Primary proximal hypospadias repair in in toilet-trained males is associated with a higher risk of post-operative complications and parental dissatisfaction

Introduction & Objectives: Hypospadias is the most common congenital malformation of the penis. There has been a lot of recent controversy in certain countries as to whether operating on distal hypospadias is warranted, and when this should occur. Proximal hypospadias, however, is much less common, with a putative aetiology within the male programming window of the first trimester. It has an association with differences of sexual development (DSD) when diagnosed alongside cryptorchidism and the operative approach is technically more challenging. The European Association of Urology (EAU) recommends initial repair between 6-18 months of age. Material(s) and Method(s): We prospectively gathered data from 24 consecutive toilet-trained children (3-7 years) who were initially listed for proximal hypospadias repair, but who were delayed as a result of resource limitations and the ongoing supply chain effects of COVID-19. The patients were operated between July 2020 and July 2022 with a mean follow-up of 7 months (3-24months). These were compared with a cohort of 16 patients who underwent proximal hypospadias repair between 12-18 months of age in the same institution. Both single and staged procedures were included. Institutional review board approval was obtained. Patients who had previously been operated on as an infant, or who were diagnosed with a DSD, or had an associated diagnosed neuropsychiatric developmental disorder were excluded. Pre-, peri- and post-operative data were statistically compared. Result(s): Overall, 40 children underwent a total of 75 primary procedures for their proximal hypospadias (7x single stage;31 x 2-stage;2 x 3-stage). All patients had an indwelling catheter placed post-operatively, were on antibiotic prophylaxis and oxybutynin for bladder spasms. Morphine was not used post-operatively in any case. Apart from age, there were no significant demographic or racial differences between these groups. The toilettrained cohort was associated with a higher rate of urethrocutaneous fistulas (58% vs. 31%;p=0.11), catheter/stent trauma (79% vs. 6%;p<0.001), pain (54% vs. 12%;p<0.01), constipation (75% vs. 37%;p=0.02). Both Likert Scales (4 vs. 8) and parental net promoter scores (-25 vs. +68.75) were worse for the toilet trained cohort compared to the infant cohort. There were no differences in glans dehiscence, or residual chordee between both groups. Conclusion(s): Primary proximal hypospadias repair is associated with a higher degree of perioperative complications in toilet-trained kids and lower levels of parental satisfaction. These cases are not deemed to be suitable to be managed conservatively and should be offered treatment within the 6-18 months window adjusted for gestational age as endorsed by the EAU.Copyright © 2023.

Cloud-Based Architecture for Early Detection and Postoperative Monitoring of Hypospadias Patients in Indonesia

Covid-19 Epidemic has significantly changed how hypospadias patients are delivered to healthcare services, particularly after hypospadias repairs (postoperative care). Some studies reported that using telemedicine schemes by sending digital documentation such as images and videos through cell phones can facilitate an assessment of postoperative monitoring of hypospadias patients. However, this approach raises various concerns, such as managing digital documentation of hypospadias patients, analyzing the data, and the security of individuals' health information. This study proposes a design of cloud-based architecture for early detection and postoperative monitoring of hypospadias patients to address the concerns above. The user acceptance test shows that most users agree that this application may be used for early detection, monitoring hypospadias patients, and helping capture videos and provide labeling to patients' data. © 2022 IEEE.

Telemedicine for follow up of paediatric urology patients during COVID 19 pandemic: Professional and patient satisfaction, a questionnaires based cross sectional study in a tertiary care hospital in South India

