Psychosocial and Sexual Outcomes in Adolescents following Surgery for Proximal Hypospadias in Childhood

Post pubertal outcome after use of oral mucosa in urethral reconstruction for hypospadias in prepubertal boys: a systematic review

Oral mucosa graft urethroplasty (OMGU) is a surgical technique used in complex hypospadias repair. However, long-term outcomes in prepubertal boys, particularly through and after puberty, are not well established. To systematically review the long-term outcomes of OMGU in prepubertal boys with hypospadias, focusing on changes observed after puberty. A systematic literature search was conducted in PubMed, Embase, and Cochrane Library. Studies reporting long-term outcomes of OMGU in prepubertal boys with hypospadias were included. The quality of evidence was assessed using the ROBINS-I tool. Three studies of moderate quality met the inclusion criteria. Outcomes were mixed, with some patients experiencing favorable results and others facing complications such as meatal stenosis, urethral strictures, and fistulas. The scarcity of high-quality, long-term studies highlights a significant knowledge gap in this area. This systematic review reveals insufficient evidence to establish the long-term efficacy and safety of OMGU in prepubertal boys with hypospadias, particularly concerning pubertal development and post-pubertal outcomes. Future research should prioritize prospective, longitudinal studies with larger sample sizes and standardized outcome measures to address these critical gaps in understanding.

Mental health and health-related quality of life in adolescents surgically treated for hypospadias in childhood

BACKGROUND

There is limited research and conflicting results on the mental health and health-related quality of life of individuals surgically treated for hypospadias in childhood. Furthermore, the significance of patient-reported outcomes (PRO) in hypospadias is growing. More research is necessary on these topics, particularly in adolescents.

OBJECTIVE

We aimed to compare mental health, health-related quality of life, body satisfaction, self-esteem, penile appearance, and sexual function outcomes in 16-year-old adolescents who had surgery for hypospadias in childhood with a healthy comparison group.

STUDY DESIGN

The study involved 16-year-old adolescents who had surgery for hypospadias in one Norwegian hospital. An age-matched comparison group of healthy adolescents was previously recruited. The study assessed self-reported outcomes on mental health using the Strengths and Difficulties Questionnaire, health-related quality of life using the Pediatric Quality of Life Inventory, body satisfaction and self-esteem using the Self-Perception Profile for Adolescents, and genital perception and sexual function using the Pediatric Penile Perception Score and a non-validated structured interview.

RESULTS

In total, 117 adolescents operated for hypospadias and 61 healthy adolescents were included. The outcomes for mental health and health-related quality of life were not statistically different between groups. However, 18 (16%) hypospadias patients were classified as cases/borderline on mental health outcomes, compared to 2 (3%) in the comparison group (p = 0.01). Patients classified as cases/borderline on mental health reported lower health-related quality of life, self-esteem, and more stressful life events. Self-reported penile appearance and sexual function were comparable between groups, however the proximal hypospadias group displayed lower satisfaction.

DISCUSSION

Although the present study had generally positive outcomes, a significant finding was that a higher number of adolescents who had previously undergone hypospadias surgery during childhood were classified as cases or borderline cases with respect to mental health issues. Hypospadias surgery in childhood may pose challenges for some patients during adolescence, particularly in the proximal group. Regular monitoring by healthcare professionals is crucial in providing necessary support. A limitation is the small size of the subgroups.

CONCLUSION

Most patients report good mental health, quality of life, and self-esteem even though patients with hypospadias report more mental health issues than the comparison group. Proximal hypospadias were less satisfied with penile appearance and sexual function. However, due to the small sample size, conclusions about this group should be treated cautiously. Assessing self-reported outcomes in follow-ups is important to identify adolescents who had hypospadias surgery and are at risk for reduced mental health.

What should be next in lifelong posterior hypospadias: Conclusions from the 2023 ERN eUROGEN and EJP-RD networking meeting

BACKGROUND

A congenital disease is for life. Posterior hypospadias, the severe form of hypospadias with a penoscrotal, scrotal, or perineal meatus, is a challenging condition with a major impact on lifelong quality of life.

