Current hypospadias management: Diagnosis, surgical management, and long-term patient-centred outcomes

Current advances in the use of artificial intelligence in predicting and managing urological complications

BACKGROUND

Artificial intelligence (AI) has emerged as a promising avenue for improving patient care and surgical outcomes in urological surgery. However, the extent of AI's impact in predicting and managing complications is not fully elucidated.

OBJECTIVES

We review the application of AI to foresee and manage complications in urological surgery, assess its efficacy, and discuss challenges to its use.

METHODS AND MATERIALS

A targeted non-systematic literature search was conducted using the PubMed and Google Scholar databases to identify studies on AI in urological surgery and its complications. Evidence from the studies was synthesised.

RESULTS

Incorporating AI into various facets of urological surgery has shown promising advancements. From preoperative planning to intraoperative guidance, AI is revolutionising the field, demonstrating remarkable proficiency in tasks such as image analysis, decision-making support, and complication prediction. Studies show that AI programmes are highly accurate, increase surgical precision and efficiency, and reduce complications. However, implementation challenges exist in AI errors, human errors, and ethical issues.

CONCLUSION

AI has great potential in predicting and managing surgical complications of urological surgery. Advancements have been made, but challenges and ethical considerations must be addressed before widespread AI implementation.

Application of intraoperative structured light scanning to enable post-operative evaluation of digital and 3D-printed penile models

BACKGROUND

Penile phenotype in hypospadias is currently assessed visually or manually (e.g., ruler, goniometer) for clinical, education, and research applications. However, these methods lack precision and accuracy across raters and cannot be reevaluated retrospectively following a surgical repair. The project aim was to evaluate the precision and reliability of penile dimensions obtained from digital and three dimensional (3D) printed models created from intraoperative (OR) structured light scans (SLS) during primary pediatric penile procedures.

METHODS

Boys ages 1 month to 6 years underwent first- or single-stage penile surgery at a single institution were enrolled in this prospective study (IRB #20-000143). For each patient, immediately following placement of a stay suture under consistent manual tension, intra-operative dimension measurements with a ruler were obtained. A digital 3D model was created prior to penile repositioning using an Artec Space Spider scanner and Artec Studio 13 software. Following the case, two different raters completed 10 digital measurements of each generated model in Autodesk Fusion 360. These digital models were subsequently 3D printed and two different raters completed 10 manual dimension measurements of each 3D printed model using a ruler. A one-way random effects intraclass correlation coefficient (ICC) evaluated measures of agreement between and within raters, respectively. Analyses were conducted in R version 4.2.

RESULTS

Six scans were obtained (hypospadias: 4, circumcision: 2). Intra-rater assessments showed excellent precision across repeated digital measurements; manual measurements of 3D printed models had excellent reliability for glans width and penile length but poor to good reliability for glans height. Inter-rater reliability was good to excellent for glans width (0.77-0.95) and good for penile length (0.71-0.88). However, there was poor inter-rater reliability for glans height (0-0.14). Following training regarding glans height location, there was an improvement in precision and repeatability of manual and digital measurements.

CONCLUSION

Digital measurement of OR-derived 3D models resulted in excellent repeatability for each rater and improved between-rater reliability over manual measurement of 3D printed models alone, ensuring that images can be compared by various surgeons both now and in the future. SLS is promising as a novel modality to digitally generate 3D models, thereby informing phenotypic analysis for research and education. Further development of digital measurement methods to ensure consistency between raters for quantitative assessment of additional parameters and assessment of the technology within the pre-operative environment for surgical planning is planned.

Prevalence of disorders of sex development in patients with hypospadias and cryptorchidism

BACKGROUND

Hypospadias and undescended testicles (UDT) are common congenital conditions, affecting approximately 1 in 125 and 1 in 33 boys, respectively. There has been limited contemporary data regarding the prevalence of Disorders of Sex Development (DSD) in patients with a history of both hypospadias and UDT.

OBJECTIVE

Our objective is to determine the prevalence of DSD among patients presenting with hypospadias and UDT.

DESIGN, SETTING, AND PARTICIPANTS

Electronic medical records were reviewed, and a retrospective chart review was conducted on 177 patients that were evaluated at our institution from 2000 to 2021 with a diagnosis of hypospadias and UDT. The degree of hypospadias, presence of and palpability of UDT, and prevalence and type of DSD were recorded.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The degree of hypospadias, presence of and palpability of UDT, and prevalence and type of DSD were recorded. Chi-squared and Fisher's exact tests were conducted for descriptive statistical analyses as appropriate. Logistic regression analyses were conducted, with adjusted models including demographic and relevant clinical data.

RESULTS

177 patients were identified with both hypospadias and UDT, with 17/111 (15.3 %) diagnosed with DSD. The most common etiology of DSD was mixed gonadal dysgenesis (35.3 %; n = 6). Proximal hypospadias made up only 59.6 % of those without DSD vs. 100 % of those with confirmed DSD (p = 0.0044). A significantly smaller proportion of DSD patients had bilaterally palpable gonads compared to those without DSD (29.4 % vs. 79.8 %, p < 0.0001). Compared to those with palpable testes, patients with one non-palpable testicle had up to 26.67 times greater odds of DSD.

CONCLUSIONS

To date, we present the largest cohort of patients that have undergone DSD work up for the combined presentation of hypospadias and UDT. Our findings highlight an increase in DSD diagnosis in proximal hypospadias patients with non-palpable UDTs, which offers further evidence and support for pursuing DSD diagnostic work-up in all proximal hypospadias patients with UDTs.

Impact of the Age at Distal Hypospadias Surgery on Behavioral Problems, Somatic Symptoms and Irritability Levels in Children

BACKGROUND

To assess the effect of age at hypospadias surgery on emotional and behavioural problems, somatic symptoms, irritability, and penile perception.

METHODS

We retrospectively identified the patients who underwent single distal hypospadias surgery and age-matched healthy controls were included. There were two further subgroups according to the age at the time of hypospadias repair (<2 vs. >2 years). The Strengths and Difficulties Questionnaire (SDQ), Revised Children's Anxiety and Depression Scale (RCADS), Affective Reactivity Index (ARI), Level 2 Somatic Symptom Scale, and Penile Perception Score (PPS) scale were used. The groups were compared using multivariate variance analysis (MANOVA).

RESULTS

Both groups consisted of 70 patients (mean age 14.0 ± 0.2 years, for both), while there were 34 patients in the hypospadias groups who underwent surgery at <2 years of age. Depressive, panic, separation anxiety, social phobia, and somatic complaint symptom scores of the hypospadias group were lower than those of the control group. Obsessive-compulsive symptom levels were significantly higher in patients who underwent hypospadias surgery at >2 vs. <2 years of age. Additionally, PPSs rated by the surgeon were significantly higher in the former. A multivariate linear regression model indicated that panic disorder symptom scores predicted child PPS in the hypospadias group. Limitations include retrospective design.

CONCLUSIONS

Single hypospadias surgery seems not to have a negative impact on emotional and behavioural status. Children who underwent distal hypospadias surgery after 2 years of age had higher levels of obsessive-compulsive symptoms. Following emotional status may help the early diagnosis of future psychopathologies.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Role of Long-Chain Cyanoacrylate as an Adjunct Interposition Layer in Repair of Hypospadias and Urethrocutaneous Fistula in Children: A Novel Technique

Purpose Hypospadias is an anomaly wherein the urethral opening is ectopically located on the ventral aspect of the penis. The most common complications after hypospadias repair are urethrocutaneous fistula (UCF) and meatal stenosis. Long Chain Cyanoacrylate (LCCA) tissue adhesive promises safety, feasibility, and durability due to its tensile strength and bacteriostatic and hemostatic properties. We conducted this study to ascertain whether LCCA tissue adhesive can prove a more effective adjunct to traditional suturing techniques. Methods Patients were divided into two groups. Group A underwent surgery with conventional reconstruction of the neourethral tube along with the buttressing layer using Buck's fascia or Tunica Vaginalis. In addition to the traditional procedure of Group A, Group B patients were administered a layer of LCCA tissue adhesive as an adjunct between the neourethral suture line and the buttressing layer. Patients were followed up for six months and were evaluated for complications like UCF, meatal stenosis, hematoma, skin infection, glans dehiscence, and flap necrosis. Results Thirty-eight children in the age group 1-6 years were studied, of which 20 were in Group A and 18 in Group B. Among patients of Group A seven (35%) developed complications. In contrast, only four (22.2%) patients developed complications in Group B. The statistical significance in the complication rates between the two groups could not be achieved due to the modest sample size. However, the numerical and proportional reduction in the number of complications was noted. Conclusion LCCA adhesive as an adjunct numerically reduces the number of complications compared to traditional suturing alone in patients undergoing surgery for hypospadias and UCF.

