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Objectives To report our immediate and delayed outcomes of non-stented tubularized incised plate (TIP) distal hypospadias repair. Methods We retrospectively reviewed all charts of children who underwent distal hypospadias repair in a single children's hospital from 2013 to 2018. Patients’ demographics, hypospadias characteristics, operative technique, and immediate and delayed outcomes were recorded. Results Of 280 consecutive distal hypospadias repairs that were identified, 74 were excluded due to the use of a repair other than TIP. Eleven stented TIP repairs were excluded as well. Of 195 non-stented repairs, immediate post-operative voiding complications were recorded in 11 (5.6%) and included multiple/ split stream in 6 (3%), dysuria and voiding difficulty in 2 (1%), urinary retention in 2 (1%), and gross hematuria that spontaneously resolved in 1 (0.5%). Late follow up was recorded in 142/195 (72.8%) repairs. Delayed urethroplasty/glansplasty complications were recorded in 12 (8.5%) and included urethrocutaneous fistula (UCF) in 10 (7.0%), meatal stenosis (MS) in 6 (4.2%) and glans/urethroplasty dehiscence (GD) in 2 (1.4%). Conclusion Avoiding post-operative urethral stents in distal hypospadias TIP repair reduces the morbidity associated with the stent and is a feasible option that carries acceptable immediate and delayed complication rates. Avoiding the stent eliminates stent-related bladder spasms, the need for other medications, and the short-term office visit for stent removal, therefore reducing parental anxiety, patient discomfort, and reducing cost.

Objective To evaluate the presenting complications of patients to reconstructive urologists after masculinizing gender affirming genital reconstructive surgery (GRS) performed elsewhere. Methods We identified patients who underwent revision surgery by one of the co-authors for sequelae of masculinizing GRS. We reviewed patient demographics, medical history, details of prior GRS, and complications from GRS. Specific attention was paid to the presence of the following: suprapubic tube dependence, vaginal remnant, urethrocutaneous fistula (UCF) within the fixed urethra (pars fixa), UCF in the phallic urethra, phallic urethral stricture, meatal stenosis, and anastomotic urethral stricture. Statistical analysis was performed using the Fisher's exact test to determine differences in presenting symptoms by GRS. Results Fifty-five patients who had reconstructive surgery for complications from masculinizing GRS from September 2004 to September 2017 were identified. The median age at surgical correction was 33 years. Fifteen (27%) patients had prior metoidioplasty and 40 (73%) had prior phalloplasty. The median time from date of GRS to presentation to a reconstructive urologist was 4 months. Urethral strictures (n = 47, 86%) were the most common indication for subsequent surgery, followed by urethrocutaneous fistulae (n = 31, 56%) and vaginal remnant (n = 26, 47%). The majority of patients presented with 2 or more simultaneous complications (n = 40, 73%). Conclusion There are several common presenting urologic complications after masculinizing GRS. Patients may present to reconstructive urologists early after GRS performed elsewhere. The long-term outcomes of GRS deserve further study.

Objective To report outcomes, complications, and risk factors of a population cohort undergoing male-to-female gender affirmation surgery via penile-inversion vaginoplasty by a single surgeon at a large academic institution. As gender dysphoria awareness increases among the medical community, so does the population of patients seeking gender-affirmation surgery. Materials and Methods A prospectively maintained database of patients undergoing penile-inversion vaginoplasty was retrospectively queried for all available patients with at least 1 week of postoperative follow-up. Univariate and multivariate analyses were performed using Fisher's exact test and logistic regression, respectively, in order to evaluate relationship of risk factors to complications at 30, 60, and 90 days, as well as the likelihood of revision/reoperation. Results From November 2016 to April 2018, 240 penile-inversion vaginoplasties were performed. Median follow-up was 87 days. When accounting for competing risk factors, only noncompliance with postoperative dilation regimen and activity restriction was significantly associated with increased risk of complications or reoperation/revision. Overall incidence of reoperation/revision was 7.9% (n = 19). Reasons for reoperation included cosmesis (3.8%; n = 9), neovaginal stenosis (2.1%; n = 5), and wound dehiscence (0.8%; n = 2), with less than 0.5% (n = 1) reoperations for meatal stenosis, hematoma or rectovaginal fistula, respectively. Incidence of Clavien IIIa-b complications was 1.7% (n = 4). There were no Clavien IV-V complications. Conclusion At short-term follow-up, gender-affirmation surgery is associated with low rates of reoperation and revision and few major complications when performed by an experienced, high-volume surgeon. Patient selection and compliance is imperative. Increased reporting among surgeons is necessary to continue to improve patient outcomes.

Objective To correct all types of glanular/subcoronal hypospadias, we performed surgery named the distal urethroplasty and glanuloplasty procedure (DUG procedure). We analyzed cases that we have experienced. Methods A vertical incision with the meatal margin was made in the 12 o'clock direction, with the margin of the external urethral meatus as the center. By this meatoplasty according to Heineke-Mikulicz principle, we changed all type of glanular/subcoronal hypospadias to the hypospadias with wide meatus and wide glans. And then Thiersh-Duplay procedure was performed. Results Consecutive 24 underwent modified DUG procedure. The mean age at the time of surgery was 19.0 ± 11.9 months and the mean preoperative glans width was 13 ± 1.5 mm. The external urethral meatus was located glanular in 13 and subcoronal in 11. Hypoplastic urethra (HU) was observed in 7. Skin chordee in 10, penile torsion in 6 and meatal stenosis in 10 were observed. The mean surgical duration was 106 ± 25.4 minutes and the mean postoperative observation period was 40.5 ± 26.2 months. All patients with preoperative skin chordee, penile torsion, and meatal stenosis were improved postoperatively, and in all cases, apart from the patient with meatal regression with longest HU from glanular to distal penile, the slit-like shape of the external urethral meatus was achieved. Conclusion DUG procedure can be used for any type of glanular/subcoronal hypospadias but care should be taken not to indicate too aggressively for glanular/subcoronal hypospadias accompanying long HU to distal penile shaft.

