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Wen X, Fan LJ, Zhang WP, Ni X, Gong CX. Genotype-phenotype correlations, surgical selections, and postoperative complications of 5α-reductase 2 deficiency in 69 children with hypospadias. Asian J Androl 2023; 25:731-736. [PMID: 37313883 DOI: 10.4103/aja202313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/14/2023] [Indexed: 06/15/2023] Open
Abstract
5α-reductase 2 deficiency prevents testosterone from being converted to dihydrotestosterone, which causes abnormal urogenital sinus development. The aim of this study was to analyze the relationship between genotype-phenotype, surgical selections, and postoperative complications of 5α-reductase 2-deficient patients with hypospadias. We retrospectively evaluated the medical records of patients who were diagnosed with 5α-reductase 2 deficiency after genetic testing in the Department of Endocrinology and underwent initial hypospadias surgery in the Department of Urology in Beijing Children's Hospital, Capital Medical University (Beijing, China), from April 2007 to December 2021. A total of 69 patients were included in this study; the mean age at surgery was 34.1 months, and the average follow-up time was 54.1 months. Sixty children were treated with preoperative hormone stimulation (PHS) to promote penile growth. The average penis length and glans width were increased by 1.46 cm and 0.62 cm, respectively. The most frequent mutations were p.R227Q (39.1%, 54/138), p.Q6* (15.2%, 21/138), p.G203S (12.3%, 17/138), and p.R246Q (11.6%, 16/138). In 64 patients who were followed up, 43 had a one-stage operation and 21 had a staged operation, and there were significant differences in external masculinization score (EMS) ( P = 0.008) and the average number of operation required to cure ( P < 0.001) between one-stage and staged operations. PHS had a positive effect ( P < 0.001) on penile development. The p.R227Q mutation was associated with higher EMS and less severe hypospadias. One-stage surgery can be selected if conditions permit. The growth and development of children are acceptable in the long term, but penis growth remains unsatisfactory. Long-term complications of hypospadias should be considered during puberty.
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Affiliation(s)
- Xu Wen
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Li-Jun Fan
- Department of Endocrinology, Genetics, Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
- Beijing Key Laboratory for Genetics of Birth Defects, Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Wei-Ping Zhang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Xin Ni
- Department of Otolaryngology Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Chun-Xiu Gong
- Department of Endocrinology, Genetics, Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
- Beijing Key Laboratory for Genetics of Birth Defects, Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
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Paraboschi I, Gnech M, Minoli DG, De Marco EA, Parente G, Mantica G, Manzoni G, Berrettini A. Indocyanine Green (ICG)-Guided Onlay Preputial Island Flap Urethroplasty for the Single-Stage Repair of Hypospadias in Children: A Case Report. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6246. [PMID: 37444094 PMCID: PMC10341559 DOI: 10.3390/ijerph20136246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/30/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023]
Abstract
First described by Duckett in 1981, and initially employed for the surgical correction of mid-penile hypospadias, the onlay preputial island flap urethroplasty has progressively gained increasing popularity, extending its indication to proximal forms. However, with the complexity of the penile anomaly, the rate of postoperative complications related to poor tissue perfusion (including skin and glans dehiscence, urethral stenoses, and fistulas) has also increased. Conventionally, the visual assessment of the onlay preputial island flap is the only option available to establish the appropriate tissue vascularization during surgery. To this end, we have first introduced the EleVision IR system (Medtronic Ltd., Hong Kong, China) to assess the vascular perfusion of the preputial island flap in a 13-month-old boy undergoing the onlay urethroplasty for the surgical correction of a mid-shaft hypospadias. This was possible 80 s after the intravenous injection of indocyanine green (ICG, 0.15 mg/kg, Diagnostic Green GmbH, Munich, Germany). ICG-based laser angiography helped define the proximal resection margin of the preputial flap, and proved to be safe, effective, and easy to employ. This innovative intraoperative imaging modality can be considered a useful adjunct for tissue perfusion evaluation and intraoperative decision-making during the onlay preputial island flap urethroplasty in children.
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Affiliation(s)
- Irene Paraboschi
- Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Michele Gnech
- Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Dario Guido Minoli
- Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Erika Adalgisa De Marco
- Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giovanni Parente
- Department of Pediatric Surgery, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Guglielmo Mantica
- Department of Urology, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Gianantonio Manzoni
- Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alfredo Berrettini
- Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Di H, Wen Y, Li Y. Preoperative hormone therapy in single-stage repair of hypospadias: A comprehensive systematic review. J Pediatr Urol 2023:S1477-5131(23)00021-9. [PMID: 36746717 DOI: 10.1016/j.jpurol.2023.01.013] [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: 08/15/2022] [Revised: 01/08/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Preoperative hormone therapy (PHT) holds promise for obtaining better surgical conditions for patients undergoing hypospadias correction and increasing the success rate. However, the application and effects of PHT remain uncertain owing to a lack of comprehensive evaluation, thus limiting treatment strategies and development of standardized guidelines. This study aimed to review the following (ⅰ) the criteria and regimens of PHT (ⅱ) its impact on penile growth, postoperative complications, and side effects (ⅲ) and sources of inconsistent clinical outcomes. METHODS This systematic review was registered at PROSPERO (CRD42022346924) and conducted and reported following international recommendations, including the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We searched the databases over the last two decades to identify eligible studies. This systematic review included literature regarding the use of PHT in the treatment of children with single stage hypospadias repair. Risk of Bias (RoB) was measured using two different tools: randomized controlled trials using a modified version of the RoB Assessment Tool and non-randomized studies of interventions using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I). The R-3.6.3 software was used for the analysis. RESULTS In total, 25 studies involving 4094 patients were included in the systematic review. The surgeons' criteria for using PHT varied, with short penile length being the most important. The most frequently reported regimens for intramuscular (IM) testosterone were either 2 mg/kg or empiric 25 mg monthly, and the duration was 2-3 months preoperatively. Androgens were significantly effective in improving penile development, and the changes commonly peaked at 2-3 months. The effects of PHT on complications and side effects are controversial, and the potential causes include hormone sensitivity, degree of hypospadias, surgical techniques, and dosing regimens. CONCLUSIONS This systematic review evaluated PHT in children with hypospadias. Building on previous studies, this review provides a more specific attitude and possible aspects for resolving the controversies. Future studies should identify the applicable subgroups of patients and standardize the dose and mode of delivery for the best clinical results.
