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Back to Journal »Urology Research and Report» Volume 13

Published on November 11, 2021, the 2021 volume: 13 pages 783-791

DOI https://doi.org/10.2147/RRU.S321188

Single anonymous peer review

Editor who approved for publication: Dr. Jan Colli

Video summary provided by Tariq O Abbas.

Tariq O Abbas1– 4 1 Department of Pediatric Urology, Sidra Medicine, Doha, Qatar; 2 School of Medicine, University of Qatar, Doha, Qatar; 3 Weill Cornell Medicine, Qatar, Doha, Qatar; 4 Department of Health Science and Technology, Aalborg University, Aalborg, Denmark Corresponding author of the Regenerative Medicine Research Group: Tariq O Abbas Email [email protection]; [email protection] Abstract: Hypospadias is a common congenital defect of male external genitalia. However, there are conflicting disputes about the best classification method and the ideal surgical technique. We introduced the Bone Plate Objective Scoring Tool (POST) to define the key particle phenotypic markers of the urethral plate. We suggest that POST can objectively, reproducibly and accurately determine the quality of the urethral plate, so that it can make a strong comparison of different surgical techniques commonly used in hypospadias repair. In addition, the POST scoring system represents a multifunctional tool that can objectively quantify key variables in hypospadias that have not yet been clearly defined. Further verification of POST should help to better identify and manage postoperative complications. Keywords: hypospadias, scoring tool, classification, POST, objective

Hypospadias is considered to be a common birth defect of boys' external genitalia. 1,2 However, there are some controversies surrounding different classification methods and ideal corrective surgical techniques. 3 We introduced the flat objective scoring tool (POST) to define the key phenotypic markers of the urethral plate (UP) in the glans. POST allows objective and reproducible determination of the quality of the urethral plate, allowing comparison of different surgical techniques commonly used for hypospadias repair. 4,5 The POST system originated from the study of the normal structure of the glans penis in children undergoing ritual circumcision anesthesia, 6 leading to the identification of three key anatomical landmarks: A, B, and C (Figure 1). The area from A to B is the range of the new bite, and B to C is the range of the vertical glandular fusion line. After determining these reference points, the ratio (AB)/(BC) defines the POST value, which represents the impression of the urethra in the glans and thus the overall quality of the urethral plate. Figure 1 shows an illustration of a typical anatomical glans markings. Point (A) is the distal range of the nasal orifice, point (B) is the proximal range of the orifice and the distal limit of the glans closure line, and point (C) is the proximal limit of the glans closure line. Note: Adapted from: Abbas TO, Ali M. Urethral Meatus and Glanular Closure Line: normal biological characteristics and clinical significance. Urol J. 2018; 15:277-279. https://doi.org/10.22037/uj.v0i0.4402.6 CC BY license.

Figure 1 shows an illustration of typical anatomical joint landmarks. Point (A) is the distal range of the nasal orifice, point (B) is the proximal range of the orifice and the distal limit of the glans closure line, and point (C) is the proximal limit of the glans closure line.

Note: Adapted from: Abbas TO, Ali M. Urethral Meatus and Glanular Closure Line: normal biological characteristics and clinical significance. Urol J. 2018; 15:277-279. https://doi.org/10.22037/uj.v0i0.4402.6 CC BY license.

The rationale behind POST scoring is fully supported by a strong embryological evidence base. During development, the opening of the zipper hypothesis begins with the urethral groove being formed by the shaft of the penis and the solid urethral plate in the glans, while the closing of the zipper depends on the fusion of the urethral layers to form the final urethral tube. 7 Therefore, the shorter urethra (AB) length is explained by the cessation of the ventral canalization in the glans around the 14th week of pregnancy. Therefore, a lower AB/BC ratio may represent an early stage of urethral development and therefore a more severe phenotypic stage.

It is important to use standardized assessment tools and measurement of penile anthropometric variables, including patient age and erectile status. 8,9 Walid et al. pointed out that the width of the urethral plate increases with age, making a clear cut-off value not suitable for defining a favorable urethral plate. 10 POST allows objective measurement of the severity of hypospadias, especially the quality of the urethral plate, before the foreskin is fully physiologically contracted (Figure 2), but the patient’s age has no significant effect on the evaluation results. Therefore, the POST system can be used in outpatient clinics to help surgeons objectively guide decision-making, inform surgical plans, and assist in appropriate parental consultations. Figure 2 Two baby boys with coronary hypospadias and POST signs may be marked with these signs during outpatient visits before the foreskin is completely retracted.

Figure 2 Two baby boys with coronary hypospadias and POST signs may be marked with these signs during outpatient visits before the foreskin is completely retracted.

Defining a favorable urethral plate is considered a basic task, but it is still difficult to objectively quantify. 5 To this end, the G component 11 of the GMS score is introduced, and both G1 and G2 can be classified into favorable categories. We have observed an excellent correlation between the POST scores (>1.2) and (G1, G2) of several pediatric urologists. (Figure 3) We also obtained high intra-rater consistency through Inter-Class Correlation (ICC) analysis. 4 Figure 3 Correlation between GMS and POST scores.

