ESPU Meeting on Thursday 9, June 2022, 16:55 - 17:40
Sara FAILY 1, Sumita CHHABRA 1 and Harriet CORBETT 2
1) Alder Hey Children's NHS Foundation Trust, Department of Surgery, Liverpool, UNITED KINGDOM - 2) Alder Hey Children's NHS Foundation Trust, Regional Department of Urology, Liverpool, UNITED KINGDOM
Previous studies have identified that up to 20% of boys undergoing circumcision for Lichen Sclerosus (LS / BXO) require later meatal intervention. It has been suggested that meatotomy at the time of circumcision is protective. This study aims to determine factors associated with requirement for further meatal procedures post circumcision.
MATERIAL AND METHODS
Patients undergoing circumcision for histologically confirmed LS between January 2011 - February 2020 were identified, boys with hypospadias were excluded. Case notes were reviewed retrospectively to identify topical steroid use pre- and post-operatively, glans involvement and meatal procedure at time of circumcision and subsequent procedures.
382 boys underwent circumcision at a mean age of 9.1 years (SD 2.9 years). 8% underwent emergency circumcision following admission with acute urinary retention. Median follow-up was 4 months (IQR 3 - 11 months). Intra-operatively, the glans was affected by LS in 213/365 (58%) cases (not documented in 17). Of these, 224/365 (61%) were prescribed post-operative topical steroids. At the time of circumcision, 25 (7%) patients underwent meatotomy and 94 (25%) underwent meatal dilatation.
Following circumcision, 40 (10%) symptomatic patients required a median of 1 further procedure for meatal stenosis (range 1 to 5); 8 (2%) had dilatation alone. 32 (8%) required meatotomy, of whom 14 had had a meatal intervention at the time of circumcision (5 meatotomy, 9 dilatation). Using multiple logistic regression analysis, initial meatotomy and / or dilatation and prescription of post-op steroids were significantly associated with requirement for any post-circumcision meatal intervention (p<0.05). Meatotomy at the time of circumcision (but not meatal dilatation) and prescription of post-op steroids were significantly associated with undergoing a further meatotomy (p<0.05).
Neither meatal intervention at the time of circumcision nor post operative topical steroids seem to protect against subsequent symptomatic meatal pathology. Prospective studies are required identify optimal management of the meatus in boys with LS.
Abdul Rauf KHAN, Muhammad Ruhul AMIN, Darrel GREGORY, Murtaza KHANBHAI and Atif SAEED
Thornhill Clinic, GP Community Clinic, Luton, UNITED KINGDOM
BACKGROUND AND PURPOSE
Circumcision with the plastic ring is commonly performed in the community in children.
Plastibell has been frequently used for children’s circumcisions. However, ring migration is often observed with Plastibell circumcision (PC). Circumplast® is a relatively new ring which is increasingly being used in our practice.
We investigated the impact of Circumplast® circumcision (CC) in minimising the risk of ring migration, early postoperative complications and interventions required to remove the rings.
MATERIAL AND METHODS
Circumplast and Plastibell were rings used in our clinic. Both PC and CC have similar principles for application, except for the design of the rings. Circumplast® has a longer sheath and is cylindrical in shape.
This study retrospectively reviewed the outcomes of circumcisions performed in children(April 2014 to December 2020). All circumcisions were performed under local anaesthesia, by trained doctors and paediatric surgeons. The choice of technique was dependent on the doctor’s preference, child’s anatomy and parental choice. The patients' demography, postoperative complications, any postoperative intervention, phone calls received, unplanned visits and follow-up were analysed.
The practice received parents’ calls (PC n=1118 vs CC n=477) for follow-up. Mean follow-up for children were 17±1 days (median 6) in PC versus CC (18±1.5 vs 13±1.3 days).
Total circumcisions(n=7633) were performed during this duration with CC 2074(27%) and PC 5559(73%). Cohort’s mean age was 7.2±0.2 months (median1.6). The overall complication rate was 9%(689/7633) with no significant difference in the complications with CC(8.1% n=169/2074) versus PC(9.4% n=520/5559(p>0.5). Delayed ring separation and migration were significantly lower in CC(1.2%) than PC(4.8%)(p<0.05). Post-operative bleeding (0.8 vs 1%) and adhesions (1 vs 0.8%) were similar in CC and PC. Suspected infections (3.7% vs 1.9%) and other minor complications (1.5% vs 0.9%) were higher in CC versus PC (P<0.05) respectively.
