Dissertation committee:
Κωνσταντινίδης Κωνσταντίνος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Μητρόπουλος Διονύσιος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αλαμανής Χρήστος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Νικητέας Νικόλαος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Στραβοδήμος Κωνσταντίνος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αναστασίου Ιωάννης, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αδαμάκης Ιωάννης, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Summary:
INTRODUCTION
The purpose of the present study is to evaluate the role of use of testosterone in the reduction of postoperative complications, as well to the best aesthetic result, in the surgical reconstruction of anterior, middle, posterior penile or scrotal hypospadias.
Particularly, the study aims to investigate the action of testosterone through the VEGF/MMPs pathway, in patients with hypospadias who have undergone plastic reconstruction, regarding the reduction of postoperative complications and the normalization of the postoperative scar.
MATERIAL AND METHODS
Thirty-three patients, boys aged 1-5½ years, with anterior, medial, posterior penile, or scrotal hypospadias who underwent one- or two-stage urethroplasty by the Duckett or Duplay technique, respectively, were studied. The average age of the sample was 3±1.4 years.
Of these, 18 were patients who received testosterone (group A) before the intervention (study group) with the main criterion being microphallia (penis <25mm or ≥2.5 standard deviations -SD- smaller size according to the patient's age), while the 15 were patients who did not receive testosterone (group B) and constituted the control group.
In the study group (group A), according to the endocrinologist's instructions, testosterone enanthate 25 mg was administered intramuscularly every 4 weeks, in 2 - 4 doses, maximum administration of 100 mg of testosterone (Luo et al., 2003). The number of doses was determined by clinical efficacy in increasing penile size, which was also the main goal of the treatment and was considered positive when penile length ≥35mm was achieved after treatment. The planning of the surgery was 3 months after the end of the treatment.
The patients of the second group (B) who were the control group did not receive testosterone, underwent the same type of operation and were studied in exactly the same way as the first group (A).
The study was conducted in accordance with the Declaration of Helsinki on the rights of patients and the parents gave their consent after being informed about the aims and methods of the study.
From the medical history, demographic data (name, age) as well as the individual patient data (type of hypospadias, time of admission and surgery, type of surgery, complications) were recorded for all participants. From the individual patient data, particular emphasis was placed on recording data regarding the complications of hypospadias surgery both in the early and the distant postoperative period (up to 6 months after surgery). The results of the reoperation to which all patients who experienced a further complication underwent were also recorded.
RESULTS
The sample consists of 33 patients (boys) who underwent surgical correction of hypospadias. 20 patients (60.6%) had two admissions, 12 (36.4%) one admission, while only one patient (3%) had three hospital admissions. 12 patients (36.3%) were with medial penile, 10 with posterior penile (30.3%), 8 with anterior penile (24.2%) and 3 with scrotal (9.1%) hypospadias. Surgical correction of hypospadias was performed in 22 patients with the Duplay technique (66.7%) and in 11 with the Duckett technique (33.3%).
In 18 patients (54.5%) testosterone was administered before the operation. Complications were presented in 7 patients (21.2%), which appeared in the immediate and later postoperative period. All patients who developed later complications (18.2%) underwent reoperation to correct the deformity.
Surgical correction of hypospadias
The correction of hypospadias cases in the study patients was done in one or two surgical stages. The 18 patients (54.5%) of the sample underwent a one-stage operation, while 15 patients (45.5%) underwent a two-stages operation. The surgical correction of hypospadias was done with the Duplay (66.7%) and Duckett (33.3%) technique.
Complications of hypospadias surgery
Hypospadias surgery was accompanied by complications in 7 patients (21.2%) and they occurred in the immediate or in the later postoperative period.
Specifically, 1 patient (3.0%) experienced postoperative bleeding, while 6 patients (18.2%) experienced postoperative fistula.
All patients who developed fistulas (18.2%) were re-operated and specifically closed, within an average postoperative interval of 1.1 years. All fistula closure procedures were successful.
Measurements
Foreskin samples were taken from all patients in the sample (N=33), while urethral plate samples were taken from 11 of them. From the samples taken, the following were determined:
• The CD31 index (number of microvessels)
• The intensity of the expression of the VEGF indicator (vessels, positive cells, stroma)
• The intensity of MMP-2 immunoexpression (vessels, positive cells, stroma)
• The intensity of MMP-9 immunoexpression (vessels, positive cells, stroma)
In the foreskin, 14 out of 18 patients in group A (77.8%) had values of CD31>15 and only 3 patients (16.7%) CD31 5-15. In contrast, all patients in group B (100%) had CD31 values of 5-15.
In the urethral plate, 4 out of 7 patients in group A (57.2%) had values of CD31>15 and 3 out of 7 (42.9%) CD31 5-15. Of group B patients, 2 out of 4 (50%) had CD31 5-15 and the same number (50%) had CD31>15 values.
