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Lucas-Herald AK, Montezano AC, Alves-Lopes R, Haddow L, O’Toole S, Flett M, Lee B, Amjad SB, Steven M, McNeilly J, Brooksbank K, Touyz RM, Ahmed SF. Effects of Sex Hormones on Vascular Reactivity in Boys With Hypospadias. J Clin Endocrinol Metab 2024; 109:e735-e744. [PMID: 37672642 PMCID: PMC10795938 DOI: 10.1210/clinem/dgad525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 08/23/2023] [Accepted: 08/31/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Arteries from boys with hypospadias demonstrate hypercontractility and impaired vasorelaxation. The role of sex hormones in these responses in unclear. AIMS We compared effects of sex steroids on vascular reactivity in healthy boys and boys with hypospadias. METHODS Excess foreskin tissue was obtained from 11 boys undergoing hypospadias repair (cases) and 12 undergoing routine circumcision (controls) (median age [range], 1.5 [1.2-2.7] years) and small resistance arteries were isolated. Vessels were mounted on wire myographs and vascular reactivity was assessed in the absence/presence of 17β-estradiol, dihydrotestosterone (DHT), and testosterone. RESULTS In controls, testosterone and 17β-estradiol increased contraction (percent of maximum contraction [Emax]: 83.74 basal vs 125.4 after testosterone, P < .0002; and 83.74 vs 110.2 after estradiol, P = .02). 17β-estradiol reduced vasorelaxation in arteries from controls (Emax: 10.6 vs 15.6 to acetylcholine, P < .0001; and Emax: 14.6 vs 20.5 to sodium nitroprusside, P < .0001). In hypospadias, testosterone (Emax: 137.9 vs 107.2, P = .01) and 17β-estradiol (Emax: 156.9 vs 23.6, P < .0001) reduced contraction. Androgens, but not 17β-estradiol, increased endothelium-dependent and endothelium-independent vasorelaxation in cases (Emax: 77.3 vs 51.7 with testosterone, P = .02; and vs 48.2 with DHT to acetylcholine, P = .0001; Emax: 43.0 vs 39.5 with testosterone, P = .02; and 39.6 vs 37.5 with DHT to sodium nitroprusside, P = .04). CONCLUSION In healthy boys, testosterone and 17β-estradiol promote a vasoconstrictor phenotype, whereas in boys with hypospadias, these sex hormones reduce vasoconstriction, with androgens promoting vasorelaxation. Differences in baseline artery function may therefore be sex hormone-independent and the impact of early-life variations in androgen exposure on vascular function needs further study.
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Affiliation(s)
- Angela K Lucas-Herald
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Center for Research Excellence, University of Glasgow, 126 University Avenue, Glasgow G12 8TA, UK
- Developmental Endocrinology Research Group, School of Medicine, Dentistry and Nursing, University of Glasgow, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, UK
| | - Augusto C Montezano
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Center for Research Excellence, University of Glasgow, 126 University Avenue, Glasgow G12 8TA, UK
- Research Institute of McGill University Health Center, McGill University, 1001 Boul Décarie, Montréal, QC H4A 3J1, Canada
| | - Rheure Alves-Lopes
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Center for Research Excellence, University of Glasgow, 126 University Avenue, Glasgow G12 8TA, UK
| | - Laura Haddow
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Center for Research Excellence, University of Glasgow, 126 University Avenue, Glasgow G12 8TA, UK
| | - Stuart O’Toole
- Department of Pediatric Surgery, Royal Hospital for Children, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, Scotland, UK
| | - Martyn Flett
- Department of Pediatric Surgery, Royal Hospital for Children, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, Scotland, UK
| | - Boma Lee
- Department of Pediatric Surgery, Royal Hospital for Children, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, Scotland, UK
| | - S Basith Amjad
- Department of Pediatric Surgery, Royal Hospital for Children, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, Scotland, UK
| | - Mairi Steven
- Department of Pediatric Surgery, Royal Hospital for Children, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, Scotland, UK
| | - Jane McNeilly
- Developmental Endocrinology Research Group, School of Medicine, Dentistry and Nursing, University of Glasgow, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, UK
- Department of Clinical Biochemistry, Queen Elizabeth University Hospital, Glasgow G51 4TF, Scotland, UK
| | - Katriona Brooksbank
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Center for Research Excellence, University of Glasgow, 126 University Avenue, Glasgow G12 8TA, UK
| | - Rhian M Touyz
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Center for Research Excellence, University of Glasgow, 126 University Avenue, Glasgow G12 8TA, UK
- Research Institute of McGill University Health Center, McGill University, 1001 Boul Décarie, Montréal, QC H4A 3J1, Canada
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry and Nursing, University of Glasgow, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF, UK
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Wen X, Fan LJ, Zhang WP, Ni X, Gong CX. Genotype-phenotype correlations, surgical selections, and postoperative complications of 5α-reductase 2 deficiency in 69 children with hypospadias. Asian J Androl 2023; 25:731-736. [PMID: 37313883 DOI: 10.4103/aja202313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/14/2023] [Indexed: 06/15/2023] Open
Abstract
5α-reductase 2 deficiency prevents testosterone from being converted to dihydrotestosterone, which causes abnormal urogenital sinus development. The aim of this study was to analyze the relationship between genotype-phenotype, surgical selections, and postoperative complications of 5α-reductase 2-deficient patients with hypospadias. We retrospectively evaluated the medical records of patients who were diagnosed with 5α-reductase 2 deficiency after genetic testing in the Department of Endocrinology and underwent initial hypospadias surgery in the Department of Urology in Beijing Children's Hospital, Capital Medical University (Beijing, China), from April 2007 to December 2021. A total of 69 patients were included in this study; the mean age at surgery was 34.1 months, and the average follow-up time was 54.1 months. Sixty children were treated with preoperative hormone stimulation (PHS) to promote penile growth. The average penis length and glans width were increased by 1.46 cm and 0.62 cm, respectively. The most frequent mutations were p.R227Q (39.1%, 54/138), p.Q6* (15.2%, 21/138), p.G203S (12.3%, 17/138), and p.R246Q (11.6%, 16/138). In 64 patients who were followed up, 43 had a one-stage operation and 21 had a staged operation, and there were significant differences in external masculinization score (EMS) ( P = 0.008) and the average number of operation required to cure ( P < 0.001) between one-stage and staged operations. PHS had a positive effect ( P < 0.001) on penile development. The p.R227Q mutation was associated with higher EMS and less severe hypospadias. One-stage surgery can be selected if conditions permit. The growth and development of children are acceptable in the long term, but penis growth remains unsatisfactory. Long-term complications of hypospadias should be considered during puberty.
