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Ting CSY, Ting SW, Kuo G, Chang PY. Taping alone for persistent ventral curvature after urethral plate transection in hypospadias. J Pediatr Urol 2024; 20:409.e1-409.e8. [PMID: 38631939 DOI: 10.1016/j.jpurol.2023.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Ventral penile curvature is a key factor in determining the surgical approach to proximal hypospadias repair. However, there is limited evidence regarding the efficacy and long-term effects of the procedures used to address curvature. This study aimed to evaluate the effects of urethral plate transection alone with tissue traction therapy on penile curvature in two-stage repair of proximal hypospadias. MATERIAL AND METHODS This was a prospective study of primary hypospadias patients who underwent a two-stage repair with urethral plate transection as the sole straightening procedure. After stage 1, taping was applied as tissue traction therapy and continued until stage 2. Penile curvature was measured using a goniometer under artificial erection before and immediately after urethral plate transection and during the second stage of repair. The primary focus of this investigation is the angle of curvature after 6-month taping. RESULTS The study included 46 patients with a median age of 13 months at the start of treatment. The median angle of penile ventral curvature was 70° after degloving, 60° after urethral plate transection, and 0° during the second stage of repair. Full correction of ventral curvature was achieved in 42 patients (91 %). DISCUSSION This publication is the first of its kind to propose taping as a method for penile traction therapy in hypospadias. The study reveals that penile ventral lengthening can be achieved through tissue traction therapy following UP transection alone. These findings challenge the current consensus that complete straightening of the penis in the first stage is necessary to prevent recurrent curvature and that ventral lengthening is required to correct corporal disproportion. However, further validation and long-term data are needed to definitively confirm the effectiveness of tissue traction therapy after urethral plate transection. CONCLUSIONS This study demonstrated significant resolution rate of penile ventral curvature in proximal hypospadias following urethral plate transection alone with taping. Long-term follow-up studies are needed to confirm the sustainability of the results through puberty.
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Affiliation(s)
- Cynthia Sze-Ya Ting
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Linkou Branch. No.5 Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan.
| | - Sze-Wen Ting
- Department of Dermatology, New Taipei City Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - George Kuo
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Pei-Yeh Chang
- Department of Pediatric Surgery, Chang Gung Children's Hospital, Chang Gung University, School of Medicine, No.5, Fuxing St., Guishan Dist., Taoyuan City 33305, Taiwan.
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Gigola F, Mantovani A, Zulli A, Bortot G, Cini C, Olivera L, Landi L, Taverna M, Masieri L, Elia A. Modified PATIO technique for urethrocutaneous fistula after hypospadias repair: Experience from a tertiary referral hospital. J Pediatr Urol 2024; 20:437.e1-437.e6. [PMID: 38369430 DOI: 10.1016/j.jpurol.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/15/2024] [Accepted: 01/31/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Urethrocutaneous fistula (UCF) is a common complication after hypospadias repair with an incidence of 5-10%. Several techniques are described for its repair: small UCFs are frequently corrected by isolation, excision, and closure with apposition of a protective second layer. In 2008 Malone described the PATIO technique: the fistula tract is turned inside out in the urethral lumen preventing contact with passing urine without direct urethral sutures. OBJECTIVE Aim of our study is to present our outcomes using a modified version of the PATIO technique, with a more reproducible isolation of the tract and without its fixation at the urethral meatus. STUDY DESIGN We retrospectively reviewed all cases of UCFs corrected with a modified PATIO technique at our center between 2016 and 2020. Data collected from electronical clinical notes were age at UCF closure, location of UCF, presence of meatal stenosis and clinical outcomes. Data are presented as median and IQR. RESULTS In the study period we performed 425 urethroplasties for distal and mid penile hypospadias. The incidence of UCFs was 7% (30/425) and 25 patients underwent UCF correction with modified PATIO. Median age at repair was 4.5 years (IQR: 2.5-6.2). At a median follow-up of 3 years (IQR: 2-4) recurrence was observed in 5 cases out of 24 with one patient who was lost at follow-up (20.8%). One case was corrected successfully with re-do modified PATIO technique, while 4 are awaiting repair. One cases was lost at follow-up. UFC-recurrence was homogeneously distributed along the study period. DISCUSSION Risk factors for UCF recurrence are mostly the type of hypospadias, neo-urethral length, and quality of the urethral plate. Among the many existing techniques, we propose a modified version of Malone's PATIO repair. We believe that the use of four stay-suture to isolate the fistula allows a well-defined dissection of the tract along its surface, compared to the use of a single stay-suture. In our experience, there is no need to keep and fix the traction on the fistula tract to the urethral meatus, probably reflecting the efficacy of the fistula closure during the introflection, which is then maintained without traction. Limitations to our study include the retrospective nature of the review, the small sample size of the cohort and the absence of control groups. CONCLUSIONS Our results appear consistent with literature regarding the efficacy of PATIO principles in treating UCF. Modified PATIO seem to be particularly reproducible, showing encouraging results.
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Affiliation(s)
- Francesca Gigola
- School of Paediatric Surgery, University of Florence, Florence, Italy; Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy
| | - Alberto Mantovani
- Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy.
| | - Andrea Zulli
- School of Paediatric Surgery, University of Florence, Florence, Italy; Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy
| | - Giulia Bortot
- Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy
| | - Chiara Cini
- Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy
| | - Laura Olivera
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Luca Landi
- Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy
| | - Maria Taverna
- Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy
| | - Lorenzo Masieri
- Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy; Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Antonio Elia
- Department of Paediatric Urology, Meyer's Children Hospital IRCCS, Florence, Italy
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Raines A, Fernandez N, Ahn J, Cain M, Joyner B, Kieran K, Merguerian P, Shnorhavorian M. Preputial pedicle flap ICG blood flow assessment during proximal hypospadias repair: Development of a standardized protocol. J Pediatr Urol 2024:S1477-5131(24)00273-0. [PMID: 38821733 DOI: 10.1016/j.jpurol.2024.05.015] [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: 11/23/2023] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 06/02/2024]
Abstract
INTRODUCTION Blood supply to preputial flap drives outcomes of hypospadias repair. Unfortunately, we only have surgeon's subjective assessment to evaluate flap perfusion which may not be accurate. Indocyanine green (ICG) has been used in a multitude of surgeries for perfusion assessment, however, no standardized protocol has been described for use of ICG in hypospadias repairs. The aim of this study is to develop a standardized protocol of ICG use in proximal hypospadias and establish perfusion patterns of preputial flaps. STUDY DESIGN A pilot study was conducted using ICG in patients with proximal hypospadias undergoing first stage repair with a preputial flap. The Stryker SPY PHI system and novel quantification software, SPY-QP, were used for ICG imaging. An adaptive approach was taken to develop and implement a standardized protocol (Summary Figure). Per the protocol, ICG was administered at 3 time points which were felt to be critical for assessment of flap perfusion. Of the study patients who have undergone second stage repair, ICG was also used to reassess the flap prior to tubularization of the urethra. RESULTS A total of 14 patients underwent first stage hypospadias repair with preputial flaps and intraoperative use of ICG. Median ICG uptake of the prepuce after degloving (dose 1) was 58.5% (IQR 43-76). ICG uptake decreased after flap harvest and mobilization (dose 2) with a median ICG uptake of 34% (IQR 26-46). ICG uptake remained stable after securing the flap in place and closing the skin (dose 3) with a median ICG uptake of 34% (IQR 25-48). ICG was able to delineate subtle findings in the preputial flaps not visible to the naked eye and in one case impacted intraoperative decision making. To date, 5 patients have undergone second stage repair. Flap assessment prior to tubularization of the urethra showed hypervascularity with a median ICG uptake of 159%. CONCLUSIONS A standardized protocol for ICG use in proximal hypospadias was successfully developed and implemented. ICG uptake in the preputial flap decreased with increasing manipulation and mobilization of the flap. ICG was able to detect changes to flap perfusion which were not able to be seen with the naked eye. Reliance on surgeon's subjective assessment of flap perfusion may be inadequate and ICG could provide a useful tool for surgeons to improve preputial flap outcomes. ICG may also enhance the learning experience for trainees and early career urologists in these complex surgeries.
