Nicol Bush

Tubularized incised plate proximal hypospadias repair: Continued evolution and extended applications

OBJECTIVE We report additional technical modifications and extended application of proximal TIP hypospadias repair in consecutive patients operated by a single surgeon. MATERIALS During a 39-month period, 36 patients underwent primary proximal hypospadias surgery, with 26 undergoing TIP and 10 two-stage repair for a thin urethral plate (UP) (1) or ventral penile curvature (VC) requiring UP transection (9). Of the TIP repairs, 16 had UP elevation from the corpora cavernosa to facilitate VC straightening while maintaining the UP for urethroplasty. All TIP patients underwent two-layer urethroplasty with tunica vaginalis coverage over the neourethra. RESULTS With mean follow up of 12 months (2-38) in 24 TIP patients, 16 had calibration and 11 urethroscopy 6-12 months postoperatively. Complications occurred in three (13%), glans dehiscence (2) and neourethral stricture (1), which represents a significant reduction versus our prior reports. Non-randomized preoperative testosterone in 8/24 with follow up did not influence complication rates. TIP incision of the elevated UP did not divide it into separate strips, or impair vascularity. CONCLUSIONS Dissection of the UP from the corpora facilitates correction of VC while preserving the plate, without increasing TIP urethroplasty complications. Overall, complication rates for TIP have significantly diminished with technical modifications and experience. The role for neoadjuvant hormonal therapy remains unclear. Despite straightening VC preserving the UP, intraoperative assessment deemed it unsuitable for TIP in one case (4%).

Hospitalizations for Pediatric Stone Disease in United States, 2002–2007

PURPOSE Although more common in adults, urolithiasis recently has been occurring with increasing frequency in children. Single institution reviews from 1950 to 1990 revealed that urolithiasis accounts for 1 in 7,600 to 1 in 1,000 pediatric hospitalizations. Stone prevalence and risk factors for hospitalization are less defined in children in North America compared to adults. To identify pediatric hospital admissions due to a diagnosis of urinary stones, we examined Pediatric Health Information System data from 41 freestanding pediatric hospitals. MATERIALS AND METHODS We retrospectively studied patients younger than 18 years hospitalized between 2002 and 2007. The Pediatric Health Information System database, a validated collection of pediatric hospital data, was searched for inpatients with a primary ICD-9 diagnosis of urolithiasis. RESULTS Among more than 2.7 million pediatric inpatients from 2002 to 2007, 3,989 hospitalizations were for 3,815 patients with urolithiasis. In contrast to adults, girls had a 1.5-fold greater likelihood of being hospitalized for stones. More than half of the children (53.1%) were younger than 13 years (mean 12.3, SD 4.23). Most patients (88%) were white. Stone hospitalizations were more common in the North Central region compared to the South. Hospitalizations for stones increased slightly in August and September. Nephrectomy was performed in nearly 1% of stone hospitalizations (29 of 3,170). CONCLUSIONS Children with stones now account for 1 in 685 pediatric hospitalizations in the United States. Surprisingly more than half of the patients are younger than 13 years at hospitalization. Similar to findings in adults, white race and occurrence in late summer months increase the risk of stone hospitalization. However, male gender and geographic location in the Southeast are not risk factors, demonstrating the unique aspects of pediatric stone hospitalization.

Algorithm for comprehensive approach to hypospadias reoperation using 3 techniques.

PURPOSE We describe comprehensive hypospadias reoperation based on presence or absence of a supple urethral plate using the 3 surgical techniques of transurethral incised plate, 1-stage inlay graft and 2-stage buccal graft. MATERIALS AND METHODS We reviewed prospective data from all reoperative hypospadias urethroplasties performed by one of us (WTS) between 2000 and 2008. Patient age, number of operations, indications for additional surgery, meatal location, reoperative surgical technique and outcomes were extracted. RESULTS A total of 133 patients underwent reoperation by transurethral incised plate (69), 1-stage inlay graft (16) or 2-stage buccal graft (48) urethroplasty. Mean number of prior failed repairs was 1.1, 1.9 and 4.3, respectively. Followup was available in 121 patients (91%), with 90 (74%) undergoing 1 successful reoperative urethroplasty. Complications occurred in 19%, 15% and 38% of patients, respectively, and most often consisted of fistulas or glans dehiscence. CONCLUSIONS Hypospadias reoperation can be accomplished using these 3 techniques without skin flaps, a potential advantage given the relative paucity of skin after failed repair. Fistulas after transurethral incised plate urethroplasty correlate with barrier layers used, while glans dehiscence is more likely in 2-stage buccal graft repairs when cheek rather than lip is used within the glans.