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Affiliation(s)
- Xu Wen
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Li-Jun Fan
- Department of Endocrinology, Genetics, Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
- Beijing Key Laboratory for Genetics of Birth Defects, Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Wei-Ping Zhang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Xin Ni
- Department of Otolaryngology Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Chun-Xiu Gong
- Department of Endocrinology, Genetics, Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
- Beijing Key Laboratory for Genetics of Birth Defects, Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
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Do MT, Kim L, Im YJ, Hahn S, Park K. Effect of Preoperative Androgen Stimulation on Penile Size and Postoperative Complication Rate in Patients with Hypospadias: A Systematic Review and Meta-analysis. World J Mens Health 2023:41.e19. [PMID: 36649924 DOI: 10.5534/wjmh.220173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To systematically review and evaluate the beneficial effects of preoperative androgen stimulation (PAS) on penile length, glans width, and postoperative complications in patients with hypospadias using meta-analysis. MATERIALS AND METHODS A comprehensive search of the published literature between 1980 and 2022 was done on PubMed, Embase, Google Scholar, Scopus, Web of Science, and Proquest. Studies of patients with 5-alpha reductase deficiency, differentiation sex disorder, or micro-penis without hypospadias were excluded. The full-text screening, quality assessment, and data acquisition were done independently by two reviewers. Meta-analysis was done to quantify the penile growth and postoperative complications. RESULTS The initial literature search yielded 2,389 records, wherein 32 studies were eligible for the systematic review and meta-analysis. Preoperative testosterone stimulation increased the penile length and glans width by 9.34 mm (95% CI: 6.71-11.97) and 3.26 mm (95% CI: 2.50-4.02), respectively. A longer penis at the baseline led to greater length gain following treatment (1 mm longer at the baseline was likely to gain 0.5 mm more). However, the increase in penile length was not associated with the severity of hypospadias. While the treatment did not affect the overall complication rate, the postoperative fistula risk was lower in those receiving PAS (RR=0.52, 95% CI: 0.30-0.91, p=0.02). CONCLUSIONS The beneficial effects of PAS on increasing the penile length and glans width were again confirmed. More gain of penile length was expected in the larger penis at baseline. There are no reported increased postoperative complications in association with PAS.
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Affiliation(s)
- Minh-Tung Do
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Louis Kim
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
| | - Young Jae Im
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea.,Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
| | - Seokyung Hahn
- Department of Human Systems Medicine, Medical Statistics Laboratory, Seoul National University College of Medicine, Seoul, Korea
| | - Kwanjin Park
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea.,Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea.
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Jabari M. Trans Dermal Testosterone Compared to Intramuscular Testosterone for Young Males with Delayed Puberty: A PRISMA Guided Systematic Review. Int J Gen Med 2023; 16:733-744. [PMID: 36872942 PMCID: PMC9984275 DOI: 10.2147/ijgm.s396144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/03/2023] [Indexed: 03/03/2023] Open
Abstract
Background Challenges in selecting the right formulation of testosterone (TE) for young males with delayed puberty (DP) arise from the fact that there is limited evidence based guidelines in recommending the most efficient and safe formulation of TE. Objective To evaluate the existing evidence and systematically review the interventional effects of transdermal TE to other modes of TE administration for the treatment of DP among young and adolescent males. Methods All types of methodologies published in English were searched from the data sources including MEDLINE, Embase, Cochrane Reviews, Web of Science, AMED and Scopus from 2015 till 2022. Boolean operators with keywords "types of TE", "modes of TE administration", "DP", "transdermal TE", "constitutional delay of growth and puberty, (CDGP)" "adolescent boys" and "hypogonadism" to optimize the search results. The main outcomes of concern were optimal serum TE level, body mass index, height velocity, testicular volume, pubertal stage (Tanner), The secondary outcomes included in this study were adverse events and patient satisfaction. Results After screening 126 articles, 39 full texts were reviewed. Only five studies could be included after careful screening and rigid quality assessments. Most studies were at high or unclear risk of bias with short duration and follow up periods. Only one study was a clinical trial covering all the outcomes of interests. Conclusion This study points out the favorable effects of transdermal TE treatment for DP in boys, while the existence of the vast gap in research needs to be acknowledged. Despite the utmost demand in an appropriate TE treatment for young males with DP, scarce efforts and trials are being undertaken to provide clear clinical guidance of treatment. Quality of life, cardiac events, metabolic parameters, coagulation profiles are important aspects of the treatment are overlooked and under evaluated in most studies. Systematic Review Registration PROSPERO CRD 42022369699.
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Affiliation(s)
- Mosleh Jabari
- Department of Endocrinology, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
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Taghavi K, O'Hagan LA, Hewitt JK, Mouriquand PDE. Defining the role of pre-operative hormonal therapy in hypospadias. J Paediatr Child Health 2022; 58:1508-1519. [PMID: 35791898 PMCID: PMC9545156 DOI: 10.1111/jpc.16087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/26/2022] [Accepted: 05/01/2022] [Indexed: 11/29/2022]
Abstract
In hypospadias surgery, pre-operative hormonal therapy (PHT) is primarily used to increase penile dimensions and the vascularity of tissues available for reconstruction, but its use is non-uniform in clinical practice, with no consensus on application or utility. This review aims to summarise: (i) the penile tissue response to hormone therapy, (ii) its impact on hypospadias surgery outcomes, and (iii) the endocrinological considerations and sequelae. PHT is more often indicated for complex cases such as proximal hypospadias, hypospadias with microphallus and hypospadias reoperations. While PHT has clear effects on penile morphometry, and more recent controlled trials suggest improved surgical outcomes, the lack of consistent outcome definitions and generally inadequate follow-up periods continue to consign many of the potential long-term effects of PHT to the unknown. There is currently insufficient robust evidence to allow a clinical guideline to be constructed. The need for a well-powered multi-centre prospective randomised trial to address this question is evident but awaits a unified consensus on issues surrounding the understanding of aetiology, classification of hypospadias morphology, definition of important prognostic variables and uniform application of outcome measures. The effects of PHT may be utilised to improve outcomes in cases of proximal and severe hypospadias, which under the current paradigm represent a significant surgical challenge.
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Affiliation(s)
- Kiarash Taghavi
- Department of Paediatric UrologyMonash Children's HospitalMelbourneVictoriaAustralia,Department of Paediatric UrologyRoyal Children's HospitalMelbourneVictoriaAustralia,Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | | | - Jacqueline K Hewitt
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia,Department of Paediatric Endocrinology and DiabetesMonash Children's HospitalMelbourneVictoriaAustralia
| | - Pierre DE Mouriquand
- Service d'Urologie PédiatriqueHôpital Mère‐Enfant, Hospices Civils de Lyon Université Claude‐Bernard59 Boulevard PinelBronFrance,Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement GénitalLyonFrance
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Ali MM, El-Hawy MM, Galal EM, Tawfiek ER, Anwar AZ. Results of two-stage transverse preputial island flap urethroplasty for proximal hypospadias with chordee that mandate division of the urethral plate. Cent European J Urol 2021; 74:89-94. [PMID: 33976922 PMCID: PMC8097640 DOI: 10.5173/ceju.2021.0245.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/12/2020] [Accepted: 12/27/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction Reconstruction of proximal hypospadias with chordee remains a difficult task. Our work aims to evaluate the role of two-stage transverse preputial island flap urethroplasty for repair of proximal hypospadias with chordee. Material and methods This is a retrospective study including 57 children who underwent two-stage transverse preputial island flap urethroplasty. Glans meatus shaft (GMS) score was applied to 24 cases. Patient’s characteristics, operative details and complications were assessed. Hypospadias objective scoring evaluation was used for postoperative assessment. Results The mean age at the first stage operation was 23.6 months (9–84); the mean time interval between the first and second stage operations was 8.1 months (6–12) and the mean follow-up duration was 52.1 months (24–96). Urethral meatus was proximal penile in 18 patients, penoscrotal in 24 and scrotal in 15. The mean degree of ventral curvature (VC) was 51.5° (30–90). After the second stage operation, postoperative complications occurred in 16 (28.1%) patients with urethrocutaneous fistula in 6 (10.5%) cases, diverticulum in 3 (5.3%), glans dehiscence in 5 (8.8%) and meatal stenosis in 2 (3.5%). All cases of glans dehiscence occurred in severe hypospadias and small glans. Moderate GMS score was present in 10 (41.7%) cases and severe GMS in 14 (58.3%). Complications occurred in 7 (29.1%) patients with 5 (20.8%) with a severe GMS score and 2 (8.3%) with a moderate GMS score. The hypospadias objective scoring evaluation showed satisfactory results, with 39 (68.4%) patients achieving a score of 16 points. Conclusions Two-stage transverse preputial flap is a good choice for repair of proximal hypospadias with an acceptable complication rate of 28.1%.
