Ventral Curvature Research Articles

Megameatus intact prepuce variant reconstruction: Long-term outcomes and comparison to post-circumcision hypospadias repair

Megameatus intact prepuce (MIP) variant is considered a surgical challenge with associated high complication rates. It is usually diagnosed and corrected only after neonatal circumcision, which is discouraged in non-MIP hypospadias. In order to determine whether the features of the MIP variant or the performance of a secondary reconstruction following circumcision comprise the cause of higher complication rates, we now compared the results of post-circumcision MIP hypospadias repair to the results of children who underwent repair of non-MIP hypospadias following neonatal circumcision. Reoperation rates of children operated for hypospadias repair following neonatal circumcision between 1999 and 2020 were compared between those with MIP and those with classic non-MIP hypospadias. In total, 139 patients who had undergone neonatal circumcision underwent surgical reconstruction at a mean age of 13 months. Sixty-nine had classic hypospadias and 70 had the MIP variant. The median follow-up was 10 years (interquartile range 6,13). The classic group had a higher rate of meatal location below the corona compared to the MIP variant group (53% vs. 28%, respectively, p=0.002). The reoperation rate was comparable for the two groups (32% vs. 27%, p=0.58, Table). Univariate analysis for the MIP hypospadias group showed no association between reoperation and the initial patient characteristics, while a higher probability of reoperation was demonstrated in the presence of ventral curvature (odds ratio 3.5, p=0.02), and a higher grade of hypospadias (odds ratio 3.3, p=0.03 for meatal location lower than the coronal sulcus) in the non-MIP group. The limitations of our work include its retrospective design wherein the patients' characteristics, including classification as MIP vs. non-MIP, are derived from medical records. More patients in the non-MIP group were documented to have penile curvature. The non-MIP group was composed of more patients with meatal location under the coronal sulcus, a factor which may increase the rates for reoperation in that group. Still, with the comparison of the largest reported cohort of circumcised MIP with circumcised non-MIP patients together with an extended follow-up period, we believe that we present strong evidence of the possible role of previous circumcision in the surgical challenge of reconstructing MIP hypospadias. Reoperation rates in MIP hypospadias are high but similar to those of classic hypospadias, both following circumcision, suggesting that circumcision, rather than the unique features of the variant, is the cause for complications.

Risk factors for postoperative complications following one-stage proximal hypospadias repair involving the disconnection of the urethral plate: a retrospective study

BackgroundChildren with hypospadias are at risk of serious physical and mental health problems, including abnormal urination, sexual dysfunction, and infertility. The sole available treatment is the surgical restoration of genital appearance and function. Proximal hypospadias (PH) correction is more challenging and carries a higher risk of complications than does distal hypospadias correction, with a higher likelihood of postoperative complications requiring additional surgery, resulting in considerable economic and psychological strain for families. Herein, we aimed to identify factors associated with complications following one-stage PH repair with urethral plate disconnection.MethodsWe retrospectively analyzed data from 236 children who underwent PH repair at our center between December 2020 and December 2022. We collected information on age, surgical procedure, length of the reconstructed urethra (LRU), glans width (GW), ventral curvature, surgical approach, preoperative androgen use, suture type, presence of prostatic utricle, body mass index, season of surgery, anesthesia type, low birth weight, preterm birth, follow-up period, and complications. Surgical complications included urethral fistulas, urethral diverticula, anastomotic strictures, urethral strictures, glans dehiscence, and penile curvature recurrences. The study population was divided into complication and no-complication groups, and univariate and multivariate analyses were conducted.ResultsOf the 236 patients with PH who had a median follow-up of 10.0 (8.0, 14.0) months, 79 were included (33.5%) in the complication group and 157 were included (66.5%) in the no-complication group. In the univariate analysis, age (P < 0.001), LRU (P < 0.001), degree of penile curvature (P = 0.049), and PH with prostatic utricle (P = 0.014) were significantly associated with complications after PH repair. In the multivariate logistic regression analysis, LRU (P<0.001, odds ratio [OR] = 3.396, 95% confidence interval [CI]: 2.229–5.174) and GW (P = 0.004, OR = 0.755, 95%CI: 0.625–0.912) were independent factors influencing postoperative complications. The optimal LRU threshold was 4.45 cm (area under the curve, 0.833; sensitivity, 0.873; specificity, 0.873; P<0.001, OR = 3.396, 95% CI: 2.229–5.174).ConclusionsLRU and GW are independent factors affecting PH complications. An LRU of < 4.45 cm and an increased GW can reduce the risk of complications.

Surgical intervention for the correction of fecal impaction in an obstipated cat with an old compression injury in the lumbosacral region of the spine

BackgroundFeline obstipation is a clinical condition often manifested by defecation inability that results in fecal impaction. This is frequently associated with a blunt traumatic injury that affects mostly the spine and surrounding structures in the caudal part of the back leading to vertebral compression.Case presentationA 6-month-old, female, mixed-breed cat of 1.49-kg BW was presented with a history of prolonged constipation (i.e., obstipation) along with discomfort and weakness. Prior to the presentation, the cat was medically treated with dietary fibers, fecal softeners, and enemas, but obstipation persisted. Clinical examinations revealed that there was straining but not effective for defecation. In addition, the cat had poor appetite and dehydration, electrolyte abnormalities, and defects in posture and gait. The lumbosacral region showed a depression that was supposed to be the consequence of an old, untreated regional injury. Radiographic imaging indicated a marked ventral curvature in the lumbosacral spine including major deviations in the positions of the L6 and L7 vertebrae and the sacrum as well. A firm tubular structure was felt on ventral abdominal palpation, and further ultrasonography revealed the tubular impaction. Laparotomy exposed a definite large bowel impaction, and enterotomy was performed to evacuate the firm feces. Postoperatively, supportive medications and care were provided for better recovery. However, the impaction recurred within 3 months after surgery, and euthanasia was a further choice.ConclusionsTraumatic injuries involving the lumbosacral spine in cats might be serious enough to lead to severe constipation and thereby bowel impaction. Therefore, treatment should be prompt and accurate in any case of spinal injury to avoid further complications.

