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Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias. Int Braz J Urol 2020; 46:1029-1041. [PMID: 32822133 PMCID: PMC7527085 DOI: 10.1590/s1677-5538.ibju.2019.0845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/20/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair. MATERIAL AND METHODS Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated. RESULTS Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream. CONCLUSIONS Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.
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Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis. Reg Anesth Pain Med 2019; 44:259-267. [PMID: 30700621 DOI: 10.1136/rapm-2018-000022] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/27/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES is commonly used for children undergoing hypospadias repair. However, the safety of caudal block for hypospadias repair in children is controversial in terms of surgical complications such as urethrocutaneous fistula and glans dehiscence. We sought to perform a meta-analysis to estimate the analgesic efficacy and relative complications of caudal block for hypospadias repair in children. METHODS We identified comparative studies of caudal block versus peripheral nerve block or no caudal block; studies were published or presented through 1 January 2018, and reports of analgesic efficacy or surgical complications of hypospadias repair in children were identified. Peripheral nerve block includes dorsal nerve penile block and pudendal nerve block. Data were abstracted from studies comparing caudal block with peripheral nerve block or no caudal block; original source data were used when available. We prespecified separate assessments of randomized controlled trials (RCTs) and observational studies given the inherent differences between types of study designs. Data from 298 patients in four RCTs and from 1726 patients in seven observational studies were included. RCT and observational data were analyzed separately. RESULTS In RCTs, caudal blocks (compared with peripheral nerve blocks) showed no detectable differences in terms of need for additional analgesia within 24 hours after the surgery (OR 10.49; 95% CI 0.32 to 343.24; p=0.19), but limited data showed lower pain scores 24 hours after the surgery (standardized mean difference (SMD) 1.57; 95% CI 0.29 to 2.84; p=0.02), a significantly shorter duration of analgesia (SMD -3.33; 95% CI -4.18 to -2.48; p<0.0001) and analgesics consumption. No significant differences were observed in terms of postoperative nausea and vomiting (OR 3.08; 95% CI 0.12 to 77.80; p=0.50) or motor weakness (OR 0.01; 95% CI -0.03 to 0.05; p=0.56). Only one randomized study showed that caudal blocks (compared with peripheral nerve blocks) were associated with detectable differences in urethrocutaneous fistula rate (OR 25.27; 95% CI 1.37 to 465.01; p=0.03) and parental satisfaction rate (OR 0.07; 95% CI 0.02 to 0.21; p<0.00001). In observational studies, caudal block was not associated with surgical complications in all types of primary hypospadias repair (OR 1.83; 95% CI 0.80 to 4.16; p=0.15). To adjust for confounding factors and to eliminate potential selection bias involving caudal block indication, we performed subgroup analysis including only patients with distal hypospadias. This analysis revealed similar complication rates in children who received a caudal block and in children not receiving caudal block (OR 1.02; 95% CI, 0.39 to 2.65; p=0.96). This result further confirmed that caudal block was not a risk factor for surgical complications in hypospadias repair. The direction of outcomes in all the other subgroup analyses did not change, suggesting stability of our results. CONCLUSIONS In RCTs, only limited data showed peripheral nerve blocks providing better analgesic quality compared with caudal blocks. In real-world non-randomized observational studies with greater number of patients (but with admitted the potential for a presence of selection bias and residual confounders), caudal blocks were not associated with postoperative complications including urethrocutaneous fistula and glans dehiscence.
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Outcome of surgical management of urethral stricture following hypospadias repair. J Pediatr Urol 2019; 15:354.e1-354.e6. [PMID: 31262655 DOI: 10.1016/j.jpurol.2019.05.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 05/20/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Reconstruction of urethral strictures in patients with a history of hypospadias repair is controversial. The authors policy has been that if a residual healthy urethral plate is present, single-stage urethroplasty is recommended. However, if the urethral plate is fibrotic or absent or if lichen sclerosus is present, two-stage repair is utilized. OBJECTIVES In this study, the authors report their experience in management of patients with urethral stricture and prior hypospadias surgery. STUDY DESIGN Between 1993 and 2015, 62 patients with urethral stricture and a prior history of hypospadias repair underwent urethroplasty. Patients were divided into two groups; patients in group 1 (n = 39) found to have a healthy residual urethral plate and underwent single-stage urethral stricture repair using either an island skin flap or a buccal mucosa graft. Patients in group 2 (n = 23) had either a scarred urethra or evidence of lichen sclerosus and underwent staged repair using a buccal mucosa graft. Post-operatively, patients were evaluated at 3 months, 6 months, 1 year, and then annually. RESULTS The median age of the patients was 10.5 years (2.5-33 years). The mean stricture length was 6.3 cm in group 1 and 7.1 cm in group 2. Overall success rate was 87.1% in group 1; a urethral fistula occurred in one patient (7.1%) who underwent skin flap onlay repair and one patient (4.5%) with a buccal mucosa graft. Recurrent urethral stricture was also diagnosed in one patient (7.1%) after repair using an island skin flap and in two patients (9%) following buccal mucosa graft. In group 2, three patients (13%) developed graft contracture and were revised before the second stage. Two patients (8.6%) had glans dehiscence following second stage urethroplasty. The final success rate in group 2 was 90.4%. DISCUSSION Both single-stage and 2-stage repair showed successful outcome in management of urethral stricture following hypospadias repair. However, the authors continue to believe that the status of the urethral plate dictates the type of surgery to be utilized. In accordance to the previously published data, the study results also further support promising outcomes of application of buccal mucosa in surgical management of these patients. CONCLUSION In patients with urethral stricture after hypospadias surgery who have a healthy residual urethral plate, single-stage repair using buccal mucosa graft is a viable option with high success rate. In patients with scarred urethral plate, a 2-stage repair is recommended.