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Affiliation(s)
- Mostafa M Ali
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
| | - Mamdouh M El-Hawy
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
| | - Ehab M Galal
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
| | - Ehab R Tawfiek
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
| | - Ahmed Z Anwar
- University Hospital, School of Medicine, Department of Urology, Minia, Egypt
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Khokar DS, Patel RV. Can Testosterone Alter the Degree of Hypospadias? A Comprehensive Study. J Indian Assoc Pediatr Surg 2021; 26:38-43. [PMID: 33953511 PMCID: PMC8074826 DOI: 10.4103/jiaps.jiaps_214_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/14/2019] [Accepted: 03/05/2020] [Indexed: 12/04/2022] Open
Abstract
Context: In this study, we observed using serial injections of parenteral testosterone whether we can alter the degree of hypospadias. Aims: The aim was to study the effect of testosterone on different parts of the phallus in hypospadias and to see if we can alter the degree of hypospadias. Settings and Design: This was a prospective observational study. Subjects and Methods: Forty-five boys with proximal and mid-penile hypospadias below the age of puberty who did not have prior testosterone injection or surgery were recruited in this study for the duration of 1 year and given testosterone injection intramuscularly and measurement taken using Vernier caliper at regular interval followed by surgery. The follow-up was at the 1st, 3rd, and 6th months of surgery. Results: Of 45 patients who received intramuscular testosterone injections, 40 showed some degree of response. Of these 40 patients, 23 showed a significant improvement in phallic size, whereas 17 showed a clinically insignificant response only. Of these 23 patients, 14 improved from a mid-penile to a distal penile hypospadias, whereas 7 improved from proximal penile to mid-penile hypospadias, and 2 showed an exceptionally good response and improved from proximal penile to distal penile hypospadias, whereas 5 patients exhibited no response at all. Conclusion: Through this study, we can conclude that intramuscular testosterone can be effective in some patients with proximal and mid-penile hypospadias to convert them into either mid- or distal penile hypospadias by the differential response of different parts of the phallus, and this may favorably alter the type of procedure required for the hypospadias repair.
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Affiliation(s)
- Dasmit Singh Khokar
- Department of Paediatric Surgery, Jehangir Hospital, Pune, Maharashtra, India
| | - Ravi Vadilal Patel
- Department of Paediatric Surgery, Jehangir Hospital, Pune, Maharashtra, India
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Ezomike UO, Nwangwu EI, Chukwu IS, Ekenze SO. Practice patterns of preoperative hormonal stimulation in pediatric penile surgeries-A survey of Nigerian pediatric surgeons. J Pediatr Urol 2020; 16:440-445. [PMID: 32586772 DOI: 10.1016/j.jpurol.2020.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Variable practice patterns exist in the use of Preoperative Hormonal Stimulation (PHS) prior to penile surgeries and there seems to be no generally agreed standards. OBJECTIVE To assess the current practice patterns of PHS before penile surgeries among Nigerian pediatric surgeons and compare with literature. MATERIALS AND METHODS Self-administered questionnaires were distributed amongst consultants and senior registrars in Pediatric surgery during the 2019 Association of Pediatric Surgeons of Nigeria (APSON) national conference. SPSS version 20 was used for data entry and analysis and results presented as ranges, percentages, tables. Test for association was done using chi square test and a p-value of <0.05 was deemed significant. RESULTS All fifty respondents comprising 43 males, 7 females; 31 consultants and 19 senior registrars have managed hypospadias, with eighty-six percent managing less than 50 per year. Seventy-six percent practice PHS and more proportion of males use PHS than females (p = 0.027).Only 15.8% and 7.9% respectively estimated serum testosterone before and after PHS. Majority (92.1%) gave PHS because of small-appearing penis and 86.8% have used it in proximal hypospadias. Most commonly used form of PHS was intramuscular testosterone (76.3%) while 2 mg/kg testosterone was commonest dose (65.7%). Ninety-one percent give intramuscular testosterone at 2-4 weeks intervals; ninety-four percent give 2-3 doses of intramuscular testosterone preoperatively with last dose given 2-4 weeks before surgery in 57.9%. Ninety-two percent thought PHS will not increase postoperative complications and pubic hair was most common complication of PHS (63%). DISCUSSION There is diversity in PHS practices among Nigerian pediatric surgeons. Though mainly low-volume surgeons, majority use PHS before penile surgeries especially in proximal hypospadias and small-appearing penis. Males tend to practice PHS more than females and most commonly used form of PHS is 2-3 doses of 2 mg/kg intramuscular testosterone at 2-4 weekly intervals with last dose given 2-4 weeks before surgery. This study may be limited by bias inherent in self-reported practices and outcomes as seen in surveys, though surveys help to evaluate practices of professionals. CONCLUSIONS Majority of Pediatric surgeons in Nigeria use PHS in form of intramuscular testosterone mainly for small appearing penis and proximal hypospadias. Most common dosing is 2 mg/kg at 2-4 weeks intervals and 2-3 doses preoperatively with the last dose 2-4 weeks preoperatively. Serum testosterone estimation is not common before PHS. Many believe that PHS does not increase complications following penile surgeries. Current diversity in practice suggests the need for further studies to encourage standardization or guidelines for practice in Nigeria.
