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We compare the effects of staged tranverse preputial island flap urethroplasty and the Byars 2-stage procedure in patients with proximal hypospadias and severe chordee.We studied 87 consecutive children referred for proximal hypospadias with severe chordee between March 2011 and March 2014. Of the cases 42 were repaired with staged tranverse preputial island flap (group 1) and 45 were managed by 2-stage Byars urethroplasty (group 2). Mean ± SD age at first stage surgery was 26.6 ± 13.3 months in group 1 and 24.8 ± 14.7 months in group 2. Postoperative complications in both groups were assessed regarding fistulas, urethral strictures, diverticula, meatal stenosis and glanular dehiscence.After the second stage 2 patients (4.8%) in group 1 and 10 (23.2%) in group 2 had urethrocutaneous fistulas (p0.05). One patient (2.4%) in group 1 and 2 patients (4.4%) in group 2 had urethral strictures (p0.05). All patients with stricture were cured by repeated dilation and no patient required reoperation. One patient (2.4%) in group 1 and no patient in group 2 had diverticulum (p0.05). No patient in either group had signs or symptoms of meatal stenosis or residual chordee. Three patients (7.1%) in group 1 and 12 (26.7%) in group 2 needed reoperation (p0.05).Two-stage urethroplasty, particularly tranverse preputial island flap partial urethroplasty, is appropriate for treating patients with proximal hypospadias and severe chordee. Use of the tranverse preputial island flap can decrease complications associated with the second stage and significantly improve the success rate.

Purpose: Buccal mucosa is the favored graft material for patients with long urethral defects and a paucity of skin. Since 2007, we have used the novel tunneled buccal mucosa tube graft urethroplasty technique in these patients. We describe this operative technique and report our surgical and functional outcomes.Materials and Methods: Between 2007 and 2013, 37 males with proximal hypospadias underwent tunneled buccal mucosa tube graft urethroplasty. After the penile shaft was optimized at a prior stage a free buccal graft was tubularized and tunneled under the intact ventral shaft skin and into the glans. We retrospectively reviewed all charts to report our results. We assessed uroflowmetry and bladder ultrasound for post-void residual urine.Results: The overall complications rate in 34 patients with more than 1-year followup was 32% (11), including fistula in 5, proximal stricture in 4 and meatal stenosis in 2. In the first 10 patients a total of 7 complications (70%) developed but there were only 4 compl...

Of boys circumcised for penile lichen sclerosus, ie balanitis xerotica obliterans, 7% to 19% require late surgery for meatal stenosis. We review the management and outcomes of boys circumcised for lichen sclerosus.Medical records of boys with clinical lichen sclerosus were reviewed for the period 2000 to 2010. Patients were excluded from the study if the foreskin was not submitted for histopathological analysis, circumcision was not performed at the center during the study period or medical records were unavailable. Data were compared by Fisher exact test and univariate analysis.Of 300 circumcised boys lichen sclerosus was confirmed in 250. A total of 50 patients had nonlichen sclerosus histology. Mean age was 9.0 years (range 4 to 16) in patients with lichen sclerosus and 8.3 years (2 to 15) in those with nonlichen sclerosus histology. Boys with lichen sclerosus were more likely to have the meatus described as abnormal (57 vs 4) and to have undergone a meatal procedure at circumcision (55 vs 2) or a meatal operation at a later date (49 vs 3, all p0.05). Boys with lichen sclerosus requiring later meatal procedures (meatal dilation in 25, meatotomy in 24) rarely underwent a meatal procedure at circumcision (4 of 49) and were less likely to have received preoperative topical steroids than boys not needing a later meatal procedure (2 of 49 vs 49 of 151, p 0.05).After circumcision for lichen sclerosus up to 1 in 5 boys requires a subsequent operation for meatal pathology. Pre-circumcision topical steroids may help decrease the rate of later meatal pathology. Submission of the foreskin for histological analysis should always be considered, as prognosis differs for lichen sclerosus vs nonlichen sclerosus histology. We recommend a care pathway for boys with lichen sclerosus.

"Snodgraft" modification has been proposed to reduce the risk of meatal/neourethral stenosis in distal hypospadias. We applied the Snodgraft technique by using inner preputial graft in primary distal hypospadias repair.A total of 102 consecutive patients undergoing the Snodgraft procedure were prospectively studied between 2006 and 2011. Mean patient age was 7.2 years. Localization of the meatus was glanular in 5 patients, coronal in 49, subcoronal in 45 and mid penile in 3. In all patients the posterior urethral plate was incised, and the graft harvested from the inner prepuce was sutured from the old meatus to the tip of the glans. A neourethra was created over a urethral catheter using 6-zero polyglactin suture. An interpositional flap was laid over the urethra as a second barrier. All patients were followed at 3 to 6-month intervals for cosmetic and functional results.At a mean of 2.4 years of followup no patient had meatal stenosis or diverticulum at the inlay graft site. However, urethrocutaneous fistula was observed in 10 patients (9.8%). A slit-like appearance of neomeatus was achieved in all patients. During followup no obstructive urinary flow pattern was detected, and early and long-term maximum urine flow rates were comparable.No meatal/neourethral stenosis was observed in any patient undergoing a Snodgraft procedure. A randomized trial will be needed to prove that the incidence of meatal/neourethral stenosis is lower after Snodgraft repair compared to routine tubularized incised plate repair.

We investigated the long-term outcome of urethral reconstruction using colonic mucosa grafts for long segment, complex urethral strictures. Another aim was to identify clinical factors impacting long-term outcomes.We retrospectively reviewed the records of 36 consecutive patients with a mean age of 39.8 years (range 17 to 70) who underwent colonic mucosal graft urethroplasty for long segment, complex urethral stricture from October 2000 to November 2006. Patients were evaluated postoperatively at scheduled office visits at our institution and/or by telephone interview. Successful repair was defined as normal voiding without any postoperative procedure such as dilation.Urethral reconstruction with done with colonic mucosa grafts 10 to 20 cm long (mean 15.1). One patient was lost to followup. Mean followup in the remaining cases was 53.6 months (range 26 to 94). Outcomes were successful in 30 of 35 patients (85.7%). Complications, specifically meatal stenosis, bulbar or bulbomembranous urethral stenosis and proximal anastomotic site stricture, developed in 5 patients (13.3%).Colonic mucosa graft urethroplasty is a feasible procedure for complex urethral strictures. The most common complications are meatal stenosis and stenosis at the anastomosis.

