Microphallic hypospadias: testosterone therapy prior to surgical repair

Preoperative hormone stimulation; does it increase hypospadias postoperative complications?

AIM OF THE STUDY

To assess the effect of Preoperative Hormone Stimulation (PHS) on glans size in proximal hypospadias with chordee and small glans, and to determine if PHS is associated with increased postoperative complications.

PATIENTS & METHODS

Between 2014 and 2021, 101 cases of proximal hypospadias with small glans (12 mm or less) were operated upon in our hospital and are the basis of this cohort. All patients underwent a standard two-stage surgical repair, undergoing a correction of the chordee in the first operation and urethroplasty in the second operation. All patients included were operated by the same surgeon. They were classified into two groups; Group A: 50 children were operated upon between 2014 and 2017 and did not receive PHS and Group B: 51 children operated between 2018 and 2021 and received PHS. Glans dimensions including Dorsal Longitudinal Length (DLL) and Glans Width (GW) were measured during the first operation. PHS was given 1-2 months before the second operation in Group B. The glans dimensions were measured again during the second operation after PHS. Follow up period ranged from 2 to 9 years (mean 5 years).

RESULTS

Following PHS a statistically significant increase in glans length (p = 0.042) and glans width (p = 0.011) was observed at the second operation, with 36 patients (70%) showing a mean glans width increase of 2.78 mm (range 2-8 mm) after receiving PHS. There was no statistically significant difference in the complication rates between the two groups (p = 0.556) with a fragility index of zero (FI = 0).

DISCUSSION

The present study separates itself from most other studies in the literature, in the fact that it has included only a specific group of proximal and perineal hypospadias with severe chordee and glans width of 12 mm or less and that glans dimensions were always objectively and accurately measured under general anesthesia. The other major difference is that PHS in our study was given after and not before the first operation. Furthermore, the fact that all patients prior to 2018 did not receive PHS and all patients after 2018 received PHS, indicates that there was no selection bias.

CONCLUSION

This study shows that PHS results in an increase the size of the glans in 70% of patients with hypospadias and a small glans without an increase in postoperative complications.

Defining the role of pre-operative hormonal therapy in hypospadias

In hypospadias surgery, pre-operative hormonal therapy (PHT) is primarily used to increase penile dimensions and the vascularity of tissues available for reconstruction, but its use is non-uniform in clinical practice, with no consensus on application or utility. This review aims to summarise: (i) the penile tissue response to hormone therapy, (ii) its impact on hypospadias surgery outcomes, and (iii) the endocrinological considerations and sequelae. PHT is more often indicated for complex cases such as proximal hypospadias, hypospadias with microphallus and hypospadias reoperations. While PHT has clear effects on penile morphometry, and more recent controlled trials suggest improved surgical outcomes, the lack of consistent outcome definitions and generally inadequate follow-up periods continue to consign many of the potential long-term effects of PHT to the unknown. There is currently insufficient robust evidence to allow a clinical guideline to be constructed. The need for a well-powered multi-centre prospective randomised trial to address this question is evident but awaits a unified consensus on issues surrounding the understanding of aetiology, classification of hypospadias morphology, definition of important prognostic variables and uniform application of outcome measures. The effects of PHT may be utilised to improve outcomes in cases of proximal and severe hypospadias, which under the current paradigm represent a significant surgical challenge.

The role of androgens in clitorophallus development and possible applications to transgender patients

BACKGROUND

The clitorophallus, or glans, is a critical structure in sexual development and plays an important role in how gender is conceptualized across the life span. This can be seen in both the evaluation and treatment of intersex individuals and the use of gender-affirming masculinizing therapies to help those born with a clitoris (small clitorophallus with separate urethra) enlarge or alter the function of that structure.

OBJECTIVES

To review the role of testosterone in clitorophallus development from embryo to adulthood, including how exogenous testosterone is used to stimulate clitorophallus enlargement in masculinizing gender-affirming therapy.