AIM

Our network meeting is aimed to identify what is currently missing in the lifelong treatment of posterior hypospadias, to improve care, quality of life, and awareness for these patients.

METHODS

The network meeting "Lifelong Posterior Hypospadias" in Utrecht, The Netherlands was granted by the European Joint Programme on Rare Diseases-Networking Support Scheme. There was a combination of interactive sessions (hackathons) and lectures. This paper can be regarded as the last phase of the hackathon.

RESULTS

Surgery for hypospadias remains challenging and complications may occur until adulthood. Posterior hypospadias affects sexual function, fertility, and hormonal status. Transitional care from childhood into adulthood is currently insufficiently established. Patients should be more involved in defining desired treatment approach and outcome measures. For optimal outcome evaluation standardization of data collection and registration at European level is necessary. Tissue engineering may provide a solution to the shortage of healthy tissue in posterior hypospadias. For optimal results, cooperation between basic researchers from different centers, as well as involving clinicians and patients is necessary.

CONCLUSIONS

To improve outcomes for patients with posterior hypospadias, patient voices should be included and lifelong care by dedicated healthcare professionals guaranteed. Other requirements are joining forces at European level in uniform registration of outcome data and cooperation in basic research.

Impact of Two Urethral Stent Types on Complications after One-Stage Hypospadias Repair Using the Duckett Procedure

BACKGROUND

The authors evaluated whether the new nickel-titanium alloy stent (NTAS) is superior to the traditional silicone stent used in hypospadias repair surgery in preventing complications such as urinary fistula.

METHODS

This retrospective cohort study included 576 patients with hypospadias who underwent NTAS or traditional silicone stent placement after hypospadias surgery between March of 2002 and August of 2019. The primary outcome was the rate of urinary fistula occurrence at 4 weeks (stent removal time), and the secondary outcomes were the rate of other complications, such as urethral stricture, urethral diverticulum, infection, and so on. The occurrence of complications in both groups was compared, and the important contributing factors of urinary fistula and urethral stricture were determined.

RESULTS

Among 576 patients, 398 were assigned to the NTAS group, and 178 were assigned to the silicone group. Thirty-five patients in the NTAS group and 30 in the silicone group developed urinary fistula, with a rate of 8.8% and 16.9%, respectively ( P = 0.005). Subgroup analysis showed that the differences were mainly in preschool patients (6 years or younger) ( P = 0.004) and those with the penile type of hypospadias ( P = 0.008). In addition, urethral stricture complicated five patients in the NTAS group and two in the silicone group, with a rate of 1.3% and 1.1%, respectively ( P = 1.000). Logistic regression showed that hypospadias type ( P = 0.001) and stent type ( P = 0.001) are the important risk factors for urethral fistula.

CONCLUSION

The NTAS reduced the occurrence of urinary fistula complications after hypospadias repair in preschool patients, and can be presented as a better choice for hypospadias surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Adult Hypospadias Outcomes for the Pediatric Urologist

PURPOSE OF REVIEW

This review article will examine the current literature on hypospadias-related complications in adult patients.

RECENT FINDINGS

In this article, we will review the most recent studies evaluating hypospadias-related stricture disease, erectile function, fertility, and psychosexual outcomes in adult men with history of hypospadias repair in childhood. Managing hypospadias-related complications in adult patients is challenging to reconstructive urologists due to the compounded complexity of innate tissue deficiency and history of prior surgical repairs. In this review, we explore overall functional outcomes of adults with history of hypospadias repair as well as repair strategies of hypospadias-related urethral stricture disease. We will review erectile function, fertility and psychosexual outcomes as well as potential complications, which often do not surface until late adolescence and adulthood. Although it is challenging to characterize and quantify hypospadias-related complications, further longitudinal study is needed to better care for this complex patient population.

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.

Web based research in sexual medicine: a position statement of the European Society for Sexual Medicine

Background

Although the use of the Web has brought major advances in every step of the research process, this also comes with several methodological challenges.

Aim

The article presents the European Society for Sexual Medicine's position statements on key methodological concerns relative to Web-based research in sexual medicine.

Methods

The authors conducted a systematic scoping review of articles using Web-based research methods in sexual medicine. For the creation of the statements, the authors processed the data from the methodology of the studies and formulated the final statements reaching 100% agreement in the group.

