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Background: Though pediatric urethral stricture is an uncommon urological problem, it is a challenging urological one. The causative factors are iatrogenic, traumatic, and inflammatory. In the current study, the authors report their experience of the treatment of pediatric long anterior urethral stricture using penile circular fasciocutaneous flap., Patients and Methods: The study included 23 pediatric patients who had long anterior urethral strictures, which were repaired using circular penile fasciocutaneous flap. The flap was elevated through a subcoronal circumferential incision and then it was split ventrally. The strictured portion of the urethra was sharply incised ventrally, extending to 1 cm into normal urethra. The flap was sutured to the urethral plate over silicone catheter of suitable size, which was removed after 3 weeks. The follow-up was scheduled every 3 months for the first year and then yearly thereafter., Results: The urethroplasty was successful in 20 cases (86.96%). There were two cases complicated by stricture recurrence, which was managed by visual internal urethrotomy. Fistula formation was reported in one case and was repaired by simple excision and closure. Penile skin necrosis was reported in only one patient and was managed by frequent dressing., Discussion: During the last five decades, there was a substantial advancement in the reconstruction of long or complex anterior strictures due to the use of grafts and flaps. During pediatric urethral stricture repair, particular attention must be paid to the differences between adults and children anatomy, e.g. the small urethral lumen and tissue delicateness. McAninch introduced the reconstruction of complex anterior urethral strictures utilizing circular penile fasciocutaneous flap. The technique of penile fasciocutaneous flap urethroplasty takes long time and requires meticulous dissection. Therefore, it should be restricted for long or complex anterior urethra strictures. Success rate in this study was 86.96%, which is in the same league as that reported in literature as regard adults penile fasciocutaneous flap urethroplasty. Whitson et al. reported success rates of 84% and 79% in the 5th and 10th years, respectively. In another study, Kim et al. revealed a success rate of 68.9%. In this study, complications incidence was 21.6%, which is consistent with reported incidence of complications of adults penile fasciocutaneous flap urethroplasty (8%-20%)., Conclusion: According to the outcomes of this study, penile fasciocutaneous flap urethroplasty is a reasonable modality for the reconstruction of long anterior urethral stricture in pediatric patients especially after circumcision., (Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: The management of long ureteric strictures is very challenging, and ureteral substitution is necessary when end-to-end anastomosis can not be accomplished., Objective: To evaluate the mid-term results of laparoscopic appendiceal interposition pyeloplasty in children with long ureteric strictures., Methods: Between March 2010 and September 2016 four patients (median age 24 months, male/female 3/1) underwent laparoscopic appendiceal interposition pyeloplasty at the current hospital. Two patients had previously failed pyeloplasty, one had a traffic injury, and one had iatrogenic ureteral injury (Summary Table). The intraoperative, postoperative and follow-up results were analyzed. Success was defined as clinical (subjective) and radiologic (objective) resolution of the stricture., Results: All surgeries were successfully completed without conversion. The mean stricture length was 4.5 cm. Two cases were right-sided strictures, and two were left-sided. The mean operative time and estimated blood loss were 238.5 min and 25.0 ml, respectively. No intraoperative complication was encountered. No Grade 3 or Grade 4 complication was observed after surgery. One was anastomosed in the antiperistaltic manner and three were in the isoperistaltic fashion. The mean postoperative hospital stay was 7.3 days. The success rate was 100% at a mean follow-up duration of 33.8 months., Discussion: There is no consensus on the best surgical approach for long ureteric strictures. Ureteric replacement with intestinal segments or kidney autotransplantation is a viable alternative treatment to long ureteric strictures. However, both methods are technically challenging with significant complications. Appendiceal interposition to restore ureteral continuity has been described in adult patients. The current results demonstrated that laparoscopic appendiceal interposition pyeloplasty is a safe and feasible minimally invasive approach for the treatment of long ureteral strictures in children., Conclusions: Laparoscopic appendiceal interposition pyeloplasty was a viable minimally invasive alternative for children with long ureteric strictures on both left and right sides. Both isoperistaltic or antiperistaltic anastomosis were feasible., (Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: Balanitis xerotica obliterans (BXO) is a common condition that can affect the foreskin, glans, meatus, and urethra, and rarely can also involve urethra leading to stricture. Numerous procedures have been suggested to treat urethral stricture secondary to BXO but these have had variable results., Objective: We describe the first prospective study of a single stage buccal mucosal inlay grafting in children with urethral strictures resistant to existing remedies., Materials and Methods: We treated five boys with resistant urethral strictures secondary to BXO with a single stage buccal mucosal inlay graft (BMIG, Figure). Uroflowmetry was performed