34th ESPU Congress in Naples, Italy

S16: HYPOSPADIAS 2

Moderators: Alex Springer (Austria), Antonio Macedo (Brazil)

ESPU Meeting on Friday 19, April 2024, 10:35 - 11:50


10:35 - 10:38
S16-1 (OP)

BEYOND EFFICIENCY: DEVELOPMENT AND VALIDATION OF AN EX-VIVO ORGAN MODEL FOR OBJECTIVE EVALUATION OF SURGICAL SKILLS ACQUISITION OF HYPOSPADIAS RECONSTRUCTION

Tariq Osman ABBAS 1, Sibel TIRYAKI 2, Ali TEKIN 2, Nicolas FERNANDEZ 3, Mohamed FAWZY 4, Ibrahim ULMAN 5, Alp NUMANOGLU 6, Ahmed HADIDI 4, Iqbal HASSAN 7 and Muhammad CHOWDHURY 8
1) Sidra Medicine, Urology, Doha, QATAR - 2) Ege University, Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Izmir, TURKEY - 3) Seattle Children's Hospital, University of Washington, Department of Urology, Division of Pediatric Urology, Washington, USA - 4) Emma and Offenbach Hospitals, Hypospadias Clinic, Department of Pediatric Surgery, Offenbach, GERMANY - 5) Ege University, Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Izmir, TURKEY - 6) University of Cape Town, Division of Paediatric Surgery, Cape Town, SOUTH AFRICA - 7) Kyushu Institute of Technology, Computer Science and Engineering, Fukuoka, JAPAN - 8) Qatar University College of Engineering, Computer Science and Engineering, Doha, QATAR

PURPOSE

The assessment of surgical proficiency in the context of hypospadias procedures is crucial for educating novice surgeons. Our goal was to objectively assess individual's technical skills gain following a short hands-on cadaveric supervised Hypospadias training.

MATERIAL AND METHODS

The study utilized a combination of subjective (questionnaires and recorded videos) and objective (surface electromyography (EMG)) methodologies to examine the development of skills following completion of a hands-on urethroplasty course using ex-vivo cadaveric calf penises. The study included a cohort of twenty surgeons with varying degrees of expertise, categorized as novices (n = 11), intermediates (n = 12), and experts (n = 3). Four key skills were assessed: urethral mobilization, dorsal inlay graft harvest and implantation, meatal based flap urethroplasty and dorsal plication. We further employed machine learning methodologies to determine the essential attributes necessary for precise performance assessment.

RESULTS

The identification of skill level was found to be significantly influenced by variables associated with movement complexity. Significant differences were seen in EMG-based metrics, total time, dominant frequency, and cumulative muscle workload among the three skill groups. Additionally, it was observed that nonlinear movement variability characteristics, such as correlation dimension and Lyapunov exponent, exhibited distinct trends among the three skill groups.

CONCLUSIONS

The results of this study indicate that both economy of motion factors and nonlinear movement variabilities are influenced by the level of surgical experience. The utilization of wearable sensor signal analysis has the potential to enable the objective assessment of urethroplasty proficiency at regular intervals during the duration of a training program.


10:38 - 10:41
S16-2 (OP)

CUMULATIVE REOPERATION RATES DURING FOLLOW-UP AFTER HYPOSPADIAS REPAIR

Annaleena ANTTILA 1, Tuija LAHDES-VASAMA 1, Niklas PAKKASJÄRVI 2 and Seppo TASKINEN 2
1) Tampere University Hospital, Pediatric Surgery, Tampere, FINLAND - 2) Helsinki University Hospital, New Children's Hospital, Helsinki, FINLAND

PURPOSE

To evaluate cumulative unplanned reoperation rates after hypospadias repair.

