Minimally invasive inguinal technique for the management of duplex ureteric anomaly.

OBJECTIVE: To present outcomes of a minimally invasive inguinal technique for the separation of the distal part of ureters in duplex systems and for the extravesical ureteroneocystostomy of only the pathologically involved ureter. MATERIALS AND METHODS: From November 2001 to February 2007, we performed extravesical reimplantation of only the involved ureter in 21 duplex systems, of which 14 were refluxing (megaureters) and seven had obstruction of the ureterovesical junction. The mean (range) age of the patients was 39 (17-59) months. In seven patients, ureterocutaneostomy (of the involved ureter only) was performed first, with reimplantation 3-6 months later, after the diameter of the ureter had decreased, to ensure safe reimplantation. The mean (range) postoperative follow-up was 28 (12-47) months. RESULTS: Postoperative voiding cysto-urethrograms (VCUGs) and magnetic resonance imaging (MRI), showed an absence of vesico-ureteric reflux (VUR) or obstruction in the ureters of the first 10 patients. In the remaining 11 patients, there was no ultrasound detectable dilatation, but symptomatic urinary tract infection developed in two of these patients. Subsequent VCUG and MRI results showed no obstructions or VURs. CONCLUSION: Our results showed that the minimally invasive inguinal approach to separation of ureters in duplex systems and single ureteroneocystostomy of only the pathologically involved ureter represents a viable treatment option.

Current surgical management of severe peyronie's disease.

OBJECTIVES: To report the principles of penile resculpturing of different deformities caused by M. Peyronie: restoration of penile length, girth and shape with or without penile prosthesis implantation. METHODS: In the period between February 2007 and March 2009, we performed grafting surgery for M. Peyronie in 98 patients aged between 24 and 72 years (mean 52 years). Penile deformities were diferent: dorsal curvature in 54 (55%), lateral in 7 (7%), ventral in 11 (11%), and combined curvature in 21 (21%) associated corporal narrowing was present in 24 patients (24%). Four (4%) patients presented isolated penile shortening without other deformity. Isolated diffuse corporal narrowing without shortening was found in two (2%) patients. Severity of curvature ranges from 60 to 90 degrees, mean 72. Thirty one (31%) patients had associated ED. Surgical options for severe Peyronie's disease were: single grafting in 26 pts (26%), complex grafting including circular tunical incision in 36 pts (36%), and in patients with ED the same procedures combined with penile prosthesis implantation (37 pts, 38%). Surgical correction was based on measurement of the tunical defect and precise calculation of graft size and shape. Penile straightening and lengthening was achieved by equalizing of shortened penile side/s with the longest one (convex) and grafting. Penile width is reestablished with additional longitudinal incision/s and grafting; graft width is determined by measurement of difference in circumference between normal and narrowed part of the corpora. We used Intexen LP (AMS) as a grafting material in all cases. RESULTS: The mean follow-up was 15 months (6-25). Mean penile length gain without prosthesis was 2.8cm (1.5-4.2) and with prosthesis 3.2cm (2-4.5cm). Insuficient straightening was in 5 patients (>15 degree) where Neuro Vascular Bundle (NVB) was limiting factor. Twenty four patients reported hypoesthesia and reduced orgasmic sensitivity that recovered spontaneously after 3-6 months. De-novo ED occurred in 6 pts and progression of disease in 6 patients. Infection occurred only in one patient with penile prosthesis implantation. Overall patients' satisfaction was 95%. CONCLUSIONS: Complete tunical reconstruction in IPP can be performed as a safe procedure by transversal, longitudinal and circular grafting with or without simultaneous penile prosthesis implantation. Maximum penile length, girth and shape restoration can be achieved using geometrical calculation, regardless of type of deformity.

Penile enhancement using autologous tissue engineering with biodegradable scaffold: a clinical and histomorphometric study.

