Hypospadias anatomy: Elastosonographic evaluation of the normal and hypospadic penis

The ratio of COL2A1:COL1A1 in dartos tissue patients with hypospadias

BACKGROUND

The inelasticity of dartos tissue and the regulation of collagen expression are significant factors in the pathophysiology of chordee associated with hypospadias. While the COL2A1:COL1A1 ratio is recognised as a measure of cell differentiation, there is yet to be a study specifically examining this ratio in hypospadias. The aim of this study was to determine the COL2A1:COL1A1 ratio.

METHODS

We collected 55 samples of dartos tissue, comprising 35 from patients with hypospadias procured from urethroplasty procedures and 20 from patients with phimosis collected during circumcision without any lichen cases at our institution. The gene expression levels of COL1A1 and COL2A1 in the dartos tissue were analyzed using reverse-transcriptase polymerase chain reaction (qPCR).

RESULTS

Based on the type of penile abnormality, the expression levels of COL1A1 and COL2A1 measured by qPCR were downregulated in hypospadias, with value of 0.83 (0.38-2.53) and 0.43 (0.10-5.66), respectively, compared to phimosis, which had levels of 1.85 (1.24-4.61) and 0.94 (0.26-2.47) (p < 0.001). The expression levels of COL1A1 and COL2A1 were also significantly downregulated among mild, moderate, severe penile curvature, and control groups (p < 0.001 and p = 0.02). However, the COL2A1:COL1A1 ratio did not show statistically significant differences based on penile abnormalities and curvature (p > 0.05).

CONCLUSION

The expression levels of COL1A1 and COL2A1 are significantly downregulated in patients with hypospadias and ventral curvature when compared to those in the phimosis group. However, the COL2A1:COL1A1 ratio was not significant.

Effect of Pre-operative Parenteral Testosterone on Penile Dimensions and Vascularity in Proximal Hypospadias: A Prospective Observational Study

INTRODUCTION

Severe or proximal hypospadias is associated with inadequate local tissue and small phallus size. Pre-operative androgens have been used to increase phallus size, but there are very few studies on its role in proximal hypospadias. This study aimed to assess the effects of pre-operative intramuscular (IM) testosterone on proximal penile hypospadias in terms of penile morphology and tissue characteristics of penile skin.

MATERIALS AND METHODS

This prospective observational study was conducted on 27 patients of proximal hypospadias over a period from June 2017 to July 2018. The patients were sequentially enrolled into two groups: Group A and Group B. Group A patients received IM testosterone before surgery, whereas Group B patients were operated without pre-operative testosterone. Outcomes were analysed in terms of change in penile dimensions and effect on vascularity of penile skin.

RESULTS

Pre-operative IM testosterone in Group A caused a significant increase in stretched penile length from a mean of 3.058 cm (±0.691) to 3.9 cm (±0.875) ( P = 0.002), penile circumference from a mean of 4.142 cm (±0.772) to 4.667 cm (±1.174) ( P = 0.029) and glans width from a mean of 1.225 cm (±0.245) to 1.750 cm (±0.571) ( P = 0.002). There was higher microvessel density in the preputial skin of Group A (mean: 12.212 [±4.745] blood vessels/high-power field [HPF]) compared to Group B (8.867 [±3.258] blood vessels/HPF) ( P = 0.043).

CONCLUSION

Pre-operative testosterone in proximal hypospadias causes significant changes in penile dimensions and tissue characteristics. Improvement in penile dimensions leads to ease in operability and better tissue handling. However, more studies with large sample size are required to establish the beneficial effects of pre-operative hormone stimulation on urethroplasty.

What should be next in lifelong posterior hypospadias: Conclusions from the 2023 ERN eUROGEN and EJP-RD networking meeting

BACKGROUND

A congenital disease is for life. Posterior hypospadias, the severe form of hypospadias with a penoscrotal, scrotal, or perineal meatus, is a challenging condition with a major impact on lifelong quality of life.

AIM

Our network meeting is aimed to identify what is currently missing in the lifelong treatment of posterior hypospadias, to improve care, quality of life, and awareness for these patients.

METHODS

The network meeting "Lifelong Posterior Hypospadias" in Utrecht, The Netherlands was granted by the European Joint Programme on Rare Diseases-Networking Support Scheme. There was a combination of interactive sessions (hackathons) and lectures. This paper can be regarded as the last phase of the hackathon.

