Proximal Hypospadias Research Articles

Epidemiological profile of patients undergoing hypospadias correction surgery at a hospital in Recife, Brazil, between 2022 and 2023

Problem: Hypospadias is the second most common genital anomaly after undescended testicles, occurring in approximately 1 in every 250 male newborns. Objectives: The present paper aims to evaluate the surgeries performed to hypospadias repair in a hospital in Recife city from March 2022 to March 2023. Methodology: A retrospective, descriptive study with a quantitative approach with secondary data from medical records. The study population consisted of 97 childrens and 99 surgeries. Results: The results showed that 49.5% of the patients presented with distal hypospadias. The most commonly used technique was Bracka, representing 31.3% of the cases. The mean age of the patients at the time of the first surgery was 5 to 9 years. Of the sample, 24.2% of the patients had complications, 41.7% of which were due to urethrocutaneous fistula. Conclusion: It was concluded that the age at the time of the first surgery was higher than that indicated in the literature. There was a slight prevalence of distal hypospadias to proximal hypospadias, evidencing a demand for complex hypospadias in this hospital.

Comparative study of modified Koyanagi and staged Duckett for proximal hypospadias.

To compare and analyze the clinical efficacy of modified Koyanagi and staged Duckett for proximal hypospadias. The clinical and prognostic data of children were treated and underwent surgery (modified Koyanagi or stage Duckett) in the Department of Urology, Kunming Children's Hospital from January 2020 to January 2023 were retrospectively analyzed. According to different surgical methods, the subjects were divided into the modified Koyanagi group and the staged Duckett group. Patients in both groups were followed up for more than 6 months after surgery. The success rate and complications of postoperative surgery in both groups were analyzed. A total of 63 patients were included in this study, 34 in the modified Koyanagi group and 29 in the staged Duckett group. A total of 14 patients in the modified Koyanagi group experienced postoperative complications, the success rate of the surgery was 58.82%, and 5 among them experienced more than two kinds of complications. A total of 5 children in the staging Duckett group experienced postoperative complications, and the success rate of the operation was 82.75%. There were significant differences in the incidence of overall complications and fistula between the two surgical methods (P = 0.028). Compare with modified Koyanagi, staged Duckett can significantly reduce the incidence of overall complications and urethral fistula in patients, and have obvious advantages in the treatment of proximal hypospadias.

Mental health and health-related quality of life in adolescents surgically treated for hypospadias in childhood

BackgroundThere is limited research and conflicting results on the mental health and health-related quality of life of individuals surgically treated for hypospadias in childhood. Furthermore, the significance of patient-reported outcomes (PRO) in hypospadias is growing. More research is necessary on these topics, particularly in adolescents. ObjectiveWe aimed to compare mental health, health-related quality of life, body satisfaction, self-esteem, penile appearance, and sexual function outcomes in 16-year-old adolescents who had surgery for hypospadias in childhood with a healthy comparison group. Study designThe study involved 16-year-old adolescents who had surgery for hypospadias in one Norwegian hospital. An age-matched comparison group of healthy adolescents was previously recruited. The study assessed self-reported outcomes on mental health using the Strengths and Difficulties Questionnaire, health-related quality of life using the Pediatric Quality of Life Inventory, body satisfaction and self-esteem using the Self-Perception Profile for Adolescents, and genital perception and sexual function using the Pediatric Penile Perception Score and a non-validated structured interview. ResultsIn total, 117 adolescents operated for hypospadias and 61 healthy adolescents were included. The outcomes for mental health and health-related quality of life were not statistically different between groups. However, 18 (16%) hypospadias patients were classified as cases/borderline on mental health outcomes, compared to 2 (3%) in the comparison group (p=0.01). Patients classified as cases/borderline on mental health reported lower health-related quality of life, self-esteem, and more stressful life events. Self-reported penile appearance and sexual function were comparable between groups, however the proximal hypospadias group displayed lower satisfaction. DiscussionAlthough the present study had generally positive outcomes, a significant finding was that a higher number of adolescents who had previously undergone hypospadias surgery during childhood were classified as cases or borderline cases with respect to mental health issues. Hypospadias surgery in childhood may pose challenges for some patients during adolescence, particularly in the proximal group. Regular monitoring by healthcare professionals is crucial in providing necessary support. A limitation is the small size of the subgroups. ConclusionMost patients report good mental health, quality of life, and self-esteem even though patients with hypospadias report more mental health issues than the comparison group. Proximal hypospadias were less satisfied with penile appearance and sexual function. However, due to the small sample size, conclusions about this group should be treated cautiously. Assessing self-reported outcomes in follow-ups is important to identify adolescents who had hypospadias surgery and are at risk for reduced mental health.

