The GUDplay technique: A shift of paradigm in glans reconstruction for midshaft and penoscrotal hypospadias with moderate chordee. A proposal of a new approach.

INTRODUCTION: After 5 years experience with the GUD (glandular urethral disassembly) technique for distal hypospadias, we present the GUDplay technique, incorporating Thiersch-Duplay tubularization of the plate till the coronal area, disassembling the glans aggressively and refurbishing the glans. METHODS: We defined the urethral plate and designed an inverted Y incision to open the glans in two wings. The glans was entirely detached from the corpora to gain a great mobility that allowed minor cranial mobilization of the urethra and caudal rotation of the wings. In sequence, there are well-known steps: Duplay urethroplasty, spongioblasts and a Dartos flap to cover the neourethra. The glans was connected to the urethra by 6.0 PDS sutures except in the ventral meatus and the glans wings are joined in the midline. RESULTS: The 5-year-old patient had midshaft hypospadias without previous surgery. The catheter was removed after a week and the healing appears to be good. DISCUSSION: We combined principles of total glans deconstruction in association to Duplay tubularization and then lifted it up to the tip of the glans divided in two wide and mobile wings. We have treated a small series of 6 cases without complications and mean follow-up of 6.2 months.

Macedo ileal catheterizable reservoir adding the scissors maneuver of channel continence: Long term follow-up.

INTRODUCTION: The Macedo ileal catheterizable channel was published in 2000 and consists of an enterocystoplasty with a catheterizable channel that precludes the need of the appendix for the efferent channel. After 25 years of experience with this technique, we decided to review our experience in a select subgroup of cases performed and followed exclusively by the author in a non-teaching hospital facility after the latest modifications of the procedure. MATERIALS AND METHODS: Since 2008, we have refined our technique with the following modifications: small skin transverse incision instead of longitudinal one, with a semicircular flap for further stoma creation in the midline and importantly the scissors maneuver. This maneuver consists of crossing two 2 cm rectus abdominis muscle flaps in the midline to create a neosphincter over the catheterizable channel. Follow-up was defined as the interval between the date of surgery and last visit to the clinic. We defined stoma continence if the dry interval between catheterization was 4hs. Early and late complications were reported as well as the reintervention rate. Additional procedures in association with bladder augmentation were also appointed. RESULTS: We have treated 49 patients. Indications were spinal dysraphism (71.4%), mainly myelomeningocele (65.3%), and others (PUV, exstrophy, anorectal anomalies). Urodynamic evaluation showed bladder pressure of high risk for upper urinary tract involvement (66%), urinary incontinence (24.5%), conversion of incontinent urinary diversion (3.8%), one exstrophy patient not considered (1.9%). Mean age at surgery was 88 months (7.3 years), 21 patients had additional surgeries in addition to Macedo ileal catheterizable channel: Macedo-Malone LACE procedure in 21 patients and bladder neck surgery to improve continence in 5 patients. Urinary stoma continence was 93.9% (46/49) after first surgery, one patient had a serous line valve revised, two patients still leak after 2 h and await revision. Overall enterocystoplasty complications rate was 12.24% and consisted of urinary leakage in 3 cases and channel/stoma stricture in 3 cases. All patients treated for sphincteric deficiency associated with bladder reconstruction are continent per urethra. Urinary stoma revision for stricture was done in 2 cases and consisted on suprafascial approach and reanastomosis, one patient resolved with dilatation of the channel to the stoma. Mean follow up is 100 months (8.3 years). CONCLUSION: We confirmed in a long term follow-up based on face-to-face visits with 8.3 years mean follow-up that the Macedo procedure associated with the scissors maneuver is associated with 93.9% continence of the stoma. Overall complications rate was 12.24%. The cosmetic aspect with a small transverse incision and a midline stoma is another strength of the technique.

Buccal mucosa graft vaginoplasty: A viable option demonstrated step-by-step.