Outcomes

European Society for Sexual Medicine statements were provided on the following domains: definition of the population of interest, selection of the population of interest, data collection quality, response rate, self-reported questionnaire, consent, and legal obligations.

Results

Researchers should justify the relevance of the Internet population to the population of interest; should clearly describe how they identified study participants; should select and employ specific measures to avoid hoax; should explicitly describe the process of calculation of response and completion rates as well as the relative implications; should validate traditional sexual health questionnaires for online and, if possible, multilingual use; should not ignore consent in Web-based research; and need to be knowledgeable of the technical measures and legal obligations to protect anonymity.

Implications

Researchers are advised to include trained computer scientists in their group, have a good understanding of their legal obligations as to collecting, storing and disseminating personal data, and design their studies by taking into account the challenges of Web-based research.

Strengths and limitations

The heterogeneity of the included studies and methodological low quality of most of them was a limitation, which also shows the importance of this study and the need for guidelines regarding Web-based research.

Conclusion

Large uncontrolled samples could be a threat to the quality of the studies and increase bias if researchers are not mindful of the methodological challenges they would need to account for.

Sexual well-being and penile appearance in adolescents operated for distal hypospadias in childhood

BACKGROUND

The importance of patient-reported outcomes (PRO) in hypospadias is increasing. However, more knowledge is needed concerning genital self-perception on appearance and function in adolescents. The complication rates for distal hypospadias is different from that for severe hypospadias, and expected outcomes related to sexual well-being and cosmetics may also differ.

OBJECTIVE

To investigate 16-year-olds' self-reported outcomes on penile appearance, sexual well-being, and voiding function in distal hypospadias, and compare with that of healthy male adolescents and a surgeon's view.

STUDY DESIGN

Sixteen-year-old patients operated for distal hypospadias were included in this cross-sectional study and compared to a group of healthy adolescents. The assessment tools included the adolescents' self-perception on genital appearance and function measured by Pediatric Penile Perception Score (PPPS) and their responses to a structured interview. We also included information on clinical data from the electronic medical records, together with a physical examination and an uroflowmetry.

RESULTS

Seventy patients and 61 healthy adolescents participated. Patients and the comparison group reported no differences on sexual well-being. The patients were satisfied with penile appearance, however their overall PPPS was significantly lower (8.9), compared to the comparison group (9.6, p = 0.03). Thirty-nine percent of patients had complications leading to re-interventions and reported lower scores on genital self-perception on appearance and function compared to those who had not re-interventions. Voiding function was normal. The surgeon's score on appearance was comparable to the patients' score.

DISCUSSION

A key finding in our study is the patients' high satisfaction on sexual well-being, which was similar to healthy adolescents. The patients were also satisfied with penile appearance but scored significantly lower than the comparison group. Surgeons and patients had comparable scores on appearance; however, they seemed to emphasize different aspects of appearance. Our results on penile appearance and sexual well-being are comparable to those of other studies on distal hypospadias. In our study, re-interventions were associated with more negative genital self-perception on appearance and function, similar to findings in other studies.

CONCLUSION

Our results show overall positive satisfaction on sexual well-being, voiding function and penile appearance despite less satisfaction on penile appearance when compared with the comparison group. Satisfaction was reported to be good also in patients experiencing re-interventions.

Small Intestinal Submucosa for corporeal body grafting in patients with proximal hypospadias and severe chordee: Long term follow-up assessing erectile function and genital self-perception

BACKGROUND

Proximal hypospadias and severe ventral chordee are often challenging to repair. To preserve penile length in chordee repair, Small Intestinal Submucosa (SIS) corporal grafting is often performed with potential long-term complications including recurrent curvature and erectile dysfunction (ED). There is a paucity of data evaluating sexual function in mid, late and post-pubertal patients.

OBJECTIVE

We aimed to assess long-term outcomes of genital self-perception and erectile function in mid, late and post-pubertal patients who underwent single-layer (1-ply) SIS corporal body grafting for correction of severe chordee.