Circumcision with Circumplast® ring decreases the risk of ring migration and impaction.
Ahmed ELHELALY 1, Fuad KHODIER 2, Fares ALHARBI 2 and Abdulhakim ALOTAY 2
1) Prince Sultan Military Medical City, Urology, Riyadh, SAUDI ARABIA - 2) Prince Sultan Military Medical City, Dept. of Urology, Riyadh, SAUDI ARABIA
Meatotomy(MT) as an office procedure with local anesthesia (LA) and/or meatoplasty(MP) under general anesthesia (GA) are the treatment options for meatal stenosis(MS). Our aim is to highlight the clinical outcomes in both procedures.
MATERIAL AND METHODS
178 boys diagnosed with meatal stenosis,in the period (2007-2018), were retrospectively evaluated . Median follow-up period was 14 months. Uncircumcised patients, those with previous urethral surgeries, and/or missed follow up, were excluded. Medical records of patients, who underwent MT and/or MP, were reviewed. Variables analyzed were age and symptoms at presentation, timing of circumcision, technique and timing of the procedure and the condition of patients during and at end of follow up. P value ˂ 0.05 is considered statistically significant.
156 patients were included, all were circumcised before 6 months age and 82% of them were in the neonatal period. 30 patients underwent (MP)and 126 underwent (MT). Median age at presentation was 4 and 6 years, and median age at time of procedure was 4.2 and 7 years, for MP and MT groups respectively. By the end of follow up period, recurrence was encountered in (6% and 12%; p-value is 0.352), in MP and MT groups respectively. Of note, no recurrence was detected in the first 2 months post-procedure; however, all recurrent cases were manifesting by 6th month of follow up post procedure. All cases with recurrent MS post MP and 87% of MS post MT were managed successfully with a second office MT, and the remaining 13% were managed successfully by MP.
Office meatotomy is a feasible effective procedure for boys with cogenital meatal stenosis. It carries no inferior success rates vs. MP, sparing this group of patients from risks of GA together with decreasing the economic burden. Second MT after failed initial procedure MT or MP still carries a very high success rate and could be offered for recurrence post either MP or MT.
Francisco De Borja NAVA Y HURTADO DE SARACCHO 1, Detlef OLIU 2, Virginia AMESTY MORELLO 3, Susana RIVAS VILA 3, Roberto LOBATO ROMERA 3, Maria Jose MARTINEZ URRUTUA 3 and Pedro LOPEZ PEREIRA 3
1) Childrens' Hospital La Paz, Pardiatric Urology, Madrid, SPAIN - 2) Complejo Hospitalario Universitario de Badajoz, Pediatric Surgery, Badajoz, SPAIN - 3) Hospital Universitario La Paz, Paediatric Urology, Madrid, SPAIN
Non-ischaemic priapism (NIP) is a partial erection lasting ≥ four hours due to unregulated cavernous inflow following formation of an arteriolar-sinusoidal fistula. Supraselective arterial embolization (SAE) is the treatment of choice in the pediatric population. No information has been published about long-term results in this population. We present our outcomes in seven patients in a twenty-year period time.
MATERIAL AND METHODS
Retrospective study of patients diagnosed with NIP between 2001-2021. Medical and radiological information were analysed. Erectile function was determined using the International Index of Erectile Function short-from (IIEF-5) in patients older than sixteen years old and a questionnaire about the characteristics of physiological erections to the parents for the rest at follow-up.
Mean age at diagnosis was 6,5 years (0,58 – 11) from a total of seven. Four patients had a clear traumatic ethiology and three patients had a normal colour-doppler ultrasound (CDU). All patients underwent embolization due to unresponsiveness to conservative approach. Three patients have a normal sexual function according to IIEF-5 with a mean result of 22,3. The remaining patients have normal day-night erections with a flaccid penis in between. No recurrences were reported.
NIP is associated with an arteriolar-sinusoidal fistula and in certain cases, the causative factor remains unknow. CDU allows to verify the preservation of blood flow and to locate possible fistulas, but this is not always possible. We demonstrated that SAE is a safe approach without long-term complications.
