Technical nuances of the concealed penis repair.

Circumcision is commonly performed but anatomic variants occur and can affect outcomes if not addressed properly. The combination of concealed penis and penoscrotal webbing is fairly common and presents across a spectrum of severity. If not repaired, this can result in a buried penis that can cause penile adhesions, wound healing concerns, and make the penis appear shorter secondary to a retracted position. We present our technique that is reproducible and highly successful in addressing both of these concerns. The paraphimotic band approach is performed more commonly and is able to reliably correct webbing and concealment without an incision at the penoscrotal junction. When more severe defect is present, a Y shaped incision is made at the penoscrotal junction to mobilize skin flaps to correct the deficit. In our cohort of 885 patients, 736 were corrected using the paraphimotic band technique while 149 underwent a complex scrotoplasty. None of the patients required a secondary surgery for complications.

Does Preoperative Testosterone Administration Decrease Complications in Distal Hypospadias Repair With Urethroplasty?

PURPOSE: Testosterone administration prior to hypospadias repair is common practice among pediatric urologists; however, its impact on surgical outcomes remains controversial. We hypothesize that testosterone administration prior to distal hypospadias repair with urethroplasty significantly decreases postoperative complications. MATERIALS AND METHODS: We queried our hypospadias database for primary distal hypospadias repairs with urethroplasty from 2015 to 2021. Patients undergoing repair without urethroplasty were excluded. We collected information on patient age, procedure type, testosterone administration status, initial visit and intraoperative glans width, urethroplasty length, and postoperative complications. To determine the role of testosterone administration on incidence of complications, a logistic regression adjusting for initial visit glans width, urethroplasty length, and age was performed. RESULTS: A total of 368 patients underwent distal hypospadias repair with urethroplasty. One hundred thirty-three patients received testosterone and 235 did not. Initial visit glans width was significantly larger in the no-testosterone vs testosterone group (14.5 mm vs 13.1 mm, P = .001). Testosterone patients had significantly larger glans width at the time of surgery (17.1 mm vs 14.6 mm [no-testosterone group], P = .001). On multivariable logistic regression analysis after controlling for age at surgery, preoperative glans width, testosterone status, and urethroplasty length, testosterone administration did show significant association with reduced odds of postoperative complications (OR 0.4, P = .039). CONCLUSIONS: This retrospective review of patients shows that on multivariable analysis there is significant association between testosterone administration and decreased incidence of complications in patients undergoing distal hypospadias repair with urethroplasty. Future studies on testosterone administration should focus on specific cohorts of patients with hypospadias as benefits of testosterone may be more evident in some subgroups than others.

Caudal anesthesia is not associated with post-operative complications following distal hypospadias repair.

INTRODUCTION: The use of caudal anesthesia at the time of hypospadias repair remains controversial as some prior studies have reported increased postoperative complication rates associated with caudal nerve block. However, these results have been called into question due to confounding factors and heterogeneous study groups. OBJECTIVE: Given the importance of identifying true risk factors associated with increased hypospadias complication rate, we examined our experience with caudal anesthesia limiting our analysis to distal repairs. We hypothesized that caudal anesthesia would not be associated with increased postoperative complications. STUDY DESIGN: We retrospectively reviewed our institutional hypospadias database from June 2007 to January 2021. All boys who underwent single-stage distal hypospadias repair with either caudal or penile block with minimum 1 month follow up were included. Records were reviewed to determine the type of local anesthesia, type of hypospadias repair, all complications, and time to complication. Association between any complication and local anesthesia type was evaluated by univariate and multivariate logistic regression analysis controlling for age at surgery and type of repair. A sub-analysis was performed for complications occurring ≤30 days. RESULTS: Overall, 1008 boys, 832 (82.5%) who received caudal and 176 (17.5%) penile block, were included. Median age at surgery was 8.1 months and median follow up was 13 months. Overall complication rate was 16.4% with 13.8% of patients requiring repeat operation. Median time to complication was 10.59 months and was significantly shorter in the caudal group (8.45 vs. 25.2 months). Caudal anesthesia was associated with higher likelihood of complication on univariate analysis; however, this was not true on multivariate analysis when controlling for age and type of repair. Caudal anesthesia was not associated with increased likelihood of complication within 30 days. DISCUSSION: Since the association between caudal anesthesia and hypospadias complications was first suggested, several studies have tried to answer this question with variable results. Our findings add to the evidence that there is no association between caudal anesthesia and increased hypospadias complications in either the short or long term. The major strengths of our study are a large, homogenous study population, robust follow up and inclusion of data from 14 surgeons over 14 years. Limitations include the study's retrospective nature as well as lack of standardized follow up protocol throughout the study period. CONCLUSIONS: After controlling for possible confounders, caudal nerve block was not associated with increased risk of postoperative complications following distal hypospadias repair.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

