Environmental, parental and gestational factors that influence the occurrence of hypospadias in male patients.

OBJECTIVE: Hypospadias is a congenital defect, which affects normal development of the male urogenital external tract. In this malformation, the urethral orifice of the penis is positioned ventrally, thus interfering with normal urination and creating, in some adults, problems during sexual intercourse. Heritability of hypospadias has been shown in some reports, and the abnormality has been associated with the presence of mutations in one of the genes involved in urogenital development. However, even for patients who were born in families with a higher incidence rate of this defect, no evident genetic alteration could be identified in known genes, indicating that the list of loci involved is still incomplete. To further complicate matters, recent reports also underline that epigenetic changes, without any identifiable gene sequence mutation, may be involved in gene function impairment. Therefore, the inheritance of most hypospadias cases is not evident, suggesting that the genetic background is not the only cause of this malformation; indeed, the majority of hypospadias cases are classified as sporadic and idiopathic. MATERIALS AND METHODS: Evidence has accumulated highlighting the role of the environment and of its relationships with the genome in the etiology of this abnormality. In particular, the interaction between some chemicals, which are able to mimic endogenous molecules such as sexual hormones--for this reason called endocrine disrupting compounds (EDC)--and specific receptors has been extensively investigated during the pregnancy. Additionally, several articles have shown that parental and gestational factors play a significant role too. Indeed, physiological alterations, such as body weight of the mother and/or of the newborn, mother's diabetes, impaired father fertility, and exposure of one parent to job-related pollutants, show in many cases a direct correlation with hypospadias incidence. The overall prevalence of this condition has been studied in many countries, suggesting that at least in some periods and/or in specific populations there are detectable fluctuations, probably mirroring the different natural environments. However, many articles present data that do not agree with these findings and, consequently, most causes of hypospadias are still highly debated. RESULTS: In this review, we summarize the developmental steps involved in urogenital tract formation, with a particular emphasis on the genes that most frequently are associated with this condition, or that are subject to environmental stress, or that may be the targets of hormone-like, exogenous molecules. Then, we make an overview of the identified factors able to impair the function of important genes, even in the absence of their mutations, including those for which contradictory reports have been published. Finally, we propose an explanation of sporadic cases of hypospadias that reconciles these contradictions and suggest some steps for moving forward in the research focused on this condition. CONCLUSION: We hypothesize that most patients develop hypospadias because of gene-environment interactions acting on polymorphic genes that, in the absence of environmental stimuli, would otherwise cause no developmental anomaly during urogenital development.

Disorders of sex development: a genetic study of patients in a multidisciplinary clinic.

Sex development is a process under genetic control directing both the bi-potential gonads to become either a testis or an ovary, and the consequent differentiation of internal ducts and external genitalia. This complex series of events can be altered by a large number of genetic and non-genetic factors. Disorders of sex development (DSD) are all the medical conditions characterized by an atypical chromosomal, gonadal, or phenotypical sex. Incomplete knowledge of the genetic mechanisms involved in sex development results in a low probability of determining the molecular definition of the genetic defect in many of the patients. In this study, we describe the clinical, cytogenetic, and molecular study of 88 cases with DSD, including 29 patients with 46,XY and disorders in androgen synthesis or action, 18 with 46,XX and disorders in androgen excess, 17 with 46,XY and disorders of gonadal (testicular) development, 11 classified as 46,XX other, eight with 46,XX and disorders of gonadal (ovarian) development, and five with sex chromosome anomalies. In total, we found a genetic variant in 56 out of 88 of them, leading to the clinical classification of every patient, and we outline the different steps required for a coherent genetic testing approach. In conclusion, our results highlight the fact that each category of DSD is related to a large number of different DNA alterations, thus requiring multiple genetic studies to achieve a precise etiological diagnosis for each patient.

Longitudinal hormonal evaluation in a patient with disorder of sexual development, 46,XY karyotype and one NR5A1 mutation.

Steroidogenic factor 1 (encoded by the NR5A1 gene) is a critical regulator of reproduction, controlling transcription of key genes involved in sexual dimorphism. To date, NR5A1 variants have been found in individuals with a 46,XY karyotype and gonadal dysgenesis, as well as with a wide spectrum of genital anomalies and, in some patients, with adrenal insufficiency. We describe evolution of gonadal function, from the neonatal period to puberty, in a patient with a 46,XY karyotype, a disorder of sexual development, and a mutation (c.691_699dupCTGCAGCTG) in the NR5A1 gene. The patient, ascertained at birth due to ambiguous genitalia, showed normal values of plasma testosterone in the late neonatal period. Evaluation of the hormonal profile over time indicated severe tubular testicular hypofunction suggestive for a 46,XY disorder of gonadal development. A comprehensive review of published reports of 46,XY and disordered sexual development related to the NR5A1 gene confirmed the clinical and hormonal variability in patients with NR5A1 mutations. Analysis of multiple data allowed us to define the most common features associated with NR5A1 mutations. We further confirmed the indication to perform NR5A1 screening in patients with 46,XY karyotype and disordered sexual development even when Müllerian structures appear to be absent and plasma testosterone levels are within the normal range for age.