De-epithelialized overlap flap to secure urethroplasty in second stage hypospadias repair: revisiting the Smith technique

BackgroundThe application of a second layer between the neourethra and skin was a major contribution, which has improved the outcome of hypospadias repair. Here, we report our experience of revisiting the original Smith technique using a de-epithelialized overlap flap to support the urethroplasty in staged hypospadias repair.MethodsThe study included primary cases of proximal hypospadias with significant chordee who underwent two-stage repair during the period 2016 through 2021. The ventral curvature was corrected at first stage by excision of the urethral plate, followed by covering the ventral shaft by skin flaps or inner preputial graft. The second stage (Thiersch -Duplay urethroplasty) was performed six months later. The de-epithelialized overlap flap (double breasting) technique was used to cover the neo-urethra in all cases, which was combined with a dartos scrotal flap to cover the proximal neourethra when indicated.ResultsThe study included 17 boys with proximal hypospadias who underwent two-stage repair. Follow up period after the second stage ranged between 6 and 30 months (mean 19.7; median 18.5). Post-operative complications were detected in 7 cases (41%). Most complications were related to distal/glanular disruptions whether partial or complete (5 cases). One case developed a penoscrotal fistula that was closed surgically. Another case (belonging to the group which used preputial graft in the 1st stage) presented 21 months after the second stage with urethral stricture (penoscrotal).ConclusionApplying the de-epithelialized double-breasting skin closure can offer alternative second layer coverage for the neourethra along the penile shaft in staged repair of proximal hypospadias.

A contemporary assessment of the evaluation and management of patients presenting to a tertiary medical center with Peyronie's disease.

Peyronie's disease continues to be poorly understood. We characterize the presenting features of Peyronie's disease within a large cohort and elucidate the factors that correlate with surgical intervention. Univariate and multivariate analyses were performed on 1483 consecutive patients to assess pre-operative predictors of surgical intervention for Peyronie's disease. Overall, 1263 patients met inclusion criteria. Mean age was 55.4 ± 11.1 years with a mean duration of disease at presentation of 33.2 ± 42.5 months. Mean primary curvature was 49.8 ± 20.8°. Primary ventral curvature was present in 11.4% and 36.5% of patient had a multiplanar curvature. During penile duplex ultrasound evaluation indentation/narrowing deformities were appreciated in 76.0%, hourglass deformity in 10.1%, and hinge effect in 33.0% of patients. Calcification was seen in 30.1% of patients. Operative intervention occurred in 35.3% of patients. Degree of primary curvature (1.03 OR, p < 0.001), hourglass deformity (1.82 OR, p = 0.01), decreased tunical elasticity (1.20 OR, p = 0.03), and prior intralesional collagenase clostridium histolyticum injections (2.94 OR, p < 0.001) predicted surgical correction on multivariate analysis. Compared to historical studies, we found a higher incidence of severe degree of curvature (27.5% >60°), indentation deformities, hinge-effect, multiplanar curvature and penile calcifications. Ultimately, predictors of surgical intervention included those with worse erectile function and more severe characteristics.

Effectiveness of penile ventral curvature correction and the trend of hypospadias repair: a prospective study of the national center in China

BackgroundHypospadias repair is a complex surgical procedure that involves correcting penile ventral curvature (VC) and performing urethroplasty. This study aims to evaluate the effectiveness of different strategies for VC correction...

Unaided visual assessment of ventral curvature during hypospadias repair is inferior to objective measurement using app goniometry.

Failure to perform artificial erection or objectively assess ventral curvature (VC) during primary hypospadias repair is an important reason for residual/ recurrent chordee. The present study compares the accuracy of unaided visual inspection (UVI) with objective VC assessment using smartphone application (app) goniometry. All patients who underwent primary hypospadias repair between January 2021 and September 2022 were included. Assistant surgeons were asked to grade the degree of VC on UVI (after degloving and an artificial erection test) into: none, mild (<30 degree), severe(>30 degree). Lateral profile photograph was taken and angle measurement was performed on an android mobile application (Angulus). Correlation was performed with both methods of assessment. During this period a total of 210 patients were analyzed; VC was noted in 40/138 (29%) cases of distal and in 62/72 (86%) cases of proximal hypospadias. Erroneous visual inspection was noted in 41/210 (20%; 95% CI 14-25%) on UVI (15 erroneously marked none while 26 marked mild). Among those found to have chordee, UVI assessed 39/82 (47%) as severe while app goniometry assessed 65/97 (67%) as severe. There was significant relative risk of labelling severe chordee as a mild one by UVI: 1.4 (95%CI 1-1.8; p=0.01). UVI was erroneous in 20% of cases. UVI was less accurate in differentiating severe chordee from mild one. In 60% patients UVI alone could have led to erroneous VC assessment and thus wrong selection of technique. Further studies are required to validate our findings and standardize VC measurement using an app goniometry.

