ESPU Meeting on Thursday 9, June 2022, 14:30 - 15:40
14:30 - 14:33
Hazem MOSA, Shahid IQBAL and Massimo GARRIBOLI
Evelina children's hospital, Paediatric urology, London, UNITED KINGDOM
Decisional regret (DR) has been reported after distal hypospadias repair and has been linked to the
desire to avoid circumcision and dissatisfaction with preoperative counselling. We aimed to study
decisional regret in parents of children who underwent distal hypospadias repair with or without foreskin
reconstruction (FR) when given the freedom to choose either.
MATERIAL AND METHODS
We surveyed Parents of patients who underwent distal hypospadias surgery. The freedom to choose FR
or circumcision was given to all parents. The survey was conducted via telephone using a standardized
form. Paediatric penile perception score (PPPS), DR score and satisfaction with preoperative counselling
were recorded. We analysed responses and linked them to patient characteristics, intraoperative
anatomical characteristics, and postoperative outcomes from a prospectively maintained database.
Multiple regression analysis was performed.
84% of contacted parents completed the survey (84/100) .97.6% were satisfied with preoperative
counselling. Patient characteristics are summarised in table. Complications were observed in 4.7%
(4/84). PPPS ranged (5-15) mean 11.2+/- 2.3 SD.. DR was not observed in 54.7% (46/84) (regret
score=0). Mild regret (regret score=1-25) was observed in 19% (16/84). Moderate to severe regret
(regret score >26) was noted in 3.5% (3/84). Regression analysis of multiple variables was performed.
DR was significantly more observed in parents of children who underwent surgery for
complications(P=0.004) and those with low PPPS(P=0.001).
|Age (range) Mean +/- SD||(9-165)26.5 +/- 33.3 SD|
|Follow up (range) Mean +/- SD||(6-60)23.6+/-15.3 SD|
|Foreskin reconstruction||42/84 (50%)|
|Circumcised at birth||10/84 (11.9%)|
|Urethrocutaneous fistula||1/84 (1%)|
|Foreskin fistula||2/84 (2.3%)|
|Meatal stenosis||1/84 (1%)|
DR is more prevalent in parents of children who undergo surgery for complications and those with low
PPPS. Lower DR scores-compared to previous studies- were observed in our cohort with high parental
satisfaction with preoperative counselling.
14:33 - 14:36
Eralp KUBILAY 1, Aykut AKINCI 2, Murat Can KARABURUN 1, Mehmet Fatih OZKAYA 1, Tarkan SOYGUR 2 and Berk BURGU 2
1) Ankara University Faculty of Medicine, Urology, Ankara, TURKEY - 2) Ankara University Faculty of Medicine, Pediatric Urology, Ankara, TURKEY
We hypothesized that widely used Pediatric-Penile-Perception-Score(PPPS)is not an objective tool for parents. Preoperative parental anxiety levels and prejudiced-fastidious communication patterns can predict the familial PPPS-evaluation and regret after surgery, thus this potential dissatisfaction can even be predicted by the surgical team at first informative visit prior to hypospadias-repair.
MATERIAL AND METHODS
In this prospective study data from 132-patients who underwent successful distal-primary-hypospadias-repair were examined. Patients with listed complications were excluded.Beck-Anxiety-Scale(BES)&Interpersonal-Communication-Competence-Scale(ICCS) were applied to parents prior to surgery. The PPPS for each child was evaluated by parents on two postoperative time-lines and PPPS was also blindly-evaluated by an independent pediatric-urologist out of the team postoperatively.
The mean age of patients was 4.6±3.5 years. Parents who had minimal(0-7)& mild anxiety levels(8-15) were satisfied by the cosmetic results of the hypospadias repair and had higher PPPS postoperatively (p<0,05)and the results was similar to the independent evaluation(p>0,05). It was revealed that there was a significant negative correlation between the anxiety levels and mean total PPPS(r:-0.78,p<0,05) and a discordance by the-independent evaluation. Parents with lower anxiety levels, had a significant improvement in PPPS scores for each visit. In addition parents who had better interpersonal communication competence(ICCS) were more satisfied by the cosmetic results of surgery and this was concordant by the independent evaluation (p<0,05).
