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Sennert M, Perske C, Fawzy M, Wirmer J, Hadidi AT. The effect of preoperative hormonal stimulation on the urethral plate; A histologic and histochemical study. J Pediatr Urol 2024:S1477-5131(24)00349-8. [PMID: 39004546 DOI: 10.1016/j.jpurol.2024.06.040] [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: 02/01/2024] [Revised: 06/24/2024] [Accepted: 06/29/2024] [Indexed: 07/16/2024]
Abstract
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.
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Affiliation(s)
- Michael Sennert
- Hypospadias Centre, Department of Pediatric Surgery, Emma and Sana Klinikum Offenbach Hospitals, Germany
| | - Christina Perske
- Institute for Pathology, University Medical Center Goettingen, Germany
| | - Mohammed Fawzy
- Hypospadias Centre, Department of Pediatric Surgery, Emma and Sana Klinikum Offenbach Hospitals, Germany
| | - Johannes Wirmer
- Hypospadias Centre, Department of Pediatric Surgery, Emma and Sana Klinikum Offenbach Hospitals, Germany
| | - Ahmed T Hadidi
- Hypospadias Centre, Department of Pediatric Surgery, Emma and Sana Klinikum Offenbach Hospitals, Germany.
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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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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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Grimstad F, Boskey ER, Taghinia A, Estrada CR, Ganor O. The role of androgens in clitorophallus development and possible applications to transgender patients. Andrology 2021; 9:1719-1728. [PMID: 33834632 DOI: 10.1111/andr.13016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The clitorophallus, or glans, is a critical structure in sexual development and plays an important role in how gender is conceptualized across the life span. This can be seen in both the evaluation and treatment of intersex individuals and the use of gender-affirming masculinizing therapies to help those born with a clitoris (small clitorophallus with separate urethra) enlarge or alter the function of that structure. OBJECTIVES To review the role of testosterone in clitorophallus development from embryo to adulthood, including how exogenous testosterone is used to stimulate clitorophallus enlargement in masculinizing gender-affirming therapy. MATERIALS AND METHODS Relevant English-language literature was identified and evaluated for data regarding clitorophallus development in endosex and intersex individuals and the utilization of hormonal and surgical masculinizing therapies on the clitorophallus. Studies included evaluated the spectrum of terms regarding the clitorophallus (genital tubercle, clitoris, micropenis, penis). RESULTS Endogenous testosterone, and its more active metabolite dihydrotestosterone, plays an important role in the development of the genital tubercle into the clitorophallus, primarily during the prenatal and early postnatal periods and then again during puberty. Androgens contribute to not only growth but also the inclusion of a urethra on the ventral aspect. Exogenous testosterone can be used to enlarge the small clitorophallus (clitoris or micropenis) as part of both intersex and gender-affirming care (in transmasculine patients, up to 2 cm of additional growth). Where testosterone is insufficient to provide the degree of masculinization desired, surgical options including phalloplasty and metoidioplasty are available. DISCUSSION AND CONCLUSION Endogenous testosterone plays an important role in clitorophallus development, and there are circumstances where exogenous testosterone may be useful for masculinization. Surgical options may also help some patients reach their personal goals. As masculinizing gender-affirming care advances, the options available for clitorophallus modifications will likely continue to expand and improve.
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Affiliation(s)
- Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA.,Center for Gender Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth R Boskey
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Amir Taghinia
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Carlos R Estrada
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Oren Ganor
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
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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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