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199 POST-PUBERTAL OUTCOME AFTER DISTAL HYPOSPADIAS REPAIR IN CHILDHOOD USING THE MEATAL MOBILIZATION (MEMO) TECHNIQUE
requirement of minimal follow-up, so, 59 cases were eligible for the study; 32 cases in group A and 27 in group B. Patients in both groups have comparable preoperative clinical data. At a mean (±SD) of 12.2 (± 3.8) months follow-up, the outcome was perfect (absence of fistula) in all children in group B while, two patients of group A presented by postoperative urethrocutaneous fistula but this relevance did not reach statistical significance (p values = 0.19). Meatal stenosis occurred in 2 cases in group A and 1 case in group B (p value= 0.66). Conclusions: There was no significant statistical difference between double layers dartos flap versus single layer in coverage of urethra as a part of TIP urethroplasty in repair of hypospadias regarding urethrocutaneous fistula. Prospective randomized clinical trials with a large number of patients are demanded to confirm or disproof this conclusion.
197
Long-term results of dorsal inlay graft urethroplasty in children with distal and mid shaft hypospadias
a palliative reaction more often scored lower on Overall satisfaction (P -0.354; p<0.05) and satisfaction with body image (P -0.34; p<0.05). In a multivariate linear regression analysis the effects of coping styles on subjective outcomes disappear. Subjective outcomes are predicted stronger by the Intercourse satisfaction (IIEF), the satisfaction of penile appearance and the severity of hypospadias than by coping styles. Conclusions: Hypospadias patients apply the coping style ‘Avoidance’ more often compared to the reference group, possibly due to their history of genital surgery. Long-term subjective outcomes (QoL) of hypospadias patients are not predicted by the coping styles. Therefore, coping styles do not provide an explanation for the discrepancy seen between objective and subjective outcomes seen in the longterm results of hypospadias repair.
199
Post-pubertal outcome after distal hypospadias repair in childhood using the meatal mobilization (MEMO) technique
Rudin Y.E., Maruchnenko D.V., Garmanova T.N. Research Institute of Urology, Dept. of Paediatrics, Moscow, Russia
Seibold J., Werther M., Gakis G., Alloussi S., Schilling D., Stenzl A., Schwentner C. Eberhard-Karls University, Dept. of Urology, Tübingen, Germany
Introduction & Objectives: Hypospadias is the most frequent congenital abnormalities of penis which boys may have. It occurs in average in 1:200 male child. The characteristic evidence of the abnormality is dystopia of the external urethral opening (meatus) and deformation of the cavernous bodies of penis. The operative therapy of the coronal, subcoronal and especially penile shaft form of the abnormality is accompanied with the large amount of the unsuccessful results 15-35%. Small size of penile glans is one of the main problems of hypospadias correction. Deficiency of plastic material results in narrowing the distal part of urethra and is the main cause of fistulas formation. Materials & Methods: 185 boys (aged 6 mo 17 years) were random divided into two groups. In the first group (n=89) one-stage (TIP) tabularised incised plate hypospadias repair was performed. Patients of the second group (n=109) underwent one-stage (TPIG) hypospadias correction. We performed the standard TIP procedure with vertical relaxing incision widens the urethral plate. The surface of being incised plate was covered with the preputial skin graft. The preputial graft was connected with the glans by 10-20 absorbable sutures. Urethral plate is tabularised with a two-layer running subepithelial absorbable sutures. The entire neourethra was covered with two lays of deepithelised preputial skin flaps. Results: Follow up was 6 months to 4 years. Cosmetic and functional results were satisfactory in the majority of patients. Complications included in the first (TIP) group - 15 fistulae (16,8%) combined with 12 glanular stenosis (8,9%). The patients of the second group (TPIG) had fistulas only in 6 cases (5,5%) without stenosis, with normal peak flow. According to uroflowmetry data at the long date (2-3 years after operation) the decrease of values of urine flow is detected at 29 children (32%) of the first group and at 3 boys (2%) of the second group. Conclusions: The operation of the vertical cut of the urethral plate plus implantation of the graft of foreskin enables to conduct the single-step plastics of urethra even upon small sizes of the balanus. The proposed method enables to drastically minimize the number of postoperative complications.
