Management of Urethral Strictures After Hypospadias Repair.

Strictures of the neourethra after hypospadias surgery are more common after skin flap repairs than urethral plate or neo-plate tubularizations. The diagnosis of stricture after hypospadias repair is suspected based on symptoms of stranguria, urinary retention, and/or urinary tract infection. It is confirmed by urethroscopy during anticipated repair, without preoperative urethrography. The most common repairs for neourethra stricture after hypospadias surgery are single-stage dorsal inlay graft and 2-stage labial mucosa replacement urethroplasty.

Patient Reported Outcomes in Preoperative and Postoperative Patients with Hypospadias.

PURPOSE: Current outcome tools for hypospadias have limited focus on the caregiver or patient perspective of important patient centered outcomes. In this study we collaborated with patients, caregivers, and lay and medical experts to develop and pilot a patient reported outcome measure for hypospadias. MATERIALS AND METHODS: We developed a patient reported outcome measure based on systematic review of the literature and focus group input. The patient reported outcome measure was piloted in caregivers for boys younger than 8 years and in patients older than 8 years who presented for urology consultation before meeting with the surgeon. Patients were classified with uncorrected hypospadias, successful repair or failed repair based on the presence or absence of complications (fistula, diverticulum, meatal stenosis/stricture, greater than 30-degree recurrent curvature, glans dehiscence and/or skin reoperation). RESULTS: A patient reported outcome measure was developed and administered to 347 patients and/or caregivers-proxies, including 105 uncorrected cases, 162 successful repair cases and 80 failed cases. Satisfaction with appearance was highest in those with successful hypospadias repair compared to failed repair and uncorrected hypospadias (93% vs 77% and 67%, respectively). Voiding symptoms such as spraying or a deviated stream were highest in failed and uncorrected cases (39% and 37%, respectively). Overall dissatisfaction with voiding was highest for uncorrected hypospadias and failed repair compared to successful cases (54% and 47%, respectively, vs 15%). CONCLUSIONS: The evaluation of patient and caregiver-proxy reported outcomes in preoperative and postoperative patients with hypospadias allows for the quantification of benefits derived from hypospadias repair and may ultimately represent the gold standard outcome measure for hypospadias. This pilot study identified preliminary patient centered themes and demonstrated the feasibility of administering hypospadias patient reported outcome measures in clinical practice.

Glans size is an independent risk factor for urethroplasty complications after hypospadias repair.

INTRODUCTION: We hypothesized small glans size could increase urethroplasty complications (UC) following hypospadias repair. To test this, we measured glans width at its widest point in consecutive patients with hypospadias, and following a protocol for surgical decision-making, we then assessed post-operative UC using pre-determined definitions. We now report analysis of glans size as a potential additional independent risk factor for UC after hypospadias repair. METHODS: Consecutive prepubertal patients undergoing hypospadias repair (2009-2013) had maximum glans width measured using calipers (Fig. 1). There were no differences in surgical technique for urethroplasty or glansplasty in this series based on the measured size of the glans. Multivariate logistic regression analyzed UC (fistula, glans dehiscence, diverticulum, stricture and/or meatal stenosis) based on glans size while adjusting for patient age, meatus (distal or midshaft/proximal), type of repair (TIP, inlay, 2-stage), surgeon, and primary or reoperative repair. Glans size was analyzed as both a continuous and dichotomous variable, with small glans defined as <14 mm. RESULTS: Mean glans size was 15 mm (10-27 mm) in 490 boys (mean 1.5 years) undergoing 432 primary repairs (380d/19mid/33prox), and 58 reoperations (28d/7mid/23prox). Increasing age between 3 months and 10 years did not correlate with increasing glans size (R = 0.01, p = 0.18). 17% had small glans <14 mm. UC occurred in 61 (13%) primary TIP, 2-stage, and reoperative repairs, including 20/81 (25%) patients with small glans <14 mm, versus 41/409 (10%) in patients with glans width ≥14 mm (p = 0.0003). On multivariate analysis, small glans size (OR 3.5, 95% CI 1.8-6.8), reoperations (OR 3.0, 95% CI 1.4-6.5) and mid/proximal meatus (OR 3.1, 95% CI 1.6-6.2) were independent risk factors for UC. Surgeon, repair type, and patient age did not impact risk for UC. Analysis with glans size as a continuous variable demonstrated each 1 mm increase in size decreased odds of UC (OR 0.8, 95% CI 0.7-0.9). CONCLUSIONS: Our analysis of prospectively-collected data from a standardized management protocol in 490 consecutive boys undergoing hypospadias repair adds small glans size, defined as width <14 mm, to proximal meatal location and reoperation as an independent risk factor for UC. Best means to modify this factor remain to be determined. Our data suggest that others analyzing potential risks for hypospadias UC should similarly measure and report glans width.

Duration of follow-up to diagnose hypospadias urethroplasty complications.