MATERIAL AND METHODS

The study included 299 consecutive patients who had surgery before the age of 5 years and who had at least 2 years of postoperative follow-up. Among these patients, 24 were operated on for isolated chordae, 166 for distal hypospadias, 34 for midshaft hypospadias, and 75 for proximal hypospadias. Data on the types of re-operations were collected, and the risk for re-operation was assessed with Kaplan-Meier analysis.

RESULTS

The median age at the time of the primary operation was 1.4 years (IQR 1.1-1.9), with a follow-up duration of 14.4 years (IQR 12.2-15.1). The Nesbit procedure was performed on 100 (33.4%) patients. Unplanned re-operations were performed for 138 (46.2%) patients, with the problem leading to repeat surgery identified during the initial three-month post-operative control in 69 of these patients (50%). The risks of unplanned re-operation at the 5-year and 15-year follow-ups were 37.0% and 49.6% for any re-operation, 14.2% and 18.7% for fistula, 12.3% and 17.1% for urethral stricture, 2.8% and 4.8% for re-curvature, and 17.5% and 24.6% for any other reason (glans dehiscence, unsatisfactory cosmesis, megalourethra), respectively. At the 5-year and 15-years follow-ups, the risk was 17.7% and 22.5% for isolated chordae, 31.2% and 42% for distal hypospadias, 26.8% and 46.8% for midshaft hypospadias, and 61.7% and 71.9% for proximal hypospadias, respectively (Logrank <0.01).

CONCLUSIONS

The risk for unplanned re-operation following hypospadias repair consistently increases with the length of follow-up, even in distal hypospadias. Notably, the most severe cases exhibited a higher risk for re-surgery.


10:41 - 10:44
S16-3 (OP)

INCIDENCE AND TIME TO COMPLICATIONS FOLLOWING HYPOSPADIAS REPAIR: RESULTS FROM A POPULATION BASED RETROSPECTIVE COHORT STUDY, ONTARIO, CANADA 2002-2017.

Noam BAR-YAAKOV 1, Andrew MCCLURE 2, Melody LAM 3, Peter Zhantao WANG 1, Blayne WELK 2 and Sumit DAVE 4
1) London Health Sciences Centre, Western University, Surgery and Pediatrics, London, CANADA - 2) London Health Sciences Centre, Western University, Surgery, London, CANADA - 3) London Health Sciences Centre, Western University, ICES Western, London, CANADA - 4) London Health Sciences Centre, Western University, Surgery and Pediatrics (Division of Urology), London, CANADA

PURPOSE

The duration and frequency of follow-up after hypospadias repair is not well described. This study aims to assess this variation in follow-up based on the incidence and time to postoperative complications and investigate predictors of secondary intervention.

MATERIAL AND METHODS

Through a retrospective population-based cohort study, patients who underwent hypospadias repair between April 2002 and March 2017 were analyzed at ICES. Baseline variables included demographics, surgical variables, and a composite variable to capture post-operative complications. The primary outcome was secondary surgical intervention and patients were followed for up for a minimum of 5-years. Regression analyses were performed to predict secondary intervention beyond 2 years of follow-up.

RESULTS

The study included 3349 patients with a mean age of 1.28 years (SD,1.84): 299 (8.9%) were proximal, 1700 (50.8%) were distal, and 1350 (40.3%) were categorized as unknown. A total of 753 (22.5%) patients experienced an early complication within 6-months of repair, including 32 (1.0%) who had a related ER visit. Secondary intervention rate over 5 years was 20.5%: 16.2% for distal, 50.2% for proximal, and 19.5% for unknown. Among these patients, 77.0% overall and 90 % of distal hypospadias had their last intervention within 3 years of surgery. Proximal location (OR=3.8, p<0.001) and post-operative complication (OR=1.39, p=0.02) were associated with intervention beyond 2 years after surgery.

CONCLUSIONS

Results from this study suggest that a minimum of 3 years of follow-up is needed after distal hypospadias repair. Proximal location and post-operative complication are likely to require secondary intervention more than 2 years after surgery.