Grafts vs. flaps: a comparative study of Bracka repair and staged transverse preputial island flap urethroplasty for proximal hypospadias with severe ventral curvature.

Bracka repair and staged transverse preputial island flap urethroplasty are both significant methods in treating proximal hypospadias. They utilize the flap and graft techniques, respectively, to achieve a satisfactory success rate. This study aimed to compare the outcomes of these 2 methods in the treatment of proximal hypospadias with severe ventral curvature. We retrospectively analyzed 117 cases of proximal hypospadias with severe ventral curvature who had undergone either Bracka repair (n = 62) or staged transverse preputial island flap urethroplasty (n = 55). All operations were performed by a single surgeon, and the choice of method was determined by the surgeon's preference based on his experience. Cosmetic outcome was evaluated with Pediatric Penile Perception Score (PPPS). Patients' characteristics including age, penis length, glans diameter, length of the urethral defect and ventral curvature degree, cosmetic outcomes, and complication rates were all compared. There was no significant difference in age, penis length, glans diameter, length of the urethral defect, or ventral curvature degree. In the Bracka group, there were 5 patients with fistula, 1 patient with stricture, and 1 case of dehiscence. In the staged transverse preputial island flap urethroplasty group, there were 4 patients with fistula, 1 with stricture, and 2 with diverticulum. The scores of shaft skin and general appearance were consistently higher in the Bracka group than in the staged transverse preputial island flap urethroplasty group. The differences in complication rate and cosmetic outcome were not statistically different (P > 0.05). Bracka repair and staged transverse preputial island flap urethroplasty are both satisfactory staged surgical options for proximal hypospadias with severe ventral curvature and have similar complication rates. Bracka repair may create a better appearance, but more studies are needed to confirm this finding. Pediatric surgeons should consider additional factors, such as the patient's specific condition, parents' inclination, and personal experience, rather than safety, to make the best choice between the 2 methods.

(424) A Contemporary Assessment of Patients Presenting to a Tertiary Medical Center with Peyronie’s Disease

Abstract Introduction Peyronie’s disease (PD) is a progressive wound-healing disorder resulting in plaque formation within the tunica albuginea. PD continues to be poorly understood and an area of investigation, with increased awareness by patients and clinicians. Most commonly, PD patients will have a singular plaque and uniplanar curvature in the dorsal or lateral direction. However, previous studies have categorized less common deformities as “atypical”, which includes ventral curvature, multiplanar curvatures, unilateral indentations, hourglass deformity, and severe loss of penile length. Objective We aim to characterize the presenting features of PD within a large cohort of patients presenting to a tertiary referral center. Furthermore, we seek to elucidate the pre-operative factors that correlate with subsequent surgical intervention. Methods 1483 consecutive patients presenting with PD from 2016 to 2021 were retrospectively identified. Patients were excluded if they only had virtual visits, refused penile duplex evaluation, or had PD surgical correction prior to presentation. Baseline demographics, prior treatments, physical exam findings, penile duplex assessment (PDDU), subsequent interventions, and clinical outcomes were documented. Univariate and multivariate analyses were performed to assess pre-operative predictors of subsequent surgical intervention. Results In total, 1263 patients met inclusion criteria. Mean age at presentation was 55.4 ± 11.1 years with a mean duration of PD at presentation of 33.2 ± 42.5 months. Mean primary curvature was 49.8 ± 20.8°. Primary ventral curvature was present in 11.4% and 36.5% of patients had a multiplanar curvature. Mean composite curvature was 60.4 ± 28.2°. Subjective penile shortening was reported by 64.8% of patients with a mean reported loss of 3.8 ± 2.1 cm. During PDDU, indentation/narrowing deformities was appreciated in 73.7%, hourglass deformity in 10.1%, and hinge effect in 33.0% of patients. Calcification was seen in 30.1% of patients. Operative intervention occurred in 35.3% of patients. Hypogonadism (1.56 OR, p=0.04), severity of primary curvature (1.03 OR, p&amp;lt;0.001), hourglass deformity (1.82 OR, p=0.01), decreased tunical elasticity (1.20 OR, p=0.03), and prior intralesional Xiaflex injections (2.94 OR, p &amp;lt;0.001) predicted subsequent surgical correction. Negative predictors of surgical intervention included use of any oral PD treatment (0.43 OR, &amp;lt;0.001) and ability to perform penetrative sex (0.72 OR, p=0.04). 446 (35.3%) patients underwent surgical intervention with 170 (38.1%) plaque incision/excision and grafting, 110 (24.7%) tunical plication, and 166 (37.2%) inflatable penile prosthesis cases. Conclusions Peyronie’s disease remains an incompletely understood disease and presenting features may be changing as a result of more sophisticated evaluation and physician experience. Ventral curvature, multiplanar curvatures, indentation deformity, hourglass deformity, and severe loss of penile length have been described as “atypical”, but these changes are not rare in our cohort of referred patients. Patients with worse erectile function and more severe PD characteristics were predictors of surgical intervention. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

(405) Penile Prosthesis Implantation and Peyronie's Disease: How to Approach the Residual Curvature – A Detailed Demonstration of Moulding Technique and Grafting Procedure

