Challenging Hypospadias - Case Discussion

So we have uh quite a few case presentations which we would like to discuss and cover points about Hyperspedia. There was, uh, quite a few questions from the audience, but instead of asking those questions separately, I, I promised that we will cover those during our case presentation. Um, I don't see Luis Braga on the screen. Oh, he's, here we are. Luis, your microphone is, uh, muted, so. I'm muted. Hello. Welcome. So welcome to our distinguished panel again. Warren Stargrass, Bob, my partner Bob Deo, Luis Braga. Um, I don't see Doctor De Castro. Maybe it's too, too late for him, and he went to bed, but, uh, I'm sure he's here in spirit. I see Marty. here and Marty you're welcome to, to join our, our distinguished panel. We always, although you lost your time, I'm sure your, your, your wisdom is still, still with you. So Luis, uh, I, I know you have a case presentation and I would like to, to, to give you an opportunity to present the case and uh after that, I'll take over. Perfect. Uh, thank you so much. I, I promise I will not go, uh, too, too long. Like I have, uh, 10 slides just to make a few points that, um, I think I have a little bit of, um, a, a different approach from Warren, but again, who, who generate nice discussion. So can I start sharing this screen? Please do. Uh, can you see me here? Yes, perfect, perfect. I just decided to call tricky hypospaus cases and then, um, um, as some of you may call, I heard this another day at the, at the AAP talk like cover hypospaus, I think for the trainees because this, um. Uh, talk is mainly for fellows that, uh, I call it the disguised hypostatus cases like no more like a proximal case. So, be, be careful and pay attention when you have a distal miromiro location with proximal division of the sponiosum, as all, we all know, this thin urethra here, ventral skin deficiency. I know, uh, Warren doesn't, uh, put a lot of importance or, uh, in the urethral plate, but again, if the plate is very shallow, I also find that you should, uh, consider this case and with, uh, um. Uh, more respect and then, um, uh, take, uh, a lot of consideration to what you put it in and also deviation of the midline Rafa. I think that's some, some tricky cases that may become much more complex than you were expecting. So, um, I have this case here with, um, as you can see, the division of the spongiosum is very proximal, but the Miero is very close at the corona level with mild curvature less than 30 degrees. So, um, this was a question for the audience. I don't know if they wanna answer in the. Uh, in the chat, what type of repair someone would consider for this, for, for this case, uh, the curvature was less than 30 degrees after the gloving. Uh, Eugene, should I give some time or just go, go, go on? I'm sorry, we don't have that pole. You'll just have to move forward. Yes, yes. So, so in this case, what, what I, what I think, um, will be interesting that I, what I'll do, so we did, um, uh, direction test here, and then this was like, um, almost 10 degrees, so a door supplication or sometimes nothing is acceptable, and then I think that's the difference that, uh, maybe a Warren doesn't do the. Um, the inlay graft, but I think it's something that I learned with Pipi Sali that we like to augment that plate, and then we are able to achieve a very conical, uh, glance with a lot of tissue between the erythromus and the glands. So I think the glens fusion, it's important to give that, uh, glens the configuration that, uh, uh, it's more what you Warren mentioned about the normal penis. So this case, uh, again, I'm, I'm talking about the urethro plate being shallow and ventral skin deficiency. Um, I find it hard to even delineate the edge or the border of the urethral plate. That is very minute here. I'm not saying that it's narrow, and then again, very, very, um, severe, uh, ventral skin deficiency. So in those cases, we think that, uh, the dorsal leg graft is a good technique, allows you to do again in one stage because the curvature is less than 30 degrees and then you have an excellent cosmetic result with, um, a slit-like meatus and a lot of glands fusion below the meatus. So another case that I, those cases that I, I'm, I'm talking about cover hypospaes, don't think they're straightforward distal cases, and I think some of the complications come, uh, the bad results from not identifying the severity of the case. So again, the division of the spongiosum is wide here, like at the base of the penis. Uh, the meres was around the distal shaft right there, and then again, very little, uh. skin deficiency, curvature, not so bad, more like a gland stilt, so that can be uh managed with dorsal application and then the uh a dorsal inlay graft. So those three main indications that we use the dorsal layers for ventral skin deficiency, like the urethral plate quality of being shallow or narrow, whatever you think, uh, the quality of the sponiosum not being great, and of course, the ventral skin deficiency. So, uh, even in cases that you may judge that you have ventral curvature greater than 30 degrees before, when you see the patient in clinic it's 90-degree curvature, but you know that some of the curvature is being, uh, it's gonna be due to the ventral skin that is short skin, can be short urethra or short corpora, but in this case it's short skin. And then you can um actually deglove the penis and you put a small uh graft and you have a very nice cosmetic result, allows the glands wings to roll over and uh um this again, a lot of, um, at least we, we measured this 4 millimeters below the uh uh end of the mitos and, and the corona. So, to me, I think that's the only thing that I would add from, from Warren that we all learned a great amount of deal with him in the past 25 years. Uh, but I think what determines the number of stages to me would be, of course, the severity of the curvature greater than 30 degrees. We, as Warren showed, uh, magnificently like you do the stage or the stack repair. But I think we also Consider the quality of the spongios and the erythroplate and the size of the penis. Sometimes the penis is very short and then I have done a stage repair to elongate that penis, even though there was that curvature less than 30 degrees. Uh, on the other hand, if the penis is long, sometimes it's, it's acceptable to do a dorsal application. We do 3, transverse corpootomies, not in all the cases, and we, uh, use testosterone. So, just to show one final thing here is that I, I had 60 cases. My research assistant just pulled the data this morning. A complication rate again, we are not as good as Warren and Nicole, but 26%. And the one thing that I thought was interesting is that we had 6 glands, the hissing, and those patients, um, we, we left them there and then so far we've never done surgery again because they decided to stop and they avoided with a good stream. So 2 patients right now have recurrent curvature and I, I believe that this may go up as we extend follow-up as data has shown from CHOP. And uh from uh Pie Pietro Be in Belgium that the longer the follow-up, the higher the complication rate. But again, if you look at the number of patients that require re-operation, it was only 8 out of 60, which is 13%, which is a good number that you can talk to a family, maybe 1 or 2 out of 10 patients with the most severe spectrum of hypospaus, and the, the way we do it is this way. We just get a patient like that, as Warren mentioned, we, uh, use a bit the goniometer, but for us it's easier to use the app. Um, we try not to rely on the eye completely, but we use the app, put the graft, that's the aspect, post-op with tubular eyes in two layers. And one thing, for the trainees that I, I always get asked this question, that they say that you cannot roll a graph to, to make an urethroplasty. You can, as you can see here, as long as you develop a nice plan to develop your glands wings, the, uh, the graph will rotate nicely, and you can, I have a Nice result. It's very similar from the distal uh case that Warren showed. One thing that it's a bit different, I do not use the Tuna vaginalis flap for all the cases like Warren said, always. Sometimes the darter's flap is, is very thick, well vascularized, and I use the darters. It's easier, it's right there, and I think it gives me a good result, but for that, I think I have given the patient testosterone, so I have a more robust uh uh tissue. So this case here, you see that there is no ventral skin deficiency. Warren mentioned about that doing this maybe in 3 stages, but