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Affiliation(s)
- U O Ezomike
- Sub-Department of Pediatric Surgery College of Medicine, University of Nigeria, Nigeria.
| | - E I Nwangwu
- Department of Surgery, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria
| | - I S Chukwu
- Department of Surgery, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria
| | - S O Ekenze
- Sub-Department of Pediatric Surgery College of Medicine, University of Nigeria, Nigeria
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Mohammadipour A, Hiradfar M, Sharifabad PS, Shojaeian R. Pre-operative hormone stimulation in hypospadias repair: A facilitator or a confounder. J Pediatr Urol 2020; 16:318.e1-318.e7. [PMID: 32402738 DOI: 10.1016/j.jpurol.2020.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Preoperative hormone stimulation (PHS) is popular in hypospadias reconstructive surgery. While still controversial, it is performed to have a more developed gross anatomy of the glans and penis for improvement of the surgical condition and outcome. OBJECTIVE In this study we assessed morphometric and histologic effects of pre-operative testosterone therapy on the penis and prepuce in patients with hypospadias. STUDY DESIGN 18 patients with hypospadias who received 3 monthly doses of 25 mg testosterone injections were compared with 23 patients with hypospadias who were managed without pre-operative androgen therapy. Penile morphometry and hormone side effects were assessed in monthly pre-operative visits. Intra operative observations and preputial histopathology were also compared between the groups. RESULTS Glans diameter enlarged significantly after the first dose of testosterone. (P < 0.001) while morphologic changes were not significant by further injections. 72.2% showed one or more hormone related side effects that were mostly mild. Severe side effects such as thick pubic hair growth, frequent erections or considerable penis hyper-sensation were observed in 27.8%. Glans to corpus ratio was 0.2 ± 0.75 in PHS group compare to 0.3 ± 0.17 in control group. (P < 0.001). Hemorrhage needing tourniquet placement was reported in 44.4% of the PHS patients compared to 26.1% among the control group. Histopathologic studies revealed increased vascularity and less inflammation of the prepuce in PHS group compared to controls. DISCUSSION The glans and penis enlargement wasn't significant in 22.2% of patients who underwent PHS. We identified the first dose of testosterone as the most effective one. This finding supports the idea of close clinical monitoring to stop PHS when a significant response is observed and the expected goals are reached. Androgen side effects were not uncommon among our patients although they were mainly mild. Intraoperative assessments showed a decreased glans wing thickness to corporal body ratio in PHS group compared to controls. This finding caused more complex glanuloplasty while wrapping the glans wings over neo urethra and enlarged corporal bodies. CONCLUSION We suggest limiting PHS to carefully selected cases considering the observed anatomical and histological changes and the side effects. Monthly monitoring during PHS is recommended to stop androgen therapy as soon as the minimum defined targets are reached. This may decrease the rate of androgen side effects while providing better surgical conditions.
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Affiliation(s)
| | - Mehran Hiradfar
- Pediatric Surgery, Mashhad University of Medical Sciences, Iran.
| | | | - Reza Shojaeian
- Pediatric Surgery, Mashhad University of Medical Sciences, Iran.
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Babu R, Chakravarthi S. The role of preoperative intra muscular testosterone in improving functional and cosmetic outcomes following hypospadias repair: A prospective randomized study. J Pediatr Urol 2018; 14:29.e1-29.e6. [PMID: 28844754 DOI: 10.1016/j.jpurol.2017.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 07/03/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are very few well-designed studies on the role of preoperative testosterone in hypospadias repair. The aims of the current study are to ascertain the efficacy of intramuscular testosterone in increasing the glans width, reducing the complications and improving the functional and cosmetic outcomes. MATERIALS AND METHODS Between January 2013 and December 2016, a total of 200 patients with distal hypospadias were recruited to this prospective randomized study. Only patients with distal hypospadias eligible for a tubularized incised plate (TIP) repair were included. Group 1 did not receive any intervention, and group 2 received three doses of intramuscular testosterone enanthate 2 mg/kg at the age of 9, 10, and 11 months. Glans width was measured in millimeters in all patients using calipers at the time of recruitment and at the time of surgery. Within group 2, those who failed to have more than a 2 mm increase in size were considered non-responders (group 2a), and the remaining were taken to be responders (group 2b). TIP repair was performed by the same surgeon, and patients were followed up, looking for urethrocutaneous fistula, glans dehiscence, meatal stenosis, etc. Cosmetic evaluation was performed using the Parental Penile Perception Score (PPPS). RESULTS A total of eight patients dropped out in group 1 (n = 92), while six dropped out in group 2 (n = 94). In group 2, 17% patients did not respond to testosterone (group 2a; n = 16), whereas 83% showed significant increase in glans width (group 2b; n = 78). The table compares the functional and cosmetic outcomes between groups. Total complications were significantly less in group 2b (17.9%) than in group 2a (50%). The reoperation rate was significantly less in group 2b (11.5%) than in group 1 (23.1%). A significantly higher number of parents (p = 0.03) were satisfied with cosmesis of the glans/meatus in group 2b (71/78; 91%) compared with group 2a (11/16; 69%) or group 1 (72/92; 78%). The overall PPPS was significantly higher (p = 0.003) in group 2b (8.88 ± 2.20) than in group 1 (8.03 ± 1.55). DISCUSSION Two systematic reviews on the role of preoperative testosterone failed to reach any conclusion. One described a glans width <14 mm as a risk factor for urethral complications after hypospadias repair but another did not support this. Our findings reveal that preoperative testosterone significantly increases the glans width thereby reducing the complications and requirement for reoperation. It also improves the cosmetic outcomes and parental satisfaction.
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Affiliation(s)
- Ramesh Babu
- Department of Pediatric Urology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India.
| | - Sibi Chakravarthi
- Department of Pediatric Urology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India
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Rynja SP, de Jong TPVM, Bosch JLHR, de Kort LMO. Testosterone prior to hypospadias repair: Postoperative complication rates and long-term cosmetic results, penile length and body height. J Pediatr Urol 2018; 14:31.e1-31.e8. [PMID: 29174377 DOI: 10.1016/j.jpurol.2017.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The use of hormonal therapy was first described in 1971 before hypospadias surgery, and it has been debated ever since. The long-term outcomes after puberty of patients treated with pre-operative testosterone in childhood are lacking. OBJECTIVES Possible long-term effects of testosterone are often asked about in daily practice. The current study investigated the long-term outcomes regarding height, penile length and penile cosmesis in adult men after hypospadias surgery in childhood with and without pre-operative testosterone. METHODS Adult men (n = 121) who underwent primary hypospadias repair in childhood were included. Pre-operative penile appearance, judged by a paediatric urologist, determined the use of pre-operative testosterone. Data on hypospadias characteristics, healing complications, surgical repair, and testosterone use were collected retrospectively. At adult age, stretched penile length and body height were measured, and penile cosmesis was evaluated using the Pediatric Penile Perception Score (PPPS). RESULTS Postoperative complication rates in patients (n = 121) with and without testosterone were similar (50% vs. 43%; P = 0.54). Sixty adult patients (50%) with a median age of 19.8 years and follow-up time of 18.3 years were examined at the outpatient clinic at adult age. Of this group, testosterone was applied in 12/43 patients with distal, 3/6 patients with midshaft, and 9/11 patients with proximal hypospadias. Adult stretched penile length (12.0 cm vs. 12.4 cm; P = 0.47) and adult height (180.1 cm vs. 179.0 cm P = 0.65) showed no difference between patients with and without testosterone treatment. Penile cosmesis was (very) satisfactory in all PPPS domains, and showed no difference between the testosterone group and the non-testosterone group. Univariate and multivariate analysis was conducted to determine if the hypospadias type or pre-operative testosterone therapy had more influence on the long-term outcomes. None of the long-term outcomes were significantly associated with pre-operative testosterone therapy on multivariate analysis. DISCUSSION This was the first study reporting long-term outcomes of hypospadias patients after puberty who received pre-operative hormonal therapy. Validated instruments were used as much as possible. Shortcomings of this study were the 50% response rate, the retrospective design, and the lack of objective inclusion criteria reported to indicate pre-operative testosterone therapy. CONCLUSION This study suggested that the long-term results of patients receiving pre-operative testosterone treatment, who often had more challenging hypospadias, were similar to those who did not. However, a randomised controlled study is needed to confirm these results.