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Affiliation(s)
- Amanda Raines
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA; Department of Urology, Louisiana State University, New Orleans, LA, USA; Division of Urology, Children's Hospital of New Orleans, New Orleans, LA, USA.
| | - Nicolas Fernandez
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Jennifer Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Mark Cain
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Byron Joyner
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Kathleen Kieran
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Paul Merguerian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Margarett Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
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Huang A, Lee V, Chauhan AE, Sahoo A, Li J, Pham D, Aninwene GE, Yiu F, Lerman S, Iyer N, Moman P, Jackson N, Sturm RM. Application of intraoperative structured light scanning to enable post-operative evaluation of digital and 3D-printed penile models. J Pediatr Urol 2024:S1477-5131(24)00269-9. [PMID: 38862294 DOI: 10.1016/j.jpurol.2024.05.011] [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: 12/31/2023] [Revised: 04/06/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Penile phenotype in hypospadias is currently assessed visually or manually (e.g., ruler, goniometer) for clinical, education, and research applications. However, these methods lack precision and accuracy across raters and cannot be reevaluated retrospectively following a surgical repair. The project aim was to evaluate the precision and reliability of penile dimensions obtained from digital and three dimensional (3D) printed models created from intraoperative (OR) structured light scans (SLS) during primary pediatric penile procedures. METHODS Boys ages 1 month to 6 years underwent first- or single-stage penile surgery at a single institution were enrolled in this prospective study (IRB #20-000143). For each patient, immediately following placement of a stay suture under consistent manual tension, intra-operative dimension measurements with a ruler were obtained. A digital 3D model was created prior to penile repositioning using an Artec Space Spider scanner and Artec Studio 13 software. Following the case, two different raters completed 10 digital measurements of each generated model in Autodesk Fusion 360. These digital models were subsequently 3D printed and two different raters completed 10 manual dimension measurements of each 3D printed model using a ruler. A one-way random effects intraclass correlation coefficient (ICC) evaluated measures of agreement between and within raters, respectively. Analyses were conducted in R version 4.2. RESULTS Six scans were obtained (hypospadias: 4, circumcision: 2). Intra-rater assessments showed excellent precision across repeated digital measurements; manual measurements of 3D printed models had excellent reliability for glans width and penile length but poor to good reliability for glans height. Inter-rater reliability was good to excellent for glans width (0.77-0.95) and good for penile length (0.71-0.88). However, there was poor inter-rater reliability for glans height (0-0.14). Following training regarding glans height location, there was an improvement in precision and repeatability of manual and digital measurements. CONCLUSION Digital measurement of OR-derived 3D models resulted in excellent repeatability for each rater and improved between-rater reliability over manual measurement of 3D printed models alone, ensuring that images can be compared by various surgeons both now and in the future. SLS is promising as a novel modality to digitally generate 3D models, thereby informing phenotypic analysis for research and education. Further development of digital measurement methods to ensure consistency between raters for quantitative assessment of additional parameters and assessment of the technology within the pre-operative environment for surgical planning is planned.
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Affiliation(s)
- Alen Huang
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Victoria Lee
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Akash E Chauhan
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Astha Sahoo
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joshua Li
- Department of Medicine Statistics Core, UCLA, Los Angeles, CA, USA
| | - Derek Pham
- Department of Medicine Statistics Core, UCLA, Los Angeles, CA, USA
| | - George E Aninwene
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Felix Yiu
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Steven Lerman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Neha Iyer
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Precious Moman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nicholas Jackson
- Department of Medicine Statistics Core, UCLA, Los Angeles, CA, USA
| | - Renea M Sturm
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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Borkar N, Tiwari C, Nair A, Sinha CK, Ratan SK, Naredi BK. Single dartos flap versus double dartos flap in hypospadias repair: A systematic review and meta-analysis with trial sequential analysis and fragility index. Urologia 2024; 91:439-447. [PMID: 38345023 DOI: 10.1177/03915603241231058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Hypospadias is a common congenital urogenital anomaly. Despite advancements in surgical techniques, still it presents challenges in management. An important aspect of hypospadias repair is the use of protective layers to cover neourethra. This review focuses on comparing the Single Dartos Flap (SDF) and Double Dartos Flap (DDF) techniques, used to cover the neourethra. These techniques differ in terms of the number of dartos layers used to cover the neourethra. METHODS This systematic review, follows PRISMA guidelines, included six RCTs from PubMed/MEDLINE, Cochrane Library, Scopus, Web of Science, and CINAHL. Patients with hypospadias repair with use of SDF or DDF were analyzed for outcome, Urethrocutaneous fistula, meatal stenosis, glans dehiscence, penile torsion and cosmetic outcomes. Statistical analysis was done using Review Manager, with TSA and FI ensuring result robustness. RESULTS Six studies met inclusion criteria, and risk of bias assessment indicated low risk across all domains. Meta-analysis results favored DDF over SDF for reducing urethrocutaneous fistula (RR 0.37, 95% CI 0.20-0.68) but showed no significant difference in meatal stenosis and glans dehiscence. DDF also associated with lower risk of penile torsion (RR 0.05, 95% CI 0.01-0.35). CONCLUSION The systematic review, based on randomized controlled trials (RCTs), provides evidence supporting the use of DDF over SDF in hypospadias repair, particularly in distal hypospadias using the TIP procedure. The article emphasizes the potential advantages of DDF in reducing UCF but further robust evidence is needed to confirm these results based on the findings of TSA and FI.
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Affiliation(s)
- Nitinkumar Borkar
- Department of Paediatric Surgery, AIIMS, Raipur, Chhattisgarh, India
| | - Charu Tiwari
- Department of Paediatric Surgery, AIIMS, Raipur, Chhattisgarh, India
| | - Abhijit Nair
- Department of Anaesthesiology, Ibra Hospital, Sultanate of Oman
| | - C K Sinha
- St George's University Hospital, London, UK
| | - Simmi K Ratan
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
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Caldwell J, Noonavath M, Maxwell A, Sapkalova V, Shnorhavorian M, Fernandez N. Comparison of hypospadias phenotype pixel segmentation to GMS score. J Pediatr Urol 2024:S1477-5131(24)00202-X. [PMID: 38710598 DOI: 10.1016/j.jpurol.2024.04.009] [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: 10/29/2023] [Revised: 04/10/2024] [Accepted: 04/15/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Hypospadias phenotype assessment determines if the anatomy is favorable for reconstruction. Glans-Urethral Meatus-Shaft (GMS) has been adopted in an effort to standardize hypospadias classification. While extremely subjective, GMS has been widely used to classify the severity of the phenotype to predict surgical outcomes. The use of digital image analysis has proven to be feasible and prior efforts by our team have demonstrated that machine learning algorithms can emulate an expert's assessment of the phenotype. Nonetheless, the creation of these image recognition algorithms is highly subjective. In order to reduce a subjective input in the evaluation of the phenotype, we propose a novel approach to analyze the anatomy using digital image pixel analysis and to compare the results using the GMS score. Our hypothesis is that pixel cluster segmentation can discriminate between favorable and unfavorable anatomy. OBJECTIVE To evaluate whether image segmentation and digital pixel analysis are able to analyze favorable vs unfavorable hypospadias anatomy in a less subjective manner than GMS score. METHODS A total of 148 patients with different types of hypospadias were classified by 1 of 5 independent experts following the GMS score into "favorable" (GG), "moderately favorable" (GM) and "unfavorable" (GP) glans. From there, 592 images were generated using digital image segmentation. 584 were included for final analysis due to certain images being excluded for poor image quality or inadequate capture of target anatomy. For each image, the region of interest was segmented separately by two evaluators into "glans," "urethral plate," "foreskin" and "periurethral plate". The values obtained for each segmented region using machine-learning statistical pixel k-means cluster analysis were analyzed and compared to the GMS score given to that image using an ANOVA analysis. RESULTS Analysis of image segmentation demonstrated that k-means pixel cluster analysis discriminated "favorable" vs "unfavorable" urethral plates. There was a significant difference between scores when comparing the GG and GM groups (p = 0.03) and GG and GP groups (p = 0.05). Pixel cluster analysis could not discriminate between "moderately favorable" and "unfavorable" urethral plates. CONCLUSIONS Through our analysis, we found significant pairwise difference for different tissue qualities. Digital image segmentation and statistical k-means cluster analysis can discriminate anatomical features in a similar way to the GMS score. Future research can target discerning between different tissue qualities in an effort to predict surgical outcomes for hypospadias repair.
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Affiliation(s)
- Joshua Caldwell
- Department of Urology, University of Washington, United States
| | | | - Adam Maxwell
- Department of Urology, University of Washington, United States
| | | | - Margarett Shnorhavorian
- Department of Urology, University of Washington, United States; Division of Pediatric Urology Seattle Children's Hospital, United States
| | - Nicolas Fernandez
- Department of Urology, University of Washington, United States; Division of Pediatric Urology Seattle Children's Hospital, United States.
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Neheman A, Schwarztuch Gildor O, Shumaker A, Beberashvili I, Bar-Yosef Y, Arnon S, Zisman A, Stav K. Use of Validated Questionnaires to Predict Cosmetic Outcomes of Hypospadias Repair. CHILDREN (BASEL, SWITZERLAND) 2024; 11:189. [PMID: 38397301 PMCID: PMC10887056 DOI: 10.3390/children11020189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024]
Abstract
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.
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Affiliation(s)
- Amos Neheman
- Meir Medical Center, Department of Urology, Kfar Saba 44281, Israel; (A.N.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
| | - Omri Schwarztuch Gildor
- Meir Medical Center, Department of Urology, Kfar Saba 44281, Israel; (A.N.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
| | - Andrew Shumaker
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Shamir Medical Center, Department of Urology, Zerifin 703001, Israel
| | - Ilia Beberashvili
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Shamir Medical Center, Department of Nephrology, Zerifin 703001, Israel
| | - Yuval Bar-Yosef
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Department of Pediatric Urology, Dana-Dwek Children’s Hospital, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Shmuel Arnon
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Meir Medical Center, Department of Neonatology, Kfar Saba 4428164, Israel
| | - Amnon Zisman
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Shamir Medical Center, Department of Urology, Zerifin 703001, Israel
| | - Kobi Stav
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (A.S.); (I.B.); (Y.B.-Y.); (A.Z.); (K.S.)