INTRODUCTION: Autologous tissue engineering with biodegradable scaffolds is a new treatment option for real penile girth enhancement. AIM: The aim of this article is to evaluate tissue remodeling after penile girth enhancement using this technique. METHODS: Between June 2005 and May 2007, a group of 12 patients underwent repeated penile widening using biodegradable scaffolds enriched with expanded autologous scrotal dartos cells. Clinical monitoring was parallel to histological investigation of tissue remodeling. During second surgical procedure, biopsies were obtained 10-14 months after first surgery (mean 12 months, N=6) and compared with those obtained after 22-24 months (mean 23 months, N=6), and control biopsies from patients who underwent circumcision (N=5). Blind evaluation of histomorphometrical and immunohistochemical finding was performed in paraffin sections. MAIN OUTCOME MEASUREMENTS: Penile girth gain in a flaccid state ranged between 1.5 and 3.8 cm (mean 2.1 ± 0.28 cm) and in full erection between 1.2 and 4 cm (mean 1.9 ± 0.28 cm). Patients' satisfaction, defined by a questionnaire, was good (25%) and very good (75%). RESULTS: In biopsies obtained 10-14 months after first surgery, highly vascularized loose tissue with collagen deposition associated with small foci of mild chronic and granulomatous inflammation surrounding residual amorphous material was observed. Fibroblast-like hyperplasia and small vessel neoangiogenesis occurred intimately associated with the progressive growth of vascular-like structures from accumulation of CD34 and alpha-smooth muscle actin-positive cells surrounding residual scaffold-like amorphous material. Capillary neoangiogenesis occurred inside residual amorphous material. In biopsies obtained after 22-24 months, inflammation almost disappeared and tissue closely resembled that of the dartos fascia of control group. CONCLUSIONS: Autologous tissue engineering using expanded scrotal dartos cells with biodegradable scaffolds is a new and promising method for penile widening that generates progressive accumulation of stable collagen-rich, highly vascularized tissue matrix that closely resemble deep dartos fascia.

The management of Peyronie's disease: evidence-based 2010 guidelines.

INTRODUCTION: The field of Peyronie's disease is evolving and there is need for a state-of-the-art information in this area. AIM: To develop an evidence-based state-of-the-art consensus report on the management of Peyronie's disease. METHODS: To provide state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of Peyronie's Disease, representing the opinion of leading experts developed in a consensus process over a 2-year period. MAIN OUTCOME MEASURES: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. CONCLUSIONS: The real etiology of Peyronie's disease and the mechanisms of formation of the plaque still remain obscure. Although conservative management is obtaining a progressively larger consensus among the experts, surgical correction still remains the mainstay treatment for this condition.

Trauma, gender reassignment, and penile augmentation.

INTRODUCTION: Penile trauma is common with standard management options. Gender reassignment techniques are rapidly changing and penile augmentation remains a controversial topic. Consequently, there is need for a state-of-the-art information in this area. AIM: This study aims to develop an evidence-based state-of-the-art consensus report on the management of penile trauma, gender, reassignment and penile augmentation. METHODS: The study provides state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of penile trauma, gender reassignment and penile augmentation, representing the opinion of leading experts developed in a consensus process over a 2-year period. MAIN OUTCOME MEASURES: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. CONCLUSIONS: Penile fracture should be managed surgically. Information should be readily available to patients to help them decide the surgical technique desired for gender reassignment and to justify any form of penile augmentation.

Iatrogenic trapped penis in adults: new, simple 2-stage repair.