Advantages of Urethroplasty Terminating at the Corona for Severe Hypospadias: Complications, Uroflowmetry, and Esthetics

PURPOSE

Mid-shaft/proximal (msp) and penoscrotal/scrotal/perineal (pssp) hypospadias treated by urethroplasty (UP) terminating at the corona (UPC) or UP terminating at the tip of the glans (UPG) were compared.

METHODS

UP performed at a single institute (n = 234) between 2003 and 2020 were grouped as: msp-UPC (n = 23), msp-UPG (n = 75), pssp-UPC (n = 81), and pssp-UPG (n = 55) to compare data obtained from medical records for post-UP complications (PUC; urethral stenosis, urethrocutaneous fistula, diverticulum formation, and bleeding; n = 234), post-UP uroflowmetry (PUF; average flow rate (Qave), maximum flow rate (Qmax), voiding time (VT), voided volume (VV) and urine flow curves) in 57 UP patients [msp-UPC (n = 5), msp-UPG (n = 12), pssp-UPC (n = 32), pssp-UPG (n = 8)] and 9 controls, and post-UPC esthetics (EST; n = 104). P < 0.05 was considered significant.

RESULTS

Mean ages at UP (years) were: msp-UPC (3.1 ± 3.0), msp-UPG (3.3 ± 1.4), pssp-UPC (4.6 ± 2.4), and pssp-UPG (3.4 ± 1.4); p < 0.0001 by ANOVA test. Overall, there were significantly more PUC in pssp-UPG compared with pssp-UPC except for bleeding. Ages at PUF assessment were similar. Mean Qave (mL/s) for pssp-UPG (4.0 ± 1.0) was significantly less than pssp-UPC (5.9 ± 2.5; p < 0.05) and both were significantly less than controls (6.9 ± 1.8; p < 0.05, p < 0.01, respectively). Mean Qmax (mL/s) for pssp-UPC (11.4 ± 4.8) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.05) and for controls (14.9 ± 4.4) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.01). All VT (seconds) were similar to controls; all urine flow curves were normal. For EST in UPC (n = 104), 3 cases requested meatal advancement.

CONCLUSIONS

UPC may be a valid option for treating pssp hypospadias because of significant differences in PUC/PUF and minimal EST issues compared with UPG.

LEVEL OF EVIDENCE

Prognosis Study Level-Ⅱ.

Outcomes of Hypospadias Repair Based on Surgical Techniques: A 4-Year Retrospective Study

Purpose

This study aimed to report the outcomes of hypospadias repair performed at a tertiary-level hospital during 2018 to 2021.

Methods

A retrospective chart review of 119 patients was performed.

Results

The most frequent coronal hypospadias cases were distal. However, the most common scrotal hypospadias cases were proximal. The average age at the time of the first surgery was 2.4 years (standard deviation, ±2.3 years). The tubularised incised plate technique was performed for 57 of these 119 patients. Urethral fistula was the most common complication associated with distal and proximal cases (23.96% and 30.43%, respectively). No significant correlation was observed between any complication and the surgical technique. Based on the logistic regression model, the duration of urethral stenting was statistically significant (p=0.025), indicating that a urinary catheter duration of more than 5 days resulted in a 2.9-times increased risk of postoperative urethral fistula.

Conclusion

Prolonged urethral stenting for more than 5 days may result in subsequent urethral fistula development. Neither the severity of hypospadias nor the surgical technique seems to affect postoperative complications.

Tissue Engineering for Penile Reconstruction

The penis is a complex organ with a development cycle from the fetal stage to puberty. In addition, it may suffer from either congenital or acquired anomalies. Penile surgical reconstruction has been the center of interest for many researchers but is still challenging due to the complexity of its anatomy and functionality. In this review, penile anatomy, pathologies, and current treatments are described, including surgical techniques and tissue engineering approaches. The self-assembly technique currently applied is emphasized since it is considered promising for an adequate tissue-engineered penile reconstructed substitute.

Use of Validated Questionnaires to Predict Cosmetic Outcomes of Hypospadias Repair

INTRODUCTION

Hypospadias is a syndrome of penile maldevelopment. The primary goal of hypospadias surgery is to create a penis with normal appearance and function. Historically, the outcome of hypospadias repair has been assessed based on the need for reoperation due to urethroplasty complications (UC), including fistula formation, dehiscence, meatal stenosis, or development of a urethral stricture. The Glans-Urethral Meatus-Shaft (GMS) score is a standardized tool to predict UC. Analysis of the cosmetic outcomes of hypospadias repair based on the appearance of the reconstructed penis has been validated, and standardized scores have been published. The Hypospadias Objective Penile Evaluation (HOPE) score is a validated questionnaire used to assess postoperative cosmetic outcomes. Although predictors of surgical outcomes and UC have been well documented, predictors of optimal cosmetic outcomes are lacking in the literature. Furthermore, reoperation due to cosmetic considerations has been poorly reported.

OBJECTIVE

To identify predictors of cosmetic outcomes after hypospadias repair and to assess the reoperation rate according to cosmetic considerations.

MATERIALS AND METHODS

This prospective cohort study included 126 boys who underwent primary hypospadias repair. The severity of hypospadias, degree of penile curvature, glans width, preoperative HOPE, and GMS scores were documented. The standard technique for single-stage repairs, the tubularized incised plate urethroplasty, was performed. The primary endpoint was cosmetic outcomes evaluated by the HOPE score questionnaire six months postoperatively. Optimal cosmetic results were defined by HOPE scores ≥ 57.

RESULTS

The study population consisted of the following cases: 87 (69%) subcoronal, 32 (25%) shaft, and 7 (6%) proximal hypospadias. Among the study participants, 102 boys (81%) had optimal cosmetic results (HOPE ≥ 57), and 24 boys (19%) had surgeries with suboptimal cosmetic outcomes (HOPE < 57). Ancillary procedures were performed in 21 boys (16%), of which 14 (11%) were solely for cosmetic considerations, and 7 were secondary to UC. Using the Receiver Operating Characteristic analysis of potential predictors of optimal cosmetic outcomes, the preoperative HOPE score had the highest area under the curve (AUC = 0.79; 95% CI 0.69-0.89, p < 0.001). After multivariable analysis, the degree of penile chordee (p = 0.013), glans width (p = 0.003), GMS score (p = 0.007), and preoperative HOPE score (p = 0.002) were significant predictors of cosmetic outcomes. Although meatal location predicted suboptimal cosmetic results in univariate analysis, it was not a factor in multivariable analysis.

CONCLUSIONS

Over 80% of boys undergoing hypospadias repair achieved optimal cosmetic outcomes. More than 10% of cases underwent ancillary procedures, secondary solely to cosmetic considerations. Predictors of optimal cosmetic outcomes after hypospadias surgery included degree of chordee, glans width, and preoperative HOPE and GMS scores, which were the best predictors of satisfactory cosmetic results. Although meatal location is the main predictor of UC, it was not a predictor for cosmetic outcomes. Factors affecting cosmetic outcomes should be clearly explained to parents during the preoperative consultation.

