Long-term outcome of male genital reconstruction in childhood

Adult outcomes of urinary, sexual functions and fertility after pediatric management of differences in sex development: Who should be followed and how?

The management of Differences of Sex Development (DSD) has evolved considerably in recent years. The questioning of systematic early childhood treatment of DSD requires a better understanding of the outcomes of such treatments and long-term studies are therefore essential to better evaluate the prognosis of DSD. Unfortunately, limitations are numerous including the limited size of the series, the absence of standardized methodology, the evaluation of managements that no longer take place today and the absence of prospective and comparative studies. Despite these difficulties, the purpose of this paper is to present the current data on the long-term follow-up of patients with DSD from the urological, sexual and fertility points of view. Even if it remains difficult at present to establish precise recommendations, we recapitulate the most important points that should drive follow-up of these patients especially the constitution of a multidisciplinary team with a holistic approach, the organization of the transition between adolescence and adulthood, a particular attention to psychological care, a careful communication with the patients and his/her family and the use of standardized data collection systems.

Isolated Male Epispadias Repair: Long-Term Outcomes

Isolated male epispadias is one of the most severe congenital genital anomalies that require surgical correction. The goals of the surgery are to reach good aesthetic and functional outcomes. The aim of this retrospective study was to analyze the long-term outcomes of surgical reconstruction of male epispadias. A total of 31 patients with a mean age of 17 years, who underwent surgical repair of isolated male epispadias from January 2000 to January 2015, were involved. The main outcome measures were defined as: aesthetic outcome, continence, postoperative complications, sexual function, and quality of life. The follow-up period ranged from 8 to 23 years, with an average of 14.4 years. Each patients underwent an average of 2.2 surgical procedures in this period. The most common postoperative complications were urethral fistula and residual curvature, in 22.6% and 12.9%, respectively. Satisfactory aesthetic outcome was reported in 71.4% of cases. The repair of male epispadias usually includes more than two procedures with satisfactory aesthetic outcome. Unsolved urinary incontinence remains a significant issue and has a high impact on the quality of life. Follow-up should be extended even after complete sexual maturity. Comprehensive long-term evaluation is necessary for proper treatment of isolated epispadias.

Caregiver disclosure of common early childhood pediatric urologic surgeries

BACKGROUND

Certain pediatric urologic diagnoses can have serious long-term adverse health outcomes. As a result, it is important for a child to be aware of their diagnosis and a prior surgery. When children have surgery prior to the age of memory formation, it is incumbent upon their caregiver to disclose this surgery. When and how to disclose this information and even if this occurs, is not clear.

OBJECTIVE

We developed a survey to assess caregiver plans to disclose early childhood pediatric urologic surgery and evaluate for predictors of disclosure and resources needed.

METHODS

A questionnaire was distributed to caregivers of male children ≤4 years old undergoing single stage repair of hypospadias, inguinal hernia, chordee, or cryptorchidism as part of an IRB approved research study. These surgeries were chosen due to being outpatient surgeries with potential long-term complications and impact. The age criteria was chosen due to likely being before patient memory formation and thus reliance on caregiver disclosure of prior surgery. Surveys were collected the day of surgery and contained information on caregiver demographics, validated health literacy screening, and plans to disclose surgery.

RESULTS

120 survey responses were collected (Summary Table). The majority of caregivers responded affirmatively to planning to disclose their child's surgery (108; 90%). There was no impact of caregiver age, gender, race, marital status, education level, health literacy, or personal surgical history on plans to disclose surgery (p ≥ 0.05). Plan to disclose was also not different across urologic surgery type. Race was significantly associated with being "concerned or nervous about disclosing the surgery to the patient". The median patient age for planned disclosure was 10 years (IQR: 7-13). Only 17 respondents (14%) stated they received any information about how to discuss this surgery with the patient, however 83 (69%) felt this information would be helpful.

CONCLUSIONS

Our study suggests that most caregivers plan to discuss early childhood urologic surgeries with children, however want further guidance in how to talk to their child. While no specific surgery or demographic factor was found to be significantly associated with plans to disclose surgery, it is concerning that one in ten patients will potentially never learn about impactful surgery they had as a child. There is an opportunity for us to better counsel our patients' families about surgical disclosure and fill this gap with quality improvement efforts.