Introduction & Objectives: Meatal mobilization (MEMO) after distal urethral preparation can be used for distal hypospadias repair with or without chordee. Initial data yielded promising cosmetic and functional results. However, nothing is yet known about the post pubertal outcome, patients` self perception and importantly sexual function. Herein, we present a cohort of patients who have reached adulthood after hypospadias repair in childhood focussing on the abovementioned items. Materials & Methods: 286 patients who underwent glandular, coronal or subcoronal hypospadias repair using the meatal mobilization (MEMO) technique were retrospectively identified. Of those 25 are older than 18 years. This cohort was invited by phone or mail and was specifically investigated using uroflow, residual urine measurement, sexual function (IIEF) and quality of life (QoL). Finally, the so-called HOSE-score (objective hypospadias symptom score) was applied. Results: All 25 patients were available for follow-up. No additional findings were documented in terms of cosmesis or fistula formation (0/25). All had a negative urine culture and no post-void residual. Uroflow-patterns were bell-shaped in all 25 men. Median HOSE-score was 15 (of maximum 16 points). All had a straight erection of the penis. IIEF-scores were normal in all men. Conclusions: Using the MEMO technique for correction of distal hypospadias, complications are minimal while the cosmetic results remain excellent over time. In the long-term follow-up no additional fistula or meatal stenosis occurred. Sexual function and quality of life after puberty are comparable to healthy age matched individuals.
198
Coping style: Indicator of reported long-term outcomes in hypospadias patients?
Rynja S.P., De Kort L.M.O., Bosch J.L.H.R., Kok E.T. University Medical Center Utrecht, Dept. of Urology, Utrecht, The Netherlands Introduction & Objectives: Long-term results of hypospadias repair often show a discrepancy between the (subjective) outcomes reported by patients and the observed (objective) outcomes. Subjective outcomes, such as quality of life (QoL), are known to be influenced by coping styles. A coping style represents the way one manages stressful situations, and can affect psychosocial, physical and social well-being. This is the first study investigating the influence of coping styles on the reported long-term results in hypospadias patients to explain this discrepancy. Materials & Methods: In total, 131 adult men could be traced, who underwent hypospadias repair in childhood. They were invited to fill out a questionnaire and to visit the outpatient clinic. The questionnaire contained the International Index of Erectile Function (IIEF), International Prostate Symptom Score (IPSS), the Dutch Relationship Questionnaire and additional cosmetic questions (VAS). The subjective parameters of QoL used for analysis were the IIEF domains ‘Overall Satisfaction’ and ‘Intercourse Satisfaction’, IPSS-QoL (question 8), total score of the Dutch Relationship Questionnaire and the satisfaction with body image, penile appearance and penile length. Coping was measured using the Utrecht Coping List (UCL) containing 7 styles: Active problem solving, Palliative reaction, Avoidance, Seeking social support, Passive reaction, Expression of emotions and Reassuring thoughts. Mean UCL-scores of hypospadias patients were compared with reference scores of a Dutch population provided by the UCL (n=55, age 20-30 years). Uni- and multivariate linear regression were used for analysis. Results: Patients with hypospadias (n=55, age 20.9 ±2.4 years) score higher on the coping style Avoidance compared to the reference group (p<0.05). UCL-scores did not vary within the group of hypospadias patients. Higher scores on the coping style ‘Avoidance’ are correlated with a lower satisfaction with penile appearance (Pearson (P) -0.30; p<0.05) and body image (P -0.38; p<0.01). Patients applying
200
A randomised trial comparing two nerve block techniques for post operative analgesia in paediatric circumcision
Cullen I.M.1, Long R.M.1, Mc Guire B.B.1, Hooker P.2, Kennedy J.2, Harmon D.2, Flood H.D.1 1 MWRH Limerick, Dept. of Urology, Limerick, Ireland, 2MWRH Limerick, Dept. of Anaesthesia, Limerick, Ireland Introduction & Objectives: Techniques to minimize the postoperative discomfort of circumcision include caudal block, penile nerve block, systemic opioids, and topical local anaesthetics. Since its description by Kirya & Werthmann in 1978, the dorsal nerve block (DNB) of the penis as an adjunct to general anesthesia in paediatric circumcision is a well established technique of minimising post operative discomfort. However, this technique has not been standardized and variations in the technique had led to varying degrees of efficacy. This institution has developed a novel technique whereby the dorsal penile nerves are infiltrated bilaterally with local anaesthetic at the root of the penis - locally termed the ‘Buck’s fascia block’ (BFB) which involves introducing a 25G needle dorsally at the base of the penis, deep to the skin at the ten and two o’clock positions. This technique has been previously described and published as an effective technique for circumcision under local anaesthetic (LA). As with the traditional DNB, ventral infiltration of LA at the site of incision is necessary for complete anaesthesia of the frenular area. Materials & Methods: 28 children (aged 26 months to 156 months), ASA physical status I and II, who were scheduled for elective circumcision, were randomly assigned to have either the traditional dorsal nerve block (DNB) or the bucks fascia block (BFB).Each nerve block was performed by the same operating surgeon in each case who also completed each circumcision in the sleeve manner. The efficacy of postoperative analgesia was measured using the modified objective pain score (OPS), in which objective behavioural variables (crying, degree of agitation, motor restlessness, pain localization) together with changes in systolic blood pressure. An increase in heart rate or mean arterial pressure of >10% during surgery was defined as 'insufficient intraoperative analgesia' and treated with fentanyl 3 mcg/kg i.v. If the OPS score was >7 (5 if child unable to verbalise) in 2 subsequent measurements the child received morphine 0.05mg/kg boluses until the pain abated. Results: A total of 6 children in the DNB group were deemed to have had ‘insufficient intraoperative anaesthesia' compared to 1 in the BFB group (p=0.114).2 children in
Eur Urol Suppl 2011;10(2):85
197
Long-term results of dorsal inlay graft urethroplasty in children with distal and mid shaft hypospadias
a palliative reaction more often scored lower on Overall satisfaction (P -0.354; p<0.05) and satisfaction with body image (P -0.34; p<0.05). In a multivariate linear regression analysis the effects of coping styles on subjective outcomes disappear. Subjective outcomes are predicted stronger by the Intercourse satisfaction (IIEF), the satisfaction of penile appearance and the severity of hypospadias than by coping styles. Conclusions: Hypospadias patients apply the coping style ‘Avoidance’ more often compared to the reference group, possibly due to their history of genital surgery. Long-term subjective outcomes (QoL) of hypospadias patients are not predicted by the coping styles. Therefore, coping styles do not provide an explanation for the discrepancy seen between objective and subjective outcomes seen in the longterm results of hypospadias repair.