Trilayer composite scaffold for urethral reconstruction:in vitroevaluation of mechanical, biological, and angiogenic properties

Regeneration of damaged urethral tissue remains a major challenge in the field of lower urinary tract reconstruction. To address this issue, various synthetic and natural biodegradable biomaterials are currently being explored for the fabrication of scaffolds that promote urethral regeneration and healing. In this study, we present an approach to fabricate a trilayer hybrid scaffold comprising a central layer of poly(lactic acid) (PLA) between two layers of chitosan. The chitosan/PLA/chitosan (CPC) scaffolds were fabricated by a sequential electrospinning process and their properties were evaluated for their suitability for urethral tissue engineering. The physical and biological properties of the CPC scaffolds were evaluated in comparison to electrospun PLA scaffolds and acellular dermis (Alloderm) as controls for a synthetic and a natural scaffold, respectively. Compared to the controls, the CPC scaffolds exhibited higher elastic modulus and ultimate tensile strength, while maintaining extensibility and suture retention strength appropriate for clinical use. The CPC scaffolds displayed significant hydrophilicity, which was associated with a higher water absorption capacity of the chitosan nanofibres. The degradation products of the CPC scaffolds did not exhibit cytotoxicity and promoted wound closure by fibroblastsin vitro. In addition, CPC scaffolds showed increased growth of smooth muscle cells, an essential component for functional regeneration of urethral tissue. Furthermore, in a chicken embryo-based assay, CPC scaffolds demonstrated significantly higher angiogenic potential, indicating their ability to promote vascularisation, a crucial aspect for successful urethral reconstruction. Overall, these results suggest that CPC hybrid scaffolds containing both natural and synthetic components offer significant advantages over conventional acellular or synthetic materials alone. CPC scaffolds show promise as potential candidates for further research into the reconstruction of the urethrain vivo.

Predictors of surgical complications in boys with hypospadias: data from an internationa registry

Background

Complications are frequently reported after hypospadias repair and there is a need to understand the factors that influence their occurrence.

Methods

Data from boys with hypospadias born between 2000 and 2020 were obtained from the International Disorders of Sex Development (I-DSD) Registry. Logistic regressions, fisher's exact tests and spearman's correlation tests were performed on the data to assess associations between clinical factors and complication rates.

Results

Of the 551 eligible boys, data were available on 160 (29%). Within the cohort, the median (range) External Masculinization Score (EMS) was 6 (2, 9). All presented with one or more additional genital malformation and 61 (38%) presented with additional extragenital malformations. Disorders of androgen action, androgen synthesis and gonadal development were diagnosed in 28 (18%), 22 (14%) and 9 (6%) boys, respectively. The remaining 101 (62%) patients were diagnosed as having non-specific 46,XY Disorders of Sex Development. Eighty (50%) boys had evidence of abnormal biochemistry, and gene variants were identified in 42 (26%). Median age at first hypospadias surgery was 2 years (0, 9), and median length of follow-up was 5 years (0, 17). Postsurgical complications were noted in 102 (64%) boys. There were no significant associations with postsurgical complications.

Conclusions

Boys with proximal hypospadias in the I-DSD Registry have high rates of additional comorbidities and a high risk of postoperative complications. No clinical factors were significantly associated with complication rates. High complication rates with no observable cause suggest the involvement of other factors which need investigation.

Dorsal inlay inner preputial graft repair versus ventral-only preputial graft repair in primary distal penile hypospadias with narrow urethral plate

Background

Tubularized incised plate (TIP) is the most common technique used for distal hypospadias repair with good outcome but with a high rate of urethral stricture. Inner preputial-free graft can be used as an inlay graft in the incised area of the narrow urethral plate, also can be used as an onlay graft for urethroplasty in hypospadias repair to avoid this complication.

Patients and Methods

A comparative prospective randomized study was conducted on two groups of hypospadias patients with narrow urethral plate. Group A: dorsal inlay inner preputial graft repair was performed (grafted TIP [G-TIP]) and Group B: ventral onlay preputial graft repair was performed. The assessment of outcome and hypospadias objective scoring evaluation (HOSE) score was done at 2 weeks and 6 months.

Results

Group A included 55 patients for whom dorsal inlay inner preputial graft repair was performed (G-TIP), and Group B which was planned to be conducted on 55 patients using onlay preputial graft (onlay graft) but was terminated after 15 cases due to high failure rate (33%). Group A showed better success rate 96% and better HOSE score (score 16) at 2 months and 6 months 83.6% and 88.2% versus 26.7% and 33.3% in Group B. Postoperative complications showed a statistically significant difference; glans dehiscence (3.6% vs. 40%), wound infection (1.8% vs. 33.3%), and skin sloughing (3.6% vs. 26.7%) in Groups A and B, respectively.

Conclusion

G-TIP is a good technique for the management of distal hypospadias with narrow urethral plate with good success rate, cosmetic outcome, and with less complications compared to onlay graft.

Urethral advancement and glanuloplasty versus tubularized incised plate urethroplasty for distal hypospadias repair: a prospective randomized study

BACKGROUND

About one in 200 to one in 300 male births has hypospadias. The prevalence of this congenital anomaly varies worldwide. The meatus is located distally in approximately 70% of cases. Several surgical techniques were described for distal hypospadias repair; despite this, there is no ideal approach. This study compares urethral advancement &glanuloplasty, and TIP techniques in terms of feasibility, duration of operation, and complications. Patients and.

METHODS

This prospective randomized comparative study was conducted at Al-Azhar University Hospitals from April 2022 to October 2022. Fifty-seven cases with different types of hypospadias were assessed for eligibility. Among them, seven cases were excluded due to the presence of severe chordee (n = 3), proximal variant (n = 2), and recurrent cases of hypospadias (n = 2). Fifty cases were randomly divided into two groups using a 1:1 ratio (computer-generated randomization). Twenty-five cases were subjected to urethral advancement and glanuloplasty, and the rest were subjected to tubularized incised plate (TIP) urethroplasty.

RESULTS

The mean age of all studied cases was 4.2 years. Approximately 52% had coronal or sub-coronal meatus, whereas 48% had glandular meatus. Both groups were matched according to age and meatus location (p > 0.05). No statistically significant difference was observed between the two groups regarding duration of operation, postoperative pain, and postoperative hospital stay. In addition, both groups did not differ significantly in late complications (meatal stenosis, meatal retraction, fistula, and glans dehiscence).

CONCLUSIONS

Both urethral advancement &glanuloplasty, and TIP urethroplasty have comparable short-term outcomes. Urethral advancement and glanuloplasty is preferred in certain conditions, especially in circumcised children or those with a narrow urethral plate.

TRIAL REGISTRATION

The study protocol was approved by the Pan African Clinical Trials Registry (number for the registry is: PACTR202211757905870) on (29/11/2022). All procedures were performed per the Helsinki Declaration.

Automated measurement of penile curvature using deep learning-based novel quantification method

Objective

Develop a reliable, automated deep learning-based method for accurate measurement of penile curvature (PC) using 2-dimensional images.

Materials and methods

A set of nine 3D-printed models was used to generate a batch of 913 images of penile curvature (PC) with varying configurations (curvature range 18° to 86°). The penile region was initially localized and cropped using a YOLOv5 model, after which the shaft area was extracted using a UNet-based segmentation model. The penile shaft was then divided into three distinct predefined regions: the distal zone, curvature zone, and proximal zone. To measure PC, we identified four distinct locations on the shaft that reflected the mid-axes of proximal and distal segments, then trained an HRNet model to predict these landmarks and calculate curvature angle in both the 3D-printed models and masked segmented images derived from these. Finally, the optimized HRNet model was applied to quantify PC in medical images of real human patients and the accuracy of this novel method was determined.

Results

We obtained a mean absolute error (MAE) of angle measurement <5° for both penile model images and their derivative masks. For real patient images, AI prediction varied between 1.7° (for cases of ∼30° PC) and approximately 6° (for cases of 70° PC) compared with assessment by a clinical expert.

Discussion

This study demonstrates a novel approach to the automated, accurate measurement of PC that could significantly improve patient assessment by surgeons and hypospadiology researchers. This method may overcome current limitations encountered when applying conventional methods of measuring arc-type PC.