In the foreskin, VEGF intensity in group A patients was moderate (++)/strong (+++) expression in vessels and cells (cell count >20), while in the stroma it was mainly weak (+) expression (66.7 %). In contrast group B patients had weak (+)/moderate (++) expression of VEGF both in vessels and cells (cell count 5-15) and in the stroma.
In the urethral plate, VEGF intensity in group A patients was moderate (++)/strong (+++) expression in both vessels and cells (cell count 10-15 and >20) and stroma. In contrast, group B patients had weak (+)/moderate (++) expression of VEGF in vessels and cells (cell count 5-15) and weak (+) expression in the stroma.
In the foreskin, MMP-2 intensity in group A patients was moderate (++)/strong (+++) expression in vessels (vessel number 5-15 and >20) and cells, while in the stroma it was mainly moderate (++)/strong (+++) expression (88.8%). In contrast, group B patients had weak (+) expression of MMP-2 in vessels (vessel number 5-15 and >20), weak (+)/moderate (++) in cells and mainly weak (+)/moderate (++) expression in stroma (93.3%).
In the urethral plate, MMP-2 intensity in group A patients was weak (+)/moderate (++) expression in vessels (vessel number 10-15 and >15), moderate (++)/strong (+++) in the cells, as well as in the stroma (85.7%). Accordingly, group B patients had weak (+)/moderate (++) expression of MMP-2 in vessels (vessel number 5-9 and >20), weak (+)/moderate (++) in cells and mainly moderate (++) expression in the stroma (50.0%).
In the foreskin, MMP-9 intensity in group A patients was of strong (+++) expression in vessels (vessel number >20), moderate (++)/strong (+++) in cells and stroma. In contrast, group B patients had weak (+)/moderate (++) expression of MMP-9 in vessels (vessel number 10-30), weak (+)/moderate (++) in cells and stroma.
In the urethral plate, MMP-9 intensity in group A patients was strong (+++) expression in vessels (vessel number 16-30 and >40), strong (+++) in cells and weak (+)/ moderate (++) expression in the stroma. Accordingly, group B patients had strong (+++) expression of MMP-9 in vessels (vessel number 5-9, 21-30 and >50), strong (+++) in cells and weak (+)/ moderate (++) expression in the stroma.
CONCLUSION:
The majority of hypospadias cases in group A were medial and posterior penile (66.6%), while most patients in group B had medial and anterior penile (73.3%) hypospadias.
The surgical correction of hypospadias in the patients of group A was done mainly with the Duplay technique (77.8%), while in the patients of group B, the Duckett technique was used mainly (46.7%) for the cases of correction in one-stage procedure.
Group A patients presented more complications (27.8%) compared to group B patients (13.3%), which were successfully treated through reoperation. All parameters examined did not show statistical significance (p>0.05).
Statistically significant differences were observed between the two groups of patients in the foreskin CD31 index values (p<0.001). Testosterone-treated patients (group A) had significantly higher microvessel count-CD31 values than control patients (group B).
No statistically significant differences were observed between the two groups of patients in the values of the CD31 index in the urethral plate (p>0.05).
Statistically significant differences were observed between the two groups of patients in the intensity of the expression of the VEGF index of vessels and cells in the foreskin (p<0.001). Testosterone-treated patients (group A) had significantly higher rates of strong (+++) VEGF expression in vessels and cells than control patients (group B). On the contrary, no statistically significant differences were observed in the expression rates of VEGF in the stroma (p>0.05).
Statistically significant differences were observed between the two groups of patients in the intensity of cell and stroma VEGF expression in the urethral plate (p<0.001). Testosterone-treated patients (group A) had significantly higher rates of moderate (++)/strong (+++) VEGF expression in cells and stroma compared to control patients (group B). On the contrary, no statistically significant differences were observed in the expression rates of VEGF in the vessels and in the number of cells (p>0.05).
Statistically significant differences were observed between the two groups of patients in the intensity of MMP-2 immunoexpression of vessels (p<0.001), cells (p<0.001) and stroma (p=0.018) in the foreskin. Testosterone-treated patients (group A) had significantly higher rates of moderate (++)/strong (+++) MMP-2 expression in both vessels and cells, as well as in the stroma, compared to patients in the control group (group B).
Statistically significant differences were observed between the two groups of patients in the number of MMP-2 vessels in the urethral plate (p=0.044). Testosterone-treated patients (group A) had significantly higher percentages with >15 MMP-2 compared to patients in the control group (group B). In contrast, no statistically significant differences were observed in the percentages of MMP-2 immunoexpression intensity of vessels, cells and urethral plate stroma (p>0.05).
Statistically significant differences were observed between the two groups of patients in the intensity of MMP-9 immunoexpression of vessels, cells and stroma in the foreskin (p<0.001). Testosterone-treated patients (group A) had significantly higher rates of strong (+++) MMP-9 expression in both vessels and cells, as well as in the stroma, compared to control patients (group B).
No statistically significant differences were observed between the two groups of patients in the percentages of MMP-9 immunoexpression intensity of vessels, cells and stroma in the urethral plate.