OBJECTIVE To determine the risk of complications requiring treatment following male circumcision by health-care professionals and to explore the impact of participant characteristics, type of circumcision and study design. METHODS We identified studies through systematic searches in online databases (MEDLINE, EMBASE and CENTRAL) and hand searches. We performed random-effects meta-analysis to determine risk of circumcision complications and mixed-effects metaregression analyses to explore the impact of participant characteristics, type of circumcision and study design. Methods were prespecified in a registered protocol (Prospero CRD42020116770) and according to PRISMA guidelines. RESULTS We included 351 studies with 4.042.988 participants. Overall complication risk was 3.84% (95% confidence interval 3.35-4.37). Our meta-analysis revealed that therapeutic circumcisions were associated with a 2-fold increase in complications as compared to nontherapeutic (7.47% and 3.34%, respectively). Adhesions, meatal stenosis and infections were the most frequent complication subgroups to therapeutic circumcisions. Bleeding, device removals and infections occurred more frequently in nontherapeutic circumcisions. Additionally, adjusted metaregression analyses revealed that children above 2 years, South American continent, older publication year and smaller study populations increased complication risk. Type of circumcision method, provider and setting were not associated with complication risk. Sensitivity analyses including only better-quality studies reporting indication, age at circumcision, treatment for complications, full-text articles, and adequate follow-up clinically for a minimum of one month or through databases confirmed our main findings while accounting better for heterogeneity. CONCLUSION Circumcision complications occur in about 4 per hundred circumcisions. Higher risks of complications were determined by therapeutic circumcisions and by childhood age when compared to infant. Future studies should assess therapeutic and childhood circumcisions separately.

Objective To evaluate the success rates of a simple posthypospadias urethrocutaneous fistula repair. Study design We evaluated children who underwent urethrocutaneous fistula closure by means of a simple standard technique in which the fistula tract was dissected to its base and resected and the urethral defect closed with a single layer of continuous sutures and covered with local subcutaneous tissue. No urethral stents or catheters were used, and the patients were discharged on the same day. Excluded were children who underwent fistula repair by a different technique, revision hypospadias repair for fistula, or concomitant meatoplasty for meatal stenosis. Study endpoints were fistula recurrence and the need for further penile surgery other than fistula repair. Results Seventy-two children underwent 81 repairs. The mean follow-up was 7.9 years. Recurrence occurred in 17 cases (21%). Seven children (9%) underwent penile surgery other than fistula repair, including meatoplasty (n = 5) and re-do hypospadias repair for a diagnosis other than fistula recurrence (n = 2). There was no significant difference in recurrence rate between large and small fistulas, coronal or more proximal fistulas, or children w/wo prior fistula repairs. Conclusion Standard fistula closure solely by adjacent tissues yielded success rates of 79% after long-term follow-up. This repair can be safely offered with the expectation of similar results for a variety of urethrocutaneous fistulas in children.

Context Meatal stenosis (MS) as a potential complication of male circumcision and controversy regarding the magnitude of risk. Objectives To conduct a systematic review and meta-analyses to assess (1) MS diagnosis after circumcision, (2) the potential association of MS with circumcision, and (3) a potential method of prevention. Data sources PubMed, Google Scholar, Cochrane Library and bibliographies of original studies were searched using the keywords circumcision and stenosis or stricture. Study Selection Studies containing original data on MS following circumcision at any age. Data Extraction Two reviewers independently verified study design and extracted data. Results Thirty eligible studies were retrieved. A random effects meta-analysis of 27 studies (350 MS cases amongst 1,498,536 males) found that the risk of MS in circumcised males was 0.656% (95% confidence interval 0.435–0.911). Meta-analysis of 3 observational studies that compared MS prevalence in circumcised and uncircumcised males found non-significantly higher prevalence in circumcised males (odds ratio 3.20; 95% confidence interval 0.73–13.9). Meta-analysis of 3 randomized controlled trials investigating the effect of petroleum jelly application to the glans after circumcision found that this intervention was associated with MS risk reduction (relative risk 0.024; 95% confidence interval 0.0048–0.12). Conclusion MS risk after circumcision is low (

Objective To compare, functionally and aesthetically, stented and unstented tubularized incised plate urethroplasty (TIPU). In addition, predictors of repair success were investigated. Materials and Methods One hundred ten children with distal hypospadias were included in this study. The length and width of the urethral plate (UP) and transverse glans diameter (TGD) were measured. Patients were randomized into two groups: stented and unstented TIPU. Postoperative assessment of pain was done using Face, Legs, Activity, Cry, Consolability (FLACC) scale, and cosmetic outcome was evaluated using hypospadias objective scoring evaluation. Uroflow was assessed at 6 months in toilet-trained boys. Complications were graded by the Clavien classification system. Results In 93 cases, Face, Legs, Activity, Cry, Consolability score, hospital stay, and dressing time were in favor of the unstented group, whereas hypospadias objective scoring evaluation score and uroflow parameters were comparable. TGD and UP width varied significantly between successful and failed cases. Cutoff values of 13.5 mm and 8.5 mm for TGD and UP width, respectively, are required for successful outcome. Acute urinary retention was 12.8% after unstented repair. Detrusor spasm was 47.8% after stented and 8.5% after unstented repair. In both groups, urethrocutaneous fistula of 5.4%, glanular dehiscence of 1.1%, and meatal stenosis of 5.4% were found in cases with small TGD and narrow UP. Conclusion Unstented TIPU evades the associated drawbacks of the stent along with lower postoperative pain, hospital stay, and dressing time. Even without a postoperative stent, the complication rate in infants with distal hypospadias is low, and short-term functional and aesthetic outcomes were not compromised.

Objective To evaluate the urethral mobilization procedure as the main technique in management of glanular, coronal, subcoronal, and distal penile hypospadias. Patients and Methods Sixty patients with distal hypospadias were included in this prospective study between January 2013 and January 2015. All of them had urethral mobilization. All patients were followed up at 2 weeks, and at 1, 3, 6, and 12 months postoperatively. Duration of the operation, hospital stay, position of meatus and its shape before and after the operation, and the postoperative complications were recorded. The force and direction of the postoperative voiding stream were observed and assessed subjectively. Results The mean operative time and hospital stay were 38 minutes and 2.2 days, respectively. Postoperatively, 2 patients developed wound infection, 1 of them developed glanular suture dehiscence managed by simple glanular suturing 3 months later. None of our patients developed urethrocutaneous fistula. Three months postoperatively, 2 patients developed meatal stenosis, 1 of them managed by meatal dilation whereas the other patient required ventral meatotomy. Conclusion Hypospadias surgery aim to construct a functionally and cosmetically normal penis with minimal complications. Recently, urethral mobilization started to regain its position in distal hypospadias repair. Its results are comparable with other popular procedures or even better. Urethral mobilization is an easy and simple procedure and it has an excellent cosmetic and functional outcome with minimal complications.

