Outcome of surgical management of urethral stricture following hypospadias repair.

INTRODUCTION: Reconstruction of urethral strictures in patients with a history of hypospadias repair is controversial. The authors policy has been that if a residual healthy urethral plate is present, single-stage urethroplasty is recommended. However, if the urethral plate is fibrotic or absent or if lichen sclerosus is present, two-stage repair is utilized. OBJECTIVES: In this study, the authors report their experience in management of patients with urethral stricture and prior hypospadias surgery. STUDY DESIGN: Between 1993 and 2015, 62 patients with urethral stricture and a prior history of hypospadias repair underwent urethroplasty. Patients were divided into two groups; patients in group 1 (n = 39) found to have a healthy residual urethral plate and underwent single-stage urethral stricture repair using either an island skin flap or a buccal mucosa graft. Patients in group 2 (n = 23) had either a scarred urethra or evidence of lichen sclerosus and underwent staged repair using a buccal mucosa graft. Post-operatively, patients were evaluated at 3 months, 6 months, 1 year, and then annually. RESULTS: The median age of the patients was 10.5 years (2.5-33 years). The mean stricture length was 6.3 cm in group 1 and 7.1 cm in group 2. Overall success rate was 87.1% in group 1; a urethral fistula occurred in one patient (7.1%) who underwent skin flap onlay repair and one patient (4.5%) with a buccal mucosa graft. Recurrent urethral stricture was also diagnosed in one patient (7.1%) after repair using an island skin flap and in two patients (9%) following buccal mucosa graft. In group 2, three patients (13%) developed graft contracture and were revised before the second stage. Two patients (8.6%) had glans dehiscence following second stage urethroplasty. The final success rate in group 2 was 90.4%. DISCUSSION: Both single-stage and 2-stage repair showed successful outcome in management of urethral stricture following hypospadias repair. However, the authors continue to believe that the status of the urethral plate dictates the type of surgery to be utilized. In accordance to the previously published data, the study results also further support promising outcomes of application of buccal mucosa in surgical management of these patients. CONCLUSION: In patients with urethral stricture after hypospadias surgery who have a healthy residual urethral plate, single-stage repair using buccal mucosa graft is a viable option with high success rate. In patients with scarred urethral plate, a 2-stage repair is recommended.

Salvaging the dehisced glans penis.

OBJECTIVE: The glans penis may show a deep groove (surgically favorable), or may appear flat with an absent sulcus (unfavorable). Glans dehiscence following hypospadias repair, especially after multiple surgeries, frequently results in a scarred, obliterated, or absent urethral plate. The glans penis appears to be flat and grooveless. This study reported on the outcome of a two-stage salvage repair for glans dehiscence in 49 consecutive patients. MATERIALS AND METHODS: Retrospective chart review was performed for all patients who underwent repair for glans dehiscence following hypospadias repair. RESULTS: Between January 2009 and April 2015, 49 children aged 16 months to 18 years presented with glans dehiscence following hypospadias repair. The prior number of operations ranged from one to six. Eleven children had urethral fistulas, and seven had chordee. In the first stage, the flat glans was incised deeply to visualize, but spare, the corpora. Thereafter, a free graft of oral mucosa harvested either from the lower lip or cheek, or the residual preputial skin, was sutured to the glans cleft. The grafts were fenestrated, quilted in the midline, and a tie-over dressing was applied. Any fistula or chordee was repaired during the first stage. The neo-plate was tubularized 6-12 months later, and urine drainage with a catheter was maintained for 10-14 days. In 11 patients, skin flaps appeared dusky, and nitroglycerine ointment 2% was applied for 24 h to enhance the blood supply of the tissues. Subsequently, six of these children received nine or ten 90-min hyperbaric oxygen therapy sessions. Following the first stage, two patients developed hypertrophy of the mucosal grafts, and one skin graft contracted. These three patients underwent revision using a second buccal mucosal graft harvested from the cheek. One recurrent fistula was closed during the second stage. Following the second stage two patients developed a urethral fistula, and the distal sutures broke down in one patient, resulting in an over-sized meatus. None developed meatal stenosis or glans dehiscence. CONCLUSION: Graft initial take and subsequent behavior were unpredictable, but the two stage approach optimized the process of take and healing. Glans dehiscence was repaired safely and successfully by developing a deep groove, with creation of a new urethral plate followed by tubularization in two stages.