PURPOSE: We present a new, 2-stage functional and cosmetic reconstruction of concealed penis in adults with short-term subjective outcomes. MATERIALS AND METHODS: Patients with excess penile skin removal, shaft tissue scarring and penile retraction with poor functional and cosmetic results underwent 2-stage repair. At stage 1 after a coronal incision and penile degloving an intrascrotal tunnel was formed and the penis was transposed through the scrotum. Three or 4 zero or 2-zero nonresorbable sutures were applied ventral to the penis, crossing through the entire scrotum to ensure complete scrotal skin adhesion to the penis (penile scrotalization). At stage 2 after 6 to 12 weeks the scrotal skin at the penile base was incised bilaterally to separate the skin around the penis from the remaining scrotal skin (penile descrotalization). Evaluation was scheduled 3, 6 and 9 months postoperatively, and annually thereafter. RESULTS: Ten men with concealed penis underwent this 2-stage penile repair, including 8 who were circumcised and 2 who underwent conservative surgery for penile cancer. Mean +/- SD operative time was 75 +/- 15 minutes for stage 1 and 45 +/- 10 minutes for stage 2. No major intraoperative or perioperative complications occurred except superficial scrotal hematoma in 1 patient. At a median followup of 20 months (range 6 to 72) all men were in satisfactory clinical condition and the median patient satisfaction visual analog score was 97 (range 85 to 100). All patients recovered normal spontaneous erection with regular sexual intercourse 4 to 8 weeks after operation 2. CONCLUSIONS: This simple, new 2-stage technique seems feasible and effective, and it is well accepted by patients. Further studies are mandatory to confirm preliminary results.

Retrospective descriptive analysis of 1,176 patients with failed hypospadias repair.

PURPOSE: To our knowledge epidemiological data on the incidence of failed hypospadias repair and the number of patients seeking further surgical treatment remain unknown. We report an observational, descriptive survey of patients who were evaluated and treated for urethral stricture disease and/or penile defects after primary hypospadias repair. MATERIALS AND METHODS: We performed a retrospective observational chart analysis of patients evaluated and treated for urethral stricture disease and/or penile defects at 2 tertiary European centers from January 1998 to December 2007. In each case we investigated the primary abnormal meatal site, the number of operations needed to repair primary hypospadias and complications of this primary repair. Patients were offered surgical repair for previous failed hypospadias treatment. After surgery evaluation was scheduled at 3, 6 and 9 months. Success was defined as a functional urethra without fistula, stricture or residual chordee and a cosmetically acceptable glanular meatus after the completion of all secondary procedures. RESULTS: A total of 1,176 patients with a mean age of 31 years were evaluated and treated. To treat failed hypospadias repair 760 (64.6%) and 416 patients (35.4%) underwent 1-stage and staged repair, respectively. Mean followup was 60.4 months. Of 1,176 cases 1,036 (88.1%) were classified as successful and 140 (11.9%) were considered failures. CONCLUSIONS: Failed hypospadias repair may be corrected by multiple and complex surgeries. Its effects are experienced during the lifetime of the patient and parents.

Genitoplasty in male-to-female transsexuals.

PURPOSE OF REVIEW: Feminizing genitoplasty in male-to-female transsexuals is gaining significant importance within society. Our aim is to evaluate current articles and assess scientific validity of the recent literature (January 2008 to June 2009) of male-to-female gender-reassignment surgery. RECENT FINDINGS: This is a very difficult and demanding field of surgery, often followed by many complications that have an impact on long-term results, quality of life and general patient satisfaction. In the last 18 months, there were only a few articles that deserve attention. Small advances are made in surgical technique, especially of aesthetics of external genitalia, which now closely resemble a natural woman, in creation of mons veneris using albugineal strip and some useful anatomical remarks regarding surgical procedure. Two articles evaluate long-term and medium-term surgical outcomes and one describes surgical complications. One study deals with body composition, volumetric and areal bone density 3 years after surgery. SUMMARY: In the last 18 months, there are only several works regarding surgical technique in male-to-female feminizing genitoplasty, which may have impact on clinical practice, whereas one work researches negative implications of hormonal treatment and surgery on bone and body composition.

Complex case of urethral duplication with megalourethra.