Objective To present our technique for staged urethroplasty with buccal mucosa graft. Methods The patient presented is a 42-year-old man with a history of congenital hypospadias repaired as a child. He developed a penile urethral stricture at age 30 and was managed with self-intermittent dilation. Recently, dilation became more difficult, and he was referred for reconstruction. Workup revealed a high-grade stricture extending from the meatus to the site of the previous anastomosis at the penoscrotal junction. To contextualize the presented case, we performed a retrospective review of all staged penile urethroplasties performed at our institution from 2013 to 2016 (n = 20). Results At 18 months' follow-up, the patient voids with an unobstructed, directable stream and has not required any urethral instrumentation. In our series, stricture etiology was lichen sclerosus in 9 (45%), failed hypospadias repair in 8 (40%), trauma in 2 (10%), and penile calciphylaxis in 1 (5%). At median follow-up of 520 days, 60% underwent second-stage urethroplasty at a median of 277 days after first-stage urethroplasty (range 213-738). No patients required grafting after first-stage surgery. Complications of second-stage surgery included wound dehiscence in 2 (17%), fistula in 1 (8%), and meatal stenosis in 1 (8%). Conclusion Staged penile urethroplasty is a safe and effective treatment option for patients with complex urethral strictures resulting from lichen sclerosus and failed hypospadias repair.

Objective To evaluate the feasibility and outcomes of full thickness penile skin grafting (FTSG) for phalloplasty during acquired buried penis repair. Materials and methods A retrospective cohort study of patients undergoing complex genital reconstruction for buried penis between January 2013 and April 2018 was performed. Patients undergoing FTSG were identified. All patients underwent escutcheonectomy, scrotoplasty, and penile skin grafting by a single Urologist (MM) and Plastic surgeon (JS). Escutcheon tissue was used for the FTSG. The primary outcome was graft take and the secondary outcome was recurrence requiring surgical revision. Results Thirteen patients were identified for inclusion in the study with average age of 43.4 and average BMI of 42. Median (range) follow-up for the cohort was 8 (3-44) months. Surgical indication was lymphedema in 6 (46.2%), morbid obesity in 6 (46.2%), and hidradenitis suppurativa in one (7.7%). Seven required concurrent urethromeatoplasty for meatal stenosis and fossa navicularis strictures. All grafts were successful. Two patients developed postoperative wound infections requiring antibiotics. One patient redeveloped lymphedema of the scrotum and required complete revision surgery although the FTSG remained intact. No patients had reburying of the penis. Minor outpatient surgical revision was performed for 2 patients for scarring and edema of the glans. Conclusion Full thickness skin grafts provide a useful option for penile reconstruction during surgical management of buried penis. Patients had excellent graft acceptance and minimal wound complications. Further research and comparative cohorts are warranted to fully determine the role of FTSG in genital reconstruction.

Objective To describe a new modification of the Koyanagi technique for the one-stage repair of severe hypospadias and its short-term outcomes. Patients and Methods Our modified Koyanagi technique was performed in 24 patients with severe hypospadias between February 2012 and January 2015. The age of the patients ranged from 1.9 to 11.9 years (mean = 3.5 years). The flap design was similar to the Koyanagi technique, but our modified technique highlighted the following points: after the chordee was completely corrected, the urethral plate was recreated using foreskin, and then a U-shaped incision was made on the original and recreated urethral plate (as in the Duplay technique); a pedicled flap of the tunica vaginalis or scrotal dartos was used for additional coverage of the neourethra. Results The operation time lasted from 120 to 150 minutes (mean = 140 minutes). There were 5 patients (20.8%) who developed complications: 4 patients (16.7%) developed a fistula and 1 patient (4.2%) developed dehiscence of the urethra. There were no reported urethral strictures, meatal stenosis, or urethral diverticula. The complications in the 5 patients were successfully addressed with secondary repair, and all patients achieved satisfactory cosmetic and urethral functional results. Conclusion The modified Koyanagi technique simplified the operation and better preserved the blood supply to the flap. The additional coverage of the neourethra using a pedicled flap of the tunica vaginalis or scrotal dartos significantly decreased the rate of fistula formation. This technique is highly suitable for the one-stage repair of severe hypospadias with penoscrotal transposition.

Objective Scrotal hypospadias still presents a challenge for reconstructive urologists. We present a novel and 1-stage technique of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and urethroplasty for severe hypospadias repair. Methods A 14-month old boy underwent repair of scrotal hypospadias with severe chordee. Penile straightening is achieved by division of short urethral plate combined with ventral grafting. Urethral reconstruction is done by combined buccal mucosa graft and longitudinal dorsal penile skin flap. Buccal mucosa graft is harvested and designed in a special “watch” shape, with the spherical part in the middle and 2 rectangular parts on both sides. The tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the “watch-shaped” graft with “U-shape” stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally creating new urethral plate. A longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with the urethral plate. Penile skin reconstruction is performed using available penile skin. Results In period between July 2014 and December 2018, this technique is performed in 35 patients (aged from 10 to 22 months) with scrotal hypospadias. In the follow-up, ranged from 10 to 63 months (mean 29 months), satisfactory results were achieved in 30 boys (86%). Urethral fistula in 3 and meatal stenosis in 2 cases were successfully treated by minor revision and temporary meatal dilatation, respectively. Good result in curvature repair was obtained in all cases based on vacuum device checking and parents' reports. Conclusion Repair of scrotal hypospadias associated with severe ventral curvature is usually done as a 2-stage procedure. A “watch” shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty is a viable and reliable option for single stage repair of scrotal hypospadias with severe chordee.

Objective To assess uroflowmetry in the long-term follow-up of symptomatic meatal stenosis patients prior to and following meatotomy. Severity of symptoms and treatment success has been defined by patient history, physical examination, and witnessed voiding. Uroflowmetry might add objective parameters for the assessment, however long-term data are lacking. Methods A prospective study following 25 symptomatic toilet-trained boys before and after meatotomy was performed with short and long-term follow-up after surgery. Patient history, physical examination, and uroflowmetry variables were recorded. Results Fifteen patients were fully evaluable. Mean age at operation was 6.4 years (2.5-10.5) with an average follow-up of 43 months. All patients were symptomatic before surgery; complete symptomatic resolution was achieved in all patients at short-term follow-up, and in 12 at long-term follow-up. A stenotic meatus was seen in all patients before surgery, at long-term follow-up 12 of 15 (80%) had an open appearing meatus (P = .0001). Abnormal uroflowmetry pattern was present in 8 of 15 (53%) prior to surgery and 2 of 15 (13%) at long-term follow-up (P = .02). Normal maximal flow rate as defined by ICCS were seen in 5, 11, and 12 patients before, 1 month after and at long-term follow-up (P = .06 and 0.02, respectively). PVR improved significantly at long-term follow-up (P = .0012). Conclusion Symptom evaluation and physical examination should be the hallmark assessing children with meatal stenosis. Clinical assessment one month after surgery suffices and long-term follow-up is unnecessary. Uroflowmetry provides objective assessment as well as surgical success; however, it is unnecessary since it does not change the management.

