Perineal hypospadias: back to the future Chordee Excision & Distal Urethroplasty

The effect of preoperative hormonal stimulation on the urethral plate; A histologic and histochemical study

AIM OF THE WORK

Preoperative hormone stimulation (PHS) is used to increase the glans size and may improve the cosmetic appearance after hypospadias surgery. The exact effect of PHS on different penile tissues remains unclear and controversial. Previous studies showed that PHS increased vessel density in the foreskin. However, the effect of PHS on the urethral has never been studied before. In this study we examine the PHS effects on the urethral plate.

MATERIALS AND METHODS

Specimens of the urethral plate and the underlying tissue were excised to correct severe chordee in 16 children with proximal and perineal hypospadias with severe chordee in 2 groups. Group A consisted of 8 children received PHS prior to surgery. Group B included 8 children with proximal and perineal hypospadias with severe chordee who did not receive PHS and served as a control group. Specimens were examined blindly using hematoxylin-eosin and elastic van-Gieson stain as well as factor 8 and SMA antibodies.

RESULTS

The median age of Group A was 13 (range 10-20) months. The median age of Group B (without prior PHS) was 17 (range 14-29) months (p = 0,03). The median vessel-density in group A (82 vessels per mm2) was significantly higher than in Group B (65 per mm2), (p < 0.05). The median vessel diameter was also significantly higher in Group A (13 μm) than in Group B (11 μm), (p < 0.05). The median epithelial layer thickness in Group A was 110 μm and in Group B 98 μm, but showed no statistical significance (p = 0,16). There was no significant change in dartos fascia layer thickness or androgen receptor expression. There was no visual change in the organization of elastic fibers.

CONCLUSION

This study is the first study to document the effect of PHS on the urethral plate in hypospadias with severe chordee. PHS significantly increased the median vessel-density as well as median vessel diameter as compared to a matching control group. The findings of the study may justify PHS administration before the first operation to improve the vascularity and may reduce the severity of chordee.

Should we correct hypospadias during childhood? Decision Regret And QUality of Life Assessment (DRAQULA) study

AIM OF THE WORK

To evaluate patient's satisfaction, Decision Regret And QUality of Life Assessment (DRAQULA) among adolescents (older than 15 years) and adults after hypospadias surgery in childhood.

PATIENTS AND METHODS

234 Patients operated on hypospadias as children in our center and their parents were contacted after they reached the age of 15 years to complete a questionnaire survey to assess satisfaction with the operative result, the regret with the operative decision and the health related quality of life (HRQOL). The survey is based on the Decision Regret Scale available in the literature with a score of 100 meaning maximum dissatisfaction or regret, and on the Kidscreen10 index. Satisfaction was measured on a scale from 1 to 5 with 5 signifying full satisfaction.

RESULTS

81 of 234 patients from 15 to 43 years (mean age 19.7 years) completed the survey (34.6 %). 44 Patients had distal, and 17 proximal hypospadias and the remaining 20 patients could not remember the type of hypospadias they had. The patient's satisfaction with the operative result was 5 (full satisfaction) in 74.1 %, 4 in 18.5 %, 3 in 6.2 % and 2 in 1.2 % (mean satisfaction score 4.7 of 5). Regarding decision regret among patients, 64/81 patients (79.0 %) had no decision regret. Only 14.8 % reported mild and 6.2 % moderate decisional regret (mean decisional regret score 4.8). 71 of 234 parents answered the parents' questionnaire (30.0 %). Fifty-eight (81.7 %) had no decision regret. 13 parents (18.3 %) had decision regret; 10 parents (14.1 %) reported mild, 2 parents (2.8 %) moderate, and only one parent (1.4 %) reported strong decisional regret. The mean HRQOL T-score was 55.9 (SD 10, control Group of adolescent males from 12 to 18 years.) and thus corresponded to the average of the reference normal population.

DISCUSSION

In this study, only 19.7 % had decision regret as compared to 50-65 % reported in literature. The decision regret scale of O'Connor needs to be revalidated as even candidates who approve of the decision of early surgery have a score less than 25 and considered to have decision regret.

CONCLUSION

The results of the survey showed that 90 % of the patients were satisfied with early hypospadias surgery with average HRQOL and low level of decisional regret in patients as well as parents. The findings support the current practice of operating hypospadias in early childhood.