MATERIALS AND METHODS

Relevant English-language literature was identified and evaluated for data regarding clitorophallus development in endosex and intersex individuals and the utilization of hormonal and surgical masculinizing therapies on the clitorophallus. Studies included evaluated the spectrum of terms regarding the clitorophallus (genital tubercle, clitoris, micropenis, penis).

RESULTS

Endogenous testosterone, and its more active metabolite dihydrotestosterone, plays an important role in the development of the genital tubercle into the clitorophallus, primarily during the prenatal and early postnatal periods and then again during puberty. Androgens contribute to not only growth but also the inclusion of a urethra on the ventral aspect. Exogenous testosterone can be used to enlarge the small clitorophallus (clitoris or micropenis) as part of both intersex and gender-affirming care (in transmasculine patients, up to 2 cm of additional growth). Where testosterone is insufficient to provide the degree of masculinization desired, surgical options including phalloplasty and metoidioplasty are available.

DISCUSSION AND CONCLUSION

Endogenous testosterone plays an important role in clitorophallus development, and there are circumstances where exogenous testosterone may be useful for masculinization. Surgical options may also help some patients reach their personal goals. As masculinizing gender-affirming care advances, the options available for clitorophallus modifications will likely continue to expand and improve.

Androgens During Infancy, Childhood, and Adolescence: Physiology and Use in Clinical Practice

We provide an in-depth review of the role of androgens in male maturation and development, from the fetal stage through adolescence into emerging adulthood, and discuss the treatment of disorders of androgen production throughout these time periods. Testosterone, the primary androgen produced by males, has both anabolic and androgenic effects. Androgen exposure induces virilization and anabolic body composition changes during fetal development, influences growth and virilization during infancy, and stimulates development of secondary sexual characteristics, growth acceleration, bone mass accrual, and alterations of body composition during puberty. Disorders of androgen production may be subdivided into hypo- or hypergonadotropic hypogonadism. Hypogonadotropic hypogonadism may be either congenital or acquired (resulting from cranial radiation, trauma, or less common causes). Hypergonadotropic hypogonadism occurs in males with Klinefelter syndrome and may occur in response to pelvic radiation, certain chemotherapeutic agents, and less common causes. These disorders all require testosterone replacement therapy during pubertal maturation and many require lifelong replacement. Androgen (or gonadotropin) therapy is clearly beneficial in those with persistent hypogonadism and self-limited delayed puberty and is now widely used in transgender male adolescents. With more widespread use and newer formulations approved for adults, data from long-term randomized placebo-controlled trials are needed to enable pediatricians to identify the optimal age of initiation, route of administration, and dosing frequency to address the unique needs of their patients.

Echocardiographic evaluation of left ventricular mass index in children with hypospadias after hormonal stimulation with topical testosterone: A randomized controlled trial

INTRODUCTION

Testosterone is often used in the preoperative period of hypospadias surgery. Previous studies have demonstrated the presence of androgen receptors in cardiac myocytes that can modulate the phenotype. The use of supraphysiological doses of androgens can lead to toxicity on the heart muscle and, in some cases, to left ventricular hypertrophy. This randomized double blind controlled clinical trial aims to evaluate the effect of topical testosterone on left ventricular mass index in boys with hypospadias.

MATERIALS AND METHODS

Boys with hypospadias aged 6 months to 9 years were included. Children were divided into two groups: G1 - boys who received testosterone propionate 1% ointment twice a day for 30 days, and G2 - boys receiving placebo ointment in the same regimen. All children were submitted to bi-dimensional echocardiographic evaluation to compare the left ventricular mass index, blood pressure, and body mass index before and after treatment (30 and 90 days). Levels of serum testosterone, LH, and FSH were measured.