We studied the effect of suturing technique and the impact of urethral plate characteristics on the complication rate following tubularized incised plate urethroplasty.We prospectively studied 80 boys (mean age 4.5 years, range 3 to 7) with primary hypospadias in a randomized fashion between January 2004 and May 2005. Of the patients 64 had anterior and 16 had mid penile hypospadias. Patients were allocated into 2 groups according to suture technique, with continuous sutures used in 40 boys and interrupted sutures in 40. We evaluated urethral plate depth, length and width before and after incision. Correlation between suture technique, plate type, width and length, and complication rate was performed.Mean followup was 3 years. Success rates were 90% and 69% for anterior and mid penile hypospadias, respectively (p = 0.037). Complications developed in 11 patients (13.8%) and consisted of fistula (8), dehiscence (2) and meatal stenosis (3). On univariate analysis the suture technique, depth and length of urethral plate, width after incision and presence of hypoplasia had no impact on complication occurrence. However, urethral plate width before incision was significantly related to complication occurrence (p = 0.048).Suture technique has no influence on the outcome of tubularized incised plate urethroplasty. Urethral plate characteristics do not affect the complication rate except for plate width, which significantly affects the outcome. Adequate urethral plate width (8 mm or greater) is essential for successful tubularized incised plate repair.

One measure of a successful outcome of meatoplasty for symptomatic urethral meatal stenosis has traditionally been witnessed voiding and subjective assessment of urinary stream. This evaluation is flawed by nonobjective criteria and potential differing interpretations by different clinicians. We sought to assess urinary flow better following meatoplasty using voiding uroflowmetry to measure objectively response to treatment.We retrospectively reviewed the records of 22 boys who underwent meatoplasty for symptomatic meatal stenosis and who had uroflowmetry (flow rates, voided volumes and voiding times) performed preoperatively and postoperatively. Statistical comparison of voiding parameters was analyzed using Student's paired t test.Mean patient age was 7 years (range 4 to 13). There were no complications and no recurrences associated with meatoplasty during a mean followup of 12 months. There was a significant increase in maximum urinary flow rates following meatoplasty (9.7 ml per second preoperatively vs 16.4 ml per second postoperatively, p = 0.001). Mean postoperative post-void residual volumes and voiding times were significantly lower than preoperative values, at 13.9 ml vs 19.3 ml (p = 0.01) and 29 seconds vs 19 seconds (p = 0.03), respectively. Voided volumes did not differ between the time intervals (157 ml preoperatively vs 147 ml postoperatively, p = 0.25). Flow patterns were abnormal in 19 of 22 patients preoperatively, and 88% of these patients had bell curve-shaped patterns following meatoplasty.Flow rates measured by noninvasive uroflowmetry showed significant increases following meatoplasty for meatal stenosis. Uroflowmetry represents an objective method to assess outcomes following meatoplasty compared to subjective visualization of the urinary stream during voiding.

We sought to evaluate the efficacy of transdermal dihydrotestosterone treatment based on the results of hypospadias repair in children with primary hypospadias.A total of 75 randomized consecutive children who were a mean of 33.4 +/- 3.7 months old and had primary hypospadias were included in the study between September 2004 and April 2006. While 37 children were treated with 2.5% transdermal gel daily, applied directly onto the penile shaft and glans for 3 months (group 1), 38 children did not receive any treatment preoperatively (group 2). All children underwent hypospadias repair using tubularized incised plate urethroplasty. Postoperative complications were analyzed using the Mann-Whitney U test with respect to fistulas, urethral strictures, diverticula, meatal stenosis, glanular dehiscence and scar formation according to the results at 1-year followup.Mean ages of the children in groups 1 and 2 were similar (30.8 +/- 5.4 months and 35.1 +/- 5.1 months, respectively). The urethral meatus was coronal in 70%, penile in 24% and penoscrotal in 5% of the patients in group 1, while it was coronal in 84% and penile in 16% of the patients in group 2. Postoperative complications included urethrocutaneous fistula in 4 patients (11%) in group 2, compared to 1 patient (3%) in group 1 (p0.05). While 3 patients (8%) in group 2 had glanular dehiscence, no patient in the dihydrotestosterone group had this complication (p0.05). There were 2 patients with meatal stenosis in group 2 (5%), and no patient with meatal stenosis in group 1 (p0.05). In addition, there were 16 patients (42%) with moderate to severe postoperative scar formation in group 2, compared to only 2 patients (5%) in the dihydrotestosterone group (p0.05). Finally, there was a significant difference between the overall reoperation rates of group 2 (9 patients, 24%) and group 1 (1 patient, 3%, p0.05). None of our patients had signs or symptoms of urethral stricture or urethral diverticulum.Pretreatment with dihydrotestosterone transdermal gel was effective in decreasing the complications and improving the cosmetic results after hypospadias repair.