Hormone receptor expression in hypospadias

INTRODUCTION

Sex hormone imbalance in utero is hypothesized to play an important role in the pathogenesis of hypospadias. Due to its easy accessibility, foreskin samples have been used to describe hormone receptor expression in rodents, and both adult and pediatric patients. In this study we conducted a systematic approach to assess hormone receptor expression in pediatric patients with hypospadias compared to healthy controls with a focus on age-matching and differences in severity and degree of hypospadias.

METHODS

Foreskin samples were collected from 35 children during hypospadias operations (18 distal and 17 proximal hypospadias) and compared with ventral foreskin samples of a control group of 32 children during circumcision (15 age-matched and 17 older boys). The samples were stained with H/E, androgen (AR), estrogen (ER) and progesterone receptors (PR). The receptor stainings were blindly evaluated. An Allred score was used to evaluate receptor expression in both the epithelium as well as stroma.

RESULTS

AR was detected in all cases. AR expression in the stroma was more evident than in the epithelium. AR expression in the hypospadias groups was significantly less than the age matched controls (p < 0.05). There was no significant difference between the two hypospadias groups nor between the two control groups. Older control group showed significantly elevated levels of AR expression compared to the hypospadias group (p < 0.05). ER was also detected in all cases. The stroma showed more ER than in epithelium. PR was minimal or negative in all samples.

CONCLUSION

Boys with hypospadias showed significantly weaker expression of androgen receptors than age matched controls. The severity of hypospadias did not influence hormone receptor distribution. AR expression is better observed in the stroma than in the epithelium. There was no difference in ER expression between the hypospadias group (distal or proximal) and age matched normal controls. ER was expressed in larger numbers in normal older preputial tissue. The foreskin of prepubertal boys shows little to no expression of PR.

Preoperative hormone stimulation; does it increase hypospadias postoperative complications?

AIM OF THE STUDY

To assess the effect of Preoperative Hormone Stimulation (PHS) on glans size in proximal hypospadias with chordee and small glans, and to determine if PHS is associated with increased postoperative complications.

PATIENTS & METHODS

Between 2014 and 2021, 101 cases of proximal hypospadias with small glans (12 mm or less) were operated upon in our hospital and are the basis of this cohort. All patients underwent a standard two-stage surgical repair, undergoing a correction of the chordee in the first operation and urethroplasty in the second operation. All patients included were operated by the same surgeon. They were classified into two groups; Group A: 50 children were operated upon between 2014 and 2017 and did not receive PHS and Group B: 51 children operated between 2018 and 2021 and received PHS. Glans dimensions including Dorsal Longitudinal Length (DLL) and Glans Width (GW) were measured during the first operation. PHS was given 1-2 months before the second operation in Group B. The glans dimensions were measured again during the second operation after PHS. Follow up period ranged from 2 to 9 years (mean 5 years).

RESULTS

Following PHS a statistically significant increase in glans length (p = 0.042) and glans width (p = 0.011) was observed at the second operation, with 36 patients (70%) showing a mean glans width increase of 2.78 mm (range 2-8 mm) after receiving PHS. There was no statistically significant difference in the complication rates between the two groups (p = 0.556) with a fragility index of zero (FI = 0).

DISCUSSION

The present study separates itself from most other studies in the literature, in the fact that it has included only a specific group of proximal and perineal hypospadias with severe chordee and glans width of 12 mm or less and that glans dimensions were always objectively and accurately measured under general anesthesia. The other major difference is that PHS in our study was given after and not before the first operation. Furthermore, the fact that all patients prior to 2018 did not receive PHS and all patients after 2018 received PHS, indicates that there was no selection bias.

CONCLUSION

This study shows that PHS results in an increase the size of the glans in 70% of patients with hypospadias and a small glans without an increase in postoperative complications.

How accurate is eyeball measurement of curvature? A tool for hypospadias surgery

INTRODUCTION

Correction of penile curvature or "chordee" is a major component in the management of hypospadias. Accurate assessment and management of penile curvature influence both short- and long-term outcomes of surgery.

AIM OF THE STUDY

The objective of this study is to investigate the accuracy of eyeball measurement and how does it compare to objective measurement by standard goniometry (SG) and smartphone app goniometry (AG).

