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Re: Prepubertal Follow-up After Hypospadias Repair with Autologous In Vitro Cultured Urothelial Cells
1904
PEDIATRIC UROLOGY
Re: Surgical Outcome in Children Undergoing Hypospadias Repair Under Caudal Epidural vs Penile Block P. Kundra, K. Yuvaraj, K. Agrawal, S. Krishnappa and L. T. Kumar Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India Paediatr Anaesth 2012; 22: 707–712.
Aim and Objective: To evaluate the effect of penile block vs caudal epidural on the quality of analgesia and surgical outcome following hypospadias repair. Background: Intraoperative penile engorgement because of caudal epidural may result in tension on surgical sutures and alter surgical outcome. Methods: Fifty-four ASA I and II children were randomly allocated to group P (penile block, 0.25% bupivacaine, 0.5 mg䡠kg⫺1; n ⫽ 27) and group C (caudal epidural, 0.25% bupivacaine, 0.5 ml䡠kg⫺1; n ⫽ 27), respectively. Quality of analgesia was assessed by visual analog scale (VAS) score recorded at 0, 0.5, 3, 6, 12, 24 h, and once a day for the next 4 days. Duration of analgesia was calculated from the institution of block to the first analgesic demand by child or VAS ⬎ 5. Total morphine consumption in the first 48 h and oral paracetamol consumption till 5th day were recorded. Children were regularly followed up in their respective outpatient clinic for early or late complications. Results: In group P, lower mean VAS scores were seen from 0.5 h after surgery till day 3 and analgesia lasted for significantly longer duration (82 min) when compared with caudal epidural, P ⬍ 0.001. Incidence of urethral fistula formation after primary hypospadias repair was 19.2%, and all had received caudal epidural. An increase of 27% in penile volume from baseline value was observed 10 min after caudal epidural placement, P ⬍ 0.05. Conclusion: Penile block provided better analgesia when compared with caudal epidural in children undergoing primary hypospadias repair. Postoperative urethral fistula formation was more likely in children who received caudal epidural. Editorial Comment: This fascinating article suggests that penile block not only is more effective than caudal block for pain associated with hypospadias repair, but also results in fewer long-term surgical complications. The authors hypothesize that the caudal block results in venous pooling, as previously reported in transurethral surgery in adults, resulting in larger penile volumes as documented in this randomized prospective study. If future series confirm these data, then we may want to substitute penile block for caudal block in boys undergoing hypospadias repair. Douglas A. Canning, M.D.
Re: Prepubertal Follow-up After Hypospadias Repair with Autologous In Vitro Cultured Urothelial Cells M. Fossum, J. Skikuniene, A. Orrego and A. Nordenskjöld Department of Paediatric Surgery, Division of Urology, Astrid Lindgren Children’s Hospital, Karolinska University, Stockholm, Sweden Acta Paediatr 2012; 101: 755–760.
Aim: To evaluate the long-term effects on hypospadias repair with cultured autologous urothelial cells. Methods: From 2000 to 2002, six patients with scrotal or perineal hypospadias and pronounced chordee were treated surgically with cultured autologous urothelial cell transplants. All patients were evaluated at 6 – 8 years postoperatively, that is, in the prepubertal period. The outcome was assessed with respect to cosmetic appearance, voiding function, urinary flow, artificial erection, urethroscopy and biopsies. Results: Median follow-up time was 7.25 years. Up to date, all patients present with a good cosmetic appearance. One of the boys prefers a sitting voiding position. Urinary flow curves are bell-shaped in all but one. All have straight erections, urethroscopy reveals an even, non-hair-bearing surface on the transplanted side and 2/6 present with urothelial cells in biopsies. Limitations of this follow-up study include a small group of patients and lack of controls. However, patients with severe hypospadias have high complication rates, and our results are equal or better than expected for the
PEDIATRIC UROLOGY
1905
phenotype. Conclusion: Tissue engineering for severe hypospadias repair can be performed in a safe manner. The method is feasible for treatment of a selected group of hypospadias, where pronounced chordee and shortage of preputial and penile skin complicates the creation of a neourethra. Editorial Comment: The authors report long-term results following use of engineered urethral tissue for hypospadias repair. In this model during the first stage repair urothelial cells are harvested and then sent to a remote laboratory for cell culturing. Six months later the 10 mm graft is placed as an onlay onto a 10 mm strip of perineal tissue over an 8Fr urethral catheter. The graft is then covered with the adjacent tissue. Four of the 6 children in this study had a bell-shaped flow rate with no evidence of stricture or fistula at more than 6 years of followup. These results are exciting. We are not far away from the commonplace use of autologous urothelium for major urethral reconstruction. Douglas A. Canning, M.D.