RESULTS

Surgery for hypospadias remains challenging and complications may occur until adulthood. Posterior hypospadias affects sexual function, fertility, and hormonal status. Transitional care from childhood into adulthood is currently insufficiently established. Patients should be more involved in defining desired treatment approach and outcome measures. For optimal outcome evaluation standardization of data collection and registration at European level is necessary. Tissue engineering may provide a solution to the shortage of healthy tissue in posterior hypospadias. For optimal results, cooperation between basic researchers from different centers, as well as involving clinicians and patients is necessary.

CONCLUSIONS

To improve outcomes for patients with posterior hypospadias, patient voices should be included and lifelong care by dedicated healthcare professionals guaranteed. Other requirements are joining forces at European level in uniform registration of outcome data and cooperation in basic research.

Current Techniques for the Objective Measures of Erectile Hardness

INTRODUCTION

One of the most discussed topics in the urology provider's office is that of the male penile erection. Moreover, this is also a frequent basis for consultation by primary care practitioners. As such, it is essential that urologists are familiar with the various means by which the male erection may be evaluated.

OBJECTIVES

This article describes several techniques presently available that may serve to objectively quantify the rigidity and hardness of the male erection. These techniques are meant to bolster information gathered from the patient interview and physical examination to better guide patient management.

METHODS

An extensive literature review was performed examining publications in PubMed on this subject, including corresponding contextual literature.

RESULTS

While validated patient questionnaires have been routinely employed, the urologist has many additional means available to uncover the extent of the patient's pathology. Many of these tools are noninvasive techniques that involve virtually no risk to the patient and take advantage of pre-existing physiologic properties of the phallus and its blood supply to estimate corresponding tissue stiffness. Specifically, Virtual Touch Tissue Quantification which precisely quantifies axial and radial rigidity, can provide continuous data on how these forces change over time, thus providing a promising comprehensive assessment.

CONCLUSION

Quantification of the erection allows for the patient and provider to assess response to therapy, aids the surgeon in choice of appropriate procedure, and guides effective patient counseling regarding expectation management. Rohrer GE, Premo H, Lentz AC. Current Techniques for the Objective Measures of Erectile Hardness. Sex Med Rev 2022;XX:XXX-XXX.

Urethral complex thickness and thickness index are the independent risk factors for urethroplasty complications after tubularized incised plate hypospadias repair

INTRODUCTION

In tubularized incised plate urethroplasty, the depth of the mid-line relaxing incision is the key factor for urethral plate tubularization without tension. The incision depths will be different from one case to the other even if they have been done by the same surgeon. This difference in depths resulted from the different thicknesses of the urethral plate and the underlying corpus spongiosum (urethral complex).

OBJECTIVES

To evaluate the urethral complex thickness and thickness index as risk factors for the complications of TIPU in penile shaft hypospadias repair.

STUDY DESIGN

All primary penile shaft (distal and mid-penile) hypospadias (with or without mild penile chordee) were operated with TIPU between March 2018 and February 2021. We measured the urethral complex thickness in the hypospadiac and proximal normal parts of urethra pre-operatively with superficial U/S probe. Intraoperative, we measured the urethral plate width before and after the midline relaxing incision, calculate the relative increase in urethral plate width (RIUPW). Stepwise logistic regression assessed the effect of different variables on the complication rate. These variables include; urethral plate width before and after incision, urethral complex thickness, thickness index, RIUPW, site of hypospadiac meatus and patients ages.

RESULTS

10 cases had 11 complications (12.7%). Fistulae were the commonest complication (8.9%). Complication rate has significant negative correlations with many variables on Univariate analysis. Stepwise logistic regression shows that urethral plate thickness and thickness index are the independent risk factors for complications after TIPU in penile shaft hypospadias.

DISCUSSION

Urethral plate width was suggested to be a risk factor for TIPU complications. In our study, Univariate analysis shows that complications were more with plate width ˂8 mm but without significant difference (P = 0.487). Also it shows that post incision width and RIUPW have significant negative correlation with complications rate. Multivariate analysis showed that the urethral complex thickness and thickness index are the independent risk factors for complications after TIPU hypospadias repair (AUC 0.94 95% CI 0.894-0.972 P ˂ 0.001 and 0.965 95% CI 0.921-0.996, respectively).