RESULTS

Thirty-five children were analyzed: 17 in G1 and 18 in G2. No differences were found in left ventricular mass index (left ventricular mass indexed by body surface area) prior to treatment. Left ventricular mass index was 59.21 ± 11.91 g/m² in G1 and 55.12 ± 8.29 g/m² in G2 (p = 0.244) after 30 days of treatment, and 61.13 ± 11.69 g/m² in G1 and 62.84 ± 35.99 g/m² in G2 (p = 0.852) after 90 days. Serum testosterone levels were 12 (7-80) ng/dL in G1 and 5 (5-7) ng/dL in G2 (p = 0.018) after 30 days of treatment, and 10 (5-11) ng/dL in G1 and 5 (4-5) ng/dL in G2 (p = 0.155), after 90 days (Figure). There was a small increase in systolic blood pressure (SBP) after 30 days (83.82 ± 7.18 mmHg) in the group who receive testosterone (G1) compared with controls (77.5 ± 6.69 mmHg) (p = 0.010). After 90 days, SBP levels returned to basal levels in G1 (82.35 ± 5.62 mmHg) and in G2 (81.38 ± 4.79 mmHg) (p = 0.588).

CONCLUSION

Topical testosterone can be considered safe in the preoperative period of children with hypospadias with no risk of left ventricular hypertrophy. An increase in systolic blood pressure occurs while using testosterone but it is transitory, returning to normal levels after 90 days.

The role of pre-operative androgen stimulation in hypospadias surgery

The hormonal stimulation for the purpose of penile enlargement before the hypospadias repair has been commonly used, but rarely reported. In addition to functional outcome, dihydrotestosterone (DHT) pretreatment has been suggested to improve cosmetic outcome in a preliminary randomized study. Since the randomized and controlled clinical trials on this topic are insufficient, the hormonal agent, the route of administration, dosing schedule, and the timing of treatment has been remained controversial. In order to confirm the efficiency of hormonal treatment, further well designed randomized studies with a larger number of patients and a placebo group are warranted.

Meta-analysis of Androgen Insensitivity in Preoperative Hormone Therapy in Hypospadias

OBJECTIVE

To define androgen insensitivity prevalence in hypospadias patients treated with preoperative hormone therapy.

MATERIALS AND METHODS

We searched databases that were published in English and Chinese up to September 10, 2014 for our studies. Eligibility criteria were pre-established. Title, abstract, and full-text screenings were conducted by 2 authors independently. Discrepancies were resolved by consensus. Quality assessment of included studies was completed. Meta-analysis was done when appropriate using R, version 3.1.1 for Windows. Heterogeneity among individual studies was tested using the Cochran chi-square Q test and quantified by calculating the I(2) index.

RESULTS

Thirteen of 1278 publications met inclusion criteria and were incorporated into this study. Of 306 patients with preoperative hormone therapy, 25 displayed androgen resistance. Meta-analysis demonstrated that the random-effects model generates a pooled estimate of 7.14% (95% confidence interval [CI], 3.16%-15.31%), whereas the fixed-effect model provides an estimate of 14.61% (95% CI, 10.00%-20.85%). Heterogeneity among included studies was found above medium (I(2) = 67.1% [95% CI, 41.2%-81.6%]; P = .0003]. After exclusion of the heterogeneity, both random-effects and fixed-effect models produce a consistent pooled estimate of 6.95% (95% CI, 0%-47.8%).

CONCLUSION

We have defined that the prevalence of androgen resistance in hypospadias is 7.14% (95% CI, 3.16%-15.31%). To distinguish isolated hypospadias from patients with androgen insensitivity syndrome, we recommend that androgen-resistant patients should be specifically targeted by molecularly focused diagnosis. Management strategies should include identification of mutations in the androgen receptor gene, timely surgery to repair hypospadias, and long-term follow-up of sexual function and fertility later in life.

The influence of pre-operative hormonal stimulation on hypospadias repair

Androgen stimulation to temporarily promote penile growth has been commonly used to facilitate hypospadias repair. Although some series suggest improvement in both functional and cosmetic outcomes, a recent systematic review and meta-analysis showed a possible relationship between pre-operative hormonal stimulation and higher complications. As a result, indications and treatment regimens remain controversial. Here, we review the available literature and present our clinical practice.