INTRODUCTION: Persistent cloaca, defined as confluence of the rectum, the vagina and the urethra into a single common channel, has an estimated incidence of 1/50,000 live births. We describe the buccal mucosa graft vaginoplasty for a 11 year old female with cloaca, who underwent at the age of 11 months a Peña repair. We performed the vaginoplasty after the onset of uterine pain due to the beginning of menstruation. MATERIAL AND METHODS: We accessed the lower lip for superficial dissection to harvest the graft. The donor site has been kept with as much submucosal fat as possible to avoid damage to the buccinatoria muscles. A second graft was further obtained from the cheek. Both grafts were submitted to multiple small sections to produce a mesh graft and increase its size. A arciform incision anterior to the anal canal and posterior to the urethra was performed followed by consecutive dissection with eletrocautery to gain profundity. The mesh-graft was placed over the neovaginal cavity and sutured with 4.0 PDS monofilament suture used to suture and then quilt the graft in place. The vaginal capacity was confirmed by ease of a two-digit insertion. Haemostasis was confirmed before the insertion of a soft vaginal mold. The patient remained with an indwelling urinary catheter. The mold was equivalent to 24Fr and had 13 cm of profundity and Foley tube were removed after 14 days postoperatively. RESULTS: Patient had an excellent postoperative course and had been instructed to perform vaginal dilatation every 3 h during the day. Current follow up is 10 months. DISCUSSION: Buccal mucosal grafting has advantages over the use of keratinized skin flaps and intestinal flaps. Buccal mucosa is ideal for female genital reconstruction, given its color, texture, lack of hair and mild mucous production. In our particular case, we connected the neovagina after two months of adequate healing to the native 1/3 through laparoscopic approach. CONCLUSIONS: BMG vaginoplasty is a viable alternative to treat females with cloaca at adolescence.

In utero myelomeningocele repair and high-risk bladder pattern. a prospective study

ABSTRACT Objectives High-risk bladder pattern can be defined by Urodynamic Evaluation (UE) as overactive bladder with detrusor leak point pressure higher than 40 cmH2O and/or higher filling pressures also above 40 cmH2O. We wanted to evaluate response to treatment in myelomeningocele patients operated in utero in this subgroup. Patients and Methods From our prospective cohort of in utero MMC we have identified patients in the high-risk group. Treatment consisted of anticholinergics (Oxybutynin 0.2 mg/Kg) 2 or 3 times daily in association with CIC. At every UE, patients were reclassified in high-risk or low-risk patterns. Patients not responding were proposed bladder reconstruction or diversion according to age. Results Between 2011 to 2020, we have been following 121 patients and 60 (49.6%) of them were initially categorized as high-risk. The initial UE was performed at a mean age of 7.9 months and detrusor overactivity was found in 83.3% (mean maximum pressure of 76.5cmH20). When evaluating patients with 2 or more UE, we identified 44 patients (follow-up: 36.8months). It was observed in the group of patients who underwent 2 to 5 UE, that response to treatment was validated by the finding of 40% of low-risk bladder patterns in the second UE and between 62% to 64% in the third to the fifth UE. The incidence of surgery was 13.3%. Conclusions Early urological treatment of high-risk bladder pattern was effective in approximately 60%. We reinforce the need to correctly treat every patient with myelomeningocele, in accordance with UE, whether undergoing in utero or postnatal treatment.

In utero myelomeningocele repair and high-risk bladder pattern. a prospective study.

