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

Plate Objective Scoring Tool (POST) in distal hypospadias: Correlation with post-repair complications

OBJECTIVES

The Plate Objective Scoring Tool (POST) accurately reflects configuration of the urethral plate in distal hypospadias. Here we assessed whether POST score also correlates with patient risk of complications after surgical repair.

METHODS

Data were obtained prospectively from pre-pubertal boys who underwent primary hypospadias repair between January 2020 and February 2023. Both POST and Glans-Urethral Meatus-Shaft (GMS) scores were determined in triplicate by three independent reviewers before evaluating correlation with complications after surgery.

RESULTS

POST ratios were strongly correlated with incidence of post-repair complications in n = 121 patients. Mean POST score was 1.10 (range 0.5-1.62) and average GMS value was 5.29 ± 1.36 (median G = 2, M = 2, S = 1). Bivariate correlation analysis indicated that POST score can accurately predict risk of complications after surgery (Pearson correlation coefficient r = 0.821 [0.724-0.918], 95 % CI). A POST threshold of 1.2 provided the highest specificity for risk of post-operative complications, which occurred in 4.4 % of patients with POST score ≥1.2 (2/45 cases), compared with 25 % among patients with POST score <1.2 (19/76 cases).

CONCLUSIONS

This study confirms that POST index can be used as a surrogate marker of urethral plate quality and accurately predicts the outcome of distal hypospadias repair. Objective scoring of POST revealed that low ratios were significantly associated with high risk of postoperative complications. In future, this approach could be used to stratify patients and better identify cases that require close follow-up care.

Use of Validated Questionnaires to Predict Cosmetic Outcomes of Hypospadias Repair

INTRODUCTION

Hypospadias is a syndrome of penile maldevelopment. The primary goal of hypospadias surgery is to create a penis with normal appearance and function. Historically, the outcome of hypospadias repair has been assessed based on the need for reoperation due to urethroplasty complications (UC), including fistula formation, dehiscence, meatal stenosis, or development of a urethral stricture. The Glans-Urethral Meatus-Shaft (GMS) score is a standardized tool to predict UC. Analysis of the cosmetic outcomes of hypospadias repair based on the appearance of the reconstructed penis has been validated, and standardized scores have been published. The Hypospadias Objective Penile Evaluation (HOPE) score is a validated questionnaire used to assess postoperative cosmetic outcomes. Although predictors of surgical outcomes and UC have been well documented, predictors of optimal cosmetic outcomes are lacking in the literature. Furthermore, reoperation due to cosmetic considerations has been poorly reported.

OBJECTIVE

To identify predictors of cosmetic outcomes after hypospadias repair and to assess the reoperation rate according to cosmetic considerations.

MATERIALS AND METHODS

This prospective cohort study included 126 boys who underwent primary hypospadias repair. The severity of hypospadias, degree of penile curvature, glans width, preoperative HOPE, and GMS scores were documented. The standard technique for single-stage repairs, the tubularized incised plate urethroplasty, was performed. The primary endpoint was cosmetic outcomes evaluated by the HOPE score questionnaire six months postoperatively. Optimal cosmetic results were defined by HOPE scores ≥ 57.

RESULTS

The study population consisted of the following cases: 87 (69%) subcoronal, 32 (25%) shaft, and 7 (6%) proximal hypospadias. Among the study participants, 102 boys (81%) had optimal cosmetic results (HOPE ≥ 57), and 24 boys (19%) had surgeries with suboptimal cosmetic outcomes (HOPE < 57). Ancillary procedures were performed in 21 boys (16%), of which 14 (11%) were solely for cosmetic considerations, and 7 were secondary to UC. Using the Receiver Operating Characteristic analysis of potential predictors of optimal cosmetic outcomes, the preoperative HOPE score had the highest area under the curve (AUC = 0.79; 95% CI 0.69-0.89, p < 0.001). After multivariable analysis, the degree of penile chordee (p = 0.013), glans width (p = 0.003), GMS score (p = 0.007), and preoperative HOPE score (p = 0.002) were significant predictors of cosmetic outcomes. Although meatal location predicted suboptimal cosmetic results in univariate analysis, it was not a factor in multivariable analysis.

CONCLUSIONS

Over 80% of boys undergoing hypospadias repair achieved optimal cosmetic outcomes. More than 10% of cases underwent ancillary procedures, secondary solely to cosmetic considerations. Predictors of optimal cosmetic outcomes after hypospadias surgery included degree of chordee, glans width, and preoperative HOPE and GMS scores, which were the best predictors of satisfactory cosmetic results. Although meatal location is the main predictor of UC, it was not a predictor for cosmetic outcomes. Factors affecting cosmetic outcomes should be clearly explained to parents during the preoperative consultation.

