ESPU Meeting on Thursday 9, June 2022, 12:10 - 13:20
12:10 - 12:13
S07-1 (OP)
Nail R. AKRAMOV 1, Vladimir V. SIZONOV 2, Ilya M. KAGANTSOV 3, Elmir I. KHAERTDINOV 4 and Vladimir M. ORLOV 5
1) ORL Medical Center, Urology, Kazan, RUSSIAN FEDERATION - 2) Rostov Regional Children's Hospital, Pediatric Urology and Anrology, Rostov On Don, RUSSIAN FEDERATION - 3) Almazov National Medical Research Centre, Research Laboratory for Surgery of Congenital and Hereditary Pathology, St. Petersburg, RUSSIAN FEDERATION - 4) KORL Medical Center, Urology, Kazan, RUSSIAN FEDERATION - 5) Rostov Regional Children Hospital, Pediatric Urology and Anrology, Rostov-On-Don, RUSSIAN FEDERATION
PURPOSE
One of the most controversial aspects of the treatment of hypospadias is the choice of a postoperative dressing. When using adhesive dressings, there is no visual control of the penis, and there is also a need to change the dressings and remove them.
MATERIAL AND METHODS
During 2018-2020, the results of treatment of 77 patients with distal hypospadias were analyzed. All patients underwent mobilization of urethra. In group I (47 boys), the wound surface of the penis was covered by acrylate application with cyanoacrylate glue n-butyl-2-cyanoacrylate or 2-octyl cyanoacrylate. In group II (30 boys), a transparent film dressing covered with a cohesive elastic bandage was used. There were no statistically significant differences in age and form of hypospadias in both groups.
RESULTS
In group I, Clavien-Dindo complications occurred in 5 (10.6%) boys: Grade I in 4 (8.5%) - pronounced swelling of the penis, grade II in 1 (2.1%) - part of the wound healed by secondary intention. In group II, complications occurred in 11 (36.7%) children: grade I - 6 (20%) patients (3 (10%) - hematoma formation, 2 (6.7%) - transient ischemia of the head and 1 (3.3%) - pronounced swelling of the penis), grade II - 5 (16.7%) patients (1 (3.3%) - healing of part of the wound by secondary intention, 2 (6.7%) - wound infection, 2 (6.7%) - migration of the bandage requiring its replacement). The rate of complications of grade 2 according to Clavien-Dindo is higher in patients of group II (p<0.05).
CONCLUSIONS
The use of acrylate application significantly reduces the likelihood of complications of grade 2 according to Clavien-Dindo, minimizes the pain associated with the care of the wound surface, and reduces the level of negative perception of the postoperative period after urethroplasty.
12:13 - 12:16
S07-2 (OP)
Aykut AKINCI 1, Murat Can KARABURUN 2, Eralp KUBILAY 2, Mehmet Fatih OZKAYA 2, Tarkan SOYGUR 1 and Berk BURGU 1
1) Ankara University Faculty of Medicine, Pediatric Urology, Ankara, TURKEY - 2) Ankara University Faculty of Medicine, Urology, Ankara, TURKEY
PURPOSE
In this prospective-randomized-trial the effect of onset-time of preoperative-hormonal-therapy on the-surgical-outcome for 2-stage-proximal-hypospadias-repair was investigated.We hypothesized that postponing the topical-hormonal-administration after the first-stage can potentially reduce the complications.
MATERIAL AND METHODS
The study included 134patients who had a2-stage hypospadias primary repair between January2011 and December2020.Topical preoperative dihyrotestosterone was used for a total of 44patients.The inclusion criteria for hormonal-therapy,was a glans diameter of less than 14mm,stretched penile length shorter than 2cm and GMS-score above 10. 22patients were randomized to groupA where the topical DHT administration(2.5%DHT transdermal-gel directly onto the penile shaft and glans daily,2 months)prior to the first-stage.Group B consisted 22patients who had the same dose and duration of topical DHT between the surgeries after the chordee correction and before the second surgery.The GroupC included 90patients who did not fulfil the criteria to use preoperative-hormones.For each case the surgery was scheduled at least 8weeks after the compilation of hormonal treatment.All first stage repairs were Byars flap.Groups were compared in terms of success and complication-rates.