OBJECTIVES: High-risk bladder pattern can be defined by Urodynamic Evaluation (UE) as overactive bladder with detrusor leak point pressure higher than 40 cmH2O and/or higher filling pressures also above 40 cmH2O. We wanted to evaluate response to treatment in myelomeningocele patients operated in utero in this subgroup. PATIENTS AND METHODS: From our prospective cohort of in utero MMC we have identified patients in the high-risk group. Treatment consisted of anticholinergics (Oxybutynin 0.2 mg/Kg) 2 or 3 times daily in association with CIC. At every UE, patients were reclassified in high-risk or low-risk patterns. Patients not responding were proposed bladder reconstruction or diversion according to age. RESULTS: Between 2011 to 2020, we have been following 121 patients and 60 (49.6%) of them were initially categorized as high-risk. The initial UE was performed at a mean age of 7.9 months and detrusor overactivity was found in 83.3% (mean maximum pressure of 76.5cmH20). When evaluating patients with 2 or more UE, we identified 44 patients (follow-up: 36.8months).  It was observed in the group of patients who underwent 2 to 5 UE, that response to treatment was validated by the finding of 40% of low-risk bladder patterns in the second UE and between 62% to 64% in the third to the fifth UE. The incidence of surgery was 13.3%. CONCLUSIONS: Early urological treatment of high-risk bladder pattern was effective in approximately 60%. We reinforce the need to correctly treat every patient with myelomeningocele, in accordance with UE, whether undergoing in utero or postnatal treatment.

High grade persistent ventral curvature after multiple hypospadias surgery: how to correct?

ABSTRACT Introduction: A challenging situation in proximal hypospadias is the presentation of patients with successful urethroplasty but with persistent or recurrent ventral curvature (VC) after multiple hypospadias repair. Materials and Methods: We present a 13 year-old boy with 7 previous surgeries (long TIP, Duplay, meatoplasty) to treat hypospadias presenting with 60 degrees of VC, in spite of a well-accepted coronally neomeatus. We degloved the penis and artificial erection clearly appointed corporal disproportion causing curvature. We disconnected urethra from corpora. After excision of remnant fibrotic tissue, there was a residual curvature so a lenghtening corporoplasty with dermal graft from groin was performed. We have adjusted the urethral meatus position into a proximal penile shaft. We used a buccal mucosa graft placed in an inverted U-shape position planning a second stage urethroplasty (1). An indwelling silicone Foley tube was left for one week. The patient was discharged the day after surgery. Results: The aspect after corporoplasty proved satisfactory curvature correction. Patient had an excellent outcome and is scheduled for a second-stage after 6 months. Discussion: Snodgrass and Bush (2) reported that on 73 patients with an average of 2.7 operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50°. We do believe that some good results with minimal dorsal plicature may recur in adolescence and therefore when these procedures may be considered, they should be performed by classic Nesbit technique (3). Otherwise, the choice for primary ventral lengthening should be taken. Conclusion: Severe curvature associated with hypospadias should undergo a major procedure at early stage to avoid decompensation after dorsal plicature in adolescence. We had a very satisfactory result, the patient awaits the second stage procedure (Figure-1). Figure 1 End aspect after complete healing of buccal mucosa. Notice that penis is straight and second stage will be performed after 6 months of interval.

Complete diphallia: How to proceed?

INTRODUCTION: Diphallia is a rare anomaly. It has a range of appearances from a small accessory penile to complete duplication. METHODS: We present a 2 year-old boy with complete penile duplication. The left penile was the largest. NMR (Nuclear Magnetic Resonance) suggested one corporal body for each penile and VCUG (Voiding Cystourethrogram) showed a normal urethra in the right penile and stricture at glandular and mid penile urethra of the left penis. A Y confluence to bulbar urethra was observed confirming only one prostate and bladder. RESULTS: The cystoscopy through the right penile identified the urethral confluence in the bulbar area. We performed a meatotomy in the left penile to insert the cystoscope and confirmed the blind ending urethra. We decided to remove this penile. The penile was degloved entirely and clamped and took out the corpora at the base. DISCUSSION: Diphallia can have three presentations: only glans duplication, bifid diphallia and complete diphallia (two corpora cavernosa and a corpus spongiosum for each penile). In our case, each penile presented only one corpora cavernosa and the decision taken was based on urethral patency. CONCLUSION: The treatment should always be planned individually whereas associated anomalies with the goal of attaining satisfactory functional and cosmetic results.

High grade persistent ventral curvature after multiple hypospadias surgery: how to correct?