STUDY DESIGN

Patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting between 2001 and 2015 were retrospectively identified. Patients were evaluated for erectile and sexual function using the modified erection hardness score (mEHS) and the modified sexual health inventory for men (mSHIM). Perceived function and straightness were measured with Hypospadias Objective Scoring Evaluation (HOSE). Penile self-perception was assessed using the Pediatric Penile Perception Score (PPPS). Results were compared to an age-matched healthy control group. Categorical variables were analyzed using Fisher's exact test, and continuous variables using paired and unpaired t-test and ANOVA.

RESULTS

Nineteen patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting and 18 controls participated in the study with a median age of 17 years for both groups. In the mEHS, 12 (63.2%) hypospadias-patients and 14 (87.5%) controls rated their erections as completely hard and very rigid. In the mSHIM, 1 (5.2%) hypospadias-patient was classified as having moderate ED. A total of 16 hypospadias-patients (84%) and 16 controls (88.9%) reported being very satisfied or satisfied with the straightness of their penis. No significant difference was observed in the mEHS, mSHIM and PPPS between groups (p < 0.05). The straightness of the erection was rated lower by participants, than by the pediatric urologist. In the HOSE, 12 (63.2%) hypospadias-patients and 16 (88.9%) controls obtained an acceptable score.

DISCUSSION

Our findings indicate favorable long-term outcomes in ED and genital self-perception; only 5% of our population reported having a mild-moderate to moderate presentation of ED, and there were no reports of severe ED. The overall PPPS satisfaction rates were statistically similar for the control and hypospadias groups. The small sample population limits the significance of our findings.

CONCLUSION

Corporal body grafting with 1-ply SIS suggests positive long-term outcomes in genital self-perception and erectile function, with mid, late and post-pubertal patients who underwent hypospadias repair having comparable results to age-matched healthy controls.

Parental decision regret among Australian parents after consenting to or refusing hypospadias repair for their son: Results of a survey with controls

INTRODUCTION

Parental decision regret in hypospadias surgery is a recognised source of long-lasting psycho-social morbidity. High parental decision regret after their child's hypospadias repair is reported. The aim of this study is to report on decision regret in Australian parents, who accepted and declined surgery for their son and explore underlying factors for decision-making, satisfaction, and regret.

MATERIALS AND METHODS

An online anonymous survey was administered to three groups of parents: 1) parents who consented for hypospadias repair, 2) parents who declined repair and 3) a control group who requested circumcision for their child. Operations occurred between 2010 and 2020 in two paediatric hospitals in New South Wales, Australia. The survey included a validated decision regret assessment tool and additional questions to explore the possible basis of the opinions.

RESULTS

One hundred and eighteen parents (invited - 381, completed - 116, response rate - 31%) participated in the survey. Decision regret was present in group 1 (n = 89) - 55% (moderate-to-severe 15%), in group 2 (n = 14) - 71% (moderate-to-severe 57%), and in the control group (n = 15) - 15% (moderate-to-severe 8%) of parents. There was a significant difference in the median decision regret score between all three groups. Parents who chose hypospadias repair were mostly concerned about function.

CONCLUSIONS

The prevalence of decision regret among Australian parents who consented for their son's hypospadias repair was lower compared with the mean decision regret reported in the literature to date (55% vs 65%). Decision regret and its severity were highest among parents who declined hypospadias repair. New strategies are needed to reduce decision regret in parents whether they elect for surgery or not.

Erectile dysfunction in hypospadiac male adult rats induced by maternal exposure to di-n-butyl phthalate