Survey of pediatric urologists on the preoperative use of testosterone in the surgical correction of hypospadias

OBJECTIVE

To better characterize the current state of testosterone use in the surgical correction of hypospadias among pediatric urologists.

METHODS

An email was sent via the pedsurology research listserv through the American Academy of Pediatrics, inviting members to participate in an anonymous survey regarding their use of preoperative testosterone in hypospadias correction.

RESULTS

Twenty-seven responses were obtained for a response rate of 53%. Almost all responders practiced in North America, had exclusively pediatric patients in their practice, and had been in practice for 30 years or less. 55% were classified as high-volume surgeons, completing >50 cases yearly, 87% of whom use preoperative androgen therapy currently, compared with 67% of low-volume surgeons. Testosterone was prescribed primarily for a small appearing penis, reduced glans circumference, reduced urethral plate width, and/or proximal hypospadias. The effect of testosterone was determined primarily by evaluating penile appearance (59%). However, the majority (56%) of physicians stopped giving testosterone when they completed a predetermined regimen.

CONCLUSIONS

While many pediatric urologists use testosterone prior to hypospadias repair, the practice patterns are variable. It appears that the use of testosterone is primarily limited to patients with proximal hypospadias, small appearing penis, reduced glans circumference or reduced urethral plate.

Hormone therapy in hypospadias surgery: a systematic review

Surgical correction of hypospadias is proposed to improve the aesthetic and functional quality of the penis. Hormone therapy preceding surgical correction is indicated to obtain better surgical conditions. However, there is divergence in the literature regarding the hormone therapy of choice, time of its use before surgery, appropriate dose, and route of application. To try to elucidate this matter, an electronic survey of the databases PubMed and Cochrane Central Library was conducted, limited to articles in English published since 1980. Search strategy identified 14 clinical trials that matched the inclusion criteria. Analysis was made in terms of study design, classification of hypospadias, association with chordee and cryptorchidism, type of hormone, route of application, dose and duration of treatment, penile length before and after hormone therapy, glans circumference before and after hormone therapy, adverse effects, and surgical complications. From the trials evaluated it was not possible to determine the ideal neoadjuvant treatment. A preference for use of testosterone was observed. Intramuscular administration seems to have fewer adverse effects than topical treatment. Side effects were seldom described, and treated patients were not followed on a long-term basis. The scarcity of randomized and controlled clinical trials regarding the topic impairs the establishment of a protocol. In conclusion, although preoperative hormone therapy is currently used before hypospadias surgery, its real benefit in terms of improvement of the penis and surgical results has not been defined.

Comparison of topical versus parenteral testosterone in children with microphallic hypospadias

INTRODUCTION

Surgical correction of genital defects was formerly proposed when the size of the penis was sufficient to permit easy surgical repair. To enlarge penile size, temporary stimulation with testosterone either topical or parenteral has been reported. Parenteral testosterone has been found to be effective; however, variable results have been reported with topical testosterone. This study was taken up as an attempt to compare the efficacy of parenteral versus topical testosterone application.

MATERIALS AND METHODS

Twenty-one consecutive children with microphallic hypospadias were randomized to receive either topical or parenteral testosterone prior to surgery. Penile length, glans circumference and secondary effects were recorded before and after therapy by the same observer.

RESULTS

Significant penile growth was noticed in both the groups of children when compared with pre-therapy size.

CONCLUSIONS

The desired therapeutic effect of significant penile growth following testosterone was achieved in both the groups of children. There was no significant difference between the two routes of administration.

