Staged Tubularized Autograft Repair for Primary Proximal Hypospadias with 30-Degree or Greater Ventral Curvature

Taping alone for persistent ventral curvature after urethral plate transection in hypospadias

INTRODUCTION

Ventral penile curvature is a key factor in determining the surgical approach to proximal hypospadias repair. However, there is limited evidence regarding the efficacy and long-term effects of the procedures used to address curvature. This study aimed to evaluate the effects of urethral plate transection alone with tissue traction therapy on penile curvature in two-stage repair of proximal hypospadias.

MATERIAL AND METHODS

This was a prospective study of primary hypospadias patients who underwent a two-stage repair with urethral plate transection as the sole straightening procedure. After stage 1, taping was applied as tissue traction therapy and continued until stage 2. Penile curvature was measured using a goniometer under artificial erection before and immediately after urethral plate transection and during the second stage of repair. The primary focus of this investigation is the angle of curvature after 6-month taping.

RESULTS

The study included 46 patients with a median age of 13 months at the start of treatment. The median angle of penile ventral curvature was 70° after degloving, 60° after urethral plate transection, and 0° during the second stage of repair. Full correction of ventral curvature was achieved in 42 patients (91 %).

DISCUSSION

This publication is the first of its kind to propose taping as a method for penile traction therapy in hypospadias. The study reveals that penile ventral lengthening can be achieved through tissue traction therapy following UP transection alone. These findings challenge the current consensus that complete straightening of the penis in the first stage is necessary to prevent recurrent curvature and that ventral lengthening is required to correct corporal disproportion. However, further validation and long-term data are needed to definitively confirm the effectiveness of tissue traction therapy after urethral plate transection.

CONCLUSIONS

This study demonstrated significant resolution rate of penile ventral curvature in proximal hypospadias following urethral plate transection alone with taping. Long-term follow-up studies are needed to confirm the sustainability of the results through puberty.

Hypospadias-associated penile curvature assessment and management: A global survey of current practice

INTRODUCTION

Our goal was to assess how surgical management of hypospadias-associated penile curvature (HAPC) varies across continents, focusing on factors that influence assessment and decision-making.

METHODS

Members of the European Society of Pediatric Urology (ESPU), Society of Pediatric Urology (SPU), and Hypospadias International Society (HIS) participated in an anonymous, 34-question online survey addressing pre-, intra-, and postoperative elements of HAPC evaluation and management. A selection of intraoperative photos were included in the survey to investigate the prevailing surgical approaches and identify management patterns.

RESULTS

Out of the 267 participants, 38.4% of them are located in Europe. Visual estimation was the predominant approach for evaluating HAPC, although being regarded as the least dependable compared to other techniques. Surgeons who performed more than 40 cases per year were more inclined to use goniometers and had varying degrees of HAPC that were considered acceptable without requiring any correction (P < .001). Out of 58% of respondents, a significant number reported regular utilization of artificial erection tests for all categories of hypospadias. Surgeons with fewer than 10 years of expertise commonly utilized erection test as part of their regular practice. A tourniquet was employed to maintain sufficient intra-corporeal pressure, by134 (50%). 116 participants (43%) inject Saline through the corpora cavernosa through the glans, while 150 (56%) administer saline from the lateral aspect. Moreover, the decision-making process differed based on the intraoperative picture scenarios of mild to moderate penile curvature during erection testing. Contrary to temperatures ranging from 25o to 35o, decision-making in cases with less severe degrees of HAPC was uncomplicated.

CONCLUSION

This survey reveals a wide range of surgical practice patterns in the assessment and management of HAPC. To our knowledge, this global survey of HAPC practice is the largest to date and could aid in developing new guidelines in pediatric urology. These findings may also provide a foundation for future prospective multinational studies.

Intracavernosal pressure of the erect penis in children with hypospadias

This study objective is to examine the intracavernosal pressure (ICP) in hypospadias boys with and without previous corporotomies. Retrospectively, the ICPs that were measured routinely as part of the artificial erection test in boys who underwent hypospadias repair were collected. The measurement (mmHg) included a slow manual saline instillation and a 21-gauge needle in the corpora cavernosa, which was connected to a pressure monitor. The full and rigid erections were defined according to the Erection Hardness Score by agreement between the two surgeons operating on the patient. Included were 61 boys with a median age of 15 months (IQR 8-27). Group A included 32 boys with coronal, subcoronal, or penile hypospadias. Group B included 29 boys with penoscrotal, scrotal, and perineal hypospadias. The median pressures at full erection for Groups A and B were 71.5 (IQR 59-79) and 62.5 (IQR 48-71) (p = 0.036), respectively, and at rigid erection were 283 (IQR 219-310) and 237 (IQR 182-278) (p = 0.032), respectively. In group B, median pressures at full erection for boys with and without previous corporotomies were 53.5 (IQR 45-65) and 69 (IQR 57-82), respectively (p = 0.001), and at rigid erection were 189.5 (IQR 113-263) and 264.5 (IQR 226-298), respectively (p = 0.003). In a comparison between group A boys to 18 boys in group B who did not have corporotomies, the median pressures at full erection were 71.5 (IQR 59-79) and 69 (IQR 57-82), respectively (p = 0.9), and at rigid erection were 283 (IQR 219-310) and 264 (IQR 226-298), respectively (p = 0.86). In conclusion, ICPs of artificial erections are lower in proximal hypospadias and in boys with previous corporotomies. The durability and the implications of these pressures require further research.

For the penile length-how shall we choose the straightening procedures in hypospadias repair?

OBJECTIVE

To define the appropriate penile straightening procedures corresponding to the specific penile curvature by comparing the penile length resulting from various straightening procedures in hypospadias repair.

METHODS

We retrospectively analyzed hypospadias patients between 2017 and 2019. Patients were divided into three groups based on the penile curvature after degloving: <30°, 30°-45°, and >45°. The penile straightening procedures include dorsal plication (DP), simple urethral plate (UP) transection, and UP transection with ventral lengthening (VL). The paired t-test was conducted for the penile length after fully straightening in each group, simultaneously calculating the length changes (∆T). In addition, the penile length changes among these procedures were compared using Spearman analysis to show the correlation between the penile curvature and the length.

RESULTS

The penile length changed significantly after fully straightening in all groups. The length decreased mildly after DP, while increased in the other procedures. The penile curvature after degloving was positively correlated with the absolute change in the penile length (P < 0.001, r = 0.424) and the ratio of ∆T in the original length (P < 0.001, r = 0.433).

CONCLUSION

For hypospadias, the 30° after degloving may serve as the cut-off for the selection of the straightening method from the perspective of the penile length. For those with < 30°, methods such as DP or UP transection can either be selected. In patients with > 30°, DP should be used with caution because of the potential risk to shorten the penis. In contrast, UP transection effectively corrects the penile curvature and increases the penile length concurrently, which should be primarily recommended in those patients.

A scoping review on chordee correction in boys with ventral congenital penile curvature and hypospadias

Introduction

Congenital penile curvature (PC), often concomitant with hypospadias, poses challenges in urology. Surgical correction techniques, including plication and corporotomy, lack standardized guidelines. This study aims to address the paucity of high-level evidence by comprehensively reviewing the outcomes of PC correction procedures in patients with and without hypospadias. This will inform clinical decision-making and provide insights for future research and meta-analyses.

Methods

We conducted this scoping review in accordance with the JBI Manual for Evidence Synthesis and PRISMA-ScR guidelines. An extensive literature search was performed and comparative studies published in English up to June 2023 were included. The studies were divided into three categories: PC without hypospadias, PC with hypospadias, and studies comparing two or more materials for covering the ventral corporotomy. Data extraction comprised author details, patient characteristics, study design, interventions, outcomes, and complications. Methodological quality was assessed using the Newcastle-Ottawa Scale.

Results

Forty-two studies were included in the review, which collectively comprised 3180 patients. Thirteen comparative studies reported the outcomes of surgery for congenital PC without hypospadias, 22 studies compared different techniques of PC correction in patients with hypospadias and 7 studies compared the type of materials for coverage following ventral corporotomy. In cases of PC without hypospadias, the most commonly reported surgery was the Nesbit's plication. For PC with hypospadias correction, the results of ventral corporotomy were superior to that of dorsal plication in most of the studies. The two-stage repair had better results when compared to the one-stage repair for patients with perineo-scrotal hypospadias. In studies comparing materials for coverage of ventral corporotomy, the tunica vaginalis flap or graft was utilized most commonly. The majority of the studies reported a success rate ranging from 85% to 100%. The methodological quality was high in all but four studies.

Conclusion

Plication procedures are generally preferred for PC without hypospadias, but they result in penile shortening. For those with hypospadias, corporotomy is associated with superior outcomes than plication, especially for those with severe curvature and redo procedures. For ventral corporotomy coverage, the tunica vaginalis flap or graft is the most commonly reported tissue in the literature.

Outcome analysis of staged preputial graft technique for primary proximal hypospadias with and without post-operative vacuum physiotherapy

PURPOSE

Management of proximal hypospadias remains challenging. We assessed the results of staged preputial graft repairs (SPG) for proximal hypospadias and hypothesize that post-operative vacuum physiotherapy (VP) improves graft suppleness and overall outcomes.

MATERIALS AND METHODS

Retrospective analysis of n = 71 patients with proximal hypospadias and severe ventral penile curvature (PC) of ≥50° after degloving. PC was corrected using ventral transverse incisions of the tunica albuginea (VTITA) without applying a tourniquet, taking care to avoid injuring the underlying erectile tissue. The ventral raw area at the penile shaft, including VTITA, were covered with either divided and partially mobilized urethral plate, or with the inner preputial graft itself. During the second stage, a tunica vaginalis flap was often used to cover the tubularized neourethra. Outcomes and post-op complications were assessed after each stage, comparing patients who received vacuum physiotherapy (VP+, n = 49) with those who did not (VP-, n = 22).