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Back to the future: The Cecil-Culp technique for salvage penile reconstructive procedures. J Pediatr Urol 2018; 14:328.e1-328.e7. [PMID: 29898866 DOI: 10.1016/j.jpurol.2018.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/17/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Re-operative penile reconstruction is challenging and requires tension-free skin closure. The repair popularized by Cecil and Culp in the 1940s, using the scrotum to provide a temporary vascularized bed for complex hypospadias repairs, fell out of favor due to temporal trends towards single-stage repairs and concern for utilizing hair-bearing skin on the penile shaft. OBJECTIVE It was hypothesized that a modified Cecil-Culp (CC) concept of penile scrotalization, leaving the penis attached to the scrotum for 1 year rather than 6 weeks as originally described, improves outcomes with this reconstruction for ventral skin deficiency or poor vascular support. METHODS Institutional Review Board-approved registries were reviewed to identify patients who underwent a CC repair during 1987-2016 at two institutions. Cecil-Culp technique was utilized in multi-stage hypospadias complication repairs or for insufficient ventral penile shaft skin coverage. Anatomic abnormality, number and type of prior surgeries, and complications before and after CC were recorded. RESULTS Thirty-nine patients underwent CC: 23 failed hypospadias repairs, three hypospadias after bladder exstrophy, 10 penile curvature following circumcision, and three with skin loss from trauma. Mean age at CC was 61.8 months (hypospadias), and 59.8 months (non-hypospadias). Hypospadias patients underwent a mean of 3.6 surgeries (range 1-9) prior to CC. Four of the 39 patients (10.3%) had perioperative complications after CC, including scrotal abscess, skin infections, and difficulty removing the urethral stent. Eight of 37 (21.6%) patients had longer-term complications related to their hypospadias repair, including fistulae, diverticula, dehiscence, and stricture. Mean time from CC placement to release was 345 and 473 days for hypospadias and non-hypospadias cases, respectively. There was no apparent scrotal skin transferred to the penile shaft at the final take-down. Mean follow-up was 22.3 months. DISCUSSION Embedding the penis into the scrotum for added vascularity and ventral skin coverage has been used effectively in cases of the most tenacious fistulas and for significant skin loss and trauma. Limitations of this study were its retrospective approach at two institutions over an extended period of time by multiple surgeons, so patient selection and procedure may have varied. CONCLUSIONS Modification of CC repair by delaying 9-12 months before CC take-down enhanced the benefits of a robust vascular bed for wound healing, and helped to avoid transfer of hair-bearing scrotal skin to the penile shaft. The CC technique is an important tool for penile reconstructive surgery of complex hypospadias repairs with inadequate skin, and for traumatic injuries.
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The hypospadias classification affected the surgical outcomes of staged oral mucosa graft urethroplasty in hypospadias reoperation: An observational study. Medicine (Baltimore) 2017; 96:e8238. [PMID: 29381913 PMCID: PMC5708912 DOI: 10.1097/md.0000000000008238] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The staged graft urethroplasty is a recommended technique for repairing complex hypospadias. This retrospective study aimed to investigate the outcomes of this technique in hypospadias patients undergoing reoperation and to analyze the underlying contributing factors including age, meatus location, and graft and suture type.We retrospectively analyzed 40 hypospadias patients undergoing reoperation who received a staged oral graft urethroplasty, including 15 buccal mucosal grafts and 25 lingual mucosal grafts. Median age at presentation was 18.5 years, and median follow-up was 17.5 months (range 8-30 months). The patients were classified according to their original meatus location.Twenty-five complications developed in 12 of 40 (30%) cases, including 6 fistulas (15%), 7 infections (17.5%), 9 cases of glans dehiscence (22.5%), and 3 cases of stenosis (7.5%). There was no significant difference in the overall complication rates between prepuberty and postpuberty groups. In addition, no significant difference in complications was found between the 2 graft techniques. The complications were significantly higher in the original perineal type compared with the original penoscrotal type (7/10 vs 5/30, P = .0031). Seven patients who originally had perineal hypospadias developed multiple complications.Based on this study, the staged graft urethroplasty is an effective technique in reoperative hypospadias repairs with reasonable complication risk. The hypospadias classification affects the surgical outcomes.
