Can paediatric surgical registrars safely perform supervised hypospadias surgery?

INTRODUCTION: Hypospadias repair is regarded as a technically demanding, complex procedure, with variable outcomes. Therefore, it tends to be performed by consultants, with limited trainee involvement. We aimed to study the clinical outcomes of supervised registrars performing proximal and distal hypospadias repairs, compared to their consultant mentors. METHODS: We undertook a retrospective review of all primary hypospadias repairs performed between April 2013-April 2022 at our tertiary paediatric urology centre. Redo repairs and patients lost to follow-up were excluded. Pre-operative anatomy, theatre time, grade of primary surgeon (registrar (trainees and non-training middle grades) or consultant), operative technique, follow-up duration, complications, and reoperation rates were recorded. The procedures were assessed in two groups according to the primary operator: registrar or consultant. The Zwisch scale is used to describe level of consultant support. Registrars as primary operators received "passive help" or "supervision" (Zwisch levels 3/4). Consultants as primary operators provided registrars with "show-and-tell" or "active help" (Zwisch levels 1/2). RESULTS: 270 procedures performed on 228 patients met the inclusion criteria. 109 were performed by registrars and 161 by consultants. In both groups, median age was two years (p = 0.23). Median theatre time was similar (registrars 2.8 h vs. consultants 2.7 h, p = 0.88), as was median follow-up (registrars 25months, vs. consultants 21months, p = 0.99). Operations performed by registrars were 76% distal and 24% proximal; and by consultants were 62% distal and 38% proximal. The overall urethroplasty complication rate was similar, at 24% for registrars and 23% for consultants (p = 0.89). The summary table shows the distribution of different complications. Re-operation rate was 16% in both groups (p = 0.99). Complications were further assessed according to operation type (TIP vs. two-stage repair). DISCUSSION: Contrary to popular belief amongst hypospadiologists, we found complication rates were similar for registrar and consultant surgeons. We question that involvement of registrars increases complications. The literature demonstrates safety of trainee performance of limited steps of the procedure. However our institution permits registrars to perform up to the whole hypospadias repair under direct supervision, with no predefined limit to their involvement. CONCLUSION: Paediatric surgical registrars can be safely supervised to have substantial involvement in proximal and distal hypospadias repair, without compromising the duration or outcomes of surgery. We hope that allowing more registrar involvement can lead to faster acquisition of surgical skills, whilst remaining under the safety of senior supervision. Increasing opportunities for those with an aptitude for hypospadias repair can equip them with skills and confidence for entering fellowship training.

Correction of curvature in single stage hypospadias repair with foreskin reconstruction.

INTRODUCTION: Many surgeons offer foreskin reconstruction (FR) as a routine part of hypospadias repair. We present a step-by-step video of the procedure of Tubularised Incised Plate (TIP) repair, FR and dorsal plication through a ventral skin incision. MATERIALS AND METHODS: A ventral incision is made between the inner preputial mucosa and the outer skin extending below the meatus. Ventral degloving is carried out. The dissection is extended laterally around the corporal bodies. The point of maximal curvature (PMC) is marked on the dorsal midline. A vertical incision is made and closed transversely with 5-0 prolene suture in a Heineke- Mikulicz fashion. Urethroplasty is performed in 2 layers using 7-0 polydioxanone (PDS). Spongioplasty and ventral dartos are used as barrier layers. Glansplasty is performed in 2 layers.FR is carried out in 3 layers. DISCUSSION: Curvature correction is key to good outcome. Dorsal degloving can be achieved through a ventral incision allowing exposure of the dorsal midline for plication sutures. RESULTS: The patient had good cosmetic and functional outcome at 1 month follow up. CONCLUSION: FR can be safely performed during TIP repair for distal hypospadias repair. Curvature of less than 30° can be corrected through a ventral incision only.

Are there anatomical limiting factors to foreskin reconstruction at the time of single-stage hypospadias repair?

INTRODUCTION: Foreskin reconstruction (FR) at the time of primary hypospadias repair is a truly anatomically complete reconstruction of the hypospadic penis. We prospectively collected penile and preputial measurement of children undergoing single-stage hypospadias repair and FR with the aim to identify possible relations between penile and preputial anatomy and the likelihood to develop complications. MATERIALS AND METHODS: We prospectively studied children who underwent single stage hypospadias repair associated with FR from 2016 to 2019. We recorded intra-operative foreskin and penile measurements and post-operative outcomes. Logistic Regression analysis was performed to explore independent factors affecting urethroplasty and skin complications. Chi square test was used to compare outcomes in different groups based on ventral foreskin defect (VFD) width, Glans size, age at surgery and meatal location. RESULTS: From a total of 181 consecutive patients, 86 boys who underwent a single stage hypospadias repair combined with FR were included in the study. Patients were excluded because they were either lost at follow up (n = 10), required a 2-stage repair (n = 2), were circumcised at birth (n = 3) or parents requested a circumcision (n = 78); in 2 patients, a decision to perform circumcision was made intraoperatively due to aesthetic reasons (monk-hood deformity of the prepuce). Median age at surgery was 17 months. Mean glans width was 14.4 mm. Mean unstretched and stretched foreskin circumference were 29.5 mm and 40.9 mm, respectively. Mean VFD (the distance between the proximal insertion of the foreskin hood on either side of the midline at the level of the coronal sulcus) was 7.2 mm (Fig. 1). At median follow-up of 8 months (6-23), 9 complications were recorded (10.4%): foreskin dehiscence occurred in 1% (1/86), a foreskin fistula was noted in 4.6% (4/86), tight, non-retractile, foreskin in 1% (1/86); urethrocutaneous fistula in 2.3% (2/86) and complete dehiscence of the glans and foreskin in 1 (1.2%). Multiple logistic regression analysis demonstrated that none of the measurements obtained was an independent risk factor for developing urethroplasty or skin complications. There was no significant difference in complications between wide VFD (>7 mm) vs. narrow VFD (≤7 mm), large glans (>14 mm) vs. small glans (≤14 mm), age at surgery ≤24 months vs. > 24 month and meatal location distal (glanular, coronal, subcoronal and distal penile) vs. proximal (midpenile, proximal penile and penoscrotal). CONCLUSION: To the best of our knowledge, this is the first study reporting a prospective and objective assessment of the foreskin in the context of single stage hypospadias repair. Individual anatomical differences in preputial and penile anatomy do not seem to affect the likelihood of skin and urethroplasty complications. FR can, therefore, be offered to all boys undergoing primary single stage hypospadias repair . Further studies on larger numbers and external validation of these measurements is necessary.