Urethral duplication and megalourethra are very rare anomalies and their concomitant presence is extremely rare, with only a few published cases. We present a complex case of complete urethral duplication with dorsal megalourethra that was severely stenotic in its bulbar part and meatus, with the ventral urethra atretic distally and dilated proximally. Both the corpus spongiosum and the cavernosum were missing. He had associated upper urinary tract abnormalities. Urethral patency was restored successfully by meatoplasty, staged buccal mucosa graft urethroplasty, and tailoring of the megalourethra. This report is unique regarding the use of a buccal mucosa graft for urethral reconstruction in patients with associated urethral duplication and megalourethra.

Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience.

INTRODUCTION: Metoidioplasty represents one of the variants of phalloplasty in female transsexuals. Its main characteristic is that it is a one-stage procedure. It involves lengthening and straightening of hypertrophied clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses. AIM: Our aim is to describe our technique and highlight its advantages. METHODS: Between September 2002 and April 2007, 82 female transsexuals, aged 18-54 years (mean age 31) underwent one-stage metoidioplasty. Clitoris is lengthened and straightened by division of clitoral ligaments and short urethral plate. Urethroplasty is done with combined buccal mucosa graft and genital skin flaps. Scrotum is created from labia majora in which two testicle prostheses are inserted. Simultaneously, female genitalia are removed. MAIN OUTCOME MEASURES: Patients' personal satisfaction about sensitivity and length of neophallus, possibility to void in standing position, real length of reconstructed urethra as well as complication rate comparing to other published data. RESULTS: The median follow-up was 32 months (range 14-69). The mean neophallic length was 5.7 cm (range 4-10). Voiding in standing position was reported in all patients, while dribbling and spraying were noticed in 23 cases and solved spontaneously. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients reported preserved sensation and normal postoperative erection. Testicle prostheses rejection was not observed in any of the patients. CONCLUSIONS: Metoidioplasty is a single-stage and time-saving procedure. It could be an alternative to total phalloplasty in female transsexuals who do not wish to have sexual intercourse. Also, it represents a first step in cases where additional augmentation phalloplasty is required.

Severe penile injuries: a problem of severity and reconstruction.

OBJECTIVES: To report our experience of treating severe penile injuries with different causes and treatments, as penile trauma presents a difficult physical and psychological problem, and the type and extent of injury varies from mild to severe, sometimes even with total amputation. PATIENTS AND METHODS: We analysed retrospectively 43 patients (mean age 28 years, range 5-52 years) with severe penile injuries referred to us from March 1999 to August 2007. The causes of penile injuries differed, including iatrogenic trauma (20), traffic accidents (11), burns (three), self-amputation (two), ritual circumcision (two), penile fracture (two), gunshot trauma (two) and electrocution (one). The management required a wide variety of surgical techniques tailored to each patient depending on the type and extent of injury. RESULTS: The mean (range) follow-up was 47 (10-108) months. The aesthetic and functional results, including satisfactory sexual intercourse were good in 35 patients. There were complications in seven patients; infection after implanting an inflatable penile prosthesis in one, protrusion of a semirigid prosthesis in one, urethral complications (one stenosis and two fistulae) in three and partial skin flap necrosis in two. CONCLUSIONS: Severe penile injuries should be treated on an individual basis, applying different techniques. However, treatment can be effective and safe only in specialized centres.

Buccal mucosa grafts for repair of stenotic catheterizable continent stoma.