A survey of parental perceptions and attitudes related to disclosure in hypospadias repair

INTRODUCTION

Boys with hypospadias often undergo reconstructive surgery to improve cosmetic appearance and functional outcomes. While the ethics of physician-patient disclosure of illness are clear, parent-child disclosure is more ambiguous. There is a paucity of research regarding the parental disclosure of past urological procedures, specifically hypospadias repair. Our objective was to determine the rate of parental disclosure in boys undergoing hypospadias repair, and to evaluate the parental perspectives regarding concerns and amount of support in relation.

METHODS

A web-based questionnaire was distributed to parents of 240 hypospadias patients at our pediatric urology outpatient clinic over 12 months. The questionnaire assessed intent to disclose, decisional regret, and cosmetic perception. Data was analyzed using descriptive statistics and chi-square analyses.

RESULTS

Two hundred and twenty-three survey responses were collected. The majority of respondents were urban dwellers (72.2%), and the mothers of the child (80.9%). Distal hypospadias was the most common variant of condition (62.7%). When asked if they plan to disclose the repair to their child, 93% said "yes", and of those, the optimal mean age of disclosure was 7.49 ± 4.30 years. Ninety percent reported that they were not offered guidance on how/when to disclose, and 43% thought they would benefit from support on this. There was a significant difference in nervousness to disclose if the condition was distal versus proximal (χ² = 15.19, p=<0.01), with proximal being more nervous. A significant difference was also observed regarding disclosure support with proximal being more likely to want formal support (χ² = 4.55, p = 0.03).

DISCUSSION AND CONCLUSIONS

As hypothesized, the majority of parents intended to disclose their son's surgery to them, but no statistically significant difference was seen between those with a distal vs. proximal repair. Additionally, demographic characteristics which were hypothesized to influence this decision (e.g., parents' level of education and relationship to the child) did not discriminate parental intent to disclose. To our knowledge, this is the first study to evaluate perceptions and attitudes around disclosure in patients with hypospadias and their families. The majority of respondents were planning to disclose the operation to their child, and were not offered any guidance or support as to the optimal way to disclose. Half of those parents thought they could benefit from resources to help them with this process. Further research is required to understand the impact of disclosure and to create tools to help caregivers with this responsibility.

Psychosexual Functioning Outcome Testing after Hypospadias Repair

Self-confidence plays an important role in both genders’ sexual functioning. Lack of genital self-esteem may have negative effects on psychosexual development, especially in males, where deviations from a standardized normal penile appearance can lead to inhibitions in entering into sexual relationships. The aim of our study was to evaluate the informativeness of studied domains of the Global Sexual Functioning (GSF) questionnaire and sexual functioning of patients surgically treated in childhood for different types of hypospadias. We evaluated 63 males with hypospadias and 60 healthy age- and gender-matched controls. The GSF questionnaire was used to estimate psychosexual function as a long-term follow-up after the surgical correction of hypospadias in the patient and control groups. Sexual activity (p = 0.017), arousal (p = 0.033) and orgasmic abilities (p = 0.002) values were significantly increased in patients. Strong correlation was noticed between sexual activity and sexual desire (R = 0.872); arousal and sexual desire (R = 0.753), as well as orgasmic and erectile abilities (R = 0.769). Different domains of psychosexual functioning in the patient group correlated with each other to various degrees, resulting in a heterogeneous expression of psychosexual dysfunctions, implicating the necessity of a personalized treatment approach.

Long-term outcomes in primary male epispadias

PURPOSE

The authors present a case series of 30 male patients who presented with primary epispadias between 1989 and 2002 and looked at their long-term outcomes.

OBJECTIVES

(1) What procedures and operations did these patients require following their original surgery? (2) What were their outcomes as adults in terms of continence, cosmesis, and sexual function?

MATERIALS AND METHODS

Primary male epispadias patients who had gone through transition into Adolescent and Adult Urology services were identified retrospectively from electronic patient records.

RESULTS

The authors identified 30 male patients with a median follow-up of 18.5 years. Twenty-four had penopubic epispadias, and six had penile epispadias. All initial surgery took place between 9 and 48 months. Twenty-eight patients needed further surgery over the follow-up period, 26 had surgery for continence, and 12 required revision surgery. At follow-up, 15 patients were continent voiding per urethra, nine patients reported stress leakage with volitional urethral voiding, six patients were using a Mitrofanoff to void, and four of these had an ileocystoplasty. Nineteen patients had documentation on their feelings toward cosmetic outcome; 17 expressed concern. Twenty-one patients had documentation about sexual function; 20 had normal erections with six reporting chordee and nine reporting retrograde ejaculation. No patients were recorded to have fathered any children.

