Search

Purpose: We reviewed our experience with buccal mucosa grafts for reconstructing difficult female urethral problems., Methods and Methods: Since 1994, we have used a buccal mucosa graft to reconstruct the urethra in 7 girls 3 to 13 years old. The underlying pathological condition was a fibrotic urethra after previous operations for cloacal exstrophy, cloacal malformation, iatrogenic urethral stricture, and multiple false passages in a previously reconstructed urethra of vaginal mucosa that made clean intermittent catheterization difficult. A full-thickness buccal mucosa graft was tubularized in situ as the neourethra to the base of the clitoris. In patients with cloacal exstrophy and cloacal malformation the bladder neck and urethra were widely exposed transabdominally by splitting the pubic symphysis. The fibrotic mucosa was excised and the tubularized buccal mucosa graft was wrapped with periurethral tissues. Other patients underwent transvaginal surgery in the prone position and the graft was covered with a buttock flap., Results: Patients were followed for 12 to 58 months (mean 34.7). Those with cloacal exstrophy and cloacal malformation had been completely incontinent before urethral reconstruction but all attained complete continence postoperatively. They and the girl who underwent urethral reconstruction for difficult catheterization performed clean intermittent catheterization easily. The patient with urethral stricture voided via the urethra without difficulty., Conclusions: In select female patients with difficult urethral reconstructive problems a tubularized free graft obtained from the buccal mucosa may be effectively used when local tissue is fibrotic and unsuitable for creating a supple new urethra.

Methods: From 1975 to 1996 a urethra was constructed using tubularized anterior vaginal wall covered with a buttock flap in 40 female patients in whom urinary incontinence was associated with a short or absent urethra. The underlying pathology included bilateral single ectopic ureters, cloacal malformation, urogenital sinus malformation, previous failed surgery of the urethra, severe trauma, myelodysplasia, female hypospadias, ectopic ureterocele with destruction of the urethra, congenital epispadias, bladder exstrophy, and previous hysterectomy and vaginectomy for clear cell carcinoma caused by intrauterine exposure to diethylstilbestrol. Other reconstructive procedures in these patients included bladder neck narrowing from above in 33 patients, ureteral reimplantation in 35, and bladder augmentation in 21. In the prone position, a tube of vaginal wall was used to create a urethra when it was absent or lengthen the urethra if it was too short. The neourethra was extended up to the base of the clitoris, using a multilayered closure of soft tissue over it distally with introital muscle and adjacent mucosa. The proximal neourethra was covered with a buttock flap., Results: All patients were originally wet. Thirty-four are now dry. Four patients have minimal stress incontinence. Two patients have urinary diversions. The majority (n=25) void normally. Fourteen patients self-catheterize to empty their bladders. One patient wears an external appliance on the abdominal wall for collection of urine. Complications included: creating stress incontinence in one patient who had been previously dry by extracting a stone from the bladder, necrosis of a buttock flap from applying a tight perineal dressing, fistula requiring surgical closure in three patients, and slippage of the buttock flap in one patient., Conclusion: This operation is a useful method to correct diverse congenital and acquired pathology that causes incontinence in girls.

Purpose: To our knowledge nephrogenic adenoma, an unusual benign metaplastic lesion of the urothelium, has not been reported previously following urethral reconstruction using bladder mucosa. Histopathological features, etiological factors and clinical features are discussed., Materials and Methods: We reviewed the records of 117 patients who underwent hypospadias repair with free grafts of bladder mucosa from 1982 to 1995., Results: Five children 6 to 11 years old and a 39-year-old man had nephrogenic adenoma of the urethra. Hematuria or dysuria was the usual reason for presentation. The lesions were located at the site of anastomosis between the graft and proximal urethra in 3 cases and the distal graft in 2, and they involved the whole graft in 1. Successful treatment consisted of endoscopic resection of the polyps in 4 patients, while open surgical correction was performed in 2, requiring complete excision of the previous graft in 1 and segmental resection in 1., Conclusions: The gross appearance of the lesion may be confused with that of transitional cell carcinoma or clear cell adenocarcinoma of the urethra, necessitating biopsy to rule out malignancy. Endoscopic management is possible for small tumors, although severe nephrogenic adenoma involving most of the reconstructed urethra may require complete resection of the graft and creation of a new urethra.

Purpose: Congenital aphallia is a rare anomaly that occurs only once in 30 million births. Five cases are described., Materials and Methods: All 5 patients 4 to 20 years old had been reared as female. The bladder neck or short urethra entered the anterior rectum in each patient. At referral 2 patients had a vesicostomy and 1 had a colostomy. Hydronephrosis and vesicoureteral reflux were present in 2 and 3 cases, respectively. After separating the urinary tract from the rectum a urethra was created in each patient and a bowel vagina was constructed in 4 during the same operation. The initial patient did not undergo simultaneous creation of a vagina., Results: One patient later required a bladder neck narrowing operation for stress incontinence. She became incontinent again after transpubic surgery to create a sigmoid vagina was performed elsewhere 8 years later. The other 4 patients are dry, and they have normal urinary and bowel control., Conclusions: A single extensive operation on the bladder, vagina and rectum simultaneously is the ideal approach in these cases using the prone posterior sagittal and supine abdominal perineal positions.