REVIEWS: Are Androgens Critical for Penile Erections in Humans? Examining the Clinical and Preclinical Evidence

Androgens are deemed critical for penile-tissue development, growth, and maintenance of erectile function, however, their role in erection, especially in humans, remains controversial. In this review, we summarize information from clinical and animal model studies to provide a comprehensive and rational argument for the role of androgens, or lack thereof, on penile erection ability in humans. The goal of this review is to present the clinical and preclinical evidence available in the literature with regard to testosterone and erectile physiology and engage the reader in this discussion. Ultimately, each reader will have to form his or her own conclusions based on the existing evidence. In humans, androgen-deficiency manifestations are noted in clinical situations such as: (i) inadequate development of the penis; and (ii) loss of erectile function in prostate cancer and benign prostatic hyperplasia patients managed with medical or surgical castration or antiandrogen therapy. Androgen treatment causes: (i) improvement in sexual function in hypogonadal patients treated with androgen supplementation; (ii) improvement in nocturnal penile tumescence in hypogonadal patients treated with androgens; (iii) improvement in erectile function with androgen supplementation in patients who did not respond to phosphodiesterase type 5 inhibitor therapy initially; and (iv) improvement in the well-being, mood, energy, and sexual function in aging men who have testosterone deficiency treated with androgen therapy. In contrast to animals, especially rodents in which the adrenal cortex does not synthesize androgens, the human adrenal is a source of peripherally circulating androgen precursors, thus, complete androgen insufficiency may not be observed in men at a younger age. Furthermore, in light of the concept that a threshold of androgen levels exists in animals and humans below which sexual function is diminished, further contributes to the complexity of understanding androgens role in erections, especially in humans. Nevertheless, based on the preclinical and clinical data available in the literature, to date, we infer that androgens play a critical role in maintaining erectile physiology in humans.

The 'learning curve' in hypospadias surgery

OBJECTIVE

To provide an insight into the 'learning curve' of fellowship-trained paediatric urologists associated with hypospadias repair, as hypospadias surgery is one of the most common yet difficult procedures used by the paediatric urologist.

PATIENTS AND METHODS

Prospective data were collected on 231 consecutive hypospadias operations performed by one paediatric urologist (M.H.) over a 5-year period, beginning with his first year after completing his fellowship. All patients were having their first surgery and none had a staged repair. Fistula formation was used as a surrogate for the complication rate, as it is an objective measurable outcome that is easily identified with little interobserver or parental/physician variability. The follow-up included several visits in the 15 months after repair, during which virtually all complications could be identified and addressed.

RESULTS

The operative results improved throughout the 5 years of observation; there was a statistically significant decline in the fistula rate in each year of observation (P < 0.001; Kruskal-Wallis exact test for ranked groups). The absolute reduction in fistula rates between the first 2 and the last 2 years was 12.7% (P < 0.02; chi squared).

CONCLUSIONS

The science and surgery of hypospadiology is mostly and correctly delegated to the paediatric urologist. Even in the hands of a fellowship-trained paediatric urologist, a successful repair, as measured by complication rate, statistically improves with time and experience.

Hypospadias surgery: when, what and by whom?

Hypospadias is repaired by paediatric surgeons, paediatric urologists, adult reconstructive urologists and plastic surgeons. This review is unique in representing all four specialities, to provide a unified policy on the management of hypospadias. The surgeon of whichever speciality should have a dedicated interest in this challenging work, ideally having an annual volume of at least 40-50 cases. The ideal time for primary repair is at 6-12 months old, although when this is not practicable there is another opportunity at 3-4 years old. A surgical protocol is presented which emphasises both functional and cosmetic refinement. Using a logical progression of a very few related procedures allows the reliable correction of almost any hypospadias deformity. A one-stage repair is used when the urethral plate does not require transection and its axial integrity can be maintained. Occasionally, when the plate is of adequate width and depth, it can be tubularized directly using the second stage of the two-stage repair. When (usually) the urethral plate is not adequately developed and requires augmentation before it can be tubularized, then that second-stage procedure is modified by adding a dorsal releasing incision +/- a graft (alias Snodgrass and 'Snodgraft' procedures). The two-stage repair offers the most reliable and refined solution for those patients who require transection of the urethral plate and a full circumferential substitution urethroplasty. From available evidence this protocol combines excellent function and cosmesis with optimum reliability. Nevertheless, it would be complacent to assume that these gratifying results will be maintained into adult life. We therefore recommend that there is still a need for active follow-up through to genital maturity.