both pre- and post-operatively. Functional outcome was the prime measure determining success., Result: All the boys had a successful functional outcome and all expressed satisfaction with cosmetic outcome as well. Uroflow parameters improved remarkably, with maximum and mean urinary flow rates significantly improved from 4.2 mL/s to 26 mL/s (p = 0.0002) and from 1.6 mL/s to 12.2 mL/s (p = 0.003), respectively. Median follow-up was 34 months (range 30-42 months)., Discussion: This paper is the first to describe the successful use of buccal mucosal inlay grafts to treat refractory BXO stricture in children. Various surgical techniques have been proposed particularly in adults including single vs. staged procedures, preputial and post auricular grafts, circular mucosal buccal grafts, as well as double mucosal grafts placed both ventrally and dorsally. All of these procedures are not without problems, and had variable results and outcome. Most of the procedures have been described in adult urethra and are not suitable for paediatric small calibre urethra. Our technique of dorsal inlay graft gives a robust structure to the distal urethra avoiding diverticula, pooling or urine spraying and can be placed onto proximal urethra as well. We have not seen recurrence of BXO in our buccal grafts, which is reported in other grafts from prepuce and post auricular grafts. The number of patients presented in our study is limited, nonetheless an excellent result in all our cases makes this a compelling approach to manage BXO urethral strictures. An early intervention in such cases is paramount to convert a salvage operation to a pre-emptive procedure., Conclusion: A single stage buccal mucosal inlay grafting in children with BXO stricture can offer an excellent outcome., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: The literature on treatment of meatal stenosis is limited to single center series. Controversy exists regarding choice of meatotomy versus meatoplasty and need for general anesthesia. Our objective was to analyze treatment efficacy, current practice patterns and utilization of anesthesia. We hypothesized that meatoplasty would be associated with a lower re-operative rate., Study Design: We used a hospital consortium database to identify children who were diagnosed with meatal stenosis between January 1, 2009 and December 31, 2012. Both univariate and multivariate analyses were completed to evaluate correlations between patient, surgeon and hospital characteristics and type of procedure. The propensity of surgeons to operate with or without general anesthesia was analyzed., Results: We identified 4373 male patients with a diagnosis of meatal stenosis treated by 123 surgeons. Fifty-percent of boys had procedural intervention during the 4-year period. Median follow-up was 25 and 22 months after meatotomy and meatoplasty, respectively. There was a re-operative rate of 3.5% and 0.2% for office meatotomy versus meatoplasty with general anesthesia. Multivariate analysis demonstrated that being White and living in the Northeast independently increased odds of intervention. Half of the surgeons treated meatal stenosis exclusively under general anesthesia., Discussion: This study is limited by an inability to determine recurrence rates. Only patients having secondary surgery at the same institution within the time period captured by the database (6 months-4 years) could be identified. As such, the true recurrence of meatal stenosis is likely higher. Although the re-operative rate is not equivalent to the recurrence rate, the two are correlated. Likewise, the surgeon's propensity to operate could be biased by their propensity to diagnosis meatal stenosis and this could affect the rates cited. In addition to the cost benefit achieved with avoidance of general anesthesia (estimated to be a 10-fold cost reduction, the 2012 Consensus Statement of the International Anesthesia Research Society has highlighted that there is increasing evidence from research studies suggesting the benefits of general anesthesia should be considered in the context of its possible harmful effects. Although this study and others have highlighted that in-office procedures are a viable alternative to meatoplasty with general anesthesia, there are multiple factors in being able to perform an office meatotomy. Arguably, the two most important are the patient's ability to cooperate and his anatomy., Conclusions: The large sample size, over 4000 patients, allowed us to show that the hypothesis, that meatoplasty would be associated with a lower re-operative rate (0.2%), is true. With a low re-operative rate (3.5%), office meatotomy is a reasonable choice of surgical treatment if the child can cooperate and the anatomy is appropriate. On the other hand, if general anesthesia is utilized, formal meatoplasty is associated with a lower re-operative rate., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To investigate the clinical and radiological parameters of posterior urethral valve (PUV) patients with residual valve or strictures after primary valve ablation., Patients and Methods: A total of 127 PUV patients were treated in our clinic between 1986 and 2009. We retrospectively reviewed the records of 101 patients, who had at least 1 year of follow-up data, regarding the presence of valve remnants or urethral strictures after PUV ablation., Results: A total of 21 patients (20.8%) underwent repeat-urethroscopy and, of these, residual valve leaflets or stricture were detected in 10 patients (10/101, 9.9%). In 2 of these 10 (20%), the urethra had been found to be normal on the first voiding cystourethrogram following ablation. However, these two boys underwent re-urethroscopy due to persistent