Development and validation of a short version of the quality of life-DSD questionnaire for parents of young children with conditions affecting sex development.

There is a paucity of information on health-related quality of life (HRQoL) outcomes in parents and children with conditions affecting sex development. The objective of this study was to develop short forms of HRQoL questionnaires which consist of a 63-item and 25-item parent self-report (PSR) and parent proxy-report (PPR), respectively, optimizing use in routine clinical settings. Short questionnaires were developed following exploratory factor analysis using raw data from 132 parents. Long and short PSRs were completed by 24 parents of children with conditions affecting sex development, with a median age of 3.6 years (range 0.1, 6.6); 21 (88%) were boys, and 11 (46%) had proximal hypospadias. A subset of 19 parents completed both long and short PPRs. Item selection, based on factor loadings of >0.8 and expert consultation, produced short PSRs and PPRs containing 16 and 7 items, respectively. There was no statistically significant difference in 11 out of 12 (92%) scales on the PSR and 4 out of 5 (80%) scales on the PPR when comparing short and long questionnaire scores. The short and long questionnaires took <1 min and 5 min to complete, respectively. Eighteen parents (75%) reported that the time taken to complete the short questionnaires was acceptable; 10 (42%) preferred short questionnaires. Ten (42%) versus 6 (25%) stated a preference for completing the short versus long questionnaires. The short versions were largely representative of the long questionnaires and are acceptable for evaluating psychosocial distress in young children and their caregivers. Further psychometric validation of the short forms is warranted.

Cumulative re-operation rates during follow-up after hypospadias repair.

To assess the cumulative rates of re-operations after hypospadias repair and evaluate long-term surgical outcomes at a tertiary paediatric urology centre. Retrospective analysis of 293 boys born between 1991 and 2003 undergoing hypospadias surgery was conducted. The study included 274 patients: 165 with distal, 34 with midshaft, and 75 with proximal hypospadias. Kaplan-Meier methods were used to evaluate the re-operation data. The median age at primary surgery was 1.3 years, with a median follow-up of 14.4 years. The overall re-operation rate was 48.2%, with approximately half of the problems detected within the first 3 months after surgery. The risk of re-operation was correlated with hypospadias severity, with 5- and 15-year re-operation risks at 39.3% and 51.8%, respectively. Limitations of the study include its retrospective nature and variations in surgical techniques from current standards. There is a significant risk of unplanned re-operations following hypospadias repair, increasing with the severity of the original condition. This underscores the need for extended follow-up and effective communication with patients and their families about the likelihood of requiring multiple surgeries for optimal outcomes.

Prevalence of disorders of sex development in patients with hypospadias and cryptorchidism