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Affiliation(s)
- S P Rynja
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - T P V M de Jong
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Pediatric Urology, University Children's Hospital UMC Utrecht and Academic Medical Center Amsterdam, Utrecht, The Netherlands
| | - J L H R Bosch
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L M O de Kort
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
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Van Praet C, Spinoit AF. Testosterone prior to hypospadias repair: No clear-cut benefit or reassurance regarding long-term safety. J Pediatr Urol 2018; 14:85-86. [PMID: 29248308 DOI: 10.1016/j.jpurol.2017.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/04/2017] [Indexed: 11/15/2022]
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Chua ME, Gnech M, Ming JM, Silangcruz JM, Sanger S, Lopes RI, Lorenzo AJ, Braga LH. Preoperative hormonal stimulation effect on hypospadias repair complications: Meta-analysis of observational versus randomized controlled studies. J Pediatr Urol 2017; 13:470-480. [PMID: 28939350 DOI: 10.1016/j.jpurol.2017.06.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Preoperative hormonal stimulation (PHS) is commonly administered to improve hypospadias outcomes. However, current literature provides no clear evidence to support its use, and controversies exist regarding its effect on postoperative complications. Herein we systematically evaluate the effect of PHS on postoperative complications rates following hypospadias repair. MATERIALS AND METHODS Comprehensive literature search performed on April 2016 including OVID MEDLINE, EMBASE, Web of Science, Cochrane Library, Clinicaltrials.gov, World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and ProQuest. Study quality assessment followed the Cochrane collaboration recommendation using risk of bias assessment, ROBINS-I and NOQAS. Effect estimates were extracted as relative risk (RR) with 95% confidence interval (CI) and pooled using Mantel-Haenzel method. Evidence quality was assessed using GRADE approach. Protocol Registration: PROSPERO CRD42016037881. RESULTS Twenty-one publications from 16 trials examining the effect of androgenic PHS on postoperative outcome were included. Subgroup analysis based on study design (including nine cohort studies with moderate to high risk of bias for patient selection) showed no significant difference on postoperative outcomes (RR 1.31, 95% CI 0.95-1.81) (table). Pooled effect estimates with moderate quality of evidence from three randomized controlled trials suggest that significant lesser postoperative complications occur among patients exposed to PHS (RR 0.36, 95% CI 0.20-0.65). Uniformly, the reported adverse effects related to PHS were mild and transient, with good overall tolerance. CONCLUSIONS Effect estimates generated from the better quality of evidence showed that PHS may decrease postoperative complications following hypospadias repair. Future studies should aim at identifying indicated subgroup of patients that will benefit from it and standardizing the dose and mode of delivery for best clinical result.
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Affiliation(s)
- Michael E Chua
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michele Gnech
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Section of Pediatric Urology, Urology Unit, University Hospital of Padova, Padua, Italy
| | - Jessica M Ming
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Stephanie Sanger
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | | | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Luis H Braga
- Department of Urology, McMaster Children's Hospital and University, Hamilton, ON, Canada; Department of Surgery/Urology, McMaster University, Hamilton, ON, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
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Current challenges with proximal hypospadias: We have a long way to go. J Pediatr Urol 2017; 13:457-467. [PMID: 28549608 DOI: 10.1016/j.jpurol.2017.03.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/17/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Proximal hypospadias repair has continued to challenge the pediatric urologist despite great efforts to develop better techniques for repair. METHODS In this article, we review the literature regarding modern proximal hypospadias repair approaches and outcomes. We also present our current approach to proximal hypospadias repair surgery and outcome tracking. Finally, we review the literature on surgical outcome tools that may help us standardize research. RESULTS Proximal hypospadias repair has significant variability in technique. Overall modern data would suggest that we require great improvement in our surgical management of this challenging problem. Though tools exist to begin to standardize the reporting of hypospadias outcomes, collaborative efforts are still required for future research. CONCLUSION Future research in proximal hypospadias repair needs to utilize new reporting tools as well as engage in collaborative efforts between institutions.
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de Andrade EC, de Castro Paiva KC, da Silva Guedes S, Souza MLC, Pereira MN, Miana LP, de Figueiredo AA, de Bessa J, Netto JMB. Echocardiographic evaluation of left ventricular mass index in children with hypospadias after hormonal stimulation with topical testosterone: A randomized controlled trial. J Pediatr Urol 2017; 13:352.e1-352.e7. [PMID: 28434633 DOI: 10.1016/j.jpurol.2017.03.019] [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: 12/30/2016] [Accepted: 03/06/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Testosterone is often used in the preoperative period of hypospadias surgery. Previous studies have demonstrated the presence of androgen receptors in cardiac myocytes that can modulate the phenotype. The use of supraphysiological doses of androgens can lead to toxicity on the heart muscle and, in some cases, to left ventricular hypertrophy. This randomized double blind controlled clinical trial aims to evaluate the effect of topical testosterone on left ventricular mass index in boys with hypospadias. MATERIALS AND METHODS Boys with hypospadias aged 6 months to 9 years were included. Children were divided into two groups: G1 - boys who received testosterone propionate 1% ointment twice a day for 30 days, and G2 - boys receiving placebo ointment in the same regimen. All children were submitted to bi-dimensional echocardiographic evaluation to compare the left ventricular mass index, blood pressure, and body mass index before and after treatment (30 and 90 days). Levels of serum testosterone, LH, and FSH were measured. RESULTS Thirty-five children were analyzed: 17 in G1 and 18 in G2. No differences were found in left ventricular mass index (left ventricular mass indexed by body surface area) prior to treatment. Left ventricular mass index was 59.21 ± 11.91 g/m2 in G1 and 55.12 ± 8.29 g/m2 in G2 (p = 0.244) after 30 days of treatment, and 61.13 ± 11.69 g/m2 in G1 and 62.84 ± 35.99 g/m2 in G2 (p = 0.852) after 90 days. Serum testosterone levels were 12 (7-80) ng/dL in G1 and 5 (5-7) ng/dL in G2 (p = 0.018) after 30 days of treatment, and 10 (5-11) ng/dL in G1 and 5 (4-5) ng/dL in G2 (p = 0.155), after 90 days (Figure). There was a small increase in systolic blood pressure (SBP) after 30 days (83.82 ± 7.18 mmHg) in the group who receive testosterone (G1) compared with controls (77.5 ± 6.69 mmHg) (p = 0.010). After 90 days, SBP levels returned to basal levels in G1 (82.35 ± 5.62 mmHg) and in G2 (81.38 ± 4.79 mmHg) (p = 0.588). CONCLUSION Topical testosterone can be considered safe in the preoperative period of children with hypospadias with no risk of left ventricular hypertrophy. An increase in systolic blood pressure occurs while using testosterone but it is transitory, returning to normal levels after 90 days.
