Is glans penis width a risk factor for complications after hypospadias repair?

INTRODUCTION: Recent studies have suggested that a smaller glans penis size may be associated with a higher likelihood of complications after hypospadias repair. Accurate identification of risk factors other than the well-understood variable of meatal location would allow development of better prognostic models and individualized risk stratification. OBJECTIVE: To test the hypothesis that a smaller width of the glans penis predicts adverse outcomes after hypospadias surgery. METHODS: Prospectively recorded clinical data were reviewed from a single-institution registry of primary hypospadias repairs performed between 2011 and 2014. Follow-up records were examined for occurrence of complications. Urethroplasty complications were defined to include meatal stenosis, dehiscence, urethrocutaneous fistula, urethral stricture, and/or urethral diverticulum. The subset of meatal stenosis and dehiscence were regarded as glanular complications. Regression analyses were performed to determine association between glans width and occurrence of complications. Because pre-operative androgen stimulation is known to increase glans penis size, separate subgroup analyses were included of patients with and without pre-operative use of testosterone cream. RESULTS: A total of 159 patients met criteria for inclusion in the study cohort: 140 patients underwent a single-stage repair, while 19 patients had a two-stage repair. The median glans penis width was 15 mm (range 10-22). Eighty-four patients (53%) received testosterone cream pre-operatively and had a significantly wider glans penis than the 75 patients who did not (median 15.5 vs 14 mm; P < 0.001). Median clinical follow-up was 7 months (IQR 1-12), with a minimum time elapsed since surgery of 10 months at the time of chart review. Twenty-four patients (15%) had one or more urethroplasty complications, including 11 (7%) with glanular complications. Overall, there was no statistically significant association between glans width and urethroplasty complications (P = 0.26) or glanular complications (P = 0.90) (Summary Table). Subgroup analyses of patients with and without pre-operative testosterone also revealed no significant associations between glans width and complications. CONCLUSIONS: Glans penis width was not a risk factor for complications after hypospadias repair. This finding differs from the results of other recent studies and encourages further research into the value of measuring penile parameters in patients undergoing hypospadias repair.

Uroflowmetry with pelvic floor electromyography: inter-rater agreement on diagnosis of pediatric non-neurogenic voiding disorders.

INTRODUCTION: Uroflowmetry with electromyography (uroflow-EMG) is commonly used for evaluation of lower urinary tract (LUT) function in children. Diagnostic criteria based largely on uroflow-EMG findings have previously been proposed for several conditions collectively termed non-neurogenic voiding disorders (NNVDs). These include dysfunctional voiding (DV), idiopathic detrusor overactivity disorder (IDOD), detrusor underutilization disorder (DUD), and primary bladder neck dysfunction (PBND). It is unknown whether practitioners with varying levels of training and experience can apply the diagnostic criteria for these conditions with a high level of consistency. OBJECTIVE: To assess inter-rater agreement on diagnosis of NNVDs using uroflow-EMG studies. STUDY DESIGN: Six raters performed post hoc evaluation of 84 uroflow-EMG studies and associated clinical data from children with symptoms of LUT dysfunction and no evidence of neurologic or anatomic abnormalities. Each rater was asked to categorize the uroflow-EMG studies as being consistent with DV, IDOD, DUD, PBND, or normal/unclassifiable. A consensus diagnosis was noted for studies on which at least four raters agreed. Inter-rater agreement was assessed via calculation of unweighted Fleiss' kappa statistics. RESULTS: Overall inter-rater agreement on NNVD diagnoses was moderate (kappa 0.46, 95% CI 0.38-0.54). Agreement between individual raters ranged from 0.33 (fair) to 0.74 (substantial) (Figure). There was no consensus on diagnosis for 20 patients (24%). DISCUSSION: Several factors may contribute to inter-rater disagreement on diagnosis of NNVDs. These include instances where patients satisfy one criterion for a particular diagnosis while missing others - or have findings consistent with more than one diagnosis. Strategies to address this may involve simplifying the diagnostic criteria, developing a clear algorithm that prioritizes certain criteria, and/or allowing assignment of multiple diagnoses. Practitioners could also benefit from standardized education regarding the diagnostic criteria for NNVDs. Potential limitations of this analysis included the use of just one uroflow-EMG study per patient in almost all cases. Also, the raters had variable levels of previous experience using the diagnostic criteria for NNVDs, and it is possible that they were not always applied as originally intended. If this were the case, it would support development of a standardized education tool to facilitate practitioner understanding and application of the criteria. CONCLUSIONS: Uroflow-EMG has shown promise for improving clinical management of NNVDs associated with pediatric LUT dysfunction. However, inter-rater agreement on NNVD diagnoses using current criteria is suboptimal. Various mechanisms should be explored to improve consistency in practitioners' diagnosis of NNVDs.