Suggested Reading De Filippo RE, Yoo JJ and Atala A: Urethral replacement using cell seeded tubularized collagen matrices. J Urol 2002; 168: 1789.
Re: Functional, Cosmetic and Psychosexual Results in Adult Men who Underwent Hypospadias Correction in Childhood S. P. Rynja, T. P. de Jong, J. L. Bosch and L. M. de Kort University Medical Center Utrecht, Utrecht, The Netherlands J Pediatr Urol 2011; 7: 504 –515.
Objective: Long-term results of hypospadias repair are scarce. Previous reviews mostly described mid-term results making extrapolation to long-term results difficult. This systematic review on long-term results in postpubertal men after hypospadias repair in childhood, aims to inform urologists and parents of a newborn boy with hypospadias about future expectations. Methods and Materials: The Pubmed/Medline and Embase databases were searched until February 2010. Inclusion criteria stated that patients with hypospadias were operated before the age of 6 years and were older than 14 years at follow up. Results were pooled and analyzed using SPSS 16.0. Data on proximal hypospadias patients and controls are described separately. Results: Twenty eligible studies investigating micturition, cosmesis and psychosexual functioning were found. Hypospadias patients report more urinary symptoms and have a lower Qmax than controls. Patients are less satisfied with penile appearance compared to controls. Objectively assessed cosmetic results are good. Sexually, patients are as active as controls, but are less satisfied. Patients less often have an intimate relationships compared to controls. Conclusion: Study outcomes were heterogeneous due to operation techniques and a lack of validated questionnaires and control groups. Long-term results of hypospadias patients should be measured in a prospective design using validated measurement tools. Editorial Comment: The authors performed a systematic literature search, including hypospadias and long-term followup, using PubMed and Embase. After long-term followup boys with repaired hypospadias complained of spraying, post-void dribbling and a feeling of incomplete emptying, and were less satisfied with penile appearance. Sexual function was satisfactory in 81% of the total hypospadias group but more controls than patients with hypospadias were satisfied (93% vs 81%). Patients with severe hypospadias less often had an intimate relationship compared to controls. Although we are making progress all the time with reconstruction for hypospadias, we still need to be cognizant of the importance of following these boys well into adulthood to be sure that we are meeting their
PEDIATRIC UROLOGY
Re: Surgical Outcome in Children Undergoing Hypospadias Repair Under Caudal Epidural vs Penile Block P. Kundra, K. Yuvaraj, K. Agrawal, S. Krishnappa and L. T. Kumar Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India Paediatr Anaesth 2012; 22: 707–712.
Aim and Objective: To evaluate the effect of penile block vs caudal epidural on the quality of analgesia and surgical outcome following hypospadias repair. Background: Intraoperative penile engorgement because of caudal epidural may result in tension on surgical sutures and alter surgical outcome. Methods: Fifty-four ASA I and II children were randomly allocated to group P (penile block, 0.25% bupivacaine, 0.5 mg䡠kg⫺1; n ⫽ 27) and group C (caudal epidural, 0.25% bupivacaine, 0.5 ml䡠kg⫺1; n ⫽ 27), respectively. Quality of analgesia was assessed by visual analog scale (VAS) score recorded at 0, 0.5, 3, 6, 12, 24 h, and once a day for the next 4 days. Duration of analgesia was calculated from the institution of block to the first analgesic demand by child or VAS ⬎ 5. Total morphine consumption in the first 48 h and oral paracetamol consumption till 5th day were recorded. Children were regularly followed up in their respective outpatient clinic for early or late complications. Results: In group P, lower mean VAS scores were seen from 0.5 h after surgery till day 3 and analgesia lasted for significantly longer duration (82 min) when compared with caudal epidural, P ⬍ 0.001. Incidence of urethral fistula formation after primary hypospadias repair was 19.2%, and all had received caudal epidural. An increase of 27% in penile volume from baseline value was observed 10 min after caudal epidural placement, P ⬍ 0.05. Conclusion: Penile block provided better analgesia when compared with caudal epidural in children undergoing primary hypospadias repair. Postoperative urethral fistula formation was more likely in children who received caudal epidural. Editorial Comment: This fascinating article suggests that penile block not only is more effective than caudal block for pain associated with hypospadias repair, but also results in fewer long-term surgical complications. The authors hypothesize that the caudal block results in venous pooling, as previously reported in transurethral surgery in adults, resulting in larger penile volumes as documented in this randomized prospective study. If future series confirm these data, then we may want to substitute penile block for caudal block in boys undergoing hypospadias repair. Douglas A. Canning, M.D.