Parental assessment of PPPS can be affected by the preoperative anxiety levels and can even be predicted by the parental communication patterns preoperatively.Reducing the anxiety levels before the surgery may be effective in progression on PPPSs.
14:36 - 14:39
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
In this study, we hypothesized that the effect of providing a structured informative video describing the operation process and postoperative visuals can reduce the anxiety level of parents.
MATERIAL AND METHODS
A total of 40patients underwent distal-hypospadias surgery between June-November 2021 were included. 80 parents were evaluated by STAI-FORM TX - I'(State-Trait Anxiety Inventory-STAI Form) parents at the first preoperative-visit. Then,80 parents were randomized to two different groups and the second interview was held(group-1:structured video information:n:40,group-2:classical informative talk:n:40). Visit duration was same in both groups. In the informative video, the operation process and the situations that may occur in the postoperative 2-month period were explained. Patient photos and videos from different postoperative periods were included. After the informative interviews, STAI-FORM-TX-I was re-applied to all parents pre and postoperatively.
The mean age of all parents was 34.8±3.9 (21-45) years. At first interview STAI TX-1 scores were similar for both groups(group-1:53.53±13.78, Group-2: 54.18±15.14; p:0,354). After informative visits, mean STAI TX-1 scores were 44.45±15.03 and 48.89±13.20 for group-1and-group-2 respectively. The decrease in anxiety levels after informations were found to be statistically significant for both groups preoperatively.(gorp-1:p:,006 and group-2:p:,028). However, the decrease in group-1 is statistically higher than group-2(p:,034). During the postoperative period improvement on STAI TX-1 was significantly better in Group1.
Providing a structured video information to the parents of children before hypospadias repair reduces the anxiety levels during the pre & postoperative period.
14:39 - 14:42
Laura RENZ 1, Alice HÖLSCHER 1, Jürg STREULI 2 and Rita GOBET 1
1) University Children's Hospital Zurich, Urology, Zürich - Schweiz, SWITZERLAND - 2) University Children's Hospital Zurich, Ethics, Zürich - Schweiz, SWITZERLAND
Surgical correction of hypospadias is recommended during infancy. Therefore, the decision for or against surgery is made by the parents. Our institution works towards shared decision making. The aim of the study is to evaluate the decisional regret (DR) among parents and identify a population at risk for regret.
MATERIAL AND METHODS
Electronic medical records of all patients treated for hypospadias between 2010-2020 were assessed. Study inclusion criteria were: a) correct diagnosis, b) operated children at least 1 year after surgery, c) non-operated children at least 1 year after initial consultation. We determined the DR score, a validated score to measure regret and distress after a health care decision, as the primary study endpoint. This score ranges from 0= no regret to 100=absolute regret.
259 of 460 patients completed the online questionnaire, representing a response rate of 56.3%. Of these, 79.5% (n=206) underwent surgery and 20.4% (n=53) did not. The overall mean Decisional Regret Scale (DR scale) was 11.4 (median 5). In operated children DR scale was 10 (median 5) and in non-operated children 16.5 (median 10). No regret at all (0 in the DR scale) was reported by 44.4% (n=155), 33.9% (n=88) showed no to mild regret (0-24 in DR scale), and 21.6% (n=56) reported severe regret (25-100 in DR scale). Higher DR scales were correlated to distal hypospadias and complications.
Overall most parents at least one year after the decision for or against hypospadias surgery don't regret their decision. The population at risk for parental decisional regret may consist of boys with milder forms and/or higher complication rates, for which it is sensible to invest resources into shared decision making.