Perioperative effects of caudal and transversus abdominis plane (TAP) blocks for children undergoing urologic robot-assisted laparoscopic surgery.

INTRODUCTION: Regional anesthesia is often used in combination with general anesthesia for pediatric surgery, however, it is unknown if adjunctive regional blocks are beneficial to children undergoing urologic laparoscopic or robot-assisted laparoscopic (RAL) procedures. OBJECTIVE: To compare perioperative outcomes in children with adjunctive caudal blocks, transversus abdominis plane (TAP) blocks, or no regional anesthesia for common RAL surgical procedures in pediatric urology. STUDY DESIGN: Inclusion in this retrospective study was limited to children who underwent RAL renal or ureteral/bladder procedures and received a standardized regimen of scheduled intravenous ketorolac and oral acetaminophen for acute postoperative pain control, with opioids as needed (PRN). Perioperative outcomes were compared between patients with an adjunctive caudal block (n = 25), bilateral TAP blocks (n = 44), or no regional anesthesia (n = 51). RESULTS: Children with a preoperative caudal block received less intraoperative opioids than children with TAP blocks or no regional anesthesia (p < 0.001). This difference was observed both for renal procedures (p < 0.01) and ureteral/bladder procedures (p = 0.01). Patients with caudal blocks were also the least likely to require postoperative antiemetics (p = 0.03). There were no significant differences between groups in postoperative opioid use, maximum pain scores within 6 and 24 hours postoperatively, or length of hospital stay (LOS). No complications attributable to regional blocks were identified by chart review. DISCUSSION: Use of adjunctive caudal blocks for pediatric RAL renal or ureteral/bladder surgical procedures may reduce need for alternate analgesic and/or anesthetic agents intraoperatively, as well as decrease postoperative nausea and vomiting. These findings may be related, since nausea and vomiting are common side effects of opioids and inhalational anesthetics. Consideration of the potential impact of caudal blocks on general anesthetic requirements is timely in light of concerns regarding the risk of anesthetic neurotoxicity in young patients. There was no evidence of improved postoperative pain control or shorter LOS for children who received regional anesthesia. It is unknown if regional blocks would have a greater impact in the absence of scheduled pain medications, which all patients in our study received. Limitations of this study include its retrospective nature and moderate sample size. Future randomized controlled trials are necessary to provide a more definitive understanding of regional anesthesia's role in minimizing pediatric surgical and anesthetic morbidity. CONCLUSION: Administration of caudal blocks should be considered for children of suitable age undergoing RAL surgery involving either the upper or lower urinary tract.

Repair of megameatus: a modified approach.

OBJECTIVE: To demonstrate surgical reconstruction of a megameatus variant of hypospadias by using a modified, patient-specific approach. METHODS: An 8-month-old male had a megameatus, which was discovered after newborn circumcision. In repair of megameatus, it is important to recognize the full extent to which the distal urethra is widened, in order to avoid inadvertent urethrotomy during mobilization of the glans wings and skin immediately proximal to the glans. In this case, a small wedge of tissue was excised from the ventral aspect of the urethra, and a midline relaxing incision of the urethral plate was made. Standard principles of hypospadias repair should be followed, with tension-free urethral tubularization, coverage of the neourethra with well-vascularized tissue, and adequate mobilization of the glans wings to allow midline reconstruction without compression of the underlying neourethra. RESULTS: There were no perioperative or postoperative complications in this case. The urethral meatus was positioned near the tip of the glans penis, and there was no evidence of meatal stenosis or urethrocutaneous fistula at 5-months follow-up. CONCLUSION: Each case of megameatus is unique, and a variety of surgical techniques can be used in formulating an approach that achieves optimal cosmetic and functional outcomes.