30th ESPU Congress - Lyon, France - 2019

S12: HYPOSPADIAS

Moderators: Pierre Mouriquand (France), Ashraf Hafez (Egypt)

ESPU Meeting on Friday 26, April 2019, 09:08 - 10:14


09:08 - 09:11
S12-1 (PP)

★ SNODGRASS VERSUS SNODGRAFT OPERATION TO REPAIR THE DISTAL AND MIDPENILE HYPOSPADIAS IN THE NARROW URETHRAL PLATE

Salah NAGLA 1, Mosaab ALDEEB 1, Mohamed ABO FARHA 2 and Ayman HASSAN 2
1) Tanta University, Urology, Tanta, EGYPT - 2) Tanta University, Tanta, EGYPT

PURPOSE

Using the snodgraft in the narrow urethral plate less than 8 mm to repair distal hypospadias is still debatable. But to our knowledge, no one compared the Snodgrass and the snodgraft operations in the narrow urethral plate less than 8 mm. we aimed to compare the short outcomes of the Snodgrass versus snodgraft operations in the narrow urethral plate less than 8mm

MATERIAL AND METHODS

This prospective study included 73 children whom had been operated for distal and mid penile hypospadias utilizing either Snodgrass or snodgraft operation from March 2017 to September 2018. Sixty (82%) of them had a narrow urethral plate less than 8mm. They were randomized into two subgroups. Every group of patients had 30 children. Group 1 underwent Tubularized incised plate (TIP), while the second group underwent snodgraft operation utilizing the inner prepuce. All the repairs were done by a single surgeon. Operative detailed, postoperative period and complications were reported and statistically analysed and compared between both groups.

RESULTS

In both groups there were no statistically differences regarding the age, urethral plate length and width. Only the operative time was longer in the snodgraft group (75.9 ± 10.6 minutes in Snodgrass versus 109.8 ± 17.3 in snodgraft). Moreover, the complication rate was not in favor of any group. We had one case of complete dehiscence, one meatal stenosis and a fistula in the snodgrass group. Also, we had one fistula at the snodgraft group

CONCLUSIONS

In the narrow urethral plate less than 8 mm, snodgraft had a longer operative time than the snodrass operation. Also, Snodgraft is not superior to Snodgrass regarding the success and occurrence of complications


09:11 - 09:14
S12-2 (PP)

PROXIMAL HYPOSPADIAS REPAIR WITH THE KOYANAGI URETHROPLASTY: RESULTS AS A TWO-STAGE PROCEDURE AND COMPLICATIONS EASILY MANAGED

François-Xavier MADEC 1, Mathias DESPLANCHES 1, Maud CHAUBAUD 1, Sabine IRTAN 1, Etienne SUPLY 2 and Georges AUDRY 1
1) Children Hospital Armand Trousseau - APHP, Sorbonne medicine University, Paediatric Surgery Department, Paris, FRANCE - 2) University Hospital, Saint Vincent de Paul, Paediatric Surgery Department, Lille, FRANCE

PURPOSE

Experience and technical refinements with the Koyanagi urethroplasty for proximal hypospadias.

MATERIAL AND METHODS

A retrospective study was conducted between 2004 and 2017. Medical records of patients treated by the Koyanagi technique were investigated. The penile ventral skin was closed either with a Byars flap or using an "Ombredanne's chasuble" (OC). The cohort was divided chronologically into two groups of the same number of patients (early -E- and late experience group -LEG-). Surgical outcomes were compared between groups using univariate analysis. A logistic regression was performed to assess factors associated with the occurrence of a post-operative urethro-cutaneous fistula or urethroplasty dehiscence (UD).

RESULTS

The Koyanagi urethroplasty was performed in 67 patients. The overall surgical complication rate was 64.2% (n=43), including 42 fistula or UD, higher in the EEG (81.8%) than in the LEG (44.1%, p<0.01). However, in the LEG, patients underwent the surgery older and the use of OC was more frequent. After multivariate analyses, factors associated with a post-operative fistula or UD were the year of surgery (OR=0.71 [0.53-0.96] p=0.02), the age at surgery (OR=1.11 [1.01-1.22], p=0.03) contrary to the skin coverage method or the stenting duration (p>0.05). An urethral stenosis occurred in 1 patient. At last follow-up, 64.2% of patients required a further procedure and 80.6% of urethral meatus were glandular.

