Hypospadias

Genistein prevents the production of hypospadias induced by Di-(2-ethylhexyl) phthalate through androgen signaling and antioxidant response in rats

Environmental estrogen exposure has increased dramatically over the past 50 years. In particular, prenatal exposure to estrogen causes many congenital diseases, among which reproductive system development disorders are extremely serious. In this study, the molecular mechanism of hypospadias and the therapeutic effect of genistein (GEN) were investigated through in vivo models prepared by Di-(2-ethylhexyl) phthalate (DEHP) exposure between 12 and 19 days of gestation. With increased DEHP concentrations, the incidence of hypospadias increased gradually. DEHP inhibited the key enzymes involved in steroid synthesis, resulting in decreasing testosterone synthesis. At the same time, DEHP increased reactive oxygen species (ROS) and produced inflammatory factors via NADPH oxidase-1 (NOX1) and NADPH oxidase-4 (NOX4) pathways. It also inhibited Steroid 5 α Reductase 2 (Srd5α2) and decreased dihydrotestosterone (DHT) synthesis. Additionally, DEHP inhibited the androgen receptor (AR), resulting in reduced DHT binding to the AR that ultimately retarded the development of the external reproductive system. GEN, a phytoestrogen, competes with DEHP for binding to estrogen receptor β (ERβ). This competition, along with GEN's antiestrogen and antioxidant properties, could potentially reverse impairments. The findings of this study provide valuable insights into the role of phytoestrogens in alleviating environmental estrogen-induced congenital diseases.

Redox mechanisms of environmental toxicants on male reproductive function

Humans and wildlife, including domesticated animals, are exposed to a myriad of environmental contaminants that are derived from various human activities, including agricultural, household, cosmetic, pharmaceutical, and industrial products. Excessive exposure to pesticides, heavy metals, and phthalates consequently causes the overproduction of reactive oxygen species. The equilibrium between reactive oxygen species and the antioxidant system is preserved to maintain cellular redox homeostasis. Mitochondria play a key role in cellular function and cell survival. Mitochondria are vulnerable to damage that can be provoked by environmental exposures. Once the mitochondrial metabolism is damaged, it interferes with energy metabolism and eventually causes the overproduction of free radicals. Furthermore, it also perceives inflammation signals to generate an inflammatory response, which is involved in pathophysiological mechanisms. A depleted antioxidant system provokes oxidative stress that triggers inflammation and regulates epigenetic function and apoptotic events. Apart from that, these chemicals influence steroidogenesis, deteriorate sperm quality, and damage male reproductive organs. It is strongly believed that redox signaling molecules are the key regulators that mediate reproductive toxicity. This review article aims to spotlight the redox toxicology of environmental chemicals on male reproduction function and its fertility prognosis. Furthermore, we shed light on the influence of redox signaling and metabolism in modulating the response of environmental toxins to reproductive function. Additionally, we emphasize the supporting evidence from diverse cellular and animal studies.

Expression of Rab25 is down-regulated in the foreskin of children with hypospadias

BACKGROUND

Hypospadias, a congenital malformation of the penis, is one of the newborns' most common developmental defects. The incidence of hypospadias is increasing yearly, and its pathogenesis is closely related to genetic susceptibility and environmental exposure to endocrine disruptors. Exploring the hypospadias' key molecular regulatory mechanism is crucial to reducing its incidence.

OBJECTIVE

To examine the differential expression of Rab25 in hypospadias and normal penile tissue and to identify whether it is a candidate gene for exploring the mechanism of hypospadias.

STUDY DESIGN

This study included 18 children aged 1-6 years undergoing hypospadias repair surgery at the Children's Hospital of Chongqing Medical University, and foreskin samples were collected. Children diagnosed with cryptorchidism, intersex status, or endocrine abnormalities were excluded from this study. Another 18 children aged 3-8 years with phimosis were included in the control group. The specimens were used for immunohistochemistry, western blotting, immunofluorescence, and polymerase chain reaction to assess the expression of Rab25.

RESULTS

Rab25 protein expression was lower in the hypospadias group than in the control group [ (2.101 ± 0.1845), (0.7506 ± 0.1779), p = 0.0008 < 0.05). The hypospadias group showed decreased expression of Rab25 protein in the epithelial cell layer. Rab25 mRNA levels were downregulated in the foreskin of children with hypospadias compared with controls [(1.697 ± 0.2005), (0.7687 ± 0.2130), p = 0.0053 < 0.05)].

DISCUSSION

Rab25 mRNA and protein expressions in the hypospadias group were significantly downregulated compared with the control group. This was consistent with the results of single-cell sequencing of fetal mice reproductive nodules at 15.5 days of gestation (Zhang Z, Liu Z, Zhang Q, et al., unpublished observations). Our study represents the first report of abnormal Rab25 expression in the foreskin tissue of patients with hypospadias. More detailed research on the relationship between Rab25 and urethral development could be conducted to reveal the molecular mechanism of hypospadias.

CONCLUSION

The expression of Rab25 in foreskin tissue was lower in the hypospadias group than in the control group. Rab25 is involved in the formation of the urethral seam and the occurrence of hypospadias. The potential mechanism by which Rab25 affects the canalization of the urethral plate needs to be further investigated.

Predictive value of ultrasound in prenatal diagnosis of hypospadias: hints for accurate diagnosis

OBJECTIVES

This study aims to assess the diagnostic accuracy of targeted ultrasound examination in prenatal diagnosis of hypospadias and to evaluate the predictive values of defined ultrasonographic findings of hypospadias.

METHODS

The cases diagnosed with hypospadias in our fetal medicine center were identified on an electronic database. The ultrasound reports, images and hospital records were reviewed retrospectively. The predictive value of prenatal ultrasound diagnosis and the predictive values of each sonographic finding were assessed according to the postnatal clinical examinations.

RESULTS

Thirty-nine cases were diagnosed with hypospadias on ultrasound during the 6 years. Nine fetuses with missing postnatal examination records were excluded. Twentytwo of the remaining fetuses had their prenatal diagnosis of hypospadias confirmed in postnatal examinations, indicating a 73.3 % positive predictive value. Normal external genitalia was detected in postnatal examinations of three fetuses. Five fetuses were diagnosed with other external genital abnormalities, including micropenis (n=2), clitoromegaly (n=2), and buried penis with bifid scrotum (n=1) in postnatal examinations. The positive predictive value of prenatal ultrasound for any external genital abnormality was 90 %.