DISCUSSION

There are only a few published studies looking at long-term outcomes of genitourinary reconstruction in primary male epispadias and their sexual function in adulthood. The majority of this patient cohort required surgery to improve their continence and had more than one continence procedure. There is limited data on continence outcomes in the literature with small cohorts and rates varying between 40 and 100% at 10-year follow-up. Despite corrective surgery, nearly all the patients were concerned about their genital appearance. Other studies have shown similar outcomes in terms of patient satisfaction and sexual function. The limitations of this work are that the information was gathered retrospectively from the electronic patient record and validated instruments on outcomes were not used.

CONCLUSIONS

The study outcomes will be useful for clinicians who are counseling patients and parents regarding what to expect as adults.

Lifelong Congenital Urology: The Challenges for Patients and Surgeons

CONTEXT

Patients born with complex congenital genitourinary anomalies (including bladder exstrophy, cloacal exstrophy, epispadias, neurogenic bladder, hypospadias and posterior urethral valves) often require major reconstructive surgery in childhood. These conditions, their treatment and sequelae require lifelong follow-up. This has created the need for adult urologists to provide care as these patients grow into adults.

OBJECTIVE

To evaluate current strategies for transition and provide a current position statement with examples of the challenges faced by patients and their health care teams as a result of these conditions and their treatment.

EVIDENCE ACQUISITION

Each of the authors was asked to provide a 500-word synthesis, based on current literature; to highlight the challenges faced in an area of their expertise.

EVIDENCE SYNTHESIS

The authors assembled in March 2018 to form a consensus based on the data gathered. The aforementioned sections were reviewed and following the consensus discussion the paper was formulated and reviewed.

CONCLUSIONS

Lifelong care of congenital problems is challenging and essential for many but not all. Expertise is needed to provide the best care for patients and make the best use of resources. Specialist centres appear to be the most effective and safe model. In the long term it would be ideal to establish an evidence base focused on the common long-term problems with these conditions to ensure excellent care with appropriate expertise.

PATIENT SUMMARY

Patients born with complex congenital anomalies of the genitourinary system require specialist care in childhood. Many will need lifelong care to manage their condition and the treatment of it. There is growing interest in this area of medicine and this consensus statement addresses the need for lifelong care in this group. The aim is to ensure that all patients that need care at any age are able to find what they need.

Isl1 mediates mesenchymal expansion in the developing external genitalia via regulation of Bmp4, Fgf10 and Wnt5a

Genital malformations are among the most common human birth defects, and both genetic and environmental factors can contribute to these malformations. Development of the external genitalia in mammals relies on complex signaling networks, and disruption of these signaling pathways can lead to genital defects. Islet-1 (ISL1), a member of the LIM/Homeobox family of transcription factors, has been identified as a major susceptibility gene for classic bladder exstrophy in humans, a common form of the bladder exstrophy-epispadias complex (BEEC), and is implicated in a role in urinary tract development. We report that deletion of Isl1 from the genital mesenchyme in mice led to hypoplasia of the genital tubercle and prepuce, with an ectopic urethral opening and epispadias-like phenotype. These mice also developed hydroureter and hydronephrosis. Identification of ISL1 transcriptional targets via ChIP-Seq and expression analyses revealed that Isl1 regulates several important signaling pathways during embryonic genital development, including the BMP, WNT, and FGF cascades. An essential function of Isl1 during development of the external genitalia is to induce Bmp4-mediated apoptosis in the genital mesenchyme. Together, these studies demonstrate that Isl1 plays a critical role during development of the external genitalia and forms the basis for a greater understanding of the molecular mechanisms underlying the pathogenesis of BEEC and urinary tract defects in humans.

Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia

INTRODUCTION

Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches.

OBJECTIVE

The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia.

STUDY DESIGN

This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings.

RESULTS

Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied.

DISCUSSION

In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population.

CONCLUSION

In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.

