Does parental opinion differ from the health care team regarding cosmesis after hypospadias repair?

OBJECTIVE: Hypospadias is the most common malformation of the male genitalia. Surgical correction has traditionally focused on anatomic and functional outcomes, with less attention being paid to cosmetic results. Our purpose is to compare the cosmetic results of hypospadias repair among different groups of observers, namely the patient's family and the health care team, using photography and a simple rating scale. METHODS: Prospective observational study included 9 boys undergoing Snodgrass hypospadias repair. Photographs of the penis taken before, immediately after, and six months after surgery were assessed by a panel of 15 observers (parents and health care team) and a scale including three questions with diagrams for comparison with the pictures was used. Observers also assigned an overall postoperative score for the cosmetic result. RESULTS: Interobserver agreement was noted for the group of parents of other children with hypospadias regarding the shape of the glans (k=0.404; p=0.008) and for the group of pediatric surgeons regarding the degree of residual curvature (k=0.467; p=0.005). Two observers in the pediatrician group have indicated good performance in the assessment of residual curvature (k=0.609; P=0.024). In the overall assessment of cosmetic outcomes, the highest scores were assigned by observers in the parents group and in the pediatrician group, while the pediatric surgeons group has one of the lowest scores (p<0.001). CONCLUSIONS: Photography appears to be suitable for documenting corrections of hypospadias regarding penile curvature, and postoperative cosmetic result. Surgeons seem more concerned about cosmesis than parents.

Does parental opinion differ from the health care team regarding cosmesis after hypospadias repair?

SUMMARY OBJECTIVE: Hypospadias is the most common malformation of the male genitalia. Surgical correction has traditionally focused on anatomic and functional outcomes, with less attention being paid to cosmetic results. Our purpose is to compare the cosmetic results of hypospadias repair among different groups of observers, namely the patient's family and the health care team, using photography and a simple rating scale. METHODS: Prospective observational study included 9 boys undergoing Snodgrass hypospadias repair. Photographs of the penis taken before, immediately after, and six months after surgery were assessed by a panel of 15 observers (parents and health care team) and a scale including three questions with diagrams for comparison with the pictures was used. Observers also assigned an overall postoperative score for the cosmetic result. RESULTS: Interobserver agreement was noted for the group of parents of other children with hypospadias regarding the shape of the glans (k=0.404; p=0.008) and for the group of pediatric surgeons regarding the degree of residual curvature (k=0.467; p=0.005). Two observers in the pediatrician group have indicated good performance in the assessment of residual curvature (k=0.609; P=0.024). In the overall assessment of cosmetic outcomes, the highest scores were assigned by observers in the parents group and in the pediatrician group, while the pediatric surgeons group has one of the lowest scores (p<0.001). CONCLUSIONS: Photography appears to be suitable for documenting corrections of hypospadias regarding penile curvature, and postoperative cosmetic result. Surgeons seem more concerned about cosmesis than parents.

Inappropriate Use of Ultrasound in Management of Pediatric Cryptorchidism.

BACKGROUND AND OBJECTIVES: There is a limited role for ultrasound in the management of an undescended testicle (UDT). We hypothesized that ultrasound remains overused by referring physicians. Our goal was to characterize the trends, patterns, and impact of ultrasound use for UDT and to reaffirm its limited diagnostic value for this indication. METHODS: The records of boys aged 0 to 18 years with UDT in Ontario, Canada, between 2000 and 2011 were reviewed by using health administrative data housed at the Institute for Clinical and Evaluative Sciences (ICES). A second review of boys referred to our institution with UDT between 2007 and 2011 was conducted to complement the health administrative data. Trends in frequency, distribution, and costs of ultrasound use were assessed. Time delays between diagnosis and definitive management were compared between the ultrasound and non-ultrasound groups. Using our institutional data, we analyzed demographic patterns of ultrasound use and compared its diagnostic accuracy by using surgical findings as the gold standard. RESULTS: Ultrasound was used in 33.5% of provincial referrals and 50% of institutional referrals. Children who underwent ultrasound experienced an approximate 3-month delay in definitive surgical management. Ultrasound correctly predicted physical examination findings in only 54% of patients. Physicians in community practice, and those with fewer years in practice, were more likely to order ultrasound. CONCLUSIONS: Ultrasound has limited value for the management of UDT but remains widely overused, with an increasing trend over time. This practice has negative implications for access to care and cost-containment. Widespread educational efforts should be undertaken, targeting current and future referring physicians.

Timing and nature of reconstructive surgery for disorders of sex development - introduction.

The ideal timing and nature of surgical reconstruction in individuals with Disorders of Sex Development (DSD) is highly controversial. Despite the increasing number of publications on this topic, evidence-based recommendations still cannot be made. However it is generally accepted that optimal care for DSD requires an experienced multidisciplinary team. This means that surgical decisions are now made within the context of a multidisciplinary team and all members of the team - and not just specialist surgeons - may be called upon to discuss choices for surgery with patients and parents. To do this well, every clinician in the team should have an understanding of the range of techniques available for genital surgery, the risks and benefits of procedures and the controversies surrounding timing of surgery. The aim of this paper is to give an overview of the variety of surgical procedures in current use and in what situation a particular technique would be indicated. The short-term risks and benefits are described and where available long-term outcome data is discussed. To date, discussions surrounding genital surgery have been led primarily by surgeons. Some non-surgical clinicians have expressed unease about decision making in genital surgery but have felt ill equipped to comment on an area with which they are unfamiliar. This review gives a detailed explanation of current surgical practice offered in a specialized center for DSD and such information should facilitate a more balanced discussion.

Is an artificial sphincter the best choice for incontinent boys with Spina Bifida? Review of our long term experience with the AS-800 artificial sphincter.

OBJECTIVE: We describe our long-term experience in a uniform population of Spina Bifida boys all treated with the AS-800 model artificial urinary sphincter (AUS) and compare our results to other treatment modalities available to children with neurogenic incontinence. MATERIALS AND METHODS: The complete medical records of 30 patients with insertion of the AS-800 were reviewed. All were boys having Spina Bifida with only one having prior bladder neck reconstruction. The mean age at insertion was 12.6 years and the average follow up was 6.5 years. Anticholinergic agents and self-intermittent catheterization were used concomitantly to the AUS in 21 and 22 patients respectively. RESULTS: In our series, 19 (63%) patients were completely dry, 6 (20%) were slightly wet, 5 (17%) were incontinent. The mean lifetime of all artificial sphincters was 4.7 years with no statistically significant difference in survival of those inserted at the bladder neck and bulbar urethra (4.6 and 4.9 years respectively). However, a survival analysis revealed a sharp drop after 100 months with only 8.3% of the sphincters implanted lasting beyond this point. There were a total of 32 revisions performed in 17 patients constituting a 0.164 revision rate/patient-years. The other surgical treatment available to these children is bladder neck reconstruction with reported continence rates ranging from 61% to 76% at about 2 years follow up. CONCLUSIONS: In our experience, the AS-800 model artificial sphincter has a long term survival which rarely exceeds 8 to 9 years putting into question whether it or bladder neck reconstruction is the best long term solution for treating children with neurogenic incontinence. This question may be only answered by a randomized, controlled trial comparing these two modalities.