RESULTS
Pre-first-stage hormones were used by 22patients,pre-second-stage hormones were used by 22patients,and no-hormones were used by 90patients.The mean age of all patients was37.4±7.6 months.There was no difference between the groups in terms of mean-age,glans-size and GMS-scores between groupA&B(p0.78;0,71;0,68).There was no significant difference between the groups in terms of fistula,glans dehiscence,meatal stenosis,bleeding and other healing complications(respectively p 0,88;0,92;0,61;0,48;0,60).Residual-chordee after the second-surgery was relatively higher in groupB but did not reach statistical significance.When genital-pigmentation and pubic-hair-growth were compared between GroupA and GroupB,no differences were found(respectively p 0,53 0,45).GroupC which consisted better patients who didn't use hormones had significantly better outcome.
CONCLUSIONS
The timing of hormone-therapy-initiation in patients with2-stage-hypospadias-repair has no influence on the surgery's success.Postponing the surgery after the first step does not improve the complication rates.
12:16 - 12:19
S07-3 (OP)
Mamdouh AHMED, Ashhad KHAN and Abdulnaser AL SAID
IBN SINA HOSPITAL, KUWAIT, PEDIARTIC SURGERY, PEDIATRIC UROLOGY UNIT, Kuwait, KUWAIT
PURPOSE
Grafted Tubularized Incised Urethral Plate Urethroplasty (G-TIP) for surgical repair of distal hypospadias became the gold standard technique in our department since November, 2011. This study aimed to evaluate the cosmetic and functional outcomes of 10 years of experience with G-TIP.
MATERIAL AND METHODS
This retrospective study included 1000 consecutive patients who underwent the G-TIP technique for distal hypospadias.
The G-TIP technique involved steps of degloving and creation of glanular wings. Midline incision of the urethral plate extends to the glans proper by 2mm and was grafted and quilted with an inner preputial graft. The augmented urethral plate was tubularized and reinforced with a dartos flap. The urethral catheter remained 7 days postoperatively.
The patients were assessed for their cosmetic and functional outcomes.
RESULTS
Thousand patients were included with a mean age of 2.2 years and mean follow-up was 65.7 months.
Slit-like apical meatus was present in 97% of the patients.
Disruption of the repair occurred in 12 of the patients' that necessitated redo surgery.
Urethrocatanous fistula has occurred in 15 patients.
Five patients had stricture in the neo-urethra dysuria that corrected by cystoscopic internal urethrotomy.
Six patients had distal glanular dehiscence with acceptable functional and cosmetic results.
Three patients have meatal stenosis.
The presence of suture tracts and edges of the graft at the margin of the neo-meatus were observed in the initial 1.1% and 1.2% of patients, respectively.
CONCLUSIONS
G-TIP is an easy and feasible technique that achieves an excellent outcome, and we recommend its universal application.
12:19 - 12:22
S07-4 (OP)
Tariq Osman ABBAS 1, Ibrahim KHALIL 2, Mohamed ABDUL MONIEM 3 and Muhammad CHOWDHURY 3
1) Sidra Medicine, Urology, Doha, QATAR - 2) Hamad Medical Corporation, Urology, Doha, QATAR - 3) Qatar University, Electrical Engineering, Doha, QATAR
PURPOSE
Although Urethral plate (UP) quality is considered a critical variable that has a significant impact on hypospadias postoperative outcomes, the quantification of the UP-quality lacks objectivity and reproducibility. The plate objective scoring tool (POST) [1] was introduced as an objective, reproducible and consistent system to stratify the quality of UP. We aim to explore the capacity of Artificial Intelligence (AI) to further streamline and optimize the process of UP quality appraisal to make the POST even more reproducible and unify it's measurements.
MATERIAL AND METHODS
The three key anatomical landmarks (A, B, and C) of the POST were marked by specialists in a 361-image dataset of prepubertal boys undergoing primary hypospadias repair. A deep learning-based landmark detection model was trained, validated, and tested using the image dataset. The predicted coordinates of A, B, and C were used to compute the AB/BC ratio for a reliable assessment of the UP quality.
RESULTS
The proposed model showed an accurate performance in localizing the landmarks with a Normalized Mean Error (NME) and Mean Squared Error (MSE) of 0.1651 and 0.0015, respectively in predicting the coordinates of the landmarks.
CONCLUSIONS
This deep learning-based AI application shows robustness and a high level of precision in operating POST to appraise the quality of UP. Further assessment using a multi-country diverse image database is ongoing and results of the validation are awaited.
Reference
[1] Abbas TO, Vallasciani S, Elawad A, Elifranji M, Leslie B, Elkadhi A, Pippi Salle JL. Plate Objective Scoring Tool (POST); An objective methodology for the assessment of urethral plate in distal hypospadias. J Pediatr Urol. 2020 Oct;16(5):675-682.