14:42 - 14:45
Yoav UCHITEL 1, Osnat ZMORA 2, Ilya BEBERASHVILI 3, Marianna RACHMIEL 4, Yakaterina VISMAN 1 and Amos NEHEMAN 1
1) Shamir Medical Center, Department of Urology, Beer Yaakov, ISRAEL - 2) Shamir Medical Center, Department of Pediatric Surgery, Beer Yaakov, ISRAEL - 3) Shamir Medical Center, Department of Nephrology, Beer Yaakov, ISRAEL - 4) Shamir Medical Center, Unit of Pediatric Endocrinology, Beer Yaakov, ISRAEL
Inappropriate exposure or activity of sex hormones in-utero has been postulated as a leading cause for the development of hypospadias and cryptorchidism. Anthropometric sexually dimorphic traits such as the 2nd to 4th digit ratio (2D:4D), anogenital distance (AGD) and the stretched penile length (SPL), have been associated with androgen and estrogen activity in-utero.
Our aim is to compare anthropometric parameters between patients with hypospadias, cryptorchidism and healthy controls.
MATERIAL AND METHODS
This is a case control study of male patients operated on between 2019-2020. Three groups were included: hypospadias, cryptorchidism and a demographically similar control group. Anthropometric parameters 2D:4D, AGD and SPL were measured intra-operatively and compared between the groups.
Included in the study were 179 paediatric patients between the ages of 9-15 months (58 patients with hypospadias, 69 with cryptorchidism and 47 controls). There was no difference in AGD, 2D:4D and SPL between patients with cryptorchidism, hypospadias and controls.
Anthropometric characteristics were not different in patients with hypospadias and cryptorchidism compared with controls.
15:02 - 15:05
Silvia PECORELLI 1, Anne BERGOUGNOUX 2, Safa AOUINTI 3, Aurelie CAZALS 4, Francoise PARIS 4, Nicolas MOLINARI 3 and Nicolas KALFA 4
1) Spedali Civili" Children's Hospital, Department of Pediatric Surgery, Brescia, ITALY - 2) CHU de Montpellier, Laboratoire de Génétique Moléculaire, PhyMedExp, INSERM, CNRS UMR, Montpellier, FRANCE - 3) CHU de Montpellier, Département de l'Information Médicale, Unité de Recherche Clinique et Épidémiologie, Montpellier, FRANCE - 4) CHU de Montpellier, Centre de Référence Maladies Rares du Développement Génital DEVGEN, Constitutif Sud, Montpellier, FRANCE
Hypospadias is multifactorial. Placental dysfunction is suspected to participate in its occurrence. We used next-generation-sequencing (NGS) to evaluate whether there is a common genetic event that could explain at the same time hypospadias, inter-uterine growth restriction and premature birth, focusing on DSD-genes expressed in the placenta.
MATERIAL AND METHODS
Prospective multicenter genetic and clinical research included 288 children (glandular to penoscrotal hypospadias without undescended testis or micro- penis). 21 genes both implicated in genital development and expressed in the placenta were studied.
Two comparisons were performed:
1-preterm versus full-term hypospadiac patients
2-small for gestational age (SGA) versus normal growth hypospadiac patients
Identified variants and potential biological consequences were assessed using MobiDetails and UniProt.
58 hypospadiac boys were premature (20.1%, mean 34WG). The variant rs498687 in CYP11A1 gene was more frequently found in preterm than in full-term babies (OR:5.2, p=0.015). CYP11A1 is essential for steroid biosynthesis and is highly expressed in the placenta.
SGA was found in 46 cases (14.5%, mean:2.07kg) who exhibited a more severe phenotype than normal-growth patients (p<0,01). Four variants were significantly associated with SGA in RSPO1, ARID1A, MAP3K1 and CITED2 which are genes implicated in placental angiogenesis, architecture and embryo implantation.
Variants in DSD-genes implicated in placental development or function are more frequent in patients with hypospadias when they are preterm or SGA. Better targeting of genetic analysis in these patients may be advisable.
15:05 - 15:08
David DIAMOND 1, Karen DOERSCH 1, Tanya LOGVINENKO 2, Saafia MASOOM 2, Ozge YETISTERICI 2, Alyssia VENNA 2 and Caleb NELSON 2
1) University of Rochester Medical Center, Urology, Rochester, USA - 2) Boston Children's Hospital, Urology, Boston, USA
There has been heightened scrutiny of surgical antibiotic prophylaxis to minimize bacterial resistance and medical expense. Stented hypospadias repair has traditioinally entailed intraoperative parenteral and post-operative oral antibiotic prophylaxis although evidence supporting either is limited. Prior studies focused on post-operative prophylaxis. We retrospecrtively investigated the benefit of perioperative parenteral antibiotic in preventing surgical site and urinary tract infections.