CONCLUSIONS

In this study the complication rate, essentially the urethro-cutaneous fistula, decreased with the experience and the age at surgery but remained high. Urethral stenosis, were rare. Considering as a 2 stage procedure koyanagi uretroplasty allows to obtain finally good results.


09:14 - 09:17
S12-3 (PP)

★ THE TUBULARIZED INCISED PLATE URETHROPLASTY ( SNODGRASS) IN RECURRENTDISTAL HYPOSPADIAS.

Souhem TOUABTI
Pr., Setif, ALGERIA

PURPOSE

To assess the success rate and postoperative cpmplications of tubularized incised-plate (Snodgrass) urethroplasty in recurrent distal hypospadias.

MATERIAL AND METHODS

Between January 2010 and december 2016; 60 children underwent a redo Snodgrass repair in prospective study.

RESULTS

in the 1st month postoperatively, the early complication rates was as follows: postoperative wound dehiscence rate was 6.7 ( 4 cases). bleeding ,oedema,wound infectionand urinary retention rates was 6% for each.
with 2-10 month of follow-up, the late complication rates were as follows: repair disruption rate was 50% ( 30 cases), the fistula formation rate 30% ( 18 cases), penile torsion rate was 10% ( 6 cases), epidermoid cust rate was 6.7% ( 2 cases); urethral stricture and meatal stenosis rates were 3% .

CONCLUSIONS

Although the Snodgrass tubularized incised-plate urethroplasty is one of the first choices in primary distal hypospadias repair.
Its rule in recurrent distal hypospadias repair in questionable, espicialy in cases with previous Snodgrass repair.
Good selection of repair type according to each patient critica in mandatory.


09:17 - 09:20
S12-4 (PP)

AUGMENTATION OF THE GLANS AND DISTAL URETHRA EFFECTIVE METHOD OF CORONAL URETHRAL FISTULAS CORRECTION

Yury RUDIN 1, Diamid MARUKHNENKO 1, Nicolay POLYAKOV 2, Georgey LAGUTIN 1, Artur VARDAK 1 and Dgamal ALIEV 1
1) N.Lopatkin,s Research Institute of Urology and IR - branch "NMRC radiology" MH RF, Department of pediatric urology, Moscow, RUSSIAN FEDERATION - 2) N.Lopatkin,s Research Institute of Urology and IR - branch "NMRC radiology" MH RF, Department of reconstructive plastic urology, Moscow, RUSSIAN FEDERATION

PURPOSE

Urethral fistula at the coronal area is the most frequent complication of urethoplasty   of hypospadias repair. These complications are observed mainly in patients with small size of glans (groove depth). Suturing of the coronal fistula  is often unsuccessful, due to the lack of plastic material in this area.

MATERIAL AND METHODS

58 boys with urethral coronal fistula underwent repair over 8 years between March 2011 and August 2018. The mean age  was 39 months (23-138).  Conventionally, children are divided into two groups. The first group (27) boys who underwent closure of  fistula. In the second group (31) patients were performed  redourethroplasty  with augmentation distal urethra (dilating of glans penis plasty) operation Graft TIP (implantation rectangular form free prepucial flap in to dissected urethral plate of glans penis and distal urethra. The suture line of neourethra in both groups was over dartos flaps of prepuce, scrotum or tissue of the process vaginal of the testicle.

RESULTS

Median length of follow up was 23 months post  operation (2-75 months). Recurrent   fistula was observed in 7(25.9%)  patients of the first group and - 3 (9.6%) in the second group (p<0,01). The reason for complications in the first group is the narrowing and partial obstruction in the distal urethra, even with free urethral age catheterization.

CONCLUSIONS

Suturing of the coronal fistula have often recurrent fistula. GTIP augmenting uretha  plasty is indicated in patients with small glans, flat groove and  coronal urethral fistulas. This technique allows to achieve a good cosmetic and functional result without disrupting the flow of urine.