Megameatus intact prepuce variant reconstruction: Long-term outcomes and comparison to post-circumcision hypospadias repair

BACKGROUND

Megameatus intact prepuce (MIP) variant is considered a surgical challenge with associated high complication rates. It is usually diagnosed and corrected only after neonatal circumcision, which is discouraged in non-MIP hypospadias.

OBJECTIVE

In order to determine whether the features of the MIP variant or the performance of a secondary reconstruction following circumcision comprise the cause of higher complication rates, we now compared the results of post-circumcision MIP hypospadias repair to the results of children who underwent repair of non-MIP hypospadias following neonatal circumcision.

STUDY DESIGN

Reoperation rates of children operated for hypospadias repair following neonatal circumcision between 1999 and 2020 were compared between those with MIP and those with classic non-MIP hypospadias.

RESULTS

In total, 139 patients who had undergone neonatal circumcision underwent surgical reconstruction at a mean age of 13 months. Sixty-nine had classic hypospadias and 70 had the MIP variant. The median follow-up was 10 years (interquartile range 6,13). The classic group had a higher rate of meatal location below the corona compared to the MIP variant group (53 % vs. 28 %, respectively, p = 0.002). The reoperation rate was comparable for the two groups (32 % vs. 27 %, p = 0.58, Table). Univariate analysis for the MIP hypospadias group showed no association between reoperation and the initial patient characteristics, while a higher probability of reoperation was demonstrated in the presence of ventral curvature (odds ratio 3.5, p = 0.02), and a higher grade of hypospadias (odds ratio 3.3, p = 0.03 for meatal location lower than the coronal sulcus) in the non-MIP group.

DISCUSSION

The limitations of our work include its retrospective design wherein the patients' characteristics, including classification as MIP vs. non-MIP, are derived from medical records. More patients in the non-MIP group were documented to have penile curvature. The non-MIP group was composed of more patients with meatal location under the coronal sulcus, a factor which may increase the rates for reoperation in that group. Still, with the comparison of the largest reported cohort of circumcised MIP with circumcised non-MIP patients together with an extended follow-up period, we believe that we present strong evidence of the possible role of previous circumcision in the surgical challenge of reconstructing MIP hypospadias.

CONCLUSIONS

Reoperation rates in MIP hypospadias are high but similar to those of classic hypospadias, both following circumcision, suggesting that circumcision, rather than the unique features of the variant, is the cause for complications.

The Role of Tissue Expanders in the Reconstruction of Proximal Hypospadias

OBJECTIVE

To report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias.

METHODS

Proximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage.

RESULTS

A total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%).

CONCLUSION

Proximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage.

Outcome of spongioplasty alone as second layer of tubularised incised plate urethroplasty in patients with hypospadias

Background

Spongioplasty alone or in combination with local tissue flaps can be used as a second layer for the prevention of complications of tubularised incised plate urethroplasty (TIPU) of hypospadias repair. It can be used when wide urethral plate and well-developed robust spongiosum are present. This study aims to review the success rate and complications of TIPU performed utilising spongioplasty alone as a second layer in Type 3 well-developed robust spongiosum.

Methods

This is a retrospective observational study conducted between January 2015 and December 2019 at a tertiary care centre. A total of 21 patients aged 4–15.4 years with primary hypospadias having a Type 3 well-developed robust spongiosum, Glans score ≤ 2, Meatal score ≤ 4, and Shaft score ≤ 3 underwent TIPU using spongioplasty alone as a second layer. The hospital stay ranged from 10 to 14 days and follow-up from 12 to 36 months.

Results

Hypospadias was distal in 12 (57.1%), mid in 5 (23.8%), and proximal penile in 4 (19.1%) patients. The mean Glans Meatus Shaft score was 6.1 (G = 1.25, M = 2.95, S = 1.9) with a range of 3–9. An early post-operative complication of preputial oedema and bladder spasm developed in 1 (4.7%) patient each. Meatal stenosis developed in 1 (4.7%) patient. None developed urethrocutaneous fistula. At 3 months all patients had good urinary flow (> 15 ml/s) and good cosmesis. All the patients/parents (in case of minors) were satisfied with the result.

Conclusion

Spongioplasty alone as the second layer after TIPU for primary penile hypospadias in patients with well-developed robust spongiosal tissue is associated with minimal, easily manageable complications.

Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision

PURPOSE

To present the results of hypospadias repair in the absence of preputial skin following neonatal circumcision, and the analyses of surgical techniques and predictors of procedural success.