For the treatment of hypospadias, a significant number of studies focus on penile reconstruction. However, scant attention is given to sexual behavior of hypospadiac patients and underlying mechanisms. A rat model of hypospadias was constructed by maternal di-n-butyl phthalate (DBP) exposure (800 mg/kg/day by gavage during gestational days 14-18). Ten-week-old male rats with hypospadias undertook significantly decreased penis/body weight ratio, reduced testis/body weight ratio, lower serum testosterone level and thinner myelin sheath thickness of cavernosum nerves. Meanwhile, erectile dysfunction (ED) was found in hypospadiac rats, which showed significant increases in transforming growth factor-β1 (TGF-β1) protein expression and decreases in the expression of alpha smooth muscle actin (α-SMA) protein, neuronal and endothelial nitric oxide synthase protein (nNOS and eNOS). In addition, phosphorylated protein kinase B/protein kinase B (pAkt/Akt) ratios were remarkably lower, but the Bcl-2-associated X protein (Bax)/Bcl-2 ratios, caspase-3 protein expression, nuclear factor erythroid 2-related factor 2/ Kelch-like ECH-associated protein 1 (Nrf2/Keap-1) ratios, NAD(P)H dehydrogenase quinone 1(NQO1) protein expression and heme oxygenase-1 (HO-1) protein expression were higher in the hypospadias groups than the control group. Notably, ED is comorbid with hypospadias in cases. Penile fibrosis, testosterone deficiency, and endothelial dysfunction lead to ED in hypospadias induced by DBP eventually, which might be explained by activating Akt/Bad/Bax/caspase-3 pathway, Nrf2/Keap-1 pathway and suppressing NOS/cGMP pathway in penis.

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.

Hypospadias and Increased Risk for Psychiatric Symptoms in Both Childhood and Adolescence: A Literature Review

Hypospadias is one of the most common congenital malformations in boys. Due to abnormal appearance in the penis with abnormal urination and erection, patients with hypospadias were vulnerable to suffering from stress and psychiatric difficulties. The present study aims to summarize all the current evidence of the association between hypospadias and the risk of psychiatric disorders by a comprehensive review. Seventeen clinical studies were identified in the four electronic databases. A total of 953,872 participants were involved, while 15,729 of them were hypospadiac patients and the remaining 938,143 were normal controls. The standard age for surgery for hypospadias ranged from 20.4 months to 21.5 years. Eight out of seventeen (8/17, 47%) included studies explicitly showed that patients with hypospadias had a significantly higher risk of psychosocial disorders (all P < 0.05). Specific types of psychiatric disorders included depression, anxiety, shyness, timidness, isolation, fear of ridicule, attention-deficit hyperactivity, autism spectrum, behavioral/emotional disorders, temper tantrums, emotionality, affective, psychosexual problems, and suicidal tendencies. Based on this review, psychiatric illnesses are frequently detected in hypospadiac patients' childhood, thus proper psychiatric guidance and early interventions from physicians, nurses, and parents may help these children to grow into less affected men.

Role of Genetic Counseling for Patients with Hypospadias and Their Families

Congenital malformations often have a genetic background associated with a recurrence risk and may be part of a syndrome. Therefore, for children with a congenital malformation, the parents should be offered genetic counseling, and the child should also be offered the same when they reach adulthood. Hypospadias is a common malformation in boys that arises during genital development in weeks 8 to 16. This results in an underdevelopment of the ventral aspect of the penis with a misplacement of the urethral opening somewhere along the penis, scrotum, or in the perineum and with different degrees of penile curvature. The cause can be monogenic, but generally it is regarded as a complex disorder caused by both genetic and environmental factors. Severe hypospadias and familial cases should be genetically investigated, as for other forms of disorders of sex development, according to current guidelines with sequencing of relevant genes. Hypospadias associated with another independent malformation may be part of a syndrome and should be investigated. Fortunately, boys born with milder hypospadias generally have a good outcome and thus the clinical value of finding a disease-causing mutation appears to be limited especially in light of the present cost of genetic analysis. However, all men born with hypospadias should be advised on the recurrence risk and risk for reduced fertility.

High satisfaction on genital self-perception and sexual function in healthy Norwegian male adolescents

BACKGROUND

Genital self-perception and self-reported outcome on sexual function represent important information in studies focusing on male adolescents born with a genital malformation. Normal data from an age-matched control group are essential for comparison and more knowledge is needed concerning age after puberty and before entering adulthood.

OBJECTIVE

To investigate the self-reported outcome on genital perception and sexual outcome of healthy male adolescents aged 16 and 17 years.