Management of the patient with failed hypospadias surgery presenting in adulthood

The management of patients who have had complications of primary surgery for the resolution of a hypospadiac deformity remains a therapeutic challenge. Adults with complications following childhood hypospadias repairs are undoubtedly a difficult population to treat, as there is usually a cosmetic deformity, lower urinary tract symptoms, and resulting psychosexual consequences. A surgeon's experience has been and still remains an important factor in determining subsequent surgical outcomes, particularly with more severe or complex cases. The purpose of this review is to evaluate the complications of hypospadias repair that present in adults and review published experience in treating them.

Craniofacial anomalies associated with hypospadias. Description of a hospital based population in South America

Introduction:

Hypospadias is a congenital abnormality of the penis, in which there is incomplete development of the distal urethra. There are numerous reports showing an increase of prevalence of hypospadias. Association of craniofacial malformations in patients diagnosed with hypospadias is rare. The aim of this study is to describe the association between hypospadias and craniofacial congenital anomalies.

Materials and Methods:

A retrospective review of the Latin-American collaborative study of congenital malformations (ECLAMC) data was performed between January 1982 and December 2011. We included children diagnosed with associated hypospadias and among them we selected those that were associated with any craniofacial congenital anomaly.

Results:

Global prevalence was 11.3 per 10.000 newborns. In this population a total of 809 patients with 1117 associated anomalies were identified. On average there were 1.7 anomalies per patient. Facial anomalies were present in 13.2%. The most commonly major facial anomaly associated to hypospadias was cleft lip/palate with 52 cases. We identified that 18% have an association with other anomalies, and found an association between craniofacial anomalies and hypospadias in 0.59 cases/10.000 newborns.

Discussion:

Hypospadias is the most common congenital anomaly affecting the genitals. Its association with other anomalies is rare. It has been reported that other malformations occur in 29.3% of the cases with hypospadias. The more proximal the meatus, the higher the risk for having another associated anomaly.

Conclusion:

Associated hypospadias are rare, and it is important to identify the concurrent occurrence of craniofacial anomalies to better treat patients that might need a multidisciplinary approach.

Better Defining the Spectrum of Adult Hypospadias: Examining the Effect of Childhood Surgery on Adult Presentation

OBJECTIVE

To describe the spectrum of adult presentations with hypospadias-related complications and examine the effect of childhood surgical repair on these adult presentations.

METHODS

A retrospective chart review over a 10-year period, from August 2004 to December 2014, demonstrated 93 adult patients who presented to a reconstructive urologist with complications related to hypospadias. Patients were divided into 2 groups: those with no prior hypospadias surgery (Group 1, N = 19) and those who underwent surgical correction as a child (Group 2, N = 74). Charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required.

RESULTS

The mean age at presentation was 34.6 ± 0.6 years. Overall, lower urinary tract symptoms (LUTS) (49%) was the most common presenting complaint, followed by spraying (24%), urethrocutaneous fistula (18%), recurrent urinary tract infections (UTIs) (15%), and chordee (14%). Comparison demonstrated that Group 2 patients were more likely to present with LUTS (55% vs 26%; P = .038) and recurrent UTIs (19% vs 0%; P = .050). There was a trend toward Group 1 patients presenting more commonly with cosmetic dissatisfaction (16% vs 4%; P = .06). Urethral stricture was demonstrated more commonly in Group 2 (47% vs 11%; P = .0043). Of these, strictures were significantly longer in the previous surgery group (5.5 ± 0.6 cm vs 3.0 ± 0.6 cm, P = .019).

CONCLUSION

Correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent UTIs, and subsequent LUTS, with a trend toward improving patient satisfaction with cosmesis compared to nonsurgical management. Follow-up of hypospadias repair patients should extend into adulthood, as a significant portion of adult presentations ultimately require surgical intervention.

Multivariate Analysis of the Factors Associated With Sexual Intercourse, Marriage, and Paternity of Hypospadias Patients

INTRODUCTION

Patients with hypospadias are treated surgically during childhood, which has the intention of enabling a satisfactory sexual life in adulthood. However, it is unclear whether patients with corrected hypospadias can lead a satisfactory sexual life and sustain a marital relationship and produce offspring.

AIM

To evaluate factors associated with achievement of sexual intercourse, marriage, and paternity in patients with hypospadias who have reached adulthood.