- Shamir Medical Center, Department of Urology, Zerifin 703001, Israel
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Johnson EK, Whitehead J, Cheng EY. Differences of Sex Development: Current Issues and Controversies. Urol Clin North Am 2023; 50:433-446. [PMID: 37385705 DOI: 10.1016/j.ucl.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Differences of sex development (DSD) encompass a broad range of conditions in which the development of chromosomal, gonadal, or anatomic sex is not typically male or female. Terms used to describe DSD are controversial, and continuously evolving. An individualized, multidisciplinary approach is key to both the diagnosis and management of DSD. Recent advances in DSD care include expanded genetic testing options, a more nuanced approach to gonadal management, and an emphasis on shared decision-making, particularly related to external genital surgical procedures. The timing of DSD surgery is currently being questioned and debated in both medical and advocacy/activism spheres.
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Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 2300, Chicago, IL, 60611, USA.
| | - Jax Whitehead
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 54, Chicago, IL 60611, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 86, Chicago, IL 60611, USA
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 2300, Chicago, IL, 60611, USA
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Zhang Y, Wang X, Wu Y, Li S, Zhang D, Ma X, Wang C, Zhang Z, Ma Y, Wei B, Guan Y. Grafts vs. flaps: a comparative study of Bracka repair and staged transverse preputial island flap urethroplasty for proximal hypospadias with severe ventral curvature. Front Pediatr 2023; 11:1214464. [PMID: 37416816 PMCID: PMC10321133 DOI: 10.3389/fped.2023.1214464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/12/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction Bracka repair and staged transverse preputial island flap urethroplasty are both significant methods in treating proximal hypospadias. They utilize the flap and graft techniques, respectively, to achieve a satisfactory success rate. This study aimed to compare the outcomes of these 2 methods in the treatment of proximal hypospadias with severe ventral curvature. Methods We retrospectively analyzed 117 cases of proximal hypospadias with severe ventral curvature who had undergone either Bracka repair (n = 62) or staged transverse preputial island flap urethroplasty (n = 55). All operations were performed by a single surgeon, and the choice of method was determined by the surgeon's preference based on his experience. Cosmetic outcome was evaluated with Pediatric Penile Perception Score (PPPS). Patients' characteristics including age, penis length, glans diameter, length of the urethral defect and ventral curvature degree, cosmetic outcomes, and complication rates were all compared. Results There was no significant difference in age, penis length, glans diameter, length of the urethral defect, or ventral curvature degree. In the Bracka group, there were 5 patients with fistula, 1 patient with stricture, and 1 case of dehiscence. In the staged transverse preputial island flap urethroplasty group, there were 4 patients with fistula, 1 with stricture, and 2 with diverticulum. The scores of shaft skin and general appearance were consistently higher in the Bracka group than in the staged transverse preputial island flap urethroplasty group. The differences in complication rate and cosmetic outcome were not statistically different (P > 0.05). Conclusions Bracka repair and staged transverse preputial island flap urethroplasty are both satisfactory staged surgical options for proximal hypospadias with severe ventral curvature and have similar complication rates. Bracka repair may create a better appearance, but more studies are needed to confirm this finding. Pediatric surgeons should consider additional factors, such as the patient's specific condition, parents' inclination, and personal experience, rather than safety, to make the best choice between the 2 methods.
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10
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Yamashiro JR, Austin JC, Braga LH, Chuang KW, Davis-Dao CA, Hecht S, Holzman SA, Khoury AE, Kurzrock EA, Lerman SE, McGrath M, Merguerian PA, Saltzman AF, Schaeffer AJ, Seideman C, Singer JS, Wang P, Wehbi EJ, Wu HY, Sturm RM. Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network. J Pediatr Urol 2023; 19:277-283. [PMID: 36775718 PMCID: PMC10686787 DOI: 10.1016/j.jpurol.2022.12.001] [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: 02/15/2022] [Revised: 09/12/2022] [Accepted: 12/04/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series. OBJECTIVE With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network. STUDY DESIGN A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation. RESULTS Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons. CONCLUSION Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.
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Affiliation(s)
- Justine R Yamashiro
- University of California Los Angeles, 200 Medical Plaza, Suite 170, Los Angeles, CA, 90095, USA.
| | - J Christopher Austin
- Oregon Health & Science University, 700 S.W. Campus Drive, Portland, Oregon, USA 97239, 875 Oak Street S.E., Salem, OR, 97301, USA.
| | - Luis H Braga
- McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada.
| | - Kai-Wen Chuang
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Carol A Davis-Dao
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Sarah Hecht
- Oregon Health & Science University, 700 S.W. Campus Drive, Portland, Oregon, USA 97239, 875 Oak Street S.E., Salem, OR, 97301, USA.
| | - Sarah A Holzman
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Antoine E Khoury
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Eric A Kurzrock
- University of California Davis, 4860 Y Street, Suite 2200, Sacramento, CA, 95817, USA.
| | - Steven E Lerman
- University of California Los Angeles, 200 Medical Plaza, Suite 170, Los Angeles, CA, 90095, USA.
| | - Melissa McGrath
- McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada.
| | - Paul A Merguerian
- University of Washington, 4800 Sand Point Way NE, OA.9.220, Seattle, WA, 98105, USA.
| | - Amanda F Saltzman
- University of Kentucky, 800 Rose Street, MS 237, Lexington, KY, 40536, USA.
| | - Anthony J Schaeffer
- University of Utah, 100 N Mario Capecchi Drive, Suite 3550, Salt Lake City, UT, 84113, USA.
| | - Casey Seideman
- Oregon Health & Science University, 700 S.W. Campus Drive, Portland, Oregon, USA 97239, 875 Oak Street S.E., Salem, OR, 97301, USA.
| | - Jennifer S Singer
- University of California Los Angeles, 200 Medical Plaza, Suite 170, Los Angeles, CA, 90095, USA.
| | - Peter Wang
- LHSC-Victoria Hospital, 800 Commissioners Road East, London, Ontario, N6A 5A5, Canada.
| | - Elias J Wehbi
- Children's Hospital of Orange County and University of California Irvine, 101 the City Dr S Pavilion 3, Orange, CA, 92686, USA.
| | - Hsi-Yang Wu
- Brown University, 593 Eddy Street, Suites 185 & 190, Providence, RI, 02903, USA.
| | - Renea M Sturm
- University of California Los Angeles, 200 Medical Plaza, Suite 170, Los Angeles, CA, 90095, USA.
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11
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Huen KH, Macaraeg A, Davis-Dao CA, Kashmiri H, Williamson SH, Boswell T, Thomas JE, Suhale Z, Chuang KW, Stephany HA, Wehbi EJ, Khoury AE. Recurrent ventral curvature after corporoplasty with tunica vaginalis flap. J Pediatr Urol 2023; 19:38.e1-38.e7. [PMID: 36307369 DOI: 10.1016/j.jpurol.2022.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/08/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION AND OBJECTIVE Optimal means to correct ventral curvature (VC) is debated. Our preferred technique for curvature greater than 45° is corporoplasty using tunica vaginalis flap (TVF). We describe our complications with TVF for ventral lengthening. METHODS Forty-four boys who underwent ventral lengthening with a corporoplasty with TVF were identified in a prospective database for proximal hypospadias repair by a single surgeon from 2008 to 2021. Corporotomy was performed by incising the tunica albuginea of the corpora cavernosa transversely at the point of maximum curvature. Harvested TVF was tailored to the size of the corporotomy and anastomosed to the edges of the tunica albuginea and on laid to the corporal defect with the mesothelial side of the TVF abutting the erectile tissue. RESULTS Median age at surgery was 1.0 years (IQR 0.72-1.82). Median follow-up time was 4.9 years (IQR 2.6-8.0). Thirteen patients (27%) were older than 10 years of age at last follow up (median 13.3, range 10-20). Twenty-two boys (50%) received preoperative testosterone. The most common location of the meatus after degloving was penoscrotal (41%). Median VC after degloving was 90° (IQR 80-100). The urethral plate was transected in 43/44 (98%) of boys, improving median VC to 60° (IQR 40-60). After corporotomy, the median longitudinal distracted distance was 15 mm (IQR 12-17). Urethral reconstruction was most commonly achieved with the transverse island preputial flap technique or its modifications (39/44; 89%). Erections were reported in 42 boys (95%). None developed corporal diverticula, and two patients (4.5%) had ascended testis associated with TVF harvest. Seven percent of boys had recurrent ventral curvature (RVC; 3/44). Median RVC was 30° (IQR 30-45). One patient had RVC at the penoscrotal junction (not at site of prior corporoplasty) identified 11 years post operatively at age 15, and underwent dorsal plication. The other 2 patients were diagnosed less than 1 year post operatively. Both patients received testosterone due to small glans size, had double-face tubularized transverse island preputial flap as urethral and ventral skin coverage, and had endocrine and genetic consultation. Both had scarring of the preputial flap and of the corporoplasty. Scar excision and superficial transverse incisions on the tunica albuginea corrected RVC. CONCLUSIONS The five-year outcome of ventral penile lengthening using TVF for corporoplasty is favorable with 7% of boys with RVC, and 4.5% with ascended testes associated with TVF harvest. None developed corporal diverticula.