Figure 3 Correlation between GMS and POST scores.

Approximately 20% of circumcised boys have a nasal passage diameter of less than 5Fr between the ages of 5 and 10 years. 12 The diagnosis of nasal passage stenosis is highly subjective, and is basically defined as “the oval shape secondary to fibrosis or scar becomes round. 13 POST score helps to objectively diagnose nasal passage stenosis. If the ventral lip of the nasal passage is located In addition to point B, this point should be considered (Figure 4). Figure 4 is the frequency spectrum of nasal passage stenosis defined by POST. The abdominal lip of the membranous mesh extends from point B to point A.

Figure 4 The frequency spectrum of the narrow nasal passage defined by POST. The ventral lip of the membranous mesh extends from point B to point A.

Bhat et al. pointed out

The anatomical features of the thigh intact prepuce (MIP) hypourethral fission presents a unique challenge to the surgeon. The anatomy of the wide nasal passage and urethral plate may lead to thin glands that are more prone to dehiscence and formation of urethral fistulas. 14

Since then, it has been assumed that the embryonic development of the urethra is caused by the 3D progression of the urethral plate from the proximal end to the distal end of the penis, which is synchronized with the development of the axial ventral to dorsal groove in the glans. This theory is consistent with several variants and anatomical findings within the hypospadias phenotype, and the consistency of these with the POST score. However, MIP variants do not follow this embryological model. It is speculated that MIP is caused by excessive ducting of the glans of the urethra, or due to compression and avascular necrosis of the distal urethra after development. However, we have observed that almost all MIP cases have an unfavorable POST score, which may reflect the underdevelopment of the cavernous capsule of the penis and distal penile urethra (Figure 5). Figure 5 MIP case shows unfavorable POST scores.

Figure 5 MIP case shows unfavorable POST scores.

Tubular incision plate (TIP) urethroplasty was promoted by Snodgrass in 1994 and has since become very common. 15 This surgical technique relies on a loose midline incision of the urethral bone plate to achieve a tension-free urethroplasty. Snodgrass recommends cutting the urethral plate deep enough to reach the urethra, and then extending from the proximal end of the lower urethra to the distal skin-mucosal junction. (Figure 6A and B). In order to reduce the risk of urethral stricture, Snodgrass recommends a modification to the TIP, where the starting point of the new urethral tubularization starts at about 3 mm below the edge of the urethral plate, approximately at the level of the "medium glans". 16 can be interpreted as an attempt to increase the (neo-AB) distance to achieve a sufficient AB/BC (POST) ratio. (Figure 7) However, this also leads to an increased chance of the (ventral) glans tract, which is considered a suboptimal result of hypospadias reconstruction surgery. On the other hand, when the urethral plate is unfavorable (AB<BC), this method may lead to a higher risk of urethral stricture. (Figure 6B) Similarly, Mane et al. further defined the distal range of the new urethral tube as approximately 5 mm from the edge of the urethral plate. 17 At the same time, Mane advises not to extend the midline loose incision of the urethral plate to the distal "tip of the urethra". Figure 6 POST landmark icon in the case of TIP repair. (A) In the case of a favorable POST, TIP will result in a wider mouth (neo-AB) than the potential alveolar fusion line (neo-BC). (B) In the case of an unfavorable POST, TIP can cause a nasal opening (neo-AB) smaller than the potential glandular fusion line (neo-BC), thereby increasing the risk of stenosis. Figure 7 The modified TIP will result in a wider mouth and nasal opening (neo-AB) than the potential alveolar fusion line (neo-BC). The distal extent of the urethroplasty (neo-B point) starts approximately 3 mm below the tip of the paraurethral incision line.

Figure 6 POST landmark icon in the case of TIP repair. (A) In the case of a favorable POST, TIP will result in a wider mouth (neo-AB) than the potential alveolar fusion line (neo-BC). (B) In the case of an unfavorable POST, TIP can cause a nasal opening (neo-AB) smaller than the potential glandular fusion line (neo-BC), thereby increasing the risk of stenosis.

Figure 7 The modified TIP will result in a wider mouth and nasal opening (neo-AB) than the potential alveolar fusion line (neo-BC). The distal extent of the urethroplasty (neo-B point) starts approximately 3 mm below the tip of the paraurethral incision line.