CONCLUSION

The thickness of the urethral plate and the underlying spongiosum is the determining factor for TIPU success. We can use it as an objective reproducible assessment tool for urethral plate quality and to predict TIPU complications.

Ultrasonographic Evaluation of the Hypospadiac Penis in Children

INTRODUCTION

Identifying key anatomical features of the hypospadiac penis is crucial to better understanding this pathology and guiding surgical reconstruction plans, thereby achieving superior functional and cosmetic outcomes.

OBJECTIVE

To Assess the feasibility and precision of penile ultrasonography (PUG) in determining key structural features for hypospadias cases (including distal extent of the spongiosal component of the urethral plate, to elucidate the healing process following tubularised incised-plate urethroplasty).

PATIENTS AND METHODS

Twenty-five children with hypospadias were assessed using PUG prior to surgical repair and then again under general anesthesia. Preoperative images were acquired using ultrasonography in sagittal and transverse planes, then later compared with anatomical findings obtained during surgical repair of urethral hypoplasia.

RESULTS

Median patient age was 1.2 years (range 0.5-12) and hypospadias types included coronal 17/25 (68%), mid-penile 5/25 (20%), and proximal penile 3/25 (12%). Distinct layers of the corpus spongiosa and mucosal layer, Buck fascia, tunica albuginea, glans, corpora cavernosa, and penile skin were delineated so that their spatial inter-relationship could be assessed. Distal extent of the spongiosal component of the urethral plate was determined by the mid-glans B-B line. The extent of urethral hypoplasia identified by PUG was relatively similar to measurements obtained intraoperatively.

CONCLUSION

PUG is a feasible and accurate approach to evaluating penile configuration in children with hypospadias. Distal extent of the spongiosal component of the urethral plate was accurately determined, hence PUG could potentially be used to improve surgical planning and appraisal of current repair procedures.

Shear wave elastography as a new, non-invasive diagnostic modality for the diagnosis of penile elasticity: a prospective multicenter study

Objective:

Shear wave elastosonography (SWE) could be used to evaluate the elasticity of penile tissue. Few studies in the literature, however, have investigated its use in patients with erectile dysfunction (ED) or have attempted to correlate findings with International Index of Erectile Function (IIEF-5) scores. The primary aim of this study was to evaluate the characteristics of erectile tissue using SWE and to determine possible relationships with IIEF-5 and Erection Hardness Scale (EHS) scores. The secondary aim was to establish a cut-off SWE examination value over which cavernous tissue stiffness could contribute to a subsequent organic alteration.

Methods:

This prospective study included male patients 18−80 years of age who attended two general andrology clinics and underwent SWE. Subjects were divided into groups according to IIEF-5 score, and correlations between SWE and IIEF-5 and EHS questionnaire scores were explored.

Results:

A total of 270 subjects (mean age 46.7 ± 16.9 years) were included. ED was reflected by low IIEF-5 and EHS scores and a decrease in the mean elasticity of the corpora cavernosa according to SWE, although the difference between the left and right corpora cavernosa was not statistically significant. No statistically significant correlation was found between measurements of the corpora cavernosa (in kPa) and age. The optimal cut-off identified was 24.75 kPa.

Conclusion:

Results demonstrated that the mean elasticity of the corpora cavernosa according to SWE was correlated with IIEF-5 score and EHS score.

Erectile dysfunction in patients undergoing multiple attempts at hypospadias repair: Etiologies and concerns

INTRODUCTION

One-third of adult patients presenting for the repair of persistent penile defects after failing multiple hypospadias repair attempts during childhood will complain of erectile dysfunction (ED). The goal of this paper is to identify possible etiological causes of its onset.