12:22 - 12:25
S07-5 (OP)
Israel FRANCO 1 and Paul ZELKOVIC 2
1) Yale school of medicine, Urology, New Haven, USA - 2) New York Medical College, Pediatric urology, Tarrytown, USA
PURPOSE
Questions abound whether different repairs exhibit different flow characteristics or is the location of the urethra that is more important. Our aim was to investigate if different hypospadias repairs lead to measurable differences in flow rates.
MATERIAL AND METHODS
A retrospective review of ICD-10 codes for all patients with hypospadias and uroflowmetry was performed over a 10 year history. Flow parameters were compiled and patients were grouped by the pre-operative location of their urethral meatus and the type of repair. . Critical parameters evaluated were Qmax, Qavg, voided volume, PVR, Qmax flow index (FI), and Qavg FI. We compared different repair types in relation to the location of the urethral opening. Descriptive statistics and Kruskal-Wallis tests with Bonferroni correction were performed using SPSS.
RESULTS
466 uroflows were performed while 346 were in patients with no complications. The average age of all patients at time of flow was 7.3 years. Of the 346 flows there were 211, 37 ,98 flows in proximal, midshaft and distal hypospadias repairs, respectively. . The only notable differences were seen in proximal cases for Qmax, voided volume and TBC. No discernible differences were noticed in QmaxFI and QavgFI. Even in the magpi repairs the Qmax and QmaxFi are lower than those seen in normal voiders.
CONCLUSIONS
There appear to exist differences is the Qmax of proximal repairs when compared to each other but on closer analysis there are no real differences due to volume differences. Since Qmax and Qave are dependent on the volume in the bladder this and explains prior differences seen in many other reports. We can readily bear this out by noting that there are no difference in the Qmax FI and Qavg FI which control for volume indicating the superiority of using flow indexes to follow flows longitudinally.
12:25 - 12:28
S07-6 (OP)
Israel FRANCO 1 and Paul ZELKOVIC 2
1) Yale school of medicine, Urology, New Haven, USA - 2) New york Medical College, Pediatric urology, Tarrytown, USA
PURPOSE
Uroflowmetry is a noninvasive method used to assess for possible obstruction after hypospadias surgery. . Our aim is to establish normal flow values in patients after repair of varying degrees of hypospadias and to identify if there are reliable differences between those with complications and those without.
MATERIAL AND METHODS
A retrospective review for all patients with hypospadias and uroflowmetry was performed. Flow parameters and pre-operative location of their urethral meatus and type of repair. Critical parameters evaluated were Qmax, Qavg, Voided volume, PVR, Qmax Flow index (FI), and Qavg FI. We compared hypospadiac flows without complications to 1,081 normal age matched male flows from a previous study. Descriptive statistics and d Kruskal-Wallis tests with Bbonferroni correction were performed using SPSS.
RESULTS
Original urethral meatal locations were recorded as distal, midshaft and proximal with 135 flows from 90 patients, 47 flows from 23 patients, and 285 flows from 109 patients, respectively, and 1,081 flows from 656 normal patients. Flows are outline in table 1 comparing normal to different urethral locations. Repaired hyspospadiacs with bell curves when compared to normal bells had lower Qmax and QmaxFI compared to normal bells. Only proximal hyposadiacs had lower Qavg and Qavg FI compared to normal. When comparing all voids the normal hypospadiacs were significantly different than the normal. When comparing patients with complications vs those without, there were differences between the different urethral positions as well.
CONCLUSIONS
We have established useful normal parameters for post-operative hypospadias which can be used to follow these patients overtime allowing for the identification of complications by simply keeping tract of flow indexes which are volume and age agnostic.We have established useful normal parameters which can be used to follow postoperative hypospadias patients over time, allowing for the identification of complications by simply keeping track of flow indexes which are volume and age agnostic.
12:48 - 12:51
S07-7 (OP)
Ahmed HADIDI, Mohamed FAWZY, Michael SENNERT and Johannes WIRMER
Emma & Sana Klinikum Offenbach, Germany, Hypospadias Center,, Seligenstadt, GERMANY
PURPOSE
To test the accuracy of the Natural Erection Test as compared to the Artificial Erection Test in assessing Penile curvature in hypospadias.