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Affiliation(s)
- Huajie Di
- Pediatrics, Xuzhou Medical University, Xuzhou 221004, China
| | - Yi Wen
- Pediatrics, Xuzhou Medical University, Xuzhou 221004, China
| | - Yuan Li
- Department of Pediatric Urology, Affiliated Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou 221002, China.
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Fernandez N, Chua M, Villanueva J, Varela D, Bagli D, Shnorhavorian M. Neural network non-linear modeling to predict hypospadias genotype-phenotype correlation. J Pediatr Urol 2023:S1477-5131(23)00013-X. [PMID: 36709079 DOI: 10.1016/j.jpurol.2023.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Hypospadias is an abnormal development of the urethral, ventral skin and corporeal bodies. Urethral meatus and ventral curvature have been historically the landmarks to define clinical severity. Genotyping has never been explored as a clinical predictor. Available reports have demonstrated a correlation between genetic mutations and syndromic hypospadias with poor surgical outcomes. We hypothesize that inclusion of genotyping can serve at classifying all types of hypospadias. We present the use of neural network algorithm to evaluate phenotype/genotype correlations and propose its potential clinical applicability. METHODS A systematic review was performed from January 1974 to June 2022. Literature was retrieved from Medline, Embase, Web of Science and Google Scholar. Included manuscripts were those that had an explicit anatomical description of hypospadias phenotype (urethral meatus location following an anatomical description) and a defined genotype (genetic mutation) description. Cases with more than one variant/mutation were excluded. A comprehensive phenotype-genotype statistical analysis using neural network non-linear data modeling SPSS™ was performed. RESULTS Genotype-Phenotype analysis was performed on 1731 subjects. Of those, 959 (55%) were distal and 772 (45%) proximal. 49 genes with mutations were identified. Neural network clustering predicted better for coronal (90%) and glanular (80%), and lowest for midshaft (22%) and perineal (45%). Using genes as predictor factor only, the model was able to highly and more accurately predict the phenotype for coronal and glanular hypospadias. The following genotypes showed association to a specific phenotype: AR gene n.2058G > A for glanular (p<0.0001), n.480C > T for coronal (p = 0.034), R840C for perineal (p = 0.002), MAMLD1 gene c.2960C > T for coronal (p< 0.0001), p. G289S for glanular (p<0.0001), gene SRD5A2 607G > A for scrotal (p<0.0001), c16C > T for penoscrotal (p<0.0001), c59 T > c for perineal (p = 0.042), V89L for midshaft and scrotal (p<0.0001, p = 0.041; respectively). DISCUSSION Hypospadias phenotype has always been described from a purely anatomical perspective. Our results demonstrate that current phenotyping has poor correlation to the genotype. Higher genotype/phenotype correlation for distal hypospadias proves the clinical applicability of genotyping these cases. The concept and classification of differences in sexual development needs to be reconsidered given high positive yield reported for distal hypospadias. Given the better predictive value of genotyping in correlation to the phenotype, future efforts should be directed towards using the genotype. CONCLUSION Hypospadias has poor phenotype/genotype correlation. Sequencing all hypospadias phenotypes may add clinical value if used in association to other predictive variables. Neural network analysis may have the ability to combine all these variables for clinical prediction.
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Affiliation(s)
- Nicolas Fernandez
- Division of Pediatric Urology. Seattle Children's Hospital. University of Washington. Seattle USA.
| | - Michael Chua
- Division of Pediatric Urology. Hospital for Sick Kids. University of Toronto. Canada
| | - Juliana Villanueva
- Division of Urology. Hospital Universitario San Ignacio. Pontificia Universidad Javeriana. Bogota Colombia
| | - Daniela Varela
- Division of Urology. Hospital Universitario San Ignacio. Pontificia Universidad Javeriana. Bogota Colombia
| | - Darius Bagli
- Division of Pediatric Urology. Hospital for Sick Kids. University of Toronto. Canada
| | - Margarett Shnorhavorian
- Division of Pediatric Urology. Seattle Children's Hospital. University of Washington. Seattle USA
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Do MT, Kim L, Im YJ, Hahn S, Park K. Effect of Preoperative Androgen Stimulation on Penile Size and Postoperative Complication Rate in Patients with Hypospadias: A Systematic Review and Meta-analysis. World J Mens Health 2023:41.e19. [PMID: 36649924 DOI: 10.5534/wjmh.220173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To systematically review and evaluate the beneficial effects of preoperative androgen stimulation (PAS) on penile length, glans width, and postoperative complications in patients with hypospadias using meta-analysis. MATERIALS AND METHODS A comprehensive search of the published literature between 1980 and 2022 was done on PubMed, Embase, Google Scholar, Scopus, Web of Science, and Proquest. Studies of patients with 5-alpha reductase deficiency, differentiation sex disorder, or micro-penis without hypospadias were excluded. The full-text screening, quality assessment, and data acquisition were done independently by two reviewers. Meta-analysis was done to quantify the penile growth and postoperative complications. RESULTS The initial literature search yielded 2,389 records, wherein 32 studies were eligible for the systematic review and meta-analysis. Preoperative testosterone stimulation increased the penile length and glans width by 9.34 mm (95% CI: 6.71-11.97) and 3.26 mm (95% CI: 2.50-4.02), respectively. A longer penis at the baseline led to greater length gain following treatment (1 mm longer at the baseline was likely to gain 0.5 mm more). However, the increase in penile length was not associated with the severity of hypospadias. While the treatment did not affect the overall complication rate, the postoperative fistula risk was lower in those receiving PAS (RR=0.52, 95% CI: 0.30-0.91, p=0.02). CONCLUSIONS The beneficial effects of PAS on increasing the penile length and glans width were again confirmed. More gain of penile length was expected in the larger penis at baseline. There are no reported increased postoperative complications in association with PAS.