We reviewed the current literature on lichen sclerosus as it related to urethral stricture disease using MEDLINE and PubMed (U.S. National Library of Medicine, National Institutes of Health) up to the current time. We identified 65 reports, 40 of which were considered relevant and form the basis of this review. Lichen sclerosus is now the accepted term, and balanitis xerotica obliterans is no longer acceptable. This common chronic inflammatory skin condition, mainly affecting the genitalia, remains an enigma, with uncertain etiology, varied presentation, and multiple treatments. In the early stages of the condition, a short course of steroids may be beneficial for some patients. If persistent, patients need long-term surveillance because of the potential development of squamous cell carcinoma. If diagnosed early, lichen sclerosus can be controlled, preventing progression. But once the disease has progressed, it is very difficult to treat. Surgical treatment by circumcision can be curative if the disease is treated early when still localized. Once progression to urethral involvement has occurred, treatment is much more difficult. Meatal stenosis alone is likely to require meatotomy or meatoplasty. Treatment of the involved urethra requires urethroplasty. Single-stage and multiple-stage procedures using oral mucosa have both been reported to give acceptable results, but the use of skin, genital or nongenital, is not recommended, because being skin, it remains prone to lichen sclerosus. With extensive disease, affecting the full length of the urethra, consideration should be given to perineal urethrostomy. A significant number of patients may prefer this simpler option.

Genital lichen sclerosus et atrophicus (LSA) is an uncommon genital dermatosis. Its resemblance to vitiligo, especially during the earlier stages, leads to delay in its diagnosis. Apart from the common complications such as meatal stenosis, balanoposthitis, phimosis, and painful erections, squamous cell carcinoma is a rare but ominous complication of genital LSA. Herein, we present a case of long-standing penile LSA complicated by squamous cell carcinoma, stressing upon the requirement of early diagnosis and management of LSA.

Objective To present the meatal mobilization with glanuloplasty inclusive (MMGPI) modification of meatal advancement and glanuloplasty inclusive. Materials and Methods A total of 120 patients with anterior hypospadias underwent MMGPI between September 2008 and October 2014 at Kermanshah University of Medical Sciences. Satisfactory outcomes were defined as continuous straight urinary flow and catheterization of new meatus without difficulty. Cosmetic outcomes were considered acceptable if patients maintained a slit-like meatus at the glanular tip. Patients were examined at 1 week, 1, 3, 6, 12, and 24 months. Results The 120 patients with anterior hypospadias underwent MMGPI. There were no hematoma, meatal necrosis, or other early complications. In patients with glanular hypospadias, there were no meatal regressions or stenosis, all voiding patterns were normal, and all patients maintained a slit-like meatus at the glanular tip. Two patients with coronal hypospadias had meatal stenosis and 2 patients had meatal regression. Five patients with sub-coronal hypospadias had 2-mm meatal regression with downward sloping urinary stream, and 2 patients had meatal stenosis. In all, meatus remained distal to the preoperative meatus with no necrosis. Small sample size was the major limitation of this study. Conclusion MMGPI represents a viable option for glanular and coronal hypospadias repair.

OBJECTIVES To review our 10-year experience with tubularized incised-plate (TIP) urethroplasty and determine the risk factors for reoperation. METHODS The hospital records of 391 patients underwent the TIP procedure from April 1997 to September 2007 were reviewed retrospectively. Data were collected with respect to patient demographics, characteristics of the hypospadias malformation, intraoperative factors and postoperative outcome. Complications requiring reoperation were identified. Univariate and multivariate analyses were used to identify risk factors for reoperation. RESULTS Median age at surgery was 2 years (range, 0.5-16). Median follow-up was 11 months (range, 3-96). Neourethral complications requiring re-operation developed in 48 patients. A total of 52 reoperations were required because of fistulae (25/6%), neourethral disruption (13/3%), meatal stenosis (13/3%), and stricture (1/0.3%). The re-operation rate was significantly higher in the presence of interrupted sutures, chordee requiring dorsal plication, penoscrotal or proximal shaft defects, a lack of neourethral vascular tissue coverage, and in children over 4 years of age. Multivariate analysis identified the last 3 of these variables as independent risk factors for reoperation. CONCLUSIONS In addition to position of the urethral meatus and the absence of vascular covering flaps, we found that an age over 4 years at the time of surgery is an additional independent risk factor for neourethral complications requiring reoperation.

Objectives To introduce a simple and effective technique for urethroplasty of distal hypospadias, using the advantages of both standard techniques of Snodgrass and Mathieu to reduce or eliminate the shortcomings of each. Methods Forty patients with primary distal hypospadias were randomized between two groups (20 in each). Patients in group I underwent standard Snodgrass urethroplasty, whereas those in group II were operated with our novel technique, Mathieu–Incised Plate (Mathieu-IP), comprising preparation of a parameatal-based skin flap as in the Mathieu procedure together with modifications (adopted from Snodgrass urethroplasty) such as a complete longitudinal incision on the urethral plate as well as coverage of the neourethra with an inner preputial flap. Operative data and outcomes of both procedures were analyzed prospectively after 1 year of follow-up. Results Both groups were age matched (group I: 7.05 ± 4.85 years; group II: 7.31 ± 2.17 years), and there were no significant differences in mean operative time (95 minutes versus 100 min in groups I and II, respectively). There were significant differences between the two groups in terms of complications. Whereas 3 cases of posturethroplasty meatal stenosis and 2 of urethrocutaneous fistula (5 complications, 25%) were detected in the Snodgrass group, neither of these complications occurred in the Mathieu-IP group. All 40 patients benefited from a slit-like meatus. Conclusions Combining the Mathieu procedure with plate incision could be considered a promising simple technique to achieve a normally shaped meatus and to reduce the rate of meatal-related complications, the major concern with the Snodgrass procedure.