Correction of congenital penoscrotal webbing in children: A retrospective review of three surgical techniques.

INTRODUCTION: Congenital penoscrotal webbing (PSW) is a condition that leads to penile shortening and is a common cause of delayed circumcision. While various techniques for PSW repair have been described, no comparative studies are currently available. OBJECTIVE: The goal of this study was to validate and critique three commonly utilized techniques for PSW repair. SUBJECTS AND METHODS: A retrospective chart review was performed on all patients who underwent repair for PSW, with or without concomitant surgical procedure, by a single surgeon (MKH) over a 7-year period. Inclusion criteria were: aged <5 years, diagnosis of PSW, documented surgical approach undertaken to correct the PSW, and follow-up for a minimum of 6 months. A total of 196 patients aged 6 months-3.4 years (average 7.8 months) were included, and underwent three different types of procedure: Heineke-Mikulicz (HM) scrotoplasty, VY scrotoplasty or Z scrotoplasty. RESULTS: Out of 196 patients, 10 (6.7%) had complications, with four (2.7%) requiring surgical revision or correction. Two patients had excision of 'dog-ear' skin tags, one required excision of a suture tract, and the fourth required revision of skin contraction after HM repair with Z scrotoplasty. DISCUSSION: Congenital penoscrotal webbing is a common condition that often requires pediatric urology consultation. Although it is felt that the severity of the defect may not impact on the operative technique for repair of PSW, data comparing these techniques is lacking. This single-surgeon series highlighted that amongst the patients who underwent one of the three described techniques (HM, VY or Z scrotoplasty), there were no significant postoperative differences in complications or parent satisfaction. Although the ease of the HM repair for minor webbing is acknowledged, Z scrotoplasty is the authors' preference for repair given its ability to address the most severe webbing. CONCLUSIONS: In this comparison of three surgical techniques for the correction of PSW, it was demonstrated that each choice is safe, with no option showing a significant difference in complication rate. Surgeon preference should therefore weigh heavily when choosing the surgical approach for PSW repair.

TPN decreases IL-4 and IL-10 mRNA expression in lipopolysaccharide stimulated intestinal lamina propria cells but glutamine supplementation preserves the expression.

Total parenteral nutrition (TPN) decreases intestinal IgA and levels of Th2 cytokines, interleukin (IL)-4, and IL-10 within the supernatants of intestinal homogenates. These cytokines are known to stimulate IgA production in vitro by cells of the gut-associated lymphoid tissue (GALT). Glutamine (GLN) supplementation of TPN normalizes GALT mass and cytokine levels. Because intestinal homogenates contain mucosa which itself is a source of cytokines, it was unclear whether cytokines change within the GALT itself. This study investigates dietary effects on IL-4 and IL-10 cytokine mRNA expression within isolated GALT lamina propria cells after lipopolysaccharide (LPS) stimulation. Prospective randomized experimental trials were used in this study. Fifty-nine mice were randomized to chow, intravenous TPN (IV-TPN), intragastric TPN (IG-TPN), complex enteral diet (CED), or 2% GLN-supplemented TPN (GLN-TPN). In experiment 1, animals were fed chow, IV-TPN, IG-TPN, or CED for 5 days and received intraperitoneal LPS (100 microg/kg BW), and then were sacrificed 1 h later. Intestine was harvested for GALT lamina propria. Total RNA was extracted from lamina propria cells and cytokine mRNA for IL-4, and IL-10 was measured by reverse transcriptase polymerase chain reaction. IgA levels of intestinal washing were also measured with ELISA. In experiment 2, mRNA for IL-4 and IL-10, and intestinal IgA levels were measured in mice fed chow, IV-TPN, or GLN-TPN as in experiment 1. Both IL-4 and IL-10 mRNA expression decreased significantly in IV-TPN mice compared to chow or CED feeding. IG-TPN resulted in IL-10 mRNA expression significantly lower than chow or CED but significantly better than IV-TPN. GLN preserved IL-4 and IL-10 mRNA levels, which correlated with intestinal IgA levels. Route and type of nutrition as well as GLN influence message for the Th2 type IgA-stimulating cytokines, IL-4 and IL-10, within the primary site of GALT IgA production, the lamina propria.