OBJECTIVE: We report the time when hypospadias urethroplasty complications (UC) were diagnosed postoperatively. METHODS: The time UC occurred after primary distal and proximal TIP and TIP reoperations was obtained from prospectively maintained databases in consecutive patients. UC included fistulas, glans dehiscences, meatal stenoses, neourethral strictures and diverticula. RESULTS: Of 125 UC, 64% were diagnosed at the first postoperative visit and 81% were encountered within the first year after repair. Median time for diagnosis was 6 months (1.5-95) for fistulas, meatal stenoses/urethra strictures, and diverticulum, versus 2 months (1 week-24 months) for glans dehiscence. CONCLUSIONS: The majority of UC are diagnosed at the first postoperative visit or within the first year following TIP hypospadias repair. Glans dehiscences are most often apparent by 2 months, whereas most fistulas and other UC are found by 6 months. After 1 year, 14 boys without UC have to be followed indefinitely to diagnose each additional complication.

Introducing the HOPE (Hypospadias Objective Penile Evaluation)-score: a validation study of an objective scoring system for evaluating cosmetic appearance in hypospadias patients.

OBJECTIVE: To determine the reliability and internal validity of the Hypospadias Objective Penile Evaluation (HOPE)-score, a newly developed scoring system assessing the cosmetic outcome in hypospadias. PATIENTS AND METHODS: The HOPE scoring system incorporates all surgically-correctable items: position of meatus, shape of meatus, shape of glans, shape of penile skin and penile axis. Objectivity was established with standardized photographs, anonymously coded patients, independent assessment by a panel, standards for a "normal" penile appearance, reference pictures and assessment of the degree of abnormality. A panel of 13 pediatric urologists completed 2 questionnaires, each consisting of 45 series of photographs, at an interval of at least 1 week. The inter-observer reliability, intra-observer reliability and internal validity were analyzed. RESULTS: The correlation coefficients for the HOPE-score were as follows: intra-observer reliability 0.817, inter-observer reliability 0.790, "non-parametric" internal validity 0.849 and "parametric" internal validity 0.842. These values reflect good reproducibility, sufficient agreement among observers and a valid measurement of differences and similarities in cosmetic appearance. CONCLUSIONS: The HOPE-score is the first scoring system that fulfills the criteria of a valid measurement tool: objectivity, reliability and validity. These favorable properties support its use as an objective outcome measure of the cosmetic result after hypospadias surgery.

Pediatric testicular torsion: demographics of national orchiopexy versus orchiectomy rates.

PURPOSE: While the timely diagnosis and management of pediatric torsion can lead to testicular salvage, limited data exist on rates of orchiopexy vs orchiectomy and associated factors. Thus, we examined the Pediatric Health Information System database for torsion outcomes and demographics at American pediatric hospitals. MATERIALS AND METHODS: Using the Pediatric Health Information System database we performed a 7-year retrospective cohort study in children 1 to 17 years old with a primary ICD-9 diagnosis of torsion, assessing CPT codes for orchiopexy and orchiectomy. Data were analyzed with SPSS®, version 17.0. RESULTS: Of 2,876 patients who underwent surgery for an ICD-9 diagnosis code of testicular torsion 918 (31.9%) underwent orchiectomy at a mean age of 10.7 years and 1,958 (68.1%) underwent orchiopexy at a mean age of 12.6 years (p <0.0001). In the age groups 1 to 9, 10 to 13 and 14 years or greater 274 (49.9%), 311 (29.4%) and 333 patients (26.2%), respectively, underwent orchiectomy. A higher orchiectomy rate was seen at age 1 to 9 vs 10 years or greater. Torsion and orchiectomy rates did not vary by season or geographic region. A higher orchiectomy rate was seen in black vs white children (37.6% vs 28.1%) and in patients without vs with private insurance (36.7% vs 27.0%). Multivariate analysis revealed an association of age (p <0.0001), race (p <0.0001) and insurance status (p <0.001) with orchiectomy. CONCLUSIONS: Nationally an average of 32% of the 411 pediatric torsion cases explored annually result in orchiectomy. Identified factors increasing the orchiectomy risk included age 1 to 9 years, black race and lack of private insurance. Efforts should continue to identify modifiable variables that can increase testicular salvage in patients with testicular torsion.

Comparative analysis of nephrolithiasis in otherwise healthy versus medically complex gastrostomy fed children.

PURPOSE: The purpose was to compare nephrolithiasis in healthy versus medically complex gastrostomy fed children. MATERIALS AND METHODS: Children with nephrolithiasis with and without gastrostomy were identified by database searches from 1999 to 2009. Gastrostomy fed stone formers (GSF) were compared to an age-matched cohort of non-gastrostomy-fed stone formers (NGSF) for demographic and clinical data. RESULTS: 16 neurologically impaired GSF (10M:6F), mean age 10.4 years (range 1.7-17.5 years), were compared to 32 matched neurologically intact NGSF. Compared to NGSF, GSF had significantly higher urine pH (6.93 vs 6.23, p = 0.001) and larger stones (14.5 vs 6.9 mm, p = 0.02) more commonly composed of calcium phosphate (7/11, 64% vs 3/28, 11%, p = 0.002). 15/16 (94%) of GSF were immobile while 0% of NGSF were immobile. GSF had lower l-spine bone density Z-scores (-3.02 vs -1, p = 0.002) but an equal rate of hypercalciuria (2/7, 29% vs 7/24, 29%, p = NS). Contributing lithogenic factors in 8/16 (50%) GSF included urinary tract infection (UTI) (5), lithogenic medications (2), and xanthinuria (1). CONCLUSIONS: Stone disease in GSF is multifactorial, and half of our study group had an identifiable risk factor for nephrolithiasis. A recurring pattern of alkaline urine and calcium phosphate stone formation was evident. GSF did not have higher rates of hypercalciuria despite chronic immobilization and markedly lower bone density. An awareness of the potential risk factors identified is mandatory for this vulnerable population.