CONCLUSIONS

Although the positive predictive value of ultrasound for genital anomalies is satisfying, it is slightly lower for the specific diagnosis of hypospadias. This reflects overlapping ultrasound findings of different external genitalia anomalies. Standardized, systematic evaluation of the internal and external genital organs, karyotyping and genetic sex determination are essential to achieve a precise prenatal diagnosis of hypospadias.

Referral patterns, clinical features and management of uncorrected hypospadias in a series of adult men

BACKGROUND

Hypospadias surgery undertaken in early life often continues to impose challenges as patients age. Little is known about the natural history of uncorrected hypospadias persisting into adulthood.

OBJECTIVE

To describe presenting symptoms and management strategies in men with uncorrected hypospadias referred to our national tertiary transitional clinic for congenital urological conditions.

MATERIALS AND METHODS

Patients with uncorrected hypospadias older than 16 years at the time of referral were identified by searching the electronic patient record system for ICD-10 hypospadias codes. Data were extracted over a 10-year period according to a predefined protocol.

RESULTS

Among 201 referrals, 65 men with hypospadias (glanular n = 12, coronal n = 26, subcoronal n = 9, corporal n = 4, penoscrotal n = 2 and MIP n = 12) had never previously had reconstructive surgery undertaken. Obstructive symptoms predominated (n = 30) and the risk of symptoms increased with advancing age (Figure). Presenting complaints varied across the age span; cosmetic issues (n = 11) and coital pain (n = 5) were primarily seen in youth as opposed to urinary obstructive symptoms that were increasingly more frequent with age (p = 0.002) (Figure). Management included reconstructive surgery (n = 24), minor procedures (preputioplasty, circumcision, meatoplasty, dilatation/urethrotomy, total n = 28) as well as counselling (n = 12). The management strategies were independent of age and hypospadias type.

DISCUSSION

The current cohort delineates the dynamic nature of hypospadias in itself. We speculate that the distinction in the primary complaint leading to referral between the extremes of age may relate to the vanity and insecurity of youth while older patients first come forward when other symptoms arise. Dissatisfaction with genital appearance is uncommon in previous smaller studies on men with uncorrected hypospadias unlike in our study, where 11 patients were assessed mainly for cosmetic concerns. Obstruction is the main symptom encountered in adult hypospadias patients operated in early life, and a similar picture was observed in our cohort of unoperated cases. Urethral dilatation and internal urethrotomy are temporizing procedures but were successful in immediate alleviation of obstructive symptoms in patients not willing to consign themselves to formal surgery. The study is limited by its retrospective design, and our symptomatic cohort may also represent the extreme end of the hypospadias spectrum.

CONCLUSION

Medical issues vary across the age span in men with unrepaired hypospadias. Minor surgical procedures as well as counselling play an equally important role as reconstructive hypospadias surgery in the management of unrepaired hypospadias in adulthood.

Urethrocutaneous fistula repair following hypospadias surgery using the PATIO technique for small fistulae: A single centre experience

INTRODUCTION

Urethrocutaneous fistula (UCF) development following primary hypospadias repair is a common complication with high rates of recurrence despite attempts at repair. A novel technique for the management of these fistulae, the PATIO (preserve the tract and turn it inside out) repair, has been described and has shown encouraging outcomes in previous reports.

OBJECTIVE

The aim of this study was to evaluate fistula repair outcomes in patients undergoing the PATIO technique compared with standard repair.

STUDY DESIGN

A retrospective chart-based review was performed for pediatric patients undergoing UCF repair from January 2005 to July 2018. Data including: age, follow-up, meatal location, meatal stenosis, number of fistulae and repairs, UCF location, complications, and outcomes was obtained. Cases were categorized into PATIO repair, standard repair, and PATIO repair following prior standard repair. Surgical outcome with respect to freedom from fistula recurrence was determined.

RESULTS

In total, 586 patients underwent hypospadias surgery with 44 patients developing 52 UCF cases that required repair during the study period for a fistula rate of 8.9%. Mean age at repair was 19 months. Median follow-up time was 28 months. For PATIO repair alone, 21/26 (81%) had success. For standard repair alone, 8/18 (44%) had success and for standard repair followed by PATIO repair, 8/8 (100%) were successful. A statistically significant difference was noted for success when comparing standard repair with PATIO repair (p = 0.023, p < 0.05) and PATIO repair following standard repair (p = 0.010, p < 0.05). There was a statistically non-significant difference between PATIO repair and PATIO repair following standard repair (p = 0.309, p < 0.05). Failure following PATIO repair was found in cases where the procedure was early in implementation and experience was limited.

DISCUSSION

UCF repair using the PATIO technique has shown encouraging results in the short-term, with a majority of patients achieving a successful outcome compared with standards techniques. As this procedure continues to be used and experience develops, a larger sample of cases will become available for analysis and longer follow-up will prove necessary in examining the long-term outcomes of this procedure. The outcomes examined have demonstrated consistency with previously reported outcomes in the literature. Limitations include small sample size, short-term follow up, and the retrospective nature of the review.

CONCLUSIONS

The findings of this study have provided further support to the use of this technique in conventional UCF repair as a means to decrease the risk of recurrence and provide durable results in the short-term. Ongoing follow up will prove necessary to examine success in the long-term.

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.

Comparison of post-urethroplasty complication rates in pediatric cases with hypospadias using Vicryl or polydioxanone sutures

Objective

Hypospadias is a common congenital problem among male newborns. Both rapid absorbable sutures (polyglactin, Vicryl) and delayed absorbable sutures (polydioxanone, PDO) are used in hypospadias repair based on the surgeon's preference. This study was conducted to compare post-urethroplasty complication rates in pediatric patients with hypospadias using Vicryl or PDO sutures.

Methods

This is a retrospective study which was designed and performed on 583 children aged 1–7 years old who had undergone hypospadias repair from January 2012 to December 2018. Required data were obtained from the patients' medical records.