10:44 - 10:55
Discussion
 

10:55 - 11:00
S16-4 (VP)

SELEIM'S TOPOGRAPHY-GUIDED ANATOMICAL REASSEMBLY (STAR) FOR THE PENILE HYPOSPADIAS WITHOUT SIGNIFICANT CHORDEE: COMPREHENSIVE ILLUSTRATION AND MIDTERM RESULTS

Hamed SELEIM
Tanta University, Pediatric Surgery, Cairo, EGYPT

PURPOSE

to report a comprehensive illustration of the newly introduced "topography-guided anatomical reassembly" approach for distal penile hypospadias, as well as the mid-term outcomes of an extended series.

MATERIAL AND METHODS

This is a prospective cohort study of all cases presenting to the author's facility with distal penile hypospadias between June 2018 and January 2023. Cases with non-preservable plates (i.e. significant chordee >30°), circumcised cases, and redo cases are excluded. The procedure follows the most recently introduced principle of a topography-guided anatomical reassembly approach for distal penile hypospadias, that is, the zipping-up of the unfolded spongiosal plate.

RESULTS

During the study's inclusion period, 97 boys with distal hypospadias were enrolled. The hypospadias meatus was coronal or sub-coronal in 35 boys, distal penile in 45 boys, and mid-penile in 17 boys. The mean age at the time of the surgical correction was 8.11 months (within the range of 6-32 months). The operative time was 40-90 min (a mean of 66.7 min). Five urethrocutaneous fistulae were reported after a mean follow-up of 24.2 months: three glanular and two sub-coronal. Meatal disfigurement with a downward stream deviation was reported in two more patients. Two more occurrences of meatal recession were identified, yet surgical correction was not necessary. The overall reoperation rate was settled at 7%.

CONCLUSIONS

The proposed topography-guided anatomical reassembly technique for distal hypospadias is shown to be simple, effective, and superiorly feasible at mid-term follow-up of the given series. Maintaining the integrity of the well-developed penile tissues (such as the glans penis and lateral shaft skin) eliminates the possibility of unforgivable tissue damage and challenging revision procedures.


11:00 - 11:05
S16-5 (VP)

★ THE GUDPLAY TECHNIQUE: A SHIFT IN THE PARADIGM OF GLANS RECONSTRUCTION BY MIDSHAFT AND PENOSCROTAL HYPOSPADIAS: INTRODUCING A NEW APPROACH (VÍDEO)

Gilmar DE OLIVEIRA GARRONE, Sérgio LEITE OTTONI, Marcela LEAL DA CRUZ, Raul GARCIA ARAGON, Rafael JORDAN BALLADARES, Taiane ROCHA CAMPELO, Renata ALVES CORREA, Emanuelle LIMA MACEDO and Antonio MACEDO JR.
FEDERAL UNIVERSITY OF SÃO PAULO, NUPEP/CACAU PEDIATRIC UROLOGY, São Paulo, BRAZIL

PURPOSE

Midshaft and penoscrotal hypospadias with moderate ventral curvature can be treated in one stage with preservation of urethral plate by a Duplay tubularization, an onlay flap or also an inlay graft and tubularization. After gaining 5 years experience with the GUD technique: glanular urethra disassembly for coronal and subcoronal hypospadias, we present the GUDplay technique, incorporating the Duplay tubularization of the plate till the coronal area and disassembling the glans aggressively, to treat the curvature and refurbish the glans and down rotating it (GUD).