Spectrum and classification of megameatus anomalies

OBJECTIVE

To define and classify megameatus anomalies, the parameters of a considerable number of cases were investigated and compared with those of normal children.

METHODS

A total of 1150 normal babies were examined during routine nonmedical circumcision, and another 750 boys referred with hypospadias were examined during the previous 3 years. All patients were evaluated and assessed for the size, location, and configuration of the urinary meatus, and penile length and girth were measured. Children with normal size and location of the meatus were considered control group A, and 42 cases of different forms of megameatus were considered group B. Other penoscrotal, urinary, and general anomalies were examined and investigated accordingly. All data were analyzed by the SPSS 9.0.1 statistical package and compared by paired t tests.

RESULTS

Forty-two uncircumcised patients aged from 1 month to 4 years (mean 18 months) were diagnosed with a urinary meatus that engrossed the whole ventral or dorsal aspects of the glans, exceeding half the width of the glans or penile girth with the complete vanishing of the glans closure in most cases. Megameatus is usually associated with the abnormal meatal position as hypospadiac, orthotopic, or epispadic. Additionally, megameatus may be associated with a normally intact or deficient prepuce. Consequently, we had four categories of megameatus, and the intact prepuce orthotopic megameatus subcategory has not been described before. Megameatus was also detected with deficient prepuce, and this was considered a hypospadiac variant.

CONCLUSION

Megameatus is diagnosed precisely with penile biometry and is classified into 4 groups: hypospadiac, epispadic, and orthotopic or central, either with or without intact prepuce. This classification is applicable for expansion to other centers.

Age-dependent early complications of hypospadias repair: a single institutional experience

PURPOSE

To correlate age at hypospadias repair with early post-operative complications and highlight need for adaptation to post-operative care in older children.

METHODS

Anecdotal evidence suggests boys with delayed surgery for hypospadias suffer increased rates of early post-operative complication. Hence, a retrospective analysis was conducted of all patients undergoing hypospadias repair between March 2019 and 2022.

RESULTS

Ninety eight patients were divided into Group A (< 2years of age at first surgery) or Group B (> 2years). While patients in Group A encountered no early post-operative complications, seven in Group B (11%) suffered a range of complications including dislodged stents (3/7), significant spasmodic pain requiring prolonged hospital stay (2/7) and urinary retention (2/7). More than half of these children required emergency supra-pubic catheter insertion.

CONCLUSION

Significantly more children undergoing hypospadias surgery after the age of 2 years suffered complications within the early post-operative period. This resulted in prolonged hospital stays and a number returning to theatre for insertion of a supra-pubic catheter. We recommend a tailored approach to the post-operative care of older children undergoing hypospadias repair, including strict parental education regarding dressing/stent care and medication compliance, as well as efforts to enhance robustness of dressings and stent anchorage in children likely to pull at stents.

Hypospadias: lessons learned. An overview of incidence, epidemiology, surgery, research, complications, and outcomes

Hypospadias is a common condition and familiar, though sometimes challenging territory for the pediatric urologist. This review is a summary of hypospadias incidence, epidemiology, surgery, research, and complications intended for the non-specialist. It outlines the history, the principles of surgery for hypospadias, and the long-term outcomes.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

INTRODUCTION & OBJECTIVE

The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events.

METHODS

A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed.

RESULTS

1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p = 0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p = 0.009). There was no difference in unplanned encounters across repair types (p = 0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter.

DISCUSSION

The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution.

CONCLUSIONS

The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

Engineered human organ-specific urethra as a functional substitute

Urologic patients may be affected by pathologies requiring surgical reconstruction to re-establish a normal function. The lack of autologous tissues to reconstruct the urethra led clinicians toward new solutions, such as tissue engineering. Tridimensional tissues were produced and characterized from a clinical perspective. The balance was optimized between increasing the mechanical resistance of urethral-engineered tissue and preserving the urothelium's barrier function, essential to avoid urine extravasation and subsequent inflammation and fibrosis. The substitutes produced using a mix of vesical (VF) and dermal fibroblasts (DF) in either 90%:10% or 80%:20% showed mechanical resistance values comparable to human native bladder tissue while maintaining functionality. The presence of mature urothelium markers such as uroplakins and tight junctions were documented. All substitutes showed similar histological features except for the noticeable decrease in polysaccharide globules for the substitutes made with a higher proportion of DF. The degree of maturation evaluated with electron microscopy was positively correlated with the increased concentration of VF in the stroma. Substitutes produced with VF and at least 10% of DF showed sufficient mechanical resistance to withstand surgeon manipulation and high functionality, which may improve long-term patients' quality of life, representing a great future alternative to current treatments.

Automated quantification of penile curvature using artificial intelligence

Objective

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

Materials and methods

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

Results

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

Conclusions

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

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

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

Clinical characteristics, socioeconomic factors and COVID-19 were associated with delayed surgery in children with hypospadias: a retrospective study of 4439 cases in a single center

BACKGROUND

Hypospadias is one of the most common congenital diseases of the genitourinary system in children. The European Association of Urology (EAU) Guidelines recommend that children undergoing hypospadias surgery should be between 6 and 18 months. In China, where many children have hypospadias, it remains unknown whether clinical characteristics, socioeconomic factors and COVID-19 were associated with delayed surgery in children with hypospadias.

METHODS

We retrospectively analyzed children with hypospadias who underwent primary surgery at the Department of Pediatric Urology in Guangzhou Women and Children's Medical Center between January 2010 and October 2021. Patients who had two-stage surgery or a second round of surgery due to complications were excluded to eliminate data duplication. The clinical characteristics and demographic information were collected. We defined delayed surgery as primary surgery performed after 18 months following the EAU Guidelines.

RESULTS

A total of 4439 children diagnosed with hypospadias were included in the study. The median age (29.1 ± 16.7 months) of surgery for hypospadias in our study was much higher than the recommended age reported in the EAU guidelines, and 76.6% of the children underwent surgery after the age of 18 months. Children without comorbidities including cryptorchidism (odds ratio [OR] = 1.562; 95% confidence interval [CI] 1.199-2.034; p = 0.001), prostatic cyst (OR = 2.613; 95% CI 1.579-4.324; p < 0.001), penile hypoplasia (OR = 1.778; 95% CI 1.225-2.580; p = 0.002), inguinal hernia (OR = 2.070; 95% CI 1.394-3.075; p < 0.001), and penoscrotal transposition (OR = 4.125; 95% CI 1.250-13.619; p = 0.020) were more likely to receive delayed surgery. Living in a low economic area (OR = 1.731; 95% CI 1.068-2.806; p = 0.026) or not close to a main medical center (OR = 1.580; 95% CI 1.370-1.824; p < 0.001) was highly associated with delayed surgery. The proportion of children undergoing delayed surgery and the median age of surgery during the COVID-19 pandemic were significantly higher than those before the COVID-19 pandemic (p = 0.004 and < 0.001, respectively).

CONCLUSIONS

Most children with hypospadias received delayed surgery (surgical age > 18 months). Comorbidities, living in a low economic area, too far from a main medical center and the COVID-19 pandemic were highly associated with delayed surgery. It is vital to improve the public awareness of hypospadias and strengthen the re-education of primary community doctors to reduce delayed surgery.

Challenges in diagnosis and management of perineal hypospadias with a testicular seminoma mimicking paratesticular tumor in a solitary testis: A case report

Diagnosing and managing perineal hypospadias in patient with a suspected paratesticular seminoma in a solitary testis may be challenging. We describe a case of 26-year-old male presented with painless left scrotal swelling with hypospadias and chordee. The patient underwent two-staged surgery: chordectomy and open inguinal testicular biopsy followed by urethroplasty and radical orchidectomy.

The use of tissue sealant in reducing urethrocutaneous fistula event following hypospadias repair: A systematic review and meta-analysis

Background

One of the most frequent complications following hypospadias repair is urethrocutaneous fistula (UCF) event. Tissue sealant has been introduced as a means to reduce UCF. However, reports regarding its benefits are varied. Thus, we initiated a systematic review and meta-analysis to investigate its role in reducing UCF following hypospadias repair.