METHODS

Self-completion questionnaires were mailed in April 2012 to patients with hypospadias at least 18 years old who had been treated at our institution during childhood from 1973 through 1998 by a single surgeon and the same surgical policy. Assessments included the International Prostate Symptom Score, the International Index for Erectile Function-5, and non-validated questions related to current social and physical status and sexual, marital, and paternity experiences. Candidate factors were extracted from patients' neonatal data, surgical findings and results, and current physical and social status obtained by the questionnaires.

MAIN OUTCOME MEASURES

Candidate factors associated with heterosexual intercourse, marriage, and paternity experiences were analyzed using univariate and multivariate proportional hazard models and log-rank test of Kaplan-Meier curves.

RESULTS

Of the 518 patients contacted, 108 (age = 18-50 years, median = 28 years) met the inclusion criteria. Two- and one-stage repairs were performed as the initial treatment in 79 and 12, respectively, and 17 of the analyzed cases were reoperations for patients initially treated elsewhere. Fifty-seven patients had the milder type (31 glandular, 26 penile), 36 had the proximal type (13 penoscrotal, 23 scrotal-perineal), and 15 had an unknown type. Multivariate analyses by Cox proportional hazard model and log-rank tests confirmed that experience of sexual intercourse was associated with the milder type of hypospadias (P = .025 and .0076 respectively), marriage was associated with stable employment (P = .020 and .026, respectively), and paternity was associated with the absence of additional surgery after completion of the initial repair (P = .013 by multivariate analysis).

CONCLUSION

There was scant overlap of factors associated with the three events. The present findings provide reference information for surgeons and parents regarding future sexual and marriage experiences of children treated for hypospadias.

Patient-reported long-term outcome after primary hypospadias repair

PURPOSE

Long-term evaluation of the surgical outcome after puberty, particularly patient reported outcome is rare in the literature. The aims of this study were to investigation the patients' satisfaction with the long-term results and their views and memories of their childhood surgery and follow-up.

METHODS

A modified version of previously used questionnaire was sent to 134 patients ages 18 years or older previously primarily repaired due to hypospadias by one of the authors (HS) between 1989 -2009.

RESULTS

Thirty-nine patients responded. Eighty-two per cent were satisfied with the appearance of their penis, 87% were satisfied with their ability to urinate and their sexual function and 92% were satisfied with the overall surgical results. Ninety per cent of patients were positive to the current duration of our post-pubertal follow-up program or would have preferred an even longer follow-up.

CONCLUSIONS

The majority of patients were satisfied with the long-term surgical results and the duration of follow-up. Despite having problems patients does not always contact the health care system spontaneously, which warrants long-term follow-up.

Fertility Issues in Disorders of Sex Development

Fertility potential should be considered by the multidisciplinary team when addressing gender assignment, surgical management, and patient and family counselling of individuals with disorders of sex development. In 46,XY individuals, defects of gonadal differentiation or androgen or anti-Müllerian hormone synthesis or action result in incomplete or absent masculinization. In severe forms, raised as females, motherhood is possible with oocyte donation if Müllerian ducts have developed. In milder forms, raised as males, azoospermia or oligospermia are frequently found, however paternity has been reported. Most 46,XX patients with normal ovarian organogenesis are raised as females, and fertility might be possible after treatment.

Sexual Health Outcomes in Adults with Complete Male Epispadias

PURPOSE

Complete male epispadias is a rare congenital anomaly characterized by failed closure of the entire penopubic dorsal urethra. Epispadias repair is typically performed during infancy, and resultant genitourinary abnormalities can have a marked impact on adult life. We assess long-term post-reconstruction sexual health and fertility outcomes in adults with complete male epispadias.

MATERIALS AND METHODS

A total of 132 patients 18 years or older with complete male epispadias who had undergone reconstruction were identified from a prospectively maintained, institutionally approved database. Patients who could be contacted were asked to complete a telephone survey regarding sexual function. Reconstructive history and clinical details were obtained by chart/database review.

RESULTS

Of 132 patients with complete male epispadias 74 met inclusion criteria and 15 (20%) completed the questionnaire. Seven patients (47%) reported currently being in a relationship. Although 12 patients (80%) reported overall satisfactory sexual intercourse, 11 (73%) admitted to 1 or more problems with sexual function, including abnormal ejaculation (53%), diminished sensation (20%) and difficulty maintaining an erection (20%). When questioned regarding the importance of fertility on a scale of 0 to 5 using a Likert-type item the response of 10 patients (67%) was 4 points or greater. Five patients (33%) reported having impregnated a sexual partner. Although 4 patients (27%) had suspicion of fertility problems, only 2 (13%) reported having abnormal semen analyses.