MATERIALS AND METHODS

Five selection criteria were used for entrance into the study: 1) Patients had to have failed ≥ three prior hypospadias repair attempts. 2) Present for evaluation between 18 and 40 years of age. 3) No known congenital or medical anomaly could be present that could have predisposed to erectile dysfunction. 4) Sexual history inventory for men (SHIM-5 score) completed. 5) All patients with moderate to severe ED (SHIM scores ≤ 16) underwent psychological screening; individuals with good quality spontaneous or self-stimulated erections, experiencing major life events, or had documented psychological problems were excluded from the study. One hundred consecutive patients meeting these criteria were assessed. We evaluated multiple factors to discern if they were associated with the onset of ED: the initial location of the urethral meatus, if a corporoplasty was performed, the type of corporoplasty used, if the urethral plate was divided or resected, the use of a ventral corporal graft, the total number of open reparative procedures performed before referral, the number of direct visual internal urethrotomies (DVIU) performed, the length of a urethral stricture at the time of the referral and whether lichen sclerosus was present. Statistical evaluations used chi-square analysis, two-tailed t-tests, or a logistic regression model where indicated, p-values < 0.05 were considered significant.

RESULTS

37% (37/100) of our patients complained of moderate to severe ED (SHIM score ≤16). Statistical analysis comparing patients with ED to those without ED (63%:63/100), revealed patients with ED were older, median age 34 yrs (range 20-40) vs 26 yrs (range 18-40) p = 0.0212, had undergone division of the urethral plate 70.3% (26/37) vs 47.6% (30/63), p = 0.0276, had placement of a ventral corporal graft, 24% (8/33) vs 1.5% (1/67), p = 0.0003 or had undergone repetitive DVIU's to manage urethral stricture disease, median number 4 (range 0-15) vs 0 (range 0-6), p < 0.0001, see table.

CONCLUSIONS

The early onset of ED in patients that failed multiple attempts at hypospadias repair in childhood is associated with advancing age, division of the urethral plate, and prior ventral corporal grafting. Especially significant is the association of ED to the use of repetitive internal urethrotomy to manage urethral stricture disease.

Histology and immunohistochemical evaluation of phimotic prepuce: The role of steroid therapy

Phimosis is one of the most frequent andrological diseases in paediatric age. Steroids are useful to treat phimosis. Through a retrospective study of histological and immunohistochemical analysis, we evaluated the effectiveness of topical steroid treatment in patients undergoing circumcision. Cases of patients treated for phimosis were selected during the two-year study period. All patients underwent circumcision and were divided into four groups: groups A (religiously circumcised patients), B (phimotic patients not undergoing steroid treatment), C (phimotic patients who do not respond to cortisone treatment) and D (hypospadic patients undergoing urethroplasty). An histological evaluation of the degree of fibrosis and an immunohistochemical evaluation of collagen IV and tenascin were carried out. Study results demonstrate that the grade of fibrosis is age-related. On histological and immunohistochemical evaluation, fibrosis was found to be lower in patients receiving steroids; higher degrees of fibrosis were found in older patients (p < .05). Different degrees of fibrosis have also been found in hypospadic patients. We can conclude that study results correlated with the clinical history of the patients. The success rate of medical therapy seems to be age-related.

The impact of COL1A1 and COL6A1 expression on hypospadias and penile curvature severity

BACKGROUND

Hypospadias, the most frequent congenital male external genitalia abnormality, is usually associated with curvature of the ventral penis, i.e. chordee. Abnormality of darto tissue has been suggested as the pathophysiology of chordees. Collagen is one of the most abundant fibrous proteins within the extracellular matrix. In this study, we determined the expression of collagen 1 (COL1A1) and COL6A1 in patients with hypospadias and associated them with the severity of penile curvature.

METHODS

We included 60 children < 18 years old, consisting of 20 distal hypospadias, 20 proximal hypospadias patients, and 20 controls in our institution from 2017 - 2020. The expression of COL1A1 and COL6A1 in darto tissue was determined by reverse-transcriptase polymerase chain reaction (qPCR). The penile curvature severity was classified as mild (< 30 degrees), moderate (30-60 degrees), and severe (> 60 degrees).

RESULTS

qPCR showed that COL1A1 and COL6A1 expression was significantly downregulated in the distal (0.88 (0.38-2.53) and 0.54 (0.16-4.35), respectively) and proximal 0.76 (0.33-2.57) and 0.57 (0.18-1.38), respectively) hypospadias groups compared to controls (1.85 (0.24-4.61) and 0.93 (0.17-4.06), respectively) with p-values of 0.024 and 0.018, respectively. Furthermore, there was a moderate correlation between COL1A1 and COL6A1 expression (r = 0.458, p < 0.0001). Interestingly, COL1A1 and COL6A1 were also significantly downregulated in the moderate and severe chordee groups compared to the mild chordee groups, with p-values of 0.003 and 0.037, respectively.