MATERIAL AND METHODS
828 patients undergoing stented, distal hypospadias repair were included. 728 received perioperative antibiotics (Cephazolin or Clindamycin) whereas 100 received no antibiotic. The large majority were TIP repairs, stented from 3-7 days. Surgical site and urinary tract infectious complications were determined in both the antibiotic prophylaxis and no antibiotic groups. Additionally, 681 of the 828 patients received post-operative oral antibiotic until stent removal.
Logistic regression (with propensity scores for antibiotic use) was used to compare effects of antibiotic on infectious complications. Bootstrap was used to obtain confidence intervals for differences between treatment groups.
Infectious complications included UTI (7), acute cellulitis (3), wound infection (1) and infected inclusion cyst (1) for an overall rate of 1.4% (12/828). Within the no parenteral antibiotic group was one infectious complication--UTI (1%, 1/100). Within the parenteral antibiotic prophylaxis group were 11 infectious complications (1.5%, 11/728). Notably, there was one case of recurrent C. Difficile infection in the parenteral antibiotic treatment group.
The odds of infectious complications were not different between the parenteral antibiotic and no parenteral antibiotic groups (OR=0.65, p=0.73).
Additionally, we discovered that all 12 patients with an infectious complication had received oral antibiotic.
In this, the largest retrospective study of antibiotic propohylaxis in stented, distal hypospadias repair we found no advantage to using perioperative, parenteral antibiotic. Neither did oral antibiotic appear to confer benefit. The C. Difficile was a reminder of antibiotic risks.
15:08 - 15:11
University Hospital Frankfurt, Department of Pediatric Surgery and Pediatric Urology, Frankfurt, GERMANY
During the COVID-19 pandemic lockdown periods, hospitals had to reduce elective surgical procedures due to restricted resources. First lockdown was from 2020/03/22 to 2020/05/04, second from 2020/12/13 to 2021/02/14. As hypospadias repair is an elective operation, we wanted to study the influence of the lockdown on hypospadias surgery nationwide.
MATERIAL AND METHODS
The national database for Germany for administrative claims data for the years 2019, 2020 and January to September 2021 was analyzed. All patients from 0-17 years admitted for surgery with the ICD-10 code for hypospadias (Q54) and code for reconstruction of hypospadias (5-624) were retrieved for further analysis.
7,582 patients with hypospadia were included, 2,896 in 2019, 2,640 in 2020 and 2,049 from 01-09/2021. 61% of the children were between one and two years of age. There was a significant reduction of admissions for correction of hypospadias during the lockdown. Mean number of admitted children per workday was 11.27 during non-lockdown, 2.86 during the first, and 7.88 during the second lockdown. During lockdown less severe hypospadias were treated. Without lockdown 35.7% had glandular, 44.9% penile, and 19.4% other types of hypospadias. During lockdown 47.9% had glandular, 34% penile, and 18.1% other type of hypospadias. Mean length of stay was 5.9 days during lockdown and 5.7 days at non-lockdown.
During the first lockdown there was a great reduction of caseloads for hypospadias surgery, during the second the health system adapted better to the situation.
15:11 - 15:14
Tariq Osman ABBAS
Sidra Medicine, Urology, Doha, QATAR
The currently utilized hypospadias severity classification systems are based on the position of the hypospadiac meatus. The introduced classification system reflects on the main pathogenesis behind this anomaly being objectively addressed. The goal of the study was to appraise the location of the bifurcation of the corpus spongiosum (BCS) relative to penile shaft as an indicator of the severity of hypospadias.
MATERIAL AND METHODS
Patients less than 18 years old with primary hypospadias were included in the study. The urethral defect ratio (UDR) results from the division of the urethral defect (distance between the glandular knobs and BCS) relative to the stretched Penile length (SPL). Hypospadias severity was then categorized into three grades: UDR <0.5, 0.5-0.99 and ≥ 1.0 respectively.
