ESPU Meeting on Thursday 20, April 2023, 09:30 - 10:25
09:30 - 09:33
S09-1 (OP)
Cynthia Sze-Ya TING and Pei-Yeh CHANG
Chang Gung Children's Hospital, Department of Pediatric Surgery, Taoyuan, TAIWAN
PURPOSE
Ventral penile curvature is one of the most important considerations when deciding on appropriate surgical procedures in proximal hypospadias repair. Curvature >30° usually requires urethral plate transection, dorsal plication, and/or ventral corporal lengthening. However, there is a dearth of evidence for the efficacy and long-term effects of these procedures. This study aimed to evaluate the effects external tissue traction after urethral plate transection alone on penile curvature in two-stage repair of proximal hypospadias.
MATERIAL AND METHODS
The degree of ventral penile curvature in each patient was measured using a goniometer under artificial erection. Measurements were taken before and immediately after urethral plate transection, and during the second stage of repair. Patients who underwent surgery other than stage repair were excluded.
RESULTS
Proximal hypospadias patients who underwent a two-stage repair with urethral plate transection were included (n = 46). No dorsal plication nor corporotomy was done. The median age at the start of treatment was 13 months. The median angle of ventral curvature measured under artificial erection was 70° after devolving, 60° after urethral plate transection, and 0° during the second stage. Of the 46 patients, ventral curvature was fully corrected in 42 (91%).
CONCLUSIONS
Most cases of ventral penile curvature in primary proximal hypospadias can be corrected following urethral plate transection alone in a two-stage repair. Full correction generally occurs over several months after urethral plate transection. Therefore, other invasive procedures such as corporotomy or ventral lengthening are not justified when ventral curvature remains present immediately after urethral plate transection.
09:33 - 09:36
S09-2 (OP)
Ruslan BATRUTDINOV 1, Zafar ABDULLAEV 2 and Saidanvar AGZAMKHODJAEV 2
1) Scandinavia Clinic, Pediatric urology, St Petersburg, RUSSIAN FEDERATION - 2) National Children's Medical Center, Pediatric urology, Tashkent, UZBEKISTAN
PURPOSE
The choice of optimal surgical repair for proximal hypospadias is still controversial. In cases of severe ventral curvature, ventral lengthening and grafting are challenging for surgeons. The newly-promoted idea of a three-stage proximal hypospadias repair - the STAC (straighten and close) seems to be a reliable surgery. Herein, we report our preliminary experience with STAC in primary proximal hypospadias in boys
MATERIAL AND METHODS
20 boys (mean age 8±2 months) with proximal hypospadias underwent three staged STAC repairs between December 2020 and August in 2022. Including criteria was ventral curvature (VC) >40~90 degrees after degloving of the penis and ventral skin deficiency with primary severe hypospadias. The mean ventral curvature was 60±34 degrees. Penile curvature was corrected by three corporotomies methods in all children, on the second stage was performed artificial erection test, and VC was less than 5 degrees in all patients. In the second stage (Bracka's first stage) mucosal grafting was performed from the lower lip and inner preputial skin in all patients. The third stage was completed with urethroplasty.
RESULTS
The first stage of surgery was successful in all patients. During the follow-up period (mean age 8±4 months) there was a slight graft contraction only in 4 (20%) patients in the second stage. The interoperative period between surgeries was at less than 6 months. The third stage was completed in 10 (50%) patients with suprapubic catheter insertion. All patients' early postoperative period was free of complications such as meatal stenosis, fistula, stricture, and glans dehiscence.
CONCLUSIONS
STAC repair achieves proper straightening of the penis and allows for reconstruction of a good urethra with a well cosmetic appearance of penis. However, long-term follow-up is important to address the results of ventral corporotomies.
