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Association between intra-operative meatal mismatch and urethrocutaneous fistula development in hypospadias repair

  • Anthony D'Oro
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
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  • Yvonne Y. Chan
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
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  • Ilina Rosoklija
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine at Northwestern University, 633 N. St. Clair Street, Chicago, IL 60611, USA
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  • Theresa Meyer
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
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  • Rachel Shannon
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
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  • Emilie K. Johnson
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine at Northwestern University, 633 N. St. Clair Street, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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  • Dennis B. Liu
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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  • Edward M. Gong
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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  • Max Maizels
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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  • Derek J. Matoka
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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  • Elizabeth B. Yerkes
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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  • Bruce W. Lindgren
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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  • Earl Y. Cheng
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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  • David I. Chu
    Correspondence
    Correspondence to: David I. Chu, Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA.
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA

    Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine at Northwestern University, 633 N. St. Clair Street, Chicago, IL 60611, USA

    Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
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Published:December 03, 2020DOI:https://doi.org/10.1016/j.jpurol.2020.11.034

      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

      Summary Figure 1
      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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