STUDY DESIGN

Sixty-one individuals were included in this cross-sectional study. The assessment tools included the adolescents' self-report on genital perception and sexual function measured by the Pediatric Penile Perception Score (PPPS) and their responses to a semi-structured interview. In addition, we added information on mental health and psychosocial functioning measured by the Strengths and Difficulties Questionnaire, and health-related quality of life (HRQoL) measured by the Pediatric Quality of Life Inventory. Body satisfaction and self-esteem were also measured by the Global Self-Worth and Physical Appearance subscales of the revised version of the Self-Perception Profile for Adolescents (SPPA).

RESULTS

Of the 73 individuals invited, a total of 61 participated. The adolescents reported high satisfaction on genital self-perception and sexual function with a score close to 10 on the overall PPPS score (maximum overall score is 12). Participants who were dissatisfied with their genitals reported penile length, alongside foreskin, as their main concern. More than 90% reported satisfaction on sexual function, concerning erection, masturbation, ejaculation, and orgasm. Results showed a higher score on body satisfaction, self-esteem, mental health and psychosocial functioning and a lower score on HRQoL compared to the normative Norwegian data. The small numbers of individuals that scored more negatively on genital self-perception and sexual function also scored more negatively in all items studied.

DISCUSSION

A key finding in our study was their high satisfaction on the overall PPPS score and reported sexual function. The results are comparable to other studies related to healthy male adolescents and the sample studied deviate little from a representative Norwegian sample. A comparison group of age-matched adolescents from the normative population is important to determine long-term outcomes on genital appearance and sexual function of patients born with a genital malformation and operated on in early childhood. Limitations of this study are the small sample-size and the lack of information on non-participants.

CONCLUSIONS

Our results show generally positive genital self-perception and sexual function in a healthy group of Norwegian male adolescents, aged 16 and 17.

The hypospadias-specific health-related quality of life conceptual framework: a scoping review of the literature

PURPOSE

Health-related quality of life (HRQoL) is an important yet understudied construct for individuals with hypospadias (HS). An important barrier towards understanding HRQoL and integrating it into research and clinical care for people with HS is the absence of an underlying conceptual framework to illustrate this construct. We propose a conceptual framework for HS-specific HRQoL based upon a scoping review of the HS literature.

METHODS/MATERIALS

We conducted a literature review of articles published between 1989 and 2019. Our search in Embase and Pubmed used the keyword "hypospadias" in combination with "quality of life" and "patient-reported outcomes." We used thematic analysis of the resulting publications to identify core HRQOL domains. From these results and review of HRQoL literature in other pediatric populations, we developed a conceptual framework representing HS-specific HRQoL.

RESULTS

We identified five domains of HRQOL previously studied in research with youth and adults with HS: penile appearance, voiding, social interaction, sexual health, and psychological or behavioral function. We propose a model of HS-specific HRQoL comprised of these domains and their areas of overlap, based upon the findings and conceptual mapping of our literature review.

CONCLUSION

This novel conceptual framework provides a foundation for understanding disease-specific HRQoL in individuals with HS and may serve as a guide for the conduct of future qualitative studies of the HS population. The overlapping biopsychosocial domains illustrate the possible effects of HS on day-to-day life. This framework may guide future surgical, clinical, and behavioral interventions that aim to improve medical care and quality of life outcomes for HS patients.

Evaluating quality of patient-reported outcome measures in patients with hypospadias

INTRODUCTION

There is growing recognition of the importance of patient-reported outcomes (PROs) in pediatric hypospadias. We have previously presented a conceptual framework for Hypospadias-Specific Health-Related Quality of Life (HRQoL), which posited 5 domains of HRQoL in this population. The framework components (domains) included penile appearance, voiding function, social function, psychological/behavioral function, and pubertal/sexual health. In this work, we investigated the established validity and relevance of PROs within each of these domains for patients with hypospadias.

MATERIALS AND METHODS

We evaluated existing measures with published psychometric data, including validation data, in the hypospadias population. We also assessed the available data on each measure according to the guidelines of the Scientific Advisory Committee of the Medical Outcomes Trust (Table) in order to establish measure quality. We also examined the power of existing validation studies according to suggested guidelines for psychometric validation and factor analysis.