INTRODUCTION: A challenging situation in proximal hypospadias is the presentation of patients with successful urethroplasty but with persistent or recurrent ventral curvature (VC) after multiple hypospadias repair. MATERIALS AND METHODS: We present a 13 year-old boy with 7 previous surgeries (long TIP, Duplay, meatoplasty) to treat hypospadias presenting with 60 degrees of VC, in spite of a well-accepted coronally neomeatus. We degloved the penis and artificial erection clearly appointed corporal disproportion causing curvature. We disconnected urethra from corpora. After excision of remnant fibrotic tissue, there was a residual curvature so a lenghtening corporoplasty with dermal graft from groin was performed. We have adjusted the urethral meatus position into a proximal penile shaft. We used a buccal mucosa graft placed in an inverted U-shape position planning a second stage urethroplasty (1). An indwelling silicone Foley tube was left for one week. The patient was discharged the day after surgery. RESULTS: The aspect after corporoplasty proved satisfactory curvature correction. Patient had an excellent outcome and is scheduled for a second-stage after 6 months. DISCUSSION: Snodgrass and Bush (2) reported that on 73 patients with an average of 2.7 operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50°. We do believe that some good results with minimal dorsal plicature may recur in adolescence and therefore when these procedures may be considered, they should be performed by classic Nesbit technique (3). Otherwise, the choice for primary ventral lengthening should be taken. CONCLUSION: Severe curvature associated with hypospadias should undergo a major procedure at early stage to avoid decompensation after dorsal plicature in adolescence. We had a very satisfactory result, the patient awaits the second stage procedure (Figure-1).

The Macedo-Malone antegrade colonic enema: A minimal invasive technique that precludes appendix use.

INTRODUCTION: Antegrade continence enema (ACE) is recommended for patients with fecal incontinence/constipation refractory to conservative management. The Malone ACE utilizes the appendix as a catheterizable channel whereas the Macedo-Malone (MM) precludes the use of the appendix. We aimed to illustrate the MM procedure. METHODS: The left colon is brought out through a small transverse incision on the upper left abdomen and a 3-cm transverse flap in a tenia is created. A 12-Fr silicone Foley catheter is placed on the mucosal surface of the flap to allow creating a tubular conduit. After closure of the anterior wall colonic, the continence valve mechanism is produced by embedding the tube over a serous lined tunnel created by interrupted sutures. The distal portion of the tube is anastomosed into a V shape to the skin flap to avoid stoma stenosis. DISCUSSION: The advantage of this technique is the all-the time availability for not requiring the appendix which some authors prefer to use for urinary reconstruction. In a previous study, we have shown that the MM produces a high rate (89%) of fecal continence (Mean follow-up: 75 months). CONCLUSION: We are convinced that this procedure can be incorporated into fecal incontinence/constipation armamentarium.

In utero myelomeningocele repair and incidence of lower urinary tract surgery. Results of a prospective study.

INTRODUCTION: The purpose of this study was to determine the incidence of lower urinary tract surgery in patients with myelomeningocele (MMC) operated in utero as well as in the subgroup of patients with a minimum age of 5 years. METHODS: We use a previously published protocol to categorize bladder patterns and propose the treatment: high risk pattern-anticholinergics and clean intermittent catheterization (CIC); incontinent and normal patterns-clinical surveillance and underactivity pattern- CIC. Non-response to clinical treatment with maintenance of detrusor pressure higher than 40 cmH20 with worsening of hydronephrosis or recurrent urinary infection were imperative indications for surgery and urinary incontinence due to sphincter deficiency and leakage pressure below 40 cmH20 in patients aged 5 years and older were possible indications too. We identified the prevalence of urinary tract surgery and concomitant treatment of constipation and refractory fecal incontinence by convenience, the technique performed and surgery outcomes. RESULTS: A total of 122 patients are part of the prospective protocol. The first UE was performed in 119 patients (median age of 4 months). The categorization of the bladder pattern was high risk in 52.1%, incontinent in 25.2%, hypocontractile 4.2% and normal in 18.5%. Current follow-up was 29.9 months (1-99 months). Surgery was performed on 10 patients (8.4%): 3 vesicostomies, 2 surgeries to treat vesicoureteral reflux, 6 bladder augmentations, 3 ACE and a sling surgery. Considering only patients older than 5 years, we identified 65 patients and seven surgeries performed (10.8%). DISCUSSION: Most bladder reconstruction studies are case series of single institutions or cooperative services, most of which are retrospective. The prospective clinical interpretation and imaging and urodynamic exams over time allowed us prospectively to define the risk of surgery in patients with myelomeningocele operated in utero. It must be considered that the response to the initial urological treatment and even the failure that leads to the need for surgery have to be evaluated in a context of follow-up time. For this reason we have studied separately patients over 5 years-old and also the group considered to be at greatest risk for surgery, the high-risk group of the categorization already described. CONCLUSION: We found an incidence of 10.8% of surgeries in patients over 5 years-old and 12.9% for the high-risk group. This information may be useful to educate parents when stating urological treatment.