09:36 - 09:39
S09-3 (OP)
Amanda RAINES, Nicolas FERNANDEZ, Jennifer AHN, Mark CAIN, Byron JOYNER, Kathleen KIERAN, Paul MERGUERIAN, Hailey SILVERII and Margarett SHNORHAVORIAN
Seattle Children's Hospital, Urology, Seattle, USA
PURPOSE
Blood supply to preputial flap drives outcomes of hypospadias repair. Unfortunately, we only have surgeon’s subjective assessment to evaluate flap perfusion which may not be accurate.
Indocyanine green (ICG) has been used in a multitude of surgeries for perfusion assessment, however, no standardized protocol has been described for use of ICG in hypospadias repairs.
We aimed to develop a standardized protocol of ICG use in proximal hypospadias and establish perfusion patterns of preputial flaps.
MATERIAL AND METHODS
A pilot study was conducted using ICG in patients with proximal hypospadias undergoing first stage repair with a preputial flap. The Stryker SPY PHI system and novel quantification software, SPY-QP, were used for ICG imaging. An adaptive approach was taken to develop and implement a standardized protocol. ICG was dosed before flap harvest, after flap mobilization, and after flap anastomosis and skin closure is completed.
RESULTS
A total of 7 cases underwent first stage hypospadias repair with preputial flaps and intraoperative use of ICG. Mean ICG uptake prior to harvesting the flap was 85.5% compared to 42% after flap harvesting and mobilization (P = 0.0008). After mobilization of the flap in 4 out of 5 cases there was significant decrease in ICG uptake with QP measurements ranging from 5-53%.
On early post operative follow up, five of the six flaps appeared healthy. One case had a band of scar tissue across the flap which correlated to an area of decreased ICG uptake intraoperatively. There were no intraoperative complications.
CONCLUSIONS
A standardized protocol for ICG use in proximal hypospadias was successfully implemented. ICG uptake decreased with mobilization of the flap. Reliance on surgeon’s subjective assessment of flap perfusion may be inadequate and ICG could provide a useful tool for surgeons to improve preputial flap outcomes.
09:39 - 09:44
S09-4 (VP)
Irene PARABOSCHI 1, Erika Adalgisa DE MARCO 1, Dario Guido MINOLI 1, Michele GNECH 1, Giovanni PARENTE 2, Filippo MOLINARI 1, Carolina BEBI 1, Gianantonio MANZONI 1 and Alfredo BERRETTINI 1
1) Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Pediatric Urology, Milano, ITALY - 2) Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Pediatric Surgery, Milan, ITALY
PURPOSE
Firstly described by Duckett in 1981 and initially used for mid-penile hypospadias, the onlay preputial island flap urethroplasty has progressively gained more popularity, extending its indication to proximal hypospadias. However, with the severity of the penile anomaly, the rate of postoperative complications has also increased. A new tool capable of assessing the vascular perfusion of the preputial island flap in real-time was therefore introduced aiming to reduce the occurrence of postoperative complications potentially induced by a reduced vascular supply.
MATERIAL AND METHODS
The EleVision IR system (Medtronic Ltd) was intraoperatively adopted to assess the vascular perfusion of the preputial island flap in a 13-month-old boy undergoing the onlay urethroplasty for a mid-shaft hypospadias, 80 seconds after the intravenous injection of indocyanine green (ICG, 0.15 mg/kg).
RESULTS
ICG-based laser angiography helped to assess the perfusion of the preputial island flap in real-time, guiding the excision of the peripheral poorly vascularized tissue and confirming the viability of the tubularized neourethra.
CONCLUSIONS
ICG-based laser angiography proved to be safe, effective, and easy to employ and should be considered as a reasonable adjunct for tissue perfusion assessment and operative decision-making in patients undergoing the reconstructive onlay preputial island flap urethroplasty.