Two-stage repair for severe hypospadias

In 39 patients a 2-stage modified Belt-Fuqua repair was performed for severe hypospadias and chordee. Patient age at initial surgery averaged 2 years and stage 2 was done 7 months later. Testosterone was given before stage 1 to 22 patients (56%) and before both stages to 13 (33%). Of 5 patients with intersex 2 had mixed gonadal dysgenesis, 1 was a true hermaphrodite and 2 were 46 XX male subjects. The preoperative meatal location was subglanular in 9 cases, mid shaft in 8, proximal shaft in 2, penoscrotal in 15 and perineal in 5. Those with subglanular meatus had hypoplastic distal urethras and severe chordee. A dorsal Nesbit procedure for chordee correction was done in 24 cases (62%). Neourethral length ranged from 3 to 7 cm. (average 4 cm.) and average followup was 16 months. Neourethral diverticula developed in 8 cases (21%) and they were repaired uneventfully an average of 7 months (range 2 to 24) after stage 2. Minor urethral strictures (3 distal and 4 proximal) were treated with a single visual internal urethrotomy and there was 1 (2.5%) urethrocutaneous fistula. All children had excellent cosmetic and functional outcomes. A staged approach allows for cosmetic reconstruction of the glans and mucosal collar during stage 1 and offers 2 opportunities to augment penile size with testosterone. Bladder or buccal mucosal grafts are avoided since the prepuce is always adequate. There are no hypospadias deformities, penile shaft torsion or asymmetry. Fistula formation is minimal and strictures are minor. The 2-stage repair remains a safe, reliable alternative for boys with severe hypospadias.

Transdermal dihydrotestosterone therapy and its effects on patients with microphallus

To investigate the efficacy of transdermal dihydrotestosterone therapy on 22 patients with microphallus, we applied dihydrotestosterone gel for 8 weeks to the external genitalia at daily doses of 12.5 mg. and 25 mg. for ages less than and older than 10 years, respectively. All patients were evaluated for penile and prostatic growth, pituitary-gonadal axis function, serum sex hormone binding globulin, lipid metabolism, hepatotoxicity, bone age and height velocity. All patients demonstrated growth of the penis during treatment. The mean increase rate (153%) in the first 4 weeks of treatment was higher than that (118%) of the second 4 weeks. Of importance is that responses were noted in 4 patients who had failed testosterone therapy for microphallus. The pituitary-gonadal axis was transiently suppressed during treatment, and serum sex hormone binding globulin and lipid metabolism were transiently affected during treatment. Serum alkaline phosphatase increased, mainly due to change of bone isoenzyme but bone ages and mean height velocity were not significantly affected. In conclusion, transdermal dihydrotestosterone therapy is an effective and relatively safe modality in the treatment of microphallus.

The use of parenteral testosterone therapy in genital reconstructive surgery

Previously, testosterone cream has been used for penile enlargement before genital surgery. The results not only were inconsistent but the absorption was variable. Therefore, we elected to study the use of parenteral testosterone as an adjunct before reconstructive surgery. In 44 patients with hypospadias (36), epispadias (5) or urethral fistulas (3) 2 mg. per kg. testosterone enanthate were given intramuscularly 5 and 2 weeks before reconstructive surgery. Testosterone caused a mean increase in penile length of 2.7 cm. and in circumference of 2.3 cm. as well as local vascularity in all patients. In addition to surgical results the potential side effects of testosterone treatment were monitored 3 months to 1 year postoperatively. Basal testosterone levels were obtained in patients before and during therapy, and postoperatively. In addition, side effects, such as increased bone age and excessive pubic hair, were not a problem. The use of preoperative testosterone significantly contributed to the successful reconstruction of these patients, particularly those with a paucity of penile skin and those who had undergone previous repairs. Temporary penile stimulation by testosterone enanthate allows for an earlier penile operation as well as provides negligible side effects.