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Lee AS, Ho CP, Creviston AH, Rana S, Délot EC, Casella DP. Objective documentation of hypospadias anatomy with three-dimensional scanning. J Pediatr Urol 2024; 20:239.e1-239.e6. [PMID: 38104026 DOI: 10.1016/j.jpurol.2023.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/26/2023] [Accepted: 11/26/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION The absence of a standardized classification of hypospadias hinders understanding of the anatomic differences among patients and the evaluation of outcomes following surgical repair. In working towards a standardized, objective method of recording patients' hypospadias anatomy, we describe our initial experience using a non-invasive three-dimensional scanner. MATERIAL AND METHODS An Artec3D Space Spider scanner was used to obtain 3D scans in 29 patients undergoing hypospadias repair. Measurements of the urethral plate width, urethral plate length, glans width, penile shaft length, and penile shaft width were made by 2 pediatric urology attendings and 1 pediatric urology fellow. Measurements were compared and inter-rater reliability was calculated. RESULTS A total of 435 measurements were made on 29 successfully generated 3D scans, ranging from distal to proximal hypospadias. The inter-rater reliability of measurements from the generated 3D models shown good inter-rater reliability of urethral plate width (ICC0.87 [95%CI:0.76,0.93]), penile shaft length (ICC0.87 [95%CI:0.70,0.94]) and glans width (ICC0.83 [95%CI:0.68,0.92]), excellent inter-rater reliability of urethral plate length (ICC0.96) and moderate inter-rater reliability of penile shaft width (ICC0.69 [95%CI:0.44,0.84]). DISCUSSION There was a high degree of reliability of measurements made across multiple users. Calculation of the ratio of the urethral plate length/total penile shaft length objectively defined the initial position of the urethral meatus. When compared to the 3-dimensional volume of the glans, a more proximally positioned urethral meatus was associated with a lower glans volume. CONCLUSION 3D scanning offers a rapid, reproducible, and non-invasive method of documenting hypospadias anatomy. The ability to evaluate three dimensional features (i.e. glans volume) offers an exciting opportunities for robust investigation of hypospadias outcomes and further understanding of the relationship between a patient's genotype and phenotype.
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Affiliation(s)
- Albert S Lee
- Division of Pediatric Urology, Children's National Medical Center, Washington, DC 20010, USA
| | - Christina P Ho
- Division of Pediatric Urology, Children's National Medical Center, Washington, DC 20010, USA
| | - Austin H Creviston
- Division of Pediatric Urology, Children's National Medical Center, Washington, DC 20010, USA
| | - Sohel Rana
- Joseph E. Robert, Jr., Center for Surgical Care, Children's National Hospital, Washington, DC 20010, USA
| | - Emmanuèle C Délot
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Medical Center, Washington, DC 20010, USA; Departments of Pediatrics and Genomics and Precision Medicine, School of Medicine, The George Washington University, Washington, DC 20052, USA
| | - Daniel P Casella
- Division of Pediatric Urology, Children's National Medical Center, Washington, DC 20010, USA; Joseph E. Robert, Jr., Center for Surgical Care, Children's National Hospital, Washington, DC 20010, USA.
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León NY, Reyes AP, Harley VR. A clinical algorithm to diagnose differences of sex development. Lancet Diabetes Endocrinol 2019; 7:560-574. [PMID: 30803928 DOI: 10.1016/s2213-8587(18)30339-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 12/15/2022]
Abstract
The diagnosis and management of children born with ambiguous genitalia is challenging for clinicians. Such differences of sex development (DSDs) are congenital conditions in which chromosomal, gonadal, or anatomical sex is atypical. The aetiology of DSDs is very heterogenous and a precise diagnosis is essential for management of genetic, endocrine, surgical, reproductive, and psychosocial issues. In this Review, we outline a step-by-step approach, compiled in a diagnostic algorithm, for the clinical assessment and molecular diagnosis of a patient with ambiguity of the external genitalia on initial presentation. We appraise established and emerging technologies and their effect on diagnosis, and discuss current controversies.
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Affiliation(s)
- Nayla Y León
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Alejandra P Reyes
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Genetics Department, Children's Hospital of Mexico Federico Gómez, Mexico City, Mexico
| | - Vincent R Harley
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia.
