5th Joint Meeting of ESPU-SPU - Virtual

S17: HYPOSPADIAS

Moderators: Gianantonio Manzoni (Italy)

ESPU-SPU Meeting on Saturday 25, September 2021, 12:25 - 13:19


12:25 - 12:28
S17-1 (PP)

THE TWO-STAGE PROXIMAL HYPOSPADIAS REPAIR: AN ANALYSIS OF COMPLICATIONS IN REGARDS TO FINAL MEATAL POSITION AFTER THE URETHROPLASTY.

Antonio MACEDO JR 1, Sergio OTTONI 2, Gilmar GARRONE 2, Ricardo MATTOS 2 and Marcela LEAL DA CRUZ 2
1) Federal University of São Paulo and NUPEP/CACAU, Urology, São Paulo, BRAZIL - 2) NUPEP/CACAU, Urology, São Paulo, BRAZIL

PURPOSE

Complex hypospadias repairs treated after the division of urethral plate is mostly treated in two-stages. We believe that most patients irrespectively of initial meatus location (penoscrotal, escrotal) can be treated in only two procedures if we do not push to place the neomeatus distally in the glans.

MATERIAL AND METHODS

We reviewed our two-stage repairs based on the Thiersh-Duplay principle done according to the flap-as-a-graft technique or the classic Thiersh-Duplay, where the dorsal foreskin is divided in the midline and transposed to ventral surface. The second stage consisted of U-urethroplasty and creation of a barrier layer with a tunica vaginalis flap. The distal urethra was placed in the proximal glans third or even coronal area without embracing the neourethra completely with the glandular wings. An indwelling silicone catheter was left for 7-10 days.

RESULTS

We treated 48 patients at a median age at the surgery of 9 months at first operation (1 to 184 months). Penoscrotal transposition was corrected at first operation by 28 patients and orchidopexy by 15 patients. We found complications after urethroplasty in only 5 patients (10.4%) consisting of four fistulas (8.3%) and one distal urethra dehiscence (2%). Mean follow up was 44.5 months (1 to 94 months).

CONCLUSIONS

Based on our results, we believe that in complex proximal hypospadia repair, the final position of urethral meatus not creating flow resistance to stream may contribute to lower complications and 90% of effectiveness of treatment in two stages.


12:28 - 12:31
S17-2 (PP)

USE OF SMALL INTESTINE SUBMUCOSA FOR CORRECTION OF SEVERE VENTRAL CURVATURE IN CHILDREN WITH PROXIMAL HYPOSPADIAS: OUR EXPERIENCE

Christian GUEVARA 1, Ruben BLACHMAN-BRAUN 1, Raquel QUINTANILLA 1, Alireza ALAM 2, Andrew LABBIE 1, Miguel CASTELLAN 1 and Rafael GOSALBEZ 1
1) Nicklaus Children's Hospital, Department of Pediatric Urology, Miami, USA - 2) Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Department of Pediatric Urology, Miami, USA

PURPOSE

Results regarding the use of small intestine submucosa (SIS) for chordee correction in children have been reported in the literature with varying rates of success. The objective of this study is to review our experience with 1 ply SIS for ventral corporal body grafting in children with severe ventral penile chordee associated with proximal hypospadias.

MATERIAL AND METHODS

From 2001 to 2019, 146 boys with proximal hypospadias and severe ventral curvature underwent single layered SIS graft to the corporal bodies in order to correct chordee (>35 degrees). In 123 patients and 6 patients, the correction was done in the first-stage of a planned 2-stage and 3-stage procedure respectively. The initial 17 patients underwent a 1-stage chordee correction. Mean follow-up was 39.2 months.

RESULTS

136 patients had no recurrence of chordee, 7 underwent correction of residual ventral chordee at 2nd or 3rd stage, 1 required correction of dorsal chordee at 2nd or 3rd stage, and 2 had long-term, asymptomatic, and mild (<10 degrees) dorsal chordee. No patients presented recurrence of ventral chordee during follow-up visit. Age at surgery (p = 0.669) and number of stages (p = 0.455) had no statistically significant association with recurrence of chordee.