METHODS

Records of all children who underwent hypospadias repair between 10/1999 and 12/2018 were retrospectively reviewed. All of those who underwent neonatal circumcision prior to surgery were included. Patients with any prior penile reconstruction surgery and those with the megameatus intact prepuce variant were excluded. The primary endpoint was the need for reoperation.

RESULTS

A total of 69 patients with a history of neonatal circumcision underwent surgical reconstruction of hypospadias during the study period. Their mean age at surgery was 14 months (interquartile range [IQR] 9,22). Forty-five cases (65%) involved distal hypospadias, and ventral curvature was present in 24 (35%). Dartos flaps were harvested from the dorsal aspect in 37/58 (64%) patients and from the ventral aspect in 21/58 (36%). Twenty-two patients (22/69, 32%) required reoperation after a median follow-up of 9 years (IQR 6,13). Indications for revision surgery included urethral fistula (n = 16, 22%), meatal stenosis (n = 5, 7%), and skin redundancy (n = 1). Ventral curvature (odds ratio [OR] 3.5, p = 0.02) and higher grades of hypospadias. (OR 3.3, p = 0.03) had a higher probability of reoperation (univariate logistic regression).

CONCLUSION

Hypospadias repair following neonatal circumcision in the absence of preputial skin is a challenging reconstruction. The reoperation rate in our cohort was 30%, similar to reoperative hypospadias surgery. Parents of newborns diagnosed with hypospadias should be encouraged to refrain from pre surgical neonatal circumcision.

LEVEL OF EVIDENCE

Treatment study, level IV.

Distal hypospadias repair: Comparative study between snodgrass and transverse preputial onlay flap

INTRODUCTION

Distal hypospadias repair has several operative strategies such as tubularized incised plate (TIP); Transverse preputial onlay flap (TPOF) and Modified Mathieu Procedure. The aim of our work is to compare between TIP and TPOF techniques in the outcome.

MATERIAL AND METHOD

We conducted this comparative study on 66 patients with different types of distal hypospadias divided in two groups A and B for TIP and TPOF respectively. We reported outcome and complications for both TIP and TPOF repair. Our results revealed mean operative time was significantly higher in group B (123.1 ± 6.8 min) than in group A (93.73 ± 3.9 min, P value < 0.001). Postoperative urinary fistula was reported in group A (15.2%) while no fistula in group B (p value = 0.05). The vertical slit appearance of meatus was better in group A (54.5%) than in group B (24.2%, P value 0.023). As regard to hypospadias objective scoring evaluation (HOSE) (Summary Figure) the meatal shape score was higher in group A (1.55 ± 0.51) than in group B (1.24 ± 0.44, p value = 0.0 l), the urinary stream score was significantly higher in group A (1.82 ± 0.39) than in group B (1.97 ± 0.17, p value = 0.04) and the urinary fistula score was significantly higher in group A (3.79 ± 0.60) than in group B (4 ± 0, p value = 0.04).

DISCUSSION

Complications are more common after TIP than in TPOF. As regard the meatus shape, the naturally looking vertical slit like meatus was achieved more in the TIP than in TPOF. We advocate further studies with a large number of patients with a long follow up period.

CONCLUSION

TPOF is a great option to consider in cases of distal hypospadias because it is an effective technique for primary distal hypospadias repair with a good cosmetic outcome and a low associated complication.

Hypospadias: A Comprehensive Review Including Its Embryology, Etiology and Surgical Techniques

Hypospadias is among the most prevalent urogenital malformations in male newborns. It is characterized by the displacement of the urethral meatus to the ventral side of the penis, an aberrant ventral curve of the penis referred to as "chordee," and an abnormally arranged foreskin with a "hood" found dorsally and lacking foreskin ventrally. Patients may have an extra genitourinary abnormality based on the area of the lesion. In around 70% of cases, the urethral meatus is positioned distally to the shaft, representing a milder form of the disease. The remaining 30% of cases are located proximally, are more complicated, and require further evaluation. Although the origin of hypospadias is mostly obscure, several suggestions exist about genetic susceptibility and hormonal factors. The objective of hypospadias restoration is to restore aesthetic and functional regularity, and surgery is currently advised at a young age, mostly between six and 18 months. At any age, hypospadias can be repaired with an equivalent risk of complications, functional outcomes, and aesthetic outcomes. However, the best age of treatment is still undetermined. Even though the long-term effects on appearance and sexual function are usually good, males may be less likely to make the first move after rectification. Also, people who have hypospadias treated are twice as likely to have problems with their lower urinary tract. These problems can last for years after the initial repair.

Outcomes of Tubularized Incised Plate Urethroplasty (TIPU) for Hypospadias at Tikur Anbesa Specialized and Menelik II referral Hospitals: One-year Prospective study"

OBJECTIVES

To evaluate the results and related factors of tubularized incised plate (TIP) urethroplasty at two institutions.