Objectives The continent catheterizable conduit was first described by Mitrofanoff and is a good option for treating patients with urinary incontinence of different etiologies and those unable to perform transurethral self-catheterization. Stomal stenosis is the most common minor complication involved in this procedure and often is not an easily dealt with problem. Stenosis has a tendency to recur, and the surgical approach becomes progressively more difficult because of local fibrosis and retraction. We present our initial experience with a new surgical technique involving umbilical grafting for the treatment of stomal and urethral meatal stenosis. Methods Four female patients who presented with either recurrent stomal or urethral meatal stenosis underwent a new surgical approach with umbilical grafting for treatment. We present the results of this new technique. Results The initial clinical results of this innovative technique, at a median of 4 months of follow-up, showed that all 4 patients remained continent and mostly satisfied with their voiding pattern. Conclusions The results of our study have shown that umbilical grafting is a viable option for the treatment of recurrent stomal and urethral stenosis.

OBJECTIVES To present our experience with a modification of tubularized incised plate (TIP) urethroplasty for treatment of anterior penile hypospadias. METHODS A total of 764 children with primary anterior penile hypospadias (462 subcoronal and 302 coronal) underwent hypospadias repair by using modified TIP urethroplasty. The technique involves, in addition to the standard TIP, the use of the dorsal prepuce which was divided in 2 flaps. The right flap was de-epithelialized on both the outer and inner sides and transferred as interposing layer between the neourethra and the coverings. The left flap was de-epithelialized on the inner side and transferred ventrally as skin coverage. The follow-up ranged between 3 and 52 months with a mean of 17 months. RESULTS Excellent functional and cosmetic results were achieved in 738 patients (96.6%). Urethral fistulae were encountered in 16 cases (2%) and were repaired successfully. Meatal stenosis was noted in 8 cases (1%) and successfully treated. Two patients had complete disruption of the wound (0.2%), which was corrected. CONCLUSIONS Excellent functional and cosmetic results can be achieved after repair of anterior penile hypospadias by using TIP urethroplasty with the modification of using double breasted de-epithelialized skin flap.

Objectives Although not pernicious, minimal distal hypospadias is frequently obvious to parents, whose concern that their child be completely normal prompts their request for repair. A simple technique for the repair of this anomaly that results in an elliptical meatus is presented. Methods A total of 28 boys ranging in age from 3 to 100 months (mean 21.8) underwent a surgical technique in which the distal urethral plate was excised, followed by advancement of the meatus into the defect thus created. Only 5 boys (17.8%) underwent hypospadias repair as an isolated procedure. Other concomitantly repaired anomalies included hooded prepuce, phimosis, redundant prepuce after neonatal circumcision, ventral penile curvature, inguinal hernia, undescended testis, penile torsion, and meatal stenosis. Results All patients had healed well at a follow-up of 3 to 4 months (mean 3.2) and uniformly had an excellent cosmetic appearance with an elliptical meatus. Conclusions We recommend a technique for the repair of minimal distal hypospadias, consisting of excision of the distal urethral plate with advancement of the dorsal lip of the meatus into the created defect, for its simplicity and resultant elliptical meatus.

Objectives A variety of surgical techniques and flaps have been described for hypospadias repair. We present our 10-year experience using a composite urethroplasty graft consisting of bladder mucosa and skin. Methods We reviewed the records of 294 patients who had undergone hypospadias repair at our institution from 1993 to 2003. The meatus was penile in 221, penoscrotal in 55, and perineal in 18. They all underwent single-stage urethroplasty consisting of a composite tubularized bladder mucosa-skin graft. Patient age at surgery was 2 to 46 years old (mean 8.9). Results Urethrocutaneous fistula formation occurred in 27 (9.1%) and urethral strictures in 9 (3.2%), for an overall complication rate of 12.3%. No proximal urethral anastomotic strictures or meatal stenosis developed. Conclusions Our results have demonstrated that composite bladder mucosa-skin flap grafts can be used successfully for urethral reconstruction in proximal, as well as distal, hypospadias repair. The distal tubularized skin flap prevented the occurrence of meatal stenosis.

Objectives To provide information about the long-term efficacy of transvesical prostatectomy from a contemporary series of patients. When comparing minimally invasive procedures with open prostatectomy, the data for the latter are usually provided from old studies or from recent ones performed in developing countries. However, this procedure is still used frequently for large-size prostates. Methods During a 5-year period, 232 patients with large (greater than 75 g) prostates underwent open transvesical prostatectomy for symptomatic benign prostatic hyperplasia. Patient charts were retrospectively reviewed for preoperative and postoperative International Prostate Symptom Scores, postvoid residual urine volumes, maximal flow rates, early and late postoperative complications, and the need for reoperation. The preoperative International Prostate Symptom Score, postvoid residual urine volume, and maximal flow rate were compared with the corresponding postoperative data at 8 to 12 months and at the last follow-up visit. Results Complete data evaluation was possible for 151 patients, with a mean follow-up of 41.8 ± 15.6 months. Improvement in International Prostate Symptom Score, postvoid residual urine volume, and maximal flow rate was statistically significant (P

Objectives To review the tubularized incised plate, a recently popularized technique, and provide outcomes. Methods From January 2000 to December 2006, 496 patients underwent the tubularized incised plate technique for hypospadias at our clinic. The patient age range was 6 months to 14 years. The postoperative follow-up time was 2 years (range 6 months to 3 years). The patients underwent the technique as described by Snodgrass, with some small technical modifications. The patients were hospitalized for 10 days postoperatively, with a urethral stent in place. Results Of the 496 patients, 48 experienced 53 complications. The most frequent complication was meatal stenosis (n = 27, 5%), followed by urethrocutaneous fistula (n = 25, 5%). Dehiscence was noted in 1 patient (0% of 496 patients and 2% of the 48 patients with complications). Initially, the fistula occurrence rate was 11% and 4% for all 496 and the 48 patients with complications, respectively, which had decreased to 3% and 8% in the most recent 3 years. During the study period, some technical modifications have applied, with a resulting decrease in the complication rates. Complications occurred in 48 patients (9%), of whom 25 required surgical repair (5% of 496 patients). Conclusions The tubularized incised plate technique is a surgical method that can be applied to most hypospadias anomalies. Increasing clinical experience and minor additions to the technique have enhanced our success with this method.

Objectives: Patients requiring urethral reconstruction but who have a paucity of usable genital tissue present a considerable technical challenge. Herein we report the experience of three centers in the use of buccal mucosa for urethral replacement. Methods: From 1991 to 1996, 22 urethral reconstructions were completed using a graft of buccal mucosa. Eighteen of 22 patients had previously failed hypospadias repairs, while three had bulbar urethral stricture and one had penile carcinoma. Grafts were taken from either the inner cheek or the lower lip, and seven were used as a combined graft. Onlay grafts were used in 6 cases and tubularized grafts in 16 cases. Results: Two patients developed complications at the donor site. Nine of 22 patients had complications of the urethroplasty—two had meatal stenosis, four developed a urethral fistula, and three developed urethral stricture. All complications have been managed successfully to date. Conclusions: Buccal mucosa is an excellent source of graft material for urethral replacement in complex urethroplasties. It is readily available, in abundant supply, and has physical properties beneficial to free graft survival.