Introduction and Objective: Telemedicine is an established modality to deliver health care to patients remotely. Its role in pediatric urology followup among middle-class semi-urban families is unknown. We conducted a prospective observational questionnaire-based study to assess the patient and provider(urologist) satisfaction and feasibility of teleconsultation across different socioeconomic strata in follow-up of paediatric urology patients during the COVID 19 pandemic. Method(s): The guardians of children treated earlier and due for follow-up were explained and the appointment for teleconsultation was fixed using a video conferencing app. After consultation, consenting caregivers were explained about study and the provider survey was filled by consulting urologist, while the patient questionnaire was filled by principal investigator telephonically. Result(s): A total of 77 virtual visits were completed over 10 months. Median age was 8 years(IQR= 4 to 12) and 82% were boys. The clinical conditions were posterior urethral valves(22%), hypospadias(18%), PUJ obstruction(18%), vesicoureteric reflux(12%) and others(30%). Clinicians found that virtual visits were effective(78%) in deliverance of the care equivalent to the inpatient visit. Patients were equally satisfied(75%). Technical difficulties due to internet connectivity were faced in 24 visits(31%). Video clarity and inability to examine were additional limitations faced(23%). Majority(90%) belonged to the middle socioeconomic strata as per modified Kuppuswamy scale. Families were estimated to have saved a mean of 26,934 rupees(SD +- 7998.06) and a median of 7 days(Range 1-15) of travel time. Conclusion(s): Telemedicine has potential for successful follow-up with cost and time savings. With improving internet connectivity, its potential is likely to increase in future.

First launch of 3D-printed high-fidelity hypospadias models, for hands-on training of standard hypospadias repairs

Introduction: Simulated training in Pediatric Surgery/Urology is gaining significance due to the following reasons: (a) being a specialty of rare diseases affects individual surgeon's exposure to index cases;(b) subspecialty areas are not universally accessible;and (c) Covid-19 affected elective surgery. Consequently, targeted training, via workshops and simulated models, is necessary. Hypospadias is the index case/operation in Pediatric Urology, requiring a spectrum of dissection and reconstruction skills. It is further challenging to revisit and redo, thus sound initial repair is crucial. To date, there has been no successfully utilizable 3D-printed hypospadias model. We hereby present our experience with silicone 3D-printed high-fidelity hypospadias models. Method(s): Overall, 27 trainees from different countries, under the supervision of 15 instructors, completed the training exercise. They were all given a seminar to show the relevant anatomy and eight key steps of the exercise. Each trainee filled a structured assessment form for the quality of the exercise and resemblance to live surgery. Each exercise was evaluated by a trainer on-site, who supervised the activity and two independent assessors through photographs of the cardinal steps. Result(s): In total, 11 (40.7%) trainees had 1-3 years of specialist training experience, 10 (37%) had 4-6 years, and 6 (22.2%) had beyond. Meanwhile, 2 (7.4%) trainees had no hypospadias experience, 16 (59.2%) assisted in procedures or performed steps, 5 (18.5%) performed whole procedures with guidance, and 4 (14.8%) without guidance. The trainees rated each step from unsatisfactory (1/5) to excellent (5/5) for each of the (1) degloving;(2) urethral marking;(3) incision;(4) tubularization;(5) glanuloplasty;(6) dartos layer preparation;(7) preputioplasty, and (8) skin closure. However, 20 (74%) trainees and 15 (100%) instructors judged the model to resemble the anomaly. Meanwhile, 17 (63%) trainees and 13 (86.6%) instructors rated needle penetrability of the material compared to human tissue >= 3/5. In total, 16 (59%) trainees and 13 (86.6%) instructors rated suture holding >= 3/5. Moreover, 11 (73.3%) and 13 (86.6%) instructors rated sutures' evenness and edge cooptation >= 3/5. Conclusion(s): Majority of instructors found this 3D-model able to mediate transferring skills. Trainees reported adequate skill acquisition.

Clinical characteristics, socioeconomic factors and COVID-19 were associated with delayed surgery in children with hypospadias: a retrospective study of 4439 cases in a single center.