No recurrence of chordee n=136 (93.2%) Correction of ventral chordee at 2nd stage n=7 (4.8%) Correction of dorsal chordee at 2nd stage n=1 (0.7%) Long-term dorsal chordee n=2 (1.4%) p-value
Age at surgery 12 [8-20] 10 [9-15] 10 11.5 0.669
Number of stages
1 16 (11.8) 0 0 1 (50)
2 115 (84.6) 6 (85.7) 1 (100) 1 (50)
3 5 (3.7) 1 (14.3) 0 0 0.455

CONCLUSIONS

Our results suggest that recurrence of chordee after SIS corporoplasty for correction of severe ventral curvature in cases of proximal hypospadias is low. A multistage approach to the repair is ideal, since it allows for the detection of both, residual ventral chordee and dorsal chordee due to over-correction.


12:31 - 12:34
S17-3 (PP)

SHOULD A COVER FLAP BE USED SYSTEMATICALLY FOR URETHROPLASTY WHATEVER THE SEVERITY OF HYPOSPADIAS?

Benoit TESSIER 1, Sami SFAR 1, Margot OLIVIER 1, Sarah GARNIER 1, Paula BORREGO 1, Christophe LOPEZ 1, Cyril AMOUROUX 2, Françoise PARIS 3 and Nicolas KALFA 1
1) CHU Lapeyronie, Service de chirurgie et urologie pédiatrique, Reference center for rare disease Genital Development (south), Montpellier, FRANCE - 2) CHU Arnaud de Villeneuve, Service Pédiatrie, Reference center for rare disease Genital Development (South), Montpellier, FRANCE - 3) CHU Lapeyronie, Service Pédiatrie, Reference center for rare disease Genital Development (South), Montpellier, FRANCE

PURPOSE

Interposition of a well-vascularized tissue between the penile skin and the neourethra has been advocated to prevent urethro-cutaneous fistula in hypospadias repair. Since some previous studies do not include comparable phenotypes and lack control groups, it remains unclear when a cover flap should be used. The aim of this case control study was to evaluate the impact of urethral covering with a vascularized tissue according to the severity of hypospadias and to determine which patients should benefit from this technique.

MATERIAL AND METHODS

A retrospective comparative study on patients with a primary hypospadias repair was performed (2011-2017). Only patients undergoing urethroplasty based on the principle of a tubularization were selected to ensure comparable groups. Patients were assigned in two groups according to the use or not of a cover flap. The cover layer used the deepithelialized foreskin or a vaginal flap according the available tissue.

RESULTS

366 patients were included with anterior (58,2%), midshaft (25,9%) and posterior hypospadias (15,9%). Outcomes with (n=194) and without flap (n=172) were compared. The overall rate of fistula was reduced with flap (p=0,002). Whereas the severity of hypospadias is a risk factor for fistula without flap (p=0.02), it is no longer when uretroplasty is covered (p=0.32). When stratifying the results according to the severity of hypospadias, the flap significantly reduces the risk of fistula in each group but its effectiveness is not homogeneous. The risk of fistula is dramatically reduced in posterior forms (OR:5.85) but midpenile and anterior hypospadias still benefit from this technique (OR 3.69 and 3.37 respectively).

CONCLUSIONS

The more severe the hypospadias is, the more effective the cover flap is. But all forms of hypospadias - included minor forms - benefit from this technique with a significant reduction of the fistula risk. A cover flap should be used systematically in all hypospadias repairs.


12:34 - 12:37
S17-4 (PP)

PROSPECTIVE EVALUATION OF INCOMPLETE PENILE DEGLOVING IN THE REPAIR OF REDO DISTAL HYPOSPADIAS USING TWO TECHNIQUES

Salah NAGLA 1, Mohamed NEGM 2, Mahmoud ELREFAEY 1, Mohamed A. OMAR 1, Mohamed GHALWASH 1 and Ayman RASHED 3
1) Tanta University, Urology, Tanta, EGYPT - 2) SOUTH VALLY UNIVERSITY, PEDIATRIC SURGERY, Qena, EGYPT - 3) 6th October University, Urology, Tanta, EGYPT

PURPOSE

Many surgeons favor the modified Mathieu over the Snodgrass technique because of the shorter operative time and the less degloving. Our aim was to compare the results of the modified Mathieu versus the Snodgrass technique in the redo distal hypospadias using the incomplete penile degloving