vesicoureteral reflux in one and persistent hydroureteronephrosis in the other, and valve remnants were detected. The remaining 8 cases had radiological signs consistent with persistent infravesical obstruction in the early period. Obstruction was due to urethral stricture and residual valve remnants in 2 and 6 cases, respectively., Conclusions: There was clinical suspicion of residual valve in about 20% of the cases and in half of these the urethra was found to be normal on urethroscopy. The possible presence of residual valve remnants after primary valve ablation should be confirmed by careful clinical, radiological and endoscopic evaluation., (Copyright © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: We report 18 years' experience of traumatic urethral strictures in boys with emphasis on recurrent strictures., Materials and Methods: Thirty-four boys with pelvic fracture urethral strictures underwent 35 repairs: 23 in the primary group (initial suprapubic cystostomy, but no urethral repair) and 12 in the re-do group (previously failed attempt(s) at urethroplasty elsewhere). The median age at operation and stricture length was 8.4 years and 3 cm in the primary and 9 years and 5.4 cm in the re-do group, respectively. Anastomotic urethroplasty was performed wherever possible, or failing this a substitution urethroplasty. Median follow up was 9 years for primary group and 8 years for re-do group., Results: Primary group: urethroplasty was successful in 22/23, with 10 by perineal and 13 by additional transpubic approach. Two have stress incontinence. Erectile function is unchanged in all and upper tracts are maintained. One had recurrent stricture. Re-do group (12 including 1 recurrence from primary group): anastomotic urethroplasty was done in 5 and substitution urethroplasty in 7. Patients needing substitution had long stricture (>5 cm), stricture extending to distal bulb, or high riding bladder neck. All patients are voiding urethrally. Two patients with substitution required dilatation for early re-stenosis. One appendix substitution required delayed revision. Two have stress incontinence. Erectile function was unaffected. Upper tracts are maintained., Conclusions: Anastomotic urethroplasty was successful in over 95% of primary cases. In re-do cases it was viable in only 41% of cases; the rest required substitution urethroplasty. Urethral substitution also gave acceptable results., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: We routinely perform a cystourethroscopy 3 months after initial ablation of posterior urethral valves. The aim of this study was to determine the predictive value of the urethral appearance on preoperative micturating cystourethrogram (MCUG) for further valve resection at check cystoscopy., Patients and Methods: We retrospectively reviewed 31 consecutive boys (aged 4-18 months) who underwent check cystoscopy and repeat MCUG between 2006 and 2008., Results: Repeat MCUG suggested remnant valves in 10, but no residual leaflets were identified cystoscopically in 4. In 20 boys, the valves appeared completely ablated on MCUG but valve leaflets received further resection in 10. One study was undiagnostic. Residual valves were resected in 83% (5/6) where valves and urethral dilatation were noted on MCUG. Where MCUG suggested either valves or persistent dilatation alone, further resection occurred in 40% (4/10). Remnant leaflets were also present in half of those (7/14) in whom the repeat MCUG had shown complete ablation and resolved/reduced posterior urethral dilatation., Conclusions: The positive predictive value of valve leaflets and/or posterior urethral dilatation on repeat MCUG for subsequent resection of valve remnants was 56%; the negative predictive value was 50%. We found repeat MCUG alone imprecise in excluding residual valve tissue and recommend check cystoscopy in all., (Copyright © 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

The purpose of this study was to evaluate the urogenital anatomy in sound spayed and intact dogs. Fourteen intact and 12 spayed sound dogs had their lower urogenital tract evaluated with conventional vaginourethrography, computed tomography (CT) vaginourethrography and uroendoscopy under general anesthesia. Measurements for each of the three imaging modalities were made. Measurements included vaginal length, vaginal height, vaginal width, vestibule length, vestibule height, vestibule width, cingulum height, cingulum width, cingulum area, urethral length, urethral height, urethral width, angle of urethra to vestibule and angle of vagina to vestibule. Group comparisons were made between sound spayed and intact dogs. In general, most measurements were greater in intact dogs compared to spayed dogs regardless of imaging modality utilized. Group-weight interactions (P<0.01) were found on conventional vaginourethrograms (vaginal height and length and vestibule height, length and width) and CT vaginourethrograms (vaginal length, vestibule height, length and width, cingulum area, urethral width and angle of vagina to vestibule). A three-way interaction (P<0.01) for vaginal length, vaginal height and vestibule height was also identified. Vestibule length and height, cingulum height and urethral length were larger (P<0.01) with increasing dog weight and in intact dogs for both conventional and CT vaginourethrograms. No difference in vestibulovaginal ratio was observed between intact dogs and spayed dogs (P=0.0221). One of 14 intact dogs and 8 of 12 spayed dogs had vestibulovaginal ratios <0.33 on conventional vaginourethrograms. Anatomical differences in the lower urogenital tract between spayed and intact dogs emphasizes the need to establish normal reference ranges for spayed and intact dogs.