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Between Concealing and Revealing Intersexed Bodies: Parental Strategies. QUALITATIVE HEALTH RESEARCH 2017; 27:1562-1574. [PMID: 28728528 DOI: 10.1177/1049732317697100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Parents of intersex children are perceived in many studies as hopeless, highly dependent on the medical system, and as gate keepers of normative gendered bodies. In this article, we challenge these perceptions and argue that parents of intersex children are problematically positioned between their children's needs for care and well-being and the socialmedical forces that aim to "normalize" them. Their in-between position leads them to establish different parental strategies within and outside of traditional sex/gender norms. We focus on three intertwined parental strategy frameworks: bodily dialogue, sex/gender framing, and concealing/revealing practices, and describe how, in each of these strategic frameworks, the parents maneuver, act in accordance with or against, react to, and challenge the medical system, social interactions, and the sex/gender paradigm. This is a comparative study based on narrative interviews with 22 parents of intersex children in Germany and Israel.
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Lingual mucosal graft two-stage Bracka technique for redo hypospadias repair. Arab J Urol 2017; 15:236-241. [PMID: 29071158 PMCID: PMC5651942 DOI: 10.1016/j.aju.2017.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/12/2017] [Accepted: 06/04/2017] [Indexed: 11/23/2022] Open
Abstract
Objectives To report our initial experience in redo hypospadias repair with a lingual mucosal graft (LMG) using a two-stage Bracka technique. Patients and methods This study was prospectively conducted and included 26 patients with hypospadias with failed previous repairs. All the patients had a LMG using a two-stage Bracka technique. In the first stage, the harvested LMG, from the ventro-lateral surface of the tongue, was implanted in a well-prepared vascularised bed in the ventral aspect of the penis. After 6 months, tubularisation of the well-taken graft was completed. Tunica vaginalis or a dartos flap was used as second-layer coverage of the neourethra. Success was defined as acceptable aesthetic and functional outcomes without any additional surgical interventions. Results The mean (SD) patient age was 5.15 (1.6) years. The mean (SD) LMG length was 3.82 (0.9) cm and the width was 1.5 (0.5) cm. The mean (SD) number of previous repairs was 2.76 (1.1). The mean (SD) follow-up was 12 (2) months. Donor-site complications included: pain in all patients, with a pain score of >3 on the visual analogue pain scale (0–10) in 10 (38%); and speech problems in 19 (73%). First-stage complications were graft loss (n = 2) and contracture (n = 1). The second stage was completed in 23 patients resulting in the following significant complications: meatal stenosis plus fistula (n = 2), breakdown (n = 1). Successful hypospadias repair was achieved in 77% (20/26) of the patients. Conclusion Lingual mucosa is a reliable and versatile graft material in the armamentarium of two-stage Bracka hypospadias repair with the merits of easy harvesting and minor donor-site complications.
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The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair. Paediatr Anaesth 2017; 27:688-694. [PMID: 28345802 PMCID: PMC5461187 DOI: 10.1111/pan.13119] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2017] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence. METHODS All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed. RESULTS We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications. CONCLUSIONS In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair.
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Tips and Techniques in Oral Mucosa Harvest for Urological Reconstruction. J Craniofac Surg 2017; 28:1117-1118. [PMID: 28277478 DOI: 10.1097/scs.0000000000003644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Old Tools, Old Problems, New Solution: The Use of a Modified Cecil-Culp Concept in the Trauma Setting. Urology 2017; 106:196-199. [PMID: 28454986 DOI: 10.1016/j.urology.2017.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 04/11/2017] [Accepted: 04/17/2017] [Indexed: 11/22/2022]
Abstract
A 12-year-old boy sustained a close-range shotgun wound with buckshot to the penis and lower abdomen. The proximal two-thirds of the corpora cavernosa was obliterated and the distal third was thrombosed. All dorsal penile skin was lost. The urethra remained intact. The patient underwent multiple debridements, allowing the wound to declare its borders. Employing the tissue transfer concept used by Cecil and Culp in hypospadias repairs, the penis was marsupialized onto the suprapubic area where it remained for 8 months. After 8 months, the patient underwent a graft delaying procedure followed by a graft harvest 2 months later and penoplasty tubularization.