DISCUSSION

Available validated measures in the hypospadias population have focused primarily on penile appearance and to a lesser degree on pubertal development/sexual health. There were no validated disease-specific measures with dedicated evaluations of other key HRQoL domains including voiding-related sequelae, social function, or psychological function. In addition, no single measure addressed all of the quality guidelines posed by the Scientific Advisory Committee.

CONCLUSIONS

Current generalized measures for PROs lack relevance to the experience of hypospadias patients, and disease-specific assessments are often focused on penile appearance. Improving measure quality is necessary to optimize the value of our assessments and better help our patients with hypospadias.

Sexual functions and fertility outcomes after hypospadias repair

Hypospadias is a common abnormality of the urogenital tract with a wide range of variety in its presentation and severity. The primary aim to correct hypospadias is to restore normal penile function and appearance. Although it can be corrected at any age, early correction between the 6 and 18 months of life is recommended. The functional and cosmetic outcomes have been very-well presented in the literature, although the aspects of sexuality and fertility of hypospadias repair in the long term are vague. In this narrative review, we aimed to gather the data around the sexuality and fertility outcomes of hypospadias repair and acknowledge urologists and parents of boys with hypospadias who will have a correction surgery about future sexual and fertility concerns.

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.

Delayed presentation of urethrocutaneous fistulae after hypospadias repair

BACKGROUND

Delayed urethrocutaneous fistula (UCF) presentation after hypospadias repair is rarely reported. The aim of this study is to report our experience with delayed UCF presenting more than 5 years after hypospadias repair.

METHODS

We conducted a retrospective review of patients who underwent UCF repair (CPT codes 54,340 and 54,344) at our institution between 1997 and 2017. Delayed UCF presentation was defined as a single normal urinary stream after initial hypospadias repair and subsequent presentation of a UCF/s urinary stream more than 5 years after initial hypospadias or UCF repair. Demographic and clinical data were reviewed after approval from our institutional review committee.

RESULTS

We identified 12 patients with delayed UCF. The mean age at hypospadias repair was 12.3 months (Range 6-32). The mean time to delayed UCF presentation was 11.5 years (Range 7.1-15.8). Four patients with delayed UCF (33.3%) required additional surgery for UCF recurrence with a mean time to recurrence of 2.2 years (Range < 1-5.6).

CONCLUSIONS

Delayed UCF presentation can occur more than 15 years after initial repair. Pubertal penile skin changes and increased genital awareness in older children may be contributing factors as all but one presented at age 10 years or older.

LEVEL OF EVIDENCE

III.

Challenges in pediatric urologic practice: a lifelong view

The role of the pediatric urologic surgeon does not end with initial reconstructive surgery. Many of the congenital anomalies encountered require multiple staged operations while others may not involve further surgery but require a life-long follow-up and often revisions. Management of most of these disorders must extend into and through adolescence before transitioning these patients to adult colleagues. The primary goal of management of all congenital uropathies is protection and/or reversal of renal insult. For posterior urethral valves, in particular, avoidance of end-stage renal failure may not be possible in severe cases due to the congenital nephropathy but usually can be prolonged. Likewise, prevention or minimization of urinary tract infections is important for overall health and eventual renal function. Attainment of urinary continence is an important goal for most with a proven positive impact on quality of life; however, measures to achieve that goal can require significant efforts for those with neuropathic bladder dysfunction, obstructive uropathies, and bladder exstrophy. A particular challenge is maximizing future self-esteem, sexual function, and reproductive potential for those with genital anomalies such as hypospadias, the bladder exstrophy epispadias complex, prune belly syndrome, and Mullerian anomalies. Few endeavors are rewarding as working with children and their families throughout childhood and adolescence to help them attain these goals, and modern advances have enhanced our ability to get them to adulthood in better physical and mental health than ever before.

The basics of transition in congenital lifelong urology

PURPOSE

Transition in urology is defined by the process that allows an adolescent or a young adult with a congenital or acquired urogenital anomaly to assume increasing responsibility for their own health care and to become the primary decision maker in their care.

METHODS

A review of the literature regarding transitional care for lifelong urologic congenital anomalies was performed with the aim of reporting expert opinion when data are non-existent. This review focuses on special considerations for adolescents and young adults with spina bifida, bladder exstrophy, anorectal malformations and differences of sexual development.