MATERIAL AND METHODS

After penile degloving with an U-shape incision at the urethral plate, we dissect spongious flaps laterally to the plate as suggested by Bhat. We then disassembly the distal urethra or in this case the urethral plate to the corpora and completely detach the glans from the corpora. The glans is opened in an inverted Y incision in two wings, producing great mobility of the glans. Two anchor sutures are made with 5.0 PDS bringing the urethral plate cranially. A 6.0 PDS non interrupted running subepithelial suture is made to tubularize the plate and create the neourethra, followed by the spongioplasty and a dartos second barrier layer. The urethra is sutured to the glans and the wings are joined in the midline by 6.0 PDS sutures. An indwelling 10Fr silicone tube is left for 7-10 days

RESULTS

Patient had an excellent outcome without any complications

CONCLUSIONS

We believe that the GUDplay technique may be a promising alternative to midshaft and some penoscrotal hypospadias adding the GUD technique principles to the classic Duplay technique.


11:05 - 11:08
S16-6 [WITHDRAWN] SIMPLIFIED PATIO TECHNIQUE FOR URETHROCUTANEOUS FISTUL AFTER HYPOSPADIAS REPAIR: EXPERIENCE FROM A TERTIARY REFERRAL HOSPITAL
 
11:08 - 11:16
Discussion
 

11:16 - 11:19
S16-7 (OP)

TWO-STAGE REPAIR FOR RE-DO HYPOSPADIAS: RESULTS OF OVER 5-YEAR FOLLOW-UP

Orhan ZİYLAN 1, İsmail SELVİ 2, M. İrfan DÖNMEZ 1, Barış AYDIN 1 and Tayfun OKTAR 1
1) İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, İstanbul, TURKEY - 2) İstanbul University/Faculty of Medicine, Department of Urology, Division of Paediatric Urology, İstanbul, TURKEY

PURPOSE

We aimed to analyze long-term clinical outcomes in patients underwent two-stage re-do hypospadias repair.

MATERIAL AND METHODS

Files of 122 boys who underwent two-stage surgery for re-do hypospadias repair between June 2001 and October 2017 with>5 years of follow-up were retrospectively reviewed. Demographics, preoperative clinical characteristics, postoperative complications, and the hypospadias objective scoring evaluation (HOSE) score at the last clinical visit were noted.  

RESULTS

Patients have undergone median 2 (range 1-8) prior surgeries. Median age at the time of first-stage and second-stage were 72 (range 12-288) and 82.8 (range 18-296) months, respectively. Of those, 44.3% had penoscrotal hypospadias, 9% had scrotal or perineal hypospadias, while 46.7% had mid penile hypospadias but a poor urethral plate/uncorrectable chordee. Topical dihydrotestosterone was used in 10.7% of cases due to glans diameter <14mm. Lower lip (78, 63.9%), upper lip (9, 7.4%) cheek (14, 11.5%), and a combination of cheek and lower lip (21, 17.2%) mucosae were used as the graft.

After median 121 (range 66-204) months of follow-up, overall complication rate was 36.8%, while 23.8% underwent another repeat intervention. The most common complication was glans dehiscence (12.3%) followed by urethrocutaneous fistula (10.7%), meatal stenosis (10.7%), residual chordee (6.6%), buried penis or skin deformities (6.6%), distal urethral dehiscence (4.9%), graft contracture after first-stage (2.5%), urethral stricture (1.6%), complete urethral dehiscence (0.8%), and urethral diverticulum (0.8%). Median time from second-stage to the repeat intervention for complications was 10 (range 4-30) months. According to HOSE score, 87.7% of the parents denoted functional and cosmetical acceptable outcomes.

CONCLUSIONS

Two-stage repair is a viable alternative for the most challenging hypospadias cases with almost 90% of parental satisfaction and a quarter needing reintervention. 


11:19 - 11:22
S16-8 (OP)

★ AN OBJECTIVE ANALYSIS OF OVER 600 PAIRED GRAFT MEASUREMENTS: PREPUTIAL VS ORAL RESULTS

Nicol BUSH 1, Hazem MOSA 2 and Warren SNODGRASS 1
1) Hypospadias Speciality Center, The Colony, USA - 2) Jenny Lind Children's Hospital, Paediatric urology, Norwich, UNITED KINGDOM

PURPOSE

Determining urethroplasty graft health and survival has been subjective, making comparative analysis difficult. We used standardized measurements to determine graft area and compared outcomes in primary (prepuce) and reoperative (oral) graft repairs.