09:20 - 09:23
S12-5 (PP)

OUTCOME OF STENTED VS UNSTENTED HYPOSPADIAS REPAIR

Tariq BURKI 1, Ahmed NAZER 2, Abdul Rahman MUJALLID 2, Abdul Wahab AL HAMS 1, Yasser JAMAL ALLAIL 1, Fayez AL MODHEN 1 and Ahmed AL SHAMMARI 1
1) King Abdullah Specialized Children Hospital, King Abdula Aziz Medical City, NGHA, Riyadh, Pediatric Urology, Riyadh, SAUDI ARABIA - 2) King Abdula Aziz Medical City, NGHA, Riyadh, Urology, Riyadh, SAUDI ARABIA

PURPOSE

We did a retrospective study of the outcomes of the hypospadias (HS) repair comparing stented (SR) vs unstented repair (UR)

MATERIAL AND METHODS

Retrospectively we studied all the patients with mid-shaft to coronal hypospadias who had undergone hypospadias repair between January 2013 till January 2018. The major variables we looked at were degree of HS, age at repair, type of repair, use of waterproofing layer, suture used and stent usage. We recorded early complications like urinary retention, severe pain before discharge or revisit to emergency within 14 days for surgery related complications mainly urinary retention, dysuria, bladder spasms, catheter blockage/dislodgment. In the follow up we only included patient who were at least 6 months post op and fully potty trained. A p-value of <0.05 was considered significant.

RESULTS

We included 120 patients (57 SR, 63 UR). There was no significant difference in severity of HS, age at repair, type of repair and length of follow up in both groups. Snodgrass procedure was done in 65 (SR 37, UR 28), and tubularization in 55 (SR 20, UR 35). PDF 6/0 was used in all cases for urethral and glanular repair. In day care only one UR patient went into retention needing insertion of catheter. 7 Patient revisited emergency (SR 5, UR 2) p 0.02, all the 5 SR patients came back with bleeding/severe swelling while two of UR came back with dysuria needing analgesia only. For follow-up 98 patients were available (SR 47, UR 51). Fistula was reported in 17 (17.3%)-SR 9 (19.1%), UR 8 (15.6%) p 0.5, meatal stenosis in 3 (SR 3) p 0.06, partial/full dehiscence 6 (SR 2, UR 4) p 0.25.

CONCLUSIONS

Early post op SR patients are more likely to return to emergency. There is no significant difference in the long term complications and outcome of stented vs unstented HS repair.


09:23 - 09:38
Discussion
 

09:38 - 09:41
S12-6 (PP)

ANGROGEN RECEPTOR EXPRESSION IN PREPUTIAL DARTOS TISSUE OF CONGENITAL MALFORMATIONS OF THE PENIS IN COMPARISON WITH CONTROLS: A NOVEL SEMIQUANTIATIVE TECHNIQUE

Anne-Françoise SPINOIT 1, Lloyd TACK 2, Marleen PRAET 3, Jo VAN DORPE 3, Sarah BUELENS 2, Erik VAN LAECKE 4, Martine COOLS 5 and Piet HOEBEKE 4
1) UNIVERSITY HOSPITAL GHENT, Urology, Ghent, BELGIUM - 2) Ghent University Hospital, Gent, BELGIUM - 3) Ghent University Hospital, Pathology, Gent, BELGIUM - 4) Ghent University Hospital, Urology, Ghent, BELGIUM - 5) Ghent University Hospital, Pediatric Endocrinology, Gent, BELGIUM

PURPOSE

As the role of androgen activity in the development of congenital malformations of the penis (CMP) is controversial, this study aimed at assessing androgen receptor (AR) expression in smooth muscle fibers of dartos tissue (DT) of patients with hypospadias, buried penis (BP) and circumcision as controls.

MATERIAL AND METHODS

428 foreskin samples were prospectively gathered: 230 CMP (197 hypospadias, 33 BP) and 198 circumcisions (age range: 0,40-54,20years; 0,36-87,51years, respectively). Immunohistochemical AR staining was semi-quantitatively studied, using a modified quick score (mQuicks) (0-6), assessing intensity (0-3) and proportion (0-3) of stained smooth muscle fibers. mQuicks obtained in hypospadias and BP were compared with controls and proximal with distal hypospadias in different age groups.  Statistical analysis was performed with IBM SPSS 20.0.