Hypospadias and undescended testicles (UDT) are common congenital conditions, affecting approximately 1 in 125 and 1 in 33 boys, respectively. There has been limited contemporary data regarding the prevalence of Disorders of Sex Development (DSD) in patients with a history of both hypospadias and UDT. Our objective is to determine the prevalence of DSD among patients presenting with hypospadias and UDT. Electronic medical records were reviewed, and a retrospective chart review was conducted on 177 patients that were evaluated at our institution from 2000 to 2021 with a diagnosis of hypospadias and UDT. The degree of hypospadias, presence of and palpability of UDT, and prevalence and type of DSD were recorded. The degree of hypospadias, presence of and palpability of UDT, and prevalence and type of DSD were recorded. Chi-squared and Fisher's exact tests were conducted for descriptive statistical analyses as appropriate. Logistic regression analyses were conducted, with adjusted models including demographic and relevant clinical data. 177 patients were identified with both hypospadias and UDT, with 17/111 (15.3%) diagnosed with DSD. The most common etiology of DSD was mixed gonadal dysgenesis (35.3%; n=6). Proximal hypospadias made up only 59.6% of those without DSD vs. 100% of those with confirmed DSD (p=0.0044). A significantly smaller proportion of DSD patients had bilaterally palpable gonads compared to those without DSD (29.4% vs. 79.8%, p<0.0001). Compared to those with palpable testes, patients with one non-palpable testicle had up to 26.67 times greater odds of DSD. To date, we present the largest cohort of patients that have undergone DSD work up for the combined presentation of hypospadias and UDT. Our findings highlight an increase in DSD diagnosis in proximal hypospadias patients with non-palpable UDTs, which offers further evidence and support for pursuing DSD diagnostic work-up in all proximal hypospadias patients with UDTs.

Current trends in the management of hypospadias: the Ibero-American experience

Introduction: Hypospadias management has seen various trends over the years, likely due to the diverse clinical presentations and evolving surgical techniques. However, there is a lack of consensus among pediatric urologists on many aspects of hypospadias management. To address this, our research aims to survey specialists and establish a consensus on hypospadias management. Methodology: In July 2021, a cross-sectional study was conducted using a Survey Monkey questionnaire consisting of 23 questions. The survey aimed to gather information about the generalities and management preferences of distal and proximal hypospadias from specialists belonging to the Ibero-American Society of Pediatric Urology (SIUP). The data collected was categorized into subgroups based on surgical techniques, perioperative preferences, and complications. Results: Most hypospadias surgeries are performed between 13-18 months. Penile curvature is evaluated with artificial erection and visual inspection. The Nesbit technique (36.1%) and ventral corportomies (26.9%) corrections are more common, while grafts corporoplasties are used less frequently (10.2%) for correction. For urethroplasty, the surveyed group prefers using a running suture or a combination of continuous and interrupted stitches (49.1% and 24.3%, respectively). The use of Polydioxanone 6-0 in a double-layer suture group yielded a higher response rate. The use of prophylactic antibiotics and their maintenance when the catheter is in place was also favored by most surgeons. Discussion: When repairing hypospadias, the surgeon must consider factors such as the quality of the urethral plate, the presence of penile curvature, and the location of the urethral opening. This study highlights the different strategies and technical preferences used for hypospadias repair by a group of specialists from different countries. Conclusion: The survey describes current trends in hypospadias management. Two-stage repair is commonly used for proximal hypospadias, while TIP repair is the most used technique for distal hypospadias. The most common complication is the development of an urethrocutaneous fistula.

TELESCOPING THE DORSAL HOOD IN HYPOSPADIAS SURGERY - AN INNOVATION TO PRESERVE MAXIMAL PENILE SKIN.

To describe a new technique or adjunct- telescoping the dorsal hood- with a view to banking excess skin on the penile shaft in hypospadias surgery. This would help if redo surgery, not a rare occurrence, is required in future. A review of a prospectively maintained database of hypospadias surgeries conducted between 1997 and 2023 by a single surgeon. After the hypospadias repair, instead of excising the dorsal hood and suturing the ventral penile skin in the usual way, a skin hook is applied on the ventral penile skin in the midline. As the skin hook is pulled down towards the scrotum, anywhere from 1 to 4 cms, it telescopes the dorsal hood down the penile shaft and also pulls in dorsal skin ventrally. (Technique described more fully in the manuscript) RESULTS: 1084 patients were operated for hypospadias over this 27 years' period. Telescoping of the dorsal hood was used in all patients, and in the 126 with proximal hypospadias, none had any skin of the dorsal hood excised! Sixty-two patients presented later with 73 fistulae which were operated on. Of note, no patient needed more than 2 surgical attempts for a cure. The dorsal hood is a useful source of not only skin but also underlying vascularised soft tissue. In hypospadias surgery where redo-operations are a predictable reality, preserving any excess skin on the phallus seems sensible. Our innovation of telescoping the dorsal hood achieves this goal nicely and takes only a few minutes to perform.