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Affiliation(s)
| | | | | | | | | | | | | | - José de Bessa
- Department of Surgery, Division of Urology, State University of Feira de Santana, UEFS, Brazil
| | - José Murillo B Netto
- Department of Surgery, Division of Urology, Federal University of Juiz de Fora, UFJF, Brazil; Department of Surgery, Division of Urology, Hospital e Maternidade Therezinha de Jesus da Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Suprema, Brazil.
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Outcome of urethroplasty after parenteral testosterone in children with distal hypospadias. J Pediatr Urol 2017; 13:292.e1-292.e7. [PMID: 28111208 DOI: 10.1016/j.jpurol.2017.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/04/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Pre-operative testosterone use in hypospadias surgery is known to increase penile dimensions and vascularity, which should facilitate tension-less formation of the urethral tube and tissue healing. However, androgens can have a negative effect on wound healing. There are very few randomized studies on postoperative results after androgen use, and this study attempted to understand the utility of pre-operative testosterone in distal hypospadias. OBJECTIVE To study the effect of parenteral testosterone in children undergoing single stage urethroplasty for distal hypospadias, especially the occurrence of urethrocutaneous fistula and wound dehiscence. DESIGN Patients were prospectively enrolled and randomized into two groups: Group 1 (control group) and Group 2 (receiving three injections of pre-operative intramuscular testosterone enanthate (2 mg/kg) at 1 monthly intervals; they were further subdivided into those operated 1 month (Group 2A) or 3 months (Group 2B) later. Patients with micropenis, previous testosterone use or any surgical intervention were excluded. Preputial skin was studied with hematoxylin and eosin (H&E) staining and CD31 immunohistochemistry. Patients were followed up for at least 18 months. RESULTS Ninety four patients underwent urethroplasty over a 3.5-year period. Penile dimensions increased significantly after testosterone use (Summary table). On H&E staining, proliferating blood vessels and increased lymphocytic infiltrates were significantly increased in Group 2B. Group 2 patients tended to have more postoperative edema and inflammation. Although urethrocutaneous fistula rates were similar in Group 1 (n = 7) and Group 2 (n = 5) (P = 0.438), wound dehiscence occurred only in Group 2 (P = 0.01). DISCUSSION The total number of patients in this study was small and this was a drawback. Although, several factors played a role in wound healing, the overall higher complication rate, especially wound dehiscence in Group 2, pointed to a higher incidence of inflammatory reaction and healing complication rates with testosterone use. CONCLUSION Testosterone should be used judiciously in distal hypospadias. While tissue availability significantly increased, there was an increase in inflammatory reaction and edema, which increased the risk of wound dehiscence in cases of precocious surgery.
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Keays MA, Dave S. Current hypospadias management: Diagnosis, surgical management, and long-term patient-centred outcomes. Can Urol Assoc J 2017; 11:S48-S53. [PMID: 28265319 DOI: 10.5489/cuaj.4386] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In this article, we present the current approach to hypospadias, a review of the classification, preoperative evaluation, and factors that enable decision-making during surgery. We will then discuss patient-reported outcomes, evaluating the patients' and parents' perspectives regarding hypospadias repair.
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Affiliation(s)
- Melise A Keays
- Division of Urology, Department of Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Sumit Dave
- Division of Urology, Department of Surgery and Pediatrics, London Health Sciences Centre, London, ON, Canada
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Springer A, Tekgul S, Subramaniam R. An Update of Current Practice in Hypospadias Surgery. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.eursup.2016.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Paiva KCDC, Bastos AN, Miana LP, Barros EDS, Ramos PS, Miranda LM, Faria NM, Avarese de Figueiredo A, de Bessa J, Netto JMB. Biometry of the hypospadic penis after hormone therapy (testosterone and estrogen): A randomized, double-blind controlled trial. J Pediatr Urol 2016; 12:200.e1-6. [PMID: 27321554 DOI: 10.1016/j.jpurol.2016.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/24/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The use of preoperative hormonal stimulation before hypospadias surgery aims to increase penile size and achieve better surgical results; however, the rules are not clear in the literature. We evaluated the effects of topical testosterone and estrogen in the hypospadic penis regarding biometric measures, side effects, and serum hormonal levels. To our knowledge, this is the first study using estradiol prior to hypospadias surgery. PATIENTS AND METHODS Sixty-nine children with hypospadias were randomly divided into three study groups: a control group (CG) of 17 children given placebo cream; a testosterone group (TG) of 28 children who used 1% testosterone propionate; and an estradiol group (EG) of 24 children using 0.01% estradiol. All subjects applied the topical ointment on the entire penis, twice daily for 30 days before surgical correction. Biometric evaluation of the penis included penile length and diameter, glans diameter, distance from the urethral meatus to the tip, and the width of the urethral plate. These measurements as well as serum hormone level, and side effects were evaluated prior to hormone use, and 30 and 90 days after. RESULTS After 30 days an increase in penile diameter and length and diameter of the glans were observed in TG (p < 0.05). The width of the urethral plate and distance from meatus to the tip increased in TG, although not significantly. The most frequent side effects were appearance of pubic hair and darkening of the genital skin, mainly in TG, but these were transient and disappeared after 90 days of treatment. No significant variations were seen in serum hormonal levels (Table). CONCLUSION As in previous studies, an increase in penile length and diameter, and glans diameter was observed with the use of testosterone. Proximal urethral plate width and distance from the meatus to the tip of the penis had a tendency to increase also in TG. Estradiol did not change biometric measure of the penis. Few side effects occurred after both hormones, and any that did improved after 90 days follow-up and did not change hormone serum levels. CONCLUSION Preoperative use of topical testosterone increases penile size, diameter of the penis and glans. The use of estradiol does not change penile biometry. Side effects occur mainly with the use of testosterone and are transient. No significant and persistent hormonal changes were observed.
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Affiliation(s)
- Kelly Christina de Castro Paiva
- Division of Pediatric Surgery, Department of Pediatrics, Federal University of Juiz de Fora (UFJF), MG, Brazil; Division of Pediatric Surgery, Department of Pediatrics, Hospital and Maternidade Therezinha de Jesus of School of Medical Sciences and Health of Juiz de Fora (HMTJ/SUPREMA), MG, Brazil
| | - André Netto Bastos
- Department of Morphology, Federal University of Juiz de Fora (UFJF), MG, Brazil.
| | - Laura Pimenta Miana
- Division of Urology, Department of Surgery, Hospital and Maternidade Therezinha de Jesus of School of Medical Sciences and Health of Juiz de Fora (HMTJ/SUPREMA), MG, Brazil
| | - Eveline de Souza Barros
- Division of Urology, Department of Surgery, Hospital and Maternidade Therezinha de Jesus of School of Medical Sciences and Health of Juiz de Fora (HMTJ/SUPREMA), MG, Brazil
| | - Plínio Santos Ramos
- School of Medical Sciences and Health of Juiz de Fora (HMTJ/SUPREMA), MG, Brazil
| | - Lara Meneguelli Miranda
- Division of Urology, Department of Surgery, Federal University of Juiz de Fora (UFJF), MG, Brazil
| | - Natália Maia Faria
- Division of Urology, Department of Surgery, Federal University of Juiz de Fora (UFJF), MG, Brazil
| | | | - José de Bessa
- Division of Urology, Department of Surgery, State University of Feira de Santana (UEFS), BA, Brazil
| | - José Murillo B Netto
- Division of Urology, Department of Surgery, Hospital and Maternidade Therezinha de Jesus of School of Medical Sciences and Health of Juiz de Fora (HMTJ/SUPREMA), MG, Brazil; Division of Urology, Department of Surgery, Federal University of Juiz de Fora (UFJF), MG, Brazil.