In the case of an unfavorable POST, a logical approach is to increase the AB/BC ratio by incising the glans at the distal end of the skin-mucosal junction to advance the A (new A) point. This will cause the original injured area in the glans penis beyond the urethral plate area and require transplantation of the incision area to prevent nasal passages (ie, dorsal inlay transplantation TIP [D-TIP]). 18,19 (Figure 8) However, it is important not to overshoot the incision in the glans to form an upper jaw passage. The POST formula can further help define the distal range of the midline incision (new point A) when performing an inlay TIP (Figure 9). Figure 8 D-TIP will create a wide nasal opening (neo-AB) by cutting the glans at the distal end of the mucosal-skin junction that is larger than the potential glans fusion line (BC). Figure 9 (I) In the unfavorable situation of POST (AB≤BC), the distal end of the urethral plate mucosal skin junction (A2) marks the boundary of the TIP urethroplasty incision. Therefore, (A2-B) will be almost equal to (BC), in which case the risk of stenosis is placed on the new mouth. On the other hand, extending the incision distally to (A1) based on (A1-B = 1.2 X BC) objectively determined will avoid this risk. In this case, transplantation is recommended. (II) In the case of favorable POST, the distal end of the urethral plate ends at the point (A1-B> 1.2 X BC) (A1=A2) and the incision at the distal end of the mucosal-skin junction will not be required. (III) In the case of bad UP, both A1 and A2 are marked at the beginning of the operation.

Figure 8 D-TIP will create a wide nasal opening (neo-AB) by cutting the glans at the distal end of the mucosal-skin junction that is larger than the potential glans fusion line (BC).

Figure 9 (I) In the unfavorable situation of POST (AB≤BC), the distal end of the urethral plate mucosal skin junction (A2) marks the boundary of the TIP urethroplasty incision. Therefore, (A2-B) will be almost equal to (BC), in which case the risk of stenosis is placed on the new mouth. On the other hand, extending the incision distally to (A1) based on (A1-B = 1.2 X BC) objectively determined will avoid this risk. In this case, transplantation is recommended. (II) In the case of favorable POST, the distal end of the urethral plate ends at the point (A1-B> 1.2 X BC) (A1=A2) and the incision at the distal end of the mucosal-skin junction will not be required. (III) In the case of bad UP, both A1 and A2 are marked at the beginning of the operation.

In the second-stage urethroplasty, a new urethral tube that is "wide enough" must be reconstructed to match the size of the glans to avoid narrowing of the distal urethra and subsequent urethral skin fistula. 20 Objectively define the minimum amount of skin/the graft strip required to construct a new urethra to achieve a more consistent surgical description and higher reproducibility (while also reducing the dryness caused by the inclusion of unwanted hairy skin) Balanitis [BXO] risk). We currently use the two side borders of the urethral plate to be tubular as our dividing line, which is formed by parallel lines that pass through the two B points at the level of the broadly divided glans and extend proximally to the level of the nasal passage. Figure 10 Figure 10 An illustration shows the landmark application of POST to define the main boundary of the new urethra during the second stage of hypospadias repair.

Figure 10 shows an illustration of the iconic application of POST, which is used to define the main boundary of the new urethra during the second stage of hypospadias repair.

The POST score can directly record the quality of the distal urethral plate and the degree of urethral development. Based on this hypothesis, we use the POST-based method to explore the extent of the hypoplastic urethra, which is defined by the distance between point B and the bifurcation of the cavernous body (Figure 11). We have observed that unfavorable UP is associated with a longer underdeveloped urethra, which matches the underdeveloped urethra (unpublished data). This is another finding that supports POST as an objective and reliable measure of urethral plate quality and urethral dysplasia. However, it is important to note how the development of the cavernous body affects the POST score, as surprisingly low values ​​may be calculated in MIP cases, where the urethra is not affected by the well-developed cavernous body (unlike distal hypospadias). support. (Figure 12) Experiment 21 based on cytokeratin showed that UP extends from the endoderm near the bladder to the distal tip of the urethral opening, instead of ectodermal invagination leading to the urethral opening. This further supports the concept that POST is well-developed with UP and the proximal-distal end of the surrounding cavernous body. Baskin et al. pointed out

From a broader perspective, the fusion process during the formation of the human penile urethra (in the shaft) consists of three separate fusion events: (a) Epidermal fusion completes the skin of the ventral penis. (b) The endoderm fuses to form the penile urethra. (c) Finally, after removing the skin seam on the midline, a left and right mesenchymal confluence is established on the ventral side where the urethra is formed. twenty two

Figure 11 The normalization of the degree of hypoplasia measured from point (B) to the bifurcation of the cavernous body divided by the stretched penis length (SPL).

Figure 12 POST can reflect the development of the cavernous body of the distal urethra. Although the urethral orifice (the end of the urethral orifice) is located at the tip of the glans, the patient's POST is low, so the distal urethra is underdeveloped.

In most cases, the degree of urethral hypoplasia is related to the length of the urethroplasty. Studies have also shown that the longer the urethral defect is, the greater the risk of repair failure, which will make the repair of the cavernous body more difficult. twenty three

The POST scoring system is a multifunctional tool that can be used to objectively quantify several key variables in hypospadias that have not yet been clearly defined. Further validation of POST is essential to better correlate preoperative assessments with postoperative complications, so that key risk factors can be defined more consistently and reproducibly.

The author declares that there is no conflict of interest in this work.

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