Abstract Introduction Insertion of a penile prosthesis is the treatment of choice in men with Peyronie’s disease and concomitant erectile dysfunction. The aim of surgery is to straighten the penis and allow adequate rigidity for sexual intercourse. A conundrum arises when there is residual curvature during device testing. Objective This video highlights strategies that will aid the implanter when faced with these intraoperative challenges. Methods This video illustrates three different scenarios and suggests strategies that can be used when there is a residual penile curvature following inflatable penile prosthesis insertion: 1) Manual moulding – In this scenario, a persistent left lateral curvature is successfully straightened by moulding the plaque following device insertion. The cylinders are fully inflated and the tubes to the pump are double clamped. One hand is positioned distal to the apex of the curvature while the other is proximal. The penis is manipulated in the opposite direction to the curvature. 2) Residual curvature after manual moulding – The plaque can be incised at the point of maximal curvature and grafted If there is a significant persistent curvature (&amp;gt;30 degrees) following moulding. A fibrin sealant patch was used in this patient and it offers a quick and effective choice for grafting the tunical defect. 3) Upfront plaque incision and grafting - Some patients are not suitable for moulding following penile prosthesis insertion. Examples include ventral penile curvature and ossified plaques. In this patient with a ventral curvature, the plaque was incised and the tunical defect grafted with bovine pericardial graft prior to corporal dilatation. Results All three patients had an uneventful post-operative outcome. They were encouraged to cycle the device from 3 weeks and allowed to commence sexual intercourse after 6 weeks post-surgery. Conclusions Manual moulding is a safe and effective first line option for residual penile curvature following inflatable penile prosthesis insertion. Plaque incision and grafting can be considered if moulding fails or where manual moulding is contraindicated. There are several choices for graft material including fibrin sealant patch or bovine pericardium. Disclosure No

(102) Complications of the Penuma Penile Implant for Genital Enhancement

Abstract Introduction The Penuma penile implant (PPI) is a subcutaneous silicone implant intended to increase penile length and girth. Only one case report and one case series of four patients have been published on the complications of PPIs. Objective To report a single center experience treating complications of the PPI both prior to and after implant removal. Methods Patients with a prior history of PPI surgery treated at our center were identified between 2012 and 2022. Demographic data, implant date, complications leading to explant, postoperative course, and functional outcomes were recorded. Our protocol is to wait 6 months after explant prior to scar excision (SE)/revision should disabling capsular contraction develop. Results A total of 13 patients were evaluated at our institution. Median age at time of implant was 36 (26-54) years. The median duration of implant was 3 months (range 3 days-33 months). Mean follow-up was 21.6 months. The most common complication leading to explant was distal lateral protrusion of the implant at the coronal margin causing patient and partner discomfort which occurred in 8 patients. Other reasons for explant were skin erosion, infection, decreased sensation, ventral curvature, and penile shortening each occurring in 1 patient. Adverse sensation changes occurred in 2 patients after implant. Following explant 9 (69%) patients developed disabling dorsal curvature, 8 (62%) patients had penile shortening, 3 (23%) had infections, 2 (15%) had de novo sensation changes, 2 (15%) had erectile dysfunction, and 1 (8%) had right lateral curvature. Curvature occurred because of capsule contraction following explant. Of those with disabling curvature, 6 (67%) underwent scar excision (SE), 1 is awaiting scar maturation for SE, 1 more is considering SE for disabling curvature, and 1 has elected not to undergo further surgery. In patients who underwent SE, severe scarring was noted superficial to the neurovascular bundles. All patients who have undergone SE had improvement in curvature and were able to have functional erections. Conclusions PPI for cosmetic penile enhancement can be associated with a variety of complications leading to device removal. Subsequent to explant, capsular contraction can result in disabling curvature and penile shortening which can be managed successfully with SE. Disclosure No

(161) Xiaflex Nonresponders Show Alteration in Penile Measurements: Post-Market Analysis of Predictors for Treatment Success

Abstract Introduction The IMPRESS trial revealed that intralesional collagenase clostridium histolyticum, Xiaflex, is safe and efficacious for treating the physical and subjective effects of Peyronie’s Disease (PD). However, little is known about the other manifestations of PD, namely penile shortening and efficacy for patients of diverse racial backgrounds or with severe penile curvatures. Objective To evaluate predictors associated with response to treatment and alterations in penile morphological measurements. Methods Consecutive patients treated with Xiaflex for dorsal, lateral, and ventral penile curvatures ≥ 25°, in the absence of hourglass deformity, were included in this study. Before treatment and eight weeks after the last injection cycle, during penile duplex Doppler ultrasound evaluation, penile curvature was measured with a goniometer after induced artificial erection via injection of prostaglandin E1 (PGE1). IIEF score, PGE1 dose, circumference, and erectile as well as stretched penile length were also assessed at these times. Based on the results of the IMPRESS trial, patients were considered Xiaflex responders if the decrease in their penile curvature were ≥ 15° (n =134) and Xiaflex nonresponders if the decrease in their penile curvature were &amp;lt; 15° (n =89). Initial measurements were in increments of 5°. Intention to treat analysis was performed. Results Two hundred and twenty-three patients with penile curvature ≥ 25° who received XIAFLEX were included in this study. One hundred and thirty-four patients (60.1%) responded to Xiaflex, while 89 (39.9%) patients did not respond. African American men were 3 times more likely to respond to treatment than their non-African American counterparts (Odds Ratio (OR) =3.35 (95% CI, 1.15-10.70), p =0.031). On the other hand, men with an initial penile curvature of greater than 60° were less likely to respond to Xiaflex (OR = 0.34; 95% CI, 0.16-0.69; p=0.003). However, patients with lateral and ventral curvatures responded at comparable rates to those with dorsal curvatures. Subsequently, changes in penile morphologic measurements post Xiaflex were analyzed. Average stretched penile length, erectile length, and erectile circumference prior to treatment for responders were 13.93 cm, 13.39 cm, and 11.81 cm, respectively; for nonresponders, it was 14.27 cm, 13.72 cm, 11.64 cm, respectively. Nonresponders were shown to experience a significant decrease in penile erect length (-0.55 cm) and circumference (-0.58 cm) (p=0.002 and p=0.002, respectively), whereas responders showed no significant alterations in penile morphologic measurements. Conclusions Our analysis revealed that men with penile curvatures ≥ 60° are less likely to respond to Xiaflex injections and thus may be considered for surgical intervention upon initial presentation. Furthermore, men who do not respond may even be at a higher risk for shortening of penile erect length and circumference. The actual clinical significance of a decrease in average erect length of 0.55 cm and circumference of 0.58 cm is difficult to determine and should be considered per patient preferences. Further investigations into predictors for response to Xiaflex and the pathophysiology behind penile shortening in Xiaflex nonresponders are warranted. Disclosure No