RESULTS

AR expression shows a bimodal distribution in both CMP and controls. The first peak is seen between 6 and 12 months of age, i.e. following mini-puberty, with half of the samples showing positive AR staining. A second peak coincides with the advent of puberty. As no samples obtained before the age of 6 months were available, it is currently unclear if the first peak coincides with onset of mini-puberty or is already present at birth. No significant difference in mQuicks were found between hypospadias, BP and controls or between proximal and distal hypospadias in all age groups

CONCLUSIONS

AR expression shows a bimodal distribution in both CMP and controls, coinciding with physiological androgen production. These findings can explain conflicting results in previous studies assessing AR expression in DT of CMP and emphasize the need for age-matched controls.


09:41 - 09:44
S12-7 (PP)

★ SCORING SYSTEM FOR GRADING HYPOSPADIAS SEVERITY AND QUANTIFYING RISK OF POSTOPERATIVE COMPLICATIONS

Melissa MCGRATH 1 and Luis BRAGA 2
1) McMaster University - McMaster Children's Hospital, Surgery, Hamilton, CANADA - 2) McMaster University - McMaster Children's Hospital, Department of Surgery / Urology, Hamilton, CANADA

PURPOSE

Grading of hypospadias severity is often a subjective task, potentially causing barriers for dissemination of findings and research collaboration. Herein, we describe a modified, more objective GMS(mGMS)scoring system to grade hypospadias phenotype and investigate its association with urethral complications(UC) post-TIP repair.

MATERIAL AND METHODS

680 patients from a prospective database were graded preoperatively using the mGMS score. We excluded F/U<3months,redos and staged repairs. Age at surgery, preop testosterone, meatal location, glans groove depth, glans size(mm) and VC were collected for a score of 4-12. Primary outcome: complication rate(fistula, glans dehiscence and meatal stenosis); secondary outcome: association of mGMS severity score groups (mild:4-5; mod:6-7; severe:8-10) with complications. Student’s t, Fisher’s exact tests and logistic regression were performed.

RESULTS

UCs developed in 40/445(9%) patients; most commonly fistulas(47%). Median age at surgery=16 months(IQR:13-21) and mean F/U=21 months(3-104). Mean mGMS score =6.3. UC rates by mGMS severity categories are shown inTable 1. The severe phenotype had a significantly higher complication rate than the mild category (19%vs.5%,p<0.01).

 

mGMS Category Phenotype

Urethral Complications 

  n                  %

Patients-n
4-5 Mild  5         (5) 106
6-7 Moderate   21         (8) 276
8-10 Severe  14        (19) 73

CONCLUSIONS

We have found the mGMS scoring system to be an objective, standardized and statistically useful instrument for describing the severity of hypospadias phenotypes and for quantifying UCs. We also identified an association between mGMS severity scores groups and UC rates. Boys in the severe mGMS score category had a 4-fold higher complication rate than those with mild hypospadias phenotype. This information can be useful for counseling during preoperative appointment.


09:44 - 09:47
S12-8 (PP)

OBJECTIVE PENILE PARAMETERS AS PROGNOSTIC FACTORS IN HYPOSPADIAS REPAIR.

Jonathan GAL 1, Leon CHERTIN 2, Paul NOH 3, Amnon ZISMAN 1 and Amos NEHEMAN 4
1) Shamir (Assaf Harofea) Medical Center, Surgical Urology, Tzrifin, ISRAEL - 2) Itzhak Shamir Medical Center, Tzrifin, ISRAEL - 3) Cincinnati Children's Hospital Medical center, Pediatric Urology, Cincinnati, USA - 4) Shamir (Assaf Harofea) Medical Center, Tzrifin, ISRAEL

PURPOSE

The main predictive factor for surgical  success of hypospadias repair is considered to be meatal location (Duckett, 1996). In this study we describe additional objective parameters and evaluated correlation to surgical and cosmetic outcomes. 