MATERIAL AND METHODS

Consecutive proximal hypospadias patients had graft measurements prospectively recorded from 2014-2023. Graft length and widths at the corona, midgraft, and urethrostomy were determined at placement and at tubularization performed ≥6 months later. Graft area and % graft contracture were calculated, with ≥50% loss considered graft failure. Perioperative Hyperbaric Oxygen Therapy (HBOT) was recommended on a protocol. Primary and reoperative (±HBOT) outcomes were compared using unpaired t-test and Chi-square.

RESULTS

627 grafts were analyzed, with results summarized (Table). Primary prepuce grafts had 7% overall graft area contraction with 9% graft failure. Reoperations without HBOT had significantly more contraction (18%) and graft failure (15%, p=0.014). Despite numerous failed prior surgeries, oral grafts treated with HBOT had similar contracture rates (9%) to primaries, and less graft failures (5%, p=0.041).

 

Prepuce(n=298)

Oral without HBOT (n=81)

Oral with HBOT (n=248)

Median Age in months (+/-SD)

18 (+/-34)

95 (+/-160)

146 (+/-183)

Median No. previous surgeries (+/-SD)

0.1(+/-0.5)

1.6 (+/-1.0)

3.1 (+/-1.8)

HBOT n (%)

41(14%)

0 (0%)

248 (100%)

Mean % contracture (+/-SD)

7% (+/-30%)

18% (+/-31%)

9% (+/-27%)

Graft failure n (%)

27 (9%)

12 (15%)

12 (5%)

CONCLUSIONS

Objective graft measurements found similar graft contraction and low rates of failure in primary prepucial grafts and reoperative oral grafts when HBOT was used. Reoperations without HBOT had more graft contracture and graft failures.


11:22 - 11:25
S16-9 (OP)

★ GRAFT AND SKIN COMPLICATIONS IN 342 PRIMARY PROXIMAL HYPOSPADIAS REPAIRS: STAG VS STAC

Warren SNODGRASS and Nicol BUSH
Hypospadias Specialty Center, Frisco, USA

PURPOSE

STAC (3-stage) graft repair seeks to improve graft and skin healing compared to STAG (2-stage). We report respective graft and skin complications in 332 consecutive primary proximal hypospadias patients.

MATERIAL AND METHODS

220 STAG repairs were completed from 2014-2020. After mid-2020, all patients instead underwent STAC. All had >/=30 degrees ventral curvature straightened by 3 ventral corporotomies. Nearly all had prepucial grafts, with dimensions measured prospectively at placement and the subsequent procedure. Graft complications were >/=50% loss requiring patch or total regrafting, or less contracture managed by inlay graft or notched transection of focal scar. Skin complications were need for scrotal flaps or Cecils to close the penile shaft, or a subsequent operation to revise scars or excise them with skin grafting.

RESULTS

The groups had similar extents of hypospadias, mean age, and glans width; STAC had greater mean ventral curvature (73 vs 57 degrees, p=0.0001). Graft contractures occurred in 50(23%) STAG (37 patch or regrafting, 3 inlays, 10 scar releases) versus 8(7%) STAC (6 patch or regrafting, 1 inlay, 1 scar release), p=0.0001.

Skin complications developed in 17(8%) STAG (2 scrotal flaps, 8 Cecils, 5 revisions, 2skin grafts), vs 10(8%) STAC. All STAC complications occurred after stage 1 in association with other congenital skin anomalies (penile torsion, single midline humps), and were corrected before urethroplasty grafting. No STAC required scrotal flaps, Cecils or external skin grafts.