Objective To report the outcome of 1-stage urethroplasty using lingual mucosal grafts (LMGs) and buccal mucosal grafts (BMGs) for the treatment of male urethral strictures associated with genital lichen sclerosus (LS). Materials and Methods This was a descriptive, observational retrospective study of male patients with urethral strictures who underwent 1-stage mucosal graft urethroplasty using different substitute materials for reconstructive urethral surgery. Study inclusion criteria were patients with histologically proven LS presenting with urethral strictures. Exclusion criteria were patients without histologically proven LS, traumatic strictures, failed hypospadias, and malignant lesions. Successful reconstruction was defined as normal voiding with a peak flow >12 mL/s, no obstructive symptoms, and no postoperative procedure, including dilation. Results Between January 2003 and December 2011, urethral strictures in 54 patients were considered associated with genital LS according to the inclusion and exclusion criteria, and 36 underwent 1-stage urethroplasty using oral mucosal grafts. The median age was 52 years (range, 32-80 years). The median stricture length was 12.5 ± 1.6 cm (range, 6-18 cm). One-stage single-sided dorsal LMG urethroplasty was performed in 22 of 36 patients. The remaining 14 patients received the same procedure combined with dual BMGs (n = 5) or with LMG combined with BMG (n = 9). The success rate was 88.9%. Postoperative urinary fistula occurred in 1 patient, and meatal stenosis developed in 3 patients. Mean follow-up was 38.7 months (range, 12-110 months). Conclusion Our survey suggests that 1-stage urethroplasty with single or combined LMGs or BMGs may be an effective option to treat urethral stricture associated with LS.

Objective To review our experience with tissue expanders for resurfacing the penis in selected cases of complex hypospadias repairs. Materials and Methods We reviewed the medical records of 6 hypospadias male patients who underwent tissue expansion for phallic skin resurfacing. The patients ranged in age from 14-29 years of age at the time of placement of the tissue expander. All 6 patients had 5-8 failed surgeries and were “hypospadias cripples.” In each case, the injection port was placed in the suprapubic area, whereas the tissue expander was placed under the skin on the dorsum of the penis. The tissue expanders were inflated slightly in the operating room and then subsequently at 2-week intervals over 12-16 weeks. At the point of maximum tissue expansion, the patients underwent reconstructive surgery and removal of the tissue expanders. Results Successful tissue expansion occurred in all 6 patients. The patients then underwent penile skin flap reconstruction of their penises. Two patients developed minor complications (1 urethrocutaneous fistula, 1 meatal stenosis), which were successfully corrected. Long-term follow-up ranged from 1-22 years. Successful phallus resurfacing with penile skin was achieved in all 6 patients. Conclusion Patients who have undergone multiple attempted hypospadias repairs may lack a sufficient amount of healthy, unscarred penile skin for a successful outcome. These patients are therefore candidates for tissue expansion of the relatively normal skin usually found on the dorsum of the penis. In our experience, tissue expanders are a safe and effective method of acquiring genital skin for resurfacing in selected cases of hypospadias cripples and therefore should have a place in the surgical armamentarium of complex and redo-hypospadias repairs.

Objectives Development of acute urinary retention (AUR) is common in the aging male. The pathophysiology of AUR is attributed primarily to prostatic obstruction. The objective of this study was to evaluate the risk of AUR in men after open radical prostatectomy (ORRP). Methods A questionnaire asking whether a urinary catheter had been inserted after its initial removal was sent to 1361 men who underwent ORRP by a single surgeon (HL) between October 2000 and January 2007. Follow-up ranged from 12 to 84 months (mean, 48 months). For those who responded that a catheter had been reinserted, a follow-up question inquired specifically when this event occurred. The reason for postprostatectomy catheter reinsertion was determined via phone interview. Results A total of 952 men (69.9% response rate) mailed a completed questionnaire to our database manager. No men underwent catheter reinsertion owing to spontaneous AUR. Ninety-two men (9.7%) answered "yes" to requiring catheter insertion postprostatectomy. The reasons for recatheterization were an intermittent catheterization regimen after dilation of an anastomotic stricture or meatal stenosis (n = 68), AUR immediately after initial catheter removal (n = 14), and elective reasons (n = 10). All urethral strictures were dilated within the first year after surgery and no patient with stricture presented with AUR. Conclusions The risk of spontaneous AUR after 1 month of catheter removal after ORRP is 0%. We believe that this is an important unrecognized clinical benefit of ORRP, especially in men with moderate to severe lower urinart tract symptoms or enlarged prostates, who are at higher risk for AUR.

Objective To evaluate the effectiveness of a lingual mucosal graft (LMG) urethroplasty for anterior urethral strictures and the donor site complications. Methods A total of 30 patients underwent urethroplasty for anterior urethral strictures using dorsal on-lay of a LMG from March 2006 to December 2006. Most patients had balanitis xerotica obliterans as the etiology. The mean stricture length was 10.2 cm (range 3.7-16.5). Postoperatively, all patients underwent pericatheter urethrography at 3 weeks, followed by retrograde urethrography with micturating cystourethrography, and uroflowmetry at 3 and 6 months. Repeat uroflowmetry was done as, and when, required. Results The mean period of follow-up was 9 months (range 4-12). The overall success rate was 83.3%. The mean peak flow rate increased postoperatively from 4.36 mL/s to 35.5 mL/s at 3 months and 25.06 mL/s at 6 months of follow-up. One patient developed repeat stricture at the anastomotic site, and 4 patients developed recurrent meatal stenosis. Conclusions The results of LMG urethroplasty were comparable to that of buccal mucosal graft urethroplasty. LMG is easy to harvest. Most importantly, the donor site complications were minimal without any functional or esthetic deficiency.

