"What should be next in lifelong posterior hypospadias: Conclusions from the 2023 ERN eUROGEN and EJP-RD networking meeting".

BACKGROUND: A congenital disease is for life. Posterior hypospadias, the severe form of hypospadias with a penoscrotal, scrotal, or perineal meatus, is a challenging condition with a major impact on lifelong quality of life. AIM: Our network meeting is aimed to identify what is currently missing in the lifelong treatment of posterior hypospadias, to improve care, quality of life, and awareness for these patients. METHODS: The network meeting "Lifelong Posterior Hypospadias" in Utrecht, The Netherlands was granted by the European Joint Programme on Rare Diseases-Networking Support Scheme. There was a combination of interactive sessions (hackathons) and lectures. This paper can be regarded as the last phase of the hackathon. RESULTS: Surgery for hypospadias remains challenging and complications may occur until adulthood. Posterior hypospadias affects sexual function, fertility, and hormonal status. Transitional care from childhood into adulthood is currently insufficiently established. Patients should be more involved in defining desired treatment approach and outcome measures. For optimal outcome evaluation standardization of data collection and registration at European level is necessary. Tissue engineering may provide a solution to the shortage of healthy tissue in posterior hypospadias. For optimal results, cooperation between basic researchers from different centers, as well as involving clinicians and patients is necessary. CONCLUSIONS: To improve outcomes for patients with posterior hypospadias, patient voices should be included and lifelong care by dedicated healthcare professionals guaranteed. Other requirements are joining forces at European level in uniform registration of outcome data and cooperation in basic research.

To Transect or Not Transect: Results from the Scandinavian Urethroplasty Study, A Multicentre Randomised Study of Bulbar Urethroplasty Comparing Excision and Primary Anastomosis Versus Buccal Mucosal Grafting.

BACKGROUND: Open surgical treatment of short bulbar urethral strictures (urethroplasty) is commonly performed as transecting excision and primary anastomosis (tEPA) or buccal mucosa grafting (BMG). Erectile dysfunction and penile complications have been reported, but there is an absence of randomised trials. OBJECTIVE: To evaluate sexual dysfunction and penile complications after urethroplasty with tEPA versus BMG. DESIGN, SETTING, AND PARTICIPANTS: Centres in Finland, Sweden and Norway participated. Patients with a bulbar urethral stricture of ≤2 cm without previous urethroplasty were randomised. The primary endpoints were the degree of erectile dysfunction and penile complications. Follow-up was 12 mo. INTERVENTION: Patients were randomised to either tEPA or BMG urethroplasty. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Sexual dysfunction was measured using the International Index of Erectile Function, 5-item version (IIEF-5) and a penile complications questionnaire (PCQ) designed for this study. Continuous data were analysed using analysis of covariance and categorical data were compared using a χ2 test. RESULTS AND LIMITATIONS: A total of 151 patients were randomised to either tEPA (n = 75) or BMG (n = 76). The tEPA group reported more penile complications (p = 0.02), especially reduced glans filling (p = 0.03) and a shortened penis (p = 0.001). There were no differences in postoperative IIEF-5 total scores. Recurrence rates were similar in both groups (12.9%) but the study was not designed to detect differences in recurrence rates. The PCQ is not validated, which is a limitation. CONCLUSIONS: More patients reported penile complications after urethroplasty with tEPA than with BMG. This should be considered when choosing the operative method, and patients should be informed accordingly. PATIENT SUMMARY: This study compared two common operations for repair of narrowing of the male urethra. Neither of the two methods seems to cause worsened erections. However, penile problems are more common after the transection technique than after the grafting technique.

Limited experience, high body mass index and previous urethral surgery are risk factors for failure in open urethroplasty due to penile strictures.

OBJECTIVE: The aim of this study was to evaluate outcomes and possible risk factors for failure of open urethroplasty due to penile urethral strictures. MATERIALS AND METHODS: A retrospective chart review was undertaken of 90 patients with penile stricture undergoing 109 open urethroplasties between 2000 and 2011. In 80 urethroplasties, a one-stage procedure was performed: 68 of these had a pediculated penile skin flap, nine had a free buccal mucosal graft and three had a free skin graft. A two-stage procedure using buccal mucosa was performed in 29 urethroplasties. Failure was defined as when further urethral instrumentation was needed. RESULTS: The mean age in the one-stage and two-stage groups were 50 and 54 years, respectively. The success rates in the corresponding groups were 65% and 72%, with follow-up times of 63 and 40 months, respectively. Multivariable analyses disclosed body mass index (BMI) and previous urethral surgery to be significant risk factors for failure in the one-stage group. Failure over time significantly decreased during the study period. CONCLUSIONS: Both one- and two-stage penile urethroplasty demonstrated success rates in line with previous reports. Limited experience, high BMI and previous urethral surgery appear to be associated with less favourable outcome.

Low risk of sexual dysfunction after transection and nontransection urethroplasty for bulbar urethral stricture.

PURPOSE: Open urethroplasty is the preferred treatment for recurrent bulbar urethral stricture. However, there are still some controversies regarding the optimal technique and the consequences of transecting the urethra in terms of sexual dysfunction, such as erectile dysfunction, penile shortening, impaired glans filling, decreased glans sensibility and ejaculatory function. We performed a retrospective analysis with long-term followup of anastomotic and substitution onlay urethroplasty in bulbar strictures with an emphasis on postoperative sexual function. MATERIALS AND METHODS: A total of 169 patients with bulbar stricture were treated with urethroplasty via the onlay technique (75) or resection followed by end-to-end anastomosis (94) during 1999 to 2009. Mean followup in the transection and onlay groups was 41 and 69 months, respectively (range 12 to 132). All patients were asked verbally about sexual function during followup. Failure was defined as the need for new surgical intervention. RESULTS: Erectile dysfunction developed in 1 patient (1%) per group. In the transection group 5 patients (5%), including 4 with longer and more distal strictures, had penile shortening/downward angulation. However, this did not interfere with sexual ability during intercourse. No patient reported impaired glans or ejaculatory function. The success rate in the transection and onlay groups was 91% and 71%, respectively. CONCLUSIONS: Transection with resection and end-to-end anastomosis is a good method for bulbar stricture with a low rate of sexual dysfunction and a high success rate postoperatively. To avoid penile angulation/shortening, it might be wise to use the onlay technique for longer and distal strictures.