Results

Overall, post-surgical complications were observed in 60 (10.3%) patients comprising urethro-cutaneous fistula (n=39, 6.7%), meatal stenosis (n=10, 1.7%), urethral stricture (n=7, 1.2%), and glans dehiscence (n=4, 0.7%). The mean age of the children with complications was 3.0±1.3 years. According to Kaplan-Meier estimate, the interval between surgery and development of complications was significantly shorter in the Vicryl group (p=0.037). Overall, complications were more prevalent in Vicryl suture than PDO suture (15.1% vs. 5.3%, p<0.001). Regression model revealed that in comparison to the distal type, proximal hypospadias (odds ratio [OR]:103.9, 95% confidence interval [CI]: 32.2–334.9, p<0.001) and mid-shaft hypospadias (OR: 82.9, 95% CI: 25.9–264.6, p<0.001) while using Vicryl suture instead of PDO suture (OR: 62.4, 95% CI: 21.2–183.8, p<0.001) increased the odds of developing post-urethroplasty complications.

Conclusion

We suggest PDO suture in the repair of hypospadias due to its lower complication rate, especially in cases of proximal and mid-shaft hypospadias which can get more complicated than the distal type.

Endocrine disrupting chemicals in the pathogenesis of hypospadias; developmental and toxicological perspectives

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Penis development is regulated by a tight balance of androgens and estrogens.

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EDCs that impact androgen/estrogen balance during development cause hypospadias.

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Cross-disciplinary collaborations are needed to define a mechanistic link.

Hypospadias is a defect in penile urethral closure that occurs in approximately 1/150 live male births in developed nations, making it one of the most common congenital abnormalities worldwide. Alarmingly, the frequency of hypospadias has increased rapidly over recent decades and is continuing to rise. Recent research reviewed herein suggests that the rise in hypospadias rates can be directly linked to our increasing exposure to endocrine disrupting chemicals (EDCs), especially those that affect estrogen and androgen signalling. Understanding the mechanistic links between endocrine disruptors and hypospadias requires toxicologists and developmental biologists to define exposures and biological impacts on penis development. In this review we examine recent insights from toxicological, developmental and epidemiological studies on the hormonal control of normal penis development and describe the rationale and evidence for EDC exposures that impact these pathways to cause hypospadias. Continued collaboration across these fields is imperative to understand the full impact of endocrine disrupting chemicals on the increasing rates of hypospadias.

Bracka Urethroplasty with Buccal Mucosa Graft: Ergonomic Management of Penile Skin Dartos in the First Stage to Facilitate Second-stage Neourethral Coverage

Aims

The aim of the study was to report a new technique of ergonomic penile skin-dartos management during buccal mucosa graft (BMG) to provide adequate penile skin-dartos for neourethral coverage at the time of second-stage tubularization.

Materials and Methods

Ten proximal hypospadias with severe chordee underwent first-stage surgery with a new technique. An incision along the urethral plate margin and preputial edge was used to split inner prepuce off preputial dartos and penile degloving leaving inner prepuce attached to corona. Urethral plate was divided into the subfascial plane. Penile dartos was bisected in the dorsal midline. Distal half of penile skin-dartos bifurcated and joined to inner preputial edges. Mobilized and lateralized penile skin-dartos was sutured flanking edges of BMG. The second-stage tubularization after 6 months provided neourethral double dartos coverage with eccentric suture lines.

Results

Adequate dartos for neourethral coverage during second-stage tubularization was available in all. Subcoronal urethrocutaneous fistula occurred in one that was repaired.

Conclusions

Ergonomic management of inner-preputial skin and ventral transfer of penile skin-dartos helps in providing neourethral coverage during subsequent second-stage tubularization to minimize the occurrence of complications.

Creation of Tissue-Engineered Urethras for Large Urethral Defect Repair in a Rabbit Experimental Model

Introduction: Tissue engineering is a potential source of urethral substitutes to treat severe urethral defects. Our aim was to create tissue-engineered urethras by harvesting autologous cells obtained by bladder washes and then using these cells to create a neourethra in a chronic large urethral defect in a rabbit model. Methods: A large urethral defect was first created in male New Zealand rabbits by resecting an elliptic defect (70 mm²) in the ventral penile urethra and then letting it settle down as a chronic defect for 5-6 weeks. Urothelial cells were harvested noninvasively by washing the bladder with saline and isolating urothelial cells. Neourethras were created by seeding urothelial cells on a commercially available decellularized intestinal submucosa matrix (Biodesign® Cook-Biotech®). Twenty-two rabbits were divided into three groups. Group-A (n = 2) is a control group (urethral defect unrepaired). Group-B (n = 10) and group-C (n = 10) underwent on-lay urethroplasty, with unseeded matrix (group-B) and urothelial cell-seeded matrix (group-C). Macroscopic appearance, radiology, and histology were assessed. Results: The chronic large urethral defect model was successfully created. Stratified urothelial cultures attached to the matrix were obtained. All group-A rabbits kept the urethral defect size unchanged (70 ± 2.5 mm²). All group-B rabbits presented urethroplasty dehiscence, with a median defect of 61 mm² (range 34-70). In group-C, five presented complete correction and five almost total correction with fistula, with a median defect of 0.3 mm² (range 0-12.5), demonstrating a significant better result (p = 7.85 × 10^-5). Urethrography showed more fistulas in group-B (10/10, versus 5/10 in group-C) (p = 0.04). No strictures were found in any of the groups. Group-B histology identified the absence of ventral urethra in unrepaired areas, with squamous cell metaplasia in the edges toward the defect. In group-C repaired areas, ventral multilayer urothelium was identified with cells staining for urothelial cell marker cytokeratin-7. Conclusions: The importance of this study is that we used a chronic large urethral defect animal model and clearly found that cell-seeded transplants were superior to nonseeded. In addition, bladder washing was a feasible method for harvesting viable autologous cells in a noninvasive way. There is a place for considering tissue-engineered transplants in the surgical armamentarium for treating complex urethral defects and hypospadias cases.