Time to complication after primary pediatric hypospadias repair with transverse preputial island flap urethroplasty.

Hypospadias is one of the most common congenital malformations in men. The transverse preputial island urethroplasty is widely used in China, especially for moderate and severe cases due to its convenient prepuce of the penis. This analysis aims to delineate the time to first complication following transverse preputial island urethroplasty. We analyzed the clinical data and follow-up results of children who underwent hypospadias repair by transverse preputial island urethroplasty in Beijing Children's Hospital, Capital Medical University from December 2018 to December 2019 retrospectively. Postoperative complications included urethral fistula, urethral diverticulum, urethral stricture, persistent chordee. Univariate analysis of clinical variables and time to complication was performed using Kaplan-Meier survival curve. One hundred and sixty-five patients were identified. During the follow-up period, complications occurred in 101 cases (61.2%). Ninety-four percent of complications occurred within 1 year. Among children who experienced complications, Kaplan-Meier survival analysis showed that age less than 18 months and the severity of hypospadias were statistically significant (P=0.005 and P=0.04, respectively). The time to urethral diverticulum was significantly longer than that of urethral fistula and urethral stricture. More than 90% of complications after the transverse preputial island urethroplasty of hypospadias occurred within 1 year, with those related to proximal hypospadias presenting earlier than those of midshaft/distal hypospadias. Surgeons may consider a more frequent follow-up within the first year after surgery to detect these complications as early as possible.

Systematic review of the comparison between simultaneous and staged surgical interventions for proximal hypospadias in children: Duckett’s procedure versus Bracka’s procedure

Selecting a treatment method for proximal hypospadias in children remains challenging. This systematic review compares the outcomes of treating proximal hypospadias with the Duckett and Bracka techniques. Literature sources published between 2008 and 2023 were searched through PubMed, Google Scholar, and eLibrary using the following keywords in English: “proximal hypospadias,” “repair OR urethroplasty,” and “outcomes OR complications.” For Russian-language sources, the keywords were “proximal hypospadias,” “urethroplasty,” “complications,” “Duckett operation,” and “Bracka operation,” After screening, four full-text articles met the inclusion criteria and were included in this review. Data from 385 patients was analyzed: 218 underwent Duckett repair and 167 underwent Bracka repair. The overall complication rate in the postoperative period was 31.11% and 10.18% for Duckett and Bracka operation, respectively. No study has been performed at a high methodological level. Currently, studies comparing single-stage and staged surgeries for proximal hypospadias are lacking. It is crucial to conduct multicenter or comparative studies that involve closer collaboration between clinics, include a larger number of patients, and have a longer followup period.

The Outcome of a Single Stage Repair for Proximal Hypospadias in Otherwise Healthy Child at Mymensingh Medical College Hospital

Hypospadias is a birth defect that involves the development of a penile urethra that opens on the ventral side of the penis. Proximal hypospadias is one of the most severe forms of hypospadias that is generally associated with chordee. Hypospadias surgery, especially in the proximal location, is challenging, and many operations have been proposed, including one-stage and two-stage operations. Objectives: The aim of the study was to evaluate the success rate and safety of a single-stage surgery in children with proximal hypospadias and to determine the complications. Materials and Methods: This interventional study was conducted on forty patients, aged between one and twelve years, who had proximal hypospadias and were admitted to Mymensingh Medical College Hospital between January 2014 and April 2015. A one-step operation with tabularized incised plate urethroplasty (TIPU) was done. Patients’ demographic data, intraoperative details, and postoperative outcomes were recorded within 3 months after the operation. Results: The common age at surgery was 2-4 years, and they were 40% of the total patients. There was Haematoma in 5% of cases, a devitalized skin flap in 7.5% of cases, and stent blockage in 10% of cases during the immediate postoperative period. In our 3-month follow-up, all the patients had conical glans and cylindrical penises. Meatal stenosis and narrow stream were noted in 5 percent of patients but were relieved with meatal dilatation. Urethrocutaneous fistulas remained patients in 7.5% of cases. Conclusion: TIPU repair of proximal hypospadias is safe, effective, yields good results, and has low risks of complications in otherwise healthy children. It is a less risky and more viable method that helps to exclude extra steps in the process.