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Affiliation(s)
- Kathy H Huen
- Division of Pediatric Urology, UCLA Mattel Children's Hospital, Los Angeles, CA, USA; Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Amanda Macaraeg
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA
| | - Carol A Davis-Dao
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Himala Kashmiri
- Division of Pediatric Endocrinology, Children's Hospital of Orange County, Orange, CA, USA; Department of Pediatrics, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Sarah H Williamson
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Timothy Boswell
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Julia E Thomas
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA
| | - Zayn Suhale
- Department of Urology, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Kai-Wen Chuang
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Heidi A Stephany
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Elias J Wehbi
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Antoine E Khoury
- Division of Pediatric Urology, Children's Hospital of Orange County, Orange, CA, USA; Department of Urology, University of California-Irvine School of Medicine, Orange, CA, USA.
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12
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Zhou W, Li C, Xia F, Zhang Q, Chen Y. Application of a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering for the single-stage repair of severe hypospadias. Front Surg 2023; 9:1047104. [PMID: 36684118 PMCID: PMC9852617 DOI: 10.3389/fsurg.2022.1047104] [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: 09/17/2021] [Accepted: 10/25/2022] [Indexed: 01/09/2023] Open
Abstract
Objective To assess the outcome of a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering (BFIC) for the single-stage repair of severe hypospadias in children. Materials and methods A retrospective study was performed on 40 children with hypospadias who were treated in our hospital from December 2017 to February 2022. The inclusion criteria were as follows: (1) the patient had proximal hypospadias, or penile curvature over 30° after degloving the penis; and (2) the patient underwent surgery for hypospadias for the first time. A free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering was performed, and all patients were followed up for more than 6 months. Results After degloving the foreskin, the urethral orifice was retracted to the perineum and scrotum in 20 cases, penoscrotal in 8 cases, and penile in 12 cases. Single-stage repair was achieved without complications in 34 (85%) patients. The remaining six patients experienced postoperative complications: urethrocutaneous fistula occurred in five cases and glans dehiscence with urethrocutaneous fistula in one case. No urethral diverticulum occurred in any case. A neomeatus with a vertically oriented slit-like appearance was achieved at the tip of the glans in all cases, with one exception. Conclusion The single-stage operation with a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering in the treatment of severe hypospadias achieves favorable functional and cosmetic outcomes.
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13
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Wahyudi I, Utomo CP, Djauzi S, Fathurahman M, Situmorang GR, Rodjani A, Yonathan K, Santoso B. Digital Pattern Recognition for the Identification of Various Hypospadias Parameters via an Artificial Neural Network: Protocol for the Development and Validation of a System and Mobile App. JMIR Res Protoc 2022; 11:e42853. [PMID: 36427238 PMCID: PMC9736751 DOI: 10.2196/42853] [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: 09/22/2022] [Revised: 11/07/2022] [Accepted: 11/18/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Hypospadias remains the most prevalent congenital abnormality in boys worldwide. However, the limited infrastructure and number of pediatric urologists capable of diagnosing and managing the condition hinder the management of hypospadias in Indonesia. The use of artificial intelligence and image recognition is thought to be beneficial in improving the management of hypospadias cases in Indonesia. OBJECTIVE We aim to develop and validate a digital pattern recognition system and a mobile app based on an artificial neural network to determine various parameters of hypospadias. METHODS Hypospadias and normal penis images from an age-matched database will be used to train the artificial neural network. Images of 3 aspects of the penis (ventral, dorsal, and lateral aspects, which include the glans, shaft, and scrotum) will be taken from each participant. The images will be labeled with the following hypospadias parameters: hypospadias status, meatal location, meatal shape, the quality of the urethral plate, glans diameter, and glans shape. The data will be uploaded to train the image recognition model. Intrarater and interrater analyses will be performed, using the test images provided to the algorithm. RESULTS Our study is at the protocol development stage. A preliminary study regarding the system's development and feasibility will start in December 2022. The results of our study are expected to be available by the end of 2023. CONCLUSIONS A digital pattern recognition system using an artificial neural network will be developed and designed to improve the diagnosis and management of patients with hypospadias, especially those residing in regions with limited infrastructure and health personnel. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/42853.
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Affiliation(s)
- Irfan Wahyudi
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Chandra Prasetyo Utomo
- YARSI E-Health Research Center, Faculty of Information Technology, YARSI University, Jakarta, Indonesia
| | - Samsuridjal Djauzi
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Muhamad Fathurahman
- YARSI E-Health Research Center, Faculty of Information Technology, YARSI University, Jakarta, Indonesia
| | | | - Arry Rodjani
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Kevin Yonathan
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Budi Santoso
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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14
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 576] [Impact Index Per Article: 288.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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Yu J, Sun N, Song H, Li M, Li L, Gong C, Zhang W. Analysis in the influence factors of urethroplasty in DSD. BMC Urol 2022; 22:124. [PMID: 35948888 PMCID: PMC9367162 DOI: 10.1186/s12894-022-01080-x] [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: 03/07/2022] [Accepted: 07/28/2022] [Indexed: 11/28/2022] Open
Abstract
Background At present, there is no specific research on the factors affecting the success rate of urethroplasty in patients with DSD. The purpose of this study is to explore the factors affecting the success of urethroplasty in DSD patients, and to provide some reference for the surgical treatment of DSD patients undergoing urethroplasty.
Method We reviewed patients with DSD who underwent urethroplasty from January 2016 to December 2019 retrospectively. Patients were divided into four groups: the successful group, the urethrocutaneous fistula group, the urethral diverticulum group, and the urethral stricture group. Risk factors were determined from the following data included the DSD classification, the age of first operation, length of urethral defect, degree of hypospadias, cryptorchidism, micropenis, gonad type, hormone therapy before operation, transposition of penis and scrotum, surgical strategy, urethral covering material, and postoperative catheter removal time. We explored the difference of each factor between four groups through the comparative study of single factor and multifactor logistic regression analysis of related factors. Result 122 cases were enrolled in this group (n = 122), 12 cases were lost to follow-up. Median follow-up was 28 months (12–55 months).We found the success rate of operation decreased with longer urethral defect (B = − 0.473, P = 0.005). The success rate of operation was higher in staged operation and TPIT (TPIT = Transverse Preputial Island Tube operation)-related operation than primary operation (B = 1.238, P = 0.006) and TPIT-nonrelated operation (B = 2.293, P = 0.001). Although there was a significant difference between the age of the first operation and the occurrence of urethrocutaneous fistula (P = 0.006 < 0.05), there was no significant difference in logistic regression analysis (P = 0.161 > 0.05). The incidence of urethrocutaneous fistula was lower in TPIT-related operation than in TPIT-nonrelated operation (B = − 2.507, P = 0.000). The incidence of postoperative urethral diverticulum was lower in staged operation than in primary operation (B = − 1.737, P = 0.015). Conclusion For patients with disorder of sex development undergoing urethroplasty, the length of urethral defect is an independent risk factor affecting both the success rate of operation and the urethrocutaneous fistula. The age of the first operation has a statistically significant effect on the occurrence of postoperative urethrocutaneous fistula, but it is not an independent factor. Urethrocutaneous fistula is less found in TPIT-related operation in the study. Staged operation is an independent protective factor for postoperative urethral diverticulum compared with one-stage operation but isn’t related to urethrocutaneous fistula.
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Affiliation(s)
- Jing Yu
- Department of Urology, National Center for Children's Health, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, 100045, China
| | - Ning Sun
- Department of Urology, National Center for Children's Health, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, 100045, China
| | - Hongcheng Song
- Department of Urology, National Center for Children's Health, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, 100045, China
| | - Minglei Li
- Department of Urology, National Center for Children's Health, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, 100045, China
| | - Lele Li
- Department of Urology, National Center for Children's Health, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, 100045, China
| | - Chunxiu Gong
- Department of Urology, National Center for Children's Health, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, 100045, China.
| | - Weiping Zhang
- Department of Urology, National Center for Children's Health, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, 100045, China.
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Experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee: A single institution study with intermediate follow up. J Pediatr Surg 2022; 57:1404-1408. [PMID: 34217511 DOI: 10.1016/j.jpedsurg.2021.05.024] [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: 04/07/2021] [Revised: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE We present our modified technique of using the inner preputial flap to cover the penile shaft, while removing the subcutaneous tissue of the distal part of the flap to act similar to graft. Herein, we present our experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee. PATIENTS AND METHODS The current study was a single-institution retrospective study between January 2016 and December 2020. Thirty-one patients with proximal hypospadias with chordee were included and underwent our modified technique. We excluded re-operative hypospadias and incomplete follow-up cases (<6 month of follow up). Patient demographics, outcomes and complications in the form of fistula formation, diverticulum, metal stenosis, stricture formation and glans dehiscence were reviewed. RESULTS A total of 31 patients were included in the study and underwent our modified technique. The median age was 18 months (9-60) & IQR 15-25). The median follow up was 40 months. Overall, success was achieved in 24 cases (77.4%). Complications occurred in seven cases (22.6%) and included urethrocutanous fistula in three patients (9.7%), diverticulum in two patients (6.5.%), metal stenosis in one patient (3.2%) and glans dehiscence in one patient (3.2%). CONCLUSION Our technique provides a favourable outcome with a low complication rate for repair of proximal severe hypospadias. LEVEL OF EVIDENCE Case Series Study (Level IV).