09:58 - 10:01
S09-5 (OP)
Samia LARAQUI, Melodie JURICIC, Olivier AZZIS, Edouard HABONIMANA and Alexis P ARNAUD
University Hospital of Rennes, Pediatric Surgery, Rennes Cedex 2, FRANCE
PURPOSE
In 2013, our preliminary study has shown the feasibility and safety of the use of an autologous platelet-rich fibrin (PRF) membrane for urethroplasty coverage in distal hypospadias. With a short median follow-up of 8 months, there was no significant statistical difference in uretro-cutaneous fistula occurrence. The aim of our present study was to evaluate the long-term risk of uretro-cutaneous fistula when using this autologous PRF membrane.
MATERIAL AND METHODS
A retrospective single center review was performed on all patients undergoing tubularized urethral plate urethroplasty associated with a covering layer, either PRF or subcutaneous flap (SF), for distal hypospadias repair between January 2010 and December 2020. Data are given in medians (range).
RESULTS
328 patients were included: 48 (15%) operated on using PRF membrane coverage and 280 (85%) using SF as a covering layer. Age at surgery was 8,9 and 8,6 months respectively. A Snodgrass incision was performed in 36 (75%) PRF patients and 209 (75%) SF patients. With a follow-up of 86,8 months (0,7-139) for PRF group and 51,1months (0,4-144) for SCF group, fistula occurred in 12 (25%) patients and 10 (3,6%) respectively (p<0,001). Time between surgery and uretro-cutaneous fistula diagnosis was 22,3 months (1,4-132) in PRF group and 10,5 months (0.5-38) in SCF group.
CONCLUSIONS
Although giving promising results in other surgery, PRF membrane seems to increase the risk of uretro-cutaneous fistula in distal hypospadias surgery and should not be used for urethroplasty coverage at first instance.
10:01 - 10:04
S09-6 (OP)
Hanno WIRMER, Mohamad FAWZY, Michael SENNERT and Ahmed HADIDI
Sana Klinikum Offenbach, Kinderchirurgie, Offenbach, GERMANY
PURPOSE
To evaluate the Decision Satisfaction and Decision Regret among adolescents and adults (older than 15 years) after early childhood hypospadias surgery and their parents
MATERIAL AND METHODS
207 Patients operated on hypospadias in infancy in a single center and now adolescent or young adults and their parents were contacted to complete a survey consisting of a questionnaire concerning the satisfaction with the operative result, the regret with the operative decision and the health related quality of life (HRQOL). Questionnaires were based on the Decision regret scale available in literature with a score of 100 meaning maximum Dissatisfaction or Regret, and on the Kidscreen10 index. Satisfaction was measured on a scale from 1-5 with 5 signifying full satisfaction.
RESULTS
Only 53 patients from 15-43 years (mean age 19,7 years) completed the survey (25%). 15,1% reported mild and 7,5% moderate decisional regret ( mean decisional regret score 5,9). The mean HRQOL T-score was 52,5 (SD 10, control Group of adolescent males from 12-18 years.).
The Patient's satisfaction with the operative Result was 5 (full satisfaction) in 66%, 4 in 22,6%, 3 in 7,5% and 2 in 1,9%, with 1,9% abstention (mean satisfaction score 4,54).
Of the 42 participating parents, 6 (14,3%) reported mild, 2 (4,8%) moderate, and 1 (2,4%) strong decisional regret (mean decisional regret score 5,1).
CONCLUSIONS
The results suggest that 88% of the patients were satisfied with early hypospadias surgery with average HRQOL and low level of decisional regret in patients as well as parents. The findings support the current practice of operating in early childhood. However, repeated assessment in a larger number of patients after the age of 30 years is warranted.