Methods

We completed a systematic search through the Embase, MEDLINE, and Scopus databases for studies assessing postoperative complications in hypospadias patients undergoing urethroplasty with and without tissue sealant. Cochrane risk of bias 2 (RoB 2) tool was used to assess the quality of randomized clinical trials (RCTs), while the observational studies were assessed with Newcastle-Ottawa Scale. The primary outcome analyzed in this study was UCF, while secondary outcomes consisted of postoperative complications such as edema, infection, and wound dehiscence that increases the risk of UCF formation, measured using odds ratio (OR) with a 95% confidence interval (CI).

Results

Six eligible studies comprising three RCTs and three non-randomized studies were included. Patients undergoing hypospadias repair with tissue sealant had lower UCF events (OR = 3.27; 95% CI 1.92–5.58; p < 0.0001). Likewise other post-operative complications, tissue sealant group had a lower rate of edema (OR = 2.29; 95% CI 1.38–3.78; p = 0.001) and infection (OR = 3.87; 95% CI 1.55–9.70; p = 0.004). The difference in wound dehiscence was insignificant between the groups (OR = 2.08; 95% CI 0.21–20.55; p = 0.53).

Conclusion

Tissue sealant can reduce UCF events following hypospadias repair as well as edema and infection that increases the risk of UCF formation.

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Tissue sealant can reduce UCF events following hypospadias repair.

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Edema and infection increase the risk of UCF formation.

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Tissue sealant provides a watertight surgical anastomosis right after application.

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Tissue sealant can resist hydrostatic pressure of urine at the surgical suture line.

Do the materials matter? A review of the literature and analysis of the materials properties of urethral stents for hypospadias repair

INTRODUCTION

Despite the prevalence of hypospadias surgery and the common use of postoperative urethral stents, there has been no evaluation of the material properties of common stents. Our study sets out to close this gap with a literature review of recent publications comparing outcomes after hypospadias surgery for different urethral stent types and an evaluation of the material properties of four common urethral stents.

STUDY DESIGN

A review of the English language literature from 2011 to 2021 was performed. Thermal analysis and mechanical analysis of the Zaontz Urethral Stent, the Firlit-Kluge Urethral Stent, the Koyle Diaper Stent, and the Bard Premature Infant Feeding Tube was also undertaken.

RESULTS

Out of 165 papers, four met inclusion criteria. There was limited research on this topic, and no significant evidence that different stent materials impacted surgical complication rates. One study found improved comfort with the Zaontz stent, and another found a reduction emergency room visits with the Koyle stent. Using a foley balloon was associated with increased fistula rates, though this was likely due to the balloon design and not the material. Analysis of stents shows that all four are rubbery polymers at body temperature (Summary Table). The Zaontz and Koyle stents are thermoplastic elastomers with strong melting transitions above body temperature, but the Firlit-Kluge stent is amorphous at 37 °C and is likely covalently cross-linked to generate the network. The Bard feeding tube was the stiffest, with a Young's Modulus of 14.0 ± 0.78 (compared to 4.12 ± 0.56 for Zaontz, 4.92 ± 0.63 for Firlit-Kluge, and 4.09 ± 0.49 for Koyle). The Bard Feeding Tube is also the least extensible, fracturing at just over 300% strain compared to the other stents that can be stretched to greater than 2000% strain before fracture. Cyclic deformation studies demonstrate that the Zaontz, Firlit-Kluge, and Koyle stents are able to stretch and recover their shape more completely, a finding determined by the lower amount of plastic deformation those stents display compared to the Bard Feeding Tube.

DISCUSSION

While there is little information associating urethral stent type with outcomes after hypospadias surgery, material properties may account for findings of prior studies. Stiffer stents may contribute to decreased postoperative comfort, while a stent that is too soft and extensible may have issues with dislodgement, kinking and breaking.

CONCLUSION

This study provides the foundation for future work optimizing urethral stents, designing support for regenerative medicine applications, and improving hypospadias outcomes.

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

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative Study of Modifying Meatal Advancement Glandular with Release Chordi versus Snodgrass Surgical Methods Regarding the Repair of Distal Hypospadias

BACKGROUND

Hypospadias is one of the most common congenital anomalies of the external genitalia of boys. No single technique can be recommended for the repair of hypospadias in its various forms. We aimed to compare modify meatal advancement glandular with release chordi versus Snodgrass surgical methods in the repair of distal hypospadias.

METHODS

In this study, conducted from Apr 2018 to the end of Sep 2020, all boys who underwent one of the two methods of Snodgrass and modify meatal advancement glanuplasty with release chordi in Imam Khomeini and Abuzar Hospitals of Ahvaz, Southern Iran, were enrolled.

RESULTS

Forty-five patients underwent Snodgrass (group S) and 55 patients underwent modified meatal advancement glandular with release chordi (group M). The mean age of patients and duration of surgical wound healing in the two groups did not differ significantly. There was no significant difference between the two groups in terms of complications, including Bleeding, Hematoma, Meatus stricture, Wound infection, detachment of the wound edge, chordi after surgery, Balanitis and Urethral stricture but the incidence of fistula in patients undergoing Snodgrass repair was significantly higher than the group modify meatal advancement glandular with release chordi (P<0.05).

CONCLUSION

The method of modify meatal advancement glandular with release chordi compared to Snodgrass method is associated with fewer complications due to surgery, although further studies are recommended.

Hypospadias: clinical approach, surgical technique and long-term outcome

Background

Hypospadias is one of the most common congenital abnormalities in male newborn. There is no universal approach to hypospadias surgical repair, with more than 300 corrective procedures described in current literature. The reoperation rate within 6–12 months of the initial surgery is most frequently used as an outcome measure. These short-term outcomes may not reflect those encountered in adolescence and adult life. This study aims to identify the long-term cosmetic, functional and psychosexual outcomes.

Methods

Medical records of boys who had undergone surgical repair of hypospadias by a single surgical team led by the same surgeon at a single centre between August 2001 and December 2017 were reviewed. Families were contacted by telephone and invited to participate. Surgical outcome was assessed by combination of clinical examination, a life-related interview and 3 validated questionnaires (the Penile Perception Score-PPS, the Hypospadias Objective Score Evaluation-HOSE, the International Index of Erectile Function-5-IIEF5). Outcomes were compared according to age, severity of hypospadias, and respondent (child, parent and surgeon).

Results

187 children and their families agreed to participate in the study. 46 patients (24.6%) presented at least one complication after the repair, with a median elapsed time of 11.5 months (6.5–22.5). Longitudinal differences in surgical corrective procedures (p < 0.01), clinical approach (p < 0.01), hospitalisation after surgery (p < 0.01) were found. Cosmetic data from the PPS were similar among children and parents, with no significant differences in child’s age or the type of hypospadias: 83% of children and 87% of parents were satisfied with the cosmetic result. A significant difference in functional outcome related to the type of hypospadias was reflected responses to HOSE amongst all groups of respondents: children (p < 0.001), parents (p=0.02) and surgeon (p < 0.01). The child’s HOSE total score was consistently lower than the surgeon (p < 0.01). The HOSE satisfaction rate on functional outcome was 89% for child and 92% for parent respondents.

Conclusion

Surgeons and clinicians should be cognizant of the long-term outcomes following hypospadias surgical repair and this should be reflected in a demand for a standardised approach to repair and follow-up.

Evaluating the literature on preoperative androgen stimulation for hypospadias repair using the fragility index - can we trust observational studies?

BACKGROUND

Preoperative androgen stimulation (PAS) is typically used in hypospadias repair for patients with a proximal meatus or small glans size. Hypospadias PAS literature suffer from small sample sizes and lack of power to claim robust conclusions. Small changes in the number of events may completely change the statistical significance, making the conclusions drawn unreliable. Fragility index (FI) is the number of additional events needed to occur in either the control or experimental group to turn a statistically significant result to a non-significant result. The objective of the report was to assess the quality of available literature revolving around PAS use in hypospadias repair and its effects on post-operative complication rates using FI.