A different approach to distal hypospadias repair: The GUD (glandular urethral disassembly) technique.

INTRODUCTION: Distal hypospadias represent the most frequent clinical presentation of hypospadias. In spite of more than 300 techniques available, there is not an ideal approach. We have proposed an alternative procedure based on the combination of minor urethral mobilization and major glans deconstruction and partial disassembly from the corpora, the GUD technique. We want to present our clinical experience with the procedure and describe it in detail. METHODS: The technique consists of disconnecting the spongious tissue and the distal urethra from the corpora and detaching partially the glans as well, from 2 to 10 o'clock. The glans is opened in midline and the procedure combines cranially mobilization of urethra with caudal and medial rotation of glans wings to refurbish the glans correcting the hypospadia without urethroplasty. RESULTS: We have treated 164 patients with distal hypospadia. Median age at the surgery was 22.4 months (1-184 months). The meatal position after penile degloving was coronal at 108 cases, subcoronal at 54 and 2 patients presented megameatus and intact foreskin. Three patients (1.8%) had mild penoscrotal transposition in addition to hypospadia. Twenty-eight patients were treated as a secondary repair (17%). We found complications in 6 patients (3.6%) consisting of five fistulas (3%) and three glans dehiscence (1.8%). Two patients had both complications. Follow up was 21 months (1-42 months) and the median follow-up time was 18 months. DISCUSSION: We acknowledge that this procedure is intended only to distal hypospadias (coronal and subcoronal). We stress that the GUD procedure can be performed irrespectively of any urethral plate "quality" as it does not require a minimum glans width as the TIP repair. Moreover, there is no need for preoperative testosterone treatment. The absence of suture and urethroplasty minimizes the risk of coronal fistulas after surgery. CONCLUSIONS: We believe that this procedure is a viable alternative to distal hypospadias repair.

A salvage procedure for redo penile prosthesis implantation in phalloplasty (De castro technique) for congenital aphallia.

INTRODUCTION: We present a different salvage procedure for penile prosthesis implantation in a De Castro neophallus. METHODS: A patient with congenital aphallia had been operated at the age of 11. Ten years later he had two non successful attempts of prosthesis implantation. Surgery consisted of adapting the implants into the aortic graft and folding it in the middle over the cylinders to reinforce its strength. RESULTS: Patient had a successful postoperative course and has now 6 months of follow-up. DISCUSSION: In a systematic review of penile prosthetic outcomes and complications in gender-affirming surgery, most of the prostheses were inflatable (83.6%) and single-cylinder (61.0%). At a mean follow-up of 3.0 years: 36.2% of prosthesis complications, 60.0% of patients had their original implant present and 83.9% reported achieving penetration. We decided to use vascular grafts as a scaffold because of former non successful attempts. CONCLUSION: The use of vascular prosthesis as a device to implant the penile prosthesis seems to be a safe and effective alternative in an attempt to offer erectile function to the neophallus in case of congenital aphallia.