Purpose: Midline dorsal plication is an efficient and safe surgical technique to correct chordee. We investigated the efficacy of midline dorsal plication for recurrent chordee in complicated hypospadias reoperations. Materials and Methods: We retrospectively evaluated the charts of 25 boys who underwent reoperation between 1999 and 2004 due to complications of primary hypospadias repair other than meatal stenosis. A total of 15 cases were initially managed elsewhere for primary repair or complications. The etiology of recurrent chordee was defined at surgical correction. When recurrent chordee was noted a midline dorsal plication was performed. Results: Of 25 patients 10 had previously undergone chordee repair. Nine of these patients were observed to have recurrent chordee and 1 had de novo chordee. A total of 10 patients had recurrent or delayed onset chordee. Mean patient age at primary repair was 6.28 years (range 1 to 33). Mean age at last operation for chordee was 15.9 years (range 4 to 66). Mean interval to recurrent chordee was 6 years (range 1 to 16), excluding a 66-year-old blind patient who did not know when recurrent chordee developed. Five patients had chordee recur before puberty at a mean interval of 2.6 years. Mean reoperation rate was 2.4 for recurrent chordee cases and 2.6 for chordee-free cases. Mean followup after midline dorsal plication for recurrent chordee repair was 22 months (range 8 to 56), while mean followup in pubertal and postpubertal cases was 20 months. No recurrence of chordee or surgery related morbidity was observed after recurrent chordee repair by midline dorsal plication. Conclusions: Chordee may recur during puberty following successful chordee repair. The midline dorsal plication technique is simple, efficient and safe even in patients who have undergone multiple surgeries for hypospadias and chordee repair.

Contains fulltext : 48693.pdf (Publisher’s version ) (Closed access) PURPOSE: We evaluated the outcome of postpubertal patients who underwent 1-stage hypospadias repair before onset of puberty with at least 10 years of followup. MATERIALS AND METHODS: A total of 2,053 patients underwent surgical repair of hypospadias between January 1981 and May 2004 at our hospital. We evaluated patients who are now at least 18 years old and who underwent 1-stage hypospadias repair. Data were collected in regard to familial incidence, age at operation, operative technique, complications and followup of at least 10 years. Evaluation was subdivided based on operative procedure. RESULTS: A total of 126 patients were included in the study. The familial incidence was 7.9% of cases and an associated undescended testis was seen in 9.5%. There were 62 cases with no complications. At least 1 complication was seen in 64 cases, including infection in 3, tissue necrosis in the operative area in 3, wound dehiscence in 6, fistula in 29, meatal stenosis in 15, urethral stenosis in 10, cosmetic dissatisfaction in 16 and other in 2. CONCLUSIONS: Even in the hands of the experienced pediatric urologists the complication rate after hypospadias repair remains high, with an average of 54% at long-term followup. Our results clearly showed that additional complications can present after long-term followup (a first complication can present after more than 5 years with the longest interval being 14 years). Therefore, final outcome of hypospadias surgery can only be evaluated once the patient has reached adulthood. The results seem to depend on the severity of the abnormality, reflected in the complication distribution rather than operative technique.

We determined the frequency with which 6 genitourinary tract complications (urethral meatal stenosis, urinary retention, bladder hypertrophy, hydronephrosis secondary to ureteral strictures, pyelonephritis and cystitis) occur in inherited epidermolysis bullosa (EB) in the American EB population.Up to 16 years of longitudinal followup was done in 3,280 consecutively enrolled patients in the National EB Registry, a National Institutes of Health funded epidemiological study covering the entire continental United States. Data were stratified by major EB type and subtype. Frequencies of occurrence were determined for each of 6 genitourinary tract variables and stratified into 10 mutually exclusive, major EB subtypes.Urinary tract complications occurred in a minority of patients across all major EB subtypes with the highest frequency seen in Herlitz junctional EB (JEB-H). Urethral meatus stenosis was the most common complication, occurring in 11.6% and 8.0% of patients with JEB-H and Hallopeau-Siemens recessive dystrophic EB (RDEB), respectively. Urinary retention, hydronephrosis and bladder hypertrophy occurred in 9.3%, 7.0% and 4.6% of JEB-H cases, respectively. In contrast, pyelonephritis and cystitis were most often seen in the setting of generalized EB simplex (Koebner variant) and inversa RDEB.The urinary tract may be involved in any subtype of inherited EB, although these complications usually arise in patients with the most severe subtypes of junctional and recessive dystrophic disease. Chronic surveillance for the presence of genitourinary tract disease activity is warranted, especially in patients with JEB and RDEB, given the potential for longterm kidney injury if untreated.

INTRODUCTION AND OBJECTIVES: The treatment of meatal stenosis associated with lichen sclerosus is traditionally treated either by meatal dilatation or ventral meatotomy. These operations have high recurrence rates or create a hypospadiac meatus. We present an established technique in the use of a dorsal approach. METHODS: Initially a small ventral meatotomy is performed. The epithelium of the urethra and glans is opposed with 3, 6-zero polyglactin (PG) sutures. This acts to widen the meatus slightly without making it hypospadiac but more importantly it allows the insertion of forceps to assess and ensure that the stricture does not extend significantly into the navicular fossa. Next a deeper dorsal meatotomy is performed. Again the epithelium of the urethra/glans are opposed. The combination of small ventral and deeper dorsal meatotomies should completely open the stenosed meatus but the cosmetic appearance at this stage is poor since the sutures of the dorsal meatotomy pucker the glans due to the thickness of the corpus spongiosum. This is overcome by an inverted V-shaped relieving incision with the apex of the V close to the proximal limit of the dorsal meatotomy. The edges of the relieving incision are freed by sharp dissection. The opposing left and right inner edges are closed with continuous PG to form the roof of the distal neourethra. The outer glans layer is opposed with interrupted PG. RESULTS: The final result is a slit-like but good calibre meatus at the tip of the glans. CONCLUSIONS: During a follow-up of 4.2 years there were recurrences in 6/116 patients, 5 of whom required re-operation (4.3%). 93% patients were either happy or very happy with the cosmetic result. Conclusion: This technique can achieve excellent aesthetic results, with low incidence of a spraying stream.