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17
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Tissue Engineering and Regenerative Medicine in Pediatric Urology: Urethral and Urinary Bladder Reconstruction. Int J Mol Sci 2022; 23:ijms23126360. [PMID: 35742803 PMCID: PMC9224288 DOI: 10.3390/ijms23126360] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 11/22/2022] Open
Abstract
In the case of pediatric urology there are several congenital conditions, such as hypospadias and neurogenic bladder, which affect, respectively, the urethra and the urinary bladder. In fact, the gold standard consists of a urethroplasty procedure in the case of urethral malformations and enterocystoplasty in the case of urinary bladder disorders. However, both surgical procedures are associated with severe complications, such as fistulas, urethral strictures, and dehiscence of the repair or recurrence of chordee in the case of urethroplasty, and metabolic disturbances, stone formation, urine leakage, and chronic infections in the case of enterocystoplasty. With the aim of overcoming the issue related to the lack of sufficient and appropriate autologous tissue, increasing attention has been focused on tissue engineering. In this review, both the urethral and the urinary bladder reconstruction strategies were summarized, focusing on pediatric applications and evaluating all the biomaterials tested in both animal models and patients. Particular attention was paid to the capability for tissue regeneration in dependence on the eventual presence of seeded cell and growth factor combinations in several types of scaffolds. Moreover, the main critical features needed for urinary tissue engineering have been highlighted and specifically focused on for pediatric application.
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Ventral penile lengthening using tunica vaginalis flap for correction of curvature in proximal hypospadias repair: Technical aspects. UROLOGY VIDEO JOURNAL 2022. [DOI: 10.1016/j.urolvj.2022.100145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Castagnetti M, El-Ghoneimi A. Surgical management of primary severe hypospadias in children: an update focusing on penile curvature. Nat Rev Urol 2022; 19:147-160. [PMID: 35039660 DOI: 10.1038/s41585-021-00555-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 11/09/2022]
Abstract
Over the past two decades, assessment and treatment of associated curvature has emerged as a major issue in treating patients with proximal hypospadias. However, the cut-off for defining a curvature as clinically significant is still unclear, as not all patients are bothered by the same degree of curvature and, although the need for a method to assess the curvature objectively has been emphasized, no standard method yet exists. Curvature is multifactorial. The same degree of curvature can be due to any possible combination of skin and/or subcutaneous dartos tethering, a short urethral plate and an intrinsic corpora disproportion. Different strategies can be used to treat curvature, depending on the underlying cause, surgeon preferences, and the goals of the repair. In the past 10 years, use of urethral plate transection and ventral lengthening procedures has increased, although the lack of long-term follow-up data on ventral lengthening procedures suggests that the use of such procedures should be selective. Furthermore, straightening manoeuvres are influenced by the technique used for subsequent urethroplasty and, in turn, may influence the success rate of the urethroplasty. This Review provides a comprehensive overview of the major developments from the past 10 years in the management of severe proximal hypospadias in children.
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Affiliation(s)
- Marco Castagnetti
- Paediatric Urology Unit, Department of Surgery, Bambino Gesù Children Hospital and Research Institute, Rome, Italy. .,Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy.
| | - Alaa El-Ghoneimi
- Department of Paediatric Surgery and Urology, Reference Centre for Rare Urinary Tract Malformations (MARVU), Hôpital Robert Debré, APHP, Université de Paris, Paris, France
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Roshandel MR, Aghaei Badr T, Kazemi Rashed F, Salomon S, Ghahestani SM, Ferrer FA. Hypospadias in toddlers: a multivariable study of prognostic factors in distal to mid-shaft hypospadias and review of literature. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000225. [DOI: 10.1136/wjps-2020-000225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/15/2021] [Indexed: 11/04/2022] Open
Abstract
BackgroundTubularized 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.MethodsA 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.ResultsPersistent 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).ConclusionsOur 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.
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21
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Babu R, Chandrasekharam VVS. Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade. J Pediatr Urol 2021; 17:681-689. [PMID: 34099397 DOI: 10.1016/j.jpurol.2021.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/08/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade. METHODS A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes. RESULTS The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load. CONCLUSIONS Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.
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Affiliation(s)
- Ramesh Babu
- Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India.
| | - V V S Chandrasekharam
- Pediatric Surgery, Pediatric Urology and MAS, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India
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22
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Mallenahalli S, Fang AH, Tong CMC, Dangle PP. A Review of Literature on Long-Term Outcomes of Proximal Hypospadias — Urinary, Sexual, and Psychosocial. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-021-00304-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Chan YY, D'Oro A, Yerkes EB, Rosoklija I, Balmert LC, Lindgren BW, Gong EM, Liu DB, Johnson EK, Chu DI, Cheng EY. Challenging proximal hypospadias repairs: An evolution of technique for two stage repairs. J Pediatr Urol 2021; 17:225.e1-225.e8. [PMID: 33388263 DOI: 10.1016/j.jpurol.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars' flaps. STUDY DESIGN A single institution, retrospective, cohort study of consecutive two-stage, primary, proximal hypospadias repairs performed from 2007 to 2017 was conducted. Patients with <6 months follow-up and incomplete operative reports were excluded. Risk of complications (fistula, dehiscence, diverticulum, meatal stenosis, stricture) were evaluated following urethroplasty and stratified by first-stage repair technique. As technique refinements have been made since 2012, comparisons between two temporal subgroups (those who underwent repair in 2007-2012 and in 2013-2017) were made. RESULTS 78 of 127 patients met inclusion criteria. Overall complication rate was 47% (Summary Table). Median follow-up was 25.4 months (range 6.4-128.5 months) after urethroplasty. Pedicled preputial flaps (hazards ratio [HR] 0.30; 95% Confidence Interval [CI] 0.14-0.65) and inlay grafts (HR 0.32; 95% CI 0.11-0.95) were associated with lower complication risks compared to Byars' flaps (Summary Table). Median time to complication was significantly shorter for Byars' flaps (5.7 months) than for inlay grafts (40.6 months) and pedicled preputial flaps (79.2 months) by Kaplan Meier analysis. Temporal subgroup comparisons showed that overall complication rates decreased from 70% to 31% (p = 0.001), but differences in complication rates by first-stage technique were not statistically significant. DISCUSSION In our cohort, repairs with Byars' flaps had the highest complication rate, which is consistent with our observations that urethras tubularized from Byars' flaps lack appropriate backing and are hypermobile and irregular. To overcome these shortcomings, modifications were made to our approach to two-stage proximal hypospadias repairs with the use of inlay grafts and pedicled preputial flaps quilted to the underlying corporal bodies to optimize the stability of the urethral plate. Our preliminary results are promising. CONCLUSION Approach to the first stage of two-stage repairs affects outcomes. Pedicled preputial flaps and inlay grafts were associated with lower complication risks than Byars' flaps. Refinement of technique and patient selection may have resulted in fewer complications in the short term. However, long-term follow-up is needed.
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Affiliation(s)
- Yvonne Y Chan
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anthony D'Oro
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ilina Rosoklija
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Lauren C Balmert
- Department of Preventative Medicine/Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bruce W Lindgren
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Edward M Gong
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dennis B Liu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilie K Johnson
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David I Chu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Earl Y Cheng
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Long-Term Undesirable Consequences of Penile Skin Island Flap to Correct Penoescrotal Transposition: A Case Report and Review of Literature. Case Rep Urol 2021; 2021:6656540. [PMID: 33505761 PMCID: PMC7815407 DOI: 10.1155/2021/6656540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/05/2021] [Indexed: 11/18/2022] Open
Abstract
Hypospadias is a congenital malformation of the male lower urinary tract, consisting of a ventral urethral opening proximal to the glans penis. This condition is corrected surgically in the paediatric age, with a great variety of techniques available. Traditionally, a tubularized genital skin was used for one- or two-stage repairs. Nowadays, the tendency is to use preputial or oral mucosa grafts, dorsally located, to avoid diverticula formation and prevent hair growth in the neourethra. We present a case of a patient born with proximal hypospadias with penoscrotal transposition, surgically corrected in his childhood, using dorsal penile skin island flap. The patient is referred to urology consultation in his adulthood for a weak urinary stream, recurrent infections, and a large amount of hair exiting through the urethral meatus.