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Resurfacing the Penis of Complex Hypospadias Repair ("Hypospadias Cripples"). J Urol 2017; 197:859-864. [PMID: 28131500 DOI: 10.1016/j.juro.2016.09.075] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE After the creation of a neourethra in a "hypospadias cripple," resurfacing the penis with healthy skin is a significant challenge because local tissue is often scarred and unusable. We reviewed our experience with various strategies to resurface the penis of hypospadias cripples. MATERIALS AND METHODS We retrospectively reviewed the records of 215 patients referred after multiple unsuccessful hypospadias repairs from 1981 to 2014. In 130 of 215 patients we performed resurfacing using local penile flaps using various techniques, including Byars flaps, Z-plasty or double Z-plasty, or a dorsal relaxing incision. Of the 215 patients 85 did not have adequate healthy local penile skin to resurface the penis after urethroplasty. Scrotal skin was used to resurface the penis in 54 patients, 6 underwent tissue expansion of the dorsal penile skin during a 12 to 16-week period prior to penile resurfacing, 23 underwent full-thickness skin grafting and another 4 received a split-thickness skin graft. RESULTS Of the 56 patients who underwent fasciomyocutaneous rotational flaps, tissue expansion or a combination of both approaches 54 (96.4%) finally had a successful outcome. All 6 patients who underwent tissue expansion had a successful outcome without complications and were reported on previously. All 23 full-thickness skin grafts took with excellent results. All 4 patients who underwent fenestrated split-thickness skin grafting had 100% graft take but secondary contraction and ulceration were associated with sexual activity. CONCLUSIONS In our experience scrotal skin flaps, tissue expansion of the dorsal penile skin and full-thickness skin grafts serve as reliable approaches in resurfacing the penis in almost any hypospadias cripple lacking healthy local skin.
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The role of tunica vaginalis flap in staged repair of hypospadias. Asian J Urol 2016; 4:107-110. [PMID: 29264214 PMCID: PMC5717980 DOI: 10.1016/j.ajur.2016.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/07/2016] [Accepted: 10/10/2016] [Indexed: 11/16/2022] Open
Abstract
Objective The surgical repair of hypospadias is done in two stages in a select group of patients with severe anomaly. The first stage (I) procedure consists of correction of penile shaft curvature and second stage (II) repair involves the creation of a neourethra. This neourethra needs a cover of an intermediate layer in order to have good functional and cosmetic results. Among the various local flaps, tunica vaginalis flap is a good option for the use as an intermediate layer. Methods We have managed 22 patients of chordee with hypospadias by staged repair. In Stage I, chordee correction was done by dividing the urethral plate and covering the penile shaft with dorsal prepucial flaps. In Stage II, a neourethra was created and covered with tunica vaginalis flap either through the same incision (14/22) or via a subcutaneous tunnel (8/22). An indwelling catheter was kept for 10 to 12 days. Results Eighteen (81.8%) patients had successful functional and cosmetic repair. Two patients (9.1%) had urethrocutaneous fistula of which one healed on subsequent dilatation while the other one (4.5%) needed repair. Overall fistula formation rate was 4.5%. In two patients, the external urinary meatus could be made upto subglanular or coronal level. Conclusion Staged repair of chordee with hypospadias is valuable in selected group of patients and tunica vaginalis flap is an excellent intermediate layer to cover the neourethra. However preoperative counseling is particularly essential in patients where the external urinary meatus can be created at coronal or subglanular level.
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Benign penile skin anomalies in children: a primer for pediatricians. World J Pediatr 2015; 11:316-23. [PMID: 25754752 DOI: 10.1007/s12519-015-0015-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 09/20/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Abnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern. DATA SOURCES The present review was based on a nonsystematic search of the English language medical literature using a combination of key words including "penile skin anomalies" and the specific names of the different conditions. RESULTS Conditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age. CONCLUSION This review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.
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Modified Mathieu repair for failed surgery for hypospadias: Perimeatal-based flap with a subdermal vascular dartos pedicle. AFRICAN JOURNAL OF UROLOGY 2015. [DOI: 10.1016/j.afju.2014.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Buccal mucosa grafting for male urethroplasty: Long-term follow up of patients’ experience with a team approach and primary closure. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2014. [DOI: 10.1016/j.ajoms.2013.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Is There a Need for Smooth Muscle Cell Transplantation in Urethral Reconstruction? Tissue Eng Part A 2014; 20:1542-9. [DOI: 10.1089/ten.tea.2013.0185] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair. J Pediatr Urol 2013; 9:754-8. [PMID: 23009885 DOI: 10.1016/j.jpurol.2012.08.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 08/31/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To compare surgical outcomes and donor site complications of buccal and lingual mucosa used as ventral onlay graft for complex hypospadias cases. PATIENTS & METHODS Forty four cases with complex hypospadias after failed previous surgery were prospectively included. All had severely scarred penile skin with reasonable residual urethral plate. Cases were categorized into two groups: Group I (23) where buccal mucosal graft [BMG] was used and group II (21) where lingual mucosal graft [LMG] was used. Donor site complications as well as functional and esthetic outcomes were recorded for each group. RESULTS Mean follow up was 20.8 months (range 12-24). Average graft harvesting time was 24 min for BMG and 19 min for LMG. Donor site pain was reported with both techniques but recovery was earlier with LMG. Slurred speech and difficult tongue protrusion were reported with lingual but not buccal grafts; however mouth tightness, peri-oral numbness and persistent oral discomfort were reported only with buccal grafts. Successful urethroplasty was obtained in 78.2% of BMG compared to 76.1% of LMG. CONCLUSION Surgical outcomes of LMG urethroplasty were comparable to those of BMG in complex hypospadias cases. Compared to buccal mucosa, LMG is easy to harvest, with minimal donor site complications.