CONCLUSIONS

This is one of few studies examining post-reconstruction sexual health and function in adults with complete male epispadias. Although small, our study demonstrates that patients are able to engage in relationships, participate in sexual intercourse and impregnate their partners. These results highlight sexual concerns and outcomes that may be of use when counselling patients with complete male epispadias and their families.

Grade of hypospadias is the only factor predicting for re-intervention after primary hypospadias repair: a multivariate analysis from a cohort of 474 patients

BACKGROUND

There is an ongoing quest on how to minimize complications in hypospadias surgery. There is however a lack of high-quality data on the following parameters that might influence the outcome of primary hypospadias repair: age at initial surgery, the type of suture material, the initial technique, and the type of hypospadias.

OBJECTIVES

The objective of this study was to identify independent predictors for re-intervention in primary hypospadias repair.

STUDY DESIGN

We retrospectively analyzed our database of 474 children undergoing primary hypospadias surgery. Univariate and multivariate logistic regression was performed to identify variables associated with re-intervention. A p-value <0.05 was considered statistically significant and therefore considered as a prognostic factor for re-intervention.

RESULTS

Distal penile hypospadias was reported in 77.2% (n = 366), midpenile in 11.4% (n = 54) and proximal in 11.4% (n = 54) of children. Initial repair was based on an incised plate technique in 39.9% (n = 189), meatal advancement in 36.0% (n = 171), an onlay flap in 17.3% (n = 82) and other or combined techniques in 5.3% (n = 25). In 114 patients (24.1%) re-intervention was required (n = 114) of which 54 re-interventions (47.4%) were performed within the first year post-surgery, 17 (14.9%) in the second year and 43 (37.7%) later than 2 years after initial surgery. The reason for the first re-intervention was fistula in 52 patients (46.4%), meatal stenosis in 32 (28.6%), cosmesis in 35 (31.3%) and other in 14 (12.5%). The median time for re-intervention was 14 months after surgery [range 0-114]. Significant predictors for re-intervention on univariate logistic regression (polyglactin suture material versus poliglecaprone, proximal hypospadias, lower age at operation and other than meatal advancement repair) were put in a multivariate logistic regression model. Of all significant variables, only proximal hypospadias remained an independent predictor for re-intervention (OR 3.27; p = 0.012).

DISCUSSION

The grade of hypospadias remains according to our retrospective analysis the only objective independent predicting factor for re-intervention in hypospadias surgery. This finding is rather obvious for everyone operating hypospadias. Curiously midpenile hypospadias cases were doing slightly better than distal hypospadias in terms of re-intervention rates. Our study however has also some shortcomings. First of all, data was gathered retrospectively and follow-up time was ill-balanced for several variables. We tried to correct this by applying sensitivity analysis, but possible associations between some variables and re-intervention might still be obscured by this. Standard questionnaires to analyze surgical outcome were not available. Therefore, we focused our analysis on re-intervention rate as this is a hard and clinically relevant end point.

CONCLUSIONS

This retrospective analysis of a large hypospadias database with long-term follow-up indicates that the long-lasting debate about factors influencing the reoperation rate in hypospadias surgery might be futile: in experienced hands, the only variable that independently predicts for re-intervention is the severity of hypospadias, the only factor we cannot modify. This retrospective multivariate analysis of a large hypospadias database with long-term follow-up suggests that the only significant independent predictive factor for re-intervention is proximal hypospadias. In our series, technique did not influence the re-intervention rate.

Transitional care in pediatric urology

The transition from childhood to adolescence and into adulthood occurs as a natural component of human development. As children progress through school and gain independence, health care practitioners must facilitate a parallel transition from pediatric to adult providers. Modern medicine has succeeded in extending the life expectancy for many children with complex conditions, and adult providers are participating in their medical care through adulthood. Transitioning pediatric urology care to adult urology care is unique to every individual and his or her underlying condition, while the transition process is universal. The objectives of all pediatric urologists include preservation of the kidneys and lower urinary tracts, safe urine storage, safe urine drainage, urinary continence, fertility, sexual function, and genital cosmesis. For some children, these objectives can be attained during childhood, while other children require lifelong maintenance and management. Children with posterior urethral valves, exstrophy-epispadias complex, cloaca, vesicoureteral reflux, neurogenic bladder, disorders of sex development, cancer, hypospadias, nephrolithiasis, undescended testes, varicoceles, ureteropelvic junction obstruction, solitary kidney, and upper tract anomalies all require long-term evaluation and management. The obstacles of altering a patient and caregiver paradigm, locating adult urologists with special expertise, coordinating care with other adult specialties such as nephrology, and navigating the adult health care environment can impede the transition process.