Malleable implant substitution for the management of penile prosthesis pump erosion: a pilot study.

INTRODUCTION: Managing isolated scrotal pump erosion or infection in patients with inflatable penile prosthesis (IPP) is a challenging problem. We describe our malleable implant substitution technique to address this problem. AIM: The aim of this study was to describe and assess the outcomes of the malleable implant substitution technique. METHODS: In this retrospective case series, six patients underwent removal of the infected and/or eroded scrotal pump, and replacement of the entire IPP with a malleable prosthesis. This procedure was only performed in men in the absence of penile pain on palpation or overwhelming sepsis. The procedure utilized components of the Mulcahy washout protocol with loose scrotal wound approximation and drains as necessary. MAIN OUTCOME MEASURES: The main outcome is a recurrent infection rate and prosthesis functionality of the malleable implant substitution technique. RESULTS: All six men who underwent the procedure have done well and remain infection-free. Two men have undergone conversion from a malleable prosthesis back to IPP. Three are considering conversion to an IPP as they are satisfied with their current malleable prosthesis function. One man had a distal erosion of the malleable prosthesis that necessitated complete removal. CONCLUSIONS: We believe the malleable implant substitution technique provides an excellent option for management of isolated scrotal pump erosion or infection and prevents the problems associated with the other common management strategies.

A case of systemic polyarteritis nodosa with spermatic cord involvement.

BACKGROUND: A 50-year-old man with a history of hyperlipidemia and hypertension presented to an emergency department after 10 days of fevers (temperature 40 degrees C), headache, malaise, myalgia, poor appetite, diarrhea, and weight loss of 6.35 kg. He would subsequently develop bilateral scrotal swelling and pain during his evaluation. INVESTIGATIONS: Physical examination, CBC, blood chemistry panel, measurement of erythrocyte sedimentation rate and C-reactive protein level, liver function profile, urinalysis, lumbar puncture, blood cultures, urine cultures, cerebrospinal fluid culture, stool analysis and cultures, multiple viral studies including hepatitis serologies, measurement of antineutrophil cytoplasmic autoantibody levels, urine protein electrophoresis, serum protein electrophoresis, CT of the head, chest, abdomen and pelvis, MRI of the brain, temporal artery biopsy and pathologic analysis, scrotal ultrasonography, right spermatic cord biopsy and pathologic analysis. DIAGNOSIS: Polyarteritis nodosa with involvement of both spermatic cords. MANAGEMENT: Prednisone 60 mg daily was started for presumed temporal arteritis, but was discontinued when no evidence of arteritis was found in the temporal artery biopsy specimen. When pathologic analysis of the spermatic cord biopsy tissue confirmed polyarteritis nodosa, prednisone 40 mg twice daily was administered and the patient's scrotal pain and swelling resolved quickly. Steroids were slowly tapered and discontinued over the next 18 months. He remained free of systemic symptoms, with normal results on physical examination and laboratory evaluation, including urinalysis, CBC, erythrocyte sedimentation rate and C-reactive protein level, 5.5 months after discontinuation of glucocorticoid therapy.

What to anticipate with experience in pediatric laparoscopic ablative renal surgery.

PURPOSE: Laparoscopic renal surgery in pediatric urology is moving forward at a slower pace than desired. To guide beginning surgeons in what to expect in their first years of surgical experience, we present our first 6 years of pediatric laparoscopic ablative renal surgery experience to highlight the changing laparoscopic surgical parameters during this interval. MATERIALS AND METHODS: We retrospectively analyzed all children who underwent laparoscopic ablative renal surgery (nephrectomy and heminephroureterectomy) performed by 1 surgeon between January 2000 and December 2005. After searching the medical, operative and anesthesia records we compared patient characteristics and operative parameters such as blood loss and operative time through the years. RESULTS: A total of 39 children (25 girls, 14 boys) with a mean age of 6.9 years underwent laparoscopic renal surgery. Mean operative time was 204 minutes for nephrectomy (26 cases) and 291 minutes for heminephroureterectomy (14). A statistically significant decrease in operative time was noted in the fourth year for nephrectomy cases (20 cases, p = 0.003). Blood loss decrease was significant at the fourth year after 10 cases of heminephroureterectomy (p = 0.036). Thus, operative time was the only changing parameter with experience in nephrectomy, while blood loss changed in heminephroureterectomy. CONCLUSIONS: This report details the operative parameters changing during the first 6 years as our experience increased in an academic setting. This outcome serves as a realistic guide regarding expectations for beginning laparoscopists, and should encourage the continuation of pediatric laparoscopic renal surgery.