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Spontaneous ventral urethral fistula in a young healty man and a modified surgical technique of urethral fistula repair. Can Urol Assoc J 2013; 6:E280-2. [PMID: 23283105 DOI: 10.5489/cuaj.12005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Urethral fistula is rare and is usually a complication of penile and urethral surgery. A few congenital cases have been reported. Also, one acquired spontaneous case in a diabetic man has been reported. We present the first case in the literature of a healthy man with a spontaneous ventral urethral fistula, with unknown etiology. We performed a modified technique of urethral fistula repair (four-layer technique).
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Single vs. double dartos layers for preventing fistula in a tubularised incised-plate repair of distal hypospadias. Arab J Urol 2012; 10:408-13. [PMID: 26558059 PMCID: PMC4442928 DOI: 10.1016/j.aju.2012.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 09/23/2012] [Accepted: 09/26/2012] [Indexed: 11/24/2022] Open
Abstract
Objective To compare the outcome of a single vs. a double-layer dartos interposition for preventing a fistula after tubularised incised-plate (TIP) distal hypospadias repair. Patients and methods We retrospectively reviewed the records of patients with primary distal hypospadias who had the hypospadias repaired between February 2009 and June 2011, operated by one surgeon (S.A.K.). In all of the children a standard TIP urethroplasty was performed, which was covered by a dartos fascial flap fashioned using one of two techniques, i.e. in Group I (48 patients) double dartos preputial flaps were used, and in Group II (52 patients) a single dorsal dartos flap was used and transposed ventrally via a ‘buttonhole’. The fistula rate and other complications related to each group were recorded. Results The mean (range) follow-up was 12 (6–22) months for Group I and 14 (6–24) months for Group II. The result was considered a success in 96% of Group I and 92% of Group II. In Group I there were no fistulae, while in Group II there were four fistulae (8%) detected; this difference was statistically insignificant (P = 0.1). Meatal stenosis was associated with a fistula in one patient in Group II but not in the other three. In Group I a meatal stenosis developed late after complete healing of the urethroplasty, with no associated fistula. The repair broke down in one patient in Group I (2%). Conclusion A double-dartos neourethral cover in TIP hypospadias repair seems to be more effective than a single layer for preventing a fistula, despite there being no statistically significant difference between the groups. However, the protective effect of double-dartos flaps must be appropriately evaluated in a prospective, randomised and controlled study in more patients.
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The Use of Tissue Expanders for Resurfacing of the Penis for Hypospadias Cripples. Urology 2011; 78:1424-9. [DOI: 10.1016/j.urology.2011.08.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 08/05/2011] [Accepted: 08/09/2011] [Indexed: 11/24/2022]
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Hypospadias repair: an overview. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2010. [DOI: 10.1111/j.1749-771x.2010.01074.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Hypospadias repair in a resource-poor region: coping with the challenges in 5 years. J Pediatr Urol 2010; 6:60-5. [PMID: 19539535 DOI: 10.1016/j.jpurol.2009.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Accepted: 04/23/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report the challenges and outcomes of hypospadias repair in a developing country such as Nigeria. PATIENTS AND METHODS This was a prospective study of children who underwent hypospadias repair at the University of Benin Teaching Hospital in 2003-2007. The challenges and outcome of repair were documented with photographs to assess cosmetic results. RESULT A total of 149 operations were performed on 127 children with hypospadias, aged between 9 days and 12 years (mean 2.3 years+/-2.1) with 33 (26.0%) presenting after circumcision; 118 (92.9%) were single and 9 (7.1%) multistage, while 13 had closure of post-hypospadias repair fistulae and redo surgery. Non-availability of suitable pediatric urethral catheters, special dressing materials and microsurgical instruments/sutures, presentation after circumcision, and lack of parents/caregivers' motivation were major challenges. Transurethral urinary diversion, dressing with petroleum jelly impregnated with antibiotic/chloramphenicol ointment, mosquito forceps, scrotal skin flaps, size 6/0 polyglactin sutures, and organized counseling/home visits were employed. Repair was successful in all the children: excellent cosmetic results in 121 (95.3%), fair in 5 (3.9%) and poor in 1 (0.9%). Urethrocutaneous fistula was the main complication with no mortality recorded. CONCLUSION Despite the challenges, improvising with available materials, counseling of parents/caregivers, adequate patient recruitment and appropriately timed repairs gave encouraging results.