MATERIAL AND METHODS

All boys undergoing hypospadias repair between 2015-2018 were prospectively evaluated. Intra operative measurements were obtained under general anastasia prior to surgical intervention: Glans penis width, height,  AP diameter and distance from initial meatal opening to desired location was measured using a caliper,  degree of chordee was assessed using a goniometer. Surgical end points were: incidence of fistula, dehiscence, and meatal stenosis. Cosmetic outcome was evaluated by the validated HOPE score. An institutional IRB and parental consent was acquired prior to data collection. SPSS system was used to analyze categorical and continuous variables.

RESULTS

54 patients met the inclusion criteria. Patient demographic and pre-operative data is presented in the table. Overall there was 13/54 (24%) addition procedure (7 fistula, 6 meatal stenosis, 4 dehiscence). Roc analysis didn’t demonstrate a correlation between any pre-operative parameters to surgical outcome. “Perfect” cosmetic outcomes (HOPE=60) was achieved in 33/54 (61%) cases. There was statistical significant correlation between degree of chordee and HOPE score (p=0.023).

Median age (months)

12.9 (IQR, 10.8-19)

Median weight (Kilogram)

10.8 (IQR, 9.3-12.5)

Meatal location:

 

Sub coronal

35

Distal shaft

4

Midshaft

11

Peno-scrotal

4

Degree of Chordee:

 

Mild (<300)

33

Moderate (300-600)

13

Severe (>600)

8

Glans Width (mm)

13 (IQR 12-14)

Glans height (mm)

10 (IQR 9-10)

Glans AP diameter (mm)

11 (IQR 10-12)

CONCLUSIONS

In this study we found no correlation between objective penile measurements and surgical outcomes. Pre-operative penile chordee was the only significant predictive factor for suboptimal cosmetic outcomes.


09:47 - 09:50
S12-9 (PP)

EFFECT OF CASTOR OIL AND PENILE PUMP ON COMPLICATION RATES IN CHILDREN UNDERGOING TWO-STAGE HYPOSPADIAS SURGERY

Halil TUĞTEPE 1, Arzu CANMEMIŞ 1, Ahsen KARAGÖZLÜ AKGÜL 1, Zeynep ÇALIKLI 2, Nicat VALIYEV 2, Tülay GÜRAN 3, Abdullah BEREKET 3 and Tolga DAĞLI 2
1) Marmara Pendik eğitim araştırma, Department of Paediatric Surgery-Division of Paediatric Urology, Istanbul, TURKEY - 2) Marmara Pendik eğitim araştırma, Department of Paediatric Surgery, Istanbul, TURKEY - 3) Marmara Pendik eğitim araştırma, Department of Paediatrics, Division of Paediatric Endocrinology, Istanbul, TURKEY

PURPOSE

Two-staged free preputial graft has recently increased in popularity for use in severe hypospadias repair. In this study, the aim was to evaluate the effect on complications of using castor oil and penile pump after 1st stage of two-stage repair with free preputial graft.

MATERIAL AND METHODS

Patients undergoing two-stage hypospadias repair between April 2013 and August 2018 were included in the study prospectively. In the study group, 14 days after 1st stage, castor oil was applied on the graft 3 times a day until 2nd stage in addition to use of penile pump. castor oil and pump was not used in the control group. Complications were compared between the two groups and Odds ratio was calculated.

RESULTS

There were 30 patients in study group and 21 patients in control group. The average age in study group at 1st and 2nd stage was 21.7months and 28.7months,and in control group  31.3 months and 39 months respectively. There were 3 patients with midshaft, 27 with penoscrotal, 18 with scrotal and 2 with perineal hypospadias. There was no statistical difference between ages, follow up times and hypospadias types between the two groups. Complications were seen in 11 patients (55%) in the control and 8 patients (26.6%) in the study group (p=0.07). Use of Indian Oil and penile pump had an Odds ratio of 0.38 (%95 CI 0.10-1.35).

CONCLUSIONS

Use of castor oil and penile pump in patients undergoing two-staged hypospadias repair reduces the complication rates. and protects from complications but this outcome did not reach statistical significance. Further studies with larger population are required.


