Alexander Springer

Trends in Hypospadias Surgery: Results of a Worldwide Survey

BACKGROUND Hypospadias is a challenging field of urogenital reconstructive surgery, with different techniques currently being used. OBJECTIVE Evaluate international trends in hypospadias surgery. DESIGN, SETTING, AND PARTICIPANTS Paediatric urologists, paediatric surgeons, urologists, and plastic surgeons worldwide were invited to participate an anonymous online questionnaire (http://www.hypospadias-center.info). MEASUREMENTS General epidemiologic data, preferred technique in the correction of hypospadias, and preferred technique in the correction of penile curvature were gathered. RESULTS AND LIMITATIONS Three hundred seventy-seven participants from 68 countries returned completed questionnaires. In distal hypospadias (subcoronal to midshaft), the tubularised incised plate (TIP) repair is preferred by 52.9-71.0% of the participants. Meatal advancement and glanuloplasty (MAGPI) is still a preferred method in glandular hypospadias. In the repair of proximal hypospadias, the two-stage repair is preferred by 43.3-76.6%. TIP repair in proximal hypospadias is used by 0.9-16.7%. Onlay flaps and tubes are used by 11.3-29.5% of the study group. Simple plication and Nesbits procedure are the techniques of choice in curvature up to 30°; urethral division and ventral incision of the tunica albuginea with grafting is performed by about 20% of the participants in severe chordee. The frequency of hypospadias repairs does not influence the choice of technique. CONCLUSIONS In this study, we identified current international trends in the management of hypospadias. In distal hypospadias, the TIP repair is the preferred technique. In proximal hypospadias, the two-stage repair is most commonly used. A variety of techniques are used for chordee correction. This study contains data on the basis of personal experience. However, future research must focus on prospective controlled trials.

Laparoscopic appendectomy in children with Enterobius vermicularis.

As surgeons gain more experience with laparoscopy in children, it is becoming apparent that one of the best applications of the technique is for appendicitis. The advantages of laparoscopic appendectomy include a better cosmetic result, particularly in young female patients, a shorter recovery time, and an early return to normal activities. In the differential diagnosis of appendicitis, the association of Enterobius vermicularis (pinworms) inflammation in the pediatric age group is not uncommon. The endo-loop technique for laparoscopic appendectomy is the standard technique used in our department. In three patients with E. vermicularis undergoing appendix removal using this technique, pinworms were found to be set free into the abdomen after dividing the appendix between the loop ligatures. Bipolar coagulating forceps were used carefully to thermally desiccate the worms, which were then removed using a blunt grasper. E. vermicularis being released into the abdomen in children undergoing laparoscopic appendectomy using the endo-loop technique has not been reported. Careful evaluation of the appendix stump and simple but careful thermal desiccation and removal of pinworms, if present, must be considered when using the endo-loop technique.

Assessment of outcome in hypospadias surgery - a review

Hypospadias is a challenging field of urogenital reconstructive surgery with different techniques being currently used. Modern surgery claims that it is possible to create a functionally and cosmetically normal penis. Continuous re-evaluation and assessment of outcome may have a major impact on future clinical practice. Assessment of outcome includes: complication rate, cosmetic appearance of the penis, functional outcome (micturition, sexuality), and psychological factors such as quality of life and psychosexual life. This article briefly reviews current strategies of outcome assessment. Somehow in the future, we will be able to give an accurate estimation of the long-term consequences of being born with hypospadias.

Response to the Council of Europe Human Rights Commissioner's Issue Paper on Human Rights and Intersex People

Intersex/disorders of sex development advocacy groups and associated health care professionals question the legitimacy of the Council of Europe issue paper, express their worries about its potentially harmful consequences, and urge the Council of Europe to consult more widely with relevant stakeholders.

Orchidopexy patterns in Austria from 1993 to 2009

OBJECTIVE To evaluate orchidopexy patterns in Austria. MATERIAL AND METHODS All boys with cryptorchidism who underwent orchidopexy (n = 19.998) in Austria between 1993 and 2009 were analyzed using the database Austrian Health Information System at the Austrian Federal Research and Planning Institute for Health Care. Regression models were constructed to examine associations between the probability of orchidopexy before 24 months of life and the following parameters: year of birth, federal state of residence, character of area of living (rural/urban) and hospital type. RESULTS Average age at operation dropped from 6 to 4.3 years (mean 5.2 years, SD 3.8 years). Total incidence of orchidopexy was continuously rising throughout the study period (p < 0.0001), with an OR of 1.007 (95% C.I.: 1.004; 1.0100) per year. The rate of operations between 0 and 2 years (p < 0.001) and 3-7 years (p < 0.001) increased, while the rate in boys older than 7 years decreased (p < 0.001). Year of birth (p < 0.0001) and place of residence (p < 0.0001 and p < 0.024) are significant predictors for having early orchidopexy. CONCLUSION In Austria the total incidence of orchidopexy is significantly rising. Moreover, the incidence of orchidopexies performed before 24 months of life is constantly rising with significant geographic differences.