BACKGROUND: Hypospadias is one of the most common congenital diseases of the genitourinary system in children. The European Association of Urology (EAU) Guidelines recommend that children undergoing hypospadias surgery should be between 6 and 18 months. In China, where many children have hypospadias, it remains unknown whether clinical characteristics, socioeconomic factors and COVID-19 were associated with delayed surgery in children with hypospadias. METHODS: We retrospectively analyzed children with hypospadias who underwent primary surgery at the Department of Pediatric Urology in Guangzhou Women and Children's Medical Center between January 2010 and October 2021. Patients who had two-stage surgery or a second round of surgery due to complications were excluded to eliminate data duplication. The clinical characteristics and demographic information were collected. We defined delayed surgery as primary surgery performed after 18 months following the EAU Guidelines. RESULTS: A total of 4439 children diagnosed with hypospadias were included in the study. The median age (29.1 ± 16.7 months) of surgery for hypospadias in our study was much higher than the recommended age reported in the EAU guidelines, and 76.6% of the children underwent surgery after the age of 18 months. Children without comorbidities including cryptorchidism (odds ratio [OR] = 1.562; 95% confidence interval [CI] 1.199-2.034; p = 0.001), prostatic cyst (OR = 2.613; 95% CI 1.579-4.324; p < 0.001), penile hypoplasia (OR = 1.778; 95% CI 1.225-2.580; p = 0.002), inguinal hernia (OR = 2.070; 95% CI 1.394-3.075; p < 0.001), and penoscrotal transposition (OR = 4.125; 95% CI 1.250-13.619; p = 0.020) were more likely to receive delayed surgery. Living in a low economic area (OR = 1.731; 95% CI 1.068-2.806; p = 0.026) or not close to a main medical center (OR = 1.580; 95% CI 1.370-1.824; p < 0.001) was highly associated with delayed surgery. The proportion of children undergoing delayed surgery and the median age of surgery during the COVID-19 pandemic were significantly higher than those before the COVID-19 pandemic (p = 0.004 and < 0.001, respectively). CONCLUSIONS: Most children with hypospadias received delayed surgery (surgical age > 18 months). Comorbidities, living in a low economic area, too far from a main medical center and the COVID-19 pandemic were highly associated with delayed surgery. It is vital to improve the public awareness of hypospadias and strengthen the re-education of primary community doctors to reduce delayed surgery.

THE IVU VIRTUAL VISITING PROFESSORSHIP PROGRAM: YOUTUBE AND ITS IMPACT ON GLOBAL HEALTH EDUCATION

INTRODUCTION AND OBJECTIVE: Like many global health organizations, International Volunteers in Urology (IVU) had to adjust to limitations on international travel during the COVID-19 pandemic that eliminated in-person surgical workshops. IVU turned to a completely virtual presence through the expansion of a visiting professorship program (VVP) of lectures given to international partner sites on requested topics via live video conference. These lectures were recorded and subsequently posted on YouTube, and promoted through social media, to increase accessibility. We reviewed the use of YouTube as an educational platform. METHODS: YouTube analytics of the IVU VVP program viewed after the live presentation from February 2020 through October 2021 were reviewed. We categorized the lectures by urology topic and evaluated them by the watch time in hours, the total number of views, and the number of channel subscribers. We then calculated an interest score, represented by the ratio of the number of views to the total number of videos under a specific topic, and a value score, represented by a ratio of total watch hours to the total number of videos. RESULTS: 68 lectures have been given over 20 months with 10,941 total views, 873.4 total hours of watch time, and 259 channel subscribers. The top three video categories by watch time and number of views included endourology (215.2 hours, 2,006 views), oncology (169.1 hours, 1,868 views), and pediatrics (164.9 hours, 3,453 views). “Ultrasound basics for urologists” was watched the most with 104.4 hours (1,000 views), while “Complex hypospadias” had the highest number of views at 1,200 (25.4 hours). The top three video categories by interest scores were endourology (287), pediatrics (247), and voiding dysfunction (189), while the top three by value scores were endourology (31), voiding dysfunction (18), and sexual health (15). For all videos, direct YouTube searches were the most common means of viewership (representing 41.7% of views), while external traffic sources represented 13.9% of views. Of the external traffic sources, the most common was from Google (14.2%). CONCLUSIONS: The COVID-19 pandemic led IVU to create a well-received VVP program, archived through YouTube to enable sustained remote education and outreach to international sites. Review of YouTube trends provided feedback on didactic topics. The difference in views and watch time highlight topics of higher educational value to international sites and may suggest areas of focus in future virtual and in-person didactics when they resume.