RESULTS

Mean PC was 66°, average follow-up duration was 13.01 months, and overall complication rate was 22.5%. Only 6 of 49 VP + patients experienced complications (12.24%; 4 fistulas; 2 urethral strictures) and no recurrence of PC after second stage was observed in this group. VP- patients displayed a significantly higher rate of complications, with 10 of 22 cases (45.45%) exhibiting fistula development (n = 5) and glans dehiscence (n = 5). Recurrence of mild PC after first-stage repair was comparable between patient groups (12% VP+, 18% VP-) and easily corrected by simple graft tubularization or dorsal plication during second-stage repair.

CONCLUSIONS

Staged repair using VTITA is effective for correcting proximal hypospadias with severe chordee. VP appears to promote and expedite graft suppleness and significantly improves patient outcomes.

What is the angle of a banana? The difficulty in reliable assessment of hypospadias chordee

INTRODUCTION

The degree of chordee associated with hypospadias impacts operative management. Unfortunately, poor inter-observer reliability in assessing chordee by multiple methods in vitro has been demonstrated. This variability may be related to the fact that chordee is not a discrete angle, but rather an arc-like curvature similar to that of a banana. On an attempt to improve this variability, we assessed the inter-rater reliability of a novel method of chordee measurement and compared it to measurements with a goniometer both in vitro and in vivo.

MATERIALS AND METHODS

In vitro assessment of curvature was performed using 5 bananas. In vivo chordee measurement was performed during 43 hypospadias repairs. On in vitro and in vivo cases, chordee was assessed independently by faculty and resident physicians. Angle assessment was performed in a standard manner with a goniometer and with a smartphone app using ruler measurements of the length and width of the arc (Summary Figure). The proximal and distal aspect of the arc to be measured was marked on the bananas, whereas the penile measurements were taken from the penoscrotal to the sub-coronal junctions.

RESULTS

In vitro banana assessment demonstrated strong intra- and inter-rater reliability for length (0.89 and 0.88, respectively) and width measurements (0.97 and 0.96). The calculated angle demonstrated an intra- and inter-rater reliability of 0.67 and 0.67. The banana goniometer/protractor measurements were weak with an intra-rater and inter-rater reliability of 0.33 and 0.21. With hypospadias chordee, the inter-rater reliability was strong for length and width measurements (0.95 and 0.94) and 0.48 for calculated angle. The inter-rater reliability of the goniometer angle was 0.96. Further assessment of inter-rater goniometer reliability was performed relative to degree of chordee as characterized by faculty. The inter-rater reliability for ≤15°, 16-30, and ≥30° was 0.68 (n = 20), 0.34 (n = 14), and 0.90 (n = 9), respectively. When the goniometer angle was classified as ≤15, 16-30, or ≥30° by one physician, it was classified outside of this range by the other physician 23%, 47%, and 25% of the time, respectively.

DISCUSSION

Our data demonstrate significant limitations of the goniometer for assessing chordee in vitro and in vivo. We were unable to demonstrate significant improvement in chordee assessment using arc length and width measurements to calculate radians.

CONCLUSIONS

Reliable and precise techniques for measuring hypospadias chordee remain elusive and draw into question the validity and usability of management algorithms employing discrete values.

De-epithelialized overlap flap to secure urethroplasty in second stage hypospadias repair: revisiting the Smith technique

BACKGROUND

The application of a second layer between the neourethra and skin was a major contribution, which has improved the outcome of hypospadias repair. Here, we report our experience of revisiting the original Smith technique using a de-epithelialized overlap flap to support the urethroplasty in staged hypospadias repair.

METHODS

The study included primary cases of proximal hypospadias with significant chordee who underwent two-stage repair during the period 2016 through 2021. The ventral curvature was corrected at first stage by excision of the urethral plate, followed by covering the ventral shaft by skin flaps or inner preputial graft. The second stage (Thiersch -Duplay urethroplasty) was performed six months later. The de-epithelialized overlap flap (double breasting) technique was used to cover the neo-urethra in all cases, which was combined with a dartos scrotal flap to cover the proximal neourethra when indicated.

RESULTS

The study included 17 boys with proximal hypospadias who underwent two-stage repair. Follow up period after the second stage ranged between 6 and 30 months (mean 19.7; median 18.5). Post-operative complications were detected in 7 cases (41%). Most complications were related to distal/glanular disruptions whether partial or complete (5 cases). One case developed a penoscrotal fistula that was closed surgically. Another case (belonging to the group which used preputial graft in the 1st stage) presented 21 months after the second stage with urethral stricture (penoscrotal).

CONCLUSION

Applying the de-epithelialized double-breasting skin closure can offer alternative second layer coverage for the neourethra along the penile shaft in staged repair of proximal hypospadias.

A novel corporoplasty technique with a urethral plate flap in hypospadias repair

OBJECTIVES

To report a novel corporoplasty technique with a urethral plate flap in hypospadias repair and evaluate its safety and efficacy for ventral lengthening.

METHODS

Data were retrospectively collected from consecutive patients with hypospadias who underwent urethral plate flap corporoplasty between July 2021 and March 2022. All patients underwent hypospadias repair using the Duckett technique. The corporoplasty procedure involved the following key steps: the half-spongiosum of the urethral plate was harvested as a flap (with a pedicle attached to the corpus cavernosum); a transverse incision of the tunica albuginea was made adjacent to the pedicle; and the flap was patched onto the corporal defect.

RESULTS

The study included 10 patients, with a median age of 20 months. The initial meatal location was penile in two patients, penoscrotal in four patients, and scrotal in four patients. The median ventral curvature was 45° after degloving and urethral plate transection. The median ventral lengthening distance proportional to penis length was 0.21. During the median follow-up of 13.8 months, complications occurred in three cases, including two cases of fistula and one case of urethral stricture with secondary diverticulum. No cases of recurrent ventral curvature, meatal stenosis, or urethral dehiscence were noted. Postoperative ultrasonography showed a good continuation of the tunica albuginea and integrity of the stratum spongiosum at the corporoplasty site.

CONCLUSIONS

Urethral plate flap corporoplasty is a simple and effective ventral lengthening procedure. The novel corporoplasty technique allows for anatomical and architectural repair of corporal disproportion.

Effectiveness of penile ventral curvature correction and the trend of hypospadias repair: a prospective study of the national center in China

BACKGROUND

Hypospadias repair is a complex surgical procedure that involves correcting penile ventral curvature (VC) and performing urethroplasty. This study aims to evaluate the effectiveness of different strategies for VC correction and analyse the trends in hypospadias repair at a national centre in China.

METHODS

Prospective data collection was conducted from 2019 to 2020 for patients undergoing hypospadias repair. The effectiveness of VC correction was assessed based on the degree of VC change with different strategies. Furthermore, the choice of surgical techniques for different types of hypospadias repair was analysed.

RESULTS

A total of 434 patients were included, with a median preoperative VC degree of 50° (35°, 70°). All patients achieved a straight penis postoperatively, with 15.2% undergoing degloving, 28.6% undergoing degloving and dorsal plication (DP), 13.1% undergoing degloving and urethral plate transection (UPT), and 43.1% undergoing degloving, UPT and DP. Degloving alone was effective in correcting VC in 57.6% of patients with VC less than 30°. In our analysis, DP after UPT resulted in a higher degree of correction (25°) compared with DP after degloving alone (20°) (p<0.001). The study identified the current trends in hypospadias repair, with tubularised incised plate urethroplasty (TIP) being the most common technique used in distal hypospadias repair (70.6% of patients) and transverse preputial island flap urethroplasty (TPIFU) being preferred for proximal hypospadias repair (63.0%).

CONCLUSIONS

Degloving alone is effective for correcting VC less than 30°. The majority of patients in our centre underwent UPT, and DP after UPT yielded better results compared with DP after degloving alone. Distal hypospadias repair commonly used TIP, while TPIFU was favoured for proximal hypospadias repair.

TRIAL REGISTRATION NUMBER

ChiCTR1900023055.

The Role of Tissue Expanders in the Reconstruction of Proximal Hypospadias

OBJECTIVE

To report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias.

METHODS

Proximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage.

RESULTS

A total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%).

CONCLUSION

Proximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage.

Application of a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering for the single-stage repair of severe hypospadias

Objective

To assess the outcome of a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering (BFIC) for the single-stage repair of severe hypospadias in children.

Materials and methods

A retrospective study was performed on 40 children with hypospadias who were treated in our hospital from December 2017 to February 2022. The inclusion criteria were as follows: (1) the patient had proximal hypospadias, or penile curvature over 30° after degloving the penis; and (2) the patient underwent surgery for hypospadias for the first time. A free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering was performed, and all patients were followed up for more than 6 months.

Results

After degloving the foreskin, the urethral orifice was retracted to the perineum and scrotum in 20 cases, penoscrotal in 8 cases, and penile in 12 cases. Single-stage repair was achieved without complications in 34 (85%) patients. The remaining six patients experienced postoperative complications: urethrocutaneous fistula occurred in five cases and glans dehiscence with urethrocutaneous fistula in one case. No urethral diverticulum occurred in any case. A neomeatus with a vertically oriented slit-like appearance was achieved at the tip of the glans in all cases, with one exception.