Modulation of organ ICAM-1 expression during IV-TPN with glutamine and bombesin.

The gut primes neutrophils (PMNs) during injury, which can then induce distant organ damage after a second insult. ICAM-1 is an important adhesion molecule in PMN attachment to the vascular endothelium. Parenteral nutrition (TPN) decreases gut levels of interleukin (IL)-4 and IL-10, two cytokines that are normal inhibitors of ICAM-1 expression. TPN also increases gut ICAM-1 expression and PMN accumulation. Since glutamine (GLN) and bombesin (BBS) prevent TPN-associated impairment of mucosal immunity, we hypothesized that GLN and BBS would modulate organ ICAM-1 expression in association with normalization of IL-4 and IL-10 levels. Forty-four mice were fed chow, TPN, or GLN-TPN (isonitrogenous 2% GLN-enriched TPN). After 5 days of diets, ICAM-1 expression was quantified in organs using the dual radiolabeled monoclonal antibody technique. In the next experiment, 29 mice were fed chow, TPN, or BBS-TPN (BBS 15 microg/kg TID) for 5 days to measure organ ICAM-1 expression. Total IL-4 and IL-10 levels were measured with ELISA from intestinal homogenates of another set of 52 mice fed chow, TPN, GLN-TPN, or BBS-TPN. TPN significantly increased ICAM-1 expression in the lung, kidney, and intestine compared with chow mice. GLN-TPN decreased intestinal, but not lung, ICAM-1 expression, while BBS-TPN reduced pulmonary, but not gut, ICAM-1 levels. GLN- and BBS-TPN returned gut IL-4 levels to normal, but failed to increase IL-10 levels. GLN and BBS had different effects on organ ICAM-1 expression induced by lack of enteral nutrition. Mechanisms other than recovery of IL-4 alone may be responsible for gut ICAM-1 expression.

Route of nutrition influences intercellular adhesion molecule-1 expression and neutrophil accumulation in intestine.

HYPOTHESIS: The levels of intestinal interleukin 10 and interleukin 4, inhibitors of intercellular adhesion molecule-1 (ICAM-1) expression, decline with total parenteral nutrition (TPN). These cytokine changes induced by lack of enteral nutrition may increase ICAM-1 expression, resulting in polymorphonuclear neutrophil accumulation in intestine. DESIGN: Prospective randomized experimental trials. SETTING: Laboratory. MATERIALS: Male mice. INTERVENTIONS: Sixty-three mice were randomized to chow, intravenous TPN, or intragastric TPN. MAIN OUTCOME MEASURES: Experiment 1: After diet manipulation, iodine 125-labeled anti-ICAM-1 antibody and iodine 131-labeled nonbinding antibody were injected to quantify ICAM-1 expression on endothelial cells in the lung, liver, kidney, and small intestine. Measurement of myeloperoxidase was used to quantify polymorphonuclear neutrophil accumulation in the organs. Experiment 2: Intestine was harvested for both ICAM-1 and myeloperoxidase levels after chow refeeding of mice in the intravenous TPN group. RESULTS: In experiment 1, uninjured mice fed intravenous TPN showed significantly increased intestinal ICAM-1 expression and polymorphonuclear neutrophil accumulation with no significant changes in the lung, liver, or kidney. No changes occurred in mice fed chow or intragastric TPN. In experiment 2, reinstitution of enteral feeding returned intestinal ICAM-1 and myeloperoxidase levels to normal. CONCLUSION: Gut changes associated with lack of enteral feeding induce endothelial changes and an immunologic response, which may influence subsequent responses to injury.