MATERIALS AND METHODS

A Dropbox file request link was shared with paediatric urologists on various social media platforms requesting participants to upload a picture of their index finger showing what they thought 30 degrees of curvature look like using their proximal inter phalangeal joint as the point of maximal curvature., The images were assessed using SG to measure the angle of curvature. The images were also assessed using AG by the principal investigator, a physician, a scrub nurse and a paediatric urology consultant., Statistical analysis was performed using SPSS statistics software version 26 (Armonk, NY: IBM Corp). A one sample t-test and a one-way chi squared test were used to evaluate significant frequency differences. Pearson correlation was used to compare AG measurements to test intra- and inter-observer reliability and to compare AG measurements vs SG measurements. Assuming 5-degree variability in goniometer measurements and 2-degree difference between the sample and population, the number of participants needed was calculated to be 49.

RESULTS

Fifty-two responses were received.32.7% of respondents simulated 30° accurately (17/52). A significant proportion (23/52, 44.2%) overrepresented the degree of curvature and 23.1% (12/52) underrepresented it (p = 0.01). Compared with objective measures, eyeball estimates differed by an average of 10° ± 1.5 SE. Measurements obtained by AG were comparable to measures obtained by SG and showed excellent intra-observer and inter-observer correlation (R = 0.983, P < 0.001).

DISCUSSION

We demonstrated a significant discrepancy between eyeball assessment of curvature and objective measurements in a cohort of hypospadiologists. This can be very relevant to intraoperative decision making. The limitation of the study is the use of a simulated model rather than assessment of curvature in patients with hypospadias. Another limitation is the lack of standardization of the way the pictures were taken.

CONCLUSION

We demonstrated a tendency among hypospadiologists to overestimate or underestimate curvature by an average of 10° on eyeball assessment. The use of App Goniometry shows excellent interobserver reliability and is comparable to standard goniometry in curvature assessment.

The urethral plate and the underlying tissue; a histological and histochemical study

OBJECTIVE

To examine the urethral plate and the underlying tissues in children with proximal hypospadias associated with severe chordee.

MATERIALS AND METHODS

The urethral plate and the underlying tissue specimens were excised to correct severe chordee in 17 children with proximal and perineal hypospadias with severe chordee. The median age was 20 months (range 8-36). Sections samples were marked and examined from proximal to distal. Specimens were examined histologically using hematoxylin-eosin (H/E) and Elastic van Gieson (EvG) stain. Histochemical examination was also performed using smooth muscle actin (SMA) and factor 8 antibodies. For control, samples from four patients with hypoplastic urethra proximal to the meatus including the hypoplastic segments until the normal urethra were taken. In addition, the urethra of an adult patient with penile tumor was used as control.

RESULTS

The average size of the 17 tissue samples was 0.5 cm × 0.5 cm x 0.3 cm in depth. There was a common pattern that was seen in all the 17 specimens with a variable degree of expression. H/E staining showed that the epithelial lining changed from pseudostratified epithelium at the proximal intact urethra to non-keratinized stratified squamous epithelium at the urethral meatus to keratinized stratified squamous epithelium distally at the urethral plate level. EvG staining showed overall very few elastic fibres that increased slightly in the distal urethral plate. SMA staining showed a circular pattern of smooth muscle cells in the proximal intact urethra that changed to a U-shaped pattern at the level of the meatus, to a triangle shaped pattern just distal to the meatus. The distal urethral plate showed an irregular, disorganized rather flat pattern of the smooth muscles. Factor 8 antibodies staining the blood spaces revealed dysplastic unorganized large blood sinusoids underneath the urethral plate that were different from normal capillaries surrounding the proximal urethra.

CONCLUSION

The urethral plate and the underlying tissues in patients with severe chordee have different structure from normal urethra as compared to available literature and the adult control patient. The lack of elastic fibres may help to explain the rigidity of the ventral penis causing chordee. The disorganized irregular distribution of the smooth muscle fibres is suggestive of the hypoplastic corpus spongiosum. The abnormal large blood sinusoids may explain the poor healing quality of the ventral penis in patients with perineal and proximal patients associated with severe chordee. This may explain persistent/recurrent chordee observed later in those patients with severe chordee when dorsal plication is used. The study also supports the recent trend of 2 stage procedure as a plan of management for patients with proximal and perineal hypospadias with severe chordee and excision of all the dysplastic tissues during the first operation.

Preoperative glans & penile dimensions in different hypospadias grades

PURPOSE

To report glans and penile dimensions in 1023 consecutive boys with hypospadias.

PATIENTS & METHODS

Boys admitted for hypospadias surgery between 2016 and 2018 were included in this study. Age ranged between 6 and 36 months. Boys who underwent previous surgery, received hormone therapy or older than 36 months were excluded. The hypospadias was classified according to ICD and WHO classification into glanular (Grade I), distal (Grade II), proximal (Grade III) and perineal (Grade IV). The flaccid penile length (PL), the dorsal glans length (DGL), the ventral glans length (VGL) and the glans width (GW) were measured in the operating room under anaesthesia just before operative correction. Small (GW) in this study was defined as less than 14 mm.