METHODS

A comprehensive search of MEDLINE, EMBASE, and grey literature (ESPU and SPU abstracts) was conducted to identify RCTs and observational studies investigating the effect of PAS on complications post-hypospadias repair between 1990 and 2020. The FI was calculated for each study. Postoperative complications were defined as: fistula, stricture/stenosis, diverticula, and dehiscence. The odds ratio (OR), 95% confidence intervals (CI), corresponding p-values was calculated for each study. A random effects mixed model was implemented to combine the ORs for each study design.

RESULTS

Fourteen studies qualified for inclusion, of which nine were observational studies and five were RCTs (Figure 1). The median sample size was 110 patients (IQR 69-171). The summary ORs for observational studies was 1.74 (95% CI: 1.10 to 2.74; p = 0.020) and for RCTs was 0.71 (9% CI: 0.34 to 1.47; p = 0.350). The median FI was 0 (IQR 0-2) of the included studies.

DISCUSSION

PAS use does not appear to significantly affect complication rates shown in RCTs, however, observational studies cumulatively suggested significantly greater odds of complications after PAS. The FI is best used for RCTs with 1-to-1 randomization and binary data. Observational studies are rarely balanced for demographics and comorbidities with unequal sample size between comparable groups. The study was limited by substantial variability in how PAS was delivered to patients, leading to restricted comparability.

CONCLUSION

Strong conclusions regarding the influence of PAS on hypospadias repair outcomes cannot be properly drawn based on the current literature due to deficits from either a statistical or methodological standpoint. The current PAS literature has shown inconclusive results, calling for well-designed RCTs, involving standardized surgical techniques and PAS protocols, to evaluate the true effect of PAS on complications post-hypospadias repair.

Parental decisional regret after surgical treatment in young boys born with hypospadias

BACKGROUND/PURPOSE

Parental decisional conflict and decisional regret are aspects in parental adjustment to childhood elective surgery. This study assessed correlates of parental decisional regret in parents of young boys treated for hypospadias.

METHODS

Parents of 261 boys treated for hypospadias at the Radboudumc between 2006 and 2014 were approached to complete questionnaires on socio-demographics, clinical details, postoperative outcomes, decisional conflict and decisional regret.

RESULTS

Of the 97 participating parents, 50.5% reported some form of decisional regret, in 11.3% this was moderate to strong. Decisional conflict (β = .68, p < .001) and psychosocial behavior problems of the child (β = .20, p < .05) significantly predicted decisional regret. Demographic and medical variables did not correlate with parental decisional regret.

CONCLUSIONS

A substantial number of parents report some form of decisional regret regarding the elective surgery for hypospadias in their child. Although most parents only show mild forms of regret, in the perspective of discussions on this surgery in early childhood, future research could shed more light on the interrelationship between medical and psychosocial factors in the process of decision-making around surgery, in boys with hypospadias and their parents.

Assessment of the Educational Value of Distal Hypospadias Repair Videos on YouTube

OBJECTIVE

To evaluate the quality of YouTube videos depicting distal hypospadias repair.

METHODS

The search terms "distal hypospadias repair" were used to identify surgical videos on YouTube. Videos were sorted by view count and the top 34 videos were reviewed for baseline video characteristics, key surgical steps covered, and conformity to a modified LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) checklist. All videos were reviewed and discussed for conformity by 2 attending pediatric urologists and a urology resident.

RESULTS

Of the 34 videos reviewed, 16 videos were excluded due to content. The median length of videos was 9.94 minutes (range, 2.57-99.12 minutes). Video quality was deemed of high quality in only 39% of videos. The most common type of hypospadias procedures described were tubularized incised plate urethroplasty (n = 13) and meatal advancement and glanuloplasty incorporated (n = 2). The median view count was 7828.5 (range, 1,133-58,619 views). Only 1 video met all modified LAP-VEGaS criteria (range of 33%-100%), and only 2 videos showed every surgical step of distal hypospadias repair (range 33%-100%). Modified LAP-VEGaS score, surgical step score, or quality of the video was not associated with a higher view count.

CONCLUSION

Despite being a common procedure, there is a paucity of high-quality videos on YouTube describing distal hypospadias repair techniques. It is unclear how learners select videos for study purposes and the most utilized videos on YouTube are not the most educational videos.

AK, Pennisi CP. Quality of Reporting in Preclinical Urethral Tissue Engineering Studies: A Systematic Review to Assess Adherence to the ARRIVE Guidelines

Preclinical research within the area of urethral tissue engineering has not yet been successfully translated into an efficient therapeutic option for patients. This gap could be attributed, in part, to inadequate design and reporting of the studies employing laboratory animals. In this study, a systematic review was conducted to investigate the quality of reporting in preclinical studies utilizing tissue engineering approaches for urethral repair. The scope was on studies performed in rabbits, published between January 2014 and March 2020. Quality assessment of the data was conducted according to the Animal Research: Reporting of in Vivo Experiments (ARRIVE) guidelines by the scoring of a 38-item checklist in different categories. A total of 28 articles that fulfilled the eligibility criteria were included in the study. The range of ARRIVE score was from 0 to 100, taking into consideration having reported the item in question or not. The mean checklist score was 53%. The items that attained the highest scores included the number of animals utilized, the size of control and experimental groups, and the definition of experimental outcomes. The least frequently reported items included the data regarding the experimental procedure, housing and husbandry, determination and justification of the number of animals, and reporting of adverse events. Surprisingly, full disclosure about ethical guidelines and animal protocol approval was missing in 54% of the studies. No paper stated the sample size estimation. Overall, our study found that a large number of studies display inadequate reporting of fundamental information and that the quality of reporting improved marginally over the study period. We encourage a comprehensive implementation of the ARRIVE guidelines in animal studies exploring tissue engineering for urethral repair, not only to facilitate effective translation of preclinical research findings into clinical therapies, but also to ensure compliance with ethical principles and to minimize unnecessary animal studies.

Genitourinary Tissue Engineering: Reconstruction and Research Models

Tissue engineering is an emerging field of research that initially aimed to produce 3D tissues to bypass the lack of adequate tissues for the repair or replacement of deficient organs. The basis of tissue engineering protocols is to create scaffolds, which can have a synthetic or natural origin, seeded or not with cells. At the same time, more and more studies have indicated the low clinic translation rate of research realised using standard cell culture conditions, i.e., cells on plastic surfaces or using animal models that are too different from humans. New models are needed to mimic the 3D organisation of tissue and the cells themselves and the interaction between cells and the extracellular matrix. In this regard, urology and gynaecology fields are of particular interest. The urethra and vagina can be sites suffering from many pathologies without currently adequate treatment options. Due to the specific organisation of the human urethral/bladder and vaginal epithelium, current research models remain poorly representative. In this review, the anatomy, the current pathologies, and the treatments will be described before focusing on producing tissues and research models using tissue engineering. An emphasis is made on the self-assembly approach, which allows tissue production without the need for biomaterials.

Individualized care for patients with intersex (differences of sex development): part 4/5.Considering the Ifs, Whens, and Whats regarding sexual-reproductive system surgery

Issues and concerns regarding surgery of the sexual-reproductive anatomy during infancy and early childhood are discussed using four actual examples. A case of a 46, XX infant with 21 hydroxylase deficiency congenital adrenal hyperplasia (CAH) with atypical (ambiguous) genitalia is discussed regarding timing and potential harms and benefits of surgery. We present the perspective of balancing the child's rights to bodily autonomy and right to an open future versus parents' decision making authority regarding what they perceive as their child's future best interests. The second case is a newborn with complete androgen insensitivity syndrome and we discuss the harms, benefits and timing of gonadectomy. The third case examines the physical and psychological impact of penile shaft hypospadias, raising the question of whether surgery is justified to prevent what may or may not be considered a permanent disability. The fourth case involves an adult woman with classic CAH, born with a urogenital sinus and clitoromegaly, who never had genital surgery and is now requesting vaginoplasty, but not clitoral reduction. The primary message of this article, as the previous articles in this series, is to encourage patient-family centered care that individualizes treatment guided by shared decision making.