199
Post-pubertal outcome after distal hypospadias repair in childhood using the meatal mobilization (MEMO) technique
Rudin Y.E., Maruchnenko D.V., Garmanova T.N. Research Institute of Urology, Dept. of Paediatrics, Moscow, Russia
Seibold J., Werther M., Gakis G., Alloussi S., Schilling D., Stenzl A., Schwentner C. Eberhard-Karls University, Dept. of Urology, Tübingen, Germany
Introduction & Objectives: Hypospadias is the most frequent congenital abnormalities of penis which boys may have. It occurs in average in 1:200 male child. The characteristic evidence of the abnormality is dystopia of the external urethral opening (meatus) and deformation of the cavernous bodies of penis. The operative therapy of the coronal, subcoronal and especially penile shaft form of the abnormality is accompanied with the large amount of the unsuccessful results 15-35%. Small size of penile glans is one of the main problems of hypospadias correction. Deficiency of plastic material results in narrowing the distal part of urethra and is the main cause of fistulas formation. Materials & Methods: 185 boys (aged 6 mo 17 years) were random divided into two groups. In the first group (n=89) one-stage (TIP) tabularised incised plate hypospadias repair was performed. Patients of the second group (n=109) underwent one-stage (TPIG) hypospadias correction. We performed the standard TIP procedure with vertical relaxing incision widens the urethral plate. The surface of being incised plate was covered with the preputial skin graft. The preputial graft was connected with the glans by 10-20 absorbable sutures. Urethral plate is tabularised with a two-layer running subepithelial absorbable sutures. The entire neourethra was covered with two lays of deepithelised preputial skin flaps. Results: Follow up was 6 months to 4 years. Cosmetic and functional results were satisfactory in the majority of patients. Complications included in the first (TIP) group - 15 fistulae (16,8%) combined with 12 glanular stenosis (8,9%). The patients of the second group (TPIG) had fistulas only in 6 cases (5,5%) without stenosis, with normal peak flow. According to uroflowmetry data at the long date (2-3 years after operation) the decrease of values of urine flow is detected at 29 children (32%) of the first group and at 3 boys (2%) of the second group. Conclusions: The operation of the vertical cut of the urethral plate plus implantation of the graft of foreskin enables to conduct the single-step plastics of urethra even upon small sizes of the balanus. The proposed method enables to drastically minimize the number of postoperative complications.
Introduction & Objectives: Meatal mobilization (MEMO) after distal urethral preparation can be used for distal hypospadias repair with or without chordee. Initial data yielded promising cosmetic and functional results. However, nothing is yet known about the post pubertal outcome, patients` self perception and importantly sexual function. Herein, we present a cohort of patients who have reached adulthood after hypospadias repair in childhood focussing on the abovementioned items. Materials & Methods: 286 patients who underwent glandular, coronal or subcoronal hypospadias repair using the meatal mobilization (MEMO) technique were retrospectively identified. Of those 25 are older than 18 years. This cohort was invited by phone or mail and was specifically investigated using uroflow, residual urine measurement, sexual function (IIEF) and quality of life (QoL). Finally, the so-called HOSE-score (objective hypospadias symptom score) was applied. Results: All 25 patients were available for follow-up. No additional findings were documented in terms of cosmesis or fistula formation (0/25). All had a negative urine culture and no post-void residual. Uroflow-patterns were bell-shaped in all 25 men. Median HOSE-score was 15 (of maximum 16 points). All had a straight erection of the penis. IIEF-scores were normal in all men. Conclusions: Using the MEMO technique for correction of distal hypospadias, complications are minimal while the cosmetic results remain excellent over time. In the long-term follow-up no additional fistula or meatal stenosis occurred. Sexual function and quality of life after puberty are comparable to healthy age matched individuals.
