Urologist validation of an artificial intelligence-based tool for automated estimation of penile curvature.

INTRODUCTION: Severity of penile curvature (PC) is commonly used to select the optimal surgical intervention for hypospadias, either alone or in conjunction with other phenotypic characteristics. Despite this, current literature on the accuracy and precision of different PC measurement techniques in hypospadias patients remains limited. PURPOSE: Assess the feasibility and validity of an artificial intelligence (AI)-based model for automatic measurement of PC. MATERIAL AND METHODS: Seven 3D-printed penile models with variable degrees of ventral PC were used to evaluate and compare interobserver agreement in estimation of penile curvatures using various measurement techniques (including visual inspection, goniometer, manual estimation via a mobile application, and an AI-based angle estimation app. In addition, each participant was required to complete a questionnaire about their background and experience. RESULTS: Thirty-five clinical practitioners participated in the study, including pediatric urologists, pediatric surgeons, and urologists. For each PC assessment method, time required, mean absolute error (MAE), and inter-rater agreement were assessed. For goniometer-based measurement, the lowest MAE achieved was derived from a model featuring 86° PC. When using either UVI (unaid visual inspection), mobile apps, or AI-based measurement, MAE was lowest when assessing a model with 88° PC, indicating that high-grade cases can be quantified more reliably. Indeed, MAE was highest when PC angle ranged between 40° and 58° for all the investigated measurement tools. In fact, among these methodologies, AI-based assessment achieved the lowest MAE and highest level of inter-class correlation, with an average measurement time of only 22 s. CONCLUSION: AI-based PC measurement models are more practical and consistent than the alternative curvature assessment tools already available. The AI method described in this study could help surgeons and hypospadiology researchers to measure PC more accurately.

Outcome analysis of staged preputial graft technique for primary proximal hypospadias with and without post-operative vacuum physiotherapy.

PURPOSE: Management of proximal hypospadias remains challenging. We assessed the results of staged preputial graft repairs (SPG) for proximal hypospadias and hypothesize that post-operative vacuum physiotherapy (VP) improves graft suppleness and overall outcomes. MATERIALS AND METHODS: Retrospective analysis of n = 71 patients with proximal hypospadias and severe ventral penile curvature (PC) of ≥50° after degloving. PC was corrected using ventral transverse incisions of the tunica albuginea (VTITA) without applying a tourniquet, taking care to avoid injuring the underlying erectile tissue. The ventral raw area at the penile shaft, including VTITA, were covered with either divided and partially mobilized urethral plate, or with the inner preputial graft itself. During the second stage, a tunica vaginalis flap was often used to cover the tubularized neourethra. Outcomes and post-op complications were assessed after each stage, comparing patients who received vacuum physiotherapy (VP+, n = 49) with those who did not (VP-, n = 22). RESULTS: Mean PC was 66°, average follow-up duration was 13.01 months, and overall complication rate was 22.5%. Only 6 of 49 VP + patients experienced complications (12.24%; 4 fistulas; 2 urethral strictures) and no recurrence of PC after second stage was observed in this group. VP- patients displayed a significantly higher rate of complications, with 10 of 22 cases (45.45%) exhibiting fistula development (n = 5) and glans dehiscence (n = 5). Recurrence of mild PC after first-stage repair was comparable between patient groups (12% VP+, 18% VP-) and easily corrected by simple graft tubularization or dorsal plication during second-stage repair. CONCLUSIONS: Staged repair using VTITA is effective for correcting proximal hypospadias with severe chordee. VP appears to promote and expedite graft suppleness and significantly improves patient outcomes.

Functional recoverability post-pyeloplasty in children with ureteropelvic junction obstruction and poorly functioning kidneys: Systematic review.