INTRODUCTION AND OBJECTIVES: The treatment of pure meatal stenosis associated with lichen sclerosus (LS) is traditionally treated either by meatal dilatation or ventral meatotomy. These operations have a high recurrence rate and/or create a hypospadiac meatus. We present a well established operation in the use of a dorsal approach first described by the senior author in 2004. METHODS: 116 consecutive patients with stenosis of the external urinary meatus underwent a Malone meatoplasty in between 1989-2011. Mean age was 40.5 years (range 4-87 years). Range of follow up was between 6 weeks and 21 years (mean 4.2 years). Patients were followed up by questionnaire. The questionnaire ascertained if the patients were happy with the post-operative cosmetic appearance, if he sprayed when he passed urine and if so to what extent. RESULTS: 90 (78%) patients responded to a questionnaire. There were recurrences in 6 patients, 5 of whom required re-operation (4.3%). 93% patients were either happy or very happy with the cosmetic result. 87% patients never sprayed or sprayed only occasionally. Of those who sprayed only 2 patients described it as severe, one of whom had declined circumcision and had progressive LS of his foreskin. CONCLUSIONS: These results confirm that the Malone meatoplasty reliably relieves pure meatal stenosis in the long term. It is reproducible and can be performed under local anaesthetia. It can achieve excellent aesthetic results, with a low incidence of a spraying stream. Given these findings, it is not justified to perform more complex urethroplasties for strictures that do not involve the navicular fossa. Equally it seems better to perform this meatoplasty as the primary procedure rather than as salvage after failed meatal dilatation or ventral meatoplasty.

Purpose: We describe a modification of the Koyanagi technique for hypospadias. Use of opposing parameatal-based skin flaps that extend distally to incorporate the inner layer of the prepuce was modified to preserve blood supply to the flaps in an attempt to reduce complications and improve results.Materials and Methods: During the last 7 years 20 boys underwent treatment of proximal hypospadias using the modified hypospadias repair.Results: Cosmetic and functional, long-term (mean 34 months) results were excellent. Complications consisted of 4 urethrocutaneous fistulas (20%). There were no instances of meatal stenosis, diverticulum or urethral stricture.Conclusions: The modified technique permits 1-stage repair of proximal hypospadias with a low complication rate.

Graft substances, such as skin and bladder mucosa, have been previously used for urethral replacement when local epithelial tissue was not available. However, these substances have been associated with meatal prolapse, stricture and fistula formation. We have used buccal mucosa as a tissue for urethral substitution in these situations during the last 8 years. We review our clinical experience in 18 urethral reconstructions performed for urethral replacement in 4 cases of exstrophy/epispadias, 12 complex hypospadias repairs and 2 cases of complex bulbar urethral strictures. There have been 5 cases of meatal stenosis (2 requiring operative revision) but none of meatal eversion. There has also been 1 urethrocutaneous fistula and 1 mid graft stricture. Mean followup was 27 months and minimum followup was 6 months.Histological examination of the buccal mucosal graft compared to grafts of skin showed that the full thickness of the dermis or lamina propria is thinnest while the native vascular supply is ...

INTRODUCTION AND OBJECTIVES: Uroflowmetry or flow rate (FR) is frequently employed in daily paediatric urology (PU) practice both for diagnostic and follow-up purposes. Our goal was to determine the impact of FR in the management of patients seen in a tertiary care center. METHODS: Retrospective chart review of FR without electromyography (EMG) performed consecutively from January 1st to March 31st 2010. Patients that had a FR as part of their PU clinic appointment and available clinical information from the same date were included. Demographics, diagnosis, FR parameters and impact of the FR on management were collected. Impact on management was defined as indication for surgery, introduction of new medications, bladder retraining or biofeedback based on clinical AND FR findings. RESULTS: 524 patients (313 male, 211 female) were included in the study. Mean age was 8.2 years old. In 63 (12%) patients, FR was performed as part of the evaluation for the 1st clinic appointment. Most common diagnoses were: dysfunctional voiding (DV-32.5%), hypospadias (20.2%), vesicoureteric reflux without evidence of DV (VUR-12.8%), monosymptomatic nocturnal enuresis (NE-6.5%), posterior urethral valves (PUV-3.8%), post-circumcision meatal stenosis (MS-3.3%) and hydronephrosis (HN-3.1%). In the DV group, FR contributed to a management decision in 25.2% of patients. In the MS group, surgical intervention was based on symptoms and supported by the FR in 41% of patients; in the PUV group, 50% of patients demonstrated high ( 20cc) post-void residual (PVR), which aided in management decisions. In contrast, there were virtually no changes in management supported by the FR in the NE, HN, VUR and hypospadias groups. In fact, only 2 patients (1.9%) in the post-hypospadias repair group had surgery indicated based on FR findings coupled with symptoms, despite the finding of a prolonged or flat flow curve in 54% of patients in this group. Overall, FR parameters had direct influence in a management decision in only 67 (12.8%) patients. Nonetheless, a repeat test was ordered for 205 out of the remaining 457 patients (44.5%). CONCLUSIONS: In an era of financial restraints and in the context of a busy tertiary PU clinic, judicious use of FR for specific indications may translate into a more cost-effective use of time and resources. As expected, patients with DV were the ones that benefited the most from the test, as did patients with MS and PUV. Patients seen for NE and HN may not need a FR at all. Despite being frequently abnormal, FR in asymptomatic patients post-hypospadias repair had limited impact on management.