The effect of preoperative hormonal stimulation on the urethral plate; A histologic and histochemical study

Preoperative hormone stimulation (PHS) is used to increase the glans size and may improve the cosmetic appearance after hypospadias surgery. The exact effect of PHS on different penile tissues remains unclear and controversial. Previous studies showed that PHS increased vessel density in the foreskin. However, the effect of PHS on the urethral has never been studied before. In this study we examine the PHS effects on the urethral plate. Specimens of the urethral plate and the underlying tissue were excised to correct severe chordee in 16 children with proximal and perineal hypospadias with severe chordee in 2 groups. Group A consisted of 8 children received PHS prior to surgery. Group B included 8 children with proximal and perineal hypospadias with severe chordee who did not receive PHS and served as a control group. Specimens were examined blindly using hematoxylin-eosin and elastic van-Gieson stain as well as factor 8 and SMA antibodies. The median age of Group A was 13 (range 10-20) months. The median age of Group B (without prior PHS) was 17 (range 14-29) months (p=0,03). The median vessel-density in group A (82 vessels per mm2) was significantly higher than in Group B (65 per mm2), (p<0.05). The median vessel diameter was also significantly higher in Group A (13μm) than in Group B (11μm), (p<0.05). The median epithelial layer thickness in Group A was 110μm and in Group B 98μm, but showed no statistical significance (p=0,16). There was no significant change in dartos fascia layer thickness or androgen receptor expression. There was no visual change in the organization of elastic fibers. This study is the first study to document the effect of PHS on the urethral plate in hypospadias with severe chordee. PHS significantly increased the median vessel-density as well as median vessel diameter as compared to a matching control group. The findings of the study may justify PHS administration before the first operation to improve the vascularity and may reduce the severity of chordee.

Uroflowmetry As a Long-Term Urological Outcome Assessment of Proximal Hypospadias Cases Repaired by Mansoura Modification of The Koyanagi Technique

Uroflowmetry As a Long-Term Urological Outcome Assessment of Proximal Hypospadias Cases Repaired by Mansoura Modification of The Koyanagi Technique

Urethral Mobilisation and Glanuloplasty Technique for Primary and Second-Stage Repair of Hypospadias: A Single Hospital Experience.

Background Over the years, the technique used to correct hypospadias has undergone several modifications to improve outcomes and reduce complication rates. In this study, a modification has been made to the second stage of the two-stage repair of proximal hypospadias. This modification utilises urethral mobilisation and glanuloplasty, traditionally used to repair distal hypospadias, in the second stage of repair of proximal hypospadias. This study aims to assess the implications of this modification on the outcomes in addition to adding to the pre-existing literature on the outcomes of urethral mobilisation and glanuloplasty in the repair of distal hypospadias. Methodology A prospective study was conducted at Salmaniya Medical Complex in Bahrain between January 2016 and December 2021. All patients with either proximal or distal hypospadias who underwent a surgical repair using the urethral mobilisation and glanuloplasty technique were included. The following cases were excluded: patients with proximal hypospadias who did not undergo a first-stage repair, those with a hypoplastic urethra, and those aged 14 years or more. Results The mean operative time for the proximal hypospadias group was 78 minutes, while it was 62 minutes in the distal hypospadias group. Furthermore, the catheter remained in situ for a mean of three days postoperatively in the proximal hypospadias group. Overall, four of 35 patients (11.4%) experienced complications in the proximal hypospadias group. Of these, there were two(5.7%) cases of meatal stenosis, two(5.7%) cases of wound dehiscence, and no cases of diverticula or urethrocutaneous fistulas. Meanwhile, in the distal hypospadias group, one of 117 patients (0.9%) experienced a complication; the complication was meatal stenosis. there was a significant correlation between the age of patients and the complication rate (p = 0.06). The operative time was also found to be a significant factor influencing the occurrence of complications. The follow-up duration ranged between five months and 12 months. All patients had good cosmetic outcomes. Conclusions This study found that urethral mobilisation and glanuloplasty for the second-stage repair of proximal hypospadias resulted in lower complications than the traditional two-stage operation and a short duration of urinary catheterisation. There is a need to conduct studies with longer follow-up durations and objective measures of function to provide a better comparison between the different techniques used.