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Affiliation(s)
- Minh-Tung Do
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Louis Kim
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
| | - Young Jae Im
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea.,Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
| | - Seokyung Hahn
- Department of Human Systems Medicine, Medical Statistics Laboratory, Seoul National University College of Medicine, Seoul, Korea
| | - Kwanjin Park
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea.,Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea.
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Zhou G, Wang R, Zhu W, Yin J, Yang Z, Li S. Risk factors for postoperative complications in children with proximal hypospadias with severe chordee who underwent urethral plate transection. Int J Urol 2022; 29:1310-1314. [PMID: 35858758 PMCID: PMC9796588 DOI: 10.1111/iju.14986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/03/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To identify the risk factors associated with developing complications after transection of the urethral plate for proximal hypospadias with severe chordee. METHODS We used a prospective database to identify patients with proximal hypospadias and severe chordee who underwent transection of the urethral plate and primary hypospadias repair in 2011 and 2021. All patients underwent urethroplasty with a follow-up period of >12 months. The association between variables (age, surgical technique, length of urethral defect, and surgeon volume) and postoperative complications (fistulas, urethral strictures, diverticula and glans dehiscence) was analyzed. RESULTS Altogether, 493 patients were included, of whom 133 (26.9%) had postoperative complications. Univariate and multivariate analyses revealed that the preoperative proximal meatal position, one-stage repair, longer urethral defect length, and low surgeon volume were significant risk factors for postoperative complications with proximal hypospadias with severe chordee who underwent transection of the urethral plate. A urethral defect length of ≥4.55 cm was considered the best cutoff value for predicting postoperative complications. CONCLUSIONS Preoperative proximal meatal location, one-stage repair, longer urethral defect length, and low surgeon volume were associated with postoperative complications in patients with proximal hypospadias with severe chordee who underwent transection of the urethral plate. A urethral defect length of ≥4.55 cm was significantly associated with the development of complications.
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Affiliation(s)
- Guanglun Zhou
- Department of Urology and Laboratory of Pelvic Floor Muscle FunctionShenzhen Children's HospitalShenzhenGuangdongP.R. China
| | - Ruifeng Wang
- Department of Gastroenterology and Zhengzhou Key Laboratory of Children's Digestive DiseasesChildren's Hospital affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's HospitalZhengzhouHenanP.R. China
| | - Wenbin Zhu
- Department of Urology and Laboratory of Pelvic Floor Muscle FunctionShenzhen Children's HospitalShenzhenGuangdongP.R. China
| | - Jianchun Yin
- Department of Urology and Laboratory of Pelvic Floor Muscle FunctionShenzhen Children's HospitalShenzhenGuangdongP.R. China
| | - Zhilin Yang
- Department of Urology and Laboratory of Pelvic Floor Muscle FunctionShenzhen Children's HospitalShenzhenGuangdongP.R. China
| | - Shoulin Li
- Department of Urology and Laboratory of Pelvic Floor Muscle FunctionShenzhen Children's HospitalShenzhenGuangdongP.R. China
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Taghavi K, O'Hagan LA, Hewitt JK, Mouriquand PDE. Defining the role of pre-operative hormonal therapy in hypospadias. J Paediatr Child Health 2022; 58:1508-1519. [PMID: 35791898 PMCID: PMC9545156 DOI: 10.1111/jpc.16087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/26/2022] [Accepted: 05/01/2022] [Indexed: 11/29/2022]
Abstract
In hypospadias surgery, pre-operative hormonal therapy (PHT) is primarily used to increase penile dimensions and the vascularity of tissues available for reconstruction, but its use is non-uniform in clinical practice, with no consensus on application or utility. This review aims to summarise: (i) the penile tissue response to hormone therapy, (ii) its impact on hypospadias surgery outcomes, and (iii) the endocrinological considerations and sequelae. PHT is more often indicated for complex cases such as proximal hypospadias, hypospadias with microphallus and hypospadias reoperations. While PHT has clear effects on penile morphometry, and more recent controlled trials suggest improved surgical outcomes, the lack of consistent outcome definitions and generally inadequate follow-up periods continue to consign many of the potential long-term effects of PHT to the unknown. There is currently insufficient robust evidence to allow a clinical guideline to be constructed. The need for a well-powered multi-centre prospective randomised trial to address this question is evident but awaits a unified consensus on issues surrounding the understanding of aetiology, classification of hypospadias morphology, definition of important prognostic variables and uniform application of outcome measures. The effects of PHT may be utilised to improve outcomes in cases of proximal and severe hypospadias, which under the current paradigm represent a significant surgical challenge.