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Tafazzoli K, Wünsch L, Bouteleux M, Lindert J, Schulz T, Birnbaum W, Marshall L, Hiort O, Tüshaus L. Endoscopy and Laparoscopy in Disorders of Sex Development. Sex Dev 2018; 12:100-105. [DOI: 10.1159/000486871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Lindert J, Hiort O, Tüshaus L, Tafazzoli-Lari K, Wünsch L. Perineal ultrasound offers useful information in girls with congenital adrenal hyperplasia. J Pediatr Urol 2016; 12:427.e1-427.e6. [PMID: 27751833 DOI: 10.1016/j.jpurol.2016.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 08/22/2016] [Indexed: 10/21/2022]
Abstract
A variable spectrum of urogenital malformations exists in girls with congenital adrenal hyperplasia (CAH). The vagina may enter the urethra at a variable level, and relations to the sphincter complex vary accordingly. Furthermore, an enlarged clitoris and variations in the bladder sphincter anatomy can be found. Endoscopy, genitography or magnetic resonance imaging (MRI) are commonly used for the assessment of these anomalies, and to provide information for counselling and treatment. When surgery is planned, introitoplasty cosmetical reduction of the clitoris and labioplasty are discussed with the families; introitoplasty is the most demanding aspect. In order to plan the most appropriate surgical approach, the entrance level of the vagina into the urethra and its relation to the bladder sphincter must be known. Thus, imaging has an important role in CAH. The imaging techniques mentioned above require sedation, anaesthesia or involve ionizing radiation of the gonads and, thus, are relatively invasive. It would therefore be highly desirable to have a minimally invasive and accurate technique that provides images of the individual anatomic situation. The present paper describes experience with perineal ultrasound in the initial imaging evaluation of girls with CAH. Ultrasound findings were compared to the results of endoscopy that was performed before surgery. From 2006 to 2012, 11 girls had perineal ultrasound and endoscopy. Measurements of clinical relevance for introitoplasty were: the length of the urogenital sinus, the distance to the vaginal opening into the urogenital sinus, and the length of the bladder neck. This retrospective analysis showed that the entrance point of the vagina into the urogenital sinus could be identified in 10 of 11 girls. In some cases, the correlation of endoscopic and ultrasound data showed a correlation between endoscopic and sonographic findings. The length of the bladder neck and the length of the urogenital sinus could be measured by ultrasound in 10 of 11 girls, and were subsequently confirmed by endoscopy. This showed, for the first time, that perineal ultrasound could provide the information required for surgical correction of the urogenital sinus anomaly in CAH. Advantages of these techniques are the minimal invasiveness and wide availability. Because long-term problems are not uncommon, perineal ultrasound may also be of value during follow-up. Widespread use of this technique has the potential to reduce costs and morbidity associated with endoscopy and genitography.
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Affiliation(s)
- J Lindert
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany.
| | - O Hiort
- Division of Paediatric Endocrinology and Diabetes, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany
| | - L Tüshaus
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany
| | - K Tafazzoli-Lari
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany
| | - L Wünsch
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany
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Hiort O, Birnbaum W, Marshall L, Wünsch L, Werner R, Schröder T, Döhnert U, Holterhus PM. Management of disorders of sex development. Nat Rev Endocrinol 2014; 10:520-9. [PMID: 25022812 DOI: 10.1038/nrendo.2014.108] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The medical term disorders of sex development (DSDs) is used to describe individuals with an atypical composition of chromosomal, gonadal and phenotypic sex, which leads to differences in the development of the urogenital tract and reproductive system. A variety of genetic factors have been identified that affect sex development during gonadal differentiation or in specific disorders associated with altered androgen biosynthesis or action. The diagnosis of DSDs in individuals and the subsequent management of patients and their families requires a targeted and structured approach, involving a multidisciplinary team with effective communication between the disciplines. This approach includes distinct clinical, imaging, laboratory and genetic evaluations of patients with DSDs. Although treatment of patients with DSDs can include endocrine and surgical options, many patients have concerns that arise from past incorrect treatments that were founded on the traditional binary concept of the sexes. To dispel these concerns, it is necessary to create centres of expertise for DSDs that include physicians, surgeons, psychologists and specialists in diagnostic procedures to manage patients and their families. Additionally, the inclusion of trained peer support in the multidisciplinary DSD team seems to be integral to the supportive management of patients with DSDs. Most importantly, dealing with DSDs requires acceptance of the fact that deviation from the traditional definitions of gender is not necessarily pathologic.
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Affiliation(s)
- Olaf Hiort
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Wiebke Birnbaum
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Louise Marshall
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Lutz Wünsch
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Ralf Werner
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Tatjana Schröder
- Department of Gynaecology and Obstetrics, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Ulla Döhnert
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Paul-Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, Christian-Albrechts-University, Schwanenweg 20, 24105 Kiel, Germany
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Hiort O, Wünsch L, Cools M, Looijenga L, Cuckow P. Requirements for a multicentric multidisciplinary registry on patients with disorders of sex development. J Pediatr Urol 2012; 8:624-8. [PMID: 23059375 DOI: 10.1016/j.jpurol.2012.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 09/11/2012] [Indexed: 11/13/2022]
Abstract
Disorders of Sexual Development (DSDs) are a group of rare to very rare congenital anomalies of the genito-urinary tract of genetic and endocrine causes. Recently, an international database I-DSD was successfully implemented to register patients with DSD and to provide the basis for epidemiologic, genetic, and clinical research. This tool needs to be adjusted and supplemented with additional modules in order to better assess the anatomical basis of DSD as well as to monitor risk factors such as gonadal histology. A proposal for the additional information to be obtained is discussed.
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Affiliation(s)
- Olaf Hiort
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatrics, University of Lübeck, Germany.
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