Delayed Referral Despite Appropriate Knowledge in Cryptorchidism as a Cause of Delayed Orchidopexies in Austria

AIM Guidelines recommend early orchidopexy in cryptorchidism to decrease the risk of infertility and tumor formation. We aimed to asses if a delayed initial presentation for cryptorchidism was due to unawareness of these guidelines or for any other reasons. METHODS A short questionnaire exploring timing and referral habits when assessing children with cryptorchidism was sent by email to all registered pediatricians in Austria. Comparatively, a chart review of performed orchidopexies was performed at our institution. RESULTS Of 369 registered pediatricians, 102 (27.6%) returned valid questionnaires. The average maximum age at which pediatricians in Austria suggested treatment of cryptorchidism was the 21.2 (8.4 months standard deviation (SD)) month of life. Assessment of testicular descent was reported to be regularly performed until the 8.8 (3-18 years SD) year of life. In contrast, from 1997-2008, 730 boys were treated surgically for cryptorchidism at our department. The mean age at operation was 3.4 years (3.1 years SD). CONCLUSION The majority of pediatricians in Austria know the correct timing for treatment of cryptorchidism. Nevertheless, orchidopexies are still carried out to later than suggested by international guidelines. Further studies and analysis to evaluate the reasons for these suboptimal referring patterns coupled with further communication improvements between pediatricians and surgeons are needed.

Timing of Hypospadias Repair in Patients with Disorders of Sex Development

What little data exist as to the optimal timing of hypospadias reconstruction is based on retrospective studies and expert opinion. No data exist as to the optimum timing of hypospadias reconstruction in the extremely small subset of patients with severe hypospadias that merits a disorder of sex development (DSD) diagnoses. Until such data exist, it seems prudent to continue to advocate for early and accurate diagnosis for patients with severe hypospadias to determine if they should be classified as a DSD. At that time, based on expert opinion, we would advocate early reconstructive hypospadias surgery as is presently done between 6 and 18 months of age. If and when evidence-based data refutes this early approach, new guidelines should be considered.

Online hypospadias support group data analysis

BACKGROUND Although hypospadias is the most common malformation of the penis, this condition is virtually unknown to the general population. This lack of information may lead to psychological distress to both parents and patients. In this study the content of an Internet-based hypospadias support group is analyzed. MATERIALS AND METHODS All comments and postings made by members of an online support group between 2001 and 2008 were analyzed. No personalized data were used for evaluation. RESULTS At the end of 2008, the group consisted of 535 members. In the study period, 3050 postings were published. Major issues discussed in the group were (a) medical questions, exchange of medical knowledge, experience, and history; (b) psychological, ethical, and philosophical aspects; (c) practical questions and recommendations; (d) recommendations for surgeons; and (e) hypospadias in adults. CONCLUSIONS Online hypospadias support groups play an important role in how parents and patients cope with the condition. Surgeons dealing with hypospadias should be aware of the importance of Internet-based information in the field of hypospadias. They may benefit from the valuable feedback information from patients and parents to improve their practice and outcome.

Preliminary Experience With the Use of Acellular Collagen Matrix in Redo Surgery for Urethrocutaneous Fistula

OBJECTIVE To show that splinting of the urethral repair with acellular collagen matrix is a safe and useful adjunct in the procedure to manage complex urethrocutaneous fistula. Urethrocutaneous fistula is one of the most common complications of hypospadias surgery. Management of persistent urethrocutaneous fistula is challenging because it is complicated by a lack of or poor quality of tissues at the site of repair. METHODS Between 2006 and 2011, 12 boys underwent urethrocutaneous fistula repair (10) or redo urethroplasty (2) using acellular collagen matrix by a single surgeon. Mean age was 6.8 years (range 3.1-14.8); median follow-up was 2.5 years (range 0.4-3.8). Urethrocutaneous fistula was closed and acellular collagen matrix was used as a splint. All the patients were assessed by an independent observer; all boys were successfully treated with no further recurrence of fistula. RESULTS On palpation, the previous site of the acellular collagen matrix implant was soft and subtle, revealing healthy underlying tissues. Cosmetic outcome was excellent in all patients, with no signs of scarring or tethering. All patients had a single good urinary stream. Uroflows were within normal range of age-matched standardized nomograms with nonobstructive bell-shaped curves. One boy had late wound infection, which healed with debridement, but had no recurrence of fistula. CONCLUSION Splinting of the urethral repair with acellular collagen matrix in redo surgery is safe and is a useful adjunct that effectively prevents further recurrence of complications such as urethrocutaneous fistula.

Epididymal Reflux in Posterior Urethral Valves

We report the findings of voiding cystourethrography in a boy with posterior urethral valves that showed reflux into the epididymis.