Comparison of Penile Appearance and Outcomes Between Prefabricated Urethra and Pre-implanted Urethral Plate for Treatment of Children With Severe Hypospadias: A Retrospective Study

Objective: To compare the effect of prefabricated urethra and pre-implanted urethral plate in the treatment of severe hypospadias in children. Methods: We retrospectively analyzed the clinical data of 53 patients who diagnosed as severe hypospadias underwent staging urethroplasty from January 2015 to January 2018 in the Department of Pediatric Surgery, First People's Hospital, Zunyi City. The patients were divided into two groups: group A (n = 25) were treated with prefabricated urethra and group B (n = 28) were treated with pre-implanted urethral plate. After the second stage surgery, the ratios of complications such as urethral fistula, urethral stenosis, urethrocele, and recurrence chordee were compared. The penis was scored from meatus, glans, shaft skin, general appearance by the parents, blinded urologists according to The Pediatric Penile Perception Score, and the scores were compared too. Results: All patients were followed up after two stage operations for an average of 28 months. Glans dehiscence occurred in two patients (8%), urethral orifice stenosis occurred in one (4%) and urethral fistula occurred in three (12%) in group A. No urethral stenosis, urethrocele and recurrence chordee was observed. One patient presented urethral plate inactivation (3.6%), two patients presented urethral fistula (7.1%) and one patient presented urethral stenosis (3.6%) in group B. No urethrocele, glans dehiscence and recurrence chordee was observed. The total complication rate in group A was 24 and 14.3% in group B, respectively, and the difference was not statistically significant (P = 0.582). The differences between two groups scored by parents in glans (P = 0.030) was statistically significant. The differences between two groups scored by operators in meatus (P = 0.041), shaft skin (P = 0.000), glans (P = 0.001), and general appearance (P = 0.007) were statistically significant. The differences between two groups scored by counterparts in meatus (P = 0.006), shaft skin (P = 0.003), glans (P = 0.010), and general appearance (P = 0.014) were statistically significant. Conclusion: Both prefabricated urethra and pre-implanted urethral plate methods are suitable for correction of severe hypospadias as staging surgery in children. In general, pre-implanted urethral plate is more worthy of spread because it is much more applied in patients with small glans and achieve good appearance of penis.

Clinical efficacy of transverse preputial island flap urethroplasty for single-stage correction of proximal hypospadias: a single-centre experience in Chinese patients

Background

This study was designed to summarize the clinical outcomes of transverse preputial island flap urethroplasty for single-stage correction of proximal hypospadias in our hospital.

Method

This study retrospectively analysed the clinical data, including the preoperative general information, intraoperative and postoperative data, and follow-up data, of 155 children with proximal hypospadias who were admitted to our hospital from January 2009 to January 2019.

Results

During follow-up, a total of 92 postoperative complications occurred, and 41 patients underwent reoperation. There were 49 patients with urinary fistula, 26 patients with urethral stricture, 9 patients with urethral diverticulum and 8 patients with urinary tract infection. Regarding the family members’ satisfaction with the cosmetic appearance of the penis, the satisfaction rate with the urinary meatus was 85.2%, the satisfaction rate with the glans appearance was 87.7%, the satisfaction rate with the the appearance of the foreskin of the penis was 92.3%, and the satisfaction rate with the overall penis shape was 89.0%.

Conclusion

Proximal hypospadias is a serious condition that is often combined with severe chordee, and transverse preputial island flap urethroplasty for single-stage correction is an effective surgical procedure for treating this condition.

New frontiers on the molecular underpinnings of hypospadias according to severity

Hypospadias, which is characterised by the displacement of the urethral meatus from its typical anatomical location in males, shows various degrees of severity. In this systematic review, we surveyed our current understanding of the genetics of isolated hypospadias in humans according to the severity of the condition. We found that sequencing and genotyping approaches were the preferred methods of study and that single nucleotide polymorphisms were the most common finding associated with hypospadias. Most genes fell into four gene-pathway categories related to androgens, oestrogens, growth factors, or transcription factors. Few hypospadias studies classify their findings by severity. Taken together, we argue that it is advantageous to take into consideration the severity of the condition in search of novel candidates in the aetiology of hypospadias. Abbreviations: AR: androgen receptor; ATF3: activating transcription factor 3; BMP4: bone morphogenetic protein 4; BMP7: bone morphogenetic protein 7; CYP17: steroid 17-alpha-hydroxylase/17,20 lyase; CYP1A1: cytochrome P450 1A1; CYP3A4: cytochrome P450 3A4; CNVs: copy number variants; DGKK: diacylglycerol kinase kappa; ESR1: oestrogen receptor 1; ESR2: oestrogen receptor 2; FGF8: fibroblast growth factor 8; FGF10: fibroblast growth factor 10; FGFR2: fibroblast growth factor receptor 2; HOXA4: homeobox protein Hox-A4; HOXB6: homeobox protein Hox-B6; HSD17B3: hydroxysteroid 17-beta dehydrogenase 3; MAMLD1: mastermind-like domain-containing protein 1; SF-1: splicing factor 1; SHH: sonic hedgehog; SNPs: single nucleotide polymorphisms; SOX9: SRY-box 9; SRD5A2: steroid 5 alpha-reductase 2; SRY: sex-determining region Y protein; STAR: steroidogenic acute regulatory protein; STARD3: StAR-related lipid transfer protein 3; STS: steryl-sulfatase; WT1: Wilms tumour protein; ZEB1: zinc finger oestrogen-box binding homeobox 1.

Prenatal and postnatal imaging techniques in the evaluation of disorders of sex development

Imaging of the reproductive tract is challenging and requires a general knowledge of congenital variations in anatomy. The anatomy of the developing fetus, whether a male phenotype or female phenotype, is also a dynamic process with many changes occurring during gestation. Families may ask details about the genitalia during prenatal imaging and when variations in what is thought to be normal are present, further investigation is sometimes needed to make sense of what is seen. This overview will describe categories of disorders of sex development (DSD), whether chromosomal or structural or both, and the current state of imaging of these anomalies.

Interaction between CYP1A1/CYP17A1 polymorphisms and parental risk factors in the risk of hypospadias in a Chinese population

Hypospadias (HS) is a common congenital malformation of the genitourinary tract in males and its etiology is viewed as multifactorial, and studies about gene-environment interaction in the etiology of HS are rare. A total of 152 cases and 151 controls were selected in the present study. Information before and during pregnancy from questionnaires finished by mothers of subjects were extracted, and the relating data were analyzed to determine the risk factors of HS. Meanwhile, maternal genomic DNA was genotyped for the single nucleotide polymorphisms (SNPs) of CYP1A1 rs1048943 and CYP17A1 rs4919686. Results of multivariable logistic regression analyses showed that several factors were associated with hypospadias risk. Analysis of the distributions of SNPs in CYP1A1 and CYP17A1 genes showed that the mutant genotype CC (OR = 4.87) of CYP1A1 rs1048943, and mutant genotype CC (OR = 5.82), recessive genotype AC + CC (OR = 2.17) and allele C (OR = 1.77) of CYP17A1 rs4919686 significantly increased the risk of HS. In addition, the additive gene-environment interactions were also found in several models. Several maternal risk factors that are associated with HS risk can interact with CYP1A1/CYP17A1 polymorphisms, which lead to infants vulnerable to occurrence of HS in Chinese populations.