The Efficacy of Active Fistulation in Duckett Procedure for Proximal Hypospadias in Children.

To explore the efficacy of active fistulation in the treatment of proximal hypospadias in children by comparing one-stage and two-stage Duckett procedure. A total of sixty-seven children who were diagnosed with proximal hypospadias and underwent Duckett operation at our hospital between January 2013 and January 2021 were selected for this study. These subjects were divided into two groups: the research group (n=36), using two-stage Duckett procedure with active fistulation, and the control group (n=31), using one-stage Duckett procedure.The incidence of postoperative complications and the score of pediatric penile perception Scale were compared between the two groups. The research group exhibits significantly lower incidence rate of urethral fistula (8.3% Vs 16.1%) and urethral stricture (5.6% Vs 12.9%) in comparison to the control group (P<0.01). Furthermore, the analysis of Pediatric Penile Perception Scale scores indicates that the research group achieves significantly higher scores in terms of urethral shape, penile skin shape, and overall appearance than the control group (P<0.05). Conclusion: In the treatment of proximal hypospadias in children, The active fistulation within the two-stage Duckett procedure significantly reduces the rate of stage 1 postoperative complications and improves parental satisfaction. The active fistulation may offer a more promising option for the treatment of proximal hypospadias in children.

Late chordee correction after tubularized incised plate repair for proximal hypospadias: An underreported problem

AbstractBackgroundRepair of proximal hypospadias remains a challenge with no consensus on the best surgical approach. Several reports have shown recurrence of chordee after plate‐preserving techniques. In this report, we present our experience in managing cases who presented with persistent/recurrence of chordee after tubularized incised plate (TIP) repair for proximal hypospadias.MethodsBetween 2015 and 2023, the study included eight patients who presented with ventral penile curvature after previous hypospadias repair in infancy (TIP urethroplasty). Reoperation to correct persistent ventral curvature was performed several years after the primary TIP repair (3–15 years; mean 7.9 years; median 7.5 years). The reoperation was a two‐stage procedure: the first stage comprised transection of the urethra and grafting (lower lip mucosal graft); the second stage (6 months later) was a Thiersch‐Duplay urethroplasty.ResultsComplications included poor taking of the graft after the first stage in one case (12.5%), which was regrafted using buccal (cheek) mucosa. Complications after second stage included urethro‐cutaneous fistulae in five (62.5%) that were successfully surgically treated at a later stage. Follow‐up after second stage ranged between 6 months and 7 years (mean 2.4 years; median 1 year). Satisfaction with reoperation to correct penile curvature was noted by parents as well as older children (adolescents) who appreciated better cosmesis by increasing ventral penile length and improved curvature.ConclusionPreservation of the urethral plate in proximal hypospadias may result in shortened penile length, mostly on the ventral aspect. A two‐stage reoperation to increase the length of the penile urethra can successfully reverse this complication.