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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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Measurement accuracy of 3-Dimensional mapping technologies versus standard goniometry for angle assessment. J Pediatr Urol 2020; 16:547-554. [PMID: 32980263 DOI: 10.1016/j.jpurol.2020.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/08/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A specific aspect of the hypospadias phenotype that may contribute to long-term outcomes is the presence of ventral penile curvature and the adequacy of its surgical correction. The current gold standard to assess this angle is intraoperative goniometry of an erect penis. 3-dimensional (3D) mapping technologies may overcome the limitations of these traditional methods through their combination of digital image and geometric replication to produce consistent 3D digital forms of a physical structure. The aim of this study is to evaluate the measurement accuracy and reliability of handheld 3D mapping technologies versus standard goniometry for angle assessment in a laboratory setting. METHODS Blocks with specified angles (10-45°) were printed using a Zortrax M200 3D printer (±0.2% accuracy). Following the completion of standardized training, blinded participants measured each block angle using a baseline digit goniometer. Additionally, complete digital models of the blocks were created using 3D mapping technologies. Structured light scanning was completed using an Artec Space Spider and Artec Studio 13. Traditional photogrammetry was completed using a Canon Eos Rebel T5i DSLR camera and Agisoft Metashape Pro. Photogrammetry with a 3D camera was completed using the VECTRA H1 and VECTRA Analysis Module. All 3D models were imported into the software Autodesk Inventor in which automated angle measurements through the central plane were obtained. Statistical analysis was performed to determine the accuracy, precision and reliability of each modality using SAS 9.4 software. The reliability of goniometry and each mapping technology was evaluated using two-way random effect models with absolute agreement. RESULTS Six 3D printed blocks were evaluated. 5 digital models per block were created using each of the 3 mapping technologies. Inter-rater reliability of goniometry was moderate (ICC 0.76, 95% CI 0.46, 0.92), whereas all mapping technologies demonstrated excellent test-retest reliability: structured light scanning (ICC 0.99; 95% CI 0.999, 0.999); traditional photogrammetry (0.99; 0.99, 0.99); 3D camera (0.99; 0.99, 0.99). Mean angle measurements and standard error for each angle and modality are provided in the table. CONCLUSIONS This study demonstrated excellent accuracy, precision and reliability of off-the-shelf, handheld 3D mapping technologies and moderate reliability for goniometry when applied to measurements of angulation in a laboratory setting. The described methods developed in the laboratory for optimization of angle analysis from 3D models are an important step toward reliable, reproducible phenotypic analysis of congenital genitourinary conditions in future intraoperative and database development applications.
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Fernandez N, Lorenzo AJ, Rickard M, Chua M, Pippi-Salle JL, Perez J, Braga LH, Matava C. Digital Pattern Recognition for the Identification and Classification of Hypospadias Using Artificial Intelligence vs Experienced Pediatric Urologist. Urology 2020; 147:264-269. [PMID: 32991907 DOI: 10.1016/j.urology.2020.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/30/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To improve hypospadias classification system, we hereby, show the use of machine learning/image recognition to increase objectivity of hypospadias recognition and classification. Hypospadias anatomical variables such as meatal location, quality of urethral plate, glans size, and ventral curvature have been identified as predictors for postoperative outcomes but there is still significant subjectivity between evaluators. MATERIALS AND METHODS A hypospadias image database with 1169 anonymized images (837 distal and 332 proximal) was used. Images were standardized (ventral aspect of the penis including the glans, shaft, and scrotum) and classified into distal or proximal and uploaded for training with TensorFlow. Data from the training were outputted to TensorBoard, to assess for the loss function. The model was then run on a set of 29 "Test" images randomly selected. Same set of images were distributed among expert clinicians in pediatric urology. Inter- and intrarater analyses were performed using Fleiss Kappa statistical analysis using the same 29 images shown to the algorithm. RESULTS After training with 627 images, detection accuracy was 60%. With1169 images, accuracy increased to 90%. Inter-rater analysis among expert pediatric urologists was k= 0.86 and intrarater 0.74. Image recognition model emulates the almost perfect inter-rater agreement between experts. CONCLUSION Our model emulates expert human classification of patients with distal/proximal hypospadias. Future applicability will be on standardizing the use of these technologies and their clinical applicability. The ability of using variables different than only anatomical will feed deep learning algorithms and possibly better assessments and predictions for surgical outcomes.
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Affiliation(s)
- Nicolas Fernandez
- Division of Urology, Seattle Children's Hospital, University of Washington, Seattle, USA
| | - Armando J Lorenzo
- Department of Surgery, Division of Urology, Hospital for Sick Children, University of Toronto, Canada
| | - Mandy Rickard
- Department of Surgery, Division of Urology, Hospital for Sick Children, University of Toronto, Canada
| | - Michael Chua
- Department of Surgery, Division of Urology, Hospital for Sick Children, University of Toronto, Canada
| | - Joao L Pippi-Salle
- Division of Pediatric Urology, Sidra Medical and Research Center, Doha, Qatar
| | - Jaime Perez
- Division of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia; Department of Urology, Fundación Santa Fe de Bogota. Bogota, Colombia
| | - Luis H Braga
- Division of Urology, McMaster Children's Hospital, McMaster University, Hamilton, Canada
| | - Clyde Matava
- Department of Anesthesia, Hospital for Sick Children, University of Toronto, Canada.
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Bandini M, Sekulovic S, Spiridonescu B, Dangi AD, Krishnappa P, Briganti A, Salonia A, Montorsi F, Djinovic R. Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias. Int Braz J Urol 2020; 46:1029-1041. [PMID: 32822133 PMCID: PMC7527085 DOI: 10.1590/s1677-5538.ibju.2019.0845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/20/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair. MATERIAL AND METHODS Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated. RESULTS Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream. CONCLUSIONS Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.
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Affiliation(s)
- Marco Bandini
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia.,Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Sasha Sekulovic
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia
| | - Bogdan Spiridonescu
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia.,FundeniClinical Institute-Center for Uronephrology and Renal Transplantation, Bucharest, Romania
| | - Anuj Deep Dangi
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia.,Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Pramod Krishnappa
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia.,Department of Urology, NU Hospitals, Bangalore, India
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Salonia
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Rados Djinovic
- Sava Perovic Foundation, Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia
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Villanueva CA. Ventral penile curvature estimation using an app. J Pediatr Urol 2020; 16:437.e1-437.e3. [PMID: 32430211 DOI: 10.1016/j.jpurol.2020.04.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/27/2020] [Accepted: 04/24/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVE The assessment of penile curvature is a key component of hypospadias surgery, as it often determines if a 1 or 2-stage procedure should be done. The objective of this study was to test the accuracy of penile curvature measurements using an App-based method among non-urologists. METHODS Lateral pictures of six plastic 3-dimensional penile models representing each decile of curvature from 20 to 70° were obtained and stored on the research project iPad. Each picture was labeled with a name (i.e. Jim). Non-urology medical professionals were recruited to estimate the curvature of the six pictures with an App-based method consisting of the Photoblend Pro App and 9 provided graded 2-dimensional penile curvature images (representing each decile of curvature from 10 to 90°). Curvature estimations were done by merging the picture of the 3-dimensional penile model with one of the 9 provided graded 2-dimensional penile curvature images inside the App in an iterative process until the penile model picture matched the graded image (see figure). A research associate taught the research subjects the App-based method and then the subjects were asked to estimate the ventral penile curvature of each of the six penile model pictures. Measurement error was calculated as the absolute difference in between the measured value and the true value for the 6 models. A comparison was then made with previous research where pediatric urologists used either a goniometer or unaided visual inspection (UVI) to measure the ventral curvature of the same plastic 3-dimensional penile models used for the pictures of this study. RESULTS Twenty-one subjects were recruited, and all completed the study. Mean errors using the App ranged from 1.9° to 7.1°, compared to 6.5°-15° for UVI and 4.4°-15.9° for goniometry. The median error for the App was 0° compared to 5-10° for both UVI and goniometry. Mean errors were significantly lower (p < 0.05) when using the app compared to UVI/goniometry for all except the 30° and 50° models. Assuming patients with VC ≤ 30° would have had a one stage repair versus a 2-stage repair if curvature was >30°, the number of measurements that could have resulted in the unintended operation was calculated. There was a statistically significant difference in number of potential unintended surgeries in between App (17%) versus UVI + Goniometer (37%) (p = 0.0133). CONCLUSION This pilot study demonstrated better penile curvature estimations using the App compared to the two most common methods currently used by pediatric urologists. Plastic models provide an avenue to test and compare penile curvature measurement techniques.
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Affiliation(s)
- Carlos A Villanueva
- Phoenix Children's Hospital, 1920 E. Cambridge Ave., Ste. 302, Phoenix, 85006, AZ, USA.