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Affiliation(s)
- Kiarash Taghavi
- Department of Paediatric UrologyMonash Children's HospitalMelbourneVictoriaAustralia,Department of Paediatric UrologyRoyal Children's HospitalMelbourneVictoriaAustralia,Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | | | - Jacqueline K Hewitt
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia,Department of Paediatric Endocrinology and DiabetesMonash Children's HospitalMelbourneVictoriaAustralia
| | - Pierre DE Mouriquand
- Service d'Urologie PédiatriqueHôpital Mère‐Enfant, Hospices Civils de Lyon Université Claude‐Bernard59 Boulevard PinelBronFrance,Centre National de Référence Maladies Rares sur les Anomalies Congénitales du Développement GénitalLyonFrance
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Özkuvancı Ü, Dönmez Mİ, Temiz MZ, Çetin B, Küçükgergin C, Olgaç V, Ziylan O, Seçkin Ş, Oktar T. Effects of systemic androgens on late-stage urethral wound healing: An animal study. Andrology 2022; 10:767-774. [PMID: 35064654 DOI: 10.1111/andr.13157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/30/2021] [Accepted: 01/08/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND There are limited data regarding the effects of systemic androgens on late-stage urethral wound healing. OBJECTIVE To evaluate the effects of systemic androgens on fibrosis and scar formation in late-stage urethral wound healing. MATERIALS AND METHODS Forty-five male Sprague Dawley rats were divided into three groups. First group consisted of 15 rats that were castrated on 23 days of age and were given 5 mg/kg testosterone undecanoate with 1/25 ml cottonseed oil intraperitoneally at weekly intervals for 3 weeks (castrated and replaced with testosterone rats [CAS+T] group). The castrated rats (CAS) group included 15 castrated rats. The remaining 15 rats underwent sham surgery. CAS and sham groups also received 1/25 ml cottonseed oil intraperitoneally at weekly intervals for 3 weeks. Furthermore, all groups were divided into three subgroups after testosterone/placebo administration (urethroplasty performed after first, second, and third weeks) in accordance with the urethroplasty timing. All animals were sacrificed 6 weeks after urethroplasty. Serum testosterone level was measured, tissue samples were investigated using hematoxylin and eosin and Masson's trichrome. Alpha-SMA, Coll 1 and Coll 3 primary antibodies were applied for immunohistochemical examination. Expression of cytokines and growth factors, such as Bax, Bcl2, IL-10, IP-10, TNF-alpha, TGFb1, MMP9, Col-I, Col-III, TIMP-1, fibronectin, fibroblast growth factor 10, platelet-derived growth factor, alpha-SMA, were also evaluated in the tissues. RESULTS The blood testosterone levels were significantly higher in CAS+T group at the time of urethroplasty compared with the levels in CAS group; however, this difference was not observed at the time of sacrification (p < 0.001 and 0.97, respectively). Histological analysis with hematoxylin and eosin and Masson's trichrome staining revealed a significantly higher fibrosis in the sham group compared with the others. Significantly lower fibrosis was detected in the CAS group in the pairwise comparison of the pathological fibrosis area between the CAS and CAS+T groups (p < 0.001). Furthermore, tissue collagen-1, collagen-3, and alpha-SMA expression levels were statistically different between CAS and CAS+T groups (p < 0.001, <0.05, and <0.001, respectively). The tissue levels of BAX, TIM-1, MMP-9, Coll-I, Coll-III, TGF-beta, TNF-alpha, and IL-10 mRNA expressions in the CAS+T group were different than the levels in CAS group (as <0.5-fold and >1.5-fold changes, respectively). The expressions of all these markers were significantly higher in the sham group. The subgroup analysis of CAS+T group (urethroplasty performed after first, second, and third weeks) revealed similar histopathological wound healing findings. DISCUSSION Debate continues on the effects and benefits of androgen use regarding urethral healing. There are two main routes for administration as systemic or local. This study focuses on the late-stage histologic and biochemical effects of systemic androgens. CONCLUSION Systemic androgens adversely affect wound healing and cause abnormal extracellular matrix as well as scar formation.
