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Small Intestinal Submucosa for Corporeal Body Grafting in Patients with Proximal Hypospadias and Severe Chordee: Long Term Follow-up Assessing Sexual and Erectile Function.
Christian Guevara, MS, George Ransford, MD, Samantha Isern, MS, Natalia Ballesteros, MD, Daniel Nassau, MD, Alireza Alam, MD, Miguel Castellan, MD, Andrew Labbie, MD, Rafael Gosalbez, MD.
Nicklaus Children's Hospital, Miami, FL, USA.

Background:
Patients with proximal hypospadias and severe ventral chordee are often challenging to repair. To preserve penile length in chordee repair, corporal grafting is often performed; however, potential long term complications include recurrent curvature and erectile dysfunction. Small Intestinal Mucosa (SIS) can be used for corporal grafting but there is a paucity of data evaluating long-term outcomes of sexual function. We aimed to assess sexual and erectile function in post-pubertal patients with proximal hypospadias and severe chordee treated with 1-ply SIS to correct penile curvature.
Methods:
We identified 77 post-pubertal patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting at our institution between 1998-2015. We defined puberty as age ≥ 144 months. Patients were contacted for evaluation of their erectile and sexual function using validated questionnaires such as the modified erection hardness score (mEHS) and the modified sexual health inventory for men (mSHIM). Perceived function and straightness were measured based on the Hypospadias Objective Scoring Evaluation (HOSE). Penile self-perception was assessed using the Pediatric Penile Perception Score (PPPS). After the questionnaire was completed, a physical exam was performed and Tanner stages were recorded.
Results:
Nineteen patients agreed to participate in the study. The age at the time of the assessment ranged from 12 to 29 years-old and the mean follow-up was 162.9 months (36-329 months). Eleven (58%) patients rated the hardness of their erections as completely hard and very rigid, 6 (31%) as hard enough for masturbation but not completely hard, and 2 (11%) as hard but not hard enough to masturbate. Nine (47%) patients reported no symptoms of ED (Table 1). Overall, a total of sixteen patients (84%) reported being satisfied with the general appearance and straightness of their penis (Table 2). Twelve (63%) patients had acceptable HOSE scores. On physical exam, it was determined on a non-erected, flaccid penis that a straight phallus with good cosmesis was achieved in fifteen (79%) patients (Table 3).
Conclusion:
Corporal body grafting with single layer SIS is a viable option for the correction of severe chordee associated with corporal body disproportion in children with proximal hypospadias. The use of 1-ply SIS is safe and provides reliable results with a low rate of recurrence of chordee post-pubertally.
Table 1. mSHIM outcomes assessing erectile dysfunction

mSHIM VariableGradeNumber of patients (%) n=19
No ED22-259 (47)
Mild ED17-213 (16)
Mild-Moderate ED12-160
Moderate8-111 (5)
Severe5-70
Not ApplicableNot Applicable6 (32)

Table 2. PPPS outcomes from penile self-perception
Very dissatisfied (%)Dissatisfied (%)Satisfied (%)Very satisfied (%)
Length of penis2 (12)3 (15)11 (58)3 (15)
Position and shape of urethral opening1 (5)010 (53)8 (42)
Shape of glans1 (5)010 (53)8 (42)
Shape of penile skin1 (5)012 (63)6 (32)
Penile axis (straightness)1 (5)2 (12)12 (63)4 (20)
General appearance2 (12)1 (5)11 (57)5 (26)

Table 3. Comparison of outcomes of hypospadias repair according to physical exam vs HOSE
PHYSICAL EXAM (%)HOSE ScoreHOSE (%)
Meatus Location
Distal glandular12 (63)413 (68)
Proximal glandular3 (16)36 (32)
Coronal4 (21)20
Meatal Shape
Vertical Slit14 (74)212 (63)
Circular5 (26)17 (37)
Urinary Stream
Single streamNot Witnessed215 (79)
SprayNot Witnessed14 (21)
Erection
Straight15 (79)47 (37)
Mild angulation3 (16)39 (47)
Moderate angulation1 (5)23 (16)
Tanner Stage
511 (58)
45 (26)
32 (11)
20
11 (5)
Fistula
None17 (90)418 (95)
Single subcoronal or more distal1 (5)30
Single - proximal1 (5)21 (5)


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