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Piñeyro-Ruiz C, Serrano H, Pérez-Brayfield MR, Jorge JC. New frontiers on the molecular underpinnings of hypospadias according to severity. Arab J Urol 2020; 18:257-266. [PMID: 33312738 PMCID: PMC7717703 DOI: 10.1080/2090598x.2020.1760589] [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] [Indexed: 10/31/2022] Open
Abstract
Hypospadias, which is characterised by the displacement of the urethral meatus from its typical anatomical location in males, shows various degrees of severity. In this systematic review, we surveyed our current understanding of the genetics of isolated hypospadias in humans according to the severity of the condition. We found that sequencing and genotyping approaches were the preferred methods of study and that single nucleotide polymorphisms were the most common finding associated with hypospadias. Most genes fell into four gene-pathway categories related to androgens, oestrogens, growth factors, or transcription factors. Few hypospadias studies classify their findings by severity. Taken together, we argue that it is advantageous to take into consideration the severity of the condition in search of novel candidates in the aetiology of hypospadias. Abbreviations: AR: androgen receptor; ATF3: activating transcription factor 3; BMP4: bone morphogenetic protein 4; BMP7: bone morphogenetic protein 7; CYP17: steroid 17-alpha-hydroxylase/17,20 lyase; CYP1A1: cytochrome P450 1A1; CYP3A4: cytochrome P450 3A4; CNVs: copy number variants; DGKK: diacylglycerol kinase kappa; ESR1: oestrogen receptor 1; ESR2: oestrogen receptor 2; FGF8: fibroblast growth factor 8; FGF10: fibroblast growth factor 10; FGFR2: fibroblast growth factor receptor 2; HOXA4: homeobox protein Hox-A4; HOXB6: homeobox protein Hox-B6; HSD17B3: hydroxysteroid 17-beta dehydrogenase 3; MAMLD1: mastermind-like domain-containing protein 1; SF-1: splicing factor 1; SHH: sonic hedgehog; SNPs: single nucleotide polymorphisms; SOX9: SRY-box 9; SRD5A2: steroid 5 alpha-reductase 2; SRY: sex-determining region Y protein; STAR: steroidogenic acute regulatory protein; STARD3: StAR-related lipid transfer protein 3; STS: steryl-sulfatase; WT1: Wilms tumour protein; ZEB1: zinc finger oestrogen-box binding homeobox 1.
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Affiliation(s)
- Coriness Piñeyro-Ruiz
- Department of Anatomy and Neurobiology, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico, USA
| | - Horacio Serrano
- Department of Internal Medicine and Department of Biochemistry, University of Puerto Rico, San Juan, Puerto Rico, USA
| | - Marcos R Pérez-Brayfield
- Department of Surgery, Section of Urology, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico, USA
| | - Juan Carlos Jorge
- Department of Anatomy and Neurobiology, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico, USA
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The current state of tissue engineering in the management of hypospadias. Nat Rev Urol 2020; 17:162-175. [DOI: 10.1038/s41585-020-0281-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2020] [Indexed: 12/20/2022]
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Obara K, Hoshii T, Hoshino S, Yamana K, Anraku T, Maruyama R, Kuroki H, Ishizaki F, Yamazaki H, Tomita Y. Free Tube Graft Urethroplasty for Repair of Hypospadias. Urol Int 2019; 104:386-390. [PMID: 31801150 DOI: 10.1159/000504146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/10/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to assess the outcome of free tube graft urethroplasty for single-stage repair of hypospadias with chordee in children. MATERIALS AND METHODS We retrospectively evaluated a series of 56 patients (16 months to 9 years old, median 24 months) who underwent free graft urethroplasty for repair of hypospadias with chordee between May 2005 and November 2017. The median follow-up was 7 years (range 1-11). RESULTS After releasing the chordee, the hypospadiac orifice was retracted to become penile in 32 patients (57%), penoscrotal in 18 patients (32%), and scrotal in 6 patients (11%). Single-stage repair was achieved without complications in 42 patients (75%). Of the remaining 14 patients with postoperative complications requiring surgical intervention, 2 had meatal stenosis, 9 had urethrocutaneous fistula, 1 had urethral diverticulum without meatal stenosis, and 1 had meatal regression. One patient who complained the urine stream went upwards in an arc underwent cutback meatoplasty to correct the stream. In all patients, a neomeatus with a vertically oriented slit-like appearance was eventually achieved at the tip of the glans. CONCLUSION A free graft is an appropriate choice for repairing hypospadias with chordee. Our procedure achieved favorable functional and cosmetic outcomes with a low postoperative morbidity rate.
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Affiliation(s)
- Kenji Obara
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan,
| | - Tatsuhiko Hoshii
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Sayaka Hoshino
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kazutoshi Yamana
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tsutomu Anraku
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ryo Maruyama
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroo Kuroki
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Fumio Ishizaki
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroyuki Yamazaki
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshihiko Tomita
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Villanueva CA. Goniometer not better than unaided visual inspection at estimating ventral penile curvature on plastic models. J Pediatr Urol 2019; 15:628-633. [PMID: 31680019 DOI: 10.1016/j.jpurol.2019.09.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVE The assessment of penile curvature is a key component of hypospadias surgery, as it often determines if a one- or two-stage procedure should be performed. The objective of this study was to compare unaided visual inspection (UVI) against goniometry estimations of ventral penile curvature (VC) among pediatric urologists. METHODS A total of nine different penile models (1.5 cm wide and 5-6 cm long) representing each decile of curvature from 10° to 90° were created. The nine models were divided in two groups: one with five models (group 1: 10°, 30°, 50°, 70°, and 90°) and the other with four models (group 2: 20°, 40°, 60°, and 80°). Each subject measured the VC of each model in group 1 using one method (i.e. UVI) and the curvature of each model in group 2 using the other method (i.e. goniometry). The next subject then used the opposite method for group 1 (goniometry) and group 2 (UVI), and so on, alternating the methods used to measure each group in between the subjects (Figure). The mean error (difference in between the true curvature and the subject estimation) was compared in between the two measurement methods (UVI and goniometry). A statistician calculated that 20-30 subjects would be needed to detect more than 10° difference in between the methods. RESULTS A total of 25 subjects were recruited for the study (24 pediatric urologists and 1 adult urologist). Mean errors for all degrees of penile curvature and methods ranged from 3.5° (90° model) to 13.6° (30° model). The mean error was not statistically different in between UVI and goniometry methods for any degree of curvature. A subgroup analysis of only goniometry estimations comparing subjects with and without prior experience with goniometry showed a statistically significant difference only for the 60° model. If choosing the correct surgery depended on determining if the curvature was ≤30° or >30°, all subjects would have chosen the right surgery for all except the 20°, 30°, and 40° models, where wrong surgery was chosen in 6/25, 15/25, and 7/25, respectively. CONCLUSIONS In this preliminary study, goniometry was not superior to UVI at estimating VC. There is pressing need in the field of hypospadias surgery to develop a tool that can measure VC in a reproducible and reliable fashion.
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Affiliation(s)
- Carlos A Villanueva
- Phoenix Children's Hospital, 1920 E. Cambridge Ave., Ste. 302, Phoenix, AZ, 85006, USA.
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Misra D, Elbourne C, Vareli A, Banerjee D, Joshi A, Friedmacher F, Skerritt C. Challenges in managing proximal hypospadias: A 17-year single-center experience. J Pediatr Surg 2019; 54:2125-2129. [PMID: 31079867 DOI: 10.1016/j.jpedsurg.2019.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are only a few publications in the medical literature reporting on complication rates in proximal hypospadias surgery, particularly with regard to long-term follow-up. METHODS Over a 17.5-year period, we operated 100 patients with penoscrotal, scrotal and perineal hypospadias. Sixty-four had a single-stage repair, including 15 who received a buccal mucosa inlay "Snodgraft" repair. Thirty-six had a two-stage Bracka repair of which 19 received buccal or lower lip grafts and 17 had preputial grafts. Overall, 34 patients received buccal grafts. The median follow-up was eight years (range 1-16 years). Three patients were operated for residual chordee years later. RESULTS Urethral fistulae occurred in a total of 26/100 (26.0%) cases, meatal stenosis in 16/100 (16.0%), wound breakdown in six (6.0%) and graft failure in one (1.0%). The fistula rate after the single-stage approach was 15/64 (23.4%), whereas it was 11/36 (30.6%) following two-stage repair (P = 0.4811). CONCLUSIONS Proximal hypospadias remains a challenging condition to treat. It is possible to perform a single-stage repair in 64.0% of cases. This brings down the median number of operations to only two. Lower lip grafts were used in 34.0% but are now used in redo-surgeries only. Our fistula rate was 26.0% but has decreased significantly in recent years. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Devesh Misra
- Department of Paediatric Urology and Paediatric Surgery, The Royal London Hospital, London, United Kingdom.