Conclusion

The single-stage operation with a free preputial tube graft coupled with urethral plate urethroplasty combined with a Buck's fascia integral covering in the treatment of severe hypospadias achieves favorable functional and cosmetic outcomes.

Fasciocutaneous foreskin twin flaps in hypospadias repair: Reconstructing a functional penis with freestyle design

BACKGROUND

Hypospadias is the most common congenital urological deformity in males; however, there is still no perfect solution or surgical method for one-stage operations to fix proximal hypospadias with ventral penile curvature (VPC). We developed a fasciocutaneous foreskin twin flap technique that can provide freestyle flap designs in hypospadias repair.

METHODS

A retrospective study including 26 patients was performed between January 2017 and June 2020. The surgical procedures included VPC correction, skin flap design, transfer and reconstruction. The urethra and shaft were reconstructed by twin flaps in one stage. All patients were followed up until 12 months.

RESULTS

All VPC cases were corrected after the operation. The fistula rate was 11.5% (3/26). No meatal stenosis, urethral diverticulum, or stricture was observed. A total of 92.3% (24/26) of patients were satisfied with their penis appearance.

CONCLUSIONS

The fasciocutaneous foreskin twin flaps provide freestyle designs in hypospadias repair, which can achieve a one-stage operation for proximal hypospadias with low fistula rates.

Complication rates of proximal hypospadias: meta-analyses of four surgical repairs

INTRODUCTION

Proximal hypospadias surgery is impacted by a high complication rate. The goal of this work was to assess the overall composite complication rate, fistula rate and stenosis rate following proximal hypospadias surgery realized according to onlay urethroplasty, Duckett, Koyanagi and Bracka techniques.

METHODS

The databases MEDLINE, EMBASE, SCOPUS, Cochrane Library, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) and Sciencedirect were searched. Studies had to report data about the mean age of population, the average duration of patient follow-up and the number of procedures required for surgical treatment of primary and proximal hypospadias. Two independent including one urologist reviewers screened all the articles and selected the articles to be included.

RESULTS

Overall composite complication rates were 32%, 34%, 49%, and 43%, for Onlay urethroplasty, Duckett's tubularized flaps urethroplasty, Koyanagi repair and Bracka 2 stages repair, respectively. Fistula rates were 13%, 18%, 21% and 23% respectively. The heterogeneity of complication rates reported in the different studies was not moderated by age, country, or patient's continent origin.

DISCUSSION

The classifications of complications used in articles were disparate and make comparisons between techniques difficult. The report of post-surgical complications in the literature is often poorly coded and follow-up times were often too short.

CONCLUSION

This meta-analysis attempts to determine to the extent possible, given the serious weaknesses in the hypospadias literature, plausible estimates of complication rates after skin flap urethroplasty. The patched onlay skin flap, the Duckett's tubularized skin flap technique, the Koyanagi's technique, and the Bracka's two-stage urethroplasty procedure lead to very high complication rates. Reported complication rates are comparable across techniques.

Evaluation of Double-Faced Tubularized Preputial Flap versus Duckett’s Procedure for Repair of Penoscrotal Hypospadias with Significant Penile Curvature: A Comparative Study

Background

Proximal hypospadias, with significant curvature, is one of the most challenging anomalies. Great diversity and a large number of procedures described over the last 4 decades confirmed the fact that no single procedure has been universally accepted or successful. So, the aim of this study is to evaluate double-faced tubularized preputial flap (DFPF) versus transverse tubularized inner preputial flap (Duckett's procedure) as regards surgical outcomes, complications rate, and cosmetic results for repair of penoscrotal hypospadias with chordee. Patients and Methods. This was a prospective comparative study on 144 children with primary penoscrotal hypospadias with moderate or severe chordee, conducted at New Damietta and Assuit hospitals, Al-Azhar University, from March 2016 to March 2022. The patients were randomly divided into two equal groups; group A (n = 72) underwent DFPF, and group B (n = 72) underwent Duckett's procedure.

Results

No significant difference was identified as regards demographic data. The follow-up period ranged from 20 to 66 months (mean of 28 months after DFPF and 31 months after Duckett's repair), and the complication rate was 20.1% (29 of 144 children). There were statistically significant differences between the two groups as regards the urethral stricture, penile rotation, and total complication rate. HOSE score was adopted for assessment of surgical outcomes, urine stream, and cosmetic results.

Conclusions

The DFPF technique is feasible and reliable for one-stage repair of penoscrotal hypospadias with chordee and can be considered as a good option as it ensures better surgical and cosmetic outcomes with lower incidence of complications.

Automated quantification of penile curvature using artificial intelligence

Objective

To develop and validate an artificial intelligence (AI)-based algorithm for capturing automated measurements of Penile curvature (PC) based on 2-dimensional images.

Materials and methods

Nine 3D-printed penile models with differing curvature angles (ranging from 18 to 88°) were used to compile a 900-image dataset featuring multiple camera positions, inclination angles, and background/lighting conditions. The proposed framework of PC angle estimation consisted of three stages: automatic penile area localization, shaft segmentation, and curvature angle estimation. The penile model images were captured using a smartphone camera and used to train and test a Yolov5 model that automatically cropped the penile area from each image. Next, an Unet-based segmentation model was trained, validated, and tested to segment the penile shaft, before a custom Hough-Transform-based angle estimation technique was used to evaluate degree of PC.

Results

The proposed framework displayed robust performance in cropping the penile area [mean average precision (mAP) 99.4%] and segmenting the shaft [Dice Similarity Coefficient (DSC) 98.4%]. Curvature angle estimation technique generally demonstrated excellent performance, with a mean absolute error (MAE) of just 8.5 when compared with ground truth curvature angles.

Conclusions

Considering current intra- and inter-surgeon variability of PC assessments, the framework reported here could significantly improve precision of PC measurements by surgeons and hypospadiology researchers.

Hypospadias: A Comprehensive Review Including Its Embryology, Etiology and Surgical Techniques

Hypospadias is among the most prevalent urogenital malformations in male newborns. It is characterized by the displacement of the urethral meatus to the ventral side of the penis, an aberrant ventral curve of the penis referred to as "chordee," and an abnormally arranged foreskin with a "hood" found dorsally and lacking foreskin ventrally. Patients may have an extra genitourinary abnormality based on the area of the lesion. In around 70% of cases, the urethral meatus is positioned distally to the shaft, representing a milder form of the disease. The remaining 30% of cases are located proximally, are more complicated, and require further evaluation. Although the origin of hypospadias is mostly obscure, several suggestions exist about genetic susceptibility and hormonal factors. The objective of hypospadias restoration is to restore aesthetic and functional regularity, and surgery is currently advised at a young age, mostly between six and 18 months. At any age, hypospadias can be repaired with an equivalent risk of complications, functional outcomes, and aesthetic outcomes. However, the best age of treatment is still undetermined. Even though the long-term effects on appearance and sexual function are usually good, males may be less likely to make the first move after rectification. Also, people who have hypospadias treated are twice as likely to have problems with their lower urinary tract. These problems can last for years after the initial repair.

Experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee: A single institution study with intermediate follow up

PURPOSE

We present our modified technique of using the inner preputial flap to cover the penile shaft, while removing the subcutaneous tissue of the distal part of the flap to act similar to graft. Herein, we present our experience with modified two stage inner preputial flap for repair of proximal hypospadias with chordee.

PATIENTS AND METHODS

The current study was a single-institution retrospective study between January 2016 and December 2020. Thirty-one patients with proximal hypospadias with chordee were included and underwent our modified technique. We excluded re-operative hypospadias and incomplete follow-up cases (<6 month of follow up). Patient demographics, outcomes and complications in the form of fistula formation, diverticulum, metal stenosis, stricture formation and glans dehiscence were reviewed.

RESULTS

A total of 31 patients were included in the study and underwent our modified technique. The median age was 18 months (9-60) & IQR 15-25). The median follow up was 40 months. Overall, success was achieved in 24 cases (77.4%). Complications occurred in seven cases (22.6%) and included urethrocutanous fistula in three patients (9.7%), diverticulum in two patients (6.5.%), metal stenosis in one patient (3.2%) and glans dehiscence in one patient (3.2%).

CONCLUSION

Our technique provides a favourable outcome with a low complication rate for repair of proximal severe hypospadias.

LEVEL OF EVIDENCE

Case Series Study (Level IV).

The modified Belt-Fuqua procedure using an asymmetric "furisode" sleeve for proximal hypospadias with severe curvature

INTRODUCTION AND OBJECTIVES

Proximal hypospadias repair is a challenge in the pediatric urology field. Although the previous reports showed that the Belt-Fuqua staged procedure is reliable with a low complication rate for midshaft hypospadias, this procedure has not been generally applied to more proximal hypospadias with severe ventral curvature due to technical limitations. To solve these technical limitations, we developed a modified Belt-Fuqua procedure using an asymmetric long skin sleeve looking like a Japanese long-sleeved Kimono called a "furisode". The aim of this study was to evaluate the outcomes of this new modification of the Belt-Fuqua procedure for the repair of proximal hypospadias with severe curvature in children.

STUDY DESIGN

The study retrospectively reviewed consecutive patients with proximal hypospadias with severe curvature underwent this new technique. The major modifications included are proximal degloving beyond the urethral meatus, asymmetrical ventral transposition of dorsal preputial skin like a furisode sleeve, and circumferential proximal anastomosis of preputial skin to native meatus in the first stage. Hypospadias severity was evaluated objectively in two ways: preoperatively by the Glans-Urethral Meatus-Shaft score and intraoperative direct measurement of ventral curvature. The primary outcome was urethroplasty complications.