Analysis of risk factors for glans dehiscence after tubularized incised plate hypospadias repair

PURPOSE We determined the incidence of glans dehiscence and the associated risk factors after tubularized incised plate hypospadias repair. MATERIALS AND METHODS All data for patients undergoing tubularized incised plate hypospadias repair, surgical details and postoperative outcomes were prospectively maintained in databases. Data were analyzed with simple and multiple logistic regression to determine if patient age, preoperative testosterone use, meatal location (distal, mid shaft or proximal), glansplasty sutures (chromic catgut vs polyglactin) or primary vs revision tubularized incised plate procedure was associated with an increased risk of glans dehiscence. RESULTS Glans dehiscence occurred in 32 of 641 patients (5%). Age at surgery, preoperative testosterone use and glansplasty suture did not impact the risk of glans dehiscence. Glans dehiscence occurred in 20 of 520 distal (4%), 1 of 47 mid shaft (2%) and 11 of 74 proximal (15%) tubularized incised plate repairs, with the odds of glans dehiscence being 3.6 times higher in patients with proximal vs distal meatal location. Patients undergoing reoperative (9 of 64, 14%) vs primary tubularized incised plate (23 of 577, 4%) had a 4.7-fold increased risk of glans dehiscence. CONCLUSIONS Proximal meatal location and revision surgery, most commonly for prior glans dehiscence, increase the odds of glans dehiscence by 3.6 and 4.7-fold, respectively, suggesting anatomical and/or host factors (wound healing) are more important than age, type of suture or preoperative testosterone use in the development of this postoperative complication.

Pediatric Testicular Torsion: Demographics of National Orchiopexy Versus Orchiectomy Rates

PURPOSE While the timely diagnosis and management of pediatric torsion can lead to testicular salvage, limited data exist on rates of orchiopexy vs orchiectomy and associated factors. Thus, we examined the Pediatric Health Information System database for torsion outcomes and demographics at American pediatric hospitals. MATERIALS AND METHODS Using the Pediatric Health Information System database we performed a 7-year retrospective cohort study in children 1 to 17 years old with a primary ICD-9 diagnosis of torsion, assessing CPT codes for orchiopexy and orchiectomy. Data were analyzed with SPSS®, version 17.0. RESULTS Of 2,876 patients who underwent surgery for an ICD-9 diagnosis code of testicular torsion 918 (31.9%) underwent orchiectomy at a mean age of 10.7 years and 1,958 (68.1%) underwent orchiopexy at a mean age of 12.6 years (p <0.0001). In the age groups 1 to 9, 10 to 13 and 14 years or greater 274 (49.9%), 311 (29.4%) and 333 patients (26.2%), respectively, underwent orchiectomy. A higher orchiectomy rate was seen at age 1 to 9 vs 10 years or greater. Torsion and orchiectomy rates did not vary by season or geographic region. A higher orchiectomy rate was seen in black vs white children (37.6% vs 28.1%) and in patients without vs with private insurance (36.7% vs 27.0%). Multivariate analysis revealed an association of age (p <0.0001), race (p <0.0001) and insurance status (p <0.001) with orchiectomy. CONCLUSIONS Nationally an average of 32% of the 411 pediatric torsion cases explored annually result in orchiectomy. Identified factors increasing the orchiectomy risk included age 1 to 9 years, black race and lack of private insurance. Efforts should continue to identify modifiable variables that can increase testicular salvage in patients with testicular torsion.

Age does not impact risk for urethroplasty complications after tubularized incised plate repair of hypospadias in prepubertal boys

OBJECTIVE Patients often present before or after the recommended age of 6-18 months for hypospadias repair. Reports indicate complications may increase when repair is delayed past 6-12 months of age. We questioned if age was an independent risk for urethroplasty complications (UC). METHODS A prospectively maintained database of consecutive patients undergoing tubularized incised plate (TIP) repair was queried for age at surgery, primary or reoperative TIP, meatal location, glansplasty suture, and learning curve. The presence of UC (fistula, dehiscence, stricture, meatal stenosis) was analyzed with logistic regression. RESULTS TIP repairs were performed for 669 consecutive prepubertal patients aged 3-144 months (mean 17.1, SD 22.5). Original meatal location was distal in 540 (80.7%), midshaft in 50 (7.5%), and proximal in 79 (11.8%). Reoperative TIP occurred in 73 (10.9%). UC occurred in 77 (11.5%). Reoperative TIP (OR 3.07, 95% CI 1.54-6.13) and meatal location (OR 1.79, 95% CI 1.34-2.40) were the only independent risk factors for UC. Neither younger nor older age increased risk for UC. CONCLUSIONS Our data from consecutive TIP repairs in prepubertal children indicate age at surgery does not increase odds of UC. Surgery can be performed any time after 3 months (in full-term, healthy boys) without raising the rate of UC.