again, in our experience, when we do this, we can cut the divide the plate, we may not go all the way down. So I just want to show an erection test because people show that if you do the corporotomies, as PP has described, if you don't go super deep, you're able to see the penis quite straight. And then, so these are after I did, I only did two cororotomies and then we're happy with that, um, maybe a tiny dorsallication, the incision of the corpootomies are there, we do the grafts and the penis is almost bent that way. So, with this result, I think we have done uh um uh a, a complication rate of 25% which I find that is acceptable. So, and the, the final slide is this one, why do I use testosterone? I know it's controversial, but why? Because it allows me to do this erection test after cororotomies because I can see that I'm cutting just the first layer of. The Albuino of the corpora, so there is no leak or minimal leak. Uh, the dorsal hood becomes larger and more vascularized, so I can get longer grafts. It's very robust dark, so I can use it as a second layer, increase the penile size, and then, um, I have, I think a healthier bed to receive the graft, and then I haven't had a lot of graft contractors. Um, so these are examples that are doing erection tests after making the cuts. Um, but again, um, I'm not entering in the, in the deep into the corpora like Warren has described or those who put a dermograph that they make that elliptical round, uh, incision in the, in the, in the corpora. So these are another example. And then this is a trick. So if you wanna harvest a long area, the penis elongates a lot, you don't go a straight line like that. You can go around like this and you are able to get 6 to 7 centimeters, and you can cover, uh, in a wide fashion because you wanna, especially when you have the scrotal or penis scrotum meatus, you don't wanna have any skin around, so you can have, uh, avoid having hair bearing urethra. So these are my tips and thank you very much. Sorry, Eugene. Sorry for what? That was a great talk and uh let me continue because you actually covered quite a few questions which were asked by audience. But before we get there, Warren can you comment about the use of those inlay grafts? Uh, do you see any role for that and what would be your indication? Well, we, we don't ever do that in a primary repair. We never do that. But I'm not going to quibble. So I think if you put Luis and I next to each other, that the differences that separate us, are much, much smaller than the similarities which have us in the same orbit. And one problem that we get into, I think, is when we have conferences like this, we spend a lot of time looking for little details of how one person does something different than another person rather than saying what's the big picture here. So the big picture with Grafting a primary. urethral plate after a tip incision. We never do it, so we can say that it's not necessary to do it, but many people don't make the tip incision deeply enough or they're hesitant to carry it out all the way to the end of the plate or other things. And so especially for people who have Concerns about it, it makes you make it, it gives you the confidence to make a deeper incision and to make it the whole length of the plate. So I don't, I don't have any objection to that at all. Um, so I, I never argue with people. I just say you don't have to do it. If you choose to do it, well, fine. I want, I want to say one thing back to Luis though, if I can. And again, not to pick on him, but just to say this, Luis, your 25% complication rate is a lot lower than what most people around the world are getting with severe hypospadius. My question would be though, for example, your fistula rate is double what ours is, and I wonder if you Run the first layer and interrupt the second layer the way Pippi does. And I also wonder, my fistula rate was 12% when I used drtose and it went down to 4% when I used tunica vaginalis. So, the, the only reason I bring it up is because you concluded that by saying my, my complication rate is 25% and I'm OK with that. And I'm going to turn around and not picking on you. I'm making an observation in general. This is what we do. And I don't think that's the right standard. It doesn't matter if you're happy with that or not. What matters is, is that the best we can accomplish? Could you get your 25% rate down to under 10%? And if the answer to that is yes, then that's what we should be doing. All of us should be doing that rather than looking at it and going, well, that's better than most people, or I think that's good enough for a difficult group of patients. The question we ask ourselves every day is, how can we do this better? How can we get that rate down even more? So again, I, I use the opportunity of what you showed to say that's very good. It's much better than most people, but I'm not sure it's the best. We have a better result, but not because we're better surgeons, but I, maybe because of a few technical things we do differently. There was quite a few questions about carparotomy, and I would like both Warren and Louis to cover it. And question were why 3 and exactly how deep you go and how you do artificial erection after that. Uh, can both of you tell us how you do it? I mean, as much details as you can give us. Warren, please. OK, so it's kind of funny. I watched a video of Pippi doing the corpootomies, uh, a day ago, and I know he's made a big point. He doesn't put a tourniquet on and he cuts through, and that way he won't cut too much. He can do an artificial erection, but honestly, while I was watching him do it, that could have easily been me doing it. There was no Difference in what I could see and what he was doing and what we do. So why do we do 3, and we almost always do 3. Occasionally that's such a distal bend right up by the glands that you can't do that, but we do 3 because the bending is on an arc. And so we put the first one in the middle. And then we just, we, to keep it balanced, we do one distal and one proximal. Now, the interesting thing is, how do you know how much you do it? Well, we do it basically from 3 to 9 o'clock, a little bit less, but basically that. And we just go through the tunic bigena and this is what we've learned. Usually, you, you can sometimes do an artificial erection afterwards, but not reliably, not reliably. So for a while, we did a triangulation measurement that Dr. Bush came up with and we proved that it worked by that method. But what, you know, honestly, what we've really learned is that the amount that those incisions open when you cut the exact same incisions varies by how bent the penis is. I'm sure Luis has noticed that when he's got a high degree of bending, that middle incision opens a lot wider than when you have a lesser degree of bending. And so what I'm going to say is that you make 3 incisions, you don't have to worry about it. If you make 3 incisions the way that I showed you that we do it and you cut through the tunic at Albigena, the penis is going to be straight in almost every case, almost every case. It works and the, the, the, the tension that's on the penis opens it to the degree it needs to, to not have the tension anymore. Louis, you have any tricks how to do car or how do you do corpootomies? Well, I think, um, like Warren mentioned that, uh, watching videos, uh, Pepe's video, like, you know, last night or the two nights ago was the same, but again, um. What, what I, what I find is that I, I thought that I, I was not getting to the corpora completely because when I used to do like for instance, I learned with Tony Curry to do like Tunicavagina flap on the corpora, like you have to put a tourniquet cause you know, things are woozing profusely when you get into the corpora and I also thought that, uh, and it is, it is true like if you have a penis that is more robust because of the testosterone stimulation. Again, you can see that, that there, there is a, uh, uh, as people will say, like a different plane that you're not going through the, completely to the corra. Um, so, it's interesting that if you, uh, use the blade and then you, you, you don't cut like with the perpendicular blade to the plane of the corpra, it's kind of an oblique angle and it's trying to scrape a little bit. I have a video, I didn't know, uh, uh, this was going to be a discussion, but, uh, again, it's similar to what PP mentioned. Again, what, you know, what Warren mentioned as well, it's, um, I, I Because I, I have seen some complications with, uh, like, you know, development of uh, uh, aneurysmal dilatation, and then some patients that I had, uh, these issues with, uh, grafts on the corpora, uh, those big grafts. So I have always been like concerned about making huge incisions in the corpora. Now, the paper, uh, from Doug Husman, I know, I know that there is a selective population, but Uh, you know, we need to be, uh, careful about long-term follow-up. So I try to make one incision and then I repeat the erection test. And then like doing this, uh, um, I'm allowed to do the erection test and I, like Warren said, they, they develop a nice triangle that they can measure and then it's fine, but if you do, uh, deep incisions, it leaks a lot, you cannot generate like a, a, a strong erection, like, you know, to the penis that'll be straight, so you can really confirm that you have a straightened penis. Because sometimes I've seen problems, uh, post-op with the, you think you have recurrence of the curvature because you did not correct completely because you couldn't assess if you, everything was done, especially for the more severe cases. I think that's my only tip, but I agree with Warren that, uh, um, it's not that I'm OK with 25%. I, I, I always wanna improve. That's why I, I, I, I used to go to his courses in Dallas. Um, uh, when he used to have them, now I, I watch the, I'm always there for the Cincinnati workshop every year. So we try to, but, uh, um, again, 13% is what I can get right now, but we're, we're, we'll improve. Um, I, I believe Doctor Reddy has a question about application promoter. Yeah, I know, thank you. Thank you, uh, both of you for excellent presentations, and, uh, again, thank you for all the teaching that you've given the entire pediatric urology community over the years on, uh, hypospadiology. Uh, it's been phenomenal. Warren, question for you is that, you know, um, I know you say you do that one dorsal placation stitch, and then you do the three corpootomies. We don't do that anymore. OK. I was gonna say, what's the point of that dorsal placation stitch if you've already mentioned that it's not sustainable, it's not gonna sustain the uh rigid turgidity of the erect penis. And then you're setting yourself for a little bit of a recurrence rate with the, you know, the corpootomies after that. If that stitch fails, now you've got some curvature again. Yeah, so when I, when I Just go back for a short history. I was doing buyer's flaps and I was doing single incision with dermal grafting for straightening the penis. And because I had a 100% complication for my buyer's flap repairs, and I met Ivor Brocka and started doing graft repairs for redos, I thought, well, I'm going to start doing graft repairs for primary cases too, but now I can't do a single incision and put a dermal graft on. So I thought, OK, I've got to straighten the penis somehow, and I decided I would make these 3 incisions, OK? But I wasn't sure if that was going to work because especially, you know, you couldn't do a reliable artificial ere, so I didn't know. So for insurance purposes, I thought I'll just put in a dorsallication too. And so I did that for a long time. We quit that years ago as we became increasingly confident. I mean, as I say, first, Um, we tried to do artificial erection. It wasn't reliable. Then Doctor Bush came up with this triangulation measurement thing and, and we could see that, nope, it's reliable. And, and now, I mean, because we do 3 corporotomies, oh, every day of the week, that, that we see all these patients back and they're straight and we've come to realize that the, the process of doing it works. You just have to do it. You don't, you have to not overthink it. You make the 3 marks through the point of greatest curvature. You make the incision down to right near the corporal tissue. You're not going to cut down, gouge into that. And then the penis is straight and you don't have to worry about it. Occasionally, a patient comes back and there is a little residual or recurrent curvature, and this is so interesting that you, you release everything here, we release the proximal urethrostomy, release everything that could be contributing to it, and there's still a little bit of curvature. I'm talking about less than 30 degrees. There's still a little bit of curvature. Try this yourself. The next time you have a patient, you're doing a primary or redo repair and you measure the, the curvature with the goniometer, and it measures 35 degrees. Make the penis firmly erect with your artificial erection, then take some AdSense and pretend you're doing a dorsallication and see if you can even pull that fully erect penis straight. Uh, you just can't. But if you've done ventral cororotomies on them, and now that's all healed and they come back six months later and they have some bending and you make it fully erect, you can take your pickups and easily. Pull that straight easily. So when there's a little bit, then that's when we do application, but we no longer do dorsalliccations as a primary straightening maneuver in, in very many patients at all, and we don't do it as an adjunctive maneuver for three cororotomies. Thank you. Do you, when you're doing your artificial erection test, the Gitdis test, do you always use a tourniquet, or do you kind of use the fingers to occlude, because I know there's some talk about super physiological erections when you have a tourniquet. Well, so I have two brief answers to that. Number one, we, we don't use a tourniquet on the first injection because sometimes The bending is surprisingly low, and we have seen a number of patients from people who we are all good friends with who must have put the tourniquet right there where it was bent and they missed it. So we always do the first injection without a tourniquet, OK? And once we know the bending is distal, then we put a tourniquet on. Uh, the second thing is, can you overinject with an artificial erection? Now that's an intriguing question. Can you get an over erection? I mean, when the penis is full and turgid, it's full and turgid, and if you could stick a needle in there and squirt in some more, you probably couldn't squirt in anymore and your penis wouldn't bend. So I don't believe that when you do an artificial erection, you see some bending towards the end of filling, that that's an artifact. I don't believe that. We do, we do not believe that to be the case. We don't think people overfill because when it gets really full, you can't push any more in, and the penis should still be straight. Um, well, there was one question. Uh, you mentioned some skin dehesions and fistula complications after your stack, stack repairs. What about diverticula? Have you seen diverticula after stag or stack repair? No, that's so interesting. When I was doing Byer's flaps and I said I, I had a 100% complication rate, 55% of those complications were diverticula, 55%. Now what I was doing there was a a buyer's flap, and the distal end of it was a tip. I kept the urethral plate, so I did a distal. I, I repair some people maybe in the audience don't fix proximal hypospadius all the way to the tip of the glands. We always fix it all the way to the tip of the glands. So my buyer's flaps had a distal urethral me. This just like a tip repair would have, and I think that put, you know, some pressure on that distensible foreskin, and I got a lot of diverticula. So interestingly, when I quit doing it inspires flaps and I took the exact same foreskin and used it as a graft, we have almost zero diverticula. That's by far our least common complication, almost 0. OK, well, I think we're gonna move to a few case presentations which we prepared for you and uh Um, I'm trying to share my slides. I just don't see it yet. Just a sec. Let me try again. But thank you for all of your fine points while I'm trying to, to share, can I ask a question while you're trying to get set up these slides so maybe Warren can answer. uh, Warren, it's just that, um, some, some things that we also struggle. Do you? Uh, in your hypospaus clinic, I, I emphasize a lot to the patients that, um, when we do stage repairs, it's very important for the family to Uh, the, uh, post-op care because I do find that if we don't have, uh, either application of steroid cream, vitamin E, uh, uh, uh, hyperbaric oxygen, I think you can have graft contracture. In our hands, uh, the contraction is like 7%, but we really, really, uh, are on top of the families because in patients of socioeconomic level, when they have not complied with what we believe it's a good thing after care, uh, we have had issues with the healing. Do you have any comments on that? Well, yeah, um, a couple of things. First off, our primary graft success rate is 92%. Interestingly, our redo oral graft success rate is also 92%, but those patients all get hyperbaric. Our primary, some do, but generally they don't. We, we, I never used steroid on any of our patients for the longest time, and that was Dr. Bush who looked at him and decided we should do that. And then we saw that the Italians had actually done that years before and published it. So we, we use it routinely. Will steroid cream undo contraction from putting a graft into a poor vascular situation? No. Will steroid cream help reverse the normal tendency of wounds to contract some and, and decrease the amount of some contraction that occurs in an otherwise pretty healthy graft? Yes. But we also do the same thing. We, we also tell the families, you know, when you start putting that cream on, go ahead and stretch that penis a little bit. The plastic surgeons say that that's good for healing. We also, when we take graft from their lip, we tell them just stretch that lip a little bit. So yes, I think all of those are good things to do, but the most important thing is to put down grafts in optimal circumstances. I used to put grafts down for everything thinking they all heal, but they don't. So you need to put them down and The best circumstances, kind of as I talked about in the talk, and then do these other things that you've mentioned to add to their success. Well, thank you Luis for that question. Actually, it was part of the questions during my presentation, so I guess that's covered already. So do you, do you see my shared, shared slides? Yeah, we can see your slides. You just advance them. Perfect, perfect. Well, I would like to start with uh so-called simple hyposperia, distal hyposperes, which, uh, like, uh, Warren mentioned in his presentation, 90% what uh hypersperes, at least we see in our, in our centers, it's distal hyposperes. So this is a 7 month old, otherwise healthy boy who present with a distal. I would say coronal sub coronal hyperspaus with mild ventral curvature and Warren, sorry, I understand the importance of uh measuring the, the, the curvature to degree, but I don't think we're here in Cincinnati to that point yet, and I promise by the next workshop, we already know the, the name of that app and we will, we will have all the necessary instruments to measure uh uh that uh curvature. So if any of our panelists uh recommend to observe that patient because a few meetings I attended, especially in Europe, there were some voices, especially coming from adult urologists, to European adult urologists who recommended not to do anything because apparently they see a lot of complications and they, they don't think that we as a pediatric urology community are doing a good job. So anybody would recommend to observe the patient like that, Warren? No, I'm glad you brought that up. If you could go back to that picture for a second. So the problem, the, the, the easiest way to answer this question for a parent or another physician is there's no glance fusion here. So, the meatus is below the whole glands. A normal meatus is enclosed with the glands to at least 2.5 millimeters. So if you have abnormal anatomy, you increase the risk for having abnormal function. In this case, urine spraying. Urine spraying is not really noticed by parents. They may see the stream deflected down, but it doesn't tend to spray. But our practice is only hypospadius, so that's teens and adults with hypospadius too. And one of the abstracts that we're sending into the meeting this year is our series of, of adults with uncorrected hypospadius, and our data is very different than, than the two papers that are quoted all the time. About adults, almost all of over 80% of our patients, their chief complaint was urine spraying. They never got used to that. Like people say. A surprising number of them also had ventral curvature. There were many complaints, but the bottom line is that this idea that people with a distal meatus that's not Not enclosed in the glands, do just fine is not the experience that we see. So you can say, well, but you're not seeing everybody, you're seeing the ones that are bothered. We're seeing people even up into their 60s who when they found out that it can be fixed, they're like, oh my gosh, where were you when I was younger? Wow. OK. Um What would be your recommendation in terms of age for the repair of distal or any other hyposperia? Louis. Oh, usually, in, in Canada, I know that um you can do a hyposperus repair uh safely after the age of 6 months, but again, sometimes in a healthcare system with universal healthcare, sometimes you may have issues with the referral um uh delay. So uh I think most of the hypospers I do it uh is usually between 9 to 15 to maximum 18 months. OK. And then Louis you mentioned the use of testosterone for proximal hypersperia repair. Do you see any use for testosterone and preoperative administration for distal hypersperia? So, that's a Uh, thank you for the question. It's an interesting question. So we have been doing that, I think, um, probably until recently as part of a research project, uh, actually going based on what, uh, uh, Warren Snodgrass and Nicole Bus showed in the past that the gland size, uh, less than 14 millimeters was associated with a higher complication rate. So our intent was to give it systematically to avoid the bias of giving, oh, this one I don't get it, this one I get it. Uh, so we did it for, uh, part of a research project, but not, uh, um, any, anymore. So this data is in process to be published, but, uh, for the proximal, for the reasons I mentioned before, we do. Warren, do you see any, any use for preoperative testosterone for any hypersperia? No, we don't, and we did for a while. I've never used it for distal hypospadius. Um, we used it for proximal with a glands that was 13 millimeters or less. And we, we did it and we gave the, with the intention to grow it to 14 millimeters or more. And so we had two groups of patients, those with proximal epispadius that already had a glands, the target size and those that got testosterone to achieve the target size. And when, when they went to surgery, they had um the same size glands. And what we found was that even though the same surgeon did the same operation in both groups of patients, the ones who got testosterone still had 30% higher complication rates. And as we've said in our data, the database is pretty simple for testosterone. It's yes, no ever because patients come to us with all different histories and regimens and also it's just, did you ever get it? Yes or no. And just using that very simple criteria. We consistently see that patients who have been treated with testosterone have higher complication rates. So we, we're waiting for the publication and if Luis has data that's different than that, at least we know that's data that's been done in a systematic and thoughtful way. If he shows us that there is a patient group that benefits from testosterone therapy, then we'll rethink it. We didn't see it and we haven't seen that published. Lots of people use it, but where's the underlying scientific justification for it? OK. So Warren, along that line, uh, do you see that your adult and teenage patients That are coming to have repairs done, whether they're re-operative or having a higher complication because they've already had their own endogenous testosterone exposure. So we published before that when you just tally up complication rates, fistulas, glands dehissitis, and all that, our overall complication rates in children and adults, whether having primary or redo surgery are the same. There's no statistical difference in them. So our data is different than the common, you know, wisdom that older people have increased complications. We, we, that wasn't our data. That's not what we see. Actually, I've, I've seen the opposite. I think that the older patients feel better. They don't have as much glands dehiscence. They don't do that, but that was my thought was that if I could just grow the glands bigger, I would have less glands dehiscence. And I had a, uh, Luis mentioned that he's had some patients with glands dehiscence, and they pee straight, and, and I'd like to amplify on that to say this, our protocol is. that if a patient we've operated on has a glands dehiscence, we will go back and close the glands dehiscence, and we know that number is that 70%, this is before we learned to dissect better, so the date is a little old, but 70% of those redo glanceplasties were effective. But then some of them weren't. And so then we would do another glanceplasty and it became apparent that if, if it happens a second time. That we don't get any benefit, see a benefit from closing it another time. So we quit. So then we followed those patients to see what would happen. And my thought was when they got up to puberty and they went through puberty, I could close the glands then. So we did that and every one of those uh failed. Every single one of those failed. So, in primary repairs in an adult, yeah, we just do, I mean, we don't do as much glands dissection and they just don't dehiss. But if you have the idea that you can follow them and let them grow and then do it, we did not find that to be effective. We have the same observation that Luis did though, and this, this is interesting. If you repair the hypospadius all the way to the tip, the way it should be, and the glands dehisses, most of those patients will urinate with a compact straight stream. If you instead do an intentional repair to the corona or whatever, the same place that it dehis to, those boys spray. So if you're gonna do, if you're kind of worried about proximal repairs, you should still fix it all the way to the tip because if the glands dehisses, they're still gonna be in better shape. And, and sorry, Warren, to push this point a little bit, but, so, can you like, um, extrapolate on why do you think that endogenous testosterone is beneficial, but exogenous testosterone actually hinders healing? Well, so that's a good question too. And, and from what I understand, there is no study. If you look at animal data and all of that, there's no study that shows that, that adding testosterone to an already androgenized animal, for example, improves wound healing. I believe I'm stating that correctly. Um, you know, I don't know if testosterone grew the penis. In the way that your question suggests, then, then why don't we treat everybody, including ourselves, with testosterone and just grow it bigger and bigger before puberty? I mean, there are, there are physiologic limitations to how testosterone actually works, and the fact is that the testosterone that we give to prepubertal boys after their neonatal spurt is not physiologic. It's, it's not supposed to be happening, but we treat it as though it's nothing. So I, I can't answer the question. All I can say is that in when we tried to study it systematically, we found it to be a dismal failure if the endpoint wasn't making the penis bigger, if the endpoint was reducing complications. Right. Warren, uh, there was a few questions about, uh, closure of the glands, penis. Do you have any special tricks how to prevent glands dehesence? And there was a few questions asking why do you use only subepithelial, uh, sutures. OK, those are excellent questions. So first, let's answer that one first. If you're closing like with mattress sutures, Then you've got, and you feel you need to do that, then you've got tension on the wound. And the problem with putting any stitch through the epithelium, even if you put a real superficial small stitch through the epithelium, is that if the glands dehisses for whatever reason, And that happens, you very frequently end up with suture marks, and we see some absolutely horrific suture cuts and damage to the glands from mattress sutures or from even simple stitches through the epithelium that cut. So we never ever traverse the epithelium of the glands with a stitch. We never do that. Um, as far as tricks to it, well, the key, Dr. Bush taught me these words. If you have tension in hypospadius on any aspect of it, your chances of having a complication go up a lot. Most glands dehiscence probably is the result of tension, and you can be surprised where that tension is coming from. It can be exerted by the scrotum, for gosh sakes. We stand in the operating room and we pulled that on the scrotum and we can see the tension line going all the way up to the glands. So, Doctor Bush has taught me and I also learned from some Japanese colleagues, you know, I wasn't taught to open the glands to the extent that we do now. It's just not how I was taught, so I didn't, and my initial gland's dissection was inadequate. I started doing a bigger glance dissection, more like what I think Duckett taught, and my glance dehiscence rate immediately came down. So that's a technical error that I was making. I thought I was doing pretty good, but I still had more glands to hisis than we do now. What do we do differently? Well, Dr. Bush came in and started opening it and feeling and saying, No, you don't have all the tension out of this. You need to cut right here. No, you need to release this right here. No, we've got to cut this band of tension right there, and, and that's what's brought our glances dehiscence rate down now, even in the most severe hypospadius to under 10%. So it's technical factors is for most. You brought something up which I would like to cover now because I'm not sure if we will be able to go through all of my cases, our cases. You mentioned in some of your videos that you think it's very beneficial to have two experienced pediatric neurologists doing proximal hypersperia and this is something we've been doing for our Uh, complex urinary construction for years. We have two attending scrub on the same case and we found it extremely, extremely useful from many different aspects. Can you just cover that issue for the benefits of the audience, why you think it's probably important to have another. Set of hands and brains, uh, when we do such a complex hypospaus repair. Yeah, well, let's say this. There are many reasons. I'll try to say it very briefly. Number one is proximal hypospadius is a rare disease. Hypospadius is a rare disease. We tell ourselves how common it is. It happens in 0.5% of patients. Proximal hypospadius happens in 0.1 001%. In the United States every year there's 1000 boys born with proximal hypospadius. So that's not very many. There are 350 pediatric urologists, and the board of urology tells us that most pediatric care, the median number of proximal repairs that we do is 2 or 3 a year. If you needed your son to have heart surgery, would you go to a pediatric cardiac surgeon who said, Yeah, I do that repair twice a year? I mean, it's ridiculous really to think in that way that we can do a complex operation infrequently in different anatomic circumstances, different degrees of severity, and get the most optimal results. What do you get if you do it as a team? Well, first off, you don't have, honestly, you don't have the distraction of the fellow. Fellows need to learn. They ask questions. They don't know. They can't, uh, they can't tell you, Oh, I don't like that stitch, or if they do, or if they think they don't like it, they're hesitant to tell you. And if they do tell you, you're not sure you believe them anyway. And when Doctor Bush and this meeting is for fellows, don't forget, please. I know, don't, I know. So I can answer that if you're, I can, I can anticipate your next question. I'll answer that while I'm doing this. The bottom line is that these proximal repairs that we do are incredibly complex and, and the skin management of them is unbelievable. Today, I'm being totally transparent. I personally would not ever do another proximal hyperspace repair without doing it with Dr. Bush, period. She handles the skin better than my brain and I see it. And it makes such a difference in the results that our results overall are better when she and I work together than they ever were with me doing it by myself. So there's the strongest recommendation I can give. My results were not bad, but my results are far better. And at the end of the day, that's what we're here for. So how do we teach? So I'm just going to say this briefly. I didn't put it in my talk, but The way I taught when I was at the university was that, you know, we did, I did mostly distal repairs in those days, and the fellows worked with me and no fellow ever did a case skin to skin ever. They did bits and pieces as I felt comfortable with them doing it. Some of them probably never developed glands wings, probably. I don't remember. And the bottom line was though, what they did was they stood there and they saw the same surgeon doing it the same way methodically day in, day out, over and over. They got to do bits and pieces of it and we proved you can disagree with that approach. But what we proved was when we published it, we looked at their outcomes in their first few years of practice compared to my outcomes at the same time, and all of my fellows when they graduated, got the same results doing distal repairs as I did during that same time period. So that way of teaching worked. You can learn. By observing, by watching, by listening, just like you have watching the videos, doing bits and pieces, you don't have to think, you have to stand there and do the whole repair to know how to do the whole repair. Our first obligation as a society is to admit our results in proximal hyperspace repair as a society are abysmal. They're absolutely abysmal, and boys, more boys get hurt every day. We cannot justify that by saying, well, I have to teach, or we can't justify it by saying, well, everybody has a high complication, right? I'm doing the best I can. The results are abysmal, and we, we have to offer a better product to the public. And that's how we're going to do it is fewer people working together as a surgical team doing the most difficult cases because the way we've done it up to this point has brought us to a point where most boys have a high complication rate and many surgeons don't even try to fix it into a normal penis. Louis, you have something to say. Yeah, I just quickly, I just echoed Doctor Sloy deGrasse's words, but I, I, I remember in 2006, Pipiali organized a Uh, workshop for hypospaes Warren was operating. I actually helped him in a few cases, assisted him there, but I remember that he made a comment, um, I think Tony Curry was doing a case and then he said that one of the most difficult steps in hypospaes was skin closure. It was funny because, um, this was in 2016 or 2006 or 2015 years ago, and then actually, um, a lot of people in the audience laughed about that, said, oh, PP, how come you don't know how to close the skin and stuff like that. And um when I went to do my fellowship at Sick Kids, I had already done fellowshipping elsewhere, and then I tell that to my residents every single time. The most difficult part of hypospaus is the skin closure. And I, it's, it's interesting that uh Warren says that he needs, uh, help or, and I remember that one of the courses in Dallas, Pepiali was given a two-stage repair, and he could not close the skin. Actually, Nicole Bush had to come and help him. It was difficult. So it, it is, it is a difficult task, and the way I teach, I think, um, it is important that the meeting is for fellows. But again, now I started my fellowship here and then the, the fellow can uh testify for what I'm saying. But you can teach uh skin closure and how to handle skin doing circumcisions. Believe me or not, there is a lot of the principles that are completely applicable. And you can actually, instead of trying to do a circumcision in 2 minutes or 5 minutes, if you do like uh, uh, we don't call it sleep technique, but you can do a lot and teach your fellow or your resident how to do and handle the tissues properly that it will help him on hypospaus. Thank you. Can I just make a quick comment? Uh, absolutely, Marty. So Warren, uh, uh, I was just gonna bring up the exact same thing, Louise, about, uh, the skin being oftentimes the most difficult thing in hypospadius repair, and I, I remember too when I presented in England one year when Nicole bailed me out too when she first finished her fellowship and came back and was working with Warren. Uh, uh, but I want to bring up one point that Edmund taught me, Warren, and whether you practice it still. I was worried in my early career about the number of suture tracks that I used to get, and he said, oh, I, I close everything subcuticular, and I've been doing that ever since. I still, to this date, don't think I have one fellow who closes everything subcuticular because nobody else did. And, you know, when you're only one, they do it. With the just like you said at the beginning of your lecture, are you closing your skin subcuticular, and if not, why not? I, I am. And that's a funny thing. My story of that is that I walked into one of our national meetings right after lunch and two people I don't remember were sitting talking. They were talking about suture tracks and, and they were talking about that. And then they turned to me and said, Whoa, Dr. Stockgrass, you're sitting there. What do you do for that? I said, Well, I put my stitches through the skin. I, I use chromic. That's why I was taught in the time when I was with Edmund. And I said, I, I don't think I ever see suture tracks. So then I went back and that was in the back of my mind, and this was at a time when I was bringing patients back after their initial tip repairs just to make sure they didn't develop strictures down the road. So these papers were coming in a couple of years after surgery, but now I started looking at them and I started tallying things as I do. And 50% of my patients had suture tracks, but I had said just a couple of weeks before, I don't think I ever see suture tracks. So we, that's part of the beginning of every operation we do on somebody who's ever been operated before. We look all over them for suture tracks cause most people have some and, and they never go away. So we always put all the stitches subepithelialally, and that gets rid of most of them, but, but not completely, probably because skin appendages under the skin, the, the, the suture gets it and they can still grow a suture tract. But these stitches that people put through the skin and then promise us that they never get suture tracts, well, we beg to differ from the patients who come to us. They do. Louis, please, you have something. Yeah, just, uh, to be the devil's advocate. I, I get it, and again, there is no way to be better than subcuticular, but I can tell you because when I came to McMaster, we didn't have the proper suture that, uh, with the vicarrapi that I couldn't get it. So I'm telling you, and then, uh, Warren knows that I do the follow-up and I follow those patients, and you've seen the, some of the pictures I'm, I'm happy to share with you. If you put it, that's why I, I, I tell, I said. That uh you can teach on circumcision if you use 7 OPDS and you put 3 knots just approximating skin when the patient comes back for um uh catheterter removal, the skins are, the stitches are gone and there is no, there are no marks. So, but again, there is a technique. You cannot put 5 knots, you cannot uh squeeze the tissue, then the, the marks will be there. If you put 3 knots, they are properly tight. Uh, then this, uh, again, if you don't have the suture, um, to do the subcuticular with a small needle, I think it's a good alternative. That's my, my, my, my, my, my, my point. Thank you. Does, think, does it give you a smooth line, Luis, or do you sometimes get irregularity because you went through the epithelium? Uh, again, you see there, like, you know, there are some pictures, you get a smooth line because it's like, uh, almost sometimes it staples. If they, you remove them early, they, they don't leave the marks. I think, um, you know, because I got, if the patient has a lot of swelling. If you don't do proper technique and stuff, then they will squeeze the knots and then the marks will be there. So, if you don't wanna get any marks, again, of course, subcuticular is better, but again, if you do it properly and then uh you, you don't get it. OK, well, let's, let's, let's move on at least with this distal hyposperus repair. So as you can see, uh, procedure was uh accomplished with the urethroplasty in a tip technique. Uh, Warren for this distal hyposperia, do you do deglining and do you do artificial erection universally on everybody? We always do an artificial erection, period, and we can show you pictures of patients who had quote normal looking spongiosum and that have over 30 degrees of bending. So the answer to that is always. Do we always de-glove? We don't de-glove when we're doing a foreskin reconstruction. If we're doing a circumcision, then yeah, we do. So, for distal hypersperus, would you start with the artificial erection or you accomplish urethroplasty first, then you do artificial erection? What's, well, because our algorithm for urethroplasty depends on ventral curvature, we always do the, that first. We always do artificial erection first. Um, and I always Wonder a bit about people that do it the other way. If you've just done a full urethroplasty and then you see the penis is bent more than you thought it was, what are the odds you're going to take all that apart or what are the odds you're going to now convert that to a staged repair? I know what people do. They placate it, and then I know that at least some of those patients fail because they end up in our practice. So, I, I posed a question for the audience, but we don't need to wait for results. I'll update you later. Uh, Louis, what would, what would be your preferable technique? To do, um, in terms of urethroplasty, yes, for distal hypostatis, yes, like I said, uh, tip repair again, unless with those variants, then I, I'm, I'm again, uh, maybe I feel uncomfortable or I think that I, I get a better result with the dorsum leg graft, but then, uh, it's, but what, what suture type would you be using for urethroplasty running interrupted full thickness? OK, so again, uh, Warren doesn't know. That, so I'm, I'm sharing my secrets with him, but again, he has influenced me more. What do you mean? Warren knows everything. What do you mean? No, no, but he, that's what I'm saying. He doesn't know that because look at that. I always learn, uh, so I'll say that I do it in two layers, always distant proximals. I always put two layers and I do um a running suture of 7 OPDS and interrupted suture with 7 OPDS because that's the suture that I had but I just 1st 1st layer is running. First layer is running is the opposite of what he does and then the second interrupted, but I'll tell you why I decide to do that because I always learned to do hypospaus closing from the tip. From the top, uh, to the, to the medias, like, you know, from top down, you know, you start from there, you mark where you wanna go and you, so then I was helping him start grass in Toronto, and then he was suturing, and then he was doing like a subcuticular, you know, his hand goes sideways and going very quickly, like, you know, I said, wow, this guy is very slick, and why is he doing that? And then I said he's left-handed. So in order for me to do the same, I, I, I'm right-handed. I'm gonna start from the bottom up. This helps. This helps me get the spongiosum, so I don't, I don't put a knot where the urethra is very, very thin. So I start with the spongiosum, do the spongioplastic covering the Y, and continue with like a sub, subethelial, and then, uh, you know, do reinforced stitches, uh, interrupted. That's how I have been doing all the time and in distal hypospheres, the complication is quite low. 50%. So you're still starting distally and going proximally, right? No, I start proximally and go distally because I'm a right-handed. I'm on the right side of the patient with like a right a subcuticular stitch go side to side. Warren, do you start proximately and go distally as well? No, no, I, I've always done it distal to proximal left-handed, yeah, but I do that I think right-handed people actually can do it. Uh, the reason I do is because the, the, the fear is to get You know, making your running stitch distally and go a little bit too far, and then people are always hesitant to undo a running stitch. Yeah, that's very important. So I, I always mark first like he taught us, you mark where you want to get your meatus and then you stop there. If you do that, you don't risk running all the way up. I would totally agree that would work fine. Eugene, can you go back one slide for a second? So, Doctor Snodgrass, and Warren, how would you, um, the very distal aspect of this urethroplasty, if you're doing a subcuticular closure, how are you approximating that meatus or maturing the meatus to the glands there? We never mature the meatus to the glands. So you've, you've not, even with your, um, proximal repair, because I know you do that with the tip, you just close the glands over and you let that kind of heal in. You've never sewn that, uh. I know there used to be people that you did like a four-way stitch to try and mature it, but you, you taught us that you never did any stitches there. Is that the same technique with your, um, uh, stag stag repair too? You don't do any fixation of the urethromaus to the glands. Yeah, when you make a, a, when you use the urethral plate or you use a neourethral plate, you do not have to sew those edges to the glands like you do, like you learned to do with onlay flaps and flip flops and all of those kinds of. You don't do that. And, and so there's a lot of advantages to not doing it, including the fact when I look at this picture of the tubularization, it's a picture, but I think it's OK. But if you had gone a half stitch further distally, it would have been too far. To me, it's bordering on being too far, and I think when people close it too far, it's because they want to mature it against the gland's wings, and we just don't ever do that ever and haven't. Ever. OK, by the way, 62% of people would, would do inverting subcuticular running suture for urethroplasty. So that was the final product. So there was quite a few questions, just technical questions. Uh, what kind of dressing do you use, uh, uh, Luis, for the distal hypospaes? So I, I just put a Tegaderm covering like a sandwich, and then I, I put it like a loose cold band around the penis and I use double diapers for the catheter. Wow. That's a quite elaborate uh uh coverage. Warren, what do you, what kind of dressing do you use for the distal hypersperia? Yeah, we also just do a Tegaderm sandwich dressing and let it fall off. And we don't do double diapers. We just let the catheter drain into a diaper. You know, the, the dressing thing doesn't make, it doesn't make any difference for your urethroplasty at the end of the day. And so our own When, when I, when people ask me, my response is, I don't care what kind of bandage you put, as long as it's not something that's painful to remove or something that the patient has to come back and have anesthesia or something. I mean, some people around the world do these things and uh we just see, you know, no medical reason to make this step complicated. And for how long do you use a stent? If you use a stent, are any tip repairs where you would not leave we tried for a while, uh, because, you know, a lot of people do it without one, and what we found was that it was fine in, in infants, not in older kids who are afraid to pee. Uh, but, um, but it, it made it where we couldn't put on as good of a bandage initially. When I said bandages don't matter, they don't, but, but they might matter just in that 1st 24 hours or so because what we found was that all of a sudden we started seeing some kids with secondary fimosis and stuff with more swelling of the skin and everything. And as soon as we said, OK, we're going to go back to leaving stents and putting on a little bit better bandage, that all went away again. So the bottom line is we do a stent and we leave a bandage and the bandage falls off by itself and the stent's in basically a week. So for how long, for how long do you leave a stent? We leave it basically a week, OK. I think just for, uh, OK, sorry, just for the young ones, I think, uh, if they wanna start their practice, I think the stents or the catheters will not make any difference. The papers have shown that in terms of the outcome, but they're gonna get called much more often to the car by the family. So, uh, it's about the, the comfort or the patient then about the outcome at the end result at the in the end. And Warren, do you offer, uh, foreskin sparing in all of your patients or only if parents bring it up themselves? Well, we, we approach it from the other direction and we just ask a parent, all parents, we said, you know, when you found out you're having a boy, was it your intention to do a circumcision or leave him natural? And if they say circumcision, we say, OK, well that'll be part of the operation. If they say we wanted him to be natural, we say, OK, we, we can make that the end result of this if you wish. And the only time that we steer people are the boys with the most severe hypospadius and a small. And the small glands. So now we're talking about like perineals and proximal scrotal hypospadius and such, where the glands is frequently like 12 millimeters. And, and what we tell them is we can do it, we can, we can do, we can do a foreskin reconstruction even in that case. But we're gonna have to take the graph from a different location. We can't use the prep use, so we're gonna be doing oral mucosa. And right there, many parents drop off. They're like, no, I want you going in his mouth if you don't need to. And then the, uh, and then we'll tell the ones that we've measured the glands and we can see it's very small. We'll tell them that the, or even using lip. That the graft heals more thick from the mouth than it does from the foreskin, and it could make it more difficult for us to get, you know, good glands fusion in the end. And, and, and some parents still say, well, that's what we prefer, and