Comparative study of urethroplasties to reduce urethral strictures in patients with severe hypospadias

Objective

Transverse island pedicle flap (TIPF) plus transected urethral plate-preserving urethroplasty is increasingly used for treatment of severe hypospadias. We aimed to reduce the occurrence of urethral strictures in patients undergoing such procedures.

Methods

Sixty-five patients with severe hypospadias were enrolled. Thirty-two patients underwent onlay-tube-onlay urethroplasty (Group A), and 33 patients underwent modified Duplay urethroplasty (Group B). Postoperative complications were recorded, including fistulas, urethral strictures, and diverticula.

Results

Three patients (9.4%) in Group A and 10 patients (30.3%) in group B had urethrocutaneous fistulas. Three patients (9.4%) in Group A and 0 patients (0%) in Group B had urethral strictures. No patient in the two groups had symptoms of diverticulum or penile chordee. The results of uroflowmetry were better in Group B than Group A, when comparing uroflow patterns.

Conclusions

TIPF plus transected urethral plate-preserving urethroplasty can lower the occurrence of stricture, which is a challenging complication. The occurrence of stricture was lower in patients who underwent modified Duplay urethroplasty, and neourethral function and quality were better in these patient. Thus, this modified procedure can be used for treatment of severe hypospadias.

Proximal hypospadias repair using the koyanagi-hayashi technique. A review of 15 cases

BACKGROUND

Several surgical approaches or modifications of existing techniques have been described for the repair of hypospadias. In Sub-Saharan Africa, a two-stage approach is the preferred option in proximal cases with severe penile curvature.

OBJECTIVE

The authors describe their experience with one-stage repair of proximal hypospadias with severe penile curvature using the Koyanagi-Hayashi technique.

METHODOLOGY

Three hundred and ten patients were seen at the outpatient clinic from November 2009 to November 2015. All patients aged between 2 and 17 years with a confirmed diagnosis of proximal hypospadias and operated according to the Koyanagi-Hashashi technique were included in the study.

RESULTS

The mean age at diagnosis was 6.7 ± 4.35 years (81 months). The level of the hypospadias was penile in 60%, scrotal 33.5%, and posterior in 6.6% of cases. The most common complications after primary repair were partial breakdown of the urethroplasty (44.8%), urethra-cutaneous fistula (3.3%), dehiscence of the glanuloplasty (22.2%), and recurrent penile curvature (11.1%).

DISCUSSION

The high psychological implication of this condition in children and adolescents at the time of diagnosis in our context was a major weakness of our study. However, it turned out to be an advantage as the patients could be involved in the decision-making in as much as the previous gender was taken into consideration.

CONCLUSION

A one-stage repair approach as described by Koyanagi-Hayashi also provides good aesthetic and functional outcome. It thus stands out as an alternative even in our African setting.

Accuracy of the hypospadias diagnoses and surgical treatment registrations in the Danish National Patient Register

Purpose

The Danish National Health registers provide a valuable data source that offers unique opportunities for observational research, including studies on the congenital anomaly hypospadias. The accuracy of the diagnosis and surgical treatment registration of hypospadias in the Danish National Patient Register (DNPR) remains unknown.

Patients and methods

We randomly sampled 500 patients diagnosed with hypospadias in the DNPR from January 1, 1995 to December 31, 2012. Among these, 384 patients were also registered with surgical treatment for hypospadias. Medical records were collected and reviewed independently by two investigators. Any classification disagreements were resolved by consensus. Using the medical records as the gold standard, we estimated positive predictive values (PPVs) with 95% confidence intervals (CIs) for the hypospadias diagnoses and surgical treatment registrations overall, as well as for the clinical subtypes.

Results

We were able to retrieve medical records for 463 (92.6%) patients with hypospadias diagnoses and for 329 (85.7%) patients registered with surgical treatment. Presence of hypospadias was confirmed in 450 of 463 patients, yielding an overall PPV (95% CI) of 97.6% (95.8%–98.7%). For subtypes of hypospadias, the PPVs ranged between 37.5% and 72.7%. For surgical treatment of hypospadias, the overall PPV was 99.7% (97.9%–99.9%).

Conclusion

The validity of the registration of hypospadias diagnoses as well as surgical treatment for hypospadias in the DNPR is overall very high. For the specific subtypes of hypospadias diagnoses codes and the specific surgical treatment codes, the PPVs are lower and cautious use is warranted. However, the DNPR remains a valuable tool for future observational research on hypospadias.

Two-stage flap repair of severe hypospadias: Usefulness of the tubularized incised plate urethroplasty

PURPOSE

The use of flaps in the two-stage repair of posterior hypospadias associated with severe chordee has been well established. Despite the almost certain guarantee of flap take, complications such as diverticuli are still relatively high. While different applications of the tubularized incised plate have been described, experience with the application of the technique to the two-stage flap repair is very limited. A previous local review of 15 cases performed at the present institution during the period 1998-2003, using the technique as described by Rekit, revealed fistulae and diverticulum rates of 20% and 27%, respectively. With the primary objective of improving surgical outcome, the midline incision was incorporated into the two-stage flap repair.

MATERIALS AND METHODS

Between 2004 and 2015, 35 boys (aged 2-15 years) with severe hypospadias that required excision of the urethral plate were operated using the two-stage flap technique. The first stage involved mobilization of preputeal or dorsal penile skin (if circumcised) to the ventral surface, as described by Retik. After a minimum interval of 6 months, the second-stage operation was performed in a way similar to the technique of tubularized incised plate urethroplasty, as popularized by Snodgrass, and involved a preliminary midline incision on the neo-urethral plate followed by tubularization and multilayered closure.

RESULTS

All but one flap took successfully. The outcome was satisfactory in 80% of patients, and there was a fistula rate of 14% ( Summary Table). One patient had a complete breakdown of the flap and was successfully treated about 12 months later by repeating the second stage of the operation. No case of diverticulum or stricture was recorded.