Duration of follow-up to diagnose hypospadias urethroplasty complications

OBJECTIVE We report the time when hypospadias urethroplasty complications (UC) were diagnosed postoperatively. METHODS The time UC occurred after primary distal and proximal TIP and TIP reoperations was obtained from prospectively maintained databases in consecutive patients. UC included fistulas, glans dehiscences, meatal stenoses, neourethral strictures and diverticula. RESULTS Of 125 UC, 64% were diagnosed at the first postoperative visit and 81% were encountered within the first year after repair. Median time for diagnosis was 6 months (1.5-95) for fistulas, meatal stenoses/urethra strictures, and diverticulum, versus 2 months (1 week-24 months) for glans dehiscence. CONCLUSIONS The majority of UC are diagnosed at the first postoperative visit or within the first year following TIP hypospadias repair. Glans dehiscences are most often apparent by 2 months, whereas most fistulas and other UC are found by 6 months. After 1 year, 14 boys without UC have to be followed indefinitely to diagnose each additional complication.

Current Referral Patterns and Means to Improve Accuracy in Diagnosis of Undescended Testis

OBJECTIVES: The goals were to determine current referral patterns for boys suspected of having undescended testis (UDT) and to identify factors to assist primary care providers in distinguishing retractile testes from UDTs on the basis of history, physical examination, or imaging findings. METHODS: By using a standardized history assessment, visual inspection of the scrotum for symmetry, physical examination, and review of previously obtained imaging findings, we performed a prospective observational study with consecutive patients referred to a pediatric urologist for evaluation of UDT. RESULTS: Of 118 boys, 51 (43%) had descended testes, 60 (51%) had UDTs, and 7 (6%) had initially indeterminate findings. Boys with UDT were referred at a median age of 43.3 months. Patients referred at <1 year or >10 years of age were significantly more likely to have UDT than were those referred at 1 to 10 years of age. History of UDT at birth, prematurity, and scrotal asymmetry strongly increased the risk of UDT. Genital ultrasonography had been performed for 25% of patients, incorrectly indicating UDT for 48%. CONCLUSIONS: Most boys were referred well beyond the recommended age of <12 months for orchiopexy. Only one-half of the patients had UDT, with most errors in diagnosis being made for boys 1 to 10 years of age, which suggests difficulty distinguishing UDT from retractile testis. Positive birth history findings, prematurity, and scrotal asymmetry predicted UDT and can be used by primary care physicians in their assessment before referral. Genital ultrasonography did not distinguish UDTs from retractile testes.

Objective use of testosterone reveals androgen insensitivity in patients with proximal hypospadias.

OBJECTIVE We report preoperative testosterone stimulation based on glans width measurements in patients with midshaft and proximal hypospadias, revealing androgen resistance in those with proximal hypospadias. METHODS Patients had maximum glans width measured preoperatively. Those <14 mm initially received 2 mg/kg testosterone cypionate intramuscularly for two to three doses, with the aim of increasing glans width ≥ 15 mm. Not all patients achieved targeted growth, and some were subsequently treated with escalating doses of testosterone. RESULTS 5/15 midshaft patients had two to three doses of 2 mg/kg testosterone, with all increasing glans width to ≥ 15 mm. 29/47 proximal patients had testosterone, with 13 (57%) not reaching desired glans width. Six of these and another six patients had escalating doses from 4 to 32 mg/kg testosterone, with 11 then achieving targeted glans width. Relative androgen resistance was found in 19/29 (66%) proximal cases, including all treated patients with perineal hypospadias. CONCLUSIONS 39/62 (63%) patients met objective criteria for preoperative testosterone stimulation based on glans width <14 mm, which is less than the average normal newborn glans diameter. Evidence of relative androgen resistance was found in 19 (49%), all with proximal hypospadias.

Comparing outcomes of slings with versus without enterocystoplasty for neurogenic urinary incontinence.

PURPOSE We compared 2 cohorts of children with neurogenic urinary incontinence undergoing bladder neck sling with and without augmentation to determine relative continence outcomes, catheterization intervals, anticholinergic requirements and health related quality of life improvement as perceived by the patients and their parents. MATERIALS AND METHODS Consecutive patients followed through our spina bifida program underwent a structured postoperative interview by a research nurse to assess continence, interval between catheterizations and anticholinergic use. In addition, the child and parent together answered a health related quality of life satisfaction survey to determine the impact of surgery from their perspectives. RESULTS There were 18 patients undergoing sling with augmentation and 23 with sling alone. Overall improved continence rate was 83%, with no difference between outcomes in patients with vs without augmentation. However, the interval between catheterizations was longer and the use of anticholinergics was less following augmentation. Nevertheless, health related quality of life responses differed significantly in only 1 area, independent care, with both cohorts reporting similarly improved overall health, and increased ability to participate in social and leisure activities. CONCLUSIONS We directly compared results in patients undergoing slings with and without augmentation. Both procedures were similarly successful in achieving improved continence, with patients undergoing augmentation having a longer interval between catheterization and requiring fewer anticholinergics. However, health related quality of life responses revealed that both cohorts were similarly satisfied with the outcomes.