MASCULINIZING GENITOPLASTY IN INTERSEX PATIENTS

Surgical management of hypospadias in cases with concomitant disorders of sex development

INTRODUCTION

To review the surgical treatment of hypospadias (HP) associated with disorders of sex development (DSD).

PATIENTS AND METHODS

HP cases were assessed for DSD by gross examination for atypical external genitalia, and assessment of hormone levels and karyotype. There were 58 HP cases with concomitant DSD treated between 1999 and 2017. DSD classification, type of HP, sex assignment, hormonal abnormality, surgical strategy, and post-urethroplasty complications (post-UPC) were reviewed.

RESULTS

DSD were sex chromosome abnormalities (n = 4), 46,XY (n = 51), 46,XX (n = 1), and 47,XY + 21 (n = 2). HP was perineal: (n = 26), scrotal: (n = 16), penoscrotal: (n = 15), and midshaft: (n = 1); repair was primary (n = 6) or staged (n = 52). Mean age at final urethroplasty (UP) was 4.12 ± 0.21 years; all cases had soft tissue interposition at UP. At mean follow-up 5.16 ± 0.56 years after final UP, observed post-UPC (n = 8; 13.8%) were urethral stenosis (n = 3), urethral diverticulum (n = 2), urethrocutaneous fistula (n = 2), and curvature (n = 1). Mean onset of post-UPC was 1.24 ± 0.77 years (range 0.1-6.3). The second half of our cases (n = 29; treated 2015 ~) had significantly less post-UPC (0/29; 0%) than the first half (8/29; 27.6%) (p = 0.0075).

CONCLUSIONS

Although UP for HP + DSD was formidably challenging, we achieved a significant decrease in post-UPC through a combination of surgical techniques and experience.

Parents need to protect: influences, risks and tensions for parents of prepubertal children born with ambiguous genitalia

AIM AND OBJECTIVES

The aim of the study was to explore parents' experiences of and the influences, risks and tensions associated with their child's genital ambiguity and the place reconstructive surgeries had in their lives.

BACKGROUND

Research into the clinical management of disorders of sex development is a complex and growing field of study. A small number of studies have indicated that the decisions parents make with regard to their child's care during infancy are confounded by moral, social and emotional factors which can influence their choices.

DESIGN

Narrative methods.

METHODS

In-depth interviews elicited stories from 10 mothers and five fathers of 11 prepubertal children.

RESULTS

A key theme from the data focused on the parents' motivations to protect their child from the real or perceived threats arising from other people's attitudes and responses to their ambiguous genitalia. Several rationales for their protective behaviours were described, which encouraged the parents to actively manage their child's care.

CONCLUSION

The dilemmas that parents face in the complex and challenging situation following the birth of a child with ambiguous genitalia require early support from insightful professionals such as nurses. This support could better prepare the parents to recognise and discuss their protective behaviours and the impact these may have on their child's future.

RELEVANCE TO CLINICAL PRACTICE

These findings draw attention to the parents' need for nurses to be knowledgeable about the impact that disorders of sex development can have on family's emotional, psychosocial well-being and decision-making. Nurses' awareness of the debate surrounding genital surgeries is important if they are to understand the motivations that underpin parents' decision-making and how to support them sensitively. Nurses are the health professionals who have the most consistent direct contact with these families throughout the child's life and, therefore, can provide support in the ongoing decision-making process.

The influence of perioperative factors on primary severe hypospadias repair

Hypospadias is one of the most common congenital malformations of the male genitalia. Severe cases present with associated curvature greater than 30° and the meatus opening proximally to the penoscrotal junction. The perioperative management of patients with primary severe hypospadias is variable. Systematic evaluation of the upper urinary tract and the search for enlarged prostatic utricles seem unnecessary in patients with isolated primary severe hypospadias, and should be limited to severe cases with associated extraurinary malformations. Detection of a disorder of sex development is key for gender assignment and prognosis, but the identification of cases warranting a full work-up and the influence of such a diagnosis on the success of hypospadias repair is controversial. Preoperative hormonal stimulation allows for penile growth irrespective of the administration route. Associated morbidity is minimal, but its influence on the success of surgery is still unknown. An age of 6-18 months is generally recommended for surgery, but no trial data support this policy. Second-layer coverage of the urethroplasty and postoperative urinary drainage seem to reduce the complications of surgery, whereas postoperative antibiotic prophylaxis and type of dressing have minimal impact on surgical success. Overall, most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined. Clinicians should be made aware of the evidence supporting any single intervention in order to standardize their management policies. We hope the issues outlined here will prompt researchers to design new studies to address the clinically relevant questions.

Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team

The Gender Medicine Team (GMT), comprised of members with expertise in endocrinology, ethics, genetics, gynecology, pediatric surgery, psychology, and urology, at Texas Children's Hospital and Baylor College of Medicine formed a task force to formulate a consensus statement on practice guidelines for managing disorders of sexual differentiation (DSD) and for making sex assignments. The GMT task force reviewed published evidence and incorporated findings from clinical experience. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence presented in the literature for establishing evidence-based guidelines. The task force presents a consensus statement regarding specific diagnostic and therapeutic issues in the management of individuals who present with DSD. The consensus statement includes recommendations for (1) laboratory workup, (2) acute management, (3) sex assignment in an ethical framework that includes education and involvement of the parents, and (4) surgical management.

