment following hypospadias surgery.

RESULTS

A total of 495 publications were retrieved, of which 28 met the inclusion criteria. Due to study design/outcome measure, heterogeneity data were synthesized narratively. Results indicate (i) patient perceptions of penile size do not differ greatly from the norm; (ii) perceptions of appearance findings are inconsistent, partially due to improving surgical techniques; (iii) patients who are approaching, or have reached, sexual maturity hold more negative perceptions and are more critical about the cosmetic outcomes of surgery than their prepubertal counterparts; (iv) patients report high levels of perceptions of deformity and social embarrassment; and (v) there is a lack of data using validated measurement tools assessing long-term patient perceptions of cosmetic outcomes, particularly with patients who have reached genital maturity.

CONCLUSIONS

Protocols for clinical postpuberty follow-up and methodologically sound studies, using validated assessment tools, are required for the accurate assessment of cosmetic and psychological outcomes of hypospadias surgery.

Modified Penile Augmentation by Dermal-Fat Graft in Post-Hypospadias Adults

BACKGROUND

Although a considerable part of patients desire further improvement in penile size after hypospadias repairs, penile augmentation is only considered in patients with congenital penile hypoplasia or acquired penile retraction. Modified penile augmentation by free dermal-fat graft is introduced to satisfy these patients and improve surgical safety.

METHODS

From April 2012 to December 2014, a total of 15 male adults after hypospadias repairs, aged 18-24 years, underwent modified penile augmentation which involved girth enhancement by a free dermal-fat graft and penile elongation (suprapubic skin advancement-ligamentolysis). A specially designed tunneling instrument was introduced to facilitate pericavernous thickening without degloving. Outcome evaluation was mainly based on objective penile measurements and results of the Male Genital Image Scale.

RESULTS

With 6 months' follow-up, all patients had achieved excellent cosmetic results, with a significant average dimensional increase of 1.53 ± 0.23 cm in flaccid girth and 1.67 ± 0.24 cm in flaccid length. No erection deficiencies or urinary fistula occurred. Patients' perception of male genitalia improved postoperatively, with the average MGIS score rising from 31.73 ± 4.86 to 40.20 ± 4.54.

CONCLUSIONS

This modified technique is safe and effective in enlarging penile size. The use of the specially designed tunneling instrument simplifies penile girth enhancement, avoiding unnecessary trauma to the neo-urethra and neurovascular bundle. It is confirmed that physical dimensional enhancement does contribute to improving their underestimation of penile size.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

EVC gene polymorphisms and risks of isolated hypospadias - a preliminary study

Introduction

Hypospadias has a complex etiology with both genetic and environmental factors contributing to the condition. Urogenital abnormalities including hypospadias, are found in 22% of cases with Ellis van Creveld syndrome (EvC). Mutations in the EVC gene can cause major and minor anomalies, which form phenotypes that partially overlap with those present in EvC.

The aim of this study was to evaluate the association between nucleotide variants of the EVC gene and the risk of hypospadias.

Material and methods

Four single nucleotide polymorphisms (SNPs) of the EVC gene (rs3774856, rs2302075, rs1383180, rs7680768) were taken under investigation in 96 patients with isolated hypospadias and 284 matched controls. Genotyping of all polymorphisms was carried out by PCR and followed by appropriate restriction enzyme digestion (PCR-RFLP).

Results

Individuals homozygous for the SNP rs2302075 (p.Thr449Lys) showed an elevated risk for hypospadias. Haplotypes containing the rs2302075 variant also revealed modest associations with hypospadias, which did not survive multiple testing corrections. None of the other tested EVC polymorphisms displayed significant association with the risk of hypospadias, either in dominant or recessive inheritance models.

Conclusions

The results of this study suggest that polymorphic variants of the EVC gene do not substantially contribute to the risk of hypospadias based on our study population. However, further studies should help to clarify the relationship between polymorphisms of EVC and hypospadias.

Sexual Health Outcomes in Adults with Complete Male Epispadias

PURPOSE

Complete male epispadias is a rare congenital anomaly characterized by failed closure of the entire penopubic dorsal urethra. Epispadias repair is typically performed during infancy, and resultant genitourinary abnormalities can have a marked impact on adult life. We assess long-term post-reconstruction sexual health and fertility outcomes in adults with complete male epispadias.

MATERIALS AND METHODS

A total of 132 patients 18 years or older with complete male epispadias who had undergone reconstruction were identified from a prospectively maintained, institutionally approved database. Patients who could be contacted were asked to complete a telephone survey regarding sexual function. Reconstructive history and clinical details were obtained by chart/database review.

RESULTS

Of 132 patients with complete male epispadias 74 met inclusion criteria and 15 (20%) completed the questionnaire. Seven patients (47%) reported currently being in a relationship. Although 12 patients (80%) reported overall satisfactory sexual intercourse, 11 (73%) admitted to 1 or more problems with sexual function, including abnormal ejaculation (53%), diminished sensation (20%) and difficulty maintaining an erection (20%). When questioned regarding the importance of fertility on a scale of 0 to 5 using a Likert-type item the response of 10 patients (67%) was 4 points or greater. Five patients (33%) reported having impregnated a sexual partner. Although 4 patients (27%) had suspicion of fertility problems, only 2 (13%) reported having abnormal semen analyses.

CONCLUSIONS

This is one of few studies examining post-reconstruction sexual health and function in adults with complete male epispadias. Although small, our study demonstrates that patients are able to engage in relationships, participate in sexual intercourse and impregnate their partners. These results highlight sexual concerns and outcomes that may be of use when counselling patients with complete male epispadias and their families.

