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Bernabé KJ, Nokoff NJ, Galan D, Felsen D, Aston CE, Austin P, Baskin L, Chan YM, Cheng EY, Diamond DA, Ellens R, Fried A, Greenfield S, Kolon T, Kropp B, Lakshmanan Y, Meyer S, Meyer T, Delozier AM, Mullins LL, Palmer B, Paradis A, Reddy P, Reyes KJS, Schulte M, Swartz JM, Yerkes E, Wolfe-Christensen C, Wisniewski AB, Poppas DP. Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia. J Pediatr Urol 2018; 14:157.e1-157.e8. [PMID: 29398588 PMCID: PMC5970022 DOI: 10.1016/j.jpurol.2017.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/23/2017] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- K J Bernabé
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - N J Nokoff
- Children's Hospital Colorado, Aurora, CO, USA
| | - D Galan
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - D Felsen
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - C E Aston
- University of Oklahoma Health Sciences Center, Department of Pediatrics, Oklahoma City, OK, USA
| | - P Austin
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - L Baskin
- University of California San Francisco, San Francisco, CA, USA
| | - Y-M Chan
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - E Y Cheng
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - D A Diamond
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - R Ellens
- Children's Hospital of Michigan, Detroit, MI, USA
| | - A Fried
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - S Greenfield
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - T Kolon
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B Kropp
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - Y Lakshmanan
- Children's Hospital of Michigan, Detroit, MI, USA
| | - S Meyer
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - T Meyer
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - A M Delozier
- Oklahoma State University, College of Arts and Sciences, Stillwater, OK, USA
| | - L L Mullins
- Oklahoma State University, College of Arts and Sciences, Stillwater, OK, USA
| | - B Palmer
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - A Paradis
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - P Reddy
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K J Scott Reyes
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - M Schulte
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J M Swartz
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - E Yerkes
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - C Wolfe-Christensen
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA; Children's Hospital of Michigan, Detroit, MI, USA
| | - A B Wisniewski
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - D P Poppas
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
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Nokoff NJ, Palmer B, Mullins AJ, Aston CE, Austin P, Baskin L, Bernabé K, Chan YM, Cheng EY, Diamond DA, Fried A, Frimberger D, Galan D, Gonzalez L, Greenfield S, Kolon T, Kropp B, Lakshmanan Y, Meyer S, Meyer T, Mullins LL, Paradis A, Poppas D, Reddy P, Schulte M, Reyes KJS, Swartz JM, Wolfe-Christensen C, Yerkes E, Wisniewski AB. Prospective assessment of cosmesis before and after genital surgery. J Pediatr Urol 2017; 13:28.e1-28.e6. [PMID: 27887913 PMCID: PMC5894813 DOI: 10.1016/j.jpurol.2016.08.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/31/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Little data exist about the surgical interventions taking place for children with disorders of sex development (DSD). Most studies that have evaluated cosmetic outcomes after genitoplasty have included retrospective ratings by a physician at a single center. OBJECTIVE The present study aimed to: 1) describe frequency of sex assignment, and types of surgery performed in a cohort of patients with moderate-to-severe genital ambiguity; and 2) prospectively determine cosmesis ratings by parents and surgeons before and after genital surgery. STUDY DESIGN This prospective, observational study included children aged <2 years of age, with no prior genitoplasty at the time of enrollment, moderate-to-severe genital atypia, and being treated at one of 11 children's hospitals in the United States of America (USA). Clinical information was collected, including type of surgery performed. Parents and the local pediatric urologist rated the cosmetic appearance of the child's genitalia prior to and 6 months after genitoplasty. RESULTS Of the 37 children meeting eligibility criteria, 20 (54%) had a 46,XX karyotype, 15 (40%) had a 46,XY karyotype, and two (5%) had sex chromosome mosaicism. The most common diagnosis overall was congenital adrenal hyperplasia (54%). Thirty-five children had surgery; 21 received feminizing genitoplasty, and 14 had masculinizing genitoplasty. Two families decided against surgery. At baseline, 22 mothers (63%), 14 fathers (48%), and 35 surgeons (100%) stated that they were dissatisfied or very dissatisfied with the appearance of the child's genitalia. Surgeons rated the appearance of the genitalia significantly worse than mothers (P < 0.001) and fathers (P ≤ 0.001) at baseline. At the 6-month postoperative visit, cosmesis ratings improved significantly for all groups (P < 0.001 for all groups). Thirty-two mothers (94%), 26 fathers (92%), and 31 surgeons (88%) reported either a good outcome, or they were satisfied (see Summary Figure); there were no significant between-group differences in ratings. DISCUSSION This multicenter, observational study showed surgical interventions being performed at DSD centers in the USA. While parent and surgeon ratings were discordant pre-operatively, they were generally concordant postoperatively. Satisfaction with postoperative cosmesis does not necessarily equate with satisfaction with the functional outcome later in life. CONCLUSION In this cohort of children with genital atypia, the majority had surgery. Parents and surgeons all rated the appearance of the genitalia unfavorably before surgery, with surgeons giving worse ratings than parents. Cosmesis ratings improved significantly after surgery, with no between-group differences.