MATERIAL AND METHODS

We used the incomplete penile degloving technique in 90 patients from December 2017 to November 2019 at our department to repair the redo distal hypospadias. Patients were randomized into two equal groups each had 45 patients: group (1) Modified Mathieu technique utilizing the sub-epithelial dartos preservation and group (2) Snodgrass technique. Cases with redo distal hypospadias, glans size ≥14 mm, and without penile curvature were included. We excluded the shallow urethral plate, deficient ventral penile skin, cases that needed complete degloving and penile rotation. The primary outcome was the development of fistula. The success meant there was no need to re-operate

RESULTS

Both groups were comparable in regard to Age (median 34&32 months), urethral plate length and width, operative time (median 52 &50 minutes) and follow-up periods (median 15&14 months). in both groups, cases which needed reoperation were 4 &5 respectively.Two fistulae and 2meatal recessions in group (1) and 2 fistulae, 2 urethral strictures and one meatal stenosis in group (2). The success was comparable in both groups (91.8 vs88.9%)

CONCLUSIONS

incomplete penile degloving is affordable in the repair of the redo distal penile hypospadias without penile curvature using the modified Mathieu or Snodgrass technique. Each technique is not superior to the other in regard to operative time and success rate


12:37 - 12:40
S17-5 (PP)

EVALUATION OF PRIMARY DISTAL HYPOSPADIAS REPAIR AND THE IMPACT OF AGE ON REOPERATION RATES- A NATIONAL STUDY WITH LONGITUDINAL FOLLOW-UP

Christopher LOFTUS 1, Jennifer AHN 2, Mark CAIN 2, Sarah HOLT 1, Paul MERGUERIAN 2 and Margarett SHNORHAVORIAN 2
1) University of Washington, Urology, Seattle, USA - 2) Seattle Children's Hospital, Urology, Seattle, USA

PURPOSE

Reoperation rates after distal hypospadias repair vary based on institution and are limited by inconsistent follow-up. Using a contemporary population-based cohort, we sought to determine the reoperation rate after initial distal hypospadias repair and the association with age at primary repair.

PATIENTS AND METHODS

Using Truven MarketScan (US nationwide employer-based insurance claims database) from 2007 to 2017, male patients with >3 years of continuous follow-up after birth and a CPT code for distal hypospadias repair were included. Patients with any diagnosis of differences in sexual development were excluded. Reoperation was defined by an additional non-staged penile-related procedure after the primary repair. Chi-squared test was used for evaluation of proportions and binary logistic regression for associations.

RESULTS

Of 2,632 patients meeting inclusion criteria, 92.7% underwent primary repair before age 18 months. Seventeen percent had a reoperation with “repair of hypospadias complication” (43.7%), “lysis of adhesions” (19.3%) and “meatotomy” (19.1%) as the most frequent. Median time to reoperation was 234 days (Table1). The rate of reoperation was higher for patients aged >18mo at primary repair (22.5 vs 16.5%, p=0.036). Diagnosis of cryptorchidism and low birth weight were associated with reoperation (p<0.001). For the 49.3% of patients (1,300/2,632) with 5-year follow-up, the reoperation rate was 17.7%.

Diagnosis age

1mo (2.9mo, SD5.5)

>1y after birth: 5.9%

Primary repair age  

8mo (9.8mo, SD6.4)

Length of total follow-up

1765 days, (1956, SD726)

% Reoperation

16.9%

Time to reoperation

233.5days (403days, SD514)

 

30d: 35.5%

31-90d: 2.3%

91-365d: 31.3%

>1y: 30.8%

Table1. Patients with 3y follow-up, Medians (Means, SD)

CONCLUSIONS

This population-based study suggest that reoperation rates for children undergoing primary distal hypospadias repair may be underestimated by single-institutional studies. Age of primary repair was positively associated with rate of reoperation.


12:40 - 12:55
Discussion
 

12:55 - 12:58
S17-6 (PP)

★ NON-INVASIVE ASSESSMENT OF VASCULAR FUNCTION IN ADOLESCENTS WITH HYPOSPADIAS

Angela LUCAS-HERALD 1, Malika ALIMUSSINA 1, Stuart O'TOOLE 2, Martyn FLETT 2, Katriona BROOKSBANK 3, Christian DELLES 3, Syed Faisal AHMED 1 and Rhian TOUYZ 3
1) University of Glasgow, Developmental Endocrinology Research Group, Glasgow, UNITED KINGDOM - 2) Royal Hospital for Children, Paediatric Urology, Glasgow, UNITED KINGDOM - 3) Institute for Cardiovascular and Medical Sciences, BHF Centre for Research Excellence, Glasgow, UNITED KINGDOM

PURPOSE

Men with hypogonadism exhibit increased cardiovascular risk. Hypospadias is often associated with hypogonadism but it is not clear whether it is associated with adverse cardiovascular outcomes. Non-invasive ultrasound assessments offer the opportunity to assess this in children and adolescents.