NR5A1 gene mutations: clinical, endocrine and genetic features in two girls with 46,XY disorder of sex development.

BACKGROUND: Steroidogenic factor 1, encoded by the NR5A1 gene, is a key regulator of endocrine function within the hypothalamic-pituitary-steroidogenic axis. Both homozygous, compound heterozygous and heterozygous mutations in the NR5A1 gene may determine 46,XY disorders of sex development (DSD). PATIENTS AND METHODS: NR5A1 gene sequencing was performed in a cohort of 6 patients with 46,XY DSD without specific diagnosis. RESULTS: Heterozygous NR5A1 gene mutations were found in 2 girls, aged 0.5 years and 14 years. The older girl harbored the c.250C>T transition in exon 4 (p.Arg84Cys), previously reported in a Japanese girl. The younger girl presented a de novo novel exon 6 heterozygous frameshift mutation (c.1074dupG) in codon 359 associated with the p.Gly146Ala polymorphism the latter inherited from her father. This baby showed severe impairment of androgen secretion from the first months of life. Overt adrenal insufficiency did not occur, but the older girl showed subnormal cortisol peak after ACTH stimulation. CONCLUSIONS: NR5A1 gene mutations are a relatively frequent cause of 46,XY DSD in humans. Clear indications for management of these individuals remain elusive, mainly when diagnosis is made in infancy. Long-term monitoring of adrenal function should be recommended.

Vaginoplasty for disorders of sex development.

One of the most common problem found in patients with Disorders of Sexual Developments is the absence or extreme hypoplasia of the vagina. The type of patients presenting this anomaly may belong to completely different groups: (1) Patients with a urogenital sinus with urethra and vagina fusing together to form a common channel. (2) Patients with absent Müllerian structures and different degrees of external virilization. (3) Complex malformations. Treatment options: treatment of these patients is under discussion and may consist, basically, in non-operative dilation methods or surgical creation of a neovagina. Consensus is far to be reached among the various surgical subspecialties regarding the optimal method of vaginal replacement. Adequate number of long-term follow up patients are still non-available so that most conclusions are based on small number series. The authors describe the different treatment options in detail.

Chromosome 9p deletion syndrome and sex reversal: novel findings and redefinition of the critically deleted regions.

Deletions of the short arm of chromosome 9 are associated with two distinct clinical entities. Small telomeric 9p24.3 deletions cause genital anomalies in male subjects, ranging from disorder of gonadal sex to genital differentiation anomalies, while large terminal or interstitial deletions result in 9p-malformation syndrome phenotype. The critical region for non-syndromic 46,XY sex reversal was assigned to a 1 Mb interval of chromosome 9p, extending from the telomere to the DMRT genes cluster. The 9p-syndrome was assigned to bands 9p22.3p24.1, but a phenotypic map has not been established for this condition, probably because of the lack of detailed molecular and/or phenotypic characterization, as well as frequent involvement of additional chromosome rearrangements. Here, we describe a unique patient with a small isolated 9p terminal deletion, characterized by array-CGH and FISH, who shows a complex phenotype with multiple physical anomalies, resembling the 9p-syndrome, disorder of sex development with gonadoblastoma, congenital heart defect and epilepsy. The observed deletion includes the 46,XY sex-reversal critical region, excluding the region so far associated with the 9p-syndrome. Genotype-phenotype correlations are tentatively established comparing our patient to seven other previously reported males with isolated terminal 9p deletions, finely defined at a molecular level. Our observations expand the 9p deletion clinical spectrum, and add significantly to the definition of a 9p-syndrome critical region.

De-hospitalization of the pediatric day surgery by means of a freestanding surgery center: pilot study in the Lazio Region.