RESULTS

1023 boys were included. 273 had glandular, 468 distal, 194 proximal and 88 perineal hypospadias. The mean glans width was 14 mm with a range of 8 to 20 mm. The mean glans width for glanular hypospadias was 14.0 mm (range 9-19 mm), 14.0 mm (range 10-20 mm) for distal hypospadias (p > 0.05), 13.1 mm (range 9-19 mm) for proximal hypospadias (p < 0.0001) and 11.1 mm (range 8-16 mm) for perineal hypospadias (p < 0.0001). 460 (45.0%) of all patients presented with a small glans width. In glanular hypospadias it was 99 (36.3%), 167 (35.7%) in distal hypospadias, 111 (57.5%) in proximal hypospadias and 83 (94.3%) in perineal hypospadias. There was no significant difference in the glans size between the age of 6 and 24 months (p > 0.2), but there was a difference when compared to patients older than 25 months (p < 0.05).

CONCLUSIONS

A small glans is found in about a third of distal, two thirds in proximal and more than 90% of perineal hypospadias.

What are the factors affecting glanular dehiscence after hypospadias surgery?

BACKGROUND

Glanular dehiscence (GD) is one of the main complications after hypospadias surgery. There is a limited number of publications regarding GD in the literature.

OBJECTIVE

The aim of this work is to reveal the factors that affect GD after a literature review.

EVIDENCE ACQUISITION

A literature search for relevant articles was performed in database using the search term glans dehiscence without setting date range limit or any other limits. All articles related to GD after hypospadias surgery were included in this study. After collecting the information from full text articles, 71 articles were included in this systematic review. In these studies, localization of hypospadic meatus, type of surgery, and other clinical data which were thought to behave as risk factors for GD were obtained. Chi-Square test was used to evaluate the differences between the parameters, where p < 0.05 was taken as statistically significant.

RESULTS

After evaluating the 71 articles that met the inclusion criteria, 309 cases (3.48%) of GD after 8858 hypospadias repairs were obtained in this review. GD rates were found significantly high for proximal hypospadias (5%), two-stage hypospadia repairs (5%) and re-do hypospadias repair (8.75%) (p = 0.002, 0.022, and 0.004, respectively). Glans width <14 mm, urethral plate (UP) width <7 mm, hypospadias surgeries performed before 6 months of age and after puberty, and caudal block anesthesia increased the rate of GD.

CONCLUSIONS

The rate of GD increases after proximal, cripple and staged hypospadias surgeries, a glans width <15 mm and UP width <8 mm, postpubertal surgeries, and caudal anesthesia use during surgery.

Ano-Scrotal Distance (ASD) : Is it a marker for the severity of chordee?

OBJECTIVE

To evaluate the relation between ASD and the severity of chordee and hypospadias in a referral center.

METHODS

The distance between the anal verge and proximal scrotal edge (ASD) was measured in hypospadias patients between 6 and 18 months between 2016 and 2020 in the operating room under anaesthesia. Patients older than 36 months and younger than 6 months were excluded. The patients were classified according to meatus into: Grade I (glandular or chordee without hypospadias), II (distal), III (proximal) and IV (perineal). Chordee was assessed by erection test and classified into 2 groups; Group I: no chordee or mild chordee <30 and Group II: with severe chordee >30. Short ASD was defined as ≤ 2.0 cm.

RESULTS

817 boys were included. The patients were classified according to the hypospadias grades I (180 pt), II (415 pt), III (120 pt) and IV (102 pt). The median ASD for group I was 3.07 cm (range 1.0-5.5), for group II 3.10 cm (range 1.5-5.0), for group III 2.40 cm (range 1.5-54.5) and for group IV 2.10 cm (range 1.0-3.5). The average ASD of the patients in Grade III and IV (2.26 cm) was significantly shorter than the average ASD of the patients in Grade I and II (3.09 cm) (p < 0.05). 184 patients had an ASD ≤2.0 cm. 38% of patients with glanular hypospadias (grade I) with ASD ≤ 2.0 cm had severe chordee.

CONCLUSION

This study shows that short ASD is a helpful marker of the severity of chordee and hypospadias. Patients with glanular hypospadias and short ASD have 38% chance of having severe chordee.