Summary
Introduction
The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used
to assess hypospadias severity and risk for post-operative complications. The ‘M’
component is based on pre-operative meatal location, but meatal location sometimes
changes after penile degloving, resulting in ‘meatal mismatch.‘
Objective
To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the
association of meatal mismatch with post-operative urethrocutaneous fistula development.
Study design
We performed a retrospective cohort study on patients who underwent primary hypospadias
repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging
(meatus moving more proximally after degloving), downstaging (moving more distally
after degloving), or none. Covariates included: pre-degloving meatal location, chordee
severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for
repair. To test the association between meatal mismatch and fistula development, we
constructed two, nested, multivariable Cox proportional hazards regression models
with and without meatal mismatch and compared them with the likelihood ratio test.
A sensitivity analysis excluded patients with <6 months of follow-up.
Results
Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging
and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly
associated with penoscrotal webbing, number of stages for repair, and pre-degloving
meatal location, with downstaging being associated with more proximal meatal location.
Over a median follow-up of 7.3 months (interquartile range 2.0–20.9), fistulae developed
in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with
a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence
Interval [CI]: 1.44–6.45) compared to no mismatch. Meatal downstaging had similar
risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29–3.35).
Multi-stage compared to single-stage repair was associated with reduced risk of fistula
development (HR: 0.24, 95% CI: 0.09–0.66). The likelihood ratio test favored the model
that included meatal mismatch. The sensitivity analysis showed similar findings.
Discussion
Our short-term results suggest that meatal mismatch may be an important additional
consideration to the GMS score as a tool to assess hypospadias severity, counsel families,
and predict outcomes. Longer-term studies are needed to enhance the precision of risk
stratification in hypospadias.
Conclusions
Graphical AbstractFlow diagram of cohort and major findings.
Summary Table 1Sensitivity Analysis (restricted to patients with ≥6 months of follow-up, N=275) multivariable
Cox regression models with and without meatal mismatch. Likelihood ratio test showed
better fit with full model (p=0.04).
| Variable | Base Model HR (95% CI), p-value | Full Model HR (95% CI), p-value |
|---|---|---|
| Pre-degloving Meatal Location | ||
| Glanular | Referent | Referent |
| Coronal | 0.54 (0.09–3.24), p = 0.50 | 0.58 (0.10-3.53), p = 0.56 |
| Distal/Midshaft | 1.61 (0.38-6.91), p = 0.52 | 2.24 (0.50-10.03), p = 0.29 |
| Proximal | 3.33 (0.69-16.18), p = 0.14 | 7.18 (1.21-42.52), p = 0.001 |
| Chordee Severity (n = 457) | ||
| None (0°) | Referent | Referent |
| Mild (1–29°) | 3.41 (0.43-26.80), p = 0.24 | 3.90 (0.50-30.50), p = 0.20 |
| Moderate (30–60°) | 3.91 (0.48-31.66), p = 0.20 | 3.61 (0.45-29.01), p = 0.23 |
| Severe (≥61°) | 4.11 (0.50-34.02), p = 0.19 | 3.95 (0.48-32.51), p = 0.20 |
| # of Stages of Repair | ||
| Single-stage | Referent | Referent |
| Multi-stage | 1.97 (1.01-3.84), p = 0.047 | 1.76 (0.89-3.47), p = 0.11 |
| Pre-operative Testosterone | ||
| No | Referent | Referent |
| Yes | 1.65 (0.92–2.98), p = 0.10 | 1.43 (0.78–2.62), p = 0.25 |
| Meatal Mismatch | ||
| No mismatch | – | Referent |
| Meatal downstaging | – | 0.88 (0.25-3.01), p = 0.84 |
| Meatal upstaging | – | 3.04 (1.34-6.88), p = 0.007 |
Keywords
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Article info
Publication history
Published online: December 03, 2020
Accepted:
November 25,
2020
Received in revised form:
November 20,
2020
Received:
August 17,
2020
Identification
Copyright
© 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
