Management of penile curvature in children:

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparing two surgical techniques in distal hypospadias repair: Urethral mobilization vs. urethral plate tubularization

OBJECTIVES

While numerous techniques have been described for hypospadias repair, the Tubularized Incised Plate (TIP) procedure is currently the most frequently used method. On the other hand, urethral mobilization techniques have less frequent preference. In this study, we aimed to compare the outcomes of these two techniques in patients with distal hypospadias, particularly those with the urethral meatus located at the coronal and subcoronal.

MATERIAL AND METHODS

A total of 75 patients with distal hypospadias underwent surgery. Patients with glanular and midpenile hypospadias whose meatus was not located at the coronal and subcoronal levels were excluded from the study. 43 patients underwent surgery performing the Eccentric Circummeatal-Based Flap with Limited Urethral Mobilization (ECMB) method, while the remaining 32 patients were treated with the TIP. We analyzed age at surgery, urethral meatus position, ventral or glanular curvature, catheterization duration, and complications.

RESULTS

The mean age at operation was 2.6 (±1.1) years. The position of the meatus was coronal in 48 patients (64%), and subcoronal in 27 (36%). Complications consist of fistula in two patients, meatal stenosis in seven patients, and preputial redundancy in two patients. No glans retraction, wound infection or glans dehiscence was observed in any patient. Complication rates were compared and no statistically significant difference was found between the two methods (P>0.05).

CONCLUSION

Mobilization techniques may be a preferable and safe option for young surgeons due to their relative ease of perform.

Pediatric urologists' confidence and accuracy in estimating penile curvature

BACKGROUND

Assessment and management of congenital penile curvature (PC) can be variable. Methods for correction of PC usually are dependent on degree of PC which is reliant on how degree is assessed. We sought to assess the confidence and accuracy of measuring PC and hence management using case-based examples.

METHODS

A survey was emailed to members of the Societies for Pediatric Urology. Demographic information, management strategies for PC, and self-reported confidence in measuring PC were assessed. A Likert scale measured self-confidence. Case scenarios were used to assess ability to measure PC and methods of correction. The cases consisted of three computer-generated penis model images with arc-type ventral curvature and one image of lateral curvature in an infant.

RESULTS

The response rate was 30% (108/355). The mean confidence score was 3.6 ± 0.8 (3-fairly confident; 4-very confident). In clinic, 89% of urologists used eyeball estimates to assess PC; 5% used both eyeball and goniometer. In the operating room, 71% used eyeball estimates, 8% used goniometer, and 16% used both. If sole decision-maker, urologists recommend surgical correction of PC over observation at median 30° (IQR 21-30°). At a median of 45°, there was a shift in corrective surgical preference from dorsal plication (DP) (IQR 30-54°) to ventral lengthening (IQR 34-60°). Urologists underestimated PC degree for all cases (summary table). For all cases, there was no association between years in practice or confidence level on estimated PC degree. In case 1, only 24% of urologists would correct a mean estimate of 23° PC; those who would correct had a higher mean PC estimate vs those who would not (28° vs 21°, p < 0.001). Case 2 and 4 had similar estimations and correction methods. In case 2, those who chose VL had a higher mean PC estimate vs those who did not (43° vs 37°, p < 0.01), but no estimate difference was seen for DP (p = 0.52). In case 4 with lateral PC, those who chose DP had a higher mean PC estimate vs those who did not (41° vs 33°, p = 0.049). Yet in case 3, there was no difference in PC estimate in urologists who chose VL vs not (57° vs 53°, p = 0.16).

CONCLUSIONS

A uniform underestimation of PC existed despite self-reported confidence in the ability to measure PC. An increasing willingness to perform surgical correction was demonstrated with a shift towards VL for ventral curvature and less so for lateral curvature as PC worsens.

Standardization of penile angle estimation with a semi-automated algorithm

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Penis growth and development in children and adolescents: a study based on GAMLSS]

OBJECTIVE

To investigate penis development in children and adolescents aged 0-16 years, and to plot the percentile curve for penis development in different age groups.

METHODS

A total of 3 024 normal male neonates, children, and adolescents aged 0-16 years in Chongqing, China were selected by simple random sampling and stratified cluster sampling. The length and diameter of the penis were measured for all subjects. A descriptive statistical analysis was used to investigate the data characteristics of the penis, and the GAMLSS fitting model was used to plot the percentile curves of P₃, P₁₀, P₂₅, P₅₀, P₇₅, P₉₀, and P97 and obtain percentile reference values.

RESULTS

The length and diameter of the penis grew rapidly before the age of 1 year, grew relatively slowly from 1 to 11 years old, and entered a rapid growth period from 11 years old. The length of the penis was positively correlated with its diameter (r=0.961, P<0.01). The percentile reference values of penis length and diameter were obtained and the percentile curve was plotted.

CONCLUSIONS

The growth and development of penis length is consistent with that of penis diameter in male children and adolescents in Chongqing, and 0-1 year and 11-16 years are rapid growth periods of penis length and diameter. The percentile curve of penis length and diameter in children and adolescents aged 0-16 years in Chongqing which has been established will provide a reference for further studies on sexual development in children and adolescents.

Clinical Study of 23 Male Patients with Congenital Ventral Penile Angulation without Hypospadias

Congenital ventral penile angulation without hypospadias is a rare disease and causes great anxiety to the parents. The aim of our study is the presentation of this disease, especially the indications of surgical treatment and the protocol applied in our clinic. We retrospectively studied 23 male patients aged 2.5 to 7 years old (av 5.2 y) with important penile angulation (over 45°) without hypospadias, treated during the past 15 years in our department. In 9 patients the cause was the skin chordee (fibrosis of the ventral part of the prepuce), in 4 the fibrotic fascia (incomplete development of dartos and Buck's fascia) and in 10 the disproportion of the corpora cavernosa. No case of congenital short urethra was reported. In our opinion, the appliance of the algorithm suggested by Donnahoo KK et al. in uncomplicated cases, along with the experience of the surgical team, results in satisfactory treatment and avoidance of complications.