Trends and predictors of incidence of hypospadias in a tertiary hospital in South Africa

BackgroundHypospadias is a penile congenital abnormality characterized by an ectopic urethral opening, ventral curvature and incomplete foreskin closure with a dorsal hooded prepuce. Management of the outcome demands high cost. The aim of this study was to determine the trends and predictors of hypospadias among babies born at Charlotte Maxeke Johannesburg Academic Hospital between 01 January 2014 and 31 December 2016.MethodsMothers’ files from the transfer unit of the labour ward were reviewed. A case–control study compared boys with hypospadias and those without born approximately at the same time. Data were retrospectively collected on data collection forms. EpiData version 3.1 and STATA version 15.1 were used for statistical analysis. The Mantel Haenszel method determined combined odds ratios for hypospadias outcome on boys whose mothers were exposed to certain conditions versus boys of unexposed mothers. Woolf’s method was used to compute confidence intervals of the odds ratios. Logistic regression analysis was used to assess the independent contributing maternal factors to the risk of hypospadias.ResultsRecords of 221 male babies were collected of which 73 were cases and 148 controls in the ratio of 1:2. Hypospadias was more frequent in boys born by Caesarean Section (p < 0.001), those with low birth weight (p < 0.001) and those small for gestational age (p < 0.002). Alcohol use (odds ratio 3.1), smoking (odds ratio 1.54), herbal use (odds ratio 2.05), medical history (odds ratio 2.8), multiple pregnancies (odds ratio 1.69) and maternal congenital abnormalities (odds ratio 3.03) indicated an increased risk of hypospadias. Surgical history (odds ratio 1.29), pre-natal vaccination (odds ratio 0.92), employment (odds ratio 0.85), and education (odds ratio 0.48) were not associated with the risk of hypospadias.ConclusionsMothers older than 36 years presented a stratifying effect on disease outcome. Our findings did not indicate major changes in trends of incidence of hypospadias. The years assessed did not have a significant effect on the number of cases.

A novel corporoplasty technique with a urethral plate flap in hypospadias repair.

To report a novel corporoplasty technique with a urethral plate flap in hypospadias repair and evaluate its safety and efficacy for ventral lengthening. Data were retrospectively collected from consecutive patients with hypospadias who underwent urethral plate flap corporoplasty between July 2021 and March 2022. All patients underwent hypospadias repair using the Duckett technique. The corporoplasty procedure involved the following key steps: the half-spongiosum of the urethral plate was harvested as a flap (with a pedicle attached to the corpus cavernosum); a transverse incision of the tunica albuginea was made adjacent to the pedicle; and the flap was patched onto the corporal defect. The study included 10 patients, with a median age of 20 months. The initial meatal location was penile in two patients, penoscrotal in four patients, and scrotal in four patients. The median ventral curvature was 45° after degloving and urethral plate transection. The median ventral lengthening distance proportional to penis length was 0.21. During the median follow-up of 13.8 months, complications occurred in three cases, including two cases of fistula and one case of urethral stricture with secondary diverticulum. No cases of recurrent ventral curvature, meatal stenosis, or urethral dehiscence were noted. Postoperative ultrasonography showed a good continuation of the tunica albuginea and integrity of the stratum spongiosum at the corporoplasty site. Urethral plate flap corporoplasty is a simple and effective ventral lengthening procedure. The novel corporoplasty technique allows for anatomical and architectural repair of corporal disproportion.

Dorsal shortening vs. ventral lengthening for congenital ventral curvature in patients with/without severe hypospadias A meta-analysis of comparative studies.

Herein, we compared surgical outcome of dorsal shortening (DS) vs. ventral lengthening (VL) for correcting congenital ventral curvatures. A systematic literature search was performed in September 2021 using the PubMed, EMBASE, Scopus, CENTRAL, ProQuest, and Clinicaltrials.gov databases. Comparative studies were identified and evaluated according to Cochrane Collaboration recommendations. Assessed outcomes included success and complication rates, which were extrapolated for the respective odds ratios (OR) with 95% confidence intervals (CIs). Subgroup analyses were performed according to congenital curvature, with or without severe hypospadias or recurrent curvatures (PROSPERO: CRD42021276193). Based on pooled effect estimates from 12 studies with 430 (DS 253, VL 177) cases of ventral curvature repair, VL rendered a better success rate for curvature correction (OR 4.20, 95% CI 2.11, 8.33) than DS, with comparable composite surgical complication rates (OR 0.77, 95% CI 0.27, 2.18). Subgroup analysis showed that the success rate remained significantly better for VL among patients with associated severe hypospadias (OR 3.59, 95% CI 1.25, 10.26) and recurrent penile curvatures (OR 5.70, 95% CI 1.69, 19.21) but not among those with congenital curvature without hypospadias or those with mild hypospadias (OR 2.99, 95% CI 0.32, 27.57). For congenital curvature associated with severe hypospadias and recurrent curvatures, VL renders a modestly better success rate; however, careful selection of patients is key for best outcome.