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Affiliation(s)
- Ünsal Özkuvancı
- Department of Urology, Division of Pediatric Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Muhammet İrfan Dönmez
- Department of Urology, Division of Pediatric Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Mustafa Zafer Temiz
- Department of Urology, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Bilal Çetin
- Department of Urology, Division of Pediatric Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Canan Küçükgergin
- Department of Biochemistry, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Vakur Olgaç
- Department of Tumour Pathology, Istanbul University Institute of Oncology, Istanbul, Turkey
| | - Orhan Ziylan
- Department of Urology, Division of Pediatric Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Şule Seçkin
- Department of Biochemistry, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Tayfun Oktar
- Department of Urology, Division of Pediatric Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
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Li B, Kong I, McGrath M, Farrokhyar F, Braga LH. Evaluating the literature on preoperative androgen stimulation for hypospadias repair using the fragility index - can we trust observational studies? J Pediatr Urol 2021; 17:661-669. [PMID: 34518122 DOI: 10.1016/j.jpurol.2021.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Preoperative androgen stimulation (PAS) is typically used in hypospadias repair for patients with a proximal meatus or small glans size. Hypospadias PAS literature suffer from small sample sizes and lack of power to claim robust conclusions. Small changes in the number of events may completely change the statistical significance, making the conclusions drawn unreliable. Fragility index (FI) is the number of additional events needed to occur in either the control or experimental group to turn a statistically significant result to a non-significant result. The objective of the report was to assess the quality of available literature revolving around PAS use in hypospadias repair and its effects on post-operative complication rates using FI. METHODS A comprehensive search of MEDLINE, EMBASE, and grey literature (ESPU and SPU abstracts) was conducted to identify RCTs and observational studies investigating the effect of PAS on complications post-hypospadias repair between 1990 and 2020. The FI was calculated for each study. Postoperative complications were defined as: fistula, stricture/stenosis, diverticula, and dehiscence. The odds ratio (OR), 95% confidence intervals (CI), corresponding p-values was calculated for each study. A random effects mixed model was implemented to combine the ORs for each study design. RESULTS Fourteen studies qualified for inclusion, of which nine were observational studies and five were RCTs (Figure 1). The median sample size was 110 patients (IQR 69-171). The summary ORs for observational studies was 1.74 (95% CI: 1.10 to 2.74; p = 0.020) and for RCTs was 0.71 (9% CI: 0.34 to 1.47; p = 0.350). The median FI was 0 (IQR 0-2) of the included studies. DISCUSSION PAS use does not appear to significantly affect complication rates shown in RCTs, however, observational studies cumulatively suggested significantly greater odds of complications after PAS. The FI is best used for RCTs with 1-to-1 randomization and binary data. Observational studies are rarely balanced for demographics and comorbidities with unequal sample size between comparable groups. The study was limited by substantial variability in how PAS was delivered to patients, leading to restricted comparability. CONCLUSION Strong conclusions regarding the influence of PAS on hypospadias repair outcomes cannot be properly drawn based on the current literature due to deficits from either a statistical or methodological standpoint. The current PAS literature has shown inconclusive results, calling for well-designed RCTs, involving standardized surgical techniques and PAS protocols, to evaluate the true effect of PAS on complications post-hypospadias repair.
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Affiliation(s)
- Bruce Li
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Isaac Kong
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Melissa McGrath
- Department of Health Research, Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada; McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Health Research, Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Luis H Braga
- Department of Health Research, Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada; Division of Urology, McMaster University, Hamilton, ON, Canada; McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, ON, Canada.
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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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11
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Ezomike UO, Nwangwu EI, Chukwu IS, Ekenze SO. Practice patterns of preoperative hormonal stimulation in pediatric penile surgeries-A survey of Nigerian pediatric surgeons. J Pediatr Urol 2020; 16:440-445. [PMID: 32586772 DOI: 10.1016/j.jpurol.2020.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Variable practice patterns exist in the use of Preoperative Hormonal Stimulation (PHS) prior to penile surgeries and there seems to be no generally agreed standards. OBJECTIVE To assess the current practice patterns of PHS before penile surgeries among Nigerian pediatric surgeons and compare with literature. MATERIALS AND METHODS Self-administered questionnaires were distributed amongst consultants and senior registrars in Pediatric surgery during the 2019 Association of Pediatric Surgeons of Nigeria (APSON) national conference. SPSS version 20 was used for data entry and analysis and results presented as ranges, percentages, tables. Test for association was done using chi square test and a p-value of <0.05 was deemed significant. RESULTS All fifty respondents comprising 43 males, 7 females; 31 consultants and 19 senior registrars have managed hypospadias, with eighty-six percent managing less than 50 per year. Seventy-six percent practice PHS and more proportion of males use PHS than females (p = 0.027).Only 15.8% and 7.9% respectively estimated serum testosterone before and after PHS. Majority (92.1%) gave PHS because of small-appearing penis and 86.8% have used it in proximal hypospadias. Most commonly used form of PHS was intramuscular testosterone (76.3%) while 2 mg/kg testosterone was commonest dose (65.7%). Ninety-one percent give intramuscular testosterone at 2-4 weeks intervals; ninety-four percent give 2-3 doses of intramuscular testosterone preoperatively with last dose given 2-4 weeks before surgery in 57.9%. Ninety-two percent thought PHS will not increase postoperative complications and pubic hair was most common complication of PHS (63%). DISCUSSION There is diversity in PHS practices among Nigerian pediatric surgeons. Though mainly low-volume surgeons, majority use PHS before penile surgeries especially in proximal hypospadias and small-appearing penis. Males tend to practice PHS more than females and most commonly used form of PHS is 2-3 doses of 2 mg/kg intramuscular testosterone at 2-4 weekly intervals with last dose given 2-4 weeks before surgery. This study may be limited by bias inherent in self-reported practices and outcomes as seen in surveys, though surveys help to evaluate practices of professionals. CONCLUSIONS Majority of Pediatric surgeons in Nigeria use PHS in form of intramuscular testosterone mainly for small appearing penis and proximal hypospadias. Most common dosing is 2 mg/kg at 2-4 weeks intervals and 2-3 doses preoperatively with the last dose 2-4 weeks preoperatively. Serum testosterone estimation is not common before PHS. Many believe that PHS does not increase complications following penile surgeries. Current diversity in practice suggests the need for further studies to encourage standardization or guidelines for practice in Nigeria.