Amr A. ELBAKRY 1, Zachary WERNER 1, Chad CRIGGER 1, Khaled ALDABEK 2 and Osama AL-OMAR 1
1) West Virginia University Hospital, Urology, Morgantown, USA - 2) West Virginia University School of Medicine, Urology, Morgantown, USA
We are presenting a rare case of true diphallia. In this video, we will present our evaluation and demonstrate the surgical technique for management of a patient with complete duplicated penis.
MATERIAL AND METHODS
Our patient is an 11-month-old male who presented initially as 28-day-old that was referred for evaluation of abnormal male genitalia. Physical examination showed duplicated penis with penoscrotal transposition and large scrotal lipoma. VCUG was done and showed Y-shaped duplicated urethra, with normal right urethra and atretic narrow left urethra. Diagnosis was confirmed with US and MRI, that showed complete duplication of the penis with separate two corpora cavernous and a corpus spongiosum and urethra in each penis. We decided to proceed with surgical correction with amputation of the left penis as right penis has the normal urethra evidenced by the VCUG. Cystourethroscopy confirmed normal right urethra. Next, bilateral sub-coronal circumferential incisions were made, and complete deglovig was completed. The lipoma of the scrotum was excised. The left penis was amputated. Next, the two hemiscrotums were mobilized. The scrotal flaps were brought ventrally and approximated in the midline. penile skin was trimmed and redistributed for penile coverage.
Our procedure was successful with total operative time of 4 hours, minimal blood loss and the patient was discharged home on the same day. Urethral catheter was removed at POD7. There was no reported Complications, no fistula, no wound dehiscence or discharge. Pathology confirmed the diagnosis of accessory penis with normal left and right corpora cavernosum and atretic urethra.
We demonstrated a surgical technique for correction and reconstruction of the male genitalia in this rare case.
Pierre AKIKI 1, Annabel PAYE-JAOUEN 2, Annabel PAYE-JAOUEN 3, Caroline FARNOUX 1, Pauline LOPEZ 2, Laetitia MARTINERIE 4, Alaa EL GHONEIMI 3, Alaa EL GHONEIMI 2, Valérie BIRAN 1, Matthieu PEYCELON 3 and Matthieu PEYCELON 2
1) Department of Neonatology, University Hospital Robert Debre, APHP, University of Paris, Paris, FRANCE - 2) Department of pediatric surgery and urology, National Reference center for Rare Urinary Tract Malformations (MARVU), University Hospital Robert Debre, APHP, University of Paris, Paris, FRANCE - 3) National Reference center for Rare Endocrine Disorders affecting Growth and Development (CRMERCD), University Hospital Robert Debre, APHP, Paris, FRANCE - 4) Department of pediatric endocrinology, 2. National Reference center for Rare Endocrine Disorders affecting Growth and Development (University Hospital Robert Debre, APHP, University of Paris, Paris, FRANCE
To establish novel nomograms for penile and glans anthropometry in neonates and to study the inter-individual variability in measurements between a resident and a senior neonatologist.
MATERIAL AND METHODS
A prospective cross-sectional mono-centric study was conducted over a 5-month period in 2021 including all infants admitted in NICU (<32GW, 32-37, >37). Exclusion criteria: major congenital malformations, DSD, bilateral undescended testicles. Resident and senior neonatologists were taught by a senior paediatric urologist how to measure penile length (PL) and glans diameter (GD) on a newborn using a paper towel. Primary endpoint: variability of measurements defined by a difference >5%. Statistics: Mann-Whitney, Fisher's, Chi2, Anova.
50 neonates at a median (IQR) term of 36.6 GW (32-39) were included. Median PL and GD were 3.1 (2.8-3.5) and 1.2cm (1.0-1.4) respectively. Median PL and GD (<32GW (N=14), 32-37 (N=12), >37 (N=24)) increased significantly with gestational age: 2.6 (2.2-2.9), 3.0 (2.8-3.2) and 3.5cm (3.2-4.2) (p<0.001); 1.0 (0.9-1.4), 1.2 (1.1-1.2) and 1.3cm (1.2-1.5) (p=0.05), respectively. Higher birth weight, no IUGR, lower maternal and paternal age, and singleton were not associated with larger measurements. Median (IQR) variability (cm and %) in PL and GD between resident and seniors was 0.1cm (0.1-0.4) (4.5%) (p>0.05) and 0.1cm (0.1-0.2) (10.6%) (p=0.01) respectively. Gestational age was a not an overall risk factor for inter-observer variability. However, a statistically significant variability for GD was found between resident and senior physicians in neonates <32GW
This pilot study tried to determine penile nomograms for preterm babies while considering the inter-observer variability between physicians. Standardization of measurements techniques is crucial to ensure reliable results.