MATERIAL AND METHODS

Boys aged 12-18 years were recruited. Cases were boys with proximal hypospadias who had undergone surgical repair for this. Controls were boys who had undergone review for constitutional delay of puberty but had not required intervention or healthy volunteers. Vascular assessment was undertaken for blood pressure, subclinical atherosclerosis (carotid artery intima media thickness (CIMT)) and endothelial function (flow mediated dilatation (FMD)).

RESULTS

14 cases and 14 age and puberty matched controls were recruited (median age (range) 14 (12, 18.5) years). All cases had normal gonadal function at the time of the study. Cases had increased systolic blood pressure standard deviation score (SDS) compared to controls (median (range) 1.4 (-0.7, 2.7) vs 0.2 (-0.7, 0.8), p<0.01) but no difference in diastolic blood pressure SDS (median (range)  0.3 (-2.1, 1.6) vs 0.1 (-0.7, 0.8), p=0.8). In addition, cases had increased CIMT SDS (median (range) 1.6 (0.7, 2.0) vs 1.2 (-1.2, 2.0), p<0.05). There was no difference in FMD score (median (range) 5.7 (2.4, 11.1) % vs 4.1 (2.1, 11.7), p=0.4).

CONCLUSIONS

The novel finding of increased CIMT and systolic blood pressure in boys with a history of proximal hypospadias and normal gonadal function raises questions about the aetiological link between hypospadias and cardiovascular disease and highlights the need for longitudinal studies. 


12:58 - 13:01
S17-7 (PP)

HYPOSPADIAS IS A PREDICTOR OF ADVERSE CARDIOMETABOLIC RISK IN ADULTHOOD - A CASE-CONTROL STUDY

Angela LUCAS-HERALD 1, Sandosh PADMANABHAN 2, Katriona BROOKSBANK 2, Linsay MCCALLUM 2, Augusto MONTEZANO 2, Rhian TOUYZ 2 and Syed Faisal AHMED 1
1) University of Glasgow, Developmental Endocrinology Research Group, Glasgow, UNITED KINGDOM - 2) Institute for Cardiovascular and Medical Sciences, BHF Centre for Research Excellence, Glasgow, UNITED KINGDOM

PURPOSE

Abnormal development of the genital tract during the first trimester can lead to hypospadias. Since poor fetal development may also be associated with long-term effects on cardiometabolic outcome, we questioned whether adults with a history of hypospadias are at increased risk of long-term cardiovascular and metabolic disease. This retrospective study determined if hypospadias is associated with increased risk of cardiometabolic disease later in life.

MATERIAL AND METHODS

Cardiovascular and diabetes admissions data were extracted through record linkage for all males with a history of hypospadias (ICD10 Q54) from 1981 to 2019 through the NHS Scotland Information Services Division. Men were excluded from analysis if there was a previous history of congenital heart disease. Multivariate analysis was performed adjusting for birthweight, gestation, antenatal steroids, maternal diabetes, maternal smoking and deprivation index using SPSS v22.

RESULTS

Admission data on 1,728 men with hypospadias and 8,073 matched controls were reviewed.  Men with hypospadias had a 3- fold higher risk of arrhythmia (OR [95% CI] 2.8[1.4-5.6], p<0.001); 3-fold higher risk of hypertension (OR [95% CI] 4.2[1.5-11.9], p<0.05) and 2-fold higher risk of heart failure (OR [95% CI] 1.9 [1.7-114.3], p<0.05). There were no statistically significant differences in admission rates for angina, diabetes, ischaemic heart disease, myocardial infarction, peripheral arterial disease, renal failure or stroke.

CONCLUSIONS

Men with a history of hypospadias are at significantly increased risk of admission for treatment for hypertension, arrhythmia and heart failure. The mechanisms underlying this observed increase are unclear and merit further evaluation. 