CONCLUSIONS

Aberrant COL1A1 and COL6A1 expression might affect abnormalities in darto tissue and penile curvature severity in hypospadias patients.

Histological and morphological characteristics of the prepuce of penis skin structure in different age groups

BACKGROUND

Hypospadias is one of the most common congenital abnormalities in childhood. The number of cases has rapidly grown in recent years.

OBJECTIVES

The purpose of this research was to analyze the histological and morphological differences of the foreskin samples taken from boys in three age groups.

STUDY DESIGN

A total of 30 Asian patients participated in the research. Clinical materials obtained via biopsy were divided into three age groups. The first group included 10 biopsy materials of preputial skin taken from boys aged <3 years. The second included 10 similar biopsy materials from boys aged 3-5 years. The third included 10 biopsy materials taken from boys aged 5-7 years. The skin areas were taken from the dorsal, two lateral and the ventral surfaces (closer to the bridle) with dimensions of 1.0 × 1.0 cm. All removed foreskins underwent histological examination.

RESULTS

Obtained results showed that the number of vein clusters in the prepuce and the cases of vessel wall fibrosis grew with age. It is worth noting that no such discoveries were made in younger boys (aged <3 years). Sample analysis showed that the number of nerve, vessel, and collagen fibers increased with age.

DISCUSSION

It is believed that it is important to continue investigating the prepuce in hypospadias, in order to gain a better understanding of the abnormality depending on type.

CONCLUSION

Peculiarities of prepuce in hypospadias discovered in different age groups allowed a full understanding of the pathology development processes.

Current Status of Tissue Engineering in the Management of Severe Hypospadias

Hypospadias, characterized by misplacement of the urinary meatus in the lower side of the penis, is a frequent birth defect in male children. Because of the huge variation in the anatomic presentation of hypospadias, no single urethroplasty procedure is suitable for all situations. Hence, many surgical techniques have emerged to address the shortage of tissues required to bridge the gap in the urethra particularly in the severe forms of hypospadias. However, the rate of postoperative complications of currently available surgical procedures reaches up to one-fourth of the patients having severe hypospadias. Moreover, these urethroplasty techniques are technically demanding and require considerable surgical experience. These limitations have fueled the development of novel tissue engineering techniques that aim to simplify the surgical procedures and to reduce the rate of complications. Several types of biomaterials have been considered for urethral repair, including synthetic and natural polymers, which in some cases have been seeded with cells prior to implantation. These methods have been tested in preclinical and clinical studies, with variable degrees of success. This review describes the different urethral tissue engineering methodologies, with focus on the approaches used for the treatment of hypospadias. At present, despite many significant advances, the search for a suitable tissue engineering approach for use in routine clinical applications continues.

Shear wave elastography: Can it be a new radiologic approach for the diagnosis of erectile dysfunction?

Introduction

Erectile dysfunction (ED) is a common health problem among males, and radiology has limited use in its diagnosis and treatment. Shear wave elastography (SWE) is a new sonographic technique. In this study, we examined the significance of SWE in the diagnosis of ED.

Methods

The study included a total number of 70 participants. The mean age of the participants was 54.14 ± 8.03 years (range: 39 and 71 years old). We composed two groups. Group 1 had 35 patients who presented to the urology clinic in our hospital complaining of ED, and had a score of 17 or lower from the International Index of Erectile Function (IIEF) questionnaire. Group 2 consisted of 35 healthy volunteers who did not have ED. SWE measurements were performed from corpus cavernosum penis in both groups, and the results were noted. Differences between the groups were evaluated statistically.

Results

The difference between the mean SWE measurements of two groups (Group 1: 20.94 ± 6.23 kPa and group 2: 24.63 ± 7.58 kPa) was found to be statistically significant (p = 0.027; p < 0.05). For a cut-off value of 17.1 kPa, the SWE method has specificity, sensitivity, positive predictive value, and negative predictive value regarding diagnosis of ED as 94.29%, 34.29%, 85.71%, and 58.93%, respectively. The mean age of the groups did not show a statistically significant difference (p = 0.287; p > 0.05).

Conclusions

Due to its high specificity and positive predictive value, SWE can offer useful data in the radiologic evaluation of ED cases.

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.