Urethral plate quality assessment and its impact on hypospadias repair outcomes: A systematic review and quality assessment

BACKGROUND

The variability of the urethral plate (UP) characteristics is one of the factors that influence technical choices for hypospadias correction. However, it is difficult to objectively evaluate the UP, leading to controversies in this subject, and vague terms utilized in the literature to describe its characteristics.

OBJECTIVE

We aim to analyze the previously described methods used to characterize and evaluate UP quality, emphasizing the pros and cons of each system, and highlighting its possible influence on different postoperative outcomes.

METHODS

We searched the databases PubMed, Embase, and Cochrane Library CENTRAL from January 1, 2000 to August 20, 2020. The following concepts were searched: urethra reconstruction/urethra replacement/urethroplasty AND hypospadias/hypospadias, AND children AND "plate" with the gray literature search. Subgroup analyses were also carried out. The quality of the involved studies was reviewed operating a modified version of the Newcastle-Ottawa Scale (NOS).

RESULTS

996 citations perceived as relevant to screening were retrieved. Thirteen studies were included comprising a total of 1552 cases. The number of patients in each study varied between 42 and 442, and the average post-surgical follow-up duration ranged between 6 months and twenty-six months. All studies used postoperative urethral stents of variable sizes and types. The impact of UP was most frequently assessed for cases treated with the tubularized incised plate (TIP) repair.

CONCLUSION

The UP quality seems to play a role as an independent factor influencing postoperative outcomes of hypospadias repair. Currently used strategies for the appraisal of UP quality are highly subjective with a low index of generalizability. Various attempts to overcome these limitations exist but none was consistently accepted, leaving a wide space for creative investigation in order to obtain an objective, reproducible, precise, and well-validated tool.

Outcome of Buck’s fascia repair with wingless glanuloplasty in distal penile hypospadias

Background

Hypospadias surgery is technically demanding and is often encountered with complications like fistula and glanular dehiscence. To prevent these complications we have instituted Buck’s fascia repair (BFR) with wingless glanuloplasty (WLP) in the cases of distal penile hypospadias (DPH) deemed to be suitable for TIP repair. The aim of this prospective study was to assess the outcome of Buck’s fascia repair (BFR) with minimal wingless glanuloplasty (WGP).

Methods

This prospective study included 50 patients with coronal, subcoronal and midpenile hypospadias who received a tubularization of incised plate (TIP) repair. The exclusion criteria were glanular hypospadias, Thiersch Duplay repair, proximal penile hypospadias, previous penile surgeries, uncorrectable chordee, glans size < 14 mm, flat glanular groove and preoperative testosterone therapy.

Results

Over a period of 3 years, 50 patients with mean age of 3.5 ± 0.8 years were recruited for the study. Meatal position was coronal, subcoronal and midpenile in 6, 24 and 20 patients, respectively. Fistula occurred in one patient (2%) and meatal stenosis in one. Straining on micturition was noted in two patients that needed dilatation in postoperative period. None of the patients had glanular dehiscence. Surgeon acceptability of the procedure was good. Cosmetic results were also fair.

Conclusion

Buck’s fascia repair with Wingless glanuloplasty is a good repair for the distal penile hypospadias. It is effective and is associated with low fistula rates and glanular dehiscence. It is technically simple procedure involving minimal dissection. However, caution should be observed in midpenile hypospadias to avoid tight repair in subcoronal region.

Time to event analysis for post-hypospadias repair complications: a single-surgeon experience

OBJECTIVE

The optimal follow-up duration and frequency following hypospadias repair is unclear within the pediatric urology community. This analysis aims to delineate the time to various complications following primary hypospadias repairs.

MATERIALS AND METHODS

A retrospective review of a single-surgeon hypospadias database over 2001-2017 was performed. The primary outcome of the study was determining the significant factors leading to complications over time. As a secondary outcome, subgroup analysis was performed to determine whether there was a significant difference in time to detecting voiding-related complications (fistula, stricture/stenosis, and diverticulum) based on age.

RESULTS

Eight hundred and thirty-two patients were identified. The complication rates for distal, midshaft, and proximal hypospadias were 17.9% (112/625), 36.7% (40/109), and 55.1% (49/89), respectively (p < 0.0001). Survival analysis using Kaplan-Meier curves showed significance in three variables for time to complication: hypospadias severity (p < 0.0001), technique (p < 0.0001), and penile curvature > 30° (p < 0.0001). Cox-regression analysis showed that hypospadias severity and penile curvature were significantly contributing to the model (p < 0.0001, p = 0.044). Patients with proximal hypospadias and penile curvature developed complications earlier than other patients, with approximately 95% of complications occurring within 2 years.

CONCLUSIONS

Complications from repair of proximal hypospadias with curvature > 30° are likely to occur within 2 years of surgery. Surgeons may consider more frequent follow-up within the first 2 years of surgery to detect these complications.

Reconstruction of Vascular and Urologic Tubular Grafts by Tissue Engineering

Tissue engineering is one of the most promising scientific breakthroughs of the late 20th century. Its objective is to produce in vitro tissues or organs to repair and replace damaged ones using various techniques, biomaterials, and cells. Tissue engineering emerged to substitute the use of native autologous tissues, whose quantities are sometimes insufficient to correct the most severe pathologies. Indeed, the patient’s health status, regulations, or fibrotic scars at the site of the initial biopsy limit their availability, especially to treat recurrence. This new technology relies on the use of biomaterials to create scaffolds on which the patient’s cells can be seeded. This review focuses on the reconstruction, by tissue engineering, of two types of tissue with tubular structures: vascular and urological grafts. The emphasis is on self-assembly methods which allow the production of tissue/organ substitute without the use of exogenous material, with the patient’s cells producing their own scaffold. These continuously improved techniques, which allow rapid graft integration without immune rejection in the treatment of severely burned patients, give hope that similar results will be observed in the vascular and urological fields.

Prenatal Diagnosis and Classification of Fetal Hypospadias: The Role and Value of Magnetic Resonance Imaging

BACKGROUND

Prenatal diagnosis and classification of hypospadias are difficult and of value for management during perinatal and neonatal periods. The conventional approach for prenatal diagnosis of hypospadias is ultrasound; however, this technique may be inconclusive in certain cases, which prompts for further exploration with magnetic resonance imaging (MRI).

PURPOSE

To investigate the role of MRI in the prenatal diagnosis and classification of fetuses with hypospadias.

STUDY TYPE

Retrospective.

POPULATION

Thirty-five fetuses (median gestational age = 37, range 24-39 weeks) with possible hypospadias.

FIELD STRENGTH/SEQUENCE

Single-shot fast spin echo T2-weighted imaging, fast imaging employing steady-state acquisition (FIESTA), and three-dimensional FIESTA acquired at 1.5 T.

ASSESSMENT

Diagnosis and classification of hypospadias using MRI were performed by three experienced radiologists based on MRI features, including a short penile shaft, abnormal penile tip, penile curvature, bifid scrotum, "tulip sign," and penoscrotal transposition. The accuracy of MRI in the diagnosis and classification of hypospadias was assessed in comparison to postnatal clinical diagnosis. The interobserver agreement between radiologists was also assessed.

STATISTICAL TESTS

Kendall's W test was applied to assess the interobserver agreement between radiologists. Taking postnatal clinical diagnosis as the reference standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated.

RESULTS

Of the 35 fetuses, 24 cases were confirmed as hypospadias through postnatal clinical diagnosis. The interobserver agreement between radiologists was substantial (Kendall's W = 0.781, P < 0.001). Of the 24 confirmed cases (13 cases of severe hypospadias and 11 cases of mild hypospadias), 22 cases were correctly diagnosed by MRI. The accuracy of MRI in the diagnosis of hypospadias, severe hypospadias, and mild hypospadias was 85.71%, 82.86%, and 80.00%, respectively.