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Affiliation(s)
- U O Ezomike
- Sub-Department of Pediatric Surgery College of Medicine, University of Nigeria, Nigeria.
| | - E I Nwangwu
- Department of Surgery, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria
| | - I S Chukwu
- Department of Surgery, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria
| | - S O Ekenze
- Sub-Department of Pediatric Surgery College of Medicine, University of Nigeria, Nigeria
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Han W, Zhang W, Sun N, Yang Y. Comparison of continuous eversion and inverting subepithelial suture in transverse preputial island flap urethroplasty in proximal hypospadias repair: A retrospective study. Int Braz J Urol 2020; 46:772-777. [PMID: 32648417 PMCID: PMC7822365 DOI: 10.1590/s1677-5538.ibju.2019.0484] [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: 07/31/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction: Transverse preputial island flap urethroplasty (TPIFU) is one of the most frequently performed technique for single-stage repair in proximal hypospadias. It was reported that the subepithelial urethroplasty would obviously decrease urethrocutaneous fistula (UF) complication after proximal TIP. But in the process of TPIFU, it had not been reported yet. Objective: We reviewed our experience to evaluate and compare the effect of continuous eversion suture (CES) versus continuous inversion subepithelial suture (CIS) on complication rates in the TPIFU. Material and methods: A retrospective review of all patients operated with CES and CIS in our institution between January 2017 and Jun 2017 was performed. Results: A total of 161 patients were enrolled in the research. Patients were followed up for 12~17 months. Total success rate was 73.9% (119/161). No statistically difference was found between the two groups with regard to age of patients (P=0.097), catheter size (P=0.52), time of catheterization (P=0.47), length of neourethra (P=0.20), non-urethral comorbidity (P=0.44) and post-operative infection (P=1.0). The overall postoperative complications had no statistically difference between the two groups (P=0.067). There were no statistically significant differences in the incidence of urethra-cutaneous fistula (UF) (OR=0.07, 95% CI: -0.24~0.037, P=0.22), urethral diverticulum (UD) (OR=0.026, 95% CI: -0.16~-0.056, P=0.323), urethral stricture (US) (OR=0.081, 95% CI: -0.15~0.15, P=1.0) and breakdown of urethral repair (BU) (OR=0.02, 95% CI: -0.118~-0.044, P=1.0). Discussion: The comparison of two group’s postoperative complications was feasible because there were no statistically differences among perioperative variables. It seemed as if continuous inversion subepithelial suture would promote healing. However, it indicated that the overall success rate and the incidences of UF, UD, US and BU complications had no statistically difference between groups. It might be accounted for the subtle differences of techniques changing the process of establishing prime and side branches vascularization. Conclusions: The CIS technique had no significantly different effect on the four complications rates when compared with CES in TPIFU. Thus, CES and CIS could be randomly adopted in TPIFU as personal preference.
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Affiliation(s)
- Wenwen Han
- Department of Urology, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, China
| | - Weiping Zhang
- Department of Urology, Children's hospital Affiliated to Zhengzhou University, Henan, China
| | - Ning Sun
- Department of Urology, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yanfang Yang
- Department of Urology, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, China
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Gorduza D, Plotton I, Remontet L, Gay CL, El Jani M, Cheikhelard A, Blanc T, El Ghoneimi A, Leclair MD, Roy P, Pirot F, Mimouni Y, Gaillard S, Chatelain P, Morel Y, Kassai B, Mouriquand P. Preoperative Topical Estrogen Treatment vs Placebo in 244 Children With Midshaft and Posterior Hypospadias. J Clin Endocrinol Metab 2020; 105:5835305. [PMID: 32386308 DOI: 10.1210/clinem/dgaa231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/06/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Urethral fistula and dehiscence are common after hypospadias surgery. Preoperative androgens have been considered to reduce these complications although this consideration is not evidence-based. Dermatologists have reported the benefits of topical estrogens on skin healing. We investigated whether the preoperative use of topical promestriene could reduce healing complications in hypospadias surgery. Our primary objective was to demonstrate a reduction of healing complications with promestriene vs placebo. Impact on reoperations and other complications, clinical tolerance, bone growth, and biological systemic effects of the treatment were also considered. METHODS We conducted a prospective, randomized, placebo-controlled, double-blind, parallel group trial between 2011 and 2015 in 4 French centers. One-stage transverse preputial island flap urethroplasty (onlay urethroplasty) was selected for severe hypospadias. Promestriene or placebo was applied on the penis for 2 months prior to surgery. The primary outcome was the presence of postoperative urethral fistula or dehiscence in the first year postsurgery. For safety reasons, hormonal and anatomical screenings were performed. RESULTS Out of 241 patients who received surgery, 122 patients were randomized to receive placebo, and 119 patients received promestriene. The primary outcome was unavailable for 11 patients. Healing complications were assessed at 16.4% (19/116) in the placebo vs 14.9% (17/114) in the promestriene arm, and the odds ratio adjusted on center was 0.93 (95% confidence interval 0.45-1.94), P = 0.86. CONCLUSIONS AND RELEVANCE Although we observed an overall lower risk of complications compared to previous publications, postsurgery complications were not different between promestriene and placebo, because of a lack of power of the study or the inefficacy of promestriene.