Snodgrass recently described a form of urethral tubularization with longitudinal incision of the urethral plate to create an elliptical meatus. To prevent fistulae, a transverse island of dorsal subcutaneous tissue was used to cover the repair. The generation of this flap may compromise blood supply to the skin that is used in the skin closure, and predispose to penile torsion. We have modified the technique to address these concerns, while accomplishing the major goal of functional success-particularly minimizing or eliminating fistulae.Eighteen boys, aged 6 months to 6 years, with distal or midshaft hypospadias, underwent a one-stage repair using a modification of Snodgrass' technique. Rather than a transverse island flap of subcutaneous tissue, a local de-epithelialized skin flap was used to cover the urethroplasty.Sixteen patients have returned for follow-up, and all patients have an excellent cosmetic and functional result with an elliptical glanular meatus. There have been no cases of fistula or meatal stenosis.Distal hypospadias repair utilizing a de-epithelialized local skin flap to cover a tubularized incised urethral plate gives an excellent cosmetic and functional result. Optimal blood supply to the ultimate skin coverage is preserved, and penile torsion is avoided.

Objectives To report the outcomes in a large series using a modified tubularized incised plate (TIP) urethroplasty (Snodgrass) technique with a local de-epithelialized skin flap to cover the urethroplasty. The use of the TIP urethroplasty (Snodgrass) technique has gained wide acceptance among pediatric urologists for the correction of hypospadias repair because of its good cosmesis, low complication rate, and reliability in creating a vertically oriented meatus. Methods A total of 101 boys, aged 6 months to 3 years, with distal (n = 85), mid-shaft (n = 8), or proximal (n = 8) hypospadias underwent one-stage repair using a modified TIP repair with a local de-epithelialized skin flap to cover the urethroplasty. Charts were reviewed for each patient to determine the complications, reoperations, cosmesis, and functional results after surgery. Results With at least 6 months of follow-up, all patients had achieved excellent functional and cosmetic results, with the meatus at the tip of the penis on follow-up. Three repairs for meatal stenosis and two for fistula were needed. Conclusions The modified TIP procedure is a safe and reliable technique. It provides excellent cosmesis with a low reoperation rate.

Objectives. To report our experience with Mathieu urethroplasty for revision of hypospadias repairs. Mathieu perimeatal-based flap urethroplasty remains a popular technique more than seven decades after its description for single-stage hypospadias repair. The excellent results of primary distal hypospadias repair are well documented, but reports of the results using the technique as a salvage procedure are sparse. The reuse of local tissue may be hampered by the presence of scar tissue and reduced vascularity. Methods. A total of 40 patients underwent salvage urethral reconstruction. Of the 40 patients, 34 (mean age 70 months, range 11 to 216) underwent salvage Mathieu urethroplasty. All patients underwent surgery at least 6 months after the previous surgery. One, two, and three or more prior procedures had been performed in 22, 6, and 6 patients, respectively. The mean follow-up period was 29 months (range 1 to 84). In 6 patients, local tissue was scarred and immobile, and they underwent the procedure using buccal mucosal grafts. Results. Satisfactory functional and cosmetic results after the initial procedure were achieved in 25 patients (74%). Two patients underwent reoperation for repair of meatal stenosis, and 5 (15%) underwent simple repair of fistula without the need for urethral reconstruction. Two patients underwent reoperation at other medical centers and were lost to follow-up. Overall, cure was achieved in 32 (94%) of the 34 patients. Conclusions. Mathieu urethroplasty is an efficient technique for salvage hypospadias repair. Patient selection is the key to successful repair. Despite the effects of previous surgery, local tissue of adequate quality to facilitate repair exists in most patients. UROLOGY 65: 1212‐1215, 2005. © 2005 Elsevier Inc.

Objectives Moderately severe hypospadias can be repaired by a simple onlay island flap procedure with penile dorsal plication in most patients. However, when the penile curvature could not be corrected, and the urethral plate could not be preserved by the procedure, a combined procedure of onlay and tubularized island flap is subsequently needed. Methods Onlay urethroplasty was performed to repair hypospadias in 39 patients with hypospadias. However, the combined procedure (onlay-tube-onlay urethroplasty) was performed on 6 patients who had severe penile curvature even after skin degloving. Results Hypospadias was repaired successfully without complications in 30 (90.9%) of the 33 patients by conventional onlay urethroplasty alone. Of the 6 patients who underwent onlay-tube-onlay urethroplasty, 1 patient developed fistula and 1 developed meatal stenosis, for a success rate of 66.7%. The complications in all patients were later resolved. Conclusions We recommend switching to onlay-tube-onlay urethroplasty when the attempt to repair moderately severe hypospadias by the simple onlay procedure has to be abandoned, and the urethral plate needs to be divided.

Objectives. To determine the parent perception of discomfort (PPD) in children receiving local anesthesia for the lysis of labial adhesions, meatotomy, and newborn circumcision; the parents’ perceived outcome of these procedures; and the overall satisfaction of parents when these procedures are performed in the office. Methods. A confidential phone survey was given to 99 parent participants whose children had received local anesthesia for the lysis of labial adhesions (n = 14), meatotomy (n = 28), or newborn circumcision (n = 57). Parents in the labial adhesion and meatal stenosis groups were asked to rate their child’s level of discomfort (PPD) during the procedure as mild (1), moderate (2), or severe (3), and those in the circumcision group were asked to use the same scale to rate their child’s discomfort after the procedure. Parents were also asked whether they thought the procedure was successful and whether they were satisfied with their decision to have it done in the office using local anesthesia. Results. Among the labial adhesion, meatotomy, and circumcision groups, the mean PPD ± SD was 1.64 ± 0.75, 1.54 ± 0.69, and 1.21 ± 0.53, respectively. The observed procedures, lysis of labial adhesions and meatotomy, had a significantly higher PPD score ( P = 0.005) than the unobserved procedure (circumcision). Parents reported good outcomes in 94 (94.9%) of 99 children, with 4 girls experiencing recurrent labial adhesions and 1 boy experiencing recurrent meatal stenosis. Overall, 95 (96.0%) of 99 parents stated that they were satisfied with their decision to have the procedure done in the office with local anesthesia. Of the remaining 4 parents, 3 parents in the circumcision group stated they would have preferred general anesthesia, and 1 parent in the labial adhesion group was undecided. Conclusions. The PPD is greater if the parent observes their child’s procedure. However, office procedures using local anesthesia for the lysis of labial adhesions, meatotomy, and newborn circumcision are well accepted among the parent population.

The use of surgical diathermy in the fulguration of penile warts is well established. The use of diathermy has been associated with urethral meatal stenosis resulting from circumferential thermal injury to the meatus. We describe the use of a plastic quill as a shield to prevent such circumferential thermal injuries.