INTRODUCTION AND OBJECTIVES: Complex anterior urethral strictures provide a surgical challenge for the reconstructive urologist. Patients often present following multiple failed procedures with persistent voiding difficulty. Tissue substitution is often required for successful repair. Buccal mucosal graft (BMG) has become the tissue of choice given its excellent graft characteristics and low associated morbidity. The use of BMG in single staged urethroplasty has shown excellent success and durability, however the outcomes following its use in staged procedures for patients with extensive urethral strictures is not well documented. We present our outcomes following a staged BMG urethroplasty at a single institution. METHODS: Patients who underwent staged BMG urethroplasty between January 1, 1999 and August 8, 2011 were identified. A retrospective chart review was performed to collect clinical data including patient demographics, stricture etiology, and post-op complications following first and second stage procedures. Outcomes were assessed including durability of results, recurrence rates, and additional procedures required. RESULTS: Fifty-seven patients underwent a staged BMG urethroplasty during the designated time period. The average patient age was 41 years. Stricture etiology was hypospadias in 26 patients (46%) followed by lichen sclerosus in 16 patients (28%) with unknown etiology in the remaining patients. The average stricture length was 7.5 centimeters. Eighty-five percent of patients had undergone at least one attempt at a prior repair, 71% had 2 prior repairs and 48% had 3 prior repairs. Following the first stage procedure 11 (20%) patients elected not to undergo a second stage procedure. Complete follow-up was available in 42 patients (74%). There were 7 major complications (12%) including fistula development in 4 patients, penoscrotal tethering in 2 patients and meatal stenosis in 1 patient. The majority of the complications were successfully treated with an additional procedure. Three other patients required additional procedures including conversion to a perineal urethrostomy, a suprapubic tube and urethral dilation. The overall success rate was 76% defined as patients who required no further procedure at an average follow-up of 25 months. CONCLUSIONS: Substitution urethroplasty is often necessary to treat complex anterior urethral strictures such as those seen in hypospadias cripples and in patients with lichen sclerosus. The staged BMG is an effective treatment for these patients with acceptable complication rates. Further follow-up is required to confirm durability.

Various techniques have been reported to repair severe hypospadias. The Koyanagi repair uses a meatal based foreskin flap. We modified this procedure and reviewed the outcome of the repair of severe hypospadias.The modified Koyanagi repair was performed in 151 children 7 months to 15 years old (mean age 3 years) with severe hypospadias. The records of these patients were reviewed. In all cases the meatus was at or proximal to the penoscrotal junction. Followup was 6 months to 16 years (mean 6 years). Flap design is the same as in the Koyanagi repair, although our modified technique requires removal of the subcutaneous tissue of the distal portion of the flap, which acts as a full-thickness free skin graft.A fistula developed in 19 patients (12.6%), meatal stenosis in 3 (2%) required meatoplasty and infection in 2 (1.3%) resulted in a regressed meatal position. Good cosmetic results were achieved in all except the latter 2 cases.Our modified Koyanagi repair affords an excellent cosmetic appearance. The complication rate is relatively low and compares favorably with that of other techniques.

Purpose: We describe the surgical technique and report the results of the first 100 patients who underwent a modification of the onlay hypospadias repair, which we refer to as split prepuce in situ onlay repair.Materials and Methods: We treated 100 boys with a mean age of 11 months at surgery who had coronal to mid shaft hypospadias with split prepuce in situ onlay hypospadias repair. The operative technique varies from that of the standard onlay procedure by preserving the whole blood supply of the half of the prepuce used for the island onlay flap, and using its abundant subcutaneous tissue to cover completely the suture lines used to create the neourethra.Results: Only 5 complications required reoperation, including 1 hematoma evacuation and 4 urethrocutaneous fistulas. No patient had meatal stenosis, urethral stricture, meatal retraction or acquired urethral diverticulum necessitating reoperation. A good cosmetic result was obtained in all cases.Conclusions: Split prepuce in situ onlay hypospa...

Purpose: We reviewed the results of a large series of hypospadias repairs (311) using the modified Barcat balanic groove technique.Materials and Methods: All patients who underwent modified Barcat repair with closure of the divergent corpus spongiosum were included in our study and were seen or contacted for postoperative followup.Results: Of 295 patients available for followup 94 percent had excellent cosmetic results. The fistula rate after primary repair was 5 percent for a glanular or coronal meatus and 18 percent for a penile meatus, and meatal stenosis was rare. After secondary repair complications were common in patients with a penile meatus.Conclusions: The Barcat technique allows anatomically superior glans reconstruction in distal hypospadias repair. Fistula rates can be reduced by tissue coverage of the neourethra.

Purpose: We describe glanuloplasty and in situ tubularization of the urethral plate, and report indications, results and complications.Materials and Methods: We evaluated our surgical results using glanuloplasty and in situ tubularization of the urethral plate in 166 boys 5 months to 13.5 years old (mean age 20 months).Results: Overall cosmetic results were excellent. No evidence of meatal stenosis, urethral stricture, residual chordee or ballooning of the neourethra was noted at followup. A small urethrocutaneous fistula that formed in 10 percent of the patients was successfully closed in a brief outpatient procedure.Conclusions: Glanuloplasty and in situ tubularization of the urethral plate is an excellent technique for the majority of boys with distal shaft and subcoronal hypospadias, producing a superior cosmetic result compared to the Mathieu procedure or meatal advancement and glanuloplasty.

We followed 62 men treated with the carbon dioxide laser for lichen sclerosus et atrophicus for an average of 30 months (3 months to 7 years). Of the patients 47 (76%) became asymptomatic and 10 (16%) had minor residual symptoms. In 26 patients (40%) concomitant superficial meatal stenosis was simultaneously treated with laser meatotomy. The cosmetic and functional results of treatment were highly encouraging. Provided that radicality is achieved at the primary application, the carbon dioxide laser is an excellent therapeutic modality for lichen sclerosus et atrophicus.

We report the results of hypospadias repair in 60 children requiring urethral reconstruction using a longitudinal or oblique preputial island flap technique that includes the inner and outer surfaces of the prepuce to construct the neourethra. Mean patient age was 3.2 years and mean length of the repair was 3.1 cm. The cosmetic and functional results were satisfactory. The incidence of urethrocutaneous fistula was 8.3% and that of meatal stenosis was 5%. Thus, this modification offers good results with a low complication rate. The range of applications can be extended by combining the technique with a tube of midline scrotal skin in cases of scrotal or perineal hypospadias. The surgical technique is described in detail.

Autologous buccal mucosa as a substitute for urethral epithelium was studied in 2 dogs and used in 6 patients with difficult urethral reconstruction problems. The indications for an operation in these patients were failed hypospadias repairs with limited skin in 3, severe structure disease after hypospadias repair in 1, a short urethra in 1 and epispadias in 1. Three urethral fistulas and 1 meatal stenosis occurred in 3 patients. No urethral stricture or diverticulum was noted, and the final outcome was good functionally and cosmetically in all patients. This technique is useful for urethral reconstruction when local skin is not available.