13:01 - 13:04
S17-8 (PP)

TOPICAL TESTOSTERONE IN PROXIMAL HYPOSPADIAS, DOES IT WORTH ?

Isiam WALI 1, Mohamed ABDEL SATTAR 2, Wael GHANEM 2, Amr ABOU ZEID 2, Nehal RADWAN 3, Mamdouh AHMED 4 and Osama AL NAJJAR 2
1) BENHA CHILDREN HOSPITALEGYPT, PEDIATRIC SURGERY, Kalyobia, EGYPT - 2) AIN SHAMS UNIVERSITY, CAIRO, EGYPT, PEDIATRIC SURGERY, Cairo, EGYPT - 3) AIN SHAMS UNIVERSITY, CAIRO, EGYPT, PATHOLOGY, Cairo, EGYPT - 4) IBN SINA HOSPITAL / AIN SHAMS UNIVERSITY, PEDIATRIC SURGERY AND UROLOGY, Kuwait, KUWAIT

PURPOSE

To evaluate the effect of preoperative application of testosterone transdermal gel on the outcome of hypospadias surgery in children with proximal hypospadias, with clarifying the possible histopathological difference.

MATERIAL AND METHODS

This a prospective study included 40 patients with proximal hypospadias with small glans( glanular width < 14mm). Patients were divided in to two equal groups randomly; Group (A) patients who received topical testosterone 1% before surgery, Penile parameters were measured before and after hormonal therapy ; Group (B) patients who didn't receive hormonal therapy. Genital skin biopsies were taken from inner foreskin during repair from all patients. Surgical repair was done in single or two stages. Paraffin blocks were prepared, Morphometric studies were done by Olympus Soft Pro Software. Additional sections were cut from paraffin blocks and were immunostained for commercially available ready to use mouse monoclonal antibody against four types of antigens: Estrogen receptor α, Estrogen Receptor β1, androgen, and vascular marker CD31.

RESULTS

There was a significant increase in all penile parameter in group A. The ventral penile length proximal to meatus was significantly respond to hormonal stimulation compared to ventral length distal to meatus , denoting a significant disproportional penile growth (p-value = 0.003). Immunohistochemical evaluation revealed that expression of ERβ1 was much more in the treated group. Whereas expression of ERα, androgen and CD31 in both groups were not significantly different. There were no statistically significant difference between both groups as regard the early and late surgical complications and HOPE score comparison except edema rate which was more in treated group than the control one.

CONCLUSIONS

: Although topical testosterone application increased penile parameters size, but this did not reflect on the improvement in the surgical outcome which was found comparable to the non treated group.


13:04 - 13:07
S17-9 (PP)

DOUBLE VS SINGLE DIAPER TECHNIQUE AFTER HYPOSPADIAS REPAIR, DOES IT REALLY MATTER?

Osama AL-OMAR and Khaled ALDABEK
West Virginia University, Department of Urology, Division of Pediatric Urology, Morgantown, USA

PURPOSE

Hypospadias repair at infancy carries stressful event for the families, adding to it the postoperative care for the dressing and the urethral catheter. Double diaper technique is a common practice after hypospadias repair to separate stool from urine, which is believed to have fewer complications and better surgical outcomes. However, this practice is not evidence-based, and families get very stressed about this particular step of wound care. This study hypothesizes that the single diaper technique offers similar surgical outcomes compared to the double diaper technique

MATERIAL AND METHODS

A total of 215 patients were retrospectively reviewed between January 2013 and September 2019. 155 patients met the inclusion criteria. We excluded 20 patients who are older than 3 years, and 40 patients for no show. Patients in single diaper technique received the same type of dressing and discharge instructions, as the double diaper group, except for leaving the catheter free inside the single diaper. We divided patients into 2 groups, group 1 (double diaper, 72 patients) and group 2 (single diaper, 83 patients).

RESULTS

The mean for patients’ age, weight, height, duration of follow up and type of hypospadias between both groups were statistically insignificant. Surgical technique was statistically significant between the two groups (p=0.01). There was no statistical difference between double diaper and single diaper groups in terms of complications and outcomes [Urinary tract infection (UTIs), surgical site infection (SSI), dehiscence, fistula and meatal stenosis].

CONCLUSIONS

Single diaper technique is simple and easy to perform by families and have no more complications compared to double diaper technique. 


13:07 - 13:19
Discussion