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Affiliation(s)
- Daniela Gorduza
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service de Chirurgie Uro-Viscérale de l'Enfant-Hôpital Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Ingrid Plotton
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service d'Endocrinologie Pédiatrique, Hôpital Mère-Enfant, Centre Hospitalo-Universitaire de Lyon, Bron Cedex, France
| | - Laurent Remontet
- Université de Lyon, Lyon, France
- Université Lyon 1; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
- Hospices Civils de Lyon, Service de Biostatistiques, Lyon, France
| | - Claire-Lise Gay
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service d'Endocrinologie Pédiatrique, Hôpital Mère-Enfant, Centre Hospitalo-Universitaire de Lyon, Bron Cedex, France
| | - Meriem El Jani
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Department of Clinical Epidemiology, Bron, France
- Université de Lyon, Lyon, France
| | - Alaa Cheikhelard
- Service de chirurgie viscérale et urologie pédiatrique, APHP, Hôpital Necker, Paris, France; Université Sorbonne Paris cité, Paris, France
| | - Thomas Blanc
- Service de chirurgie viscérale et urologie pédiatrique, APHP, Hôpital Necker, Paris, France; Université Sorbonne Paris cité, Paris, France
| | - Alaa El Ghoneimi
- Service de chirurgie viscérale et urologie pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Robert Debré, APHP, Université Paris Diderot, Paris, France
| | - Marc-David Leclair
- Service de chirurgie pédiatrique, CHU de Nantes, Nantes, Loire Atlantique, France
| | - Pascal Roy
- Université de Lyon, Lyon, France
- Hospices Civils de Lyon, Service de Biostatistiques, Lyon, France
| | - Fabrice Pirot
- Service pharmaceutique, Plateforme FRIPHARM, Groupement Hospitalier Edouard Herriot, Lyon Cedex, France
- Laboratoire de Recherche et Développement de Pharmacie Galénique Industrielle, Plateforme FRIPHARM, Faculté de Pharmacie, Laboratoire de Biologie Tissulaire et Ingénierie Thérapeutique - UMR 5305, Université Claude Bernard Lyon 1, Lyon Cedex, France
| | - Yanis Mimouni
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Department of Clinical Epidemiology, Bron, France
- Université de Lyon, Lyon, France
| | - Segolene Gaillard
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Department of Clinical Epidemiology, Bron, France
- Université de Lyon, Lyon, France
| | - Pierre Chatelain
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service d'Endocrinologie Pédiatrique, Hôpital Mère-Enfant, Centre Hospitalo-Universitaire de Lyon, Bron Cedex, France
| | - Yves Morel
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Laboratoire d'Hormonologie d'Endocrinologie Moléculaire et des Maladies Rares, INSERM 1208, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Behrouz Kassai
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Department of Clinical Epidemiology, Bron, France
- Université de Lyon, Lyon, France
| | - Pierre Mouriquand
- Centre de Référence Maladies Rares Développement Génital: du Fœtus à l'Adulte, Hospices Civils de Lyon, Bron, France
- Service de Chirurgie Uro-Viscérale de l'Enfant-Hôpital Mère Enfant, Hospices Civils de Lyon, Bron, France
- Université Claude-Bernard-Lyon 1, Lyon, France
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14
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Wang Y, McGrath M, Braga LH. Pitfalls of prospective non randomized studies: Why study results mislead. J Pediatr Urol 2020; 16:340-341. [PMID: 32513442 DOI: 10.1016/j.jpurol.2020.05.143] [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: 04/28/2020] [Accepted: 05/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Yuding Wang
- Division of Urology, McMaster University, Hamilton, Ontario, Canada
| | - Melissa McGrath
- Division of Urology, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Luis H Braga
- Division of Urology, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
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15
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Mohammadipour A, Hiradfar M, Sharifabad PS, Shojaeian R. Pre-operative hormone stimulation in hypospadias repair: A facilitator or a confounder. J Pediatr Urol 2020; 16:318.e1-318.e7. [PMID: 32402738 DOI: 10.1016/j.jpurol.2020.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Preoperative hormone stimulation (PHS) is popular in hypospadias reconstructive surgery. While still controversial, it is performed to have a more developed gross anatomy of the glans and penis for improvement of the surgical condition and outcome. OBJECTIVE In this study we assessed morphometric and histologic effects of pre-operative testosterone therapy on the penis and prepuce in patients with hypospadias. STUDY DESIGN 18 patients with hypospadias who received 3 monthly doses of 25 mg testosterone injections were compared with 23 patients with hypospadias who were managed without pre-operative androgen therapy. Penile morphometry and hormone side effects were assessed in monthly pre-operative visits. Intra operative observations and preputial histopathology were also compared between the groups. RESULTS Glans diameter enlarged significantly after the first dose of testosterone. (P < 0.001) while morphologic changes were not significant by further injections. 72.2% showed one or more hormone related side effects that were mostly mild. Severe side effects such as thick pubic hair growth, frequent erections or considerable penis hyper-sensation were observed in 27.8%. Glans to corpus ratio was 0.2 ± 0.75 in PHS group compare to 0.3 ± 0.17 in control group. (P < 0.001). Hemorrhage needing tourniquet placement was reported in 44.4% of the PHS patients compared to 26.1% among the control group. Histopathologic studies revealed increased vascularity and less inflammation of the prepuce in PHS group compared to controls. DISCUSSION The glans and penis enlargement wasn't significant in 22.2% of patients who underwent PHS. We identified the first dose of testosterone as the most effective one. This finding supports the idea of close clinical monitoring to stop PHS when a significant response is observed and the expected goals are reached. Androgen side effects were not uncommon among our patients although they were mainly mild. Intraoperative assessments showed a decreased glans wing thickness to corporal body ratio in PHS group compared to controls. This finding caused more complex glanuloplasty while wrapping the glans wings over neo urethra and enlarged corporal bodies. CONCLUSION We suggest limiting PHS to carefully selected cases considering the observed anatomical and histological changes and the side effects. Monthly monitoring during PHS is recommended to stop androgen therapy as soon as the minimum defined targets are reached. This may decrease the rate of androgen side effects while providing better surgical conditions.
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Affiliation(s)
| | - Mehran Hiradfar
- Pediatric Surgery, Mashhad University of Medical Sciences, Iran.
| | | | - Reza Shojaeian
- Pediatric Surgery, Mashhad University of Medical Sciences, Iran.