RESULTS

Urologic goals during the transition from childhood to adulthood continue to include attention to the preservation of renal function and optimization of lower urinary tract function. Additional concerns include care to decrease long-term surgical complications (especially after augmentation cystoplasty), to monitor for malignancy, to prepare for sex activity and fertility, and to help the adult patient in decision making. Transition aims to maximize quality of life and independence by ensuring uninterrupted appropriate care through a multidisciplinary approach which varies by geographical location and healthcare setting. Barriers include patient and family factors as well as provider and system related factors. A dedicated team is an important element of successful transition.

Psychosexual Functioning Outcome Testing after Hypospadias Repair

Self-confidence plays an important role in both genders’ sexual functioning. Lack of genital self-esteem may have negative effects on psychosexual development, especially in males, where deviations from a standardized normal penile appearance can lead to inhibitions in entering into sexual relationships. The aim of our study was to evaluate the informativeness of studied domains of the Global Sexual Functioning (GSF) questionnaire and sexual functioning of patients surgically treated in childhood for different types of hypospadias. We evaluated 63 males with hypospadias and 60 healthy age- and gender-matched controls. The GSF questionnaire was used to estimate psychosexual function as a long-term follow-up after the surgical correction of hypospadias in the patient and control groups. Sexual activity (p = 0.017), arousal (p = 0.033) and orgasmic abilities (p = 0.002) values were significantly increased in patients. Strong correlation was noticed between sexual activity and sexual desire (R = 0.872); arousal and sexual desire (R = 0.753), as well as orgasmic and erectile abilities (R = 0.769). Different domains of psychosexual functioning in the patient group correlated with each other to various degrees, resulting in a heterogeneous expression of psychosexual dysfunctions, implicating the necessity of a personalized treatment approach.

Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life

Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.

Community engagement of adolescents in the development of a patient-centered outcome tool for adolescents with a history of hypospadias repair

INTRODUCTION

Hypospadias may lead to long-term issues with urination, sexual function and psychosocial well-being. Limited evidence exists regarding the healthcare communication preferences of male adolescents regarding sensitive topics.

OBJECTIVE

The purpose of this qualitative study was to explore the healthcare communication preferences of male adolescents regarding sensitive topics (e.g. urinary and sexual issues) and engage them in the initial stages of development of a patient-centered outcome tool for adolescents with a history of hypospadias repair.

STUDY DESIGN

A multidisciplinary team with communication design expertise, pediatric urology experts, and health services researchers developed a self-reported toolkit for adolescent patients who had hypospadias repair as children. The toolkit featured short writing/diagramming exercises and scales to facilitate participant reflections about genital appearance, urination, sexual function, and psychosocial well-being. We recruited students from two local high schools for two focus groups to obtain feedback about the usability/acceptability of the toolkit's appearance/content. We inquired about language preferences and preferred format and/or setting for sharing sensitive information with researchers. The focus groups were audio recorded, professionally transcribed, checked for accuracy, and analyzed by two coders using qualitative content analysis. Major themes and subthemes were identified, and representative quotes were selected.

RESULTS

We conducted two focus groups in January 2018 with 33 participants, aged 14-18 years. Participants preferred language that would make patients feel comfortable and serious, clinical language rather than slang terms/sexual humor (Extended Summary Table). They recommended avoidance of statements implying that something is wrong with a patient or statements that would pressure the patient into providing answers. They suggested fill-in-the-blank and open-ended responses to encourage freedom of expression and colorful graphics to de-emphasize the test-like appearance of the toolkit. Most participants preferred a toolkit format to a one-on-one interview to discuss sensitive topics such as urinary or sexual issues. Participants would prefer either a male interviewer or would like to have a choice of interviewer gender for individual qualitative interviews, and they recommended a focus group leader with a history of hypospadias repair.

DISCUSSION

This study provides a rich description of a group of male high school students' experiences with healthcare providers and researchers. Its qualitative design limits generalizability, and our findings may not be similar to those of adolescents with a history of hypospadias repair.

CONCLUSION

We used focus group feedback on the toolkit prototype to refine the tool for use in a future study of adolescents with a history of hypospadias repair.