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Affiliation(s)
- N J Nokoff
- Department of Pediatrics, Section of Pediatric Endocrinology, University of Colorado Denver School of Medicine, 13123 East 16th Ave Box B265, Aurora 80045, CO, USA.
| | - B Palmer
- Department of Urology, The University of Oklahoma College of Medicine, 920 Stanton L Young Blvd, WP 3150, Oklahoma City 72104, OK, USA
| | - A J Mullins
- Department of Psychology, Oklahoma State University, 116 North Murray, Stillwater 74078, OK, USA
| | - C E Aston
- Department of Pediatrics, The University of Oklahoma College of Medicine, 920 Stanton L Young Blvd, WP 3150, Oklahoma City 72104, OK, USA
| | - P Austin
- Department of Surgery, Division of Urology, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8242, St. Louis 63110, MO, USA
| | - L Baskin
- Department of Urology, University of California San Francisco, 400 Parnassus Ave, San Francisco 94143, CA, USA
| | - K Bernabé
- Department of Urology, Weill Cornell Medicine, 525 East 68th St., Box 94, New York 10065, NY, USA
| | - Y-M Chan
- Department of Pediatrics, Division of Endocrinology, Harvard Medical School, 300 Longwood Ave, Boston 02115, MA, USA
| | - E Y Cheng
- Department of Urology, Northwestern University, Feinberg School of Medicine, 225 E Chicago Ave, Box 24, Chicago 60611, IL, USA
| | - D A Diamond
- Department of Urology, Harvard Medical School, 300 Longwood Ave, Boston 02115, MA, USA
| | - A Fried
- Department of Pediatric Urology, Women and Children's Hospital of Buffalo, Buffalo 14222, NY, USA
| | - D Frimberger
- Department of Urology, The University of Oklahoma College of Medicine, 920 Stanton L Young Blvd, WP 3150, Oklahoma City 72104, OK, USA
| | - D Galan
- Department of Urology, Weill Cornell Medicine, 525 East 68th St., Box 94, New York 10065, NY, USA
| | - L Gonzalez
- Pediatric Nephrology and Urology, University of California San Francisco, 400 Parnassus Ave, San Francisco 94143, CA, USA
| | - S Greenfield
- Department of Pediatric Urology, Women and Children's Hospital of Buffalo, Buffalo 14222, NY, USA
| | - T Kolon
- Department of Urology, Perelman School of Medicine, University of Pennsylvania, 34th Street & Civic Center Blvd., Philadelphia 19104, PA, USA
| | - B Kropp
- Department of Urology, The University of Oklahoma College of Medicine, 920 Stanton L Young Blvd, WP 3150, Oklahoma City 72104, OK, USA
| | - Y Lakshmanan
- Department of Urology, Wayne State University School of Medicine, 3901 Beaubien, Detroit 48201, MI, USA
| | - S Meyer
- Department of Pediatric Urology, Women and Children's Hospital of Buffalo, Buffalo 14222, NY, USA
| | - T Meyer
- Department of Urology, Northwestern University, Feinberg School of Medicine, 225 E Chicago Ave, Box 24, Chicago 60611, IL, USA
| | - L L Mullins
- Department of Psychology, Oklahoma State University, 116 North Murray, Stillwater 74078, OK, USA
| | - A Paradis
- Department of Surgery, Division of Urology, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8242, St. Louis 63110, MO, USA
| | - D Poppas
- Department of Urology, Weill Cornell Medicine, 525 East 68th St., Box 94, New York 10065, NY, USA
| | - P Reddy
- Department of Pediatrics, Division of Pediatric Urology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, MLC 5037, 3333 Burnet Ave, Cincinnati, OH, USA
| | - M Schulte
- Department of Pediatrics, Division of Pediatric Urology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, MLC 5037, 3333 Burnet Ave, Cincinnati, OH, USA
| | - K J Scott Reyes
- Department of Urology, The University of Oklahoma College of Medicine, 920 Stanton L Young Blvd, WP 3150, Oklahoma City 72104, OK, USA
| | - J M Swartz
- Department of Pediatrics, Division of Endocrinology, Harvard Medical School, 300 Longwood Ave, Boston 02115, MA, USA
| | - C Wolfe-Christensen
- Department of Pediatrics, The University of Oklahoma College of Medicine, 920 Stanton L Young Blvd, WP 3150, Oklahoma City 72104, OK, USA; Department of Urology, Wayne State University School of Medicine, 3901 Beaubien, Detroit 48201, MI, USA
| | - E Yerkes
- Department of Urology, Northwestern University, Feinberg School of Medicine, 225 E Chicago Ave, Box 24, Chicago 60611, IL, USA
| | - A B Wisniewski
- Department of Urology, The University of Oklahoma College of Medicine, 920 Stanton L Young Blvd, WP 3150, Oklahoma City 72104, OK, USA; Department of Pediatrics, The University of Oklahoma College of Medicine, 920 Stanton L Young Blvd, WP 3150, Oklahoma City 72104, OK, USA
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