Comprehensive multidisciplinary phenotyping of patients with hypospadias. A pilot study

Hypospadias is an abnormal formation of the urethra, ventral skin, and corporal bodies. Location of the urethral meatus has historically been the phenotypic landmark that defines hypospadias. Nonetheless, classifications following location of the urethral meatus fail to consistently predict outcomes and have no correlation with the genotype. Description of the urethral plate is very subjective and difficult to reproduce. We hypothesize that the use of digital pixel cluster analysis and correlation to histological analysis can provide a novel method to describe the phenotype of patients with hypospadias. A standardized hypospadias phenotyping protocol was developed. 1. Digital images of the anomaly, 2. Anthropometric assessment of penile dimensions (penile length, urethral plate length and width, glans width, ventral curvature), 3. Classification using the GMS score, 4. Tissue sampling (foreskin, glans, urethral plate, periurethral ventral skin) and H&E analysis by a blinded pathologist. A k-means colorimetric pixel cluster analysis was performed following the same anatomical landmark distribution as the histology samples. Analysis was performed using MATLAB v R2021b 9.11.0.1769968. A total of 24 patients prospectively enrolled with a standard protocol. Mean age at surgery was 16.25 months Urethral meatus was distal shaft in 7 patients, 8 coronal, 4 glanular, 3 midshaft, 2 penoscrotal. Average GMS score was 7.14 (±1.58). Average glans size was 15.71mm (±2.33) and urethral plate width 5.57mm (±2.06). Eleven patients underwent Thiersch-Duplay repair, 7 TIP, 5 MAGPI, and 1 a first stage preputial flap. Mean follow-up was 14.25 months (±3.7 months). Two (8.3%) postoperative complications (1 urethrocutaneous fistula and 1 ventral skin wound dehiscence) were reported in the study period. Eleven (52.3%) patients with histological analysis had an abnormal pathology report. Of those, 6 (54%) had reported abnormal lymphocyte infiltration interpreted as chronic inflammation at the urethral plate. The second most common finding was hyperkeratosis visualized in the urethral plate in 4 (36.3%) and one with reported fibrosis in the urethral plate. K-means pixel analysis demonstrated a k1 mean of 64.2 for reported urethral plate inflammation vs 53.1 for non-reported urethral plate inflammation (p=0.002) CONCLUSIONS: Current phenotyping of hypospadias using only anthropometric variables can be expanded including histological and pixel analysis correlation. Pixel clustering has a potential for a priori prediction of urethral plate quality beyond the current subjective assessment. A larger cohort will allow identification of possible predictive associations that might impact intraoperative decision-making and surgical outcomes.

MP36-02 SAFETY AND EFFECTIVENESS OF INTRALESIONAL CLOSTRIDIUM HISTOLYTICUM INJECTIONS FOR ATYPICAL PRESENTATIONS OF PEYRONIE'S DISEASE

You have accessJournal of UrologyCME1 Apr 2023MP36-02 SAFETY AND EFFECTIVENESS OF INTRALESIONAL CLOSTRIDIUM HISTOLYTICUM INJECTIONS FOR ATYPICAL PRESENTATIONS OF PEYRONIE'S DISEASE Zhan Wu, Mystie Chen, Jasmine Kashkoush, and Ryan Mori Zhan WuZhan Wu More articles by this author , Mystie ChenMystie Chen More articles by this author , Jasmine KashkoushJasmine Kashkoush More articles by this author , and Ryan MoriRyan Mori More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003270.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Peyronie’s disease (PD) is a common condition that causes sexual dysfunction and significant psychosocial distress. Intralesional injection of Clostridium Histolyticum (CCH) is a safe and effective treatment for well selected patients with PD. Limited data currently address the use of CCH for atypical presentations of PD which include hourglass deformity, ventral curvature, multi-planar curvature, and calcified plaque. We aim to assess the safety and effectiveness of CCH for patients with atypical PD. METHODS: A retrospective review was conducted on patients who received CCH at an integrated health system from October 2016 to September 2022. Patients were split into two groups: typical PD and atypical PD. Atypical PD patients included those with hourglass deformity, ventral curvature, multi-planar curvature, and calcified plaque. Demographics, treatment details, objective outcomes (curvature assessments), patient-reported outcome measures (Peyronie’s Disease Questionnaire), and complications were assessed. RESULTS: 83 men with stable phase PD underwent intralesional CCH injections. The mean age was 55.27 (SD=8.09). This included 44 men (53%) with atypical PD: 25 with hourglass deformity, 16 with multi-planar curvature, 13 with calcified plaque, and 4 with ventral curvature. The mean absolute change in penile curvature for patients with atypical PD was similar to patients with typical PD (18.3 degrees vs. 20.8 degrees, p=0.294). This represented an overall improvement in curvature by 38.9% and 40.8% for atypical and typical PD respectively (p=0.656). CCH was equally well tolerated with both groups with only minor complications. The most common post-procedural complaints were ecchymosis and mild penile pain. Corporal rupture was exceedingly rare with 1 case in each group. The composite psychosocial/physical symptoms score on PDQ assessment decreased by 4.88 and 4.48 for typical and atypical PD respectively (p=0.859). Likewise, the composite symptom bother score of PDQ decreased by 4.13 and 2.76 for typical and atypical PD respectively (p=0.270). CONCLUSIONS: Intralesional CCH has been shown to be safe and effective for treatment of PD presenting as isolated unidirectional dorsal or lateral deformity. These data suggest CCH is safe and effective for atypical presentations of PD including hourglass deformity, ventral curvature, multi-planar curvatures, and calcified plaque. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e479 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zhan Wu More articles by this author Mystie Chen More articles by this author Jasmine Kashkoush More articles by this author Ryan Mori More articles by this author Expand All Advertisement PDF downloadLoading ...