METHODES

This was a prospective cohort analytical study conducted over a period of 12 months. All patients who underwent TIP urethroplasty in the specified period were studied. Quantitative and qualitative data of the intrinsic parameters of the penis were obtained and patients were followed up for an average period of 14.72±3.67 months (range 9-21months) after surgery.

RESULTS

One hundred twenty-nine patients (N = 129) were included in the study. The mean age at surgery was 50.93 months. The mean glans size and pre-incised urethral plate width were 14.34 mm and 8.38mm respectively. The post-operative results were satisfactory with the meatus in a glanular position in 122(94.6%) patients. Overall, 49 patients (38%) developed complications. Eighteen patients (14%) developed early complications whereas forty-two (32.6%) patients had late complications. UCF and Meatal stenosis occurred in 27 (20.9%) & 14 (10.9%) patients respectively. Seven patients developed recurrent hypospadias and dehiscence of glans occurred in eight patients (6.2%).

CONCLUSIONS

TIP can be used to repair for all types of hypospadias in the absence of severe penile curvature. It has more complications rate in proximal than distal hypospadias. Distal hypospadias was the most common type of hypospadias corrected with TIP. UCF and meatal stenosis were the most common complication followed by glans dehiscence and recurrent hypospadias. Glans size, age at surgery, plate width, location of meatus and stretched penile length were the most determinant factors for the outcome.

Hypospadias in toddlers: a multivariable study of prognostic factors in distal to mid-shaft hypospadias and review of literature

Background

Tubularized incised plate urethroplasty is the most common hypospadias repair technique. However, there are unanswered questions and debates about the anatomical prognostic factors affecting the repair outcomes. This study tried to address some of the problems in the studies compromising the results of the current body of literature.

Methods

A prospective cohort of 101 males aged 1–3 years undergoing primary distal to mid-shaft hypospadias repair were enrolled in the study. Complications including edema, erection, inadvertent removal of the urethral stent, surgical wound infection, bladder spasm, hematoma, and hemorrhage were evaluated. Studies in the current literature were reviewed to achieve a better perspective for future investigations.

Results

Persistent complications were found in 16 cases (15.8%) including fistula formation, the persistence of chordee, meatal stenosis, glans, and urethral dehiscence. The mean follow-up time was 6.6±3.4 months. In the single-variable analysis, the meatal location, the length and width of the urethral plate, and the reversible acute postoperative events were significantly associated with the complications. Furthermore, fistula formation was associated with acute surgical site infection (p<0.001). However, the multivariable regression study revealed the presurgical meatal location to be the only statistically significant factor (p=0.03). Notably, the glans diameter or glanular groove shape, urethral plate dimensions, or presence of mild chordee were not independently associated with the outcomes (p>0.05).

Conclusions

Our study on the toddlers with hypospadias surgery revealed that the location of urethral meatal was the main predicting factor in the development of major complications. Furthermore, the fistula formation at the infected surgical site emphasizes the importance of postsurgical care.

Predictors of successful outcome of tubularized incised plate for primary distal hypospadias repair

Background

Several preoperative factors affect the outcome of Tabularized Incised Plate (TIP) repair. Our aim was to collect and analyze all these factors to define what the most important predictive factors are.

Methods

Hundred patients (1–5 years old) with primary distal hypospadias were included. Exclusion criteria included previous penile operations and hormonal treatment or associated congenital anomalies. Anogenital distance (AGD), stretched penile length (SPL), meatal site, glanular shape, chordee and torsion degree, plate width and glans meatus shaft (GMS) score were assessed. TIP repair was done to all patients and followed up for one year. The outcome was correlated with the above parameters.

Results

Mean ± SD of age of patients was 3.5 ± 1.5 years, while weight was 14.1 ± 3.0 kg. Complication rate was 18% including urethrocutaneous fistula (UCF) and meatal stenosis 14%, repair breakdown 1% and urethral stricture 3%. Patients with chordee degree < 30° and distal penile meatal location were associated with increased risk for complications by 11.6 and 8.2 times; 95% CI was (1.46–91.75) and (1.02–66.52), respectively (p < 0.05 for each). Plate width ≥ 9 mm, AGD > 5 cm, GMS score ≤ 7 (p < 0.001 for each), age of patient ≤ 2 years old, and SPL > 3.5 cm (p < 0.01 for each) were associated with successful outcome of repair.

Conclusion

The proposed successful criteria of TIP repair were absent chordee, coronal/subcoronal penile meatal location, plate width ≥ 9 mm, AGD > 5 cm, age of patient ≤ 2 years old, GMS score ≤ 7, SPL > 3.5 cm and grooved glanular shape.