We report the technique and late results of a procedure for selected cases of distal hypospadias called sleeve advancement urethroplasty. This procedure incorporates correction of chordee, distal urethral mobilization and glans plasty in patients with coronal or distal subcoronal hypospadias. A total of 69 boys underwent this procedure at our institution: 59 as a primary repair and 10 for correction of meatal retraction after a previous failed reconstruction. Cosmetic results were excellent in most patients. Complications included meatal retraction in 2 patients and mild meatal stenosis in 2 in the primary repair group, and meatal stenosis in 3 (with associated fistula in 1) in the secondary repair group. Although not a replacement for meatal-based flap procedures, and more tedious to perform than the meatal advancement and glanuloplasty procedure, we have been impressed with the superior cosmetic results and minimal morbidity of the sleeve advancement urethroplasty.

Objective To evaluate the preventive effect of neonatal circumcision on urinary tract infection and the incidence of complications following neonatal circumcision using Plastibell. Materials and methods A prospective study was carried out between 2004 and 2008. During this period, there were 3000 neonatal circumcisions. All of the cases were examined for any complications 1 week later, and occurrence of meatal stenosis was followed up to 15 months of age. In this group, urine analysis and culture was successfully performed four times for 2000 circumcised infants at 1.5, 3, 9 and 15 months. In the control group of 3000 uncircumcised infants, 1000 cases accomplished urine analysis and culture at the same designated intervals. Results A positive urine culture was observed in none of the circumcised cases and in 20 (2%) uncircumcised cases after obtaining a suprapubic bladder aspiration sample. The latter 20 infants were circumcised and follow-up cultures were negative in 17 cases. The overall complication rate in the circumcised group was 1.6%. The difference in frequency of urinary tract infection between the two groups was statistically significant ( P Conclusion Neonatal circumcision has few complications and reduces the incidence of asymptomatic urinary infection. It may be considered as a preventative health measure.

Purpose: We determined if a difference in pain management occurred when topical anesthetics LMX (formerly ELA-Max, lidocaine 4%) and EMLA (lidocaine 2.5% and prilocaine 2.5%) were compared in boys undergoing office meatotomy for symptomatic meatal stenosis. Materials and Methods: A prospective randomized study was performed on 52 boys who underwent office meatotomy by a single pediatric urologist. Of the boys 26, 2 to 9 years old (mean age 4.4) underwent meatotomy 45 minutes after topical anesthetic application (LMX 13, EMLA 13) between February and December 2001, 26, ages 1 to 10 years old (4.6) underwent meatotomy 30 minutes after topical anesthetic application (LMX 13, EMLA 13) between April 2002 and January 2003. A single pediatric urological nurse performed pain assessment using the Wong-Baker Faces scale before applying the anesthetic ointment and immediately following the procedure. Each child had either LMX or EMLA applied and covered with an occlusive dressing for either 45 or 30 minutes before the procedure. Oral acetaminophen (10 mg/kg) was given at the time of anesthetic application. A meatotomy was then performed using a straight crushing hemostat for 1 to 2 minutes followed by incision. Mann-Whitney rank sum test was implemented to determine statistical significance. Results: Excellent procedure outcomes were experienced by all patients without recurrent meatal stenosis. Conclusions: There was no significant difference between LMX and EMLA when applied 45 minutes before meatotomy. When applied 30 minutes before meatotomy LMX provided significantly superior pain management than EMLA.

Case 1. A 7-year-old boy presented to the emergency room from elsewhere 1 hour after distal penile amputation, which had occurred accidentally during circumcision. The penis had been completely severed 5 mm. proximal to the corona, transecting the urethra and the corpora, and devascularizing the distal portion (fig. 1). The amputated part had been placed in sterile ice saline solution and it accompanied the patient. Using general anesthesia the proximal stump and amputated penis were irrigated with normal saline. Under operating microscopy the deep dorsal and cavernous arteries, veins and nerve fibers were not identifiable. A tourniquet was applied around the proximal stump to gain vascular control of the proximal cavernosum during the procedure. A 8Fr Foley catheter was inserted through the urethra of the amputated part and remaining proximal urethral stump, and passed on into the bladder (fig. 1). End-to-end urethral mucosa anastomosis was formed with 6-zero polyglactin interrupted sutures over the Foley catheter. The corpus spongiosum was then repaired using interrupted 6-zero polyglactin sutures. The tunica albuginea was closed with interrupted 5-zero polyglactin to restore corporeal continuity. The fascial layer and skin were then closed with a 6-zero polyglactin suture. A mild compressive gauze dressing was placed over the distal penis to control bleeding. Parenteral broad-spectrum antibiotics were administered for antimicrobial prophylaxis. Testosterone enanthate (25 mg.) was injected on day 1 after the operation. By the end of postoperative week 1 a thin eschar was forming around the meatus on the glans penis. The Foley catheter was removed at the end of postoperative week 3. The thin eschar around the meatus gradually peeled off, leaving appropriate glans tissue and a meatus with a good cosmetic appearance at week 4 (fig. 2). Two months postoperatively penile cosmesis was excellent, glans sensation was present, and early morning erection and erectile response to touch had been reestablished. Voiding was normal. Case 2. A 12-year-old boy presented 1 hour after accidental amputation of the distal glans penis during circumcision. The excised tissue included the whole glans penis and distal urethra. Amputation had occurred at the level of the coronal sulcus dorsolaterally and the urethra was transected just proximal to the meatus. A 8Fr Foley catheter was inserted into the bladder to stabilize the amputated penis. Under operating microscopy the urethra was anastomosed with interrupted 6-zero polyglactin sutures over the catheter. The edge of the amputated glans was closed over the reattached part of the proximal penile shaft skin and fascial layer with interrupted 6-zero polyglactin sutures. A mild compressive dressing was placed on the glans penis. Testosterone enanthate (50 mg.) was injected on day 1 after the operation. The Foley catheter was removed after 2 weeks. Eschar around the meatus remained until 7 weeks postoperatively. At 3 months there was mild meatal stenosis. Early morning erection was maintained and there was an erectile response during penile manipulation. Glans sensation was present but decreased.