RESULTS

A total of 66 patients completed both stages of the furisode technique. The median Glans-Urethral Meatus-Shaft score was 11. Overall, 60 (91%) patients showed ventral curvature greater than 60 degrees after degloving, and 35 (53%) underwent ventral grafting with a dermal graft in the first stage. Median urethral length constructed at the second stage was 41.5 mm. The median follow-up period was 25 months. Complications occurred in 9 patients (14%); 7 had urethral diverticula, 1 showed a fistula and 1 had a urethral stricture. Neither glans dehiscence nor meatal stenosis occurred.

DISCUSSION

There are a couple of advantages of this furisode technique to other tunneled flap techniques like the Ulaanbaatar procedure. The first is the ease of glans reshaping with a Firlit collar at the first stage because of no urethra in the glans. The second is that a long neourethra could be made by the same skin flap with one anastomosis to the native urethra.The weakness of this procedure was that urethral diverticula were prone to occur less than one year after urethroplasty.

CONCLUSION

The furisode technique, a new modification of the Belt-Fuqua procedure, provides an alternative staged repair of proximal hypospadias. This technique was easily applied for hypospadias with severe curvature requiring ventral grafting.

Evaluation of penile curvature in patients with hypospadias; gaps in the current practice and future perspectives

BACKGROUND/PURPOSE

Penile curvature (PC) is a significant phenotypic anomaly associated with hypospadias that can affect hypospadias repair post-operative outcomes and impact on long-term quality of life as well as psychosexual wellbeing of affected patients. While several previous studies have attempted to define PC assessment criteria, there is still no accurate, reproducible, and reliable tool for quantifying severity. Our goal was to review the pros and cons of the current tools utilized for assessing the degree of PC in children, stressing on both strengths and limitations of each method.

METHODS

A wide and deliberate review of the literature discussing the assessment of PC in hypospadias patients was conducted. We also draw on relevant methods employed in adults with PC and Peyronie's disease where a greater breadth of studies has been conducted.

RESULTS

The appraisal outcomes combined with our recommendations were presented in a structured approach discussing the pre-, intra-, and post-operative evaluation of PC in patients with hypospadias. Critical appraisal of the evaluation tools in terms of availability, cost, objectivity, and potential reproducibility was presented.

CONCLUSION

This review reflects on current tools used for assessing the degree of PC in children, highlighting both strengths and limitations of each method. A wide variety of approaches are currently being practiced or investigated, with each method displaying particular utility and reliability characteristics. Several approaches are currently being explored with high potential to overcome the current difficulties encountered when measuring PC both in clinical practice and research studies.

Plate Objective Scoring Tool: A new preoperative indicator of penile curvature degree in children with distal hypospadias

OBJECTIVES

There is an unmet need for preoperative methods that surgeons can use to objectively quantify hypospadias anatomic variables and determine risk of penile curvature. We, therefore, assessed whether Plate Objective Scoring Tool measurements were correlated with degree of ventral curvature in affected children.

METHODS

Patients undergoing distal hypospadias repair were enrolled into the study between January 2018 and December 2020 and were categorized independently by at least two surgeons using Plate Objective Scoring Tool. Scores were compared statistically to determine the degree of ventral curvature and requirement for correction.

RESULTS

Sixty-five patients with a median age of 18 months (interquartile range 13-26) were enrolled into the study prior to surgery for primary distal hypospadias. Patient probability of significant postoperative curvature (>20°) was determined with moderate confidence using a cutoff Plate Objective Scoring Tool score of 1 (sensitivity 75%, specificity 60%). Presurgery Plate Objective Scoring Tool scores were negatively correlated with subsequent degree of curvature (r = -0.37, P = 0.003), with values <1.0 predicting >20° curvature.

CONCLUSIONS

Plate Objective Scoring Tool scoring offers a succinct method of describing hypospadias severity and correlates well with postoperative outcomes. The Plate Objective Scoring Tool system can therefore be used to objectively predict the likelihood of penile curvature and aid communication between surgeons and researchers, as well as improving parental counseling.

A meta-analysis comparing dorsal plication and ventral lengthening for chordee correction during primary proximal hypospadias repair

PURPOSE

Recurrent chordee (RC) is an important complication of proximal hypospadias repair. In this meta-analysis we compared RC incidence following dorsal plication (DP) versus ventral lengthening (VL).

METHODS

We searched the databases to identify all papers between 2001 and 2021 pertaining to proximal hypospadias and recurrent chordee. Duplicate publications, review articles and incomplete articles were excluded. Meta-analysis of heterogeneity was reported with I² statistics. The pooled outcomes were compared to Chi square/Fishers exact test.

RESULTS

A total of 17 articles were included covering 582 patients. The I² statistics for prevalence of RC among different publications showed no heterogeneity for DP (I² = 0%) and low heterogeneity for VL (I² = 26%). RC was noticed in 31/122 (25.4%; 95% CI 18%-33%) among patients who had DP alone while it was significantly lower, 24/460 (5.3%; 95% CI 4%-8%) when VL was used (p = 0.0001). When compared to DP, all VL techniques had significantly lower incidence of RC. Among the VL techniques lowest incidence of RC was found for ventral corporotomies (4%) followed by small-intestinal- submucosa (SIS 4.2%) and tunica vaginalis flap (TVF)/free graft-TVFG (5%). Among the VL subtypes: the proportion of RC with use of TVF (4/70, 5.7%) and TVFG (3/69, 4.3%) for corporoplasty was comparable (p = 1); single-layer SIS was associated with significantly less RC (1/90, 1.1%) than 4-layer SIS (5/51, 9.8%; p = 0.02).

CONCLUSION

For correction of severe ventral chordee during primary proximal hypospadias repair, dorsal plication carries a higher risk of recurrence compared to ventral lengthening procedures.

Masculinizing surgery in disorders/differences of sex development: clinician- and participant-evaluated appearance and function

OBJECTIVES

To report the long-term follow-up outcomes of masculinizing surgery in disorders/differences of sex development (DSD), including both physicians' and patients' perspectives on appearance and functional outcome, including sexuality.

PATIENTS AND METHODS

In total, 1040 adolescents (age ≥16 years) and adults with a DSD took part in this multicentre cross-sectional clinical study in six European countries in 2014/2015. Of those, 150 living in other than the female gender had some kind of masculinizing surgery: hypospadias repair, orchidopexy, breast reduction and/or gonadectomy. The study protocol included medical data collection, an optional genital examination, and patient-reported outcomes including satisfaction with appearance and current sexual functioning.

RESULTS

Diagnoses included partial and mixed gonadal dysgenesis (45,XO/46,XY; n = 38), Klinefelter syndrome/46,XX males (n = 57), and various 46,XY DSDs (n = 42; e.g. partial androgen insensitivity syndrome, severe hypospadias) and 13 with other diagnoses. Of the participants, 84 underwent hypospadias surgery, 86 orchidopexy, 52 gonadectomy and 32 breast reduction (combinations possible). Physicians evaluated anatomical appearance at genital examination as poor in approximately 11% of patients. After hypospadias surgery, 38% of participants reported that they were (very) dissatisfied with anatomical appearance and 20% with function. The physician and patient evaluations were moderately correlated (r = 0.43).

CONCLUSION

The majority of participants were neutral to satisfied with the appearance and function in the long-term after masculinizing surgery. Given the initial severe phenotype and a risk of unsatisfactory results after masculinizing surgery in DSD, treatment should be handled by experienced multidisciplinary teams in order to optimize the postoperative results.

Surgical management of primary severe hypospadias in children: an update focusing on penile curvature

Over the past two decades, assessment and treatment of associated curvature has emerged as a major issue in treating patients with proximal hypospadias. However, the cut-off for defining a curvature as clinically significant is still unclear, as not all patients are bothered by the same degree of curvature and, although the need for a method to assess the curvature objectively has been emphasized, no standard method yet exists. Curvature is multifactorial. The same degree of curvature can be due to any possible combination of skin and/or subcutaneous dartos tethering, a short urethral plate and an intrinsic corpora disproportion. Different strategies can be used to treat curvature, depending on the underlying cause, surgeon preferences, and the goals of the repair. In the past 10 years, use of urethral plate transection and ventral lengthening procedures has increased, although the lack of long-term follow-up data on ventral lengthening procedures suggests that the use of such procedures should be selective. Furthermore, straightening manoeuvres are influenced by the technique used for subsequent urethroplasty and, in turn, may influence the success rate of the urethroplasty. This Review provides a comprehensive overview of the major developments from the past 10 years in the management of severe proximal hypospadias in children.

Reoperation frequency after transverse preputial Island flap urethroplasty "Duckett's technique" in treatment of severe hypospadias: A single center study

PURPOSE

Transverse Preputial Island Flap Urethroplasty (TPIFU) is one of the most common techniques for treating severe hypospadias. Studies on the reoperation frequency after TPIFU is lacking. In the present study, we reported our clinical outcomes of severe hypospadias treated with one-staged TPIFU and analyzed the operation frequency.

METHODS

We retrospectively analyzed the clinical data of severe hypospadias patients who underwent one-stage TPIFU from December 2018 to December 2019 in the department of Urology at Beijing Children's Hospital. A stepwise approach was used to manage the curvature. Severe hypospadias was defined as those residual curvature was higher than 30° after degloving. Urethroplasty complications included fistula, urethral stricture, and diverticulum. The short-term cure was identified as no complications occurring for 12 months after the date of last-time surgery. The reoperation rate and operation frequency of TPIFU were analyzed.