DATA CONCLUSION

MRI has good performance in the diagnosis of fetal hypospadias. In addition, MRI could help evaluate the severity of fetal hypospadias.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Multivariate analysis of early surgical management factors affecting posttraumatic penoscrotal avulsion injury: a level I trauma center study

Background

To conduct an accurate evaluation of patients presenting with posttraumatic penoscrotal injuries, and to formulate a treatment algorithm based on this assessment.

Methods

We conducted a retrospective chart review study. Patients with penoscrotal defects admitted to our level I trauma center from 2017 to 2019 were evaluated. The Braden scale score was used for wound evaluation and the Korean patient classification system (KPCS) was used for assessment of severity. Univariate and multivariate analyses were performed for potential risk factors associated with early surgical management.

Results

In total, there were 58 male patients, and the average Braden scale score was 12.08 ± 2.54, with the scrotum (36.20%), and the penile shaft (32.76%) being popular sites for injuries. The wounds requiring surgical treatment were 20.68% (n = 12), with local flaps (33.33%) being most commonly used. The significant predictors of advanced wounds which required surgical treatment were old age (p = 0.026, odds ratio [OR] 8.238), orthopedic combined injuries (p = 0.044, OR 1.088), intubation (p = 0.018, OR 9.625), restraint (p = 0.036, OR 0.157) and blood transfusion (p < 0.001, OR 2.462).

Conclusion

In multiple trauma patients, penoscrotal defects caused by high-speed trauma are an important matter of concern. Specifically, patients with combined skeletal injuries or requiring respiratory care were prone to advanced wounds. We proposed a five-category algorithm to manage such patients, which included severity of the patient’s condition, respiration, hemodynamic status, comorbidity, and immobilization. Additionally, inter-departmental cooperation and active intervention by plastic surgeons is needed for the comprehensive treatment of such injuries.

Trial registration This study was performed in line with the principles of the Declaration of Helsinki. The study and all its protocols were approved by the institutional review board of Ajou Medical Center (approval no. AJIRB-MED-MDB-17-254). The need for informed consent was waived by the institutional review board of our hospital due to the retrospective design of the study.

The burden of waiting: wait times for pediatric surgical procedures in Quebec and compliance with national benchmarks

Background

Wait time information and compliance with national guidelines are limited to a few adult conditions in the province of Quebec. We aimed to assess compliance with Paediatric Canadian Access Targets for Surgery (P-CATS) guidelines and determine the burden incurred due to waiting for 3 common elective surgical conditions (inguinal hernia, cryptorchidism and hypospadias) in a pediatric population.

Methods

We carried out a population-based retrospective cohort study of randomly selected children residing in Quebec without complex chronic medical conditions, using administrative databases belonging to the Régie de l’assurance maladie du Québec for the period 2010–2013. Disability-adjusted life years (DALYs) were calculated to measure the burden due to waiting. Multivariate forward regression identified risk factors for compliance with national guidelines.

Results

Surgical wait time information was assessed for 1515 patients, and specialist referral wait time was assessed for 1389 patients. Compliance with P-CATS benchmarks was 76.6% for seeing a specialist and 60.7% for receiving surgery. Regression analysis identified older age (p < 0.0001) and referring physician specialty (p = 0.001) as risk factors affecting specialist referral wait time target compliance, whereas older age (p = 0.040), referring physician specialty (p = 0.043) and surgeon specialty (p = 0.002) were significant determinants in surgical wait time compliance. The total burden accrued due to waiting beyond benchmarks was 35 DALYs.

Conclusion

Our results show that provincial compliance rates with wait time benchmarks are still inadequate and need improvement. Patient age and physician specialty were both found to have significant effects on wait time target compliance.

Preclinical Experiments for Hypospadias Surgery: Systematic Review and Quality Assessment

Background: There is a steadily growing number of different reconstructive surgical procedures for hypospadias that were tested on animal models prior to their human application. However, the clinical translatability and reproducibility of the results encountered in preclinical urethral reconstruction experiments is considered poor, with significant factors contributing to the poor design and reporting of animal experiments. Our objective was to evaluate the quality of the design and reporting in published articles of urethral reconstructive preclinical studies. Methods: Both PubMed and EMBASE databases were searched for animal urethral repair experiments between January 2014 and September 2019. Internal quality (bias) was evaluated through several signaling questions arising from the Systematic Review Centre for Laboratory animal Experimentation (SYRCLE), while the quality of reporting was assessed by the Animal Research: Reporting of In vivo Experiments (ARRIVE) guidelines by scoring of a 20-item checklist. Results: A total of 638 articles were initially screened after the literature search. Employing the inclusion and exclusion criteria, 30 studies were chosen for full-text screening and 21 studies were considered eligible for the quality assessment. The mean score of the checklist was 66%. The elements that accomplished the highest grades included the number of animals utilized, the number in each investigational and control group, and the delineation of investigational conclusions. The items that were least commonly stated comprised information about the experimental method, housing and husbandry, rationalization of the number of animals, and reporting of adverse events. No paper stated the sample size estimation. Conclusion: We found that several critical experiment design principles were poorly reported, which hinders a rigorous appraisal of the scientific quality and reproducibility of the experiments. A comprehensive implementation of the ARRIVE guidelines in animal studies exploring urethral repair is necessary to facilitate the effective translation of preclinical research findings into clinical therapies.

Dorsal midline incision: A versatile technique for correction of meatal stenosis during hypospadias repair

Objectives:

To our knowledge, the incidence of congenital meatal abnormalities associated with hypospadias varies from 9.6% to 31%, of which meatal stenosis is the most common, affecting 9.1–16.7% of patients. Traditionally, meatal stenosis has been dealt with by meatal dilatation, although ventral meatotomy until the normal urethra is encountered has also been used. Here, we report the outcome of a technique where, during hypospadias repair, a dorsal midline incision was performed instead of a ventral urethral incision, starting at the narrow meatus and subsequently extending proximally to treat the meatal stenosis.

Methods:

Patients having distal hypospadias with meatal stenosis were included in this study. In this technique, a dorsal midline incision was extended until normal calibre urethra was encountered. Patients with chordee >15°, proximal hypospadias, redo cases, glans width <14 mm, where separation of the skin from the underlying urethra was not possible and with a follow-up of less than three months were excluded from the study. A total of 73 patients were operated on using this technique. Results were assessed with regards to urethrocutaneous fistula (UCF) and stricture formation.

Results:

Five (6.85%) patients developed UCF: one (5%) in the subcoronal group, two (8.0%) in the distal penile group and two (14.3%) in the mid-penile hypospadias group. Postoperatively, only one patient had meatal stenosis.

Conclusion:

We think hypospadiac meatal stenosis is best treated by a dorsal midline incision, as it does not lead to a proximal shift of the meatus, and this defect heals by re-epithelisation without significant scarring, which in turn decreases the possibility of UCF. That is why the fistula rate in our study was 6.85%, which is lower than in various published series.

Use of dCELL (Decellularized Human Dermis) in Repair of Urethrocutaneous Fistulas or Glans Dehiscence

Background

In hypospadias repairs, there is some evidence to suggest that a "waterproofing" layer can be helpful in reducing the risk of urethrocutaneous fistula formation. The most likely role of this layer is to prevent the creation of overlapping suture lines. Many hypospadias surgeons use a dartos fascia interposition flap for this purpose. However, raising a dartos fascia flap adds time to the procedure, can result in devascularization of the overlying skin, and can create unsightly torsion of the penis, which may be hard to correct. To avoid these problems, the senior author has started to use dCELL (decellularized human dermis) as an alternative to dartos fascia to separate the suture lines.

Methods

Between March and July 2018, a pilot study was performed in 8 patients undergoing closure of a urethrocutaneous fistula or glans dehiscence combined with dCELL. Data on infections, wound breakdown, length of stay and catheterization, surgical time, and hospital stay were collected.

Results

All patients had a successful reconstruction. One patient developed a urinary tract infection, possibly related to prolonged catheterization following his repair.

Conclusion

Our results suggest that dCELL may be useful in the repair of urethrocutaneous fistulas and glans dehiscence after hypospadias surgery.