Conversion of vesicostomy into continent catheterizable reservoirs in myelomeningocele

ABSTRACT Introduction: Vesicostomy should be considered in children with neuropathic bladder in case first-line therapies fail. This simple and reversible procedure can reduce febrile urinary tract infections and protect the upper urinary tract (1) until more definitive alternatives can be proposed. We describe in this video how we approach patients that underwent vesicostomy and want it to be converted into a continent catheterizable reservoir. Material and methods: We perform an infra-umbilical longitudinal incision with a semicircular flap where the stoma will be placed (outside vesicostomy). After releasing the bladder, we proceed with usual steps of the Macedo-Pouch technique (2). We perform the reservoir from 35cm of ileum that constructs a catheterizable channel from the same bowel segment from a 3cm width flap from anterior and posterior wall of ileum in the mid part of it. The continence mechanism of the efferent tube is based on angulation and a serous lined tunnel created with 3-4 3.0 prolene sutures. The stoma is placed in the midline (3). Results: Patient had an uneventful evolution and is continent performing CIC every 4 hours with 9 months of follow-up. We have in the last 3 years a consecutive series of 12 patients operated according to this principle. Discussion: Vesicostomy should be regarded as an alternative for patients with neurogenic bladder refractory to clinical treatment at a younger age in order to postpone definitive treatment such as any an enterocystoplasty. This option must be considered as transient, since definitive reconstructive surgery can provide preservation of renal function and continence achievement. In this context, our video demonstrates that performing a bladder augmentation on a patient with a vesicostomy is safe and feasible. We reinforce that our method precludes the need of appendix or creation of a Monti tube as the outlet channel and the whole procedure is performed from a single piece of bowel.

The GUD technique: glandar urethral disassembly. An alternative for distal hypospadias repair

ABSTRACT Introduction We present an alternative procedure for distal hypospadias consisting of urethral mobilization and partial glandar disassembly, namely GUD (glandar urethral disassembly) technique. Materials and Methods A subcoronal circumcision exposes distal dysplastic urethra. We incise the Buck´s fascia on both sides of urethra releasing it partially from the corpora. We keep a thin bridge of urethral plate to the glans and disassembly almost completely the glans from the corpora, except for the bridge. The glans is incised creating two wide wings that are extremely mobile. The urethra is mobilized, advanced and sutured to the tip of the glans. The glans wings embrace the distal urethra producing a conical glans. Discussion The concept of urethral mobilization has been reported and popularized by Koff in the literature to correct distal hypospadias. One of the limitations of this procedure is the risk of urethral retraction due to extensive proximal dissection. We got inspiration from Mitchell and Bagli' s work of penile disassembly in epispadias to develop the GUD concept. We adopt minimal urethral mobilization mainly in glandar/proximal penile shaft and complete deconstruction of the glans, detaching the corpora from the glans and rotating the wide glans wings to embrace the urethra. Therefore we avoid suture urethroplasty and refurbish the glans to a better conical shape. Conclusion We are convinced that this operation can be regarded as a genuine alternative to distal hypospadias (coronal and subcoronal) but should not be addressed to midshaft forms.

Robotic-assisted excision of a prostatic utricle cyst in a 12-month boy with proximal hypospadia and 45X0/ 46XY karyotype.

INTRODUCTION: Prostatic utricle cysts result from incomplete regression of Mullerian duct structures and occur most frequently in males with perineal or peno-scrotal hypospadias. Utricular cysts may present with various signs and symptoms including urinary tract infection, pain and post-void incontinence, a palpable abdominal mass or recurrent epididymitis. MATERIAL AND METHODS: We present a 12 months boy we treated due to proximal hypospadias in two stages, in association to a dysplastic undescended testis that was excised. The karyotype of the patient was 45X0/46XY and after successful hypospadias treatment, the mother complained of purulent discharge in the diapers. A sonogram showed a large cyst behind the bladder with heterogeneous content. The diagnosis of utricle cyst was confirmed by a NMR with detailed anatomy and low confluence of the neck of the cyst to the urethra. RESULTS: We performed a robotic excision of the cyst consisting of careful dissection between bladder and rectum and a safe ligation of the communication of it to the urethra. CONCLUSION: Patient outcome was uneventful. To the best of our knowledge this is the youngest patient with utricle cyst treated with robotic approach reported in the literature.