DISCUSSION

Even though there was a marginal improvement in the fistula rate, the most striking observation was the complete absence of diverticulum or stricture. With a reported incidence rate of 20-63%, different authors have reported diverticulum formation (despite the absence of distal obstruction) to be a major problem of the two-stage flap technique. Attempts by these authors at reducing the risk of diverticulum by reducing flap size have tended to increase the risk of strictures. This has been the main reason given by some authors for abandoning the technique. The main limitations of the present study included the wide age range of the patients and the small sample size.

CONCLUSION

The inclusion of a midline incision in a two-stage flap urethroplasty for proximal hypospadias appears to prevent the development of diverticulum.

A new modification of the Duckett technique for one-stage repairing urethral plate transected hypospadias: Another option for severe hypospadias?

OBJECTIVES

The study aimed to evaluate the new modification of the Duckett technique in decreasing the incidence of urethral strictures for urethral plate transected hypospadias and also explored its clinical application.

METHODS

Thirty-three patients (aged 7 months to 12 years, mean age 2.8 years) who underwent repair of primary hypospadias using the new one-stage urethroplasty were enrolled. Clinical data, including cosmetic and its complications, and uroflowmetry data were documented. Uroflowmetry data of 19 patients who underwent Duckett urethroplasty were used as a comparison.

RESULTS

The length of the urethral defect ranged from 2.5 to 5.0 cm. The postoperative follow-up was 14-30 months. Ten patients (30.3%) had fistulas; no patients had strictures or diverticula. All ten fistulas were small (<0.5 cm) and repaired with fistula repairing operation. The appearance of the penis remained satisfactory, and the meatus was located in the normal anatomic position. Among 17 patients who underwent uroflowmetry, all patients were bell-shaped or platforms, and Q _max was 7.37 ± 2.45 ml/s. Compared with 14 of 19 patients who underwent Duckett urethroplasty, the urethral function achieved with new one-stage urethroplasty was significantly better (p < 0.05).

CONCLUSIONS

The incidence of strictures was dramatically lowered in patients with proximal hypospadias. Small fistulas are common complications and can be repaired easily. Based on the uroflow pattern results, the quality of neourethra and function of it were better than Duckett urethroplasty. These preliminary results suggested that the modified procedure seems to be reliable and can be a suitable option for proximal hypospadias.

Association of reproductive disorders and male congenital anomalies with environmental exposure to endocrine active pesticides

There is growing evidence that environmental exposure to pesticides may increase the risk of developing reproductive and developmental disorders. This study determined the prevalence and risk of developing gestational disorders and male congenital genitourinary malformations in areas with distinct exposure to pesticides, many of them with potential endocrine disrupting properties. A population-based case-control study was carried out on pregnant women and male children living in ten health districts of Andalusia classified as areas of high and low environmental exposure to pesticides according to agronomic criteria. The study population included 45,050 cases and 950,620 controls matched for age and health district. Data were collected from computerized hospital records between 1998 and 2005. Prevalence rates and risk of miscarriage, low birth weight, hypospadias, cryptorchidism and micropenis were significantly greater in areas with higher use of pesticides in relation to those with lower use, thus supporting and extending previous information.

Maternal inflammatory bowel disease and hypospadias in male offspring: a population-based study in Denmark

Background

The occurrence of inflammatory bowel disease (IBD) and hypospadias has been concurrently increasing, possibly through shared environmental risk factors such as endocrine disrupting compounds. Also, maternal IBD may disturb the normal development of the fetal reproductive tract. However, whether maternal IBD increases the risk of hypospadias in male offspring is unknown. We compared hypospadias risk in sons of mothers with and without IBD.

Methods

We used Danish nationwide population-based registries to conduct a longitudinal prevalence study including all live-born boys from 1979 through 2009. We computed HRs, as estimates of prevalence ratios (PRs), with 95% CIs for hypospadias, using Cox proportional hazards regression, while adjusting for measured confounding.

Results

Among 966 038 live-born boys, 4688 (0.5%) had a mother with a history of IBD diagnosis before the relevant childbirth. Among the boys with maternal IBD, 36 (0.8%) were diagnosed with hypospadias any time after birth, whereas 6112 (0.6%) sons of mothers without IBD diagnosis had hypospadias (adjusted PR: 1.20, (95% CI 0.86 to 1.67). Adjusted PRs for maternal Crohn's disease and ulcerative colitis were 1.38 (95% CI 0.83 to 2.29) and 1.10 (95% CI 0.71 to 1.68), respectively. Analyses defining hypospadias diagnosis recorded <6 months postpartum showed similar results.

Conclusions

We found no convincing evidence of an association between maternal IBD and hypospadias.

Better Defining the Spectrum of Adult Hypospadias: Examining the Effect of Childhood Surgery on Adult Presentation

OBJECTIVE

To describe the spectrum of adult presentations with hypospadias-related complications and examine the effect of childhood surgical repair on these adult presentations.

METHODS

A retrospective chart review over a 10-year period, from August 2004 to December 2014, demonstrated 93 adult patients who presented to a reconstructive urologist with complications related to hypospadias. Patients were divided into 2 groups: those with no prior hypospadias surgery (Group 1, N = 19) and those who underwent surgical correction as a child (Group 2, N = 74). Charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required.

RESULTS

The mean age at presentation was 34.6 ± 0.6 years. Overall, lower urinary tract symptoms (LUTS) (49%) was the most common presenting complaint, followed by spraying (24%), urethrocutaneous fistula (18%), recurrent urinary tract infections (UTIs) (15%), and chordee (14%). Comparison demonstrated that Group 2 patients were more likely to present with LUTS (55% vs 26%; P = .038) and recurrent UTIs (19% vs 0%; P = .050). There was a trend toward Group 1 patients presenting more commonly with cosmetic dissatisfaction (16% vs 4%; P = .06). Urethral stricture was demonstrated more commonly in Group 2 (47% vs 11%; P = .0043). Of these, strictures were significantly longer in the previous surgery group (5.5 ± 0.6 cm vs 3.0 ± 0.6 cm, P = .019).

CONCLUSION

Correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent UTIs, and subsequent LUTS, with a trend toward improving patient satisfaction with cosmesis compared to nonsurgical management. Follow-up of hypospadias repair patients should extend into adulthood, as a significant portion of adult presentations ultimately require surgical intervention.