Dressing or Not after Tubularized Incised Plate Urethroplasty

BACKGROUND

Many surgical techniques, as well as dressing models, were identified in the treatment of hypospadias. There are many publications in the literature that are the result of the effort to find the ideal dressing after hypospadias surgery. The dressing has some benefits; however, it has some adverse effects. The present study aimed to discuss outcomes of the patients who have been operated through the tubularized incised plate urethroplasty (TIPU) method and followed with and without dressing postoperatively.

METHODS

Patients operated on through the TIPU method between March 2015 and August 2019 were reviewed retrospectively. The patients were divided into two groups, dressing and undressing. Preoperative hypospadias severity was evaluated according to the Glans-Urethral Meatus-Shaft (GMS) scoring method. The care results of the patients were recorded. Postoperative outcomes were compared according to the Hypospadias Objective Scoring Evaluation (HOSE) scale, and statistical analyses were conducted. The results of both groups were compared statistically.

RESULTS

One hundred and nineteen patients were divided into two groups: dressing (n = 56) and nondressing (n = 63). The patients' average age was 3.54 ± 2.97 years in group 1 and 3.50 ± 3.01 years in group 2 (p = 0.940). There was not any statistically significant difference between the two groups for demographic data. Minimal bleeding had stopped in three patients in the nondressing group spontaneously before discharging. No severe edema or hematoma, which might have concerned the parents, appeared. Two (3.5%) and 3 (4.7%) patients underwent a maximum of three urethral dilation sessions in dressing and nondressing groups, respectively (p = 0.556). We found no significant difference between groups in the comparison of preoperative GMS and postoperative HOSE scoring.

DISCUSSION

The most important limitation of the study is that it is retrospective. Pre- and postoperative scoring systems are objective. The data obtained in the literature show that surgeons prefer to apply dressings commonly after the TIPU technique. Advantages and disadvantages of dressing are mentioned in the literature. Even if the paradigm is dressing in hypospadias surgery, according to the results of our study, dressing may not affect the functional and cosmetic results of TIPU repair.

CONCLUSION

Postoperative functional and cosmetic results of TIPU in hypospadias appear to be independent of dressing. However, the results must be supported by further research.

Association between intra-operative meatal mismatch and urethrocutaneous fistula development in hypospadias repair

INTRODUCTION

The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used to assess hypospadias severity and risk for post-operative complications. The 'M' component is based on pre-operative meatal location, but meatal location sometimes changes after penile degloving, resulting in 'meatal mismatch.'

OBJECTIVE

To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the association of meatal mismatch with post-operative urethrocutaneous fistula development.

STUDY DESIGN

We performed a retrospective cohort study on patients who underwent primary hypospadias repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging (meatus moving more proximally after degloving), downstaging (moving more distally after degloving), or none. Covariates included: pre-degloving meatal location, chordee severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for repair. To test the association between meatal mismatch and fistula development, we constructed two, nested, multivariable Cox proportional hazards regression models with and without meatal mismatch and compared them with the likelihood ratio test. A sensitivity analysis excluded patients with <6 months of follow-up.

RESULTS

Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly associated with penoscrotal webbing, number of stages for repair, and pre-degloving meatal location, with downstaging being associated with more proximal meatal location. Over a median follow-up of 7.3 months (interquartile range 2.0-20.9), fistulae developed in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence Interval [CI]: 1.44-6.45) compared to no mismatch. Meatal downstaging had similar risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29-3.35). Multi-stage compared to single-stage repair was associated with reduced risk of fistula development (HR: 0.24, 95% CI: 0.09-0.66). The likelihood ratio test favored the model that included meatal mismatch. The sensitivity analysis showed similar findings.

DISCUSSION

Our short-term results suggest that meatal mismatch may be an important additional consideration to the GMS score as a tool to assess hypospadias severity, counsel families, and predict outcomes. Longer-term studies are needed to enhance the precision of risk stratification in hypospadias.

CONCLUSIONS

Meatal mismatch occurred in 20% of patients undergoing hypospadias repair. Among this cohort, meatal upstaging was associated with a 3-fold increased risk of post-operative urethrocutaneous fistula development.

Results of two-stage transverse preputial island flap urethroplasty for proximal hypospadias with chordee that mandate division of the urethral plate

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%.

Relationship between maternal age and anogenital distance in patients with primary hypospadias: A case-control study

Objective

To evaluate the correlation between maternal age and anogenital distance (AGD) in patients with hypospadias.