Re: Prepubertal Follow-up After Hypospadias Repair with Autologous In Vitro Cultured Urothelial Cells M. Fossum, J. Skikuniene, A. Orrego and A. Nordenskjöld Department of Paediatric Surgery, Division of Urology, Astrid Lindgren Children’s Hospital, Karolinska University, Stockholm, Sweden Acta Paediatr 2012; 101: 755–760.
Aim: To evaluate the long-term effects on hypospadias repair with cultured autologous urothelial cells. Methods: From 2000 to 2002, six patients with scrotal or perineal hypospadias and pronounced chordee were treated surgically with cultured autologous urothelial cell transplants. All patients were evaluated at 6 – 8 years postoperatively, that is, in the prepubertal period. The outcome was assessed with respect to cosmetic appearance, voiding function, urinary flow, artificial erection, urethroscopy and biopsies. Results: Median follow-up time was 7.25 years. Up to date, all patients present with a good cosmetic appearance. One of the boys prefers a sitting voiding position. Urinary flow curves are bell-shaped in all but one. All have straight erections, urethroscopy reveals an even, non-hair-bearing surface on the transplanted side and 2/6 present with urothelial cells in biopsies. Limitations of this follow-up study include a small group of patients and lack of controls. However, patients with severe hypospadias have high complication rates, and our results are equal or better than expected for the
PEDIATRIC UROLOGY
1905
phenotype. Conclusion: Tissue engineering for severe hypospadias repair can be performed in a safe manner. The method is feasible for treatment of a selected group of hypospadias, where pronounced chordee and shortage of preputial and penile skin complicates the creation of a neourethra. Editorial Comment: The authors report long-term results following use of engineered urethral tissue for hypospadias repair. In this model during the first stage repair urothelial cells are harvested and then sent to a remote laboratory for cell culturing. Six months later the 10 mm graft is placed as an onlay onto a 10 mm strip of perineal tissue over an 8Fr urethral catheter. The graft is then covered with the adjacent tissue. Four of the 6 children in this study had a bell-shaped flow rate with no evidence of stricture or fistula at more than 6 years of followup. These results are exciting. We are not far away from the commonplace use of autologous urothelium for major urethral reconstruction. Douglas A. Canning, M.D.
Suggested Reading De Filippo RE, Yoo JJ and Atala A: Urethral replacement using cell seeded tubularized collagen matrices. J Urol 2002; 168: 1789.
Re: Functional, Cosmetic and Psychosexual Results in Adult Men who Underwent Hypospadias Correction in Childhood S. P. Rynja, T. P. de Jong, J. L. Bosch and L. M. de Kort University Medical Center Utrecht, Utrecht, The Netherlands J Pediatr Urol 2011; 7: 504 –515.
Objective: Long-term results of hypospadias repair are scarce. Previous reviews mostly described mid-term results making extrapolation to long-term results difficult. This systematic review on long-term results in postpubertal men after hypospadias repair in childhood, aims to inform urologists and parents of a newborn boy with hypospadias about future expectations. Methods and Materials: The Pubmed/Medline and Embase databases were searched until February 2010. Inclusion criteria stated that patients with hypospadias were operated before the age of 6 years and were older than 14 years at follow up. Results were pooled and analyzed using SPSS 16.0. Data on proximal hypospadias patients and controls are described separately. Results: Twenty eligible studies investigating micturition, cosmesis and psychosexual functioning were found. Hypospadias patients report more urinary symptoms and have a lower Qmax than controls. Patients are less satisfied with penile appearance compared to controls. Objectively assessed cosmetic results are good. Sexually, patients are as active as controls, but are less satisfied. Patients less often have an intimate relationships compared to controls. Conclusion: Study outcomes were heterogeneous due to operation techniques and a lack of validated questionnaires and control groups. Long-term results of hypospadias patients should be measured in a prospective design using validated measurement tools. Editorial Comment: The authors performed a systematic literature search, including hypospadias and long-term followup, using PubMed and Embase. After long-term followup boys with repaired hypospadias complained of spraying, post-void dribbling and a feeling of incomplete emptying, and were less satisfied with penile appearance. Sexual function was satisfactory in 81% of the total hypospadias group but more controls than patients with hypospadias were satisfied (93% vs 81%). Patients with severe hypospadias less often had an intimate relationship compared to controls. Although we are making progress all the time with reconstruction for hypospadias, we still need to be cognizant of the importance of following these boys well into adulthood to be sure that we are meeting their