198
Coping style: Indicator of reported long-term outcomes in hypospadias patients?
Rynja S.P., De Kort L.M.O., Bosch J.L.H.R., Kok E.T. University Medical Center Utrecht, Dept. of Urology, Utrecht, The Netherlands Introduction & Objectives: Long-term results of hypospadias repair often show a discrepancy between the (subjective) outcomes reported by patients and the observed (objective) outcomes. Subjective outcomes, such as quality of life (QoL), are known to be influenced by coping styles. A coping style represents the way one manages stressful situations, and can affect psychosocial, physical and social well-being. This is the first study investigating the influence of coping styles on the reported long-term results in hypospadias patients to explain this discrepancy. Materials & Methods: In total, 131 adult men could be traced, who underwent hypospadias repair in childhood. They were invited to fill out a questionnaire and to visit the outpatient clinic. The questionnaire contained the International Index of Erectile Function (IIEF), International Prostate Symptom Score (IPSS), the Dutch Relationship Questionnaire and additional cosmetic questions (VAS). The subjective parameters of QoL used for analysis were the IIEF domains ‘Overall Satisfaction’ and ‘Intercourse Satisfaction’, IPSS-QoL (question 8), total score of the Dutch Relationship Questionnaire and the satisfaction with body image, penile appearance and penile length. Coping was measured using the Utrecht Coping List (UCL) containing 7 styles: Active problem solving, Palliative reaction, Avoidance, Seeking social support, Passive reaction, Expression of emotions and Reassuring thoughts. Mean UCL-scores of hypospadias patients were compared with reference scores of a Dutch population provided by the UCL (n=55, age 20-30 years). Uni- and multivariate linear regression were used for analysis. Results: Patients with hypospadias (n=55, age 20.9 ±2.4 years) score higher on the coping style Avoidance compared to the reference group (p<0.05). UCL-scores did not vary within the group of hypospadias patients. Higher scores on the coping style ‘Avoidance’ are correlated with a lower satisfaction with penile appearance (Pearson (P) -0.30; p<0.05) and body image (P -0.38; p<0.01). Patients applying
200
A randomised trial comparing two nerve block techniques for post operative analgesia in paediatric circumcision
Cullen I.M.1, Long R.M.1, Mc Guire B.B.1, Hooker P.2, Kennedy J.2, Harmon D.2, Flood H.D.1 1 MWRH Limerick, Dept. of Urology, Limerick, Ireland, 2MWRH Limerick, Dept. of Anaesthesia, Limerick, Ireland Introduction & Objectives: Techniques to minimize the postoperative discomfort of circumcision include caudal block, penile nerve block, systemic opioids, and topical local anaesthetics. Since its description by Kirya & Werthmann in 1978, the dorsal nerve block (DNB) of the penis as an adjunct to general anesthesia in paediatric circumcision is a well established technique of minimising post operative discomfort. However, this technique has not been standardized and variations in the technique had led to varying degrees of efficacy. This institution has developed a novel technique whereby the dorsal penile nerves are infiltrated bilaterally with local anaesthetic at the root of the penis - locally termed the ‘Buck’s fascia block’ (BFB) which involves introducing a 25G needle dorsally at the base of the penis, deep to the skin at the ten and two o’clock positions. This technique has been previously described and published as an effective technique for circumcision under local anaesthetic (LA). As with the traditional DNB, ventral infiltration of LA at the site of incision is necessary for complete anaesthesia of the frenular area. Materials & Methods: 28 children (aged 26 months to 156 months), ASA physical status I and II, who were scheduled for elective circumcision, were randomly assigned to have either the traditional dorsal nerve block (DNB) or the bucks fascia block (BFB).Each nerve block was performed by the same operating surgeon in each case who also completed each circumcision in the sleeve manner. The efficacy of postoperative analgesia was measured using the modified objective pain score (OPS), in which objective behavioural variables (crying, degree of agitation, motor restlessness, pain localization) together with changes in systolic blood pressure. An increase in heart rate or mean arterial pressure of >10% during surgery was defined as 'insufficient intraoperative analgesia' and treated with fentanyl 3 mcg/kg i.v. If the OPS score was >7 (5 if child unable to verbalise) in 2 subsequent measurements the child received morphine 0.05mg/kg boluses until the pain abated. Results: A total of 6 children in the DNB group were deemed to have had ‘insufficient intraoperative anaesthesia' compared to 1 in the BFB group (p=0.114).2 children in
Eur Urol Suppl 2011;10(2):85