Patients, subjects and methods

A total of 82 participants were divided into two groups, Group 1 included 52 male children with different types of primary hypospadias and Group 2 included 30 normal controls. In both groups, child age and weight, maternal age, and AGD were recorded. In Group 1, the Glans-Urethral Meatus-Shaft score was used to categorise the patients into mild (score 3–6), moderate (score 7–9) and severe (score 10–12) hypospadias.

Results

Both groups were similar for maternal age, child age and child weight (P = 0.308, P = 0.283 and P = 0.664, respectively). The mean (SD) AGD was 4.64 (1.23) and 5.33 (1.01) cm for groups 1 and 2, respectively (P = 0.011). Patients in Group 1 were subdivided regarding severity of hypospadias into mild (40.4%), moderate (38.5%) and severe (21.1%). There was a significant relationship between older maternal age and short AGD in both groups (P < 0.001 for Group 1 and P = 0.001 for Group 2). In Group 1, there was a significant correlation between both short AGD and older maternal age, and severe hypospadias (both P < 0.001). Maternal age of ≥34 years significantly predicted a severe hypospadias score (10–12) (sensitivity 100% and specificity 68.3%).

Conclusion

Older maternal age is associated with a shorter AGD in patients with hypospadias and controls. Maternal age of ≥34 years is significantly correlated with patients with severe hypospadias.

Plate Objective Scoring Tool (POST); An objective methodology for the assessment of urethral plate in distal hypospadias

BACKGROUND

Estimation of the quality of the urethral plate (UP) seems to be important when assessing postoperative outcomes of hypospadias repair, but its evaluation remains subjective. We developed an objective model aiming to standardize this assessment, proposing a methodology that could be adopted in future studies designed to evaluate outcomes in the treatment of hypospadias.

OBJECTIVES

To evaluate the inter and intra observer reliability of a method to assess the quality of the urethral plate (UP) in hypospadias (POST - Plate Objective Scoring Tool) based on elements of glans characteristics. The reliability of such scoring methodology was compared to an analog accepted tool: the Glans-Urethral Meatus-Shaft (GMS) score. A secondary goal was to compare some characteristics of the UP in GMS score to POST values; aiming to find the threshold between favorable and unfavorable plates.

METHODS

Data were prospectively obtained from prepubertal boys who underwent primary hypospadias repair between January 2018 and November 2019. Intrinsic elements of the glanular UP (A: distal midline mucocutaneous junction; B: Glanular knob where the mucosal edges of the UP's edge change direction; C: Glanular/coronal junction) were marked and the AB/BC ratio calculated. The "G" and "M" components of the GMS score were measured electronically three times by four different reviewers with variable pediatric urology experience and blinded to each other values. Favorable UP, according to the GMS score was compared to measurements obtained by POST (AB/BC ratio).

RESULTS

84 subjects were enrolled. The POST score had an excellent inter-observer agreement for the evaluation of the UP in distal hypospadias (Kappa = 0.832) while the "G" parameter of the GMS correlated poorly among the observers. The Inter-Class Correlation (ICC) analysis to examine the intra-rater agreement value was 0.914 (95% CI 0.87, 0.95.). AB/BC ratio values ranged from 0.6 to 1.6, with a mean of 1.12. The POST cut-off value for "favorable" UP was 1.2 (AUC = 0.62) 95% CI (0.52-0.84) (sensitivity 80% and specificity 60%).

CONCLUSIONS

The POST score has higher inter-observer reliability and functions favorably when compared to the GMS. In addition, it demonstrated a high intra-observer reliability among observers of variable experience. Our findings suggest that the POST score adds to evaluation of the UP and could be incorporated as an additional criterion to assess outcomes in distal hypospadias repairs.

The feasibility of urethral plate preservation in proximal and mid-penile hypospadias: sequential and anatomical approach to the repair

Background

The assessment of a child having hypospadias with chordee/ventral curvature (VC) and meatal position that appears to be proximal/mid-penile can be challenging with regard to the choice of chordee correction and type of urethroplasty. The feasibility of preservation of native urethral plate is dependent on these choices. Classically, urethral plate resection of the corpora is performed to correct severe VC, whenever VC is presumed to be due to short urethral plate. But VC is seen to persist in many such cases, in spite of this maneuver that commits the patient to a more complex reconstruction. The aim of the study was to analyze the variation in preoperative and intraoperative assessment of proximal and mid-penile hypospadias, with respect to severity and possible surgical options, in patients treated by a standard protocol of sequential and anatomical approach to repair. The other objective was to ascertain if “extensive ventral urethral detethering” (in all cases) and “urethral plate augmentation” (in select cases) could facilitate more anatomical repair in these cases, with urethral plate preservation and utilization for repair wherever feasible.