Soft tissue interposition is effective for protecting the neourethra during hypospadias surgery and preventing postoperative urethrocutaneous fistula: a single surgeon's experience of 243 cases

PURPOSE

Soft tissue interposition (STI) during hypospadias repair (HR) purportedly prevents postoperative urethrocutaneous fistula (PUF) by supporting the neourethra. We report our experience.

METHODS

Data from 243 hypospadias patients treated by a single surgeon from 1997 to 2014 by urethroplasty (UP) with STI (n = 229; UP + STI) and UP without STI (n = 14; UP-STI) were collated prospectively and compared for incidence of PUF. Re-operative UP were excluded.

RESULTS

Hypospadias was distal (n = 55), mid-shaft (n = 59), proximal/penoscrotal (n = 109), scrotal (n = 15), and perineal (n = 5). UP was single-staged in 86, multi-staged in 157; mean age at UP was 3.1 ± 2.4 years. Soft tissue used for STI was prepucial inner dartos fascia (inner dartos: n = 88), ventral dartos fascia (ventral dartos: n = 15), pedicled external spermatic fascia (ESF: n = 84), adipose tissue surrounding the spermatic cord (pericordal: n = 9), scrotal adipose tissue (n = 8), or a combination of tissues (combined: n = 25). Mean follow-up was 6.4 ± 4.6 (range 0.6-16.8) years. Overall incidence of PUF was 10/243 (4.1 %); 7/229 (3.1 %) for UP + STI and 3/14 (21.4 %) in UP-STI (p < 0.05); incidence versus type of hypospadias was 1/55 for distal (1.8 %), 3/59 for mid-shaft (5.1 %), 5/109 for proximal/penoscrotal (4.6 %), 0/15 for scrotal (0 %), and 1/5 for perineal (20 %); incidence versus type of STI was 7/88 for inner dartos, 0/15 for ventral dartos, 0/84 for ESF, 0/9 for pericordal adipose tissue, 0/8 for scrotal adipose tissue, and 0/25 for combined. All PUF were repaired successfully. Satisfaction with penile cosmesis was acceptable (10.3 %) or good (89.7 %) without any testicular complications or scrotal deformity.

CONCLUSION

STI, especially ESF, would appear to effectively prevent PUF in HR.

Abnormalities of the external genitalia

Abnormalities of the external genitalia span the spectrum from subtle findings of limited clinical significance to profound anomalies that call into question such essential questions as sex determination. In addition, missing a diagnosis of congenital adrenal hyperplasia in a newborn female child with virilized external genitalia can result in near-term mortality, whereas a large inguinal hernia could present rapidly with incarceration if undetected. To that end, this article seeks to present a survey of commonly encountered genital abnormalities while highlighting those scenarios that require multidisciplinary interventions.

[Prevalence and possible causes of hypospadias]

Hypospadias is the most common congenital malformation of the male external genitalia. After the heart and circulatory system, it is the second most common developmental disorder in males. It is due to a midline fusion defect of the male urethra, which results in a misplaced urethral meatus. Hypospadias may be distal, medial and proximal. It may occur as an isolated defect or it may develop together with other genital disorders (retention of testes in one or both sides, microphallus, bifid scrotum) or with malformation of other organs. In some cases syndromic forms may also occur. Genetic factors play a crucial role in the occurrence of early developmental defect, but endocrine and environmental factors may also be important in the aetiology of hypospadias. It may be associated with various sex and autosomal chromosomal abnormalities. Monogenic and chromosomal causes of hypospadias accounts for about in 30% of all cases, while genetic factors remain unknown in 70% of cases. The authors summarize the development of the male external genitalia, the prevalence and possible causes of hypospadias. They propose that better understanding of the pathogenesis of the disease may contribute to the prevention and decreased prevalence of the disease.

Do adult men with untreated hypospadias have adverse outcomes? A pilot study using a social media advertised survey

OBJECTIVE

Hypospadias is usually treated in childhood. Therefore, the natural history of untreated mild hypospadias is unknown. We hypothesized that men with untreated hypospadias, especially mild, do not have adverse outcomes.

MATERIALS

Facebook was used to advertise an electronic survey to men older than 18 years. Men with untreated hypospadias identified themselves and indicated the severity of hypospadias with a series of questions. Outcomes included: Sexual Health Inventory for Men (SHIM), penile curvature and difficulty with intercourse, International Prostate Symptom Score (IPSS), Penile Perception Score (PPS), psychosexual milestones, paternity, infertility, sitting to urinate, and the CDC HRQOL-4 module.

RESULTS

736 men completed self-anatomy questions and 52 (7.1%) self-identified with untreated hypospadias. Untreated hypospadias participants reported worse SHIM (p < 0.001) and IPSS scores (p = 0.05), more ventral penile curvature (p = 0.003) and resulting difficulty with intercourse (p < 0.001), worse satisfaction with meatus (p = 0.011) and penile curvature (p = 0.048), and more sitting to urinate (p = 0.07). When stratified by mild and severe hypospadias, severe hypospadias was associated with more adverse outcomes than mild hypospadias.

CONCLUSION

Men with untreated hypospadias reported worse outcomes compared with non-hypospadiac men. Mild untreated hypospadias had fewer adverse outcomes than severe hypospadias. Research is needed to determine if treatment of childhood hypospadias improves outcomes in adults, especially for mild hypospadias.

[Questions and dilemmas in the management of hypospadias]

Hypospadias is the second most common congenital malformation in males. Etiology remains unknown in about 70% of the cases. Distal hypospadias is considered not only developmental abnormality of the urethra in males, but it may also constitute a mild form of sexual development disorder in 46,XY males. Most urologists and endocrinologists consider that it is necessary to perform a detailed investigation of children presenting with proximal hypospadias associated with a small phallus or poorly developed scrotum and undescended testes. Currently, there is no generally accepted recommendation for the preoperative evaluation of hypospadias and, therefore, masculinizing surgery without preoperative evaluation is performed in these children. The authors summarize the international literature data and their own experience for the assessment and management of hypospadias concerning questions and problems related to preoperative investigation, masculinizing surgery and additional surgery. A detailed algorithm is presented for preoperative evaluation of both proximal and distal hypospadias.