RESULTS

A total of 136 patients who underwent one-stage TPIFU were included in the study. The follow-up after primary urethroplasty ranged from 22 to 50 months. The median age at primary surgery was 22.5 months (range from 13 to 132 months). After primary TPIFU surgery, 53 (39%) patients underwent additional surgical interventions to treat postoperative complications. Among them, 24 patients (17.6%) developed fistula, 17 patients (12.5%) developed urethral stricture and 11 patients (8.1%) developed diverticulum. After the second surgery, five patients remained fistula, five patients remained urethral stricture, and seven patients remained diverticulum. Overall, 61% (85 patients) met the cured standard after the primary operation, and the two operations cure rate was 87.5% (119 patients). 91.2% (124 patients) were cured in three operations.

CONCLUSIONS

Although the complication rates after primary TPIFU were relatively high, more than half of patients achieved short-term cured through a single operation, and the cure rate after two or three operations was acceptable.

Staged transverse preputial island flap urethroplasty for some proximal hypospadias with moderate-to-severe chordee

BACKGROUND

We aimed to assess the outcome of staged transverse preputial island flap (TPIF) urethroplasty for repairing certain cases of primary proximal hypospadias with moderate-to-severe chordee in children.

METHODS

Nighty-two consecutive boys who underwent either one-stage or staged TPIF urethroplasty for the repair of proximal hypospadias with moderate-to-severe chordee between August 2015 and December 2019 were evaluated retrospectively. Patients were divided into two groups: one-stage TPIF urethroplasty group (n = 44) and staged TPIF urethroplasty group (n = 48). We noted and compared the postoperative complications, including urethrocutaneous fistula, urethral diverticula, residual penile curvature, and urethral stricture in both groups.

RESULTS

Both groups were followed up for 1-5 years, with an average of 3 years. No cases of residual or recurrence of penile chordee were reported in either group. In Group A, 9 patients (9/44, 20.4%) had postoperative urethrocutaneous fistula, and all patients underwent urinary fistula repair or urethroplasty. In Group B, postoperative urethrocutaneous fistula occurred in 2 cases (2/48, 4.1%), and one patient developed a urethrocutaneous fistula after the first operation, which was successfully repaired during the second operation. A urethrocutaneous fistula occurred in 1 case after completion of the second-stage operation; urethral fistula repair was performed successfully 6 months later. There were 2 cases of urethral stricture in Group A (2/44, 4.5%) and none in Group B. There were 6 cases of urethral diverticulum in Group A (6/44, 13.6%) and no cases of urethral diverticulum in Group B. The operative success rates were 61.3% and 95.8% in Group A and Group B, respectively (P < 0.001).

CONCLUSIONS

Compared with one-stage TPIF urethroplasty, staged TPIF urethroplasty in the treatment of certain cases of primary proximal hypospadias with moderate-to-severe chordee resulted in fewer postoperative fistulas, urethral strictures and urethral diverticula. The staged TPIF urethroplasty procedure was effective in reducing the operation difficulty and complication rate of hypospadias, improving the curative effect of complex hypospadias and having good clinical application value.

Acellular dermal matrix graft for ventral corporal lengthening orthoplasty in 2-stage proximal hypospadias repair

BACKGROUND

Correcting ventral curvature (VC) by lengthening the ventral corpora using a graft has been verified feasible, but still has been associated with the recurrence. The use of acellular dermal matrix (ADM) in the setting of tissue reconstruction has captured the attention of many surgeons. There are few reports on the use of ADM exclusively as correction of VC. Thus, we evaluate the safety and effectiveness of repairing the defect with ADM for straightening the VC in proximal hypospadias repair.

METHODS

We retrospectively analyzed the records of patients with proximal hypospadias who underwent ventral corporal lengthening with graft in staged repair from January 2013 to December 2019. Those with curvature greater than 30° after urethral plate transection were enrolled. ADM was used for repairing the defect left by transversely transection of tunica albuginea. Patient outcomes were compared with the non-matched control group who underwent the same procedure with tunica vaginalis (TV) repair. Patient demographics, operative techniques, complications, reoperations were summarized and compared between 2 groups.

RESULTS

Forty-three patients underwent ventral lengthening with ADM repair after transverse urethral plate transection and 35 patients with TV patching respectively. At a mean follow-up of 10 months in those with the first-stage ventral lengthening, 5 of 43 (11.6%) in ADM group was detected with recurrent VC, while 2 of 35 (5.7%) in TV group were observed with recurrent curvature contemporarily (P=0.363). At a mean follow-up of 46.8 and 45.3 months, persistent curvature in ADM group was not significantly different comparing to TV group (1/43, 2.3% vs. 1/35, 2.9%; P=0.883).

CONCLUSIONS

Ventral corporal lengthening using ADM graft may facilitate correction of VC without increasing the risk of urethroplasty complications. It offers a promising material that can be safe, effective and simple to use and provides psychological and aesthetic benefits. Additional series assessment and further randomized controlled trials will elucidate the clinical impact of using ADM with ventral lengthening.

Retrospective Study Over the Hypospadias Surgery in a Single Tertiary Center

Hypospadias surgery is a common activity in every department for pediatric surgery, increased incidence of this condition contributing this aspect. For this purpose permanent review of the data of cases is probably necessary, in order to promptly evaluate short and long term results.

MATERIAL AND METHODS

The authors are presenting this retrospective clinical and statistical study, enrolling 149 patients, hospitalized and operated in the Department of Pediatric Surgery and Orthopedics, between 2009 and 2018. several parameters were taken into consideration: moment of conception, type of hypospadias, associated malformations, use of meatoplasty, age at meatoplasty, age at urethroplasty, type of urethroplasty, postoperative incidents and complications.

RESULTS

Most of the patients included in the study were classified as anterior type of hypospadias, associated malformations were present in 20,13% of the patients, and 80% of the associated malformations belonged to the urogenital system. Over 60% of the cases underwent meatoplasty as a tactical procedure. Mathieu was the most appreciated procedure (74,5%) for urethroplasty and over a half of the patients were operated after the age of 3 years. Early and late postoperative fistula formation was noted in 18,12% of cases.

CONCLUSIONS

Better parameters to assess the exact type of hypospadias are needed to be introduced. Also, clear protocols for preoperative work-up in detection of other abnormalities, especially genito-urinary. Meatoplasty as a tactical procedure is having unclear influence for urethroplasty. Decreasing the age at urethroplasty should be the next goal. Some surgeons should really get overspecialized for this type of surgery.

Staged Buccal Mucosa Graft Urethroplasty for Proximal Hypospadias in Children: A Short- to Mid-Term Follow-Up Retrospective Study

INTRODUCTION

 The aim of this study is to report our experience with modified staged buccal mucosa graft urethroplasty for the repair of proximal hypospadias in children and adolescents.

MATERIALS AND METHODS

 A total of 183 patients were treated at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between 2010 and 2019. The patients were grouped according to age: (1) within 1.5-year-old group, (2) prepuberty group (Tanner stage 1), and (3) puberty group.

RESULTS

 In total, 153 patients were included in this study. Thirty-six patients had complications: seven after stage one; 29 after stage two; one patient had two complications. Maximum flow rates were 11.80 ± 1.46 mL/s in the 1.5-year-old group, 13.24 ± 2.61 mL/s in the prepuberty group, and 13.60 ± 2.20 mL/s in the puberty group (p = 0.199). Average flow rates were 6.86 ± 1.37, 7.94 ± 1.74, and 7.88 ± 1.22 mL/s, respectively (p = 0.203). The optimal hypospadias objective scoring evaluation score of 16 was seen in 117 patients (76%), the score of 15 in 23 patients (15%), 14 in 10 (7%), and 13 in 3 patients (2%). Patients with an uncomplicated treatment (no complication) had a higher clinical outcome than patients with a complication (15.8 ± 0.53 vs. 15.3 ± 0.97, with or without complication, p = 0.000). Multivariable analyses showed that previous treatment was closely related to the complication rate (p = 0.016).

CONCLUSION

 The modified procedure allows for two-stage repair of proximal hypospadias with good results with a low complication rate and good functional results. Delaying operation did not increase complication rates in our research.

Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade

BACKGROUND

Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade.

METHODS

A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes.

RESULTS

The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load.

CONCLUSIONS

Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.

Recurrent ventral curvature after proximal TIP hypospadias repair

EXTENDED SUMMARY

Most boys with proximal hypospadias have ventral curvature (VC) which must be straightened while preserving the urethral plate to use TIP repair. That is usually done by dorsal plication (DP). However, we reported recurrent VC was commonly found after DP in boys with proximal urethroplasty complications, and have diagnosed VC in patients similarly straightened by WS. We reviewed our proximal TIP patients and now report their recurrent VC.

METHODS

We used a prospectively-maintained database to identify all patients with proximal TIP by WS and document recurrent VC. Penile straightening was primarily done by midline DP using 5-0 or 6-0 polypropylene, and/or other maneuvers including combinations of urethral plate elevation off the corpora, mobilization of the urethra to the external sphincter, and ventral corporotomies. Recurrent VC was suspected by a characteristic 'hunched-over' appearance and resistance to lifting the glans cephalad (Figure), and confirmed in all cases by artificial erection intraoperatively.

RESULTS

58 of the 77 patients with follow up had VC straightened. Recurrent VC was diagnosed in 26%. It was suspected during this review in another 10% who had recurrent urethroplasty complications which we now know often indicate VC, or urethral plate elevation with no treatment for corporal disproportion. This recurrent VC was objectively measured in nearly half those diagnosed, averaging 52 (30-75). It was diagnosed before puberty in all cases. There was no difference in recurrent VC in those managed with DP alone versus those straightened by DP and/or other maneuvers.