BACKGROUND: The management of poorly functioning kidneys (PFK) associated with ureteropelvic junction obstruction (UPJO) is controversial. There is contradictory information about how to best manage these cases: pyeloplasty or nephrectomy? OBJECTIVE: To systematically summarize the available evidence concerning the effects of pyeloplasty on the differential renal function of PFK in children with unilateral UPJO, highlighting the ongoing challenges in their definition, management, and long-term follow-up. In addition, we aim to verify potential predictors of renal functional recoverability that could help clinicians choose candidates for pyeloplasty. METHODS: We searched several databases including PubMed, Embase, and Cochrane Library CENTRAL until August 20, 2021, according to the PRISMA guidelines. The following concepts were searched: pediatric, ureteropelvic junction obstruction, UPJO, pyeloplasty, recovery, split renal function, and differential renal function. We enrolled studies where the PFK was defined as preoperative differential renal function (DRF) ≤30% by renal scintigraphy. Potential predictors of renal functional recoverability were assessed and compared among studies. The quality of the included studies was evaluated using a modified version of the Newcastle-Ottawa scale (NOS). RESULTS: 1499 citations perceived as relevant to screening were retrieved. After screening, 20 studies were included, comprising a total of 625 cases. The number of patients in each study varied between 5 and 84, while the average post-surgical follow-up duration ranged between 3 months and 180 months. The most significant preoperative predictive factor for postoperative functional recoverability was the baseline DRF, especially when antenatally diagnosed. The quality was considered average in a significant portion of included studies. CONCLUSION: A significant proportion of PFK showed an increase of DRF post-pyeloplasty. However, no consistent predictive factors for functional recoverability have yet been determined apart from preoperative DRF. Until further evidence appears, pyeloplasty should be considered a valid option in the armamentarium of UPJO management in PFK.

Plate Objective Scoring Tool (POST); An objective methodology for the assessment of urethral plate in distal hypospadias.

BACKGROUND: Estimation of the quality of the urethral plate (UP) seems to be important when assessing postoperative outcomes of hypospadias repair, but its evaluation remains subjective. We developed an objective model aiming to standardize this assessment, proposing a methodology that could be adopted in future studies designed to evaluate outcomes in the treatment of hypospadias. OBJECTIVES: To evaluate the inter and intra observer reliability of a method to assess the quality of the urethral plate (UP) in hypospadias (POST - Plate Objective Scoring Tool) based on elements of glans characteristics. The reliability of such scoring methodology was compared to an analog accepted tool: the Glans-Urethral Meatus-Shaft (GMS) score. A secondary goal was to compare some characteristics of the UP in GMS score to POST values; aiming to find the threshold between favorable and unfavorable plates. METHODS: Data were prospectively obtained from prepubertal boys who underwent primary hypospadias repair between January 2018 and November 2019. Intrinsic elements of the glanular UP (A: distal midline mucocutaneous junction; B: Glanular knob where the mucosal edges of the UP's edge change direction; C: Glanular/coronal junction) were marked and the AB/BC ratio calculated. The "G" and "M" components of the GMS score were measured electronically three times by four different reviewers with variable pediatric urology experience and blinded to each other values. Favorable UP, according to the GMS score was compared to measurements obtained by POST (AB/BC ratio). RESULTS: 84 subjects were enrolled. The POST score had an excellent inter-observer agreement for the evaluation of the UP in distal hypospadias (Kappa = 0.832) while the "G" parameter of the GMS correlated poorly among the observers. The Inter-Class Correlation (ICC) analysis to examine the intra-rater agreement value was 0.914 (95% CI 0.87, 0.95.). AB/BC ratio values ranged from 0.6 to 1.6, with a mean of 1.12. The POST cut-off value for "favorable" UP was 1.2 (AUC = 0.62) 95% CI (0.52-0.84) (sensitivity 80% and specificity 60%). CONCLUSIONS: The POST score has higher inter-observer reliability and functions favorably when compared to the GMS. In addition, it demonstrated a high intra-observer reliability among observers of variable experience. Our findings suggest that the POST score adds to evaluation of the UP and could be incorporated as an additional criterion to assess outcomes in distal hypospadias repairs.

Upper lip graft (ULG) for redo urethroplasties in children. A step by step video.

PURPOSE: Lower lip and cheek are commonly used sources of buccal mucosa grafts for urethroplasty. In recent years, aiming to improve the donor site morbidity, our preference changed to the use (ULG). The aim of this video is to illustrate the technical details of the ULG harvesting for children. MATERIAL AND METHODS: The inner surface of the upper lip is exposed by two stay sutures. The frenulum is spared, the mucosa to be harvested is marked and local submucosal infiltration is done with a solution of bupivacaine plus epinephrine. The edges are incised ant the submucosa plane created with a scissor. The graft is detached, defatted, and applied with quilting stitches over the recipient site with the standard technique. Hemostasis is secured and the donor site is left open. RESULTS: From 2015 to 2018, 25 ULG harvests were done in 24 patients. Only one (5%) presented local pain associated to the procedure in the first 24 h. After minimum 2 months after surgery, none of the patients presented perioral nubmness, difficulty with mouth opening, contraction of the donor site or changes in salivation. CONCLUSIONS: ULG harvest is easy and a suitable alternative source of oral mucosa for urethroplasty in children.