Antoine SOUTIF 1, Claude LOUIS-BORRIONE 2, Estelle AUBRY 3, Aline RANKE 4, Daniela GORDUZA 5, Alaa EL-GHONEIMI 6, Caroline CAMBY 7, Sophia MOUTTALIB 8, Magali VIAUD 9, Yves HELOURY 10, Georges AUDRY 1 and Alaa CHEIKHELARD 11
1) Trousseau University Hospital, Pediatric Surgery and Urology, Paris, FRANCE - 2) Marseille University Hospital / Hôpital La Timone-Enfants, Pediatric Surgery and Urology, Marseille, FRANCE - 3) Lille University Hospital - Hôpital Jeanne de Flandres, Pediatric Surgery and Urology, Lille, FRANCE - 4) Nancy University Hospital, Pediatric Surgery and Urology, Nancy, FRANCE - 5) Lyon University Hospital - Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Pediatric Surgery and Urology, Bron, FRANCE - 6) Robert-Debré University Children Hospital, Pediatric Surgery and Urology, Paris Cedex 19, FRANCE - 7) Nantes University Hospital, Pediatric Surgery and Urology, Nantes, FRANCE - 8) Toulouse Children's University Hospital, Pediatric Surgery and Urology, Toulouse Cedex 9, FRANCE - 9) National Reference Center for Gynecological Rare Diseases - Necker University Hospital, Pediatric endocrinology, Paris, FRANCE - 10) Necker University Hospital, Pediatric Surgery and Urology, Paris, FRANCE - 11) National Reference Center for Rare Gynecological Diseases - Necker University Hospital, Pediatric Surgery & Urology, Paris, FRANCE
Vaginal agenesis with functionnal uterus (VAFU) is very rare, and its management complex: restore the continuity of the genital tract in the context of painful obstructed menstruation at menarcha, without compromising the future sexual function. We aimed to analyse VAFU management by pediatric surgeons expert in pediatric gynecology (PSEPG) throughout the country.
MATERIAL AND METHODS
Multicenter retrospective observational study.
Inclusion criteria: All patients with VAFU managed by PSEPG.
Exclusion criteria: MRKH, hymenal imperforation, OHVIRA, DSD, severe pelvic malformation.
Groups: High-VAFU (Long-Gap) n=25, low-VAFU n=24, vaginal diaphragm n=3.
Pathway to diagnosis, management, results and complications were reviewed.
52 patients were managed in 9 centers since 1994, mean age: 20 yrs, mean follow-up: 5.5 yrs.
Urological malformations were more frequent when utero-cervical anomalies coexisted (50% vs 10%)
41 patients presented with painful primary amenorrhea, 9 didn't have preoperative MRI, 4 had urgent inappropriate surgery. 11 had diagnosis and 4 were operated before puberty.
19 had urgent surgery, including 11 only drained.
49 had reconstruction:
-high-VAFU: sigmoido-vaginoplasty (SV) n=10 (53%), vaginal lowering (LV) n=7 (37%) including 2 after vaginal dilatation, others n=5.
-low-VAFU: various vulvo-vaginal plasties.
-diaphragm: vaginal plasties
After SV, more late complications (8/12 (67%)) and late revisions (7/12 (58%)) occurred, compared to LV (respectively 2/7 (29%), NS and 1/7 (14%), NS). Postoperative dilatations were necessary in 67% and 71% respectively.
92% of SV were perfomed before 2014, 71% of VL after (p =0.073).
All but one achieved normal menstruation, 13 (32%) were sexually active, 1 had 2 children, 1 had hysterectomy.
2 are dilating under therapeutical amenorrhea, 1 is prepubescent (all high-VAFU)
The management of VAFU, and especially high-VAFU has shifted from an immediate anatomical approach to a delayed holistic patient-centered approach. VL by laparoscopy preceeded by vaginal dilatation, a promising technique, is definitely replacing SV.