MATERIAL AND METHODS
30 children were subjected to both natural and artificial erection tests intraoperatively between January 2020 and June 2021. These included 4 glanular, 16 Distal, 5 proximal and 5 perineal hypospadias patients with chordee. All Patients were followed up for at least 6 months. Under anaesthesia, the curvature was assessed before degloving, then after degloving using both the natural and the artificial erection test.
Technique of Natural Erection Test: Two fingers of the left hand press against the root of the penis to stop blood drainage from the penis and two fingers of the right hand massage the blood from the perineum distally into the penis until it becomes hard. The standard artificial erection test was performed using saline injected through a butterfly needle. Photos were taken of both tests using the exact angle and angle of curvature was measured using Angle Meter APP.
RESULTS
The measurements were analyzed using paired sample t-test. There was no statistically significant difference between both erection tests with a P value of 0.9050. Bland Altman plot also showed that all points were within the limits of agreement with a mean difference of -0.1
CONCLUSIONS
This pilot study suggests that the Natural Erection Test is a simple, reliable and non-invasive alternative to artificial erection test.
|
Paired sample t-test |
|
|
Mean difference |
0.1333 |
|
Standard deviation of differences |
6.0671 |
|
Standard error of mean difference |
1.1077 |
|
95% of CI of difference |
-2.1321 to 2.3988 |
|
Test static t |
0.120 |
|
Degree of freedom (DF) |
29 |
|
Two tailed probability |
P=0.9050 |
|
Differences |
|
|
D’Agostino-Pearson test for Normal distribution of differences |
Accept Normality (P=0.1144) |
12:51 - 12:54
S07-8 (OP)
David BEN-MEIR 1 and Michael FRUMER 2
1) Schneider Childrens Medical Center of Israel, Pediatric urology, Nirit, ISRAEL - 2) Scneider Childrens Medical Center of Israel, Pediatric Urology, Petach Tikva, ISRAEL
PURPOSE
While there is data for intracavernosal pressure during erection in adults, for children none was reported and especially if corporotomies performed in severe penile curvature may harm the erection. We aimed to examine intracavernosal pressure in children with hypospadias, including those who have undergone corporotomies.
PATIENTS AND METHODS
Retrospective study including 38 children who underwent hypospadias repair at a median age of 15 months (IQR 8, 37).
The pressure measurement was done by inserting a 21G needle into the corpora and connecting it to a pressure sensor. A saline solution was instilled through a 2nd butterfly needle and pressures were measured at first full erection and during forced erection.
RESULTS
Seventeen (44%) boys had distal (group A) and 21 (56%) proximal hypospadias (group B). In group A, median pressures in full and forced erections were 74 (IQR 59,81) and 286 (IQR 221,317) mmHg, respectively. In group B, median full and forced erection median pressures were 65 (IQR 49,78) and 243 (IQR 182,286) mmHg, respectively. No differences were found between groups (p=0.16, p=0.11, respectively).
In group B, 10 patients underwent corporotomies. Full and forced erection pressures were 56 (IQR 42,66) and 184 (IQR 89,264) mmHg, respectively, and 4/10 had venous leakage. For the eleven boys without corporotomies, full and forced pressures were 67 (IQR 56,80) (p= 0.03) and 260 (IQR 194,297), respectively, p=0.054.
CONCLUSIONS
Erectile pressures in children are slightly lower than in adults. Pressures were similar at different degrees of hypospadias. Erection quality may be impaired in some children who undergo corporotomies.
12:54 - 12:57
S07-9 (OP)
Hazem MOSA, Eskinder SOLOMON, Anu PAUL and Massimo GARRIBOLI
Evelina children's hospital, Paediatric urology, London, UNITED KINGDOM
PURPOSE
Correction of penile curvature is a major component in the management of hypospadias. Accurate assessment and management of penile curvature influence both short- and long-term outcomes of surgery. We aimed to investigate the accuracy of eyeball measurement and how does it compare to objective measurement by standard goniometry (SG) and smartphone app goniometry (AG).
MATERIAL AND METHODS
A Dropbox file request link was shared with paediatric urologists on various social media platforms requesting participants to upload a picture of their index finger showing what they thought 30 degrees of curvature look like using their proximal inter phalangeal joint as the point of maximal curvature. The images were assessed using SG. The images were also assessed using AG by the principal investigator, a physician, a scrub nurse and a paediatric urology consultant. Pearson correlation was used to test intra- and inter-observer reliability.
