Hypospadias dilemmas: A round table

While numerous techniques have been described for hypospadias repair, the Tubularized Incised Plate (TIP) procedure is currently the most frequently used method. On the other hand, urethral mobilization techniques have less frequent preference. In this study, we aimed to compare the outcomes of these two techniques in patients with distal hypospadias, particularly those with the urethral meatus located at the coronal and subcoronal.

A total of 75 patients with distal hypospadias underwent surgery. Patients with glanular and midpenile hypospadias whose meatus was not located at the coronal and subcoronal levels were excluded from the study. 43 patients underwent surgery performing the Eccentric Circummeatal-Based Flap with Limited Urethral Mobilization (ECMB) method, while the remaining 32 patients were treated with the TIP. We analyzed age at surgery, urethral meatus position, ventral or glanular curvature, catheterization duration, and complications.

The mean age at operation was 2.6 (±1.1) years. The position of the meatus was coronal in 48 patients (64%), and subcoronal in 27 (36%). Complications consist of fistula in two patients, meatal stenosis in seven patients, and preputial redundancy in two patients. No glans retraction, wound infection or glans dehiscence was observed in any patient. Complication rates were compared and no statistically significant difference was found between the two methods (P > 0.05).

Mobilization techniques may be a preferable and safe option for young surgeons due to their relative ease of perform.

Alors que de nombreuses techniques ont été décrites pour la réparation de l’hypospadias, la procédure de la plaque incisée tubularisée (PIT) est actuellement la méthode la plus fréquemment utilisée dans le traitement. D’autre part, les techniques de mobilisation de l’urètre sont moins fréquemment préférées. Dans cette étude, nous avons cherché à comparer les résultats de ces deux techniques chez les patients atteints d’hypospadias distal, en particulier ceux dont le méat urétral était situé au niveau coronaire et subcoronaire.

Au total, 75 patients atteints d’hypospadias distal ont subi une intervention chirurgicale. Les patients atteints d’hypospadias glandulaire et médian dont le méat n’était pas situé au niveau coronaire et subcoronaire ont été exclus de l’étude. 43 patients ont subi une intervention chirurgicale selon la méthode du lambeau circonférentiel excentré avec mobilisation limitée de l’urètre (LCME), tandis que les 32 autres patients ont été traités par la PIT. Nous avons analysé l’âge au moment de la chirurgie, la position du méat urétral, la courbure ventrale ou glanulaire, la durée de la cathétérisation et les complications.

L’âge moyen à l’opération était de 2,6 (±1,1) ans. La position du méat était coronaire chez 48 patients (64 %) et subcoronaire chez 27 (36 %). Les complications comprenaient une fistule chez deux patients, une sténose méatique chez sept patients et une redondance préputiale chez deux patients. Aucune rétraction du gland, infection de la plaie ou déhiscence du gland n’a été observée chez aucun patient. Les taux de complications ont été comparés et aucune différence statistiquement significative n’a été trouvée entre les deux méthodes (p > 0,05).

Les techniques de mobilisation peuvent être une option préférable et sûre pour les jeunes chirurgiens en raison de leur facilité relative de réalisation.

In our center the level of division of the corpus spongiosum as the determinant to classifying hypospadias. The hypospadias with a distal division is less severe and they present a little curvature.

We present a case of distal hypospadias corrected by Koff technique and we showed our tricks for avoiding curvature.

In this selected case a Koff procedure are preferred because it has the main advantage of exicing the dysplastic tissues and avoiding a urethroplasty using nonurethral tissues. Late penile curvature is a source of concerns for some, but in our experience no significant curvature was found at follow up.

We believe that some tricks, showed in our video, are necessary to avoid iatrogenic curvature and to obtain a good cosmetic result.

Koff technique is a good technique for hypospadias with distal division of corpus spongiosum, without significant curvature at follow up.

To report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias.

Proximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage.

A total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%).

Proximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage.

Hypospadias is an abnormal development of the urethral, ventral skin and corporeal bodies. Urethral meatus and ventral curvature have been historically the landmarks to define clinical severity. Genotyping has never been explored as a clinical predictor. Available reports have demonstrated a correlation between genetic mutations and syndromic hypospadias with poor surgical outcomes. We hypothesize that inclusion of genotyping can serve at classifying all types of hypospadias. We present the use of neural network algorithm to evaluate phenotype/genotype correlations and propose its potential clinical applicability.

A systematic review was performed from January 1974 to June 2022. Literature was retrieved from Medline, Embase, Web of Science and Google Scholar. Included manuscripts were those that had an explicit anatomical description of hypospadias phenotype (urethral meatus location following an anatomical description) and a defined genotype (genetic mutation) description. Cases with more than one variant/mutation were excluded. A comprehensive phenotype-genotype statistical analysis using neural network non-linear data modeling SPSS™ was performed.

Genotype-Phenotype analysis was performed on 1731 subjects. Of those, 959 (55%) were distal and 772 (45%) proximal. 49 genes with mutations were identified. Neural network clustering predicted better for coronal (90%) and glanular (80%), and lowest for midshaft (22%) and perineal (45%). Using genes as predictor factor only, the model was able to highly and more accurately predict the phenotype for coronal and glanular hypospadias. The following genotypes showed association to a specific phenotype: AR gene n.2058G > A for glanular (p<0.0001), n.480C  >  T for coronal (p = 0.034), R840C for perineal (p = 0.002), MAMLD1 gene c.2960C > T for coronal (p< 0.0001), p. G289S for glanular (p<0.0001), gene SRD5A2 607G > A for scrotal (p<0.0001), c16C > T for penoscrotal (p<0.0001), c59 T  >  c for perineal (p = 0.042), V89L for midshaft and scrotal (p<0.0001, p = 0.041; respectively).

Hypospadias phenotype has always been described from a purely anatomical perspective. Our results demonstrate that current phenotyping has poor correlation to the genotype. Higher genotype/phenotype correlation for distal hypospadias proves the clinical applicability of genotyping these cases. The concept and classification of differences in sexual development needs to be reconsidered given high positive yield reported for distal hypospadias. Given the better predictive value of genotyping in correlation to the phenotype, future efforts should be directed towards using the genotype.

Hypospadias has poor phenotype/genotype correlation. Sequencing all hypospadias phenotypes may add clinical value if used in association to other predictive variables. Neural network analysis may have the ability to combine all these variables for clinical prediction.