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Functional Restoration of Penis With Partial Defect by Scrotal Skin Flap. J Urol 2009; 182:2358-61. [PMID: 19762052 DOI: 10.1016/j.juro.2009.07.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Indexed: 10/20/2022]
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Algorithm for comprehensive approach to hypospadias reoperation using 3 techniques. J Urol 2009; 182:2885-91. [PMID: 19846161 DOI: 10.1016/j.juro.2009.08.062] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE We describe comprehensive hypospadias reoperation based on presence or absence of a supple urethral plate using the 3 surgical techniques of transurethral incised plate, 1-stage inlay graft and 2-stage buccal graft. MATERIALS AND METHODS We reviewed prospective data from all reoperative hypospadias urethroplasties performed by one of us (WTS) between 2000 and 2008. Patient age, number of operations, indications for additional surgery, meatal location, reoperative surgical technique and outcomes were extracted. RESULTS A total of 133 patients underwent reoperation by transurethral incised plate (69), 1-stage inlay graft (16) or 2-stage buccal graft (48) urethroplasty. Mean number of prior failed repairs was 1.1, 1.9 and 4.3, respectively. Followup was available in 121 patients (91%), with 90 (74%) undergoing 1 successful reoperative urethroplasty. Complications occurred in 19%, 15% and 38% of patients, respectively, and most often consisted of fistulas or glans dehiscence. CONCLUSIONS Hypospadias reoperation can be accomplished using these 3 techniques without skin flaps, a potential advantage given the relative paucity of skin after failed repair. Fistulas after transurethral incised plate urethroplasty correlate with barrier layers used, while glans dehiscence is more likely in 2-stage buccal graft repairs when cheek rather than lip is used within the glans.
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Posttraumatic ventral urethral fistula: a case report. CASES JOURNAL 2009; 2:8644. [PMID: 20181212 DOI: 10.1186/1757-1626-0002-0000008644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 08/12/2009] [Indexed: 11/10/2022]
Abstract
INTRODUCTION We present the first case reported in the medical literature of a patient with a posttraumatic urethral fistula accompanied by retraction urethral catheter with balloon. CASE PRESENTATION A 69-year-old man was admitted to our hospital with the recurrence urinary tract infection. The patient reports history of urethral trauma, which is retraction urethral catheter with balloon 2 years ago. Cystoscopy and fistulography were performed, and urethrocutaneous fistula was detected. Initial surgical treatment consisted of surgical debridement of fistula tissue, and a urethral catheterization was performed. After 4 weeks of the operation the urethral fistula resolved. In a follow-up period of 24 months no recurrence and no urinary tract infection were occurred. CONCLUSION Self retraction of the urethral catheter with balloon may result with clinically important urethral fistula. A wide range of possible options such as complete excision of the fistula tract and primary closure may be considered for individual cases.
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Staged reconstruction of long segment urethral strictures in men with previous pediatric hypospadias repair. J Urol 2008; 181:685-9. [PMID: 19091342 DOI: 10.1016/j.juro.2008.10.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Reconstruction of long segment urethral stricture disease in adults with a history of pediatric hypospadias repair remains complex secondary to poor urethral blood supply, extensive penile scarring and the need for significant amounts of graft or flap tissue. We describe our experience with staged urethroplasty in this cohort of men. MATERIALS AND METHODS A total of 15 males underwent staged urethroplasty for urethral stricture disease following previous hypospadias repair in childhood. All men underwent 2-stage repair with a minimum of 6 months separating each operation. Bulbar urethral stricture disease due to previous dilation was seen in 2 of the 15 men (14%). Graft sources included buccal mucosa in 12 cases, full-thickness hairless abdominal wall skin in 2, penile skin in 1 and posterior auricular tissue in 1. RESULTS Median patient followup was 22 months (range 5 to 62) after stage 2 closure. Median patient age at presentation was 31 years (range 19 to 57). Mean stricture length was 8 cm (range 5 to 14) and mean graft area was 22 cm(2) (range 10 to 38). There was no clinical evidence of stricture recurrence, fistula or wound dehiscence at last followup in 13 of the 15 men (86%). Two men with a congenital hypoplastic glans were left with distal hypospadias. Minor voiding symptoms were described in 3 of the 15 men (21%) with resolution in all by 6 months postoperatively. CONCLUSIONS We describe outcomes after staged reconstruction for extensive urethral stricture disease in men after previous pediatric hypospadias repair in childhood. At intermediate followup staged urethroplasty provided acceptable outcomes.