RESULTS
52 responses were received.32.7% of respondents simulated 30 degrees accurately (17/52). A significant proportion (23/52, 44.2%) overrepresented the degree of curvature and 23.1% (12/52) underrepresented it (p = 0.01). Compared with objective measures, eyeball estimates differed by an average of 10 degrees +/- 1.5 SE. Measurements obtained by AG were comparable to those obtained by SG with excellent intra-observer (R=0.94, P=0.001) and inter-observer correlation (R= 0.983, P <0.001).
CONCLUSIONS
We demonstrated a tendency among hypospadiologists to overestimate or underestimate curvature by an average of 10 degrees on eyeball assessment. The use of App Goniometry shows excellent interobserver reliability and is comparable to standard goniometry in curvature assessment.
12:57 - 13:00
S07-10 (OP)
Muthana AL-SALIHI 1, Ahmed ALBAKR 2, Tariq Osman ABBAS 1, Mohammed ELIFRANJI 1, Santiago VALLASCIANI 1, Abderrahman ELKADHI 1 and J.L. PIPPI SALLE 1
1) Sidra Medicine, Urology, Doha, QATAR - 2) Hamad Medical Corporation, Urology, Doha, QATAR
PURPOSE
Management of Proximal hypospadias remains challenging. The aim of our study is to evaluate the outcomes of staged preputial graft (SPG) repairs with and without post-operative vacuum physiotherapy (VP) to minimize post-operative complications including: recurrence of chordee (RC), fistulas and strictures.
MATERIAL AND METHODS
Retrospective analysis of 71 patients with proximal hypospadias and severe ventral curvature (VC) 60 degrees or greater after degloving. VC was repaired using deep transverse incisions tunica albuginea (DTITA), avoiding injury of the erectile tissue and using no tourniquet. The ventral corporotomies defects were covered either with the divided and partially mobilized urethral plate or with the preputial graft itself. In Group 1 (49 patients); VP was applied twice a day starting the 3rd postoperative week. Group 2: (22 patients) no VP used. Outcomes and post op complications were assessed after second stage.
RESULTS
Mean ventral curvature was 66.08 degrees. Mean follow up: 13.01 months. Overall complication rate was 22.5%. In group 1: 6 out of 49 (12.24%) had complications (4 fistulas; 2 urethral stricture) but no recurrence of VC. In group 2: 10 out of 22 patients (45.45%), (p <0.005), developed fistulas (5), glans dehiscence (5) including 1 recurrence of VC. Both groups developed mild (<20o) VC after first stage which was easily repaired by simple graft tubularization or dorsal plication at time of second stage.
CONCLUSIONS
SPG and DTITA is an effective technique to repair proximal hypospadias with chordee. VP improves graft suppleness and decreases recurrence of VC and post-operative complications.
13:00 - 13:03
S07-11 (OP)
Tariq Osman ABBAS 1, Mohamed ABDELMONIEM 2, Ibrahim KHALIL 3 and Muhammad CHOWDHURY 2
1) Sidra Medicine, Urology, Doha, QATAR - 2) Qatar University, Electrical Engineering, Doha, QATAR - 3) Hamad Medical Corporation, Urology, Doha, QATAR
PURPOSE
Penile curvature (PC) is a critical phenotypic feature in hypospadias and accurate quantification of PC is critical for disease severity stratification and management decision-making. We aim to develop and validate an artificial intelligence (AI)-based algorithm for automated PC measurements using 2-Dimensional images.
MATERIAL AND METHODS
Nine 3D printed penile models with differing curvature angles (ranging from 18° to 90°) were used to compile a 900-image dataset featuring different camera positioning, inclination angles, and background/lighting conditions to develop and validate the proposed framework of PC angle estimation. The proposed framework consists of three stages: automatic penile area localization, shaft segmentation, and curvature angle estimation. The penile model images, which were captured using a smartphone camera were used to train and test a Yolov5 model to automatically crop the penile area from the captured image. Then an Unet-based segmentation model was trained, validated, and tested to segment the penile shaft and finally, using a custom Hough-Transform-based angle estimation technique used to estimate the degree of PC.
RESULTS
The proposed framework had a robust performance in cropping the penile area with an mean average precision (mAP) of 99.4 % and segmenting the shaft with a Dice Similarity Coefficient (DSC) of 98.4%. Furthermore, the proposed curvature angle estimation technique has generally demonstrated excellent performance with an average MAE of 8.5 compared to the ground truth curvature angles.
CONCLUSIONS
Considering the current intra- and inter-surgeon variabilities in PC measurements, the reported framework can significantly help in the precise measurements of PC for surgeons and researchers of hypospadiology.