PRIMARY REPAIR OF PROXIMAL (GRADE IV) HYPOSPADIAS UTILIZING TUNICA VAGINALIS VASCULARISED FLAP

Background: Proximal (grade IV) hypospadias like scrotal and perineal are considered as severe challenging types for surgeons, problematic for the patients and their families, More than three hundreds surgical techniques were used to manage different type of hypospadias . Most of them associated with high incidence of complications. These complications are much more common in the proximal types as in our study. Post-operative fistula formation is expected complications. Utilising the tunica vaginalis as an additional layer during repair may prevent such complications. In this study we evaluated the benefits of using the tunica vaginalis flap as a supportive layer in the primary repair. Most related literatures about this subject used this technique after surgery to manage cases with post-operative fistulas. In the contrary we used this technique during the formal surgery to cover the new urethra to prevent fistula formation not after surgery. Aims of the study: A retrospective study, on fourteen patients with severe hypospadias (Proximal types), to evaluate the role of tunica vaginalis flap in the primary repair of the hypospadias. Patients and Methods: Between January 2016 and January 2024, fourteen children with Grade IV hypospadias were operated on. Only severe cases were treated with this method other simpler and more common cases were treated by different surgeries like Snodgrass technique. The age range was 2 to 16 years. All of them had 2 staged repair the first stage was correcting the chordae by incising the urethral plate excising the fibrous chordae tissues then covering the bare shaft with dorsal flaps. The tunica flap was used in the second stage which was done 6 to 12 months later. Folly's catheter was used for ten to fourteen days after surgery. And the patients were followed for a variable time 3months to 2 years period for the development of complications like fistula formation or stricture. Cosmetic considerations were also noted. Results: All the fourteen patients had proximal types (Grade IV) hypospadias. After surgery all patients had a good cosmetic outcome no fistula formation two had mild distal urethral stricture cured after few urethral dilatation. No post-operative penile torsion was noted. Two patients developed local infection treated conservatively. One patient had partial glanular dehiscence at the distal end which had no clinical significance. One patient complained from on and off penile cutaneous swelling lasted 3 weeks. Conclusions: Using tunica vaginalis vascularised flap to cover the new urethra in severe proximal hypospadias during the second stage seems to be a successful way in preventing fistula formation without increasing the patient's morbidity.

Long-term Effects of Pre-operative Testosterone and Dihydrotestosterone on Glans Width in Boys With Hypospadias

BackgroundSmall glans width is a risk factor for urethroplasty complications. This study aimed to assess and compare short- and long-term effects of two pre-operative topical androgen treatment protocols on maximum glans width. Furthermore, to evaluate post-operative complications when surgery was delayed >3 months following hormonal treatment completion. MethodsTopical 2.5% dihydrotestosterone (February 2016–July 2018) and 5% testosterone (August 2018–December 2022) treatment protocols, completed >3 months before surgery, were offered to all children with proximal hypospadias and small glans width requiring urethroplasty. Serial glans width measurements were collected prospectively pre- and post-androgen treatment. Demographic data and complications were collected retrospectively. ResultsA significant increase in mean glans width was observed following both dihydrotestosterone (6.1 mm [95% CI 4.3–7.9 mm] pre-dihydrotestosterone to 14.9 mm [13.2–16.6 mm, p < 0.0001] post-dihydrotestosterone in 11 children) and testosterone (10.5 mm [9.9–11.1 mm] pre-testosterone to 14.6 mm [13.7–15.5 mm, p < 0.0001] post-testosterone in 32 children). Serial post-treatment measurements showed no loss of gained width >1 year after treatment completion. Mean increase in glans width from pre-treatment measurement at 0–3 months, 4–12 months and >12 months following treatment was 7 mm (95% CI 3.8–10.2), 9 mm (7.2–10.8) and 10 mm (7.3–12.7) post-dihydrotestosterone and 4.4 mm (95% CI 3.4–5.4 mm), 4.3 mm (3.5–5.2) and 5.1 mm (4–6.2) post-testosterone respectively. Complications were noted in 4/22 patients who received topical androgen prior to initial hypospadias surgery and had completed all surgical stages. ConclusionsBoth treatment protocols produced a significant, sustained increase in glans width. Delaying hypospadias surgery for >3 months following androgen application may circumvent androgen induced vascularity and poor wound healing. Level of EvidenceLevel IV. Type of StudyTreatment study.