A total of 67 patients aged 12.3 ± 3.7 months with primary hypospadias were enrolled. The UDR ranged between 0.2 and 1.3. There was a significant difference observed between UDR grades and the degree of curvature (P<0.0001), and urethral plate quality(P<0.0001), and associated anomalies(P<0.05) unlike in the case of meatal position-based classification system.
A hypospadias severity scoring system based on urethral defect reflects on its embryological etiology and relative to the penile shaft appears objective, feasible and consistent tool. This system could facilitate objective description of the hypospadias anomaly and further supports precise communication between surgeons and centers.
15:14 - 15:17
Childern‘s hospital of Shanghai, Urology, Shanghai, CHINA
To investigate the relationship between anogenital distances(AGDs) and different characteristics of hypospadias.
MATERIAL AND METHODS
total of 113 hypospadias cases and 127 male controls with normal genitalia were retrospectively collected in our single center between August 2019 and August 2020. Boys with hypospadias were classified as different severities, preterm and term, birth weight(BW)＜2500g and BW≥2500g, and small for gestational age(SGA) and appropriate for gestational age(AGA) group respectively, while relevant data about patients' age, height, weight, BW and gestational age (GA) were obtained from medical records system. AGDs were measured by digital calipers under anaesthetic. The relationship between AGDs and different characteristics of hypospadias was assessed statistically.
Males with hypospadias had shorter AGDs[(36.26±10.98)mm vs (40.76±10.73)mm, (70.79±18.52)mm vs (79.97±11.05)mm, (82.51±20.89)mm vs (91.06±11.74)mm;P＜0.05)] compared with controls. There was no difference between two groups in age, height and weight(P＞0.05).In addition,anogenital distance-1(AGD-1) and anogenital distance-2(AGD-2) were observed significantly negatively correlated with the severities of hypospadias(P＜0.05). In boys with hypospadias, there were significantly shorter AGDs in boys born SGA and shorter AGD-1 in boys born premature or BW＜2500g.
These results indicated that boys with hypospadias had shorter AGDs compared with controls, and there were shorter AGDs in severe hypospadias. Meanwhile, boys born SGA, premature and low birth weight had significantly shorter AGDs.
15:17 - 15:20
Shreyas RAI 1, Pranav JASUJA 1 and Rajendra NERLI 2
1) JAWAHARLAL NEHRU MEDICAL COLLEGE, KLE UNIVERSITY, UROLOGY, Belagavi, INDIA - 2) JN Medical College, KLE Academy of Higher Education and Research, Urology, Belagavi, INDIA
Despite hypospadias being common congenital anomaly in boys,exact mechanism remains unclear. Disruption of balance between androgens and estrogens required for normal sexual differentiation of the external genitalia is an important cause.We have analyzed AR expression in children with hypospadias and compared them with children having normal genitalia.
MATERIAL AND METHODS
Group 1 (controls) consisted of children with normal genitalia (who underwent circumcision for phimosis or other reasons), while Group 2 involved children with hypospadias, with bilateral fully descended testis, and had not received any preoperative testosterone. Foreskin was collected during surgery , was fixed in formalin, paraffin embedded, and sectioned.Foreskin specimens were analyzed for AR expression using immunohistochemistry. AR staining was expressed as H score which was calculated by multiplying the intensity of staining and the percentage of stained cells showing cytoplasmic positivity . The mean H score was compared between hypospadias children and controls using Student’st‐test.
There were 24 patients in Group 1 and 32 in Group 2. In Group 2, 12 patients had proximal hypospadias while 20 had distal hypospadias. Mean H score was significantly higher (P= 0.001) in hypospadias patients (221.5) compared to controls (94.0). H score was significantly higher in children with proximal hypospadias compared to children with distal hypospadias.
AR expression was significantly elevated in children with hypospadias , and was similarly higher in children with proximal hypospadias when compared to children with distal hypospadias, probably due to end‐organ overexpression.