INTRODUCTION & OBJECTIVE: The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events. METHODS: A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed. RESULTS: 1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p = 0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p = 0.009). There was no difference in unplanned encounters across repair types (p = 0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter. DISCUSSION: The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution. CONCLUSIONS: The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

Expanding the reproductive organ phenotype of CHD7-spectrum disorder.

CHD7 disorder is a multiple congenital anomaly syndrome with a highly variable phenotypic spectrum, and includes CHARGE syndrome. Internal and external genital phenotypes frequently seen in CHD7 disorder include cryptorchidism and micropenis in males, and vaginal hypoplasia in females, both thought to be secondary to hypogonadotropic hypogonadism. Here, we report 14 deeply phenotyped individuals with known CHD7 variants (9 pathogenic/likely pathogenic and 5 VOUS) and a range of reproductive and endocrine phenotypes. Reproductive organ anomalies were observed in 8 of 14 individuals and were more commonly noted in males (7/7), most of whom presented with micropenis and/or cryptorchidism. Kallmann syndrome was commonly observed among adolescents and adults with CHD7 variants. Remarkably, one 46,XY individual presented with ambiguous genitalia, cryptorchidism with Müllerian structures including uterus, vagina and fallopian tubes, and one 46,XX female patient presented with absent vagina, uterus and ovaries. These cases expand the genital and reproductive phenotype of CHD7 disorder to include two individuals with genital/gonadal atypia (ambiguous genitalia), and one with Müllerian aplasia.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis.

INTRODUCTION AND OBJECTIVE: Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events. STUDY DESIGN: All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated. RESULTS: 438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p = 0.04). DISCUSSION: The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries. CONCLUSIONS: Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

Office Based Pediatric Urologic Procedures: A Safe and Effective Alternative to Interventions Under Anesthesia.

OBJECTIVE: To report on our experience performing office-based pediatric urologic procedures. We hypothesize that office-based interventions are safe and effective for children, avoiding unnecessary risk and cost associated with general anesthesia. METHODS: We retrospectively identified patients undergoing office-based interventions from 2014 to 2019, including lysis of penile or labial adhesions, division of skin bridges, meatotomy and excision of benign lesion. Success was defined as a completed attempt in the office. Failure includes any unsuccessful office attempts. Complications include 30-day ED visits/readmissions and recurrent skin bridge post division of skin bridge. RESULTS: We identified 1326 interventions: 491 lyses of penile adhesions (37%), 320 division of skin bridges (24%), 128 lyses of labial adhesions (10%), 348 meatotomies (26%), and 39 excisions of benign lesions (3%) [Table 1]. There was a >95% success rate reported in every procedure with an overall complication rate of 0.6%. Excision of benign lesion had 100% success rate. ED visits within 30 days are rare (0.2%), and no patients required admission after their procedure [Table 2]. The rate of recurrence was highest following lysis of labial adhesions (13.3%). Of the 54 patients who underwent retreatment, very few required general anesthesia (n = 6). CONCLUSION: Office-based urologic interventions in children are well tolerated with excellent safety and efficacy. Complications and recurrence are universally low. Ultimately, 99.5% of this cohort was managed under local anesthetics, thereby avoiding the risks of anesthesia use in the pediatric population.

Quantifying Glans Width Changes in Response to Preoperative Androgen Stimulation in Patients Undergoing Hypospadias Repair.