CONCLUSIONS

Despite having worse ventral curvature, only 1 of every 14 STAC patients had graft complications, versus 1 of every 4 STAG patients. The rate of overall skin complications was similar, but were less severe in STAC and did not require non-penile flaps or external skin grafts, which can impact aesthetic outcome. These data support straightening curvature and correcting ventral skin deficiency, then allowing for healing before urethroplasty grafting.


11:25 - 11:36
Discussion
 

11:36 - 11:41
S16-10 (VP)

EXTENDING THE GRAFT HARVESTING AREA IN A SEVERE PENOSCROTAL HYPOSPADIAS: THE RAINBOW TECHNIQUE

Yaqoub JAFAR 1, Ziyad ALZAHRANI 1, Melissa MCGRATH 1, Bruno LESLIE 1 and Luis H. BRAGA 2
1) McMaster University, Surgery-Urology, Hamilton, CANADA - 2) McMaster University - McMaster Children's Hospital, Department of Surgery / Urology, Hamilton, CANADA

PURPOSE

In this video, we introduce a novel technique for preputial skin harvesting in cases of proximal hypospadias where a longer graft is needed.

MATERIAL AND METHODS

A 2-year-old was referred for penoscrotal hypospadias. Examination revealed a scrotal meatus, bifid scrotum, and severe chordee (>90) with descended testicles. The karyotype was 46XY and the hormonal profile was normal.
During the first stage, chordee was corrected by dividing the urethral plate and 3 transverse corporotomies, creating a ventral penile defect of 6 cm to be grafted. As the inner prepuce diameter was only 4 cm long, we could not perform the conventional rectangular preputial skin graft technique. A semicircular rainbow-like incision was marked on the dorsal preputial hood, with a minimum of 2 cm from the foreskin edge, creating a graft harvesting area of 7 cm, which was used to cover the entire penile ventral surface.

RESULTS

The tie-over dressing was removed on postoperative day 4. 6-month follow-up showed a healthy graft with no contraction. The child is awaiting second-stage hypospadias repair.

CONCLUSIONS

This technique serves as a valuable alternative when the conventional rectangular preputial graft harvest falls short in providing sufficient graft length for the first-stage hypospadias repair eliminating the need for buccal mucosa.


11:41 - 11:44
S16-11 (OP)

COMPARING TAIPEI TECHNIQUE WITH DIFFERENT FLAPS IN PENILE CURVATURE CORRECTION

Cynthia Sze-Ya Ting TING and Pei-Yeh CHANG
Chang Gung Memorial Hospital, Pediatric Surgery, Taoyuan, TAIWAN

PURPOSE

In this study, we examine the effectiveness of TAping Inbetween PEnile Incisions(TAIPEI) for correcting penile curvature following transection of urethral plate(UP) in conjunction with two different staged flap techniques and report the follow-up data.

MATERIAL AND METHODS

Our prospective study included patients with primary hypospadias who underwent two types of staged flap repairs involving UP transection and TAIPEI. Curvature angles were objectively measured during artificial erection after degloving, after UP transection, and at stage 2. After stage 2, curvature assessments were conducted either with natural erection photos or artificial erection whenever patients returned to the operating room.

RESULTS

We analyzed data from 64 eligible patients. In the first stage, all patients underwent UP transection alone. Of these, 19 patients received Transverse Preputial Island Flap, while 45 patients underwent Byar's Flap. The median curvature angle was 55º after degloving, 52º after UP transection, and 0º in the second stage after TAIPEI. There was no significant difference in the success rate of curvature correction between the two flap groups. Nineteen patients had their curvature reassessed under artificial erection at least six months post-second stage, all but 4 patients had curvature less than 30º. With an average follow-up duration of 19.3 months after stage 2, no significant recurrent/persistent curvature was observed based on available data.

CONCLUSIONS

TAIPEI technique following UP transection alone corrects curvature in either transverse preputial island flap or Byar's flap. Long-term follow-up is indicated for these patients to comprehensively assess the durability of this approach.


11:44 - 11:50
Discussion