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Abstract
The hormonal stimulation for the purpose of penile enlargement before the hypospadias repair has been commonly used, but rarely reported. In addition to functional outcome, dihydrotestosterone (DHT) pretreatment has been suggested to improve cosmetic outcome in a preliminary randomized study. Since the randomized and controlled clinical trials on this topic are insufficient, the hormonal agent, the route of administration, dosing schedule, and the timing of treatment has been remained controversial. In order to confirm the efficiency of hormonal treatment, further well designed randomized studies with a larger number of patients and a placebo group are warranted.
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Affiliation(s)
- Cevdet Kaya
- 1 Department of Urology, Marmara University, School of Medicine, Istanbul, Turkey ; 2 Department of Pediatric Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Radmayr
- 1 Department of Urology, Marmara University, School of Medicine, Istanbul, Turkey ; 2 Department of Pediatric Urology, Medical University of Innsbruck, Innsbruck, Austria
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GÖLLÜ BAHADIR G, ERGÜN E, TELLİ O, KHANMAMMADOV F, ÇAKMAK AM. Hormone therapy in hypospadias surgery: a survey on the current practice in Turkey. Turk J Med Sci 2016; 46:1624-1628. [DOI: 10.3906/sag-1507-72] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 01/30/2016] [Indexed: 11/03/2022] Open
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Oswald J. [Disorders of sex development and proximal hypospadias]. Urologe A 2015; 55:35-43. [PMID: 26659830 DOI: 10.1007/s00120-015-0004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with ambiguous genitalia due to different chromosome or gonadal sex are a particular challenge concerning the diagnostic and therapeutic implications. Proximal hypospadias patients with normal gonadal development should be distinguished from children with DSD (disorders of sex development) to guarantee normal gender identity and the best possible surgical therapy. OBJECTIVES This paper focuses on the terminology, embryology, and pathophysiology of the different manifestations of DSD. The state of knowledge about this disease pattern with particular emphasis on proximal hypospadias based on national and international scientific discussions is presented. MATERIALS AND METHODS The different clinical pictures as well as therapeutic options of DSD with a special focus on recent literature and giving particular attention to patients with proximal hypospadias are presented. RESULTS Because of the complexity of patients suffering from disorders of sex development an interdisciplinary DSD healthcare team including a paediatric endocrinologist as well as paediatric urologist should be provided. These specialists enable an accurate diagnosis in severe hypospadias patients without reference to DSD diseases patterns.
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Affiliation(s)
- J Oswald
- Abteilung für Kinderurologie, Krankenhaus der Barmherzigen Schwestern, Seilerstätte 4, 4010, Linz, Österreich. .,Universität Innsbruck, Innsbruck, Österreich.
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Asgari SA, Safarinejad MR, Poorreza F, Asl AS, Ghanaie MM, Shahab E. The effect of parenteral testosterone administration prior to hypospadias surgery: A prospective, randomized and controlled study. J Pediatr Urol 2015; 11:143.e1-6. [PMID: 25837705 DOI: 10.1016/j.jpurol.2014.12.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/22/2014] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The goal of hypospadias surgery is to provide a functionally and cosmetically normal penis. Whether this goal will be to the patient's satisfaction depends largely on the original anatomy, surgical technique and surgeon's experience. It has been suggested that androgen administration is associated with better outcomes in hypospadias repair; however, few studies have included control groups and the issue is still controversial. PURPOSE To evaluate the effects of parenteral testosterone administration on the results of hypospadias repair in children with untreated hypospadias. MATERIALS AND METHODS A total of 182 children with midshaft or distal hypospadias and a mean age of 30 months (range 18-52 months) were enrolled in this study. Consecutive children were randomly allocated to the study group (testosterone administration) (Group 1, n = 91) or control group (Group 2, n = 91). Only children with a flat urethral plate were included in this study. The control group did not receive any pre-operative treatment. Children with a previous history of hypospadias repair and any proven endocrine disorder were excluded. The study children received 2 mg/kg testosterone enanthate monthly for two months before surgery. Tubularized incised plate (TIP) urethroplasty, with or without chordee correction, was performed for all children in both groups by the same urologist. Hypospadias repair was performed 4 weeks after the second dose of testosterone administration. Postoperative complications were recorded, including: urethrocutaneous fistulas, urethral diverticula, meatal stenosis, and glanular dehiscence. The mean stretched penile length and circumference were measured at baseline and at 1 month and 2 months post operation. All children were examined every month for any adverse affects to testosterone treatment, like pubic and axillary hair, and height acceleration, up to 3 months post operation. RESULTS An increase in penile length (from 28.1 ± 2.2 mm to 38.5 ± 2.6 mm) (P = 0.001) and penile circumference (from 35.1 ± 1.6 mm to 45.5 ± 2.2 mm) (P = 0.001) were noticed in all but four children in Group 1. The actual values for increase in penile length in the study group were, 22.0%, 35.0% and 36.0%, at postinjection months 1, 2 and 3, respectively (P = 0.01, P = 0.001 and P = 0.001, respectively) (Figure). The actual values for increase in penile circumference in the study group were, 16.0%, 27.0% and 29.0%, at postinjection months 1, 2 and 3, respectively (P=0.01, P=0.001 and P =0.001, respectively). The overall complication rates were significantly higher in Group 2 [12 children, 13.18%) compared to Group 1 (five children, 5.45%) (P=0.03). Urethrocutaneous fistula was the most common complication in both groups (four children [4.39%] in Group 1 and seven children [7.69%] in Group 2) (P=0.02), followed by meatal stenosis (one child [1.09%] in Group 1 and three children [3.29%] in Group 2) (P=0.03). All children in Group 1 developed pigmentation of the genitalia, and scant pubic hair appeared in 14 of them. These side effects disappeared by the 3 months postoperation follow-up visit. DISCUSSION Tubularized incised plate urethroplasty is a popular reconstructive method for hypospadias repair and is widely accepted by pediatric urologists. It is a reliable and simple technique with low complication rates. Testosterone administration before hypospadias repair decreases complication rates, reduces the need for reoperation and results in better cosmetic outcomes. Some studies have demonstrated temporary side effects like pubic hair growth and aggressive behavior, which gradually became normalized after treatment cessation. Nowadays, many pediatric urologists administer testosterone prior to hypospadias surgery; however, this can be variable. CONCLUSION Parenteral testosterone administration before hypospadias repair is beneficial in decreasing complication rates.