Results

Fifty-two children who underwent the specific protocol of repair during the 5-year period from January 2014 to December 2018 at a tertiary teaching institution were included in the study. The essential principles adopted for the surgery were as follows: (i) urethral plate preservation in all possible situations; (ii) “extensive ventral urethral detethering” up to the bulb, as a preliminary step, (iii) sequential correction of VC with urethral plate augmentation (in select cases); and (iv) selecting the optimal repair based on the following principles: (a) urethral plate tubularization, (b) urethral plate augmentation, and (c) urethral plate substitution. There was considerable difference in the preoperative and intraoperative assessment of meatal position, with 12 of the apparently mid-penile hypospadias being reclassified as distal penile after preliminary dissection. Three of the penoscrotal variants were regrouped as proximal penile and 6 of the proximal penile were regrouped as mid-penile type. Majority of cases which were deemed to require complex reconstruction on preoperative assessment could be treated by a single-stage procedure.

Conclusion

The meatal position is seen to shift distally in select cases of proximal or mid-penile hypospadias after thorough degloving, dartos release, and detethering of Buck’s fascia over ventral urethra. Urethral plate can be preserved for utilization in repair in many of these cases by augmenting the urethral plate, enabling a more anatomical neourethral reconstruction. Resection of urethral plate can be thus restricted to the most severe cases of VC.

The risk factors of Urethrocutaneous fistula after hypospadias surgery in the youth population

Background

The current research aims to evaluate the risk factors of urethrocutaneous fistula after hypospadias surgery among the youth in China.

Methods

One hundred twenty hypospadias patients were enrolled in our study. All of them were defined as Tanner 4 or 5. The information collected from the participants include age, urethral operation history, urinary comorbidities before operation, urine test before operation, body temperature before and after operation, type of surgical repair, chordee degree, urethral defect length and whether received vesicostomy after surgery or not. Independent t test, chi-square test and multivariate logistic regression were performed to evaluate the risk factor of urethrocutaneous fistula.

Results

Among the enrolled patients, 39 patients (32.5%) developed urethrocutaneous fistula after hypospadias repair. Our result showed significant association between the group with urethrocutaneous fistula and the group without urethrocutaneous fistula with respect to age, pyuria before operation, urethral defect length and the urethral operation history. The following logistic regression showed that urethral defect length and the urethral operation history were the risk factors of urethrocutaneous fistula.

Conclusions

Urethral defect length and urethral operation history should be taken into consideration before undergoing hypospadias surgery since our study discovered that the risk of developing urethrocutaneous fistula after hypospadias repair is associated with urethral defect length and urethral operation history. Age, surgical procedure, type of surgical repair, chordee degree and other factors were not obviously related to the development of urethrocutaneous fistula.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0366-z) contains supplementary material, which is available to authorized users.

Current challenges with proximal hypospadias: We have a long way to go

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.

High GMS score hypospadias: Outcomes after one- and two-stage operations

INTRODUCTION

Established criteria to assist surgeons in deciding between a one- or two-stage operation for severe hypospadias are lacking. While anatomical features may preclude some surgical options, the decision to approach severe hypospadias in a one- or two-stage fashion is generally based on individual surgeon preference. This decision has been described as a dilemma as outcomes range widely and there is lack of evidence supporting the superiority of one approach over the other.

OBJECTIVES

The aim of this study is to determine whether the GMS hypospadias score may provide some guidance in choosing the surgical approach used for correction of severe hypospadias.

STUDY DESIGN

GMS scores were preoperatively assigned to patients having primary surgery for hypospadias. Those patients having surgery for the most severe hypospadias were selected and formed the study cohort. The records of these patients were reviewed and pertinent data collected. Complications requiring further surgery were assessed and correlated with the GMS score and the surgical technique used for repair (one-stage vs. two-stage).

RESULTS

Eighty-seven boys were identified with a GMS score (range 3-12) of 10 or higher. At a mean follow-up of 22 months the overall complication rate for the cohort after final planned surgery was 39%. For intended one-stage procedures (n = 48) an acceptable result was achieved with one surgery for 28 patients (58%), with two surgeries for 14 (29%), and with three to five surgeries for six (13%). For intended two-stage procedures (n = 39) an acceptable result was achieved with two surgeries for 26 patients (67%), three surgeries for eight (21%), and four surgeries for three (8%). Two other patients having two-stage surgery required seven surgeries to achieve an acceptable result. Complication rates are summarized in the Table. The complication rates for GMS 10 patients were similar (27% and 33%, p = 0.28) for one- and two-stage repairs, respectively. GMS 11 patients having a one-stage repair had a significantly higher complication rate (69%) than those having a two-stage repair (29%) (p = 0.04). GMS 12 patients had the highest complication rate with a one-stage repair (80%) compared with a complication rate of 37% when a two-stage repair was used (p = 0.12).