Male genitoplasty for intersex disorders

Aim. To evaluate surgical procedures adopted for male genitoplasty in intersex disorders. Patients and Methods. Case records of intersex patients undergoing male genitoplasty from Pediatric Intersex clinic were studied. Results. Of 356 intersex cases undergoing urethroplasty from 1989–2007, the hypospadias was penoscrotal (68%), scrotal (17%) and perineal (15%). 351 patients underwent chordee correction for mild: moderate: severe chordee in 24 : 136 : 191 cases. Byars flaps were fixed upto the corona in 267 cases. Urethroplasty performed was Theirsch duplay in 335 cases, Snodgrass in 16 cases and Ducketts onlay graft in 5 cases that did not require chordee correction. Age at urethroplasty was 2.5 years—22 years (mean 11.5 years, median—5.6 years). Penoscrotal transposition correction and testicular prosthesis insertion were performed independently. Complications included fistula (45), recurrent fistula (11), stricture (12), baggy urethra (8) and recurrent infection due to persistent vaginal pouch (5). Additional distal urethroplasty was required in 15 patients for previous urethroplasty done upto the corona 5–15 years earlier. Conclusion. Hypospadias in intersex disorders is associated with severe chordee in most cases and requires an early chordee correction to allow phallic growth, staged urethroplasty and multiple surgeries to achieve good cosmetic and functional results.

Detubularized pedicled vaginal onlay flap urethroplasty: a new method for hypospadias repair of ambiguous genitalia

PURPOSE

We introduce the detubularized pedicled vaginal onlay flap urethroplasty for single stage repair in ambiguous genitalia with perineoscrotal hypospadias and accompanying vagina, and report its preliminary surgical outcome.

MATERIALS AND METHODS

A total of 10 children with severe perineoscrotal hypospadias and genital ambiguity presenting with vagina and urogenital opening underwent single stage reconstruction with vaginal onlay urethroplasty. Through the posterior sagittal or abdominoperineal approach the vagina was released and pulled out, with care taken to preserve its vascular pedicle. Two incisions were made along the lateral margins of the vagina, reaching each other on the upper surface of the vaginal base, converting the vagina into a longitudinal flap twice as long as its original length. The vagina was then trimmed and reconfigured into a suitable sized flap to cover the urethral plate and form a neourethra with the onlay technique. The onlay-tube-onlay technique was also used in 2 patients with insufficient urethral plate. In 5 cases severe ventral chordee was also corrected concurrently with free vaginal graft to the ventral corpus cavernosum without further dorsal plication.

RESULTS

The first 3 operations using the posterior sagittal approach failed due to improper surgical access, and the vagina was discarded. However, we achieved a satisfactory outcome with no failure after switching to an abdominoperineal approach. Immediate postoperative and short-term results revealed no urethrocutaneous fistula, urethral breakdown or necrosis at the distal end of the neourethra. Only 1 patient presented with severe mid shaft ring stricture, which required surgical revision.

CONCLUSIONS

Incorporating the vagina of intersex patients into urethroplasty using detubularized pedicled vaginal onlay flap seems to provide a safe and practical method to treat severe hypospadias with genital ambiguity. Short-term satisfactory results are achievable by choosing the proper surgical approach and preserving the vaginal blood supply. However, longer followup in a large series of patients is needed before applying this method to clinical practice.

Ambiguous genitalia: an overview of 17 years' experience

AIM

The newborn with abnormal genital development presents a difficult diagnostic and treatment challenge for the pediatric surgeon providing care. The purpose of this study was to evaluate the results of surgical treatment for children with ambiguous genitalia.

PATIENTS AND METHODS

The records of 85 children managed surgically for ambiguous genitalia in our unit from 1988 to 2005 were reviewed retrospectively. Age at surgery, operative procedures, sex of rearing, and outcome were recorded.

RESULTS

The intersex committee's decision concerning sex assignment was female for 62 children (75%) and male for 23 children (25%). The etiologies of children reared as female were congenital adrenal hyperplasia (n = 37), male pseudohermaphroditism (n = 12), mixed gonadal dysgenesis (n = 6), true hermaphroditism (n = 4), and Mayer-Rokitansky syndrome (n = 3). Fifteen children with male pseudohermaphroditism, 5 children with congenital adrenal hyperplasia, and 3 children with true hermaphroditism were reared as male. The mean age at surgery was 4.4 years and follow-up period averaged 7 years. Eighteen (29%) patients with feminization procedures and 8 (34%) of 23 patients with masculinization procedures experienced complications and required redo operations. Vaginal stenosis was the most common complication.

CONCLUSION

The surgical management of ambiguous genitalia has always been difficult, and it must be performed by skilled pediatric surgeon. Genital surgery in infancy needs to be reassessed in the light of literature findings revealing poor outcome. In patients who underwent feminizing genitoplasty, vaginal reconstruction should be delayed until adolescence to achieve better cosmetic and functional results.