PURPOSE: Testosterone (T) administration prior to hypospadias surgery to increase glans size remains controversial. Understanding T's effect on glans width (GW) is essential to understanding its potential impact on surgical outcomes. We hypothesized that preoperative T in prepubertal boys significantly increases GW at the time of hypospadias surgery. MATERIALS AND METHODS: Our single institutional database was queried to identify patients who underwent hypospadias surgery from 2016 to 2020, in which data for T administration and GW were available. Descriptive, nonparametric and categorical statistics were performed as indicated. RESULTS: A total of 579 patients were eligible for analysis. Median age at surgery was 0.9 years (IQR 0.6-1.6). A total of 247/579 patients (42.7%) received T. The median GW at surgery was 15 mm (IQR 13-17). When comparing patients who had T administered to those who did not, we found a significant difference in GW at surgery (16 mm vs 14 mm, p <0.001). The median change in GW from the office to surgery was 4 mm for those receiving T vs 0 mm for those not receiving T (p <0.001). We identified a greater change in GW from preoperative to intraoperative measurements in patients who received 2 doses of T vs 1 dose (4 mm vs 2 mm, p <0.001). A histogram plot revealed the distribution of GW change at surgery. CONCLUSIONS: In our prospectively collected cohort of patients undergoing hypospadias surgery, we were able to quantitate the change in GW from preoperative T. Two doses of T resulted in a significant increase in GW vs 1 dose.

A novel transurethral approach to inlay oral mucosal graft urethroplasty technique for meatal and fossa navicularis stricture resulting from distal hypospadias repair.

INTRODUCTION: Meatal and fossa navicularis stricture after hypospadias repair is a challenging condition. A range of management techniques have been applied to treat meatal and fossa navicularis stenosis but, as yet, there is no consensus as to the best method. Open urethroplasty with oral mucosal graft (OMG) has been widely accepted to be the gold standard in repairing the stricture. Generally, the stricture site is approached through a ventral midline, subcoronal, and circumcising incision. A novel effective technique for short segment stricture, transurethral approach to inlay oral mucosal graft urethroplasty would help in avoiding ventral glans, distal penis or ventral urethral incision and can preserve glans of the penis. METHOD: A 5-year-old boy with mid-shaft hypospadias underwent repair when he was 3 years old. Two months after surgery, he had developed urethral meatal and fossa navicularis stenoses. He is to undergo a novel transurethral approach of inlay OMG urethroplasty. The procedure consisted of transurethral excising the fibrotic tissue at the dorsal site of the stricture urethra. The bougies dilator was used for calibrating the size of the urethra up to 12 Fr. An OMG with a size of 5 × 6 mm was then harvested from the lower lip and applied to cover the defect. A urethral catheter was inserted for 1 week. RESULT: The outcome was shown to be successful and the patient can void with a good flow after removing the catheter. The graft was well vascularized and the glans was cosmetically acceptable. There was no recurrent stricture after 12 months follow up. CONCLUSION: This novel technique is simple, effective and may be beneficial as it obviates the need for complex reconstruction. However, this technique would only be feasible in selected patients with suitable conditions of meatal opening and those with a short segment of stricture.

Results and complications of adolescent varicocele repair with intraoperative sodium morrhuate sclerotherapy.

PURPOSE: Adolescent varicocele has been shown to affect spermatogenesis and correlate with decreased ipsilateral testicular volume, prompting treatment in a select population. We report our experience with 3 varicocele ligation procedures in concordance with sclerotherapy in adolescent patients. MATERIALS AND METHODS: A total of 120 males underwent varicocele surgery at our institutions during an 8-year period. Sodium morrhuate sclerotherapy was used in 91 patients and 73 adolescent males fulfilled the 6-month followup criteria. The 73 males who were 9 to 17 years old underwent a total of 75 (bilateral in 2) procedures for varicocele treatment. Of the patients 23 underwent subinguinal microscopic varicocelectomy (group 1), 9 underwent loupe assisted subinguinal varicocelectomy (group 2) and 41 underwent loupe assisted inguinal varicocelectomy (group 3). All patients received intraoperative sclerotherapy using sodium morrhuate injection. Outcome measures included recurrence, complications and catch-up growth at a minimum of 6 months of followup. RESULTS: The varicocele recurrence rate was 2.7% in patients receiving combined surgical ligation and sclerotherapy ablation. Group 1 had 2 recurrent varicoceles and no hydrocele formation, group 2 had no varicocele recurrence and no hydrocele formation, and group 3 had no varicocele recurrence and 2 postoperative hydroceles. Catch-up growth in the ipsilateral testis was seen in 85% of patients. No atrophy or testicular loss was noted. CONCLUSIONS: This preliminary experience with combined surgical ligation and sclerotherapy ablation in the adolescent population resulted in low varicocele recurrence with minimal morbidity. Outcomes of loupe assisted varicocelectomy appear to be improved compared to those in previous studies, alluding to an advantage in the addition of sclerotherapy.