CONCLUSIONS

Guidelines to help standardize the surgical approach to severe hypospadias are needed. Staged surgery for GMS 11 and 12 patients may result in a lower complication rate but may not reduce the number of surgeries required for an acceptable result. Although further study is needed, the GMS score may be helpful for establishing such criteria.

Assessing quality of life of patients with hypospadias: A systematic review of validated patient-reported outcome instruments

BACKGROUND

Patient-reported outcomes have the potential to provide invaluable information for evaluation of hypospadias patients, aid in decision-making, performance assessment, and improvement in quality of care. To appropriately measure patient-relevant outcomes, well-developed and validated patient-reported outcome (PRO) instruments are essential.

OBJECTIVE

To identify and evaluate existing PRO instruments designed to measure quality of life and/or satisfaction of individuals with hypospadias that have been developed and validated in a hypospadias population.

METHODS

A systematic search of MEDLINE, EMBASE, PsycINFO, CINAHL and Health and Psychosocial Instruments was conducted in April 2016. Two reviewers independently assessed studies and identified PRO instruments for inclusion. Data were extracted on study characteristics, instrument development and validation, and content domains.

RESULTS

A total of 32 studies were included that used or described five PRO instruments: Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), Penile Perception Score (PPS), Genital Perception Scale (GPS) for adults, and GPS for children/adolescents. Instrument development and validation was limited. The majority of identified instruments focused on postoperative cosmetic satisfaction, with only one instrument considering urinary function, and no instruments evaluating sexual function and psychosocial sequelae.

CONCLUSIONS

While many hypospadias studies have acknowledged the necessity of a patient-reported element, few have used validated PRO instruments developed in a hypospadias population. Existing instruments to measure patient-reported outcomes in hypospadias require improvement in both the breadth of content and in their development and validation methodology.

Proximal hypospadias: we aren't always keeping our promises

Hypospadias surgery is a humbling art form. The evolution of surgical techniques has made distal hypospadias outcomes favorable, but recent publications suggest that our complication rates for proximal hypospadias are much higher than previously reported. To explain these shortcomings, we examine the literature and focus on the lack of standardized documentation, the subsequent inability to objectify the severity of the phenotype, and the underestimation of complications due to lack of long-term follow up. The variability in surgical technique and the fact that the literature abounds with small case series from single institutions also limits our ability to compare outcomes. We believe that the use of standardized and scored phenotype assessments from diagnosis through the extended postoperative period will allow for improved scientific assessment of outcomes. This will facilitate multi-institution collaboration and tabulation of outcomes, allowing rapid data accumulation and assessment for this rare disorder. As surgeons, we must follow boys through puberty into adulthood and must honestly report our results in order to advance our surgical approach to this complicated problem.

CEVL e-learning teaches GUMS method to "score" hypospadias preoperatively and predict postoperative outcomes

INTRODUCTION

Pediatric urological surgeons recognize the importance of formalizing the assessment of outcomes after hypospadias repair. To this end, surgical outcomes may be predicted by correlation with a summative score of objective assessments (Likert 1-4) of each: glans size, urethra plate appearance, meatus position, and extent of shaft chordee (GUMS). The best surgical outcome will be found in cases with the lowest score (GUMS = 4) and the worst surgical outcome in cases with the highest score (GUMS = 16).

OBJECTIVE

We aimed to determine if e-learning is suitable for training of the GUMS method. We did this by re-formatting the GUMS method of assessment of the hypospadias penis into an e-learning platform. Re-formatting was done using the CEVL (Computer Enhanced Visual Learning) context.

METHODS

A total of 49 cases provided content for the following content groups: learn basics (4 cases), scoring samples (16 cases), learn by examples (4 cases), practice scoring (15 cases), and self-test (10 cases). The content was formatted, edited (Adobe), and imported for interactive use (Articulate Storyline). Various frequently asked questions on how to score are also presented.

RESULTS

The survey respondents were pediatric urology attendings or fellows (60%) or urology residents (40%). E-learning GUMS scoring was done under 40 min before completion of the survey. Over 80% of respondents agreed/strongly agreed with the utility of the CEVL platform for learning the method. Respondents assigned GUMS scores to the survey cases and, on average, agreed on exactly the same scores for each component 63% of the time. The respondents chose the consensus score, or the next most common consensus score, 90% of the time.

CONCLUSION

We show that CEVL e-learning is an effective tool, which requires a minimal time investment, for teaching GUMS scoring. We believe that e-learning is a good platform to promote uniform clinical practices in outcomes research and for resident training.