Purpose: We describe a new device and technique for retrograde urethrography without instrumentation of the male urethra.Materials and Methods: We performed retrograde urethrography with a vacuum uterine cannula in 160 patients. Stricture of the distal tip of the urethra and iatrogenic damage to the urethra were evaluated.Results: No patient sustained iatrogenic damage to the urethra and stricture of the distal tip of the urethra was visualized in 12 patients.Conclusions: We recommend the use of this technique of retrograde urethrography without instrumentation to determine urethral disease when manipulation of the urethra must be avoided or is impossible due to meatal stenosis.

The complications of hypospadias surgery include urethrocutaneous fistula, meatal stenosis, wound dehiscence and urethral stricture. Fistula formation, the most common complication, may be minimized using optical magnification, meticulous surgical technique and coverage of the neourethra with vascularized tissue. Techniques that provide vascularized coverage of the neourethra include redundant pedicles (island flaps), and de-epithelialized, subcutaneous and tunica vaginalis flaps. In 1986 Snow first reported using tunica vaginalis to decrease the risk of fistula formation after hypospadias surgery.' The method involves obtaining a well vascularized pedicle of tunica vaginalis, which is then used as a blanket to cover the neourethra. Careful attention to dissecting parallel to the spermatic cord, and leaving the surrounding tissue and cremasteric fibers is important for success. This technique has been successful in primary as well as secondary hypospadias Snow et a1 recently reported a n 8-year experience with the tunica vaginalis flap in proximal hypospadias repair." When combined with intraoperative microscopy, the fistula rate was zero. Complications of a tunica vaginalis flap include scrotal abscess and scrotal hematoma." We report on 2 patients in whom severe penile torque developed that was exacerbated by the cremasteric reflex after a tunica vaginalis flap was used. To our knowledge this complication has not been previously reported.

Purpose: We evaluated the Mitchell complete penile disassembly technique for epispadias repair.Materials and Methods: A total of 42 males 1 month to 22 years old presented for repair of epispadias between 1998 and 2002. Cases were divided into 2 groups. Group 1 included 29 cases of complete epispadias as a component of bladder exstrophy, 8 with previous continent urinary diversion. Group 2 included 13 cases of epispadias alone (10 primary and 3 secondary). Of the 29 patients in group 1, 21 underwent complete penile disassembly as part of 1-stage primary closure of bladder exstrophy.Results: Mean followup was 37.5 months (range 6 to 52). Ischemic changes at the glans penis were observed in 5 cases during our initial experience. Ventral orthotopic meatus was observed in all 42 patients, conical glans in 40 (95.2%), straight shaft in 34 (81%) and urethral fistula in 1 (2.4%). There were no cases of dehiscence, meatal stenosis or urethral stricture. Erectile function was preserved in all patients.Conc...

0022-5347/95/1533-07788ln.00/0 ‘bur Jouruuu. or Uaococv Copyright 0 1995 by Manic»: Usououlcu. Assocumon. lsc. Vol. I53. 778-779. March I995 Pnnted in USA. NEWBORN PENILE GLANS AMPUTATION DURING CIRCUMCISION AND SUCCESSFUL REATTACHMENT GORDON R. GLUCKMAN, MARSHALL L. STOLLER, MARK M. JACOBS AND BARRY A. KOGAN* From the Department of Uroltm, University of California School of Medicine, San Francisco and Department of Obstetrics and Gynecology, Marin General Hospital, San Rafael. California ABSTRACT Circumcision. the most common operation in male patients in the United States, is performed by a variety of health care professionals. Although not technically ditficult, it results in a large number of reported and unreported complications annually. We report the successful reattach- ment of a distal penile glans, which was amputated when the Sheldon clamp was used for newborn circumcision. The literature is reviewed, and prevention and treatment of this type of circumcision injury are described. KEY WORDS: circumcision, amputation, complications, penis Circumcision is the moat common operation in male new- borns in the United States.‘ In a nonritual setting its risks and benefits remain controversial. Although not technically difficult, it can result in complications ranging from insignif- icant to tragic. We describe the successful reattachment of a distal penile glans, which was amputated during newborn circumcision by a nonurologist specialist with the Sheldon clamp. We also discuss the potential complications of this procedure with suggestions for the prevention of injury. CASE HISTORY A male newborn who was the product of an uncomplicated 38-week pregnancy underwent a guillotine type circumcision elsewhere with the Sheldon crushing clamp (fig. 1). Preoper- atively the distal aspect of the penis was swabbed with alco- hol and 0.5 ml. 1% lidocaine solution was injected into the prepuce for local anesthesia.” The prepuce—glans adhesions were broken with a hemostat and the foreskin was left in place over the glans. The Sheldon clamp was placed over the prepuce. and the foreskin was pulled through the clamp and crushed. A scalpel was used to excise the prepuce. It was immediately recognized that the distal third of the penile glans had been surgically amputated. The excised tissue was wrapped in sterile saline soaked gauze, placed in a plastic bag and stored on an ice water slush bath for transport to our medial center. Approximate time from amputation to surgi- cal reattachment was 3 hours. Accepted for publication July 15. 1994. ‘ Rafluests for re r-inta: Department of Um, U-575, University of Cal‘ ornia. San rancisco, California 941 738. FIG. 1. Circumcision complication with Sheldon clamp Intraoperative examination revealed a viable penis with partial shaft skin loss, and clean excision of the foreskin and distal third of the glans (fig. 2, A). The glans and amputated tissue were debrided gently. and the corpus spongiosum and urethra were reanastomosed with 6-zero chromic suture us- ing loupe magnification (fig. 2, B). A 5F pediatric feeding tube was used to stent the urethra. The penile shafl: skin was reapproximated with 4-zero chromic suture and a bulky pet- rolatum gauze/mineral oil immobilizing dressing was ap- plied. The patient was sedated and observed in the neonatal intensive care unit for 48 hours. Intravenous gentamicin and vancomycin were given during hospitalization, and oral first generation cephalosporin was continued for 1 week after discharge home. The urethral stent was removed after 3 weeks with 90% take of the grafi. There was some skin loss at the coronal sulcus. Polymyxin B-bacitracin ointment was applied to the glans twice daily. At 3 months postoperatively the grafted glans tissue was mildly contracted but cosmesis was excellent overall and voiding was normal through the meatus (fig. 2, C), which easily accepted an 8F catheter. DISCUSSION In the United States 65% of male newborns are circum- cised.’ Indications have changed with time and now can be cultural. religious, medical or cosmetic. The many techniques of circumcision have a common goal: to remove equal amounts of inner and outer epithelial preputial tissue in a rapid, minimally traumatic and hemostatic fashion. The po- tential for complications during circumcision is real and ranges from the insignificant to the tragic. The fairly high rate (1.5 to 15%) reflects the fact that the procedure is often performed by an inexperienced individual without attention to basic surgical principles.’ Bleeding is common and can oflen be controlled by pressure but occasionally necessitates a suture or cautery. Another common problem is a displeas- ing cosmetic result with too much or too little foreskin re- maining, which can be avoided by carefully marking the skin to be removed with a pen at the beginning of the procedure. Occasionally penile shafl skin will be removed while the inner prepuce is left. forming a concealed penis that requires surgical release.‘ Most often this complication occurs when the surgeon fails to take down all of the glanular adhesions at the start of the operation. Infection occurs more frequently in postnatal circumcision, and can range from minor infection to sepsis and death?’ No reports suggested the use of pro- phylactic antibiotics in all cases but aseptic technique should minimize the postoperative infection rate. Urinary retention. meatitis and meatal stenosis (the result of contact between 778