Preputial pedicle flap ICG blood flow assessment during proximal hypospadias repair: Development of a standardized protocol

Blood supply to preputial flap drives outcomes ofhypospadias repair. Unfortunately, we onlyhave surgeon's subjective assessment to evaluate flap perfusion which may not be accurate. Indocyanine green (ICG) has been used inamultitude of surgeries for perfusion assessment,however, no standardized protocol has been described for use of ICG in hypospadiasrepairs. The aim of this study is to develop a standardized protocol of ICG use in proximal hypospadias and establish perfusion patterns ofpreputial flaps. A pilot study was conducted using ICG in patientswith 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 (Summary Figure). Per the protocol, ICG was administered at 3 time points which were felt to be critical for assessment of flap perfusion. Of the study patients who have undergone second stage repair, ICG was also usedto reassess the flap prior to tubularization ofthe urethra. A total of 14 patients underwent first stage hypospadias repair with preputial flaps and intraoperative use of ICG. Median ICG uptake of the prepuce after degloving (dose 1) was 58.5% (IQR 43-76). ICG uptake decreased after flap harvest and mobilization (dose 2) with a median ICG uptake of 34% (IQR 26-46). ICG uptake remained stable after securing the flap in place and closing the skin (dose 3) with a median ICG uptake of 34% (IQR 25-48). ICG was able to delineate subtle findings in the preputial flaps not visible to the naked eye and in one case impacted intraoperative decision making. To date, 5 patients have undergone second stage repair. Flap assessment prior to tubularization of the urethra showed hypervascularity with a median ICG uptake of 159%. A standardized protocol for ICG use in proximal hypospadias was successfully developed and implemented. ICG uptake in the preputial flap decreased with increasing manipulation and mobilization of the flap. ICG was able to detect changes to flap perfusion which were not able to be seen with the naked eye. Reliance on surgeon'ssubjective assessment of flap perfusion may be inadequate and ICG could provide a useful tool for surgeons to improve preputial flap outcomes. ICG may also enhance the learning experience for trainees and early career urologists in these complex surgeries.

Development and verification of machine learning model based on anogenital distance, penoscrotal distance, and 2D:4D finger ratio before puberty to predict hypospadias classification.

To describe the anatomical abnormalities of hypospadias before puberty using current commonly used anthropometric index data and predict postoperative diagnostic classification. Children with hypospadias before puberty who were initially treated at Sichuan Provincial People's Hospital from April 2021 to September 2022 were selected. We recorded their preoperative penoscrotal distance, anogenital distance, 2D:4D finger ratio, and postoperative hypospadias classification. The receiver operating character curve was used for univariate analysis of the diagnostic predictive value of each index for hypospadias classification in the training set. Binary logistic regression, random forest, and support vector machine models were constructed. In addition, we also prospectively collected data from October 2022 to September 2023 as a test set to verify the constructed machine learning models. This study included 389 cases, with 50 distal, 167 midshaft, and 172 proximal cases. In the validation set, the sensitivity of the binary LR, RF, and SVM was 17%, 17% and 0% for identifying the distal type, 61%, 55% and 64% for identifying the midshaft type, and 56%, 60% and 48% for identifying the proximal type, respectively. The sensitivity of the three-classification RF and SVM models was 17% and 17% for distal type, 64% and 73% for midshaft type, 60% and 60% for proximal type, respectively. In the Testing set, the sensitivity of the binary LR, RF and SVM was 6%, 0% and 0% for identifying the distal type, 64%, 55% and 66% for identifying the midshaft type, and 48%, 62% and 39% for identifying the proximal type, respectively. The sensitivity of the three-classification RF and SVM models was 12% and 0% for distal type, 57% and 77% for midshaft type, and 65% and 53% for proximal type, respectively. Compared with binary classification models, the sensitivity of the three-classification models for distal type was not improved. Anogenital distance and penoscrotal distance have a favorable predictive value for midshaft and proximal hypospadias, among which AGD2, with higher test efficiency and stability, is recommended as the preferred anogenital distance indicator. The 2D:4D finger ratio (RadioL, RadioR) has little predictive value for hypospadias classification.