MP36-01 AN ANALYSIS OF THE PSYCHOLOGICAL BOTHER IN MEN WITH PEYRONIE'S DISEASE

You have accessJournal of UrologyCME1 Apr 2023MP36-01 AN ANALYSIS OF THE PSYCHOLOGICAL BOTHER IN MEN WITH PEYRONIE'S DISEASE Luis F. Novaes, Lawrence C. Jenkins, Jean E. Terrier, Hisanori Taniguchi, Bruno Nascimento, Sigrid Carlsson, Christian Nelson, Jose M. Flores, and John P. Mulhall Luis F. NovaesLuis F. Novaes More articles by this author , Lawrence C. JenkinsLawrence C. Jenkins More articles by this author , Jean E. TerrierJean E. Terrier More articles by this author , Hisanori TaniguchiHisanori Taniguchi More articles by this author , Bruno NascimentoBruno Nascimento More articles by this author , Sigrid CarlssonSigrid Carlsson More articles by this author , Christian NelsonChristian Nelson More articles by this author , Jose M. FloresJose M. Flores More articles by this author , and John P. MulhallJohn P. Mulhall More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003270.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is an association between Peyronie's disease (PD) and psychological bother, depression and relationship dissatisfaction. We aimed to describe the prevalence of these psychosocial issues using validated instruments. METHODS: On presentation, all patients with PD who responded to 3 validated questionnaires were included in this study. The inventories included: the Peyronie’s Disease Questionnaire (PDQ), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Self-Esteem and Relationship (SEAR) questionnaire. The PDQ has 3 subdomains, psychological and physical symptoms, penile pain, and bother signs. With worsening negative impact, PDQ scores are higher; a bother domain score ≥9 indicates clinically meaningful bother. A CES-D score, ≥16/60 suggests clinical depression. The SEAR contains 14 questions, divided into the domains of sexual relationship and confidence (self-esteem; overall relationship), with a normalized score of 0-100, (higher scores better QOL). Demographics and PD characteristics are reported. We evaluated potential predictors of psychological bother. Parameters included in univariable (UVA) and multivariable (MVA) analysis models: age, sexual orientation, PD duration, multiplanar curvature, pain, intercourse, curvature, penile instability. RESULTS: 720 patients were analyzed. Median age 58 [52, 64] years, 20% had ≥2 comorbidities, 7% were current smokers. Median PD duration was 10 [4, 24] months, 28% multiplanar curvature, median degree of the primary was 32° [21, 46]. Curvature location: mid-shaft 64%, distal 25%, proximal 11%. 49% had dorsal, 37% lateral, and 14% ventral curvature. Median PDQ scores: psychological and physical (0-24) was 9 [4, 14]; pain (0-30) was 3 [0, 8]; bother (0-16) was 4 [3, 6]; 5% had clinically significant bother. Median CES-D scores 8 [3, 15], 23% had scores ≥16, indicating clinical depression. Median SEAR scores: sexual relationship 28 [16, 41]; confidence 32 [23, 41]. On UVA, pain (OR: 4.67; 95% CI: 1.4, 14.8; p: 0.009) curvature magnitude (OR: 1.47; 95% CI: 1.1, 1.9; p: 0.007) were predictors of bother. Median PDQ pain scores in bothered patients was 14.5 [8.5, 21.2], vs 2 [0, 7] in non-bothered. On MVA (Table 1), pain was the only predictor of bother. CONCLUSIONS: Pain and curvature is associated with bother, and 1 in 4 PD patients have clinical depression. Source of Funding: SMSNA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e479 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luis F. Novaes More articles by this author Lawrence C. Jenkins More articles by this author Jean E. Terrier More articles by this author Hisanori Taniguchi More articles by this author Bruno Nascimento More articles by this author Sigrid Carlsson More articles by this author Christian Nelson More articles by this author Jose M. Flores More articles by this author John P. Mulhall More articles by this author Expand All Advertisement PDF downloadLoading ...