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Tunneled tunica vaginalis flap for recurrent urethrocutaneous fistulae. Adv Urol 2008; 2008:615928. [PMID: 19009031 PMCID: PMC2581732 DOI: 10.1155/2008/615928] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2008] [Accepted: 08/11/2008] [Indexed: 11/21/2022] Open
Abstract
The tubularized incised plate (TIP) hypospadias repair is currently the most widely used urethroplasty technique. The most significant post-TIP complication is urethrocutaneous fistula (UCF) development. Tunneled tunica vaginalis flap (TVF) is a well-described technique for the repair of UCF. We retrospectively reviewed all patients undergoing repeat repair of UCF after TIP repair from 2001 to 2005. Twelve boys underwent TVF repair at our institution for recurrent UCF. Fistulae ranged from distal penile to penoscrotal in location. Median surgical time was 45 minutes and no postoperative complications occurred. After a median follow-up of 32 months (range 16-48 months), no patient has yet had a recurrence of UCF. In conclusion, TVF repair is a successful technique for the treatment of UCF after previous failed repair. TVF is technically simple to perform and should be considered for treating UCF following TIP urethroplasty, particularly in a repeat surgical setting.
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Detubularized pedicled vaginal onlay flap urethroplasty: a new method for hypospadias repair of ambiguous genitalia. J Urol 2008; 180:2159-66. [PMID: 18804820 DOI: 10.1016/j.juro.2008.07.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE We introduce the detubularized pedicled vaginal onlay flap urethroplasty for single stage repair in ambiguous genitalia with perineoscrotal hypospadias and accompanying vagina, and report its preliminary surgical outcome. MATERIALS AND METHODS A total of 10 children with severe perineoscrotal hypospadias and genital ambiguity presenting with vagina and urogenital opening underwent single stage reconstruction with vaginal onlay urethroplasty. Through the posterior sagittal or abdominoperineal approach the vagina was released and pulled out, with care taken to preserve its vascular pedicle. Two incisions were made along the lateral margins of the vagina, reaching each other on the upper surface of the vaginal base, converting the vagina into a longitudinal flap twice as long as its original length. The vagina was then trimmed and reconfigured into a suitable sized flap to cover the urethral plate and form a neourethra with the onlay technique. The onlay-tube-onlay technique was also used in 2 patients with insufficient urethral plate. In 5 cases severe ventral chordee was also corrected concurrently with free vaginal graft to the ventral corpus cavernosum without further dorsal plication. RESULTS The first 3 operations using the posterior sagittal approach failed due to improper surgical access, and the vagina was discarded. However, we achieved a satisfactory outcome with no failure after switching to an abdominoperineal approach. Immediate postoperative and short-term results revealed no urethrocutaneous fistula, urethral breakdown or necrosis at the distal end of the neourethra. Only 1 patient presented with severe mid shaft ring stricture, which required surgical revision. CONCLUSIONS Incorporating the vagina of intersex patients into urethroplasty using detubularized pedicled vaginal onlay flap seems to provide a safe and practical method to treat severe hypospadias with genital ambiguity. Short-term satisfactory results are achievable by choosing the proper surgical approach and preserving the vaginal blood supply. However, longer followup in a large series of patients is needed before applying this method to clinical practice.
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Abstract
The complication rate of hypospadias repair still ranges between 20 and 30%, although operative skills and technical devices have improved. Different aspects like dressing are important for prevention of complications. Early complications are bleeding, hematoma, and infection. Late complications are fistulas, meatal stenosis, partial and complete breakdown, persisting curvature, a hairy urethra, and hypospadias cripples. Detailed preoperative diagnostics are important. There are several operative techniques that can be used for repair including the use of mesh graft or foreign material. Two or multiple stages are often needed. The surgery to correct complications after hypospadias repair is a challenge, which should only be done by an experienced surgeon.
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Morbidity Associated With Oral Mucosa Harvest for Urological Reconstruction: An Overview. J Oral Maxillofac Surg 2008; 66:739-44. [PMID: 18355598 DOI: 10.1016/j.joms.2007.11.023] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2007] [Revised: 09/13/2007] [Accepted: 11/28/2007] [Indexed: 12/13/2022]
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Spontaneous ventral urethral fistula in a young diabetic man: a case report. J Med Case Rep 2007; 1:80. [PMID: 17803821 PMCID: PMC2025600 DOI: 10.1186/1752-1947-1-80] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Accepted: 09/05/2007] [Indexed: 11/23/2022] Open
Abstract
We present the first case reported in the medical literature of a patient with a spontaneous ventral urethral fistula accompanied by severe infection due to diabetes mellitus. A 34-year-old man with poor controlled adult-onset diabetes mellitus was admitted to our hospital with a large subcutaneous abscess involving the complete penis, scrotum and perineum. The patient did not report any history of any penile trauma or local infection but has experienced transient swelling of the perineal region following urination. Initial surgical treatment consisted of surgical debridement of necrotic tissue. At this time reconstructive surgery was impossible and a suprapubic cystostomy was performed. After 4 months of suprapubic urinary diversion the urethral fistula resolved and function of external genitalia was reestablished. In a follow-up period of 40 months no recurrence occurred. Spontaneous diabetes-associated ventral urethral fistulas are extremely rare and we are not aware of any other published case report.