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16
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Chua ME, Rong M, Tuba-Ang K, Silangcruz JMA, Tanseco PP, Ming JMC, Kim KH, Hui CC, Farhat WA. The impact of sex hormones on genital wound healing in mice: a comparative study. J Pediatr Urol 2019; 15:635-641. [PMID: 31629667 DOI: 10.1016/j.jpurol.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 09/02/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVE The effects estrogen and testosterone have on penile wound healing are still uncertain. This study evaluated the effects of these hormones on the wound healing process of penile and non-penile skin in wild-type (Mus musculus species) 4-5-week-old mice. METHODOLOGY Seventy wild-type Mus musculus species were randomly assigned to four groups control (n = 17), 1-week post-operative topical estrogen (n = 18), 1-week pre-operative testosterone (n = 17), and immediate post-operative testosterone (n = 18). Incisions were made on the ventrum of the penis and dorsal neck skin. On post-operative day 3, 7, and 14, incision sites were harvested. Evaluation was performed grossly for postsurgical penile edema and histologically for inflammatory cell concentration, presence of fibrinopurulent materials and distribution of collagen-fibroblastic cells. Each treatment group was compared at the three post-operative time points using the Fisher-Freeman--Halton exact test. CD34 and androgen receptor immunohistostaining was performed for between-group differences to assess microvascular density or vasodilatation and androgen receptor upregulation. RESULTS In this study, the experiment noted significant penile edema on post-operative day 7 in the testosterone groups, whereas less edema in the estrogen group (P = 0.010; Figure). On histologic evaluation of the penile wounds, a significantly increased inflammatory cell concentration was noted for both pre-operative and post-operative testosterone groups on post-operative day 14 (P = 0.023). The estrogen group revealed significantly increased fibrinopurulent material on the 3rd and 7th post-operative days (P = 0.045 and P = 0.005, respectively). No significant between-group differences in the collagen-fibroblastic distribution were noted over the three-time phases. On histologic evaluation of the skin wounds, no significant differences were noted between the groups for inflammatory cell concentration and presence of fibrinopurulent materials. However, compared with the testosterone treatment groups, a significant higher collagen-fibroblast distribution was noted in the estrogen groups on post-operative day 3 and 14 (P = 0.001 and P = 0.044, respectively). CONCLUSION Sex hormones, when given peri-operatively, may affect the wound healing process in mice. Testosterone appears to stimulate a prolonged inflammatory effect on penile wounds. Conversely, estrogen induces a fibrinopurulent congregation early in the penile wound healing process. For general skin healing, estrogen induces earlier collagen and fibroblast distribution, whereas testosterone has a delayed effect. The findings of this study should be further investigated in larger animal model with longer follow-up period.
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Affiliation(s)
- Michael E Chua
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Institute of Urology, St. Luke's Medical Center, NCR, Quezon City, Philippines.
| | - Mo Rong
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Molecular Genetics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen Tuba-Ang
- Department of Pathology, Baguio General Hospital and Medical Center, Baguio, Benguet, Philippines
| | | | - Patrick P Tanseco
- Institute of Urology, St. Luke's Medical Center, NCR, Quezon City, Philippines
| | - Jessica Megan C Ming
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Division of Urology, University of New Mexico, Albuquerque, NM, USA
| | - Kyoung-Han Kim
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Molecular Genetics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Chi Chung Hui
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Molecular Genetics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Walid A Farhat
- Division of Urology, University of Wisconsin, Madison, WI, USA; Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
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Tanseco PP, Randhawa H, Chua ME, Blankstein U, Kim JK, McGrath M, Lorenzo AJ, Braga LH. Postoperative complications of hypospadias repair in patients receiving caudal block vs. non-caudal anesthesia: A meta-analysis. Can Urol Assoc J 2019; 13:E249-E257. [PMID: 30526802 PMCID: PMC6737734 DOI: 10.5489/cuaj.5688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION We performed a meta-analysis of the current literature to assess the association of caudal block and postoperative complication rates following hypospadias repair. METHODS A Systematic literature search was conducted on October 2017. Five reviewers independently screened, identified, and evaluated comparative studies assessing postoperative outcomes following hypospadias repair with and without caudal block. The incidence of post-surgical complications from each study was extracted for caudal block and control groups to generate the odds ratio (OR) and corresponding 95% confidence intervals (CI). Effect estimates were pooled using inverse-variance method with random-effects model. Subgroup analyses were performed according to study type and hypospadias severity. RESULTS Nine studies (2096patients) of low- to moderate-quality were included for meta-analysis. Overall pooled effect estimates demonstrated increased occurrence of postoperative complication rates among patients with caudal block (OR 2.32; 95% CI 1.29-4.16). Subgroup analysis according to hypospadias severity revealed that a significant increased OR in complication rate was noted among proximal hypospadias (OR 3.55; 95% CI 1.80-7.01), but not distal hypospadias (OR 1.31; 95% CI 0.59-2.88). CONCLUSIONS Our meta-analysis of poor-quality evidence may have revealed a significant association between caudal block and postoperative complications following hypospadias repair. However, subgroup analysis demonstrated that hypospadias severity is important in determining complication rates, suggesting that confounding factors and selection bias may play a central role in characterizing the true effect of the anesthesia approach.
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Affiliation(s)
| | | | - Michael Erlano Chua
- Institute of Urology, St. Luke’s Medical Center, Quezon City, NCR, Philippines
- The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Jin Kyu Kim
- The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Armando J. Lorenzo
- The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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