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Affiliation(s)
- S A Asgari
- Urology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - M R Safarinejad
- Clinical Center for Urological Disease Diagnosis and Private Clinic Specializing in Urological and Andrological Genetics, Tehran, Iran.
| | - F Poorreza
- Urology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - A Safaei Asl
- Urology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - M Mansour Ghanaie
- Urology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - E Shahab
- Urology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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McNamara ER, Schaeffer AJ, Logvinenko T, Seager C, Rosoklija I, Nelson CP, Retik AB, Diamond DA, Cendron M. Management of Proximal Hypospadias with 2-Stage Repair: 20-Year Experience. J Urol 2015; 194:1080-5. [PMID: 25963188 DOI: 10.1016/j.juro.2015.04.105] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE We describe our experience with 2-stage proximal hypospadias repair. We report outcomes, and patient and procedure characteristics associated with surgical complications. MATERIALS AND METHODS We retrospectively studied patients with proximal hypospadias who underwent staged repair between January 1993 and December 2012. Demographics, preoperative management and operative technique were reviewed. Complications included glans dehiscence, fistula, meatal stenosis, nonmeatal stricture, urethrocele/diverticula and residual chordee. Cox proportional hazards model was used to evaluate the associations between time to surgery for complications and patient and procedure level factors. RESULTS A total of 134 patients were included. Median patient age was 8.8 months at first stage surgery and 17.1 months at second stage surgery, and median time between surgeries was 8 months. Median followup was 3.8 years. Complications were seen in 71 patients (53%), with the most common being fistula (39 patients, 29.1%). Reoperation was performed in 66 patients (49%). Median time from urethroplasty to surgery for complication was 14.9 months. Use of preoperative testosterone decreased risk of undergoing surgery for complication by 27% (HR 0.73, 95% CI 0.55-0.98, p = 0.04). In addition, patients identified as Hispanic were at increased risk for undergoing surgery for complications (HR 2.40, 95% CI 1.28-4.53, p = 0.01). CONCLUSIONS We review the largest cohort of patients undergoing 2-stage hypospadias repair at a single institution. Complications and reoperation rates were approximately 50% in the setting of complex genital reconstruction.
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Affiliation(s)
- Erin R McNamara
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Harvard-Wide Pediatric Health Services Research Fellowship, Boston, Massachusetts.
| | - Anthony J Schaeffer
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tanya Logvinenko
- Clinical Research Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Ilina Rosoklija
- Divison of Urology, Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alan B Retik
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David A Diamond
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc Cendron
- Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Effects of oral testosterone undecanoate treatment for severe hypospadias. Int Urol Nephrol 2015; 47:875-80. [DOI: 10.1007/s11255-015-0972-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/31/2015] [Indexed: 11/26/2022]
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26
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Zhao W, Yin J, Yang Z, Xie J, Zhang Y, Xu W, Li JL. Meta-analysis of Androgen Insensitivity in Preoperative Hormone Therapy in Hypospadias. Urology 2015; 85:1166-1172. [PMID: 25805521 DOI: 10.1016/j.urology.2015.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 01/08/2015] [Accepted: 01/27/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To define androgen insensitivity prevalence in hypospadias patients treated with preoperative hormone therapy. MATERIALS AND METHODS We searched databases that were published in English and Chinese up to September 10, 2014 for our studies. Eligibility criteria were pre-established. Title, abstract, and full-text screenings were conducted by 2 authors independently. Discrepancies were resolved by consensus. Quality assessment of included studies was completed. Meta-analysis was done when appropriate using R, version 3.1.1 for Windows. Heterogeneity among individual studies was tested using the Cochran chi-square Q test and quantified by calculating the I(2) index. RESULTS Thirteen of 1278 publications met inclusion criteria and were incorporated into this study. Of 306 patients with preoperative hormone therapy, 25 displayed androgen resistance. Meta-analysis demonstrated that the random-effects model generates a pooled estimate of 7.14% (95% confidence interval [CI], 3.16%-15.31%), whereas the fixed-effect model provides an estimate of 14.61% (95% CI, 10.00%-20.85%). Heterogeneity among included studies was found above medium (I(2) = 67.1% [95% CI, 41.2%-81.6%]; P = .0003]. After exclusion of the heterogeneity, both random-effects and fixed-effect models produce a consistent pooled estimate of 6.95% (95% CI, 0%-47.8%). CONCLUSION We have defined that the prevalence of androgen resistance in hypospadias is 7.14% (95% CI, 3.16%-15.31%). To distinguish isolated hypospadias from patients with androgen insensitivity syndrome, we recommend that androgen-resistant patients should be specifically targeted by molecularly focused diagnosis. Management strategies should include identification of mutations in the androgen receptor gene, timely surgery to repair hypospadias, and long-term follow-up of sexual function and fertility later in life.
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Affiliation(s)
- Weiguang Zhao
- Department (I) of Paediatric Urology, Shenzhen Children's Hospital, Shenzhen, China
| | - Jianchun Yin
- Department (I) of Paediatric Urology, Shenzhen Children's Hospital, Shenzhen, China
| | - Zhilin Yang
- Department (I) of Paediatric Urology, Shenzhen Children's Hospital, Shenzhen, China
| | - Jinjin Xie
- Department (I) of Paediatric Urology, Shenzhen Children's Hospital, Shenzhen, China
| | - Yingtian Zhang
- Department (I) of Paediatric Urology, Shenzhen Children's Hospital, Shenzhen, China
| | - Wanhua Xu
- Department (I) of Paediatric Urology, Shenzhen Children's Hospital, Shenzhen, China
| | - Ji-Liang Li
- School of Biotechnology, Southern Medical University, Guangzhou, China; Molecular Oncology Laboratories, Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.
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27
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Hofer MD, Cheng EY, Bury MI, Xu W, Hong SJ, Kaplan WE, Sharma AK. Androgen Supplementation in Rats Increases the Inflammatory Response and Prolongs Urethral Healing. Urology 2015; 85:691-7. [DOI: 10.1016/j.urology.2014.11.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 10/27/2014] [Accepted: 11/25/2014] [Indexed: 11/29/2022]
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28
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Wong NC, Braga LH. The influence of pre-operative hormonal stimulation on hypospadias repair. Front Pediatr 2015; 3:31. [PMID: 25954736 PMCID: PMC4406073 DOI: 10.3389/fped.2015.00031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 04/05/2015] [Indexed: 11/13/2022] Open
Abstract
Androgen stimulation to temporarily promote penile growth has been commonly used to facilitate hypospadias repair. Although some series suggest improvement in both functional and cosmetic outcomes, a recent systematic review and meta-analysis showed a possible relationship between pre-operative hormonal stimulation and higher complications. As a result, indications and treatment regimens remain controversial. Here, we review the available literature and present our clinical practice.
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Affiliation(s)
- Nathan C Wong
- Department of Urology, McMaster University , Hamilton, ON , Canada ; Department of Pediatric Urology, McMaster Children's Hospital , Hamilton, ON , Canada
| | - Luis H Braga
- Department of Urology, McMaster University , Hamilton, ON , Canada ; Department of Pediatric Urology, McMaster Children's Hospital , Hamilton, ON , Canada
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