Antegrade and retrograde endoscopic dextranomer/hyaluronic Acid bladder neck bulking for pediatric incontinence.

PURPOSE: Endoscopic bladder neck bulking techniques offer the potential for a relatively noninvasive cure for a difficult clinical problem. We review our experience using antegrade and retrograde approaches. MATERIALS AND METHODS: A total of 34 children (18 boys and 16 girls, mean age 11.7 years) have been treated since March 2003. Of the patients 28 (82%) had neurogenic bladder and 6 had nonneurogenic sphincteric incontinence. Urodynamics confirmed low detrusor leak point pressures and adequate bladder capacity. Patients were treated with either a retrograde or an antegrade approach. In 82% of patients an antegrade approach was used and a posttreatment suprapubic tube was placed. RESULTS: Mean followup was 11.7 months (range 3 to 31). Patients averaged 1.47 injections (range 1 to 5). Detailed followup of 19 patients revealed significant improvement in continence in 78% (mean 1.6 injections), with an average followup of approximately 1 year. CONCLUSIONS: Our 31 months of experience with antegrade/retrograde bladder neck bulking demonstrates that it is a viable therapy for this group of children. While some patients have experienced prolonged success, re-treatment can be beneficial. The antegrade approach offers several advantages, including intraoperative leak point pressures, improved visualization and placement of a suprapubic tube to limit post-procedural remodeling.

Effect of urethral plate characteristics on tubularized incised plate urethroplasty.

PURPOSE: We determined outcomes of tubularized incised plate urethroplasty based on preoperative urethral plate configuration or width. MATERIALS AND METHODS: Records of consecutive prepubertal boys undergoing tubularized incised plate distal hypospadias repair were reviewed. The urethral plate was characterized as flat, cleft or deep, and results in each group were noted. In addition, the width of the plate after separation from the glans wings before midline incision was measured in some patients, with outcomes determined according to those less than 8 mm versus 8 mm or greater. RESULTS: Of 159 patients plate configuration was recorded in 143, widths in 48 and both in 46. Outcomes were determined at a mean of 8 months postoperatively. Overall, there were no cases of meatal stenosis and fistulas occurred in 3 patients (2%). No significant difference in results was predicted by plate configuration or width. CONCLUSIONS: Tubularized incised plate urethroplasty for distal hypospadias repair has a low complication rate regardless of urethral plate configuration or width. Therefore, this procedure is potentially applicable in all cases of primary distal hypospadias.

Management of vesicoureteral reflux.

Four cases of vesicoureteral reflux are discussed by prominent pediatric urologists. The condition can range from minimal reflux into the distal ureter to massive reflux causing tortuosity of the ureter and hydronephrosis. Treatment options range from medical management to tapering of the ureter with reimplantation. The cross-trigonal technique is popular among pediatric urologists, and the Politano-Leadbetter technique is a very successful technique that has stood the test of time. The extravesical approach to ureteral reimplantation reduces morbidity, shortens hospital stays, reduces medical costs, and maintains the high success rates of the intravesical techniques. Subureteric injection of bulking agents to correct the reflux holds promise as an alternative to open surgery, but presents the challenge of identifying the ideal bulking agent.

Glandular hypospadias repair.

Glandular hypospadias represents approximately 15% of the hypospadias variants seen. This article will examine common surgical approaches applicable to the child with glandular hypospadias. Hypospadias repairs discussed in this article will include urethromeatoplasty, MAGPI, the GAP procedure, MIV glans plasty, urethral advancement procedure, and parameatal based flap variants, including the Mathieu and Barcat procedures. Because these anomalies are cosmetically less aberrant than more proximal variants, only those surgical techniques which assure a normal-appearing penis should be undertaken.