DISCUSSION

The finding that 1 of every 4 patients had recurrent VC after proximal TIP, and that as many as 1 of every 3 might have had that complication, is concerning. During most the study the extent of VC was visually estimated, and most patients were thought to have <45° with no tension on the UP after straightening. We reported 70% of patients operated elsewhere for proximal hypospadias and presenting with urethroplasty complications had recurrent VC ≥ 30° following earlier DP. In that series, in the current patients, and in an earlier report by Braga et al., an intact urethral plate correlated with increased risk for recurrent VC. Despite our improved ability to diagnose recurrent VC, we have not found it in boys who underwent STAG repair with urethral plate transection.

CONCLUSIONS

Recurrent VC after proximal TIP repair occurred in at least 1 of every 4 patients despite DP and/or additional maneuvers to straighten the penis while preserving the urethral plate. Accordingly, we now only perform proximal TIP when there is little (<30°) or no VC.

Standardization of penile angle estimation with a semi-automated algorithm

INTRODUCTION

Penile curvature (PC) refers to an abnormal bending of the main longitudinal axis of the penis. It is frequently associated to hypospadias. To date, accurate and objective evaluation of PC is not easily reproducible amongst surgeons and there are no stablished protocols on how to measure PC in a standard way and in real-time to guide intraoperative decision making. For this reason, we want to present the results of creating a semi-automated algorithm to establish a reproducible and objective assessment of PC and propose it as a standard protocol for clinical applicability using inanimate 3-D penile models.

METHODS

This project consisted in two different phases. 1. Creation of an automated algorithm to estimate penile angle based on digital images. 2 Use of the algorithm to estimate penile angle on 3-D models and estimate interrater agreement using the algorithm. The algorithm was created to initially identify the geometrical centerline of the penile model to establish an automated output for angle estimation. 3-D printed penile models with known curvature angles ranging from 10 to 90° were used to test the algorithm (total of 9 penile models. These models were curved at one hinge as opposed to an arc type model. For each inanimate model, a set of 5 pictures were obtained from a lateral view at different camera angles (0⁰, 15⁰, 30⁰, 45⁰ and 60⁰) at a standard distance of 75 cm. Angle estimation using our designed PC algorithm was performed by a total of 10 different evaluators. Inter-rater reliability analysis in using the semiautomated algorithm was performed using the inter-class correlation coefficient (ICC) with two-way mixed effect model.

RESULTS

If the camera angle was greater than 30°, the absolute angle mean difference was greater than 10°. Camera angle with the smallest mean difference was at 0⁰ with a mean difference of 7.83°. Agreement between raters showed greater variability towards the higher camera angles. Nonetheless, a high degree of between evaluator reliability was found between the measurements at different camera angles. Single measures ICC ranges from .873 to .946, p-values were all <.0001.

CONCLUSION

Our results help standardize PC assessment using digital images and reduce subjectivity using an algorithm for PC estimation. Optimal camera position between 0⁰ to 30⁰ vertical from the penis gives the least variable and most accurate angle estimation. Future studies using algorithms will help define predictive PC cutoff values and evaluate postoperative outcomes.

Association between intra-operative meatal mismatch and urethrocutaneous fistula development in hypospadias repair

INTRODUCTION

The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used to assess hypospadias severity and risk for post-operative complications. The 'M' component is based on pre-operative meatal location, but meatal location sometimes changes after penile degloving, resulting in 'meatal mismatch.'

OBJECTIVE

To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the association of meatal mismatch with post-operative urethrocutaneous fistula development.

STUDY DESIGN

We performed a retrospective cohort study on patients who underwent primary hypospadias repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging (meatus moving more proximally after degloving), downstaging (moving more distally after degloving), or none. Covariates included: pre-degloving meatal location, chordee severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for repair. To test the association between meatal mismatch and fistula development, we constructed two, nested, multivariable Cox proportional hazards regression models with and without meatal mismatch and compared them with the likelihood ratio test. A sensitivity analysis excluded patients with <6 months of follow-up.

RESULTS

Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly associated with penoscrotal webbing, number of stages for repair, and pre-degloving meatal location, with downstaging being associated with more proximal meatal location. Over a median follow-up of 7.3 months (interquartile range 2.0-20.9), fistulae developed in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence Interval [CI]: 1.44-6.45) compared to no mismatch. Meatal downstaging had similar risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29-3.35). Multi-stage compared to single-stage repair was associated with reduced risk of fistula development (HR: 0.24, 95% CI: 0.09-0.66). The likelihood ratio test favored the model that included meatal mismatch. The sensitivity analysis showed similar findings.

DISCUSSION

Our short-term results suggest that meatal mismatch may be an important additional consideration to the GMS score as a tool to assess hypospadias severity, counsel families, and predict outcomes. Longer-term studies are needed to enhance the precision of risk stratification in hypospadias.

CONCLUSIONS

Meatal mismatch occurred in 20% of patients undergoing hypospadias repair. Among this cohort, meatal upstaging was associated with a 3-fold increased risk of post-operative urethrocutaneous fistula development.

Results of two-stage transverse preputial island flap urethroplasty for proximal hypospadias with chordee that mandate division of the urethral plate

Introduction

Reconstruction of proximal hypospadias with chordee remains a difficult task. Our work aims to evaluate the role of two-stage transverse preputial island flap urethroplasty for repair of proximal hypospadias with chordee.

Material and methods

This is a retrospective study including 57 children who underwent two-stage transverse preputial island flap urethroplasty. Glans meatus shaft (GMS) score was applied to 24 cases. Patient’s characteristics, operative details and complications were assessed. Hypospadias objective scoring evaluation was used for postoperative assessment.

Results

The mean age at the first stage operation was 23.6 months (9–84); the mean time interval between the first and second stage operations was 8.1 months (6–12) and the mean follow-up duration was 52.1 months (24–96). Urethral meatus was proximal penile in 18 patients, penoscrotal in 24 and scrotal in 15. The mean degree of ventral curvature (VC) was 51.5° (30–90). After the second stage operation, postoperative complications occurred in 16 (28.1%) patients with urethrocutaneous fistula in 6 (10.5%) cases, diverticulum in 3 (5.3%), glans dehiscence in 5 (8.8%) and meatal stenosis in 2 (3.5%). All cases of glans dehiscence occurred in severe hypospadias and small glans. Moderate GMS score was present in 10 (41.7%) cases and severe GMS in 14 (58.3%). Complications occurred in 7 (29.1%) patients with 5 (20.8%) with a severe GMS score and 2 (8.3%) with a moderate GMS score. The hypospadias objective scoring evaluation showed satisfactory results, with 39 (68.4%) patients achieving a score of 16 points.

Conclusions

Two-stage transverse preputial flap is a good choice for repair of proximal hypospadias with an acceptable complication rate of 28.1%.

Using Buck's Fascia as an Integral Covering in Urethroplasty to Restore the Anatomical Structure of the Penis in One-Stage Hypospadias Repair: A Multicenter Chinese Study Comprising 1,386 Surgeries

Objectives: The objective of the study is to investigate the feasibility and efficacy of urethroplasty with a Buck's fascia integral-covering technique (BFIC) to wrap and restore the normal anatomical structure of the penis in one-stage hypospadias surgery. Methods: One-stage surgeries for hypospadias management were performed using BFIC from January 2016 to September 2020 at four high-volume medical centers in China. The technique integrates Buck's fascia with glans wings to mobilize and wrap the urethra and restore penile anatomical relationships. The clinical data, postoperative follow-up data, and complications were recorded, and the results were analyzed. Results: A total of 1,386 patients were included in the study: 1,260 cases of primary hypospadias and 126 cases of re-operations; distal in 382 cases (27.6%), mid-shaft in 639 (46.1%), proximal in 365 (26.3%); tubularized incised plate (TIP) in 748 cases, inlay-graft in 124, onlay-graft in 49, Mathieu in 28, free-tube graft urethroplasty in 406, and 31 of hybrid procedures. One thousand one hundred forty-two patients (82.4%) were found to have penile curvature (>10°) after artificial erection and all corrected by dorsal plication/s or transection of the urethra plate (UP) simultaneously. The median followed-up time was 27 months (6-62). A total of 143 (10.3%) complications were recorded: 114 (9.0%) in the primary operations and 29 (23%) in the re-operations, 15 (3.9%) in distal hypospadias, 61 (9.5%) in mid-shaft, and 67 (18.4%) in proximal. The complication rate in UP preservation and transection was 10.1 and 10.8%, respectively. Of all case complications, there were 73 (5.2%) of fistula, 10 (0.6%) of dehiscence, 22 (1.6%) of meatal stenosis, 21 (1.5%) of stricture, 6 (0.7%) of diverticulum, and resident curvature in 11 cases (1.2%). The overall complication rate in TIP and free-tube procedure was 9.8 and 9.9%, respectively, and fistula occurred in primary TIP of 33 cases (4.9%). Conclusions: Buck's fascia with the glans can be used as an integral covering technique in one-stage distal to proximal hypospadias and primary or re-operative hypospadias repair. It is safe, feasible, and effective for the repair of hypospadias.

Staged repair of proximal hypospadias: Reporting outcome of staged tubularized autograft repair (STAG)

INTRODUCTION

Proximal hypospadias (PPH) repair is a challenge. Dilemma exists whether to do it in single or staged repair. Staged repair is our adopted procedure which was recently modified by Snodgrass into staged tubularized autograft repair (STAG), in which attention was given to ventral straightening of the penis together with some other technical details. Herein, we report our experience with STAG in a cohort of primary posterior hypospadias.