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Abstract
PURPOSE OF REVIEW To review recent publications on the surgical treatment of hypospadias failures, including prognostic factors, which may influence final outcome in hypospadias surgery. RECENT FINDINGS Interim good outcomes for single-stage dorsal inlay grafting in patients with multiple failed repairs would suggest a greater role for this new technique over other available options. Slowly emerging long-term data confirm our suspicion that a good result early on is not necessarily indicative of a satisfactory long-term outcome. SUMMARY Hypospadias surgery remains a considerable technical challenge and improvement will come from the development of specialized units.
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Management of Multiple Failed Repairs of the Phallus Using Tissue Expanders: Long-Term Postpubertal Results. J Urol 2007; 177:1872-7. [PMID: 17437839 DOI: 10.1016/j.juro.2007.01.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2006] [Indexed: 11/23/2022]
Abstract
PURPOSE We present the long-term results of our experience with application of tissue expanders for phallic reconstruction in patients with a history of multiple surgical repairs. MATERIALS AND METHODS We retrospectively reviewed the medical records of 16 patients who underwent penile tissue expansion for treatment of failed phallic reconstruction. The patients were 5 to 22 years old (mean age 9.9) at the time of the procedure. The original diagnoses were congenital adrenal hyperplasia (1 patient), partial penile amputation (1), epispadias (3) and proximal hypospadias (11). We used different shapes and numbers of tissue expanders according to the estimated skin augmentation requirement for final reconstructive surgery. The injection port was placed at the suprapubic area lateral to the penile base, with a small incision between the anticipated expander pouch and the reservoir. Penile tissue expanders were inflated by injections after 1 to 2 weeks postoperatively. Definitive reconstructive surgery was then planned and the tissue expander was removed at penile reconstruction at 2 to 11 months (mean 4.6) after implantation. RESULTS Only 1 tissue expander was removed due to erosion. However, sufficient expanded skin was available for urethral reconstructions and penile skin coverage in all patients (100%). There were 2 cases of overlying penile skin redness, which resolved with temporary balloon deflation. Two patients had urethrocutaneous fistulas, which were successfully repaired later. Two additional patients required meatal dilation/urethromeatoplasty for meatal stenosis. These complications were corrected within 1 year postoperatively. After a long-term followup of 3 to 10 years (mean 6.5) as patients progressed through puberty, only 3 had mild chordee. At the end of followup acceptable cosmetic and functional results were achieved in 13 patients (81%). CONCLUSIONS Tissue expansion is associated with few complications and good cosmetic results for phallic reconstruction in patients with minimal residual skin available for additional reconstructive efforts after repeated surgeries.
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Bibliography. Current world literature. Reconstructive surgery. Curr Opin Urol 2006; 16:460-3. [PMID: 17053527 DOI: 10.1097/mou.0b013e328010dc58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tunneled Tunica Vaginalis Flap is an Effective Technique for Recurrent Urethrocutaneous Fistulas Following Tubularized Incised Plate Urethroplasty. J Urol 2006; 176:1578-80; discussion 1581. [PMID: 16952688 DOI: 10.1016/j.juro.2006.06.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2006] [Indexed: 11/15/2022]
Abstract
PURPOSE In the last several years the use of the tubularized incised plate hypospadias repair has greatly increased. The most significant complication after this mode of urethroplasty is urethrocutaneous fistula development. Tunneled tunica vaginalis flap is a well described technique for repair of urethrocutaneous fistula. However, to our knowledge its use after tubularized incised plate repair has not yet been described. We present our results with this technique. MATERIALS AND METHODS We retrospectively reviewed all patients undergoing repair of urethrocutaneous fistula after initial tubularized incised plate repair between January 2001 and December 2005. We analyzed the initial number and location of fistulas, number of previous urethrocutaneous fistula repairs, duration of surgery, and intraoperative and postoperative complications. RESULTS A total of 16 boys (median age 2.2 years) underwent tunica vaginalis flap repair at our institution for urethrocutaneous fistula following initial failed tubularized incised plate repair. Of these patients 4 had not previously undergone urethrocutaneous fistula repair and 12 had undergone 1 to 4 failed repair attempts. All boys had a subcoronal fistula and 8 had additional fistulas along the penile shaft, 4 each with 3 and 4 fistulas, including 1 penoscrotal fistula. Mean surgical time was 45 minutes, and no intraoperative or postoperative complications occurred. After a mean followup of 18 months (range 4 to 36) no patient had recurrence of urethrocutaneous fistula. CONCLUSIONS Tunneled tunica vaginalis flap repair is a highly successful technique for the treatment of urethrocutaneous fistula after initial failed tubularized incised plate repair. The technique is technically simple to perform, and we encountered no complications. Tunneled tunica vaginalis flap repair should be considered for treating urethrocutaneous fistula following initial failed tubularized incised plate hypospadias surgery, particularly in a repeat surgical setting.
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