Pediatric surgical complications of major genitourinary reconstruction in the exstrophy-epispadias complex

PURPOSE

Urinary continence is the goal of exstrophy-epispadias complex (EEC) reconstruction. Patients may require a continent urinary diversion (CUD) if they are a poor candidate for bladder neck reconstruction or are receiving an augmentation cystoplasty (AC) or neobladder (NB). This study was designed to identify the incidence of surgical complications among various bowel segments typically used for CUD.

METHODS

A prospectively kept database of 1078 patients with EEC at a tertiary referral center from 1980 to 2012 was reviewed for major genitourinary reconstruction. Patient demographics, surgical indications, perioperative complications, and outcomes were recorded.

RESULTS

Among reviewed EEC patients, 134 underwent CUD (81 male, 53 female). Concomitant AC was performed in 106 patients and NB in 11. Median follow up time after initial diversion was 5 years. The most common CUD bowel segments were appendix and ileum. The most common surgical complications after CUD were small bowel obstruction, post-operative ileus, and intraabdominal abscess. There was a significantly increased risk in the occurrence of pelvic or abdominal abscess when colon was used as a conduit compared to all other bowel segments (OR=16.7, 95% CI: 1.16-239) and following NB creation compared to AC (OR=39.4, 95% CI: 3.66-423). At postoperative follow-up, 98% of patients were continent of urine via their stoma.

CONCLUSION

We report the largest series to date examining CUD in the EEC population. The increased risk of abdominal and pelvic abscesses in patients who receive a colon CUD and undergo NB compared to AC indicates that while surgical complications following major genitourinary reconstruction are rare, they do occur. Practitioners must be wary of potential complications that are best managed by a multi-disciplinary team approach.

Urologic complications of major genitourinary reconstruction in the exstrophy-epispadias complex

OBJECTIVE

To present the authors' experiences with urologic complications associated with various techniques used to create a continent stoma (CS), augmentation cystoplasty (AC), and neobladder in the exstrophy-epispadias complex (EEC) population.

METHODS

Retrospective review of medical records of patients who underwent CS with or without bladder augmentation were identified from an institutional review board-approved database of 1208 EEC patients. Surgical indications, tissue type, length of hospital stay, age, preoperative bladder capacity, prior genitourinary surgeries, postoperative urological complications, and continence status were reviewed.

RESULTS

Among the EEC patients reviewed, 133 underwent CS (80 male, 53 female). Mean follow-up time after initial continent stoma was 5.31 years (range: 6 months to 20 years). Appendix and tapered ileum were the primary bowel segments used for the continent channel and stoma in the EEC population. The most common stomal complications in this population were stenosis, incontinence, and prolapse. Seventy-nine percent of EEC CS patients underwent AC primarily done with sigmoid colon or ileum. Eleven patients (8%) underwent neobladder creation with either colon or a combination of colon and ileum. Bladder calculi, vesicocutaneous fistula, and pyelonephritis were the most common non-stomal complications. Stomal ischemia was significantly increased in Monti ileovesicostomy compared to Mitrofanoff appendicovesicostomy in classic bladder exstrophy patients (p = 0.036). Furthermore, pyelonephritis was more than twice as likely in colonic neobladder than all other reservoir tissue types in the same cohort (OR = 2.53, 95% CI: 1.762-3.301, p < 0.001).

CONCLUSIONS

To the best of the authors' knowledge, this is the largest study examining catheterizable stomas in the exstrophy population. While Mitrofanoff appendicovesicostomy is preferred to Monti ileovesicostomy because it is technically less challenging, it may also confer a lower rate of stomal ischemia. Furthermore, even though ileum or colon can be used in AC with equally low complication rates, practitioners must be wary of potential urologic complications that should be primarily managed by an experienced reconstructive surgeon.