BACKGROUND: Day surgery should take place in appropriate organizational settings. In the presence of high volumes, the organizational models of the Lazio Region are represented by either Day Surgery Units within continuous-cycle hospitals or day-cycle Day Surgery Centers. This pilot study presents the regional volumes provided in 2010 and the additional volumes that could be provided based on the best performance criterion with a view to suggesting the setting up of a regional Freestanding Center of Pediatric Day Surgery. METHODS: This is an observational retrospective study. The activity volumes have been assessed by means of a DRG (Diagnosis Related Group)-specific indicator that measures the ratio of outpatients to the total number of treated patients (freestanding indicator, FI). The included DRGs had an FI exceeding the 3rd quartile present in at least a health-care facility and a volume exceeding 0.5% of the total patients of the pediatric surgery and urology facilities of the Lazio Region. The relevant data have been provided by the Public Health Agency and relate to 2010. The best performance FI has been used to calculate the theoretical volume of transferability of the remaining facilities into freestanding surgery centers. Patients under six months of age and DRGs common to other disciplines have been excluded. The Chi Square test has been used to compare the FI of the health-care facilities and the FI of the places of origin of the patients. RESULTS: The DRG provided in 2010 amounted to a total of 5768 belonging to 121 types of procedures. The application of the criteria of inclusion have led to the selection of seven final DRG categories of minor surgery amounting to 3522 cases. Out of this total number, there were 2828 outpatients and 694 inpatients. The recourse of the best performance determines a potential transfer of 497 cases. The total outpatient volume is 57%. The Chi Square test has pointed to a statistically significant difference of the facilities and to a non-significant difference of inferiority of the regional places of origin with respect to the city of Rome. CONCLUSIONS: The activity volumes would seem to support the setting up of a Freestanding Regional Center of Pediatric Day Surgery. This Center represents the healthcare facility that is most likely to allow a de-hospitalization process. Subsequent studies will be required to confirm the validity of this pilot study.

Maternal exposures to endocrine disrupting chemicals and hypospadias in offspring.

BACKGROUND: Prenatal exposures to endocrine-disrupting chemicals (EDCs) are suspected risk factors in the etiology of hypospadias. The aim of this case-control study was to test the hypothesis of an association between maternal environmental exposures to EDCs and hypospadias in the offspring. METHODS: Detailed questionnaire data on occupational and dietary exposures to EDCs in the perinatal period were collected from 80 mothers with hypospadiac infants and from 80 mothers with healthy controls within 24 months of childbirth. Maternal exposure to selected EDCs was also ascertained by measuring the concentration of dichlorodiphenyldichloroethylene, hexachlorobenzene, and several polychlorinated biphenyl congeners in the serum of primiparous mothers of 37 cases and 21 controls. RESULTS: The risk to bear an hypospadiac infant was associated with perinatal maternal occupational exposures to EDCs evaluated by a job-exposure matrix: jobs with exposure to one class of EDCs (odds ratios [OR](crude), 2.83; 95% confidence intervals [CI], 1.32-6.07; OR(adjusted), 2.44; 95% CI, 1.06-5.61) and jobs with exposure to more than one group of EDCs (OR(crude), 4.27; 95% CI, 1.43-12.78; OR(adjusted), 4.11; 95%CI, 1.34-12.59). Increase in risk was also found among mothers consuming a diet rich in fish or shellfish (OR(crude), 3.41; 95% CI, 1.42-8.23; OR(adjusted), 2.73; 95%CI, 1.09-6.82). Serum hexachlorobenzene concentration above the median of all subjects was significantly associated with the risk of hypospadias (OR(adjusted), 5.50; 95% CI, 1.24-24.31). CONCLUSIONS: This study, although based on a limited number of cases, for the first time provides evidence of an association between maternal exposure to EDCs, in particular elevated plasma hexachlorobenzene concentration, and the development of hypospadias in the offspring.

A new suture material for hypospadias surgery: a comparative study.

PURPOSE: We compared the results of hypospadias repair using polyglytone versus polydioxanone to evaluate the potential benefit of using a suture with a rapid absorption time. MATERIALS AND METHODS: A total of 100 patients 8 to 24 months old affected by distal isolated penile hypospadias were considered for this study. Patients were randomized and assigned to 2 different groups according to the suture material used during the surgical procedure (tubularized incised plate repair with or without preputial reconstruction). Polyglytone was used in group A and polydioxanone was used in group B. All patients were evaluated at 4 intervals (1 week, 1 month, 6 months and 2 years postoperatively). Persistence of sutures on penile skin, urethral fistulas, skin dehiscence, infection and skin tracks were recorded. Statistical analysis was performed using chi-square test. RESULTS: Followup data documented the absence of significant differences in terms of urethral fistula rate, skin dehiscence and acute skin infection. Persistence of sutures and multiple skin tracks at long-term followup were significantly greater in patients in group B. CONCLUSIONS: Both sutures are adequate for hypospadias surgery in small children. The use of a rapid absorption monofilament may allow much more rapid disappearance of the skin sutures. In the long term this outcome means almost complete absence of suture tracks. No statistically significant difference in terms of urethrocutaneous fistula was observed, suggesting that the tensile strength of polyglytone is adequate.