The search for continence in bladder exstrophy: Bladder neck transection and Macedo catheterizable reservoir to augment the nativebladder.

INTRODUCTION: Bladder exstrophy remains one of the most challenging abnormalities in pediatric urology. We propose bladder neck transection and bladder augmentation with a catheterizeable reservoir technique to achieve continence after previous anatomic reconstruction in stages. METHODS: At the age of 5-6 years, we offer the transection of bladder neck and enterocystoplasty to achieve continence. We report on a 6-year-old boy that underwent this procedure. We perform the reservoir from ileum according to Macedo-technique that constructs a catheterizeable channel from the same bowel segment. The continence mechanism of the efferent tube is based on angulation and a serous lined tunnel created with 3.0 prolene sutures. The stoma is placed in the midline. RESULTS: Patient had an uneventful evolution and is continent performing CIC every 4 h with 9 months of follow up. DISCUSSION: In spite of continuous development of bladder exstrophy surgery, the urethral continence and voluntary micturition is still not possible in the majority of patients. We discuss with our patients honestly and offer this method as a viable alternative to achieve continence. CONCLUSION: In our experience, most patients accept urethral transection and suprapubic CIC when educated about results with other alternatives of bladder neck plasty.

The GUD technique: Glandular urethral disassembly for distal hypospadias repair.

INTRODUCTION: We present an alternative procedure for distal hypospadias consisting of urethral mobilization and glandular disassembly, named GUD-technique. MATERIAL AND METHODS: After circumcision and exposure of distal dysplastic urethra, it is entirely mobilized from corpora and glans. Glans is deconstructed and incised in midline producing two wings almost not connected to glandular urethra at all. The urethra is then mobilized cranially and sutured to the tip of glans. Glans wings embrace the distal urethra producing a refurbished conical glans. DISCUSSION: Koff et al. published a technique consisting of extensive urethral mobilization for hypospadias repair. Mitchell & Blagi and Perovic et al. reported on complete penile disassembly for epispadia repair as a way to complete release of the rotation of the penis and treat chordee bringing the urethra to a more functional location. We incorporated these two principles in GUD. The rationale is to avoid suture urethroplasty, simply repositioning the mobilized urethra distally and working aggressively on glans disassembly creating a more conical and cosmetic glans. The aggressive deconstruction of glans makes this technique unique. CONCLUSION: We are convinced that this operation can be regarded as a genuine alternative to distal hypospadias after performing 100 cases in 3 years of experience.

The GUD technique: glandar urethral disassembly. An alternative for distal hypospadias repair.

INTRODUCTION: We present an alternative procedure for distal hypospadias consisting of urethral mobilization and partial glandar disassembly, namely GUD (glandar urethral disassembly) technique. MATERIALS AND METHODS: A subcoronal circumcision exposes distal dysplastic urethra. We incise the Buck´s fascia on both sides of urethra releasing it partially from the corpora. We keep a thin bridge of urethral plate to the glans and disassembly almost completely the glans from the corpora, except for the bridge. The glans is incised creating two wide wings that are extremely mobile. The urethra is mobilized, advanced and sutured to the tip of the glans. The glans wings embrace the distal urethra producing a conical glans. DISCUSSION: Koff et al. published a modification of the Barcat technique known as extensive urethral mobilization and confirmed excellent cosmetic and functional results on 168 patients with only 3.5% of reoperation. This procedure has several modifications but none has reported an aggressive disconnection of corpora to the glans, but simply incising two glans wings. Mitchell & Blagi and Perovic et al. reported on complete penile disassembly for epispadia repair as a way to complete release of the rotation of the penis and treat dorsal chordee. We joined these two procedures to propose the GUD technique. The rationale for this procedure is to avoid suture urethroplasty and create a more conical and cosmetic glans. CONCLUSION: We are convinced that this operation can be regarded as a genuine alternative to distal hypospadias (coronal and subcoronal) but should not be addressed to midshaft forms.