PATIENTS AND METHODS

In the period from 2011 to 2018 we operated 43 primary posterior hypospadias. Two principal surgeons (HB, MY) and multiple assistants operate children the same way, and data are recorded in a prospectively designed data base. In all children, inner prepuce graft was utilized, when curvature is more than 30 degrees, plate transection with or without ventral corporotomies were adopted.

RESULTS

Forty-three children with PPH and ventral curvature more than 30 degrees underwent first stage with median age 12 months (6-132 IQR16). Penile curvature was corrected by plate transection in 27 children (62.8%), ventral corporotomies in 16 children (37.2%). Graft take was successful in 90.7%, 4 children needed revision of fibrotic graft. Second stage was completed in 37 children, success was 56.8%, 21.6% fistula, 24.3% glanular dehiscence. Overall success after third surgery to correct complications was 78.4%. In a mean follow up of 3.2 years, we had recurrence of curvature in 2 children taking success rate to 72.9%. No meatal stenosis, no diverticulum, no stricture, no urethral dehiscence was encountered. Cosmetic appearance was excellent in follow up.

CONCLUSION

STAG achieves proper straightening of the penis and allows for reconstruction of a good urethra, yet urethrocutaneous fistula and glanular dehiscence remain the main complications. Follow up is important to address results of ventral corporotomies.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

Level IV case series with no comparison group.

Urological results and patient satisfaction in adolescents after surgery for proximal hypospadias in childhood

BACKGROUND

Proximal hypospadias repair is associated with a considerable complication risk. Long-term follow-up is required to present realistic expectations in pre-operative counseling.

OBJECTIVE

To investigate adolescents after childhood surgery for proximal hypospadias in a prospective cohort study describing the urological outcome, complication rates and patient satisfaction with penile appearance.

STUDY DESIGN

39 adolescents ≥14 years with penoscrotal to perineal hypospadias and primary urethroplasty (tubularized incised plate (TIP), preputial flap as Onlay or tubularized (Duckett)) from 1996 to 2005 at a single center were evaluated. The clinical assessment, at Md 16.5 years (14-25), included voiding history, genital examination including the Hypospadias Objective Scoring Evaluation (HOSE), uroflowmetry plus chart data from previous urinary flows and evaluation of patient satisfaction using the Penile Perception Score (PPS).

RESULTS

Twenty-nine patients with penoscrotal and 10 with scrotal/perineal hypospadias underwent surgery with TIP (N = 14), Onlay (N = 14) and Duckett (N = 11). Uroflows improved significantly compared with prepubertal maximal flows. Impaired flow rate (<10 mL/s) was found in 14% (5/36). Fifty-one percent (20/39) required reoperations, 29% (4/14) of TIP, 50% (7/14) of Onlay and 82% (9/11) of Duckett (p = 0.0062). Median penile length in adolescence was 8.7 cm (4.0-11.0). Forty-four percent (12/27) of patients were dissatisfied with penile length. Patients were 'satisfied' or 'very satisfied' with meatal position and shape despite HOSE for meatal position being 11% (4/38) distal, 76% (29/38) proximal glanular and 13% (5/38) coronal. TIP patients had more curvature at puberty than Duckett (p = 0.0062). Patients that had a decurvature procedure had shorter penile length (p = 0.019).

DISCUSSION

A high complication rate is previously described, predominantly within the first years. Our study shows 50% of reoperations were performed after >3 years, illustrating the need for long-term follow-up. Patient satisfaction with a deviant meatal position is rarely reported [1,2]. Our results support a conservative approach to an asymptomatic retracted meatus. Limitations of this descriptive study are the non-comparable groups and the retrospective data for correlation, impeding evaluation of prognostic outcome-factors. The shorter penile length found in patients after plication, and increased curvature after TIP, is therefore merely descriptive. However, the findings are in line with earlier publications suggesting limited use of TIP, and plication (recommending ventral lengthening instead) to avoid penile shortening and curvature in these cases [3-5].

CONCLUSIONS

The urological long-term outcome after proximal hypospadias repair is good, although late reoperations are common. In adolescence, patients were dissatisfied with the short penile length but satisfied with meatal position, indicating that in proximal hypospadias, preserving penile length and correcting curvature are prioritized over a distal meatus.

Ventral penile curvature estimation using an app

INTRODUCTION AND OBJECTIVE

The assessment of penile curvature is a key component of hypospadias surgery, as it often determines if a 1 or 2-stage procedure should be done. The objective of this study was to test the accuracy of penile curvature measurements using an App-based method among non-urologists.

METHODS

Lateral pictures of six plastic 3-dimensional penile models representing each decile of curvature from 20 to 70° were obtained and stored on the research project iPad. Each picture was labeled with a name (i.e. Jim). Non-urology medical professionals were recruited to estimate the curvature of the six pictures with an App-based method consisting of the Photoblend Pro App and 9 provided graded 2-dimensional penile curvature images (representing each decile of curvature from 10 to 90°). Curvature estimations were done by merging the picture of the 3-dimensional penile model with one of the 9 provided graded 2-dimensional penile curvature images inside the App in an iterative process until the penile model picture matched the graded image (see figure). A research associate taught the research subjects the App-based method and then the subjects were asked to estimate the ventral penile curvature of each of the six penile model pictures. Measurement error was calculated as the absolute difference in between the measured value and the true value for the 6 models. A comparison was then made with previous research where pediatric urologists used either a goniometer or unaided visual inspection (UVI) to measure the ventral curvature of the same plastic 3-dimensional penile models used for the pictures of this study.

RESULTS

Twenty-one subjects were recruited, and all completed the study. Mean errors using the App ranged from 1.9° to 7.1°, compared to 6.5°-15° for UVI and 4.4°-15.9° for goniometry. The median error for the App was 0° compared to 5-10° for both UVI and goniometry. Mean errors were significantly lower (p < 0.05) when using the app compared to UVI/goniometry for all except the 30° and 50° models. Assuming patients with VC ≤ 30° would have had a one stage repair versus a 2-stage repair if curvature was >30°, the number of measurements that could have resulted in the unintended operation was calculated. There was a statistically significant difference in number of potential unintended surgeries in between App (17%) versus UVI + Goniometer (37%) (p = 0.0133).

CONCLUSION

This pilot study demonstrated better penile curvature estimations using the App compared to the two most common methods currently used by pediatric urologists. Plastic models provide an avenue to test and compare penile curvature measurement techniques.

Edges-On-Dartos: An Easy Way to Improve Graft Performance in Staged Hypospadias Repair

OBJECTIVES

To present a technical tip to be incorporated in the first stage of a 2-stage graft repair of proximal hypospadias associated with curvature, aiming at widening the graft bed and enhancing mobility of the lateral portions of the graft for subsequent urethroplasty.

METHODS

After penile straightening, the dorsal dartos layer, carefully preserved attached to the dorsal penile skin used for penile coverage, is anchored to the lateral edges of the denuded corpora cavernosa with 3 to 4 interrupted 6-0 resorbable stiches on each side. The dartos creates a sort of hammock in-between the corpora, on which the central portion of the graft is quilted as in standard staged graft repair, and the skin margins laterally. Therefore, it widens the graft bed by 3-4 mm on each side. The lateral portions of the graft, laying on dartos, also remain supple for subsequent tabularization.

RESULTS

Between 2017 and 2019, the technique was used in 16 cases (range 10-19 months). None of these patients required re-grafting because of severe longitudinal graft shrinkage.

CONCLUSION

The described modification seems a simple tip to be incorporate in staged graft urethroplasty. Putative advantages include that a wider graft can compensate for some graft shrinkage occurring in-between stages; during the second stage, it can facilitate dissection and improve mobility of the lateral graft portions for tubularization, and make retrieval of a dartos flap for urethroplasty coverage easier. Prospective evaluation and comparative data are needed.

Validity and reliability of a home-based, guardian-conducted video voiding test for voiding evaluation after hypospadias surgery

Purpose

To investigate the validity and reliability of a home-based, guardian-conducted video voiding test for assessing postoperative voiding function after hypospadias surgery.

Materials and Methods

In a single center, patients who had undergone urethroplasty by a single surgeon and postoperative uroflowmetry and video voiding tests conducted between 2008 and 2016 were retrospectively reviewed. Urinary stream was categorized into five grades by three pediatric urologists in a blinded manner. The primary outcome was statistical correlation across raters as measured by Spearman correlation coefficient to validate the interpretation of the video voiding test. The secondary outcome was the reliability of the voiding video test compared with maximum urinary flow rate assessed by uroflowmetry.

Results

Thirty-one patients with hypospadias were enrolled. The patients' average ages were 12.3±3.2 months (range, 8–21 months) and 42.8±3.9 months (range, 35–48 months) at the time of surgery and voiding video tests, respectively. Hypospadias was anterior, penile, and proximal in 1 (3.2%), 18 (58.1%), and 12 (38.7%) patients, respectively. The number of patients with each voiding stream grade was as follows: very poor, 4; poor, 4; fair, 13; good, 4; and very good, 6. All intraclass correlation coefficients of the stream grade among the three observers were >0.95. Correlation between the maximum flow rate obtained by use of conventional uroflowmetry and the video voiding stream grade was validated (rho 0.778, p<0.001).

Conclusions

The home-based guardian-conducted video voiding test is easy to perform and the present results demonstrate its validity and reliability for assessing patients' post-urethroplasty voiding pattern.

Hyperbaric oxygen therapy for pediatric "hypospadias cripple"-evaluating the advantages regarding graft take

INTRODUCTION

Hypospadias cripple patients pose a major surgical challenge with high complication rates attributed mainly to graft contraction. Hyperbaric oxygen therapy (HBOT) is an established treatment for compromised grafts and used extensively as a salvage therapy for compromised grafts and ischemic non-healing wounds.