PURPOSE: Different tubular structures have been used to create cutaneous catheterizable continent urinary stomas. The most common complication is stomal stenosis on the cutaneous end of the tubes. We present a variant of stomal stenosis repair that uses a buccal mucosa graft. MATERIALS AND METHODS: Between January 2000 and March 2006 stenotic stomal repair was performed in 10 patients between 3 and 17 years old (mean age 6). A Mitrofanoff channel was created from a bladder tube in 4 patients, from appendix in 3, from ileum in 2 and from the ureter in 1. The procedure involved the removal of scar tissue and the creation of well vascularized dermal beds by skin de-epithelialization (epidermis removal). After that we formed 2 elliptical dermal flaps. Two elliptical buccal mucosa grafts were quilted to the recipient bed (the dermal flap) and anastomosed with the mucosa of the normal part of the channel. The flaps were joined, tubularized and sutured to the skin. An indwelling catheter was left in the channel for 2 weeks. Postoperatively the buccal mucosa was wetted with saline solution for 4 consecutive days. RESULTS: Followup was between 12 and 39 months (mean 22). There was no partial or total graft necrosis. None of the patients experienced repeat stenosis. The stoma was visible (uncovered) and the esthetic appearance was satisfactory in all patients. CONCLUSIONS: Repair of Mitrofanoff stomal stenosis using a buccal mucosa graft is a minor procedure. It is a good salvage procedure that excludes the need to create a new channel.

Re: a new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report.

Wang and colleagues described the use of fasciocutaneous flap based on deep inferior epigastric perforator (DIEP) vessels for vaginal reconstruction. They presented four patients with congenital vaginal agenesis and one with vaginal tumor. The rhombus-shaped abdominal flap was designed according to the location of deep inferior epigastric vessels perforators. The size of the flap ranged from 9 x 12 to 11 x 12 cm. The flap was elevated without underlying muscle, dissecting perforators together with the pedicle-deep inferior epigastric vessels up to their origin. The fully mobilized flap was tabularized, transposed paravesically to the previously prepared vaginal bed, and anastomosed to vaginal introitus. Primary donor-site closure was accomplished in all patients with conspicuous scars. All flaps survived and the authors reported a normal appearance of external genitalia with sufficient neovaginal depth and width. During the short follow-up (6-14 mo), two patients reported satisfactory sexual intercourse.

Combined buccal mucosa graft and dorsal penile skin flap for repair of severe hypospadias.

OBJECTIVES: Urethral reconstruction in severe hypospadias presents a great challenge. We have designed a method of combining a longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in most severe hypospadias. METHODS: Between January 2003 and March 2007, 17 patients (aged from 9 to 23 months) underwent severe hypospadias repair (13 penoscrotal and 4 scrotal hypospadias). Short urethral plate was divided in all cases and remaining curvature repaired by dorsal plication. We harvested and fixed a buccal mucosa graft to the ventral side of corpora cavernosa to be the first half of a neourethra. A longitudinal dorsal island skin flap was created and buttonholed ventrally. We sutured it together with the buccal mucosa graft to form the neourethra. We fixed the abundant flap pedicle laterally to cover all suture lines of the neourethra. We performed penile skin reconstruction using available penile skin. RESULTS: The mean (range) follow-up was 25 (7 to 58) months. We achieved satisfactory, functional, and aesthetic results in 14 patients. In 3 cases urethral fistula (2) and distal stricture (1) required secondary treatment. CONCLUSIONS: Combined longitudinal island skin flap and buccal mucosa graft could be a good choice for urethral reconstruction in most severe hypospadias repairs.

New insight into surgical anatomy of epispadiac penis and its impact on repair.

PURPOSE: Surgical anatomy of the epispadiac penis is still not fully described. Using our complete disassembly technique, we discovered some anatomical features of epispadiac penis that may have significant impact on surgical outcome. MATERIALS AND METHODS: A total of 52 patients 2 days to 19 years old (mean age 43 months) underwent primary repair of epispadias between October 1996 and December 2006. After complete penile disassembly, ie full mobilization of the corporeal bodies, neurovascular bundles and urethral plate, reassembly of the penile entities was done. The urethral plate is tubularized and ventralized. The corporeal bodies are straightened and lengthened by 2 transverse incisions and grafting, joined medially and fixed to the glans cap. The glans is reconstructed, and the neurovascular bundles are moved dorsally and joined. The skin is reconstructed using different local flaps. RESULTS: Investigating the anatomical features of the epispadiac penis, we discovered several distinguishing features. The corporeal bodies are separated and triangular in shape. They represent the main substrate of dorsal curvature due to the significant disproportion in length between the long ventral and short wedge-shaped dorsal sides. The length of the neurovascular bundles is determined by their course-they are longer if they overlie the ventral side of the corpora and shorter if positioned over the dorsal side. The skin between the scrotum and penis has characteristics similar to penile skin. A good functional and esthetic outcome was achieved in 46 patients. Erection and glanular sensitivity were preserved in all patients. There was no necrosis of the glans or corporeal bodies. Complications included urethral fistula in 4 patients, stenosis in 2 and mild residual curvature in 2. CONCLUSIONS: New insights into the anatomical features of the epispadiac penis can have a significant impact on surgical outcomes.

Sacrospinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery.

OBJECTIVES: To report our experiences of vaginal sacrospinous ligament fixation after vaginoplasty in male transsexual patients with the aim of preventing its postoperative prolapse. METHODS: From August 1997 through November 2005, a total of 62 male transsexual patients (mean age 26 years, range 18 to 58) underwent sacrospinous ligament fixation for neovaginal prolapse during male-to-female sex reassignment surgery. The neovagina was created from a penile skin tube flap combined with a urethral flap. A deep and wide perineal cavity between the urethra, bladder, and rectum was created by dissection of the tendineous center and rectourethral muscle. The right pararectal space was opened by penetrating the right pararectal fascia (rectal pillar) and right ischial spine was palpated. Using the ischial spine as a prominent landmark, the sacrospinous ligament was palpated. Long-handled Deschamps ligature was used to pierce the ligament medially to the ischial spine. Vaginopexy to the sacrospinous ligament was performed, and the neovagina was placed deep in the perineal cavity. RESULTS: The median follow-up was 32 months (range 7 to 102). Sacrospinous ligament fixation was successfully performed in all patients. The mean vaginal length was 10.7 cm (range 9.5 to 16). Of the 62 patients, 42 (76%) were able to have normal sexual intercourse. The appearance of the neovagina was aesthetically acceptable in 52 patients. In 3 cases, a minor bulge of the anterior vaginal wall was easily resolved by simple excision. CONCLUSIONS: Vaginal sacrospinous fixation is feasible in male transsexuals for neovaginal prolapse prevention. However, extensive experience with male pelvic surgery is required to avoid possible complications.

Total phalloplasty using a musculocutaneous latissimus dorsi flap.

OBJECTIVE: To present total phalloplasty in children and adults using a musculocutaneous latissimus dorsi (MLD) free flap to create a large neophallus, that allows easy urethroplasty and implantation of a prosthesis. PATIENTS AND METHODS: From April 1999 to January 2006, 16 patients (mean age 24 years, range 10-34) had a total phalloplasty; the indications were congenital anomalies of the penis in 12, iatrogenic in two and accidental penile trauma in two. The MLD flap is mobilized on a subscapular artery and vein, and a thoracodorsal nerve. The neophallus is created on-site and after dividing the neurovascular pedicle, transferred to the pubic region, where it is anastomosed with the femoral artery, saphenous vein and ilio-inguinal nerve. The donor site was closed directly in 15 patients while in one a split-thickness skin graft was used to cover the defect. In the following stages, two- or three-stage buccal mucosa urethroplasty was used in 11 patients; a penile prosthesis was implanted in seven. RESULTS: The mean (range) follow-up was 31 (12-74) months; the penis was 14-18 cm long and 11-15 cm in circumference. There was no partial or total flap necrosis; the donor site healed satisfactorily in 13 patients while in the remaining three there was moderate scarring. The patency of the urethra was good in all patients. Two urethrocutaneous fistulae developed; one closed spontaneously and the other was successfully treated with minor surgery. The function of the implanted penile prostheses was satisfactory in all patients. CONCLUSIONS: The MLD flap allows the creation of a neophallus of good size and with a good aesthetic appearance; it allows urethroplasty and safe implantation of a penile prosthesis, and it can also be used in children.