Questions in Hypospadias Treatment: Background Material

About the Event      Moderators     Background Material      Future Webinar Topics 

Preoperative Testosterone    Hypospadias Phenotype    Patient Cases    Attend the Event

Questions in Hypospadias Treatment focuses on questions regarding the use of preoperative testosterone and better ways to characterize the hypospadias phenotype. The format will be presentations on these topics followed by discussions of challenging patient cases relevant to the questions raised in the presentations. The moderators suggest the following videos, slides, and journal articles on recent discussions regarding these two questions. After revieiwng these materials, attend the webinar on March 15, 2017.

Who Should Receive Preoperative Testosterone (and When)?

Who and When To Receive Preoperative Testosterone?

Presented by Laurence S. Baskin, M.D., Fourth Quinquennial John W. Duckett Festschrift (Slides).

While its use appears safe, proper sudies have not been done to determine if preoperative androgen stimulation is effective in improving hypospadias surgical outcomes. Professional opinion is to use testosterone/HCG in the diagnostic work up of severe/varsity hypospadias.

What Is Hypospadias?

Laurence Baskin, M.D., Clin Pediatr (Phila). 2017 Jan 1:9922816684613. doi: 10.1177/0009922816684613. [Epub ahead of print]

Hypospadias is the second most common genital anomaly after undescended testes occurring in approximately 1 in 250 newborn males. Hypospadias can be defined as a combination of any or all of the following 3 associated anomalies: (1) ectopic urethral meatus, (2) penile curvature (chordee), and (3) ventral foreskin deficiency. The diagnosis of hypospadias is based on clinical examination. Prenatal diagnosis is possible with the majority of patients being diagnosed on well-baby examination after birth. Severe hypospadias can masquerade as atypical genitalia necessitating a workup for a disorder of sex development.
There remains confusion in diagnosing hypospadias and determining what is clinically significant hypospadias that requires either pediatric urologic referral and/or future surgical reconstruction? Suffice it to say, not all hypospadias needs medical attention and/or repair. The goal of this review is to accurately define the different types of hypospadias and delineate strategies for referral, diagnostic workup, and surgical reconstruction.

Hormone therapy in hypospadias surgery: a systematic review

Netto JM, Ferrarez CE, Schindler Leal AA, Tucci S Jr, Gomes CA, Barroso U Jr. J Pediatr Urol. 2013 Dec;9(6 Pt B):971-9. doi: 10.1016/j.jpurol.2013.03.009. Epub 2013 Apr 19.

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.

Chromosome abnormalities in hypospadias? An analysis of 131 patients

Yabumoto H1, Fichtner J, Shima H, Ikoma F, Sakamoto H, Furuyama J. Urologe A. 1992 Jul;31(4):227-30. [Article in German]

Chromosome studies were performed in 131 patients presenting with hypospadias, with the aim of detecting any causal connections between chromosomal abnormalities and the induction of hypospadias. Autosomal abnormalities were revealed in 6 and sex chromosomal abnormalities in 10 patients. Although a significant causal relationship between the occurrence of hypospadias and chromosomal abnormalities was seen in this study in only two cases of mixed gonadal dysgenesis (45,X/46,XY and streak gonad), the high incidence of chromosomal abnormalities observed (12.2%) seems noteworthy compared with the incidence of only 0.61% in the normal male population.

Effect of preoperative hormonal stimulation on postoperative complication rates after proximal hypospadias repair: a systematic review.

Wright I, Cole E, Farrokhyar F, Pemberton J, Lorenzo AJ, Braga LH., J Urol. 2013 Aug;190(2):652-59. doi: 10.1016/j.juro.2013.02.3234. Epub 2013 Apr 15.

A systematic review and meta-analysis were conducted to summarize the effect of preoperative hormonal stimulation on complication rates following proximal hypospadias repair. The search yielded 288 citations, of which 11 (622 patients) met inclusion criteria and were incorporated into the systematic review. Most series were retrospective observational studies of moderate or low methodological quality. Of the patients 45% underwent administration of preoperative hormonal stimulation, with intramuscular testosterone being the most commonly prescribed formulation. Four studies addressed postoperative complication rate stratified by preoperative hormonal stimulation use and were included in a meta-analysis. The odds ratio for a complication occurring with preoperative hormonal stimulation use was 1.67 (CI 0.96-2.91, p = 0.07, I(2) = 0%). No persistent side effects due to preoperative hormonal stimulation were reported.

This is the only systematic review and meta-analysis thus far that has critically assessed the effect of preoperative hormonal stimulation on operative outcomes after hypospadias repair. The published literature is of low quality and lacks standardized reporting of important patient and surgical details. The effect of preoperative hormonal stimulation on operative outcomes after hypospadias repair remains unclear and requires further investigation.

Hypospadias, all there is to know

van der Horst HJ, de Wall LL. Eur J Pediatr. 2017 Feb 11. doi: 10.1007/s00431-017-2864-5. [Epub ahead of print]

Hypospadias is one of the most common congenital anomalies in men. The condition is typically characterized by proximal displacement of the urethral opening, penile curvature, and a ventrally deficient hooded foreskin. In about 70%, the urethral meatus is located distally on the penile shaft; this is considered a mild form that is not associated with other urogenital deformities. The remaining 30% are proximal and often more complex. In these cases, endocrinological evaluation is advised to exclude disorders of sexual differentiation, especially in case of concomitant unilateral or bilateral undescended testis. Although the etiology of hypospadias is largely unknown, many hypotheses exist about genetic predisposition and hormonal influences. The goal of hypospadias repair is to achieve cosmetic and functional normality, and currently, surgery is recommended between 6 and 18 months of age. Hypospadias can be corrected at any age with comparable complication risk, functional, and cosmetic outcome; however, the optimal age of repair remains conclusive. Although long-term overall outcome concerning cosmetic appearance and sexual function is fairly good, after correction, men may more often be inhibited in seeking sexual contact. Moreover, lower urinary tract symptoms occur twice as often in patients undergoing hypospadias repair and can still occur many years after the initial repair.

This study explores the most recent insights into the management of hypospadias.

What is known:

  • Guidelines advise referral for treatment between 6 and 18 months of age.
  • Cosmetic outcome is considered satisfactory in over 70% of all patients.

What is new:

  • Long-term complications include urinary tract symptoms and sexual and cosmetic issues.
  • New developments allow a more individualized approach, hopefully leading to less complications and more patient satisfaction.

How We Can Better Characterize the Hypospadias Phenotype?

How Best To Characterize Hypospadias Phenotypes?

Presented by James M. Elmore, M.D., Fourth Quinquennial John W. Duckett Festschrift (Slides)

There is still no widely accepted, standardized method for evaluating or describing hypospadias phenotypes or a criteria for what constitutes "severe" hypospadias. An ideal system would assess an entire complex, be numeric, be simple and fast, and be reproducible and objective. A G(lans), M(eatus), S(haft) scoring criteria is proposed as providing a reproducible, simple numeric system that correlates with outcomes.

Case Presentations in Hypospadias Treatment


Author Tags: