Arlen Angela M, Kirsch Andrew J, Leong Traci, Broecker Bruce H, Smith Edwin A, Elmore James M
Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University of Medicine, Atlanta, GA, USA.
Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA.
J Pediatr Urol. 2015 Apr;11(2):71.e1-5. doi: 10.1016/j.jpurol.2014.11.015. Epub 2015 Feb 26.
The Glans-Urethral Meatus-Shaft (GMS) score is a concise and reproducible way to describe hypospadias severity. We classified boys undergoing primary hypospadias repair to determine the correlation between GMS score and postoperative complications.
Between February 2011 and August 2013, patients undergoing primary hypospadias repair were prospectively scored using the GMS classification. GMS scoring included a 1-4 scale for each component: G - glans size/urethral plate quality, M - meatal location, and S - degree of shaft curvature, with more unfavorable characteristics assigned higher scores [Figure]. Demographics, repair type, and complications (urethrocutaneous fistula, meatal stenosis, glans dehiscence, phimosis, recurrent chordee and stricture) were assessed. Total and individual component scores were tested in uni- and multivariate analysis.
Two-hundred and sixty-two boys (mean age 12.3 ± 13.7 months) undergoing primary hypospadias repair had a GMS score assigned. Mean GMS score was 7 ± 2.5 (G 2.1 ± 0.9, M 2.4 ± 1, S 2.4 ± 1). Mean clinical follow-up was 17.7 ± 9.3 months. Thirty-seven children (14.1%) had 45 complications. A significant relationship between the total GMS score and presence of any complication (p < 0.001) was observed; for every unit increase in GMS score the odds of any postoperative complication increased 1.44 times (95% CI, 1.24-1.68). Urethrocutaneuous fistula was the most common complication, occurring in 21 of 239 (8.8%) of single-stage repairs. Patients with mild hypospadias (GMS 3-6) had a 2.4% fistula rate vs. 11.1% for moderate (GMS 7-9) and 22.6% for severe (GMS 10-12) hypospadias (p < 0.001). Degree of chordee was an independent predictor of fistula on multivariate analysis; S4 (>60° ventral curvature) patients were 27 times more likely to develop a fistula than S1 (no curvature) boys (95% CI, 3.2-229).
The GMS score is based on anatomic features (i.e. glans size/urethral plate quality, location of meatus, and degree of chordee) felt to most likely impact functional and cosmetic outcomes following hypospadias repair. We demonstrated a statistically significant increase in the likelihood of any postoperative complication with every unit increase in total GMS score. The concept that factors aside from meatal location affect hypospadias repair and outcomes is not novel, and degree of ventral curvature and urethral plate quality are often cited as important factors. In our series, boys with greater than 60° of ventral curvature undergoing a single-stage repair were 27 times more likely to develop a fistula than those without chordee on multivariate analysis, making severe curvature an independent predictor of urethrocutaneous fistula formation. That meatal location did not retain significance on multivariate analysis highlights the importance of considering the entire hypospadias complex when determining severity, rather than just evaluating the position of the meatus. Our study has several limitations that warrant consideration. While GMS scores were assigned prospectively, the data was collected retrospectively, subjecting it to flaws inherent with such study design. Furthermore, type of repair is influenced by surgeon preference and subjective assessment of hypospadias characteristics not incorporated in our scoring system (i.e. tissue quality, urethral hypoplasia, penoscrotal transposition). Despite these limitations, our study demonstrates a strong correlation between the GMS classification and surgical complications, furthering supporting its potential as a tool to standardize hypospadias severity and gauge postoperative complications.
The Glans-Urethral Meatus-Shaft (GMS) classification provides a means by which hypospadias severity and reporting can be standardized, which may improve inter-study comparison of reconstructive outcomes. There is a strong correlation between complication risk and total GMS score. Degree of chordee (S score) is independently predictive of fistula rate.
阴茎头-尿道外口-阴茎干（GMS）评分是一种描述尿道下裂严重程度的简洁且可重复的方法。我们对接受一期尿道下裂修复术的男孩进行分类，以确定GMS评分与术后并发症之间的相关性。
2011年2月至2013年8月期间，对接受一期尿道下裂修复术的患者采用GMS分类法进行前瞻性评分。GMS评分的每个组成部分采用1-4分制：G-阴茎头大小/尿道板质量，M-尿道口位置，S-阴茎干弯曲程度，特征越不利得分越高[图]。评估了人口统计学资料、修复类型和并发症（尿道皮肤瘘、尿道口狭窄、阴茎头裂开、包茎、复发性阴茎下弯和尿道狭窄）。对总分和各组成部分得分进行单因素和多因素分析。
262例接受一期尿道下裂修复术的男孩（平均年龄12.3±13.7个月）获得了GMS评分。GMS平均评分为7±2.5（G 2.1±0.9，M 2.4±1，S 2.4±1）。平均临床随访时间为17.7±9.3个月。37名儿童（14.1%）出现了45例并发症。观察到GMS总分与任何并发症的发生之间存在显著相关性（p<0.001）；GMS评分每增加一个单位，任何术后并发症的发生几率增加1.44倍（95%CI，1.24-1.68）。尿道皮肤瘘是最常见的并发症，在239例一期修复手术中有21例（8.8%）发生。轻度尿道下裂（GMS 3-6）患者的瘘管发生率为2.4%，中度（GMS 7-9）为11.1%，重度（GMS 10-12）为22.6%（p<0.001）。在多因素分析中，阴茎下弯程度是瘘管形成的独立预测因素；S4（腹侧弯曲>60°）患者发生瘘管的可能性是S1（无弯曲）男孩的27倍（95%CI，3.2-229）。
GMS评分基于解剖学特征（即阴茎头大小/尿道板质量、尿道口位置和阴茎下弯程度），这些特征最有可能影响尿道下裂修复后的功能和外观效果。我们证明，GMS总分每增加一个单位，任何术后并发症的发生可能性就会有统计学意义的增加。尿道口位置以外的因素影响尿道下裂修复和结果这一概念并不新鲜，腹侧弯曲程度和尿道板质量常被认为是重要因素。在我们的系列研究中，多因素分析显示，腹侧弯曲大于60°且接受一期修复的男孩发生瘘管的可能性是无阴茎下弯男孩的27倍，这使得严重弯曲成为尿道皮肤瘘形成的独立预测因素。尿道口位置在多因素分析中不再具有显著性，这突出了在确定严重程度时考虑整个尿道下裂复合体的重要性，而不仅仅是评估尿道口的位置。我们的研究有几个局限性值得考虑。虽然GMS评分是前瞻性分配的，但数据是回顾性收集的，存在此类研究设计固有的缺陷。此外，修复类型受外科医生偏好以及我们评分系统未纳入的尿道下裂特征主观评估的影响（即组织质量、尿道发育不全、阴茎阴囊转位）。尽管有这些局限性，我们的研究表明GMS分类与手术并发症之间存在很强的相关性，进一步支持了其作为标准化尿道下裂严重程度和评估术后并发症工具的潜力。
阴茎头-尿道外口-阴茎干（GMS）分类提供了一种标准化尿道下裂严重程度和报告方式的方法，这可能会改善重建结果的研究间比较。并发症风险与GMS总分之间存在很强的相关性。阴茎下弯程度（S评分）是瘘管发生率的独立预测因素。