V11-01 DEEP DORSAL VEIN BED PLICATION FOR VENTRAL PENILE CURVATURE

You have accessJournal of UrologyCME1 Apr 2023V11-01 DEEP DORSAL VEIN BED PLICATION FOR VENTRAL PENILE CURVATURE Pedro Caetano Edler Zandoná, Guilherme Garcia Barros, Igor Valente Coimbra, Plinio Moreira De Góes, Eduardo Zinoni Silva Pato, William Carlos Nahas, Bruno Chiesa Gouveia Nascimento, and Jorge Hallak Pedro Caetano Edler ZandonáPedro Caetano Edler Zandoná More articles by this author , Guilherme Garcia BarrosGuilherme Garcia Barros More articles by this author , Igor Valente CoimbraIgor Valente Coimbra More articles by this author , Plinio Moreira De GóesPlinio Moreira De Góes More articles by this author , Eduardo Zinoni Silva PatoEduardo Zinoni Silva Pato More articles by this author , William Carlos NahasWilliam Carlos Nahas More articles by this author , Bruno Chiesa Gouveia NascimentoBruno Chiesa Gouveia Nascimento More articles by this author , and Jorge HallakJorge Hallak More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Either Congenital Penile Curvature or Peyronie’s Disease may cause severe ventral curvature. Historically, surgical techniques for this type of deformities were associated with longer operative time and greater patient dissatisfaction, mainly due to neurovascular bundle (NVB) dissection [1]. Previous studies described a midline dorsal plication technique in pediatric patients, allowing for an effective correction without requiring NVB manipulation [2-5]. Neuroanatomical studies have demonstrated the distribution of nerve fibers and identified the 12 o'clock position as the only nerve-free position [2]. Finally, in 2021, Bagnara et al published the description of the Giammusso corporoplasty in adults [6]. We aim to demonstrate with this video article the step by step of this previously published technique for ventral penile curvature correction. METHODS: This video article is a compilation of images of three surgeries performed for ventral penile curvature utilizing an adaptation of the Giammusso Corporoplasty technique. In the main video, the procedure was performed for a 26-year old male with a 62-degree ventral congenital penile curvature. Supplementary photographs of other two cases were added to the video: a 77-year old male with a 68-degree Peyronie’s ventral curvature and a 29-year old male with a 28-degree ventral congenital penile curvature. In all cases, a subcoronal incision was performed, and penile skin and Dartos’ fascia were degloved. The point of maximum curvature was identified after a saline induced artificial erection, Buck’s fascia was incised, and deep dorsal vein and its branches were then dissected and ligated. Differently from the Giammusso technique, we did not perform a corporoplasty, but a simple plication as described by Akdemir et al [5]. This latter technique however spares the deep dorsal vein. For the plication, after planning and marking their sites with Allys clamp and artificial erection confirming functional alignment, we utilized 3 inverted non-absorbable 2-0 coated polyester sutures for each plication site. Circumcision was performed for penile shaft closure. RESULTS: The three patients shown in this video obtained functional penile alignment, and no change in glans sensation. No severe adverse event was observed, with one patient developing a small penile hematoma managed conservatively. CONCLUSIONS: This video article describes Deep Dorsal Vein Bed Plication, a feasible and effective technique for ventral penile curvature treatment, which avoids NVB dissection and its associated risks such as glans hypoesthesia and glans necrosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e999 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pedro Caetano Edler Zandoná More articles by this author Guilherme Garcia Barros More articles by this author Igor Valente Coimbra More articles by this author Plinio Moreira De Góes More articles by this author Eduardo Zinoni Silva Pato More articles by this author William Carlos Nahas More articles by this author Bruno Chiesa Gouveia Nascimento More articles by this author Jorge Hallak More articles by this author Expand All Advertisement PDF downloadLoading ...

Post-pubertal functional outcomes of one-stage anatomical reconstruction of the corpus spongiosum, bulbo-spongiosus muscle and dartos in 46 children with proximalhypospadias

Anatomical studies of hypospadias show failure of zipping-up of histologically normal urethral plate and corpus spongiosum. With the commonly utilized substitution urethroplasties for proximal hypospadias, a reconstructed urethra of just an "epithelial-lined tube" with no spongiosal support, is apt to long-term urinary and ejaculatory dysfunctions. We completed a one-stage anatomical reconstruction in children with proximal hypospadias whenever the ventral curvature could be reduced to <30° and evaluated the post-pubertal outcomes. This is a retrospective analysis of prospectively maintained data on one-stage anatomical repair of proximal hypospadias between 2003 and 2021. In children with proximal hypospadias, the corpus spongiosum, bulbo-spongiosus muscle (BSM), Bucks', and Dartos' layers of the shaft were anatomically re-aligned prior to assessing the ventral curvature visually. When the curvature was >30°, the urethral plate was divided at the glans for a 2-stage procedure, and those patients were excluded from the study. Otherwise, the anatomical repair was continued (this series). The Hypospadias Objective Scoring Evaluation (HOSE) and the Paediatric Penile Perception Score (PPPS) were used for post-pubertal assessment. Prospective records provided details of 105 patients with proximal hypospadias who had complete primary anatomical repair. The median age at surgery was 1.6 years, and 15.9 years at the post-pubertal assessment. Forty-one (39%) had complications that necessitated re-operations. Thirty-five (33.3%) patients had complications involving the urethra. For fistula and diverticula, eighteen cases required only one corrective procedure, while one required two. Other 16 patients required an average of 1.78 corrective operations for severe chordee and/or breakdown, with 7 requiring Bracka's 2-stage procedure. Fifty patients (47.6%) were over 14 years old; 46 (92.0%) had pubertal reviews and scoring, while four were lost to follow-up. The mean HOSE score was 14.8/16, and the mean PPPS score was 17.8/18. Five patients had residual curvature of >10°. 17 and 10 patients, respectively, were unable to comment on glans firmness and ejaculation quality. During erections, 26/29 (89.7%) patients reported a firm glans, and 36/36 (100%) reported normal ejaculations. This study proves the need for reconstruction of normal anatomy for normal post-pubertal function. In all proximal hypospadias, we strongly recommend anatomical reconstruction (zipping up) of the corpus spongiosum and BSM. When the curvature can be reduced to <30°, a complete one-stage reconstruction is possible; otherwise, anatomical reconstruction of the bulbar and proximal penile urethra is recommended, reducing the length of the epithelial-lined substitution tube for the distal shaft and glans.