| | - Ceri Elbourne
- Department of Paediatric Urology and Paediatric Surgery, The Royal London Hospital, London, United Kingdom
| | - Anastasia Vareli
- Department of Paediatric Urology and Paediatric Surgery, The Royal London Hospital, London, United Kingdom
| | - Debasish Banerjee
- Department of Paediatric Urology and Paediatric Surgery, The Royal London Hospital, London, United Kingdom
| | - Ashwini Joshi
- Department of Paediatric Urology and Paediatric Surgery, The Royal London Hospital, London, United Kingdom
| | - Florian Friedmacher
- Department of Paediatric Urology and Paediatric Surgery, The Royal London Hospital, London, United Kingdom
| | - Clare Skerritt
- Department of Paediatric Urology and Paediatric Surgery, The Royal London Hospital, London, United Kingdom
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Persistent or recurrent ventral curvature after failed proximal hypospadias repair. J Pediatr Urol 2019; 15:344.e1-344.e6. [PMID: 31068257 DOI: 10.1016/j.jpurol.2019.03.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/17/2019] [Accepted: 03/29/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Persistent or recurrent ventral curvature (VC) in patients with complications after proximal hypospadias repair is reported. METHODS Records of patients undergoing re-operation for complications after proximal repair performed elsewhere were reviewed, including earlier operative reports when available. Original extent of VC, means used for straightening, and presenting complaints and findings at re-operation were tabulated. Ventral curvature at re-operation was objectively measured by goniometry and classified as due to short ventral skin and/or scarring of skin/dartos, short neourethra, or short ventral corpora (corporal disproportion). The finding of corporal disproportion at re-operation was considered to be failure of initial straightening. RESULTS There were 73 patients with an average of 2.7 [1-5] prior operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50° (30-90). This was due to short skin/scarring in 7% patients, a short neourethra in 23%, and corporal disproportion in 70%. Initial straightening was performed by chordee excision in 18 patients, dorsal plication in 23, and ventral lengthening in 15. Persistent or recurrent corporal disproportion was significantly more likely after chordee excision or dorsal plication than after ventral lengthening (p = 0.005). Of patients with VC, 93% also had urethroplasty complications, including recurrent fistulas and wound dehiscences that appeared related to the curvature. DISCUSSION The VC that was encountered during proximal hypospadias re-operations was important for several reasons. First, all patients with VC who had completed urethroplasty had complications that included recurrent fistulas and wound dehiscences (Figure). Even if they had healed without complications, this VC exceeded 30° in all cases, which is associated with sexual dysfunction in adults. This VC was not reported by 37% of caregivers and sometimes not apparent on pre-operative physical examination. It is possible there is selection bias in this series, although nearly all patients were self-referred for complications, and nearly 40% of them were not aware their son had VC. Furthermore, the finding that most initially had dorsal plication agrees with an earlier survey of pediatric urologists' preferences for straightening penile curvature. CONCLUSIONS The most common complication in this series was persistent or recurrent VC, and nearly all these patients also had urethroplasty complications. This VC was more likely when the urethral plate was preserved during straightening and when chordee excision or dorsal plication rather than ventral lengthening was performed. These data suggest that surgeons should objectively measure VC and consider ventral lengthening rather than chordee excision or dorsal plication when it is ≥ 30°. Re-operations for urethroplasty complications should include artificial erection.
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Djordjevic ML, Bizic M, Stojanovic B, Bencic M, Kojovic V, Korac G. Buccal mucosa graft for simultaneous correction of severe chordee and urethroplasty as a one-stage repair of scrotal hypospadias (watch technique). World J Urol 2018; 37:613-618. [PMID: 30306261 DOI: 10.1007/s00345-018-2517-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE Severe hypospadias repair still presents a great challenge. We evaluated a novel approach of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and new urethral plate creation, in combination with longitudinal dorsal island skin flap, as a one-stage repair of severe hypospadias. METHODS Between July 2014 and September 2017, 26 patients (aged from 12 to 22 months) underwent scrotal hypospadias repair. Short and non-elastic urethral plate is divided. Buccal mucosa graft is harvested from the inner cheek, and designed in a special "watch" shape, with the spherical part in the middle and two rectangular parts on both sides. Tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" buccal mucosa with 6-8 "U-shape" stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally. Longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with buccal graft. Penile skin reconstruction is performed using available penile skin. RESULTS The mean follow-up was 22 months (range from 9 to 46 months). Satisfactory results were achieved in 22 patients. Two urethral fistulas were successfully repaired by minor surgery after 3 months, while one meatal stenosis and one urethral diverticulum were successfully treated by temporary urethral dilation. There were no cases of residual curvature. CONCLUSION Specially shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty could be a good choice for single-stage repair of scrotal hypospadias with severe curvature.
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Affiliation(s)
- Miroslav L Djordjevic
- School of Medicine, University of Belgrade, Belgrade, Serbia. .,Department of Urology, University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia.
| | - Marta Bizic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Urology, University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia
| | - Borko Stojanovic
- Department of Urology, University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia
| | - Marko Bencic
- Department of Urology, University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia
| | | | - Gradimir Korac
- Department of Urology, University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia
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Kim S, Rosoklija I, Johnson EK. Surgical, Patient, and Parental Considerations in the Management of Children with Differences of Sex Development. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Rynja SP, de Jong TPVM, Bosch JLHR, de Kort LMO. Proximal hypospadias treated with a transverse preputial island tube: long-term functional, sexual, and cosmetic outcomes. BJU Int 2018; 122:463-471. [PMID: 29624839 DOI: 10.1111/bju.14234] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study long-term urinary and sexual function, and cosmetic outcomes in adult patients who underwent single-stage transverse preputial island tube (TPIT) for proximal hypospadias repair in childhood. Long-term data on outcomes of patients with proximal hypospadias with severe coexisting curvature and insufficient urethral plate are scarce, but are necessary to decide which repair technique is most beneficial. PATIENTS, SUBJECTS AND METHODS Patients with proximal hypospadias operated with TPIT (TPIT Group) were compared to patients with distal hypospadias repair (Distal Group) and to a control group of male medical students (Control Group). Participants completed the International Prostate Symptom Score, the International Index of Erectile Function (IIEF-15), additional non-validated questions, and performed uroflowmetry. Cosmesis was assessed in the patients with hypospadias using the Pediatric Penile Perception Score (PPPS); stretched penile length was also measured. RESULTS Of the 121 eligible patients with hypospadias, 54 with either TPIT or distal hypospadias repairs participated. The TPIT Group comprised 12 patients (median age of 20.0 years) and the Distal Group comprised 42 patients (median age of 19.6 years). The complication rates were similar, at 8 of the 12 patients in the TPIT Group vs 26/42 (62%) in the Distal Group (P = 0.76). Urinary outcomes were similar in the TPIT, Distal, and the Control (comprised of 148 medical students with a median age of 21.0 years) groups. The TPIT Group had a lower maximum urinary flow rate compared to the Control Group, at 24.1 vs 28.6 mL/s (P < 0.05). IIEF-15 scores were similar in the TPIT, Distal and Control groups, except for 'Orgasmic Function' (7.5 vs 10.0 vs 10.0, respectively; P < 0.01). Although the TPIT Group had a smaller penile length compared to the Distal Group (10.1 vs 12.9 cm, P < 0.01), PPPS outcomes were similar. CONCLUSION In these TPIT patients, long-term urinary, sexual and cosmetic outcomes were similar to those in patients with distal hypospadias repairs and controls.
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Affiliation(s)
- Sybren P Rynja
- University Medical Center (UMC), Utrecht, The Netherlands
| | - Tom P V M de Jong
- University Children's Hospital UMC Utrecht, Utrecht, The Netherlands
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Bernabé KJ, Nokoff NJ, Galan D, Felsen D, Aston CE, Austin P, Baskin L, Chan YM, Cheng EY, Diamond DA, Ellens R, Fried A, Greenfield S, Kolon T, Kropp B, Lakshmanan Y, Meyer S, Meyer T, Delozier AM, Mullins LL, Palmer B, Paradis A, Reddy P, Reyes KJS, Schulte M, Swartz JM, Yerkes E, Wolfe-Christensen C, Wisniewski AB, Poppas DP. Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia. J Pediatr Urol 2018; 14:157.e1-157.e8. [PMID: 29398588 PMCID: PMC5970022 DOI: 10.1016/j.jpurol.2017.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/23/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches. OBJECTIVE The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia. STUDY DESIGN This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings. RESULTS Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied. DISCUSSION In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population. CONCLUSION In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.
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Affiliation(s)
- K J Bernabé
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - N J Nokoff
- Children's Hospital Colorado, Aurora, CO, USA
| | - D Galan
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - D Felsen
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - C E Aston
- University of Oklahoma Health Sciences Center, Department of Pediatrics, Oklahoma City, OK, USA
| | - P Austin
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - L Baskin
- University of California San Francisco, San Francisco, CA, USA
| | - Y-M Chan
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - E Y Cheng
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - D A Diamond
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - R Ellens
- Children's Hospital of Michigan, Detroit, MI, USA
| | - A Fried
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - S Greenfield
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - T Kolon
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B Kropp
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - Y Lakshmanan
- Children's Hospital of Michigan, Detroit, MI, USA
| | - S Meyer
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - T Meyer
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - A M Delozier
- Oklahoma State University, College of Arts and Sciences, Stillwater, OK, USA
| | - L L Mullins
- Oklahoma State University, College of Arts and Sciences, Stillwater, OK, USA
| | - B Palmer
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - A Paradis
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - P Reddy
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K J Scott Reyes
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - M Schulte
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J M Swartz
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - E Yerkes
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - C Wolfe-Christensen
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA; Children's Hospital of Michigan, Detroit, MI, USA
| | - A B Wisniewski
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - D P Poppas
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
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Pohl HG. Commentary to 'Current challenges with proximal hypospadias: We have a long way to go'. J Pediatr Urol 2017; 13:468-469. [PMID: 28479205 DOI: 10.1016/j.jpurol.2017.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/01/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Hans G Pohl
- Children's National Medical Center, United States.
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