09:50 - 09:53
S12-10 (PP)

COMPARISSON BETWEEN "MACHINE-LEARNING" AND HUMAN TO IDENTIFY AND CLASSIFY HYPOSPADIAS

Nicolas FERNANDEZ 1, Armando LORENZO 2, Joao Luis PIPPI SALLE 3, Luis BRAGA 4, Jaime PEREZ 5, Mandy RICKARD 2 and Clyde MATAVA 2
1) Hospital for SickKids/Hospital Universitario San Ignacio Pontificia Universidad Javeriana/Fundacion Santafe de Bogota, Urology, Bogota, COLOMBIA - 2) Hospital for SickKids, Toronto, CANADA - 3) Sidra Medical Center Doha Qatar, Urology, Doha, QATAR - 4) McMaster University, Urology, Hamilton, CANADA - 5) Hospital Universitario San Ignacio Pontificia Universidad Javeriana, Bogota, COLOMBIA

PURPOSE

Anatomical variables such as meatal location, quality of the urethral plate, glans size and ventral curvature have been identified as predictors for post-operative outcomes. Nonetheless, there is still significant subjectivity between evaluators. Hereby we propose the use of machine learning/image recognition to increase objectivity of hypospadias recognition and classification.

MATERIAL AND METHODS

Using an image database, a total of 1169 anonymous images (837 distal and 332 proximal) were used. All pictures had the same format (ventral aspect of the penis including the glans, shaft and scrotum). Images were classified into distal or proximal and shown the computer for training with TensorFlowÒ. Data from the training was outputted to TensorBoard, to assess for the loss function. The model was then run on a set of 29 “Test” images arbitrarily selected. Same set of images were distributed amongst expert clinicians in pediatric urology. Inter and intrarater analysis were performed using Fleiss Kappa statistical analysis.

RESULTS

After training phase with 627 images (440 distal and 187 proximal), detection accuracy was 60%. When training was increased to 1169 images, accuracy increased to 90%. Overall inter-rater analysis amongst expert pediatric urologists was k= 0.86 and intra-rater 0.74.

CONCLUSIONS

Image recognition model after established training has an accuracy detection rate of 90% which emulates the almost perfect inter-rater agreement between experts.  Future applications of this technology may be used as a predictive tool for surgical outcomes and to identify image properties to better define difficult variables such as the quality of the urethral plate.


09:53 - 09:56
S12-11 (PP)

★ A LOWER D2/D4 DIGIT RATIO AND SCROTAL BASE DISTANCE IN MALE INFANTS WITH HYPOSPADIAS AND/OR CRYPTORCHIDISM THAN NORMAL BOYS.

Tariq Osman ABBAS 1, A ELKADHI 2 and Joao PIPPI SALLE 3
1) Hamad General Hospital, Pediatric Surgery, Doha, QATAR - 2) Hamad Medical Corporation, Pediatric Surgery, Doha, QATAR - 3) Sidra Medicine, Urology, Doha, QATAR

PURPOSE

In humans, the ratio of the index finger to the ring finger is sexually dimorphic, as the mean ratio was found to be shorter in men than in women. It has been suggested that this difference is related to prenatal androgen exposure in men. This has been also demonstrated in children with severe hypospadias and congenital adrenal hyperplasia. We have shown previously that scrotal base distance is lower in patients with Hypospadias and undescended testes. We therefore aimed to determine if the 2D:4D digit ratio was correlating with scrotal base distance (SBD) in this group of patients.

MATERIAL AND METHODS

We prospectively enrolled prepubertal patients with cryptorchidism or hypospadias between September 2016 and January 2018. We then compared their D2:D4 digit ratio with SBD in two control groups made up of normal boys and with Hypospadias or undescended testes.

RESULTS

57 boys with hypospadias or cryptorchidism, 79 boys undergoing circumcision we included. The mean D2:D2 ratio for left hands was significantly different between the two groups, and correlating with SBD (p<0.05).

CONCLUSIONS

It appears that boys with cryptorchidism or hypospadias have a lower D2:D4 digit ratio than boys without genital anomalies. This ratio is correlating with the newly described genital anthropometric measure "scrotal base distance". This validate the utilization of this measure as an a physical reflection to male fetal underverilization.


09:56 - 10:14
Discussion