Since July 1982, 23 children between 10 and 28 months old underwent correction of hypospadias. After chordee was resected the urethral orifice was in the perineum in 3, at the penoscrotal junction in 5, on the proximal or mid shaft in 10 or at the distal shaft in 5. The neourethra was fashioned from a transverse island pedicle of preputial skin for proximal hypospadias or by using Mustarde's technique for distal hypospadias. A perforated silicone tube was left in the urethra and a feeding tube was passed through the lumen of the urethral stent to drain the bladder. Up to 4 days later the bladder catheter was removed and the children voided per the neourethra. The urethral stent was removed between 6 and 30 days postoperatively. Voiding through a recently constructed urethra was well tolerated. The boys did not experience bladder spasms, urinary extravasation did not occur and cosmetic results were good. Meatal stenosis did not occur. Three children (13 per cent) required closure of a fistula, which was noted 1 to 2 1/2 years later. It appears that briefly diverting bladder urine after hypospadias repair ameliorated postoperative morbidity without compromising the results. This technique was found to be inappropriate in older boys because of significant dysuria.

Fossa navicularis strictures have troubled urologists for years. Although several flap procedures have been described none truly leaves a normal-appearing penis postoperatively. A new technique is described of the reconstruction of the fossa navicularis with a ventral transverse island flap on a broad, dependable pedicle. All 5 patients who have undergone the procedure have excellent cosmetic and functional results. The appearance of the penis postoperatively is normal, with a median followup of 17 months. Early reconstruction of fossa strictures may avoid the sequelae of more conservative attempts at management, thus, correcting the fossa stricture itself before the occurrence of penourethral stricture disease secondary to repeated dilations, meatotomy and internal urethrotomy.

The management of patients with hypospadiae anomalies requires sound surgical judgment to obtain optimal results. From January 1983 to June 1985, 150 patients were operated on for hypospadias. Of these patients 37 underwent the Hodgson XX (modified Asopa) repair. Two patients suffered urethral fistulas, 1 had meatal stenosis and 1 had mild torsion. No strictures were noted. Based on our findings it appears that the Hodgson XX (modified Asopa) procedure provides excellent results for patients with hypospadias and chordee.

We report on a girl with urethral meatal stenosis that produced severe bilateral hydroureteronephrosis.

Single stage repair of moderately severe degrees of hypospadias with correction of chordee and reconstruction of the neourethra presents a difficult challenge for the surgeon. Traditionally, a 2-stage approach to correct these defects has been used. However, more recently a 1-stage repair with correction of chordee and creation of a neourethra has increased in popularity. From 1978 to 1985 we treated 86 patients with moderately severe hypospadias and chordee with a 1-stage technique using either a transverse island pedicle flap, a Hodgson III hypospadias repair or a free preputial skin graft. Despite an over-all complication rate of 50 per cent, our final results based on cosmesis and function were deemed excellent in 90 per cent of the cases. Of the 44 complications 23 were strictures, most frequently at the proximal anastomosis. Two-thirds of these strictures responded to a single dilation with the patient under anesthesia. Our fistula rate was 10 per cent and flap necrosis, meatal stenosis or prolapse and residual chordee accounted for the remaining 12 complications. Our experience indicates that a 1-stage repair for moderately severe hypospadias and chordee can be performed in patients with a satisfactory success rate of more than 90 per cent, minimal morbidity and an acceptable complication rate.

Not all patients with meatal stenosis require a complete urologic study. In those asymptomatic patients presenting with a small meatus found on routine examination, a urologic study is required only for clear historical or laboratory evidence of infection. Complete evaluation is still required for those patients with hematuria or a suggestive history on physical examination. We do not suggest abandoning the evaluation of meatal stenosis but hopefully provide guide lines for the evaluation of patients with a small meatus and no other symptoms or history. The management of these patients in the office or in day-care surgical facilities may be a suitable alternative to formal hospitalization. This should minimally include a careful history and physical examination, urinalysis, urine culture and consultation with the referring physician when necessary.