Ex vivo absorption of promestriene from oil-in-water emulsion into infant foreskin

Hypospadias is a birth defect in which the urinary tract opening is not at the tip of the penis. Hypospadias surgery is frequently complicated by healing deficiencies. Topical treatments with oestrogens were reported to improve healing. In the present study, ex vivo percutaneous absorption of promestriene, a synthetic oestrogen resulting of the double esterification of estradiol was conducted as a pre-requisite for further clinical trial in infants. Penetration of promestriene into infant foreskin treated with commercial oil in water emulsion (10 μg mg(-1)) for 24 h was characterized showing controlled release properties enabling epidermal concentration more than six times higher than dermal concentration (4.13±2.46 mg g(-1) versus 0.62±0.84 mg g(-1), respectively). Furthermore, apparent promestriene fluxes into and through the skin (i.e., 1.5 μg cm(-2) h(-1) and<0.89 μg cm(-2) h(-1), respectively) were calculated from (i) drug amount retained into epidermis and dermis, or (ii) the limit of detection into the receptor fluid. In conclusion, less than 2% of initial dose were absorbed within 24h which compared well with others steroids applied topically in colloidal systems.

Hypospadias repair at a tertiary care center: long-term followup is mandatory to determine the real complication rate

PURPOSE

The field of reconstructive surgery for hypospadias is lacking standard techniques and followup. Most published series include complication rates after a short followup. We report and analyze the long-term outcome of primary hypospadias repair at a single tertiary care center.

MATERIALS AND METHODS

We reviewed 1,061 operations performed at our institution between 1997 and 2010 and registered as hypospadias repair. The operations were performed in 543 patients born between June 1997 and June 2005. A retrospective database was created with information about hypospadias characteristics, surgery and followup.

RESULTS

A total of 474 primary repairs were selected, excluding incomplete/incorrect files. Distal penile hypospadias was reported in 366 patients (77.2%), mid penile hypospadias in 54 (11.4%) and proximal hypospadias in 54 (11.4%). Initial repair technique was based on incised plate in 189 patients (39.9%), meatal advancement in 171 (36%), onlay flap in 82 (17.3%) and other or combined techniques in 25 (5.3%). Insufficient information was reported for 7 patients (1.5%). Mean age at first operation was 22.6 months (range 4 to 134) and mean followup after first operation was 34.0 months (0 to 145). Of the children 360 (75.9%) had a good long-term outcome and required only 1 procedure. Reoperation was needed in 114 patients (24.1%), of whom 54 (47.4%) underwent reoperation in the first year of followup.

CONCLUSIONS

Overall a good long-term outcome without further complication was achieved in 75.9% of our cases. Of the 24.1% of patients who needed reoperation only 47.4% presented within the first year postoperatively, indicating the need for long-term followup when reporting outcomes of hypospadias repair.

Hypospadias repair: an overview of the actual techniques

Hypospadias is one of the most common congenital genital anomalies for which surgery early in life is indicated. The surgical treatment is changing progressively, often by repeating treatment strategies that have been used decades ago. Indeed, historically two-stage procedures were replaced by one-stage procedures and nowadays two-stage procedures gain new interest. The same for reconstructions using the urethral plate, which decades ago were based on the Thiersch Duplay principle. In the 1980s, preputial onlay flaps were most often used and today we see a new interest in the use of the urethral plate. The actual surgical approach to hypospadias is described and technical details are given.

Factors associated with delayed pediatric hypospadias surgery in Taiwan: a population-based, nationwide analysis

BACKGROUND/PURPOSE

Current guidelines recommend that hypospadias repair should be performed before age 18 months. This study aims to investigate the trends of surgical timing and to determine what factors are associated with age at surgery.

METHODS

The present study utilized a subset of the National Health Insurance Research Database, known as Longitudinal Health Insurance Database 2005, which contains the data of all paid medical benefit claims over the period from 1997 to 2007 for a subset of one million beneficiaries randomly drawn from the population of 22.72 million individuals in NHI program during any part of calendar year 2005. We analyzed claims data for all subjects with the diagnoses of hypospadias.

RESULTS

Among 52,705 live male newborns, 218 were diagnosed with hypospadias and thus were included as subjects in our study. Among them, 89 received repair surgery. Approximately 60.6% of the study subjects received repair after the age of 18 months. Multivariate analysis showed that several factors were significantly associated with age at hypospadias surgery: specialty of clinics where first diagnosis was made; specialty of physician making the first diagnosis, age of physician making the first diagnosis; specialty of surgeon performing the surgery; number of years since surgeon's board certification; urbanization level of subject's residence; modality of surgery; concomitant cryptorchidism; concomitant prematurity and low birth weight; age at diagnosis; and number of well-baby clinic visits.

CONCLUSION

This study addresses an important issue of delayed hypospadias surgery in Taiwan, which provides a potential opportunity for improvement in quality of care.

A model of delivering multi-disciplinary care to people with 46 XY DSD

In 2006, a consensus statement was jointly produced by the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society of Paediatric Endocrinology (ESPE) concerning the management of disorders of sex development (DSD) [1]. A recommendation provided by this consensus was that evaluation and long-term care for people affected by DSD should be performed at medical centers with multi-disciplinary teams experienced in such conditions. Here we provide our team's interpretation of the 2006 consensus statement recommendations and its translation into a clinical protocol for individuals affected by 46 XY DSD with either female, or ambiguous, genitalia at birth. Options for medical and surgical management, transitioning of care, and the use of mental health services and peer support groups are discussed. Finally, we provide preliminary data to support the application of our model for delivering multi-disciplinary care and support to patients and their families.

Technique for preservation of penile skin in genital reconstruction: free graft to the scrotum

OBJECTIVE

To describe a new technique to preserve the penile epithelium with good cosmetic results when additional surgery is a significant possibility. Complex genital reconstruction can require multiple procedures.

METHODS

Seven patients underwent grafting of the penile epithelium to the scrotum during genital reconstruction to bank the tissue for potential future use. The graft size was 8-40 mm in the maximal length.

RESULTS

The median age at surgery was 8.1 months. The median interval to the last follow-up examination after surgery was 13.5 months. All 7 patients demonstrated excellent wound healing with good cosmetic results.

CONCLUSION

In patients with complex genital anomalies, nonhair-bearing epithelium is a valuable asset. At times, the paucity of available local tissue necessitates autografting with nongenital epithelium. The need for nongenital tissue can be reduced if excess penile skin is banked for potential use at a later date. We describe a technique in which the penile skin is preserved for potential future reconstruction using free grafting to the scrotum.