How accurate is eyeball measurement of curvature? A tool for hypospadias surgery.

INTRODUCTION: Correction of penile curvature or "chordee" is a major component in the management of hypospadias. Accurate assessment and management of penile curvature influence both short- and long-term outcomes of surgery. AIM OF THE STUDY: The objective of this study is to investigate the accuracy of eyeball measurement and how does it compare to objective measurement by standard goniometry (SG) and smartphone app goniometry (AG). MATERIALS AND METHODS: A Dropbox file request link was shared with paediatric urologists on various social media platforms requesting participants to upload a picture of their index finger showing what they thought 30 degrees of curvature look like using their proximal inter phalangeal joint as the point of maximal curvature., The images were assessed using SG to measure the angle of curvature. The images were also assessed using AG by the principal investigator, a physician, a scrub nurse and a paediatric urology consultant., Statistical analysis was performed using SPSS statistics software version 26 (Armonk, NY: IBM Corp). A one sample t-test and a one-way chi squared test were used to evaluate significant frequency differences. Pearson correlation was used to compare AG measurements to test intra- and inter-observer reliability and to compare AG measurements vs SG measurements. Assuming 5-degree variability in goniometer measurements and 2-degree difference between the sample and population, the number of participants needed was calculated to be 49. RESULTS: Fifty-two responses were received.32.7% of respondents simulated 30° accurately (17/52). A significant proportion (23/52, 44.2%) overrepresented the degree of curvature and 23.1% (12/52) underrepresented it (p = 0.01). Compared with objective measures, eyeball estimates differed by an average of 10° ± 1.5 SE. Measurements obtained by AG were comparable to measures obtained by SG and showed excellent intra-observer and inter-observer correlation (R = 0.983, P < 0.001). DISCUSSION: We demonstrated a significant discrepancy between eyeball assessment of curvature and objective measurements in a cohort of hypospadiologists. This can be very relevant to intraoperative decision making. The limitation of the study is the use of a simulated model rather than assessment of curvature in patients with hypospadias. Another limitation is the lack of standardization of the way the pictures were taken. CONCLUSION: We demonstrated a tendency among hypospadiologists to overestimate or underestimate curvature by an average of 10° on eyeball assessment. The use of App Goniometry shows excellent interobserver reliability and is comparable to standard goniometry in curvature assessment.

Pediatric Nephrectomy: Comparison of Perioperative Outcomes of Three Different Minimally Invasive and Open Approaches.

Background: Minimally invasive surgery (MIS) is now the gold standard for nephrectomy in pediatric patients. Retroperitoneoscopic (using either one or two instruments) and transperitoneal (TP) approaches are described. We compared the perioperative outcomes of different techniques [single-instrument retroperitoneoscopic (SIRP), two-instrument retroperitoneoscopic (TIRP), TP, and open approach]. Patients and Methods: Retrospective review of patients who underwent nephrectomy surgery in the period from January 2009 to January 2020 at a single center was carried out. We excluded patients who underwent other procedures under the same anesthetic, underwent heminephrectomy, and those with incomplete records. The primary outcome measures were operative time, intraoperative complications, postoperative complications, and length of hospital stay. One-way analysis of variance (ANOVA) test was used to analyze continuous variables. Chi square test was used to compare categorical variables. Results: A total of 213 nephrectomies were analyzed; SIRP (n = 35), TIRP (n = 50), TP (n = 74), and open (n = 54). Median age (months) was 71 for SIRP, 113 for TIRP, 67 for TP, and 21 for open. No statistical difference was identified for mean operative time (P = .067) or mean hospital stay (P = .69). Intraoperative complications were significantly more in the open group (P = .03). Postoperative complications were rare and only noted in the open group. There was no conversion to open surgery in the SIRP and TIRP groups. Conversion rate was 5.4% (4/74) in the TP group. Conclusion: MIS nephrectomy is safe, and no difference among techniques (SIRP, TIRP and TP) has been demonstrated. They are comparable to open surgery in terms of operative time and hospital stay, but are associated with significantly less complications.

Congenital Anterior Urethrocutaneous Fistula with a Persistent Urethral Groove.

Congenital anterior urethrocutaneous fistula (CAUF) is a rare penile anomaly with only 63 cases reported in the literature. The anomaly can present in isolation or in association with chordee or hypospadias. We report the case of an 8-month-old boy with CAUF that resembles the embryological urethral groove. On examination, a wide urethral groove was noted to cover the midshaft of the penis with a well formed urethra extending proximally and distally and with a normal glandular anatomy, a wide glandular meatus, and a complete foreskin. The urethral groove was tubularized and covered in layers. Surgery was complicated with early superficial skin dehiscence not affecting the urethral repair. Refashioning of the skin was then performed. A satisfactory aesthetic and functional outcome was observed at 7 years' follow-up. Defining the anatomy of CAUF and distal urethra is key in management of these children.