it's OK. I mean, we have people come from Europe, particularly where the Europeans won't repair their foreskin, and we will, and, and, you know, their attitude is he needs to look like his mates at school, and our attitude is, well, even if his glands dehisses under an intact foreskin, it's not going to be really particularly a problem. So, we don't have an argument about it. If somebody wants it, we do it. We don't push it. We don't push away from it, except in the boys with most severe epispadius where we do a very informed consent and then whatever they want, that's what we do. Brian, you have a question? Um, I, I know that by the clock we were supposed to, uh, end by 3:30, so I don't know if you're gonna be able to get through your next case, but I, I wanted to probably not. That is why let's cover everything now because I, I wanted to ask Luis and Warren, um, you know, historically. Uh, Doctor Snodgrass was saying that he would have maybe done a dermograft and a buyer's flaps, and then the second stage would have been probably a tear urethroplasty with the buyer's flaps. If you are seeing a patient that comes to your center after their first Uh, stage that underwent a dermograft and a buyer's flats. How do you approach, and we're gonna tell you that the patient has a straight penis by parental observations. What do you, are, are you going to, uh, use a sort of a neourethral graft and move the buyer's flaps and take it to kind of creating a graft for urethral reconstruction on top of that dartos dermograft and let that heal and come back or how would, how would you guys approach that patient that sort of switched gears? And has left you with a straight penis with buyer's flaps on the ventrum. Luis, yeah, I see you're raising your hand. Yeah, so, um, I had a few, uh, cases with that because my partner just retired a few years ago and he used to do the bias flap a lot. So he left some of those patients and then also we've seen some patients that came, uh, later. So instead of taking everything down. And then he restarting again with Bucko Mukosa graft. Uh, I think what we have done with good results, um, and, uh, we learned that from our, one of our, um, residents that actually became a staff with us, trained with Kulkarni, the Indian guy. So what we have done is a dorso inlay graft to using buckle. So we're just putting the buckle there because then that, that's gonna fix the problem with the bias flap with the diverticulum and left and leaving that soft urethra that is gonna balloon after, after your tubular rise if you wanna put it all the way up to the uh to the glands. So, but if you do this, uh, inlay graft, the, the, the buccal mucosa will actually affix that urethra to the corpora, and then you can trim the, the lateral sides, the wings like a diverticulum, and then it's gonna be fine, you know that when you re-operate the diverticulum, it doesn't recur because, um, you know, that you're fixing the, the stuff. So that's how I have approached, uh, it's a good operation because you can do your one stage and, um, they are older patients, they are happier. But again, like Warren mentioned. Uh, the problem was not only this, like, you know, I haven't encountered a lot of patients that came in this scenario. Most of them, 90% of them had the recurrent curvature or residual curvature. So then you have to redo everything. But if you have a, a case that the penis is straight, the best way to do it is like that. I have no doubt we have like 67 cases. So I think it's a good, uh, and we learned from the adult urologists, so it was very good. Let me just finish the topic on the distal hyperspaia since we're very, very short on time. Warren, what kind of long-term follow-up do you recommend on those kids? Do you, do, would you recommend to see them after they toilet trained? Would you recommend to do Euroflow at any point? Just give, give the audience an idea. Yeah, I almost hate to wade into that because there are such strong emotions and such misinformation about what benefit there is from long term follow up. So we, our other abstract that we're going to submit this year is on. Patients presenting with complications during puberty and after puberty, and what the abstract will show is that almost no new problems occur during puberty, almost none. So, basically, what the, if you're gonna have glands dehiscence, that happens at 2 weeks post-op, and if it hadn't happened by 2 weeks, it almost is never going to happen. Most fistulas are apparent within just a few weeks after surgery, not all. Strictures take a longer time to show up, but if you do repairs the way we do, you should have almost zero strictures. We have less than 0.0%. If you're having meatal stenosis very often and it's not due to BXO later on, then you're making a technical error because you should almost never have meal. Stenosis after a primary hypospadius repair. So what's the point in following them forever and ever and ever and ever if almost all complications happen in the first year? And that's not just our data, that's also Marco Castanetti's data where they followed patients for much longer, but then they published all the complications they diagnosed occurred within the first year. So we can talk about this forever. We could have a whole conference just on this, but what happens is people are not following them serially on a regular basis. The patient comes back, even in Europe, the patient will just show back up and have a fistula when they're 8 and they go, oh well, if we hadn't followed you, we'd have never seen it. Well, they weren't following them. Nobody has a series where they did 100 repairs this year and they followed them next year and the next year and the next year. They did 100 more and they added those in and, and every one of those patients came back and all that. No one anywhere has published that. The recurrent curvature that people talk about at puberty, again, isn't recurrent curvature. It's curvature that's been there for a long time that was just the, the surgeon said, no, it's not there. You ask the patients, I am yet to see the 16-year-old who walks in and goes, wow, I had hyperspabury when I was a kid and my penis was absolutely normal until 16 and all of a sudden it bent and it came apart and I grew these scars on the skin and all of that. No. No, that doesn't happen. But we all fall into this trap. When you ask about that, if I say like I just did, you follow them for long enough to see if they have a complication. If you have another indication to follow, if you want to know about ejaculation or something, then you're going to have to see them at a later date, but you don't have to follow them every year until that date. OK, well, um, I think our time is up, uh, promote, uh, any comments for the closure of our day? No, I, I would just like to thank everyone that participated, uh, Warren Luis, uh, Doctor Coyle, Doctor, uh, De Castro. Um, Sarah Cooper, Sarah Fox, um, Doctor Sutilil, I mean, this is phenomenal, phenomenal first day. This is our first time doing this workshop as a virtual, um, conference, and, uh, I'd also like to thank our Globalcast MD team because, uh, it's been pretty. Uh, technologically pretty smooth and, uh, you know, no major hiccups. So big round of applause to them and of course to all the attendees. I mean, taking time out of your day to improve yourselves as, as Doctor Snodgrass said, you know, you can only learn to be better and offer good results. I mean, the patients are not gonna be happy with. 30% complication rate. They want zero% complication rate, right? And so that's what we should strive for and that's what workshops like this, inviting thought leaders and, uh, experts to come in and continuously go on that journey of self-improvement till we get to that zero complication rate. Thank you everyone. Have a wonderful evening and we'll see you at 7:45 tomorrow starting off at 8 o'clock. Ramo. Next time you have to find a way to make the dinner, uh, for us at the same time. I'm not sure I promise, I will send you the dinner. There you go. You are welcome. All of you are welcome to my home, whenever it's free to travel. Welcome to my home. I will. Get you a nice home cooked phenomenal Indian dinner. I'm taking you up on that, of course. You can send us a, a chili and ice cream, you know that. I don't know what some people don't like the chili. Eugene does, but not everyone does. Yeah, but all of us love the ice cream, of course, ice cream. We'll do that. Avocado ice cream, huh? Thank you, everybody. Thanks everybody. Have a good evening. Thank you.