OBJECTIVE

We evaluated the graft-take rates in hypospadias cripple cases undergoing a staged tubularized autograft repair (STAG) and compared between patients treated with or without preemptive HBOT.

MATERIALS AND METHODS

All patients underwent a STAG. Patients receiving preemptive HBOT were compared with patients receiving the standard surgical procedure without HBOT. The HBOT protocol included a daily session, 5 days per week for four weeks before the surgery and 10 additional daily sessions immediately after first-stage surgery. Each HBOT session included 90 min exposure to 100% O₂ at 2 atmospheres absolute with 5 min air breaks every 20 min. The primary endpoint was graft take. Sequential tubularization without tension at second stage was defined as success.

RESULTS

Seven boys received HBOT and 14 boys comprised the control group. All patients in the HBOT group had good graft take with no graft contraction. In the control group, 57% had good graft take and could proceed to the second-stage surgery and 43% had graft contraction (Table). Except for one patient who had claustrophobia while entering the chamber, no significant side-effects developed during the HBOT.

DISCUSSION

The basic pathophysiology of compromised flaps includes both ischemia and reperfusion injury, which can be attenuated by HBOT. The beneficial effects of HBOT relates to several mechanisms, including hyperoxygenation, fibroblast proliferation, collagen deposition, angiogenesis, and vasculogenesis. Graft contraction is a well-known complication in hypospadias cripple population with reported failure rate of 39-63%. The HBOT procedure was found to be very effective and the entire HBOT group had a good graft take. Accordingly, all patients in the HBOT group proceeded to a successful second-stage tubularization. In addition, HBOT was found to be safe and generally well tolerated by this pediatric population. Study limitations were a relative small, non-homogenous sample size and lack of prospective randomization. Success was defined as sufficient graft elasticity sufficing for tubularization of the neourethra, and exact graft measurements are lacking in this study.

CONCLUSIONS

Preemptive HBOT can be used safely in the hypospadias cripple pediatric population and can potentially reduce the expected high surgical failure secondary to graft contraction.

Goniometer not better than unaided visual inspection at estimating ventral penile curvature on plastic models

INTRODUCTION AND OBJECTIVE

The assessment of penile curvature is a key component of hypospadias surgery, as it often determines if a one- or two-stage procedure should be performed. The objective of this study was to compare unaided visual inspection (UVI) against goniometry estimations of ventral penile curvature (VC) among pediatric urologists.

METHODS

A total of nine different penile models (1.5 cm wide and 5-6 cm long) representing each decile of curvature from 10° to 90° were created. The nine models were divided in two groups: one with five models (group 1: 10°, 30°, 50°, 70°, and 90°) and the other with four models (group 2: 20°, 40°, 60°, and 80°). Each subject measured the VC of each model in group 1 using one method (i.e. UVI) and the curvature of each model in group 2 using the other method (i.e. goniometry). The next subject then used the opposite method for group 1 (goniometry) and group 2 (UVI), and so on, alternating the methods used to measure each group in between the subjects (Figure). The mean error (difference in between the true curvature and the subject estimation) was compared in between the two measurement methods (UVI and goniometry). A statistician calculated that 20-30 subjects would be needed to detect more than 10° difference in between the methods.

RESULTS

A total of 25 subjects were recruited for the study (24 pediatric urologists and 1 adult urologist). Mean errors for all degrees of penile curvature and methods ranged from 3.5° (90° model) to 13.6° (30° model). The mean error was not statistically different in between UVI and goniometry methods for any degree of curvature. A subgroup analysis of only goniometry estimations comparing subjects with and without prior experience with goniometry showed a statistically significant difference only for the 60° model. If choosing the correct surgery depended on determining if the curvature was ≤30° or >30°, all subjects would have chosen the right surgery for all except the 20°, 30°, and 40° models, where wrong surgery was chosen in 6/25, 15/25, and 7/25, respectively.

CONCLUSIONS

In this preliminary study, goniometry was not superior to UVI at estimating VC. There is pressing need in the field of hypospadias surgery to develop a tool that can measure VC in a reproducible and reliable fashion.

Challenges in managing proximal hypospadias: A 17-year single-center experience

BACKGROUND

There are only a few publications in the medical literature reporting on complication rates in proximal hypospadias surgery, particularly with regard to long-term follow-up.

METHODS

Over a 17.5-year period, we operated 100 patients with penoscrotal, scrotal and perineal hypospadias. Sixty-four had a single-stage repair, including 15 who received a buccal mucosa inlay "Snodgraft" repair. Thirty-six had a two-stage Bracka repair of which 19 received buccal or lower lip grafts and 17 had preputial grafts. Overall, 34 patients received buccal grafts. The median follow-up was eight years (range 1-16 years). Three patients were operated for residual chordee years later.

RESULTS

Urethral fistulae occurred in a total of 26/100 (26.0%) cases, meatal stenosis in 16/100 (16.0%), wound breakdown in six (6.0%) and graft failure in one (1.0%). The fistula rate after the single-stage approach was 15/64 (23.4%), whereas it was 11/36 (30.6%) following two-stage repair (P = 0.4811).

CONCLUSIONS

Proximal hypospadias remains a challenging condition to treat. It is possible to perform a single-stage repair in 64.0% of cases. This brings down the median number of operations to only two. Lower lip grafts were used in 34.0% but are now used in redo-surgeries only. Our fistula rate was 26.0% but has decreased significantly in recent years.

LEVEL OF EVIDENCE

Level III.

Persistent or recurrent ventral curvature after failed proximal hypospadias repair

PURPOSE

Persistent or recurrent ventral curvature (VC) in patients with complications after proximal hypospadias repair is reported.

METHODS

Records of patients undergoing re-operation for complications after proximal repair performed elsewhere were reviewed, including earlier operative reports when available. Original extent of VC, means used for straightening, and presenting complaints and findings at re-operation were tabulated. Ventral curvature at re-operation was objectively measured by goniometry and classified as due to short ventral skin and/or scarring of skin/dartos, short neourethra, or short ventral corpora (corporal disproportion). The finding of corporal disproportion at re-operation was considered to be failure of initial straightening.

RESULTS

There were 73 patients with an average of 2.7 [1-5] prior operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50° (30-90). This was due to short skin/scarring in 7% patients, a short neourethra in 23%, and corporal disproportion in 70%. Initial straightening was performed by chordee excision in 18 patients, dorsal plication in 23, and ventral lengthening in 15. Persistent or recurrent corporal disproportion was significantly more likely after chordee excision or dorsal plication than after ventral lengthening (p = 0.005). Of patients with VC, 93% also had urethroplasty complications, including recurrent fistulas and wound dehiscences that appeared related to the curvature.

DISCUSSION

The VC that was encountered during proximal hypospadias re-operations was important for several reasons. First, all patients with VC who had completed urethroplasty had complications that included recurrent fistulas and wound dehiscences (Figure). Even if they had healed without complications, this VC exceeded 30° in all cases, which is associated with sexual dysfunction in adults. This VC was not reported by 37% of caregivers and sometimes not apparent on pre-operative physical examination. It is possible there is selection bias in this series, although nearly all patients were self-referred for complications, and nearly 40% of them were not aware their son had VC. Furthermore, the finding that most initially had dorsal plication agrees with an earlier survey of pediatric urologists' preferences for straightening penile curvature.

CONCLUSIONS

The most common complication in this series was persistent or recurrent VC, and nearly all these patients also had urethroplasty complications. This VC was more likely when the urethral plate was preserved during straightening and when chordee excision or dorsal plication rather than ventral lengthening was performed. These data suggest that surgeons should objectively measure VC and consider ventral lengthening rather than chordee excision or dorsal plication when it is ≥ 30°. Re-operations for urethroplasty complications should include artificial erection.

Prenatal imaging of genital defects: clinical spectrum and predictive factors for severe forms

OBJECTIVES

To report the clinical spectrum of genital defects diagnosed before birth, identify predictive factors for severe phenotypes at birth, and determine the rate of associated malformations.

PATIENTS AND METHODS

A retrospective study (2008-2017) of 4580 fetuses, identified prenatally with abnormalities evaluated by our Reference Center for Fetal Medicine, included cases with fetal sonographic findings of abnormal genitalia or uncertainty of fetal sex determination. Familial, prenatal and postnatal data were collected via a standardised questionnaire.

RESULTS

In all, 61 fetuses were included. The positive predictive value (PPV) of the prenatal diagnosis of genital defects was 90.1%. Most cases were 46,XY-undervirilized boys, 42 cases (68.8%), which included 29 with mid-penile or posterior hypospadias, nine with anterior hypospadias, and epispadias, micropenis, scrotal transposition, and buried penis (one each). In all, 46,XX-virilized girls were identified in seven cases (11.5%), which included four with congenital adrenal hyperplasia, two with isolated clitoromegaly, and one with ovotestis. Other defects included prune belly syndrome and persistent cloaca (six cases). Early detection during the second trimester (58.1% vs 18.8%, P = 0.03), intra-uterine growth restriction (IUGR) (45.2% vs 9.1%, P = 0.06), and curvature of the penis (38.7% vs 0%, P = 0.02), were more frequently related to severe defects in male newborns. Associated malformations (14 cases, 22.9%) and genetic defects (six) were frequent in undervirilized boys.

CONCLUSION

Prenatal imaging of genital defects leads to a wide range of phenotypes at birth. Its PPV is high and extra-urinary malformations are frequent. Early diagnosis during the second trimester, associated IUGR, and curvature of the genital tubercle, should raise suspicion of a severe phenotype and may justify delivery near a multidisciplinary disorders/differences of sex development team.