10:04 - 10:07
S09-7 (OP)
Daniela Brindusa GORDUZA 1, Yaqoub JAFAR 2, Valeska BIDAULT 2, Pierre Yves MURE 3 and Pierre MOURIQUAND 3
1) CENTRE HOSPITALIER UNIVERSITAIRE DE SAINT-ETIENNE, Hôpital Nord, PAEDIATRIC SURGERY, Saint Etienne, FRANCE - 2) Hospices Civils de Lyon, Hôpital Mère-Enfant, Department of Pediatric Surgery and Urology, Lyon, FRANCE - 3) Universite Claude Bernard Lyon 1, Hospices Civils de Lyon, Hôpital Mère-Enfant, Department of Pediatric Surgery and Urology, Lyon, FRANCE
PURPOSE
The Koyanagi technique is use for the most severe form of hypospadias. The goal of this study was to evaluate the results of the Koyanagi urethroplasty in 88 perineal hypospadias.
MATERIAL AND METHODS
Single center retrospective cohort study was conducted. Only the patients with perineal hypospadias corrected by Koyanagi technique was included. Surgery was performed between 2003-2017 using the same protocol. Long term results were evaluated at the last follow-up consultation.
RESULTS
The mean age at surgery was 21 months (11 months – 11 years). Seventy-six/88 patients had an endocrine and genetic assessment (27/76 (35%) had identified hormonal or genetical abnormalities). Sixty-six received preoperative androgen stimulation. Thirty-three required a concomitant corporeoplasty to straighten the penis. The mean follow up was 6 years. Sixty-seven patients (76%) presented with complications: 59 % dehiscence, 11.3 % fistula, 5.6 % stricture, 4.5 % urethrocele, 9% urinary tract infection. Sixty-three had re-do surgeries, 29 of them had complications after re-do surgery. Late functional and cosmetic results were satisfactory in 57 patients (67%).
CONCLUSIONS
This technique has a significant complication rate and re-operations like all the techniques used for proximal hypospadias. Parents should be informed that several stages are usually required in most proximal hypospadias treated with the Koyanagi procedure. More studies are essential to fully evaluated the long-term outcome after puberty.
10:07 - 10:11
S09-8 (LOP)
Ayse KARAGOZ 1, Nil COMUNOGLU 2, Hakan SAHIN 3, Meral KOYUTURK 4 and Haluk EMIR 1
1) Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Pediatric Surgery, İstanbul, TURKEY - 2) Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Pathology, Istanbul, TURKEY - 3) Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Basic Medical Sciences, Histology and Embryology, Istanbul, TURKEY - 4) Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Basic Medical Sciences, Histology and Embryology, Istanbul, TURKEY
PURPOSE
It is known that penile tourniquet (PT) causes ischemic damage on erectile tissues that increases with longer durations. This study aims to investigate the effects of “continuous artificial erection” (CAE) technique on penile erectile tissues, in an experimental model.
MATERIAL AND METHODS
A total of 35 rats were randomized into 5 study groups. Twenty and forty minutes of PT alone (20T and 40T) or with CAE (20T&E and 40T&E) were applied in 4 experiment groups. CAE was achieved via continuous intracavernosal saline injection. Penectomy was performed 3 weeks after the procedures in the experiment groups and directly in the control group. Erectile tissue samples were evaluated via light microscopy and immunohistochemistry (eNOS, CD62E and ICAM-1 staining). One or two cases from each group were also investigated via transmission electron microscopy (TEM), as a preliminary study.
RESULTS
Highest histopathological scores for inflammation and fibrosis, and the most significant immunohistochemical findings of endothelial damage were seen in the 40T group. The 20T&E and 40T&E groups showed decreased degree of fibrosis and endothelial damage in comparison with the isolated PT groups. The 20T&E group revealed no evidence of fibrosis, and all of the endothelial markers were preserved in this group. Among the binary comparisons between experiment groups, most significant differences were found between the 20T&E and 40T groups. The preliminary TEM results showed reduced endothelial vesicules and widened subendothelial space in all groups, and connective tissue fiber ondulations in T&E groups.
CONCLUSIONS
Findings of this experimental study support that continuous artificial erection via intracavernosal saline injection does not increase the erectile tissue damage that is already caused by PT, but rather decreases it. More detailed TEM studies are required for further investigation.