[Fundamentals and principles of grafts and flaps]

Reconstructive surgery of large urethral stenosis and the management of congenital anomalies such as hypospadias and epispadias require covering large cutaneous and mucosal defects with different techniques. The objective of this work is to define the main differences between tissues to be transferred and to study the principles that must govern the management of the various flaps and grafts used for these techniques. We analyze the anatomical and physiological features that may be key to understand the success and possible failures of these procedures, and we review technical details that must accompany in every case, not only during the operation, but also during the preoperative and postoperative period. We conclude stating that grafts (mainly oral and preputial mucosa) and flaps are increasingly used for the repair of urethral stenosis. Grafts must be prepared adequately in the back table and thinned to the maximum, and also be fixed properly, to guarantee their immobility until neovascularization is assured.

Birth of healthy twins after fertilization with in vitro cultured spermatids from a patient with massive in vivo apoptosis of postmeiotic germ cells

OBJECTIVE

To examine whether the results of assisted reproduction with the use of elongated spermatids from a man with incomplete arrest of spermiogenesis and a high frequency of apoptosis among postmeiotic germ cells can be improved by germ cell in vitro culture.

DESIGN

Case report.

SETTING

Private assisted reproduction centers and a university department.

PATIENT(S)

Man with incomplete spermiogenesis failure.

INTERVENTION(S)

Testicular spermatid extraction, in vitro culture of testicular biopsy samples, intraoocyte injection of elongated spermatids, embryo culture, and transfer.

MAIN OUTCOME MEASURE(S)

Fertilization rate, embryo morphology, and pregnancy.

RESULT(S)

An assisted reproduction attempt with viability-selected elongated spermatids from a fresh testicular biopsy sample resulted in a poor fertilization result and embryo quality. Further analysis of the sample used in this attempt showed a high incidence of apoptosis among postmeiotic germ cells. A second attempt was then performed with in vitro culture of testicular cells for 24 hours before spermatid injection. This procedure led to a significant decrease in the frequency of apoptosis among viability-selected spermatids, to improvement of the fertilization rate and embryo quality, and to the birth of healthy twins.

CONCLUSION(S)

In vitro culture of testicular biopsy samples before assisted reproduction with elongated spermatids may improve the efficacy of treatment in cases of massive in vivo apoptosis of postmeiotic germ cells.