Penile length is a very important factor for cosmesis, function and psychosexual development in patients affected by hypospadias: Results from a long-term longitudinal cohort study

Few studies of long-term outcome of hypospadias treatment in terms of voiding, surgical complications, sexual functioning, intimate relationships and cosmetic results have been investigated and contrasting results have been obtained so far. The aim of our study is to investigate the long-term outcome of urinary and sexual function, cosmesis and the quality of intimate relationships in a series of hypospadias. In this study, 42 patients who underwent surgery for hypospadias were prospectively followed for 15 years. Medical records provided the hypospadias data, the number of reconstructive operations and the reconstruction technique that was used. Patients underwent physical examination, including penile length measurement and completed International Prostatic Symptoms Score (I-PSS), International Index Of Erectile Function (IIEF 15) and the Penile Perception Score questionnaire (PPPS). Twenty patients agreed to participate in the study. At the enrolment, the median value of HOSE was 13, as regards PPPS, 18/20 (90%) were satisfied, while in 1998 only 80% were satisfied. No significant statistical difference has been reported from the results obtained at enrolment and those obtained at follow-up, in terms of PPPS (P = 0.81), IPSS and IIEF-15. Penile length was 6.5 cm flaccid and 10.5 cm stretched. Our data show how cosmesis, function and psychosexual development for these patients are highly connected to surgical outcome, which is understood to be a decrease in penile size.

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.

Long-term outcome of male genital reconstruction in childhood

Hypospadias, epispadias with or without exstrophy, and disorders of sex development are among the most common anomalies of genitalia that occur during childhood. Considering the tremendous effect of genitourinary reconstruction on adult life, the evaluation of the long-term results of different techniques of genitoplasty in pediatrics is of the utmost importance. After reviewing the literature, the authors summarize the available long-term outcomes of genitoplasty in childhood, specifically focusing on the cosmetic, psychosocial, psychosexual and functional results, and emphasize that, contrary to the widely available data on early outcomes of genital reconstruction in the pediatric population, very few well described controlled studies have evaluated the long-term effect of genitoplasty in puberty and adulthood, in the sense that the surgeon should describe the peroperative findings in more detail and also be more structured in evaluating the postoperative result at follow-up visits. Finally, the authors conclude that more attention should be paid to the impact of these techniques on cosmetic aspects and psychosexual development in these patients after puberty, as they play a crucial role in their adult quality of life.

Objective and subjective sexual outcomes in adult patients after hypospadias repair performed in childhood

PURPOSE

We evaluated sexual function and psychosexual adjustment in adults who underwent hypospadias repair in childhood.

MATERIALS AND METHODS

After receiving institutional review board approval, 119 of 449 adult patients (26.6%) who underwent hypospadias repair between 1978 and 1993 responded to questionnaires on penile appearance and sexual life. Patients were divided into 3 groups according to primary meatal location in childhood, including group 1-45 (37.8%) with glanular hypospadias, group 2-56 (48.2%) with distal hypospadias and group 3-18 (14%) with proximal hypospadias.

RESULTS

All group 1 and 2 patients, and 11% in group 3 were satisfied with the penile appearance. Of group 1 patients 8.9% reported mild erectile dysfunction, as did 50% and 72.2% in groups 2 and 3, respectively. A total of 99 patients (83.2%) complained of premature ejaculation. All group 1 and 2 patients reported excellent self-esteem and relationship on the Self-Esteem and Relationship questionnaire. Most group 3 patients were satisfied with their relationship and only 1 (5.6%) was not satisfied. Two-thirds of the patients in groups 1 and 2 reported that sexual quality of life was excellent and the others described it as good. In group 3 sexual quality of life was somewhat decreased in all patients and 1 (5.6%) had poor sexual quality of life. Physical and mental component summaries were satisfactory in all patients reviewed.

CONCLUSIONS

Our data show that the high incidence of mild erectile dysfunction and premature ejaculation should not be disregarded and requires appropriate counseling before surgery.

Testicular function and physical outcome in young adult males diagnosed with idiopathic 46 XY disorders of sex development during childhood

OBJECTIVE

There are few studies of outcome in male patients with undefined 46 XY disorder of sex development (DSD). We aimed to assess testicular function and clinical characteristics after puberty in men with idiopathic 46 XY DSD. Design We conducted a University Hospital-based observational follow-up study.

METHODS

Nineteen patients with severe hypospadias associated with other signs of defective virilization, such as microphallus, cryptorchidism, and/or bifid scrotum, who were initially managed during childhood between 1988 and 1994, were evaluated at a median age of 17.6 (16.3; 17.8) years. Outcome measures included clinical findings and serum testosterone, FSH, LH, and inhibin B concentrations.

RESULTS

Testicular function was normal in only five (26%) patients. Impaired testicular function was observed in 14 (74%) patients and was partial (n=6; 32%) or total (n=8; 42%), requiring testosterone treatment for the initial (n=2) or secondary (n=6) induction of puberty. Undescended testis (unilateral n=3, bilateral n=2) was found and surgically managed only in the 14 patients with testicular impairment. Testosterone treatment in early childhood greatly increased penis length in all patients, but persistent microphallus following surgical treatment was observed at the end of puberty in most patients, with no difference between patients with and without testicular dysfunction (penis length of 68 (60; 75) vs 65 (60; 65) mm; P=0.42). Half the patients presented an adult height more than 5 cm below their target height.

CONCLUSION

Men diagnosed with idiopathic 46 XY DSD during childhood are at high risk of testicular insufficiency and persistent micropenis, and this should be taken into account during the follow-up.