EXAMINING THE 1-YEAR IMPACT OF COVID-19 ON UROLOGY RESIDENT SURGICAL EXPERIENCE: AN ANALYSIS OF NATIONAL SURGICAL CASE LOGS

INTRODUCTION AND OBJECTIVE: The emergence of the COVID-19 pandemic resulted in elective surgical closures beginning in March 2020. In the immediate 6-months after COVID-19 began, there was a significant reduction in national resident operative experience. Our objective is to evaluate the impact of COVID-19 on urology resident surgical experience the year before and after COVID-19 using a national surgical case log registry. METHODS: Canadian national urology resident case log data (T-Res) was analyzed for the 2-year time period from March 15, 2019 - March 14, 2021 with respect to the 14 most commonly performed urological procedures. The 12-month time period prior to COVID-19 was compared to the 12-month time period after COVID-19. Data was analyzed from 11 residency programs with regular active users generating case logs over this time period. Total and specific case volumes per program and per resident user of the time period were analyzed. A paired Wilcoxon signed-rank test was used for comparison of mean cases pre- and post-COVID-19 with an alpha of 0.05 defined as significant. RESULTS: A total of 26,715 procedures were recorded over the 24-month period among 150 unique resident users in 11 training programs. In the 12-months prior to COVID-19, 11,906 procedures were logged while 14,809 procedures were logged in the 12-months after. Nationally, mean total case numbers per program (1082.4 vs. 1346.3;p=0.27) and per resident were not significantly reduced in the 12-months after COVID-19 when compared to 12-months prior (144.5 vs. 135.9;p=0.53). For specific surgeries by program, mean volumes per resident before and after COVID-19 were not significantly different including TURBT (18.5 vs. 19.4;p=0.66), TURP (11.3 vs. 11.7;p=0.72), PCNL (4.1 vs. 3.3;p=0.80), circumcision (6.9 vs. 5.9;p=0.25), hypospadias repair (0.9 vs. 0.6;p=0.39), hydrocelectomy (3.9 vs. 2.6;p=0.37), orchidopexy (4.2 vs. 4.1;p=0.99), ureteroscopy (18.6 vs. 21.3;p=0.53), stent insertion (17.7 vs. 16.7;p=0.77), radical prostatectomy (4.9 vs. 4.8;p=0.89), radical nephrectomy (3.6 vs. 4.0;p=0.75), partial nephrectomy (2.4 vs. 3.0;p=0.29), radical cystectomy (2.8 vs. 3.2;p=0.51), and cystolitholapaxy (3.1 vs. 2.5;p=0.48). While nationally overall case volumes were stable, 3/11 (27.3%) of programs continue to report a significant reduction in surgical volumes 1 year after COVID-19 even when adjusted for number of resident users. CONCLUSIONS: Based on this national case log sample resident operative experience has rebounded one year after COVID-19. However, 27.3% of programs still report significantly reduced case volumes per resident after COVID-19 and this may warrant further examination to ensure focal deficiencies in training don't arise.

Results of two-stage transverse preputial island flap urethroplasty for proximal hypospadias with chordee that mandate division of the urethral plate.

INTRODUCTION: Reconstruction of proximal hypospadias with chordee remains a difficult task. Our work aims to evaluate the role of two-stage transverse preputial island flap urethroplasty for repair of proximal hypospadias with chordee. MATERIAL AND METHODS: This is a retrospective study including 57 children who underwent two-stage transverse preputial island flap urethroplasty. Glans meatus shaft (GMS) score was applied to 24 cases. Patient's characteristics, operative details and complications were assessed. Hypospadias objective scoring evaluation was used for postoperative assessment. RESULTS: The mean age at the first stage operation was 23.6 months (9-84); the mean time interval between the first and second stage operations was 8.1 months (6-12) and the mean follow-up duration was 52.1 months (24-96). Urethral meatus was proximal penile in 18 patients, penoscrotal in 24 and scrotal in 15. The mean degree of ventral curvature (VC) was 51.5° (30-90). After the second stage operation, postoperative complications occurred in 16 (28.1%) patients with urethrocutaneous fistula in 6 (10.5%) cases, diverticulum in 3 (5.3%), glans dehiscence in 5 (8.8%) and meatal stenosis in 2 (3.5%). All cases of glans dehiscence occurred in severe hypospadias and small glans. Moderate GMS score was present in 10 (41.7%) cases and severe GMS in 14 (58.3%). Complications occurred in 7 (29.1%) patients with 5 (20.8%) with a severe GMS score and 2 (8.3%) with a moderate GMS score. The hypospadias objective scoring evaluation showed satisfactory results, with 39 (68.4%) patients achieving a score of 16 points. CONCLUSIONS: Two-stage transverse preputial flap is a good choice for repair of proximal hypospadias with an acceptable complication rate of 28.1%.