Three unique cases of urethral duplication, often referred to as congenital posterior urethral perineal fistulae, are presented. Presenting signs and symptoms, evaluation, and treatment are discussed, and the literature is reviewed. Although labeled as a fistula in the literature, this entity most likely represents a distinct type of urethral duplication. A functional dorsal urethra separates it from the other forms of urethral duplication.

We evaluated urodynamically 41 patients with posterior urethral valves because of signs or symptoms of incontinence (35), frequency (3), hydronephrosis (2) and infection (1). Findings included normal urodynamic evaluations in 3 patients, 2 had high voiding pressures secondary to outlet resistance and 1 had incontinence on the basis of external urethral sphincter damage. In the remainder 3 patterns of bladder dysfunction were identified. Myogenic failure with overflow incontinence occurred in 14 patients. In this group clean intermittent catheterization or Valsalva's voiding was used for emptying. Hyperreflexic bladders were seen in 10 patients. Pharmacological suppression of instability was effective in 5 of 7 patients treated; 1 required bladder augmentation. Eleven children had a small capacity bladder and poor compliance. Post-void residuals were low and these bladders were generally but not always stable. Pharmacological bladder relaxation was successful in 3 patients, 3 underwent augmentation, 1 did well with alpha-agonists and followup is unavailable on the other 4. These 3 patterns of bladder dysfunction represent an overlapping constellation of residual urodynamic abnormalities due to previous bladder outlet obstruction. Individual patients may show facets of several types of dysfunction associated with 1 predominant pattern.

A unique case of bladder outlet obstruction secondary to posterior urethral valves in an octogenarian is presented.

Five incontinent girls between 4 and 18 years old were made continent by constructing in each case a long extension of the urethra up to the clitoris. Previous operations at the proximal end of the urethra, to narrow the bladder neck, had not achieved continence. Lengthening the urethra was accomplished by tubularizing the anterior vaginal wall and covering that with a generous pedicle flap from the perineum. The base of the pedicle flap was divided later, restoring the introitus to a normal appearance. Of the 5 patients 3 had the underlying problem of ureteral ectopia with congenital deficiency of the urethra and the bladder neck, 1 had a marked degree of female hypospadias with absence of the distal urethra and in 1 the cause for incontinence was extensive internal urethrotomy during early childhood. This procedure should be applicable to certain difficult cases of incontinence in pediatric and adult patients.

A tubed, free skin graft was used to construct a urethra in 49 young male subjects. Indications included 1) multiple previous hypospadias operations, 2) new severe hypospadias cases, 3) chordee without hypospadias but with a short urethra, 4) epispadias, 5) distal urethral stricture and 6) a small number of patients undergoing an initial operation for hypospadias by the Horton-Devine technique. No fistulas or leaks occurred. The over-all complication rate was low. Based on our own experience and that reported by others we believe that a free tubed graft is an excellent method for making a substitute urethra in a variety of urethral problems in children and young adults. It is important that the graft is of full or nearly full thickness because thin grafts tend to contract.

Six cases are described of congenital female epispadias and incontinence. Of these patients 3, who were seen in the last 4 years, were made continent by a 1-stage operation using a combined perineal and transvesical approach. The procedure includes excising the abnormally wide roof of the distal urethra from below narrowing the urethral caliber and mons plasty. From above the upper urethra and bladder neck are narrowed. Ureters are reimplanted if they have reflux or to facilitate bladder neck narrowing. The 3 other cases are described in which this combined procedure could have been used, in retrospect, to obtain a satisfactory result with fewer operations. In female epispadias complete repair of the abnormally wide urethra is better than other alternatives that have been proposed for treating this rare malformation.

A graft of bladder mucosa was used to construct the urethra in 35 males. Most were complicated hypospadias cases. In all patients there was insufficient prepucial or penile shaft skin available to use for making a substitute urethra. The bladder mucosa worked well in every case. There were no fistulas. There was no case with stenosis of the anastomosis between the graft and the patient's own urethral tissue. The one possible disadvantage encountered in using bladder mucosa was its tendency to become edematous and irritated if the graft was redundant at the meatus, a situation that is not encountered with grafts made from prepucial skin or skin taken from a remote area. Revision of the meatus was required in six patients. It is the experience of the authors that a free graft that is covered by two well vascularized layers, subcutaneous tissue, and skin, fares as well or better than a graft with a vascular pedicle.

From 1979 to 1987 we treated 28 patients with severe penile malformations who required a dermal graft to straighten the shaft and a free graft to construct a urethra. In 10 patients the 2 grafts were placed simultaneously with good results. In 15 patients the dermal graft was placed initially and a urethral graft was placed over it later. In 3 patients the urethroplasty has not been done yet. No complications resulted from the combined use of dermal and urethral free grafts. The principle of "graft on graft" can be applied successfully to correct certain severe penile problems. Indications, technique and results are presented.