Objectives. To use pressure-flow urodynamic parameters to evaluate the outcome of patients with benign prostatic hyperplasia (BPH) who were treated with transurethral vaporization of the prostate (TUVP) using the Vaportrode. Methods. Forty consecutive patients (mean age 71.7 years) undergoing TUVP for treatment of symptomatic obstructive BPH or urinary retention were evaluated preoperatively and postoperatively with American Urological Association (AUA) Symptom Score, uroflowmetry, and pressure-flow multichannel urodynamic studies. Results. Twenty-nine patients were voiding preoperatively. Eleven patients presented with urinary retention and were analyzed separately. At 3-month mean follow-up, the AUA Symptom Score decreased from 20.7 to 7.2 (n = 26). Peak uroflow rate (Qmax) increased from 8.2 to 15.5 mL/s (n = 27), whereas detrusor pressure at maximal flow (Pdet) decreased from 95.0 to 44.7 cm H2O (n = 24), indicating relief of obstruction. Postvoid residual urine volume decreased from 181.8 to 37.3 mL (n = 27). At 1-year mean follow-up, the AUA Symptom Score was 5.6 (n = 15) and Qmax was 14.3 mL/s (n = 19). The overall complication rate was 17.5% and included meatal stenosis (n = 1), bulbar urethral stricture (n = 1), refractory detrusor hyperreflexia (n = 1), dystrophic bladder neck calcification (n = 1), prostatic synechial formation requiring revision (n = 2), and residual prostatic tissue requiring revision (n = 1). Conclusions. This study provides objective evidence that TUVP is effective in providing prompt relief of bladder outlet obstruction with durable improvement in symptoms and flow rate with no acute morbidity. Accordingly, TUVP should continue to be considered as a minimally invasive surgical alternative to transurethral resection of the prostate.

Flip flap is a popular technique used for correction of distalpenile hypospadias. When the flap length is more than 2 cm, meatal stenosis may develop postoperratively. This stenosis is probably due to the ischemia at the tip of the flap. We have used flaps with wide base to ensure good blood supply to avoid this complication. The results were excellent in all of the cases in which this modification was used.

Meatal stenosis is uncommon after hypospadias surgery even when the meatus is placed at the tip of the glans. However, when it occurs. such, stenosis can be quite troublesome. A conventional meatotomy done in the presence of inflammation is often attended by recurrent stenosis. In such. situations we therefore advocate placing a tourniquet around the base of the penis and raising a V-shaped flap of glans with the point of the V at the dorsum of the meatus. The stenosis is then incised along the back wall of the urethra down into non-inflamed tissues. The tip of the flap is sutured to this point and additional absorbable sutures are used to anchor the flap in place so that healthy tissue crosses the stenotic area. Recurrent stenosis after this maneuver is unusual.

Hypospadias in a congenital anomaly which in most cases has to be corrected surgically. We include micturition cystourethrography (MCU) in the preoperative workup of all these children as well as three months postoperatively. Meatal stenosis and müllerian duct remnants are known to occur in this condition, but vesicoureteral reflux (VUR) was an unexpected finding in many boys who were asymptomatic and had no evidence of urinary tract infection. Fifty-eight of 305 hypospadiacs, examined by MCU, proved to have reflux, most of them grade II. In 37, VUR was found before surgery and in the remaining 21 after surgical correction, many of them with meatal stenosis. In 10 patients reflux appeared in the postoperative period where there had been none in the preoperative study; 8 of the 10 had a postoperative stricture of the distal urethra, and VUR subsided in 4 after adequate dilatation. We conclude that vesicoureteral reflux is not uncommonly found in patients with hypospadias, even in those who are completely asymptomatic. We believe this is an additional incentive to include an MCU in the pre- and postoperative evaluation of patients with this anomaly.

The goal of this study was to analyze, discuss, and compare risks and results obtained with the “buried strip” and two “tube” techniques for hypospadias repair in a personal series. From 1976 through 1982, 82 patients underwent complete two-stage repair of hypospadias using either the Denis Browne procedure (23 patients) or the Belt-Fuqua technique (41) and Byars procedure (18), respectively. Only those patients with originally distal and mid shaft hypospadias plus chordee were included in this series. The mean age at the time of repair was 4.9 years, with a range of two to sixteen years. The overall complication rate was 13.4 per cent (11 of 82 The tube procedures alone had a complication rate of 6.8 per cent (4 of 59) compared with 30 per cent (7 of 23) with the Denis Browne technique. Complications noted were: fistulas 6 (Denis Browne 5, Belt-Fuqua 1); meatal stenosis 4 (Denis Browne 2, Byars 2); urethral stricture 1 (Belt-Fuqua Our results confirm the general belief that tube techniques have a higher reliability than does the Denis Browne procedure. Each procedure improves with the experience of the surgeon, although the tube technique appears to cause less trouble in our hands. The running subcutaneous and intracutaneous sutures give a far smoother healing. We believe this study supports the virtues of two-stage tube repairs.

The use of optical magnification (loupes) to repair hypospadiac anomalies in children is well known. A mouth-controlled operating room microscope (Zeiss OPMI 6CH Contraves Stand) became available that has been utilized in 34 cases of hypospadias repair which included 13 flip flap, 4 MAGPI, 14 Hodgson XX (modified Asopa), and 3 other procedures. Other results show that in 2 patients fistula developed and in 1 meatal stenosis. Based on our experience, we believe this new microscope compares favorably with previous results and allows the surgeon to use small sutures with great accuracy.

A sixty-seven-year-old white man was seen in February, 1981, with complaints of urinary frequency, incontinence, and gross hematuria of one-year duration. The patient had a history of von Recklinghausen neurofibromatosis since birth and had undergone multiple orthopedic procedures on his left leg for malformations secondary to his disease. Five months prior to admission, the patient had an inguinal herniorrhaphy with postoperative bladder hypotonia requiring a suprapubic catheter for two months. Physical examination was remarkable for innumerable pedunculated and subcutaneous neurofibromas covering the entire skin surface, and the previously noted left knee deformity and scarring. Intravenous pyelogram (IVP) demonstrated mild left hydroureteronephrosis. Cystoscopy revealed visual obstruction by the prostate gland, heavy trabeculation of the bladder wall, a laterally placed left ureteral orifice, and questionable left ureteral meatal stenosis, which was incised with an endoscopic scissors. A transurethral resection of 10 Gm of prostate was performed, but high post-void residual

We report on 9 children with subcoronal meatus and an excessively deep glanular groove who underwent a simple surgical repair. All the procedures were done on an outpatient basis, and there was no urinary diversion. The surgical results have been satisfactory, with no fistula formation, or urethral or meatal stenosis. The technique described is useful in selected cases.