Syndromic true hermaphroditism due to an R-spondin1 (RSPO1) homozygous mutation.

XX true hermaphroditism, also know as ovotesticular disorder of sexual development (DSD), is a disorder of gonadal development characterized by the presence of both ovarian and testicular tissue in a 46,XX individual. The genetic basis for XX true hermaphroditism and sex reversal syndromes unrelated to SRY translocation is still mostly unclear. We report mutational analysis of the RSPO1 gene in a 46,XX woman with true hermaphroditism, palmoplantar keratoderma, congenital bilateral corneal opacities, onychodystrophy, and hearing impairment. R-spondin1 is a member of the R-spondin protein family and its pivotal role in sex determination has been recently described. We identified a homozygous splice-donor-site mutation in the RSPO1 gene in our patient. We found that the c.286+1G>A mutation led to an aberrantly spliced mRNA (r.95_286del), which is presumably translated into a partially functional protein (p.Ile32_Ile95del). Our case demonstrates for the first time, to our knowledge, that XX true hermaphroditism can be caused by a single gene mutation. The reported findings represent a further step toward a complete understanding of the complex mechanisms leading to DSDs.

Reoperative hypospadias.

PURPOSE OF REVIEW: To review recent publications on the surgical treatment of hypospadias failures, including prognostic factors, which may influence final outcome in hypospadias surgery. RECENT FINDINGS: Interim good outcomes for single-stage dorsal inlay grafting in patients with multiple failed repairs would suggest a greater role for this new technique over other available options. Slowly emerging long-term data confirm our suspicion that a good result early on is not necessarily indicative of a satisfactory long-term outcome. SUMMARY: Hypospadias surgery remains a considerable technical challenge and improvement will come from the development of specialized units.

Do patients with hypospadias and cryptorchidism share a common phenotype? Case-control study of an Italian paediatric population.

OBJECTIVE: A large number of children affected by hypospadias and undescended testis (UDT) are characterized facially by a large forehead with frontal bossing, telecanthus and broad flat nasal bridge. These traits are classically part of the clinical spectrum of the Opitz-GBBB and other syndromes. The aim of this study was to test the hypothesis that the presence of these features in isolated hypospadias and UDT is not correlated with chromosomal anomalies and/or syndromes, but defines a distinct morphology. PATIENTS AND METHODS: Two hundred patients affected by isolated hypospadias and 100 presenting with a UDT were evaluated for facial biometric indices. An age-matched group of patients was used as control. The parameters inter-pupillary/inner canthal ratio and glabella-nose tip/nasion distance were then calculated. RESULTS: The glabella-nose tip/nasion distance was significantly different between hypospadias and control groups, but was not different between UDT and control groups. There was no difference in inter-pupillary/inner canthal ratio. CONCLUSION: Children affected by hypospadias and/or UDT frequently present peculiar phenotypic features making it possible to recognize them 'at first glance'. This association needs to be explained in future studies.

Hypospadias surgery: when, what and by whom?

Hypospadias is repaired by paediatric surgeons, paediatric urologists, adult reconstructive urologists and plastic surgeons. This review is unique in representing all four specialities, to provide a unified policy on the management of hypospadias. The surgeon of whichever speciality should have a dedicated interest in this challenging work, ideally having an annual volume of at least 40-50 cases. The ideal time for primary repair is at 6-12 months old, although when this is not practicable there is another opportunity at 3-4 years old. A surgical protocol is presented which emphasises both functional and cosmetic refinement. Using a logical progression of a very few related procedures allows the reliable correction of almost any hypospadias deformity. A one-stage repair is used when the urethral plate does not require transection and its axial integrity can be maintained. Occasionally, when the plate is of adequate width and depth, it can be tubularized directly using the second stage of the two-stage repair. When (usually) the urethral plate is not adequately developed and requires augmentation before it can be tubularized, then that second-stage procedure is modified by adding a dorsal releasing incision +/- a graft (alias Snodgrass and 'Snodgraft' procedures). The two-stage repair offers the most reliable and refined solution for those patients who require transection of the urethral plate and a full circumferential substitution urethroplasty. From available evidence this protocol combines excellent function and cosmesis with optimum reliability. Nevertheless, it would be complacent to assume that these gratifying results will be maintained into adult life. We therefore recommend that there is still a need for active follow-up through to genital maturity.