Increased expression of intestinal P-selectin and pulmonary E-selectin during intravenous total parenteral nutrition.

HYPOTHESIS: Intravenous total parenteral nutrition (TPN) induces intestinal polymorphonuclear neutrophil recruitment with increased intestinal intercellular adhesion molecule-1 expression. While intercellular adhesion molecule-1 causes firm adhesion of leukocytes to the endothelial cells, P- and E-selectin mediate leukocyte recruitment via rolling. Therefore, manipulation of nutrition may also affect P- and E-selectin expression in organs. DESIGN: Prospective randomized experimental trials. SETTING: Laboratory. MATERIALS: Male mice. INTERVENTIONS: Fifty-three mice were randomized to chow, intravenous TPN, or intragastric TPN. MAIN OUTCOME MEASURES: After 5 days of diet, mice were administered iodine 125-labeled anti-P-selectin antibody (or iodine 125-labeled anti-E-selectin antibody) and iodine 131-labeled nonbinding antibody to quantify P-selectin (or E-selectin) expression in organs (lung, liver, kidney, small intestine, colon, stomach, pancreas, mesentery, heart, and skeletal muscle). RESULTS: P-selectin in small intestine, colon, stomach, and pancreas in the intravenous TPN group increased significantly as compared with the chow and the intragastric TPN groups. E-selectin expression was up-regulated after intravenous TPN in the lung but not in other sites. CONCLUSIONS: In a time frame (5 days) when intercellular adhesion molecule-1 expression and neutrophil recruitment are increased, intestinal expression of P-selectin remains up-regulated. Early lung inflammatory changes are reflected by increases in E-selectin. This change may reflect early pulmonary dysfunction with intravenous TPN, but its significance requires further study.

New surgical method for one-stage total remodeling of massively dilated and tortuous ureter: tapering in situ technique.

During the past five years a surgical technique for extensive ureteral tailoring and preservation of its blood supply has been developed. Seventeen congenitally dilated and tortuous ureters were operated on. One-stage surgical remodeling involved excision of the ureteral kinks, total tapering from the ureterovesical to the ureteropelvic junctions, and ureteroneocystostomy. The rationale, technique, pitfalls, and results are discussed. In situ ureteral remodeling is indicated in massive ureteral dilatation and tortuosity, secondary operation following previous diversion or tailoring, and multiple obstructions in the same ureter. The success with these procedures suggests that one-stage surgical reconstruction in the most dilated and tortuous ureter, that would have been considered for skin exteriorization or multistaged tailoring can be accomplished safely with gratifying results.

Review of fundamental urodynamics in children.

During the past three years, 190 children were seen with varied and mostly complicated urodynamic problems. Over 300 studies were performed. This experience prompted a reappraisal of fundamental urodynamic concepts pertinent to pediatric bladder disorders.

Reconstruction of umbilicus during functional closure of bladder exstrophy.

In babies born with bladder exstrophy, the umbilicus is caudally displaced, and attached to the upper margin of the exstrophied bladder. Reconstructive surgery often removes the navel. A surgical technique for preservation and repositioning of the umbilicus is presented.

New concept in bladder remodeling.

During the past five years a surgical procedure for rehabilitation of partially decompensated large-capacity bladders has been developed and utilized in 9 children and 2 adult patients. The patients presented with detrusor muscle failure. The key steps of this procedure are (1) creation of laterally-based mucosa-free detrusor pedicle flap, (2) reduction of bladder size and wrapping the flap around the body of the bladder thus doubling the muscle bulk, and (3) mobilization and extraperitonealization of the greater omentum to the reconstruction site. The indications, rationale, and surgical technique are presented. The gratifying results, as gauged by urodynamic testing, suggest that detrusor remodeling is a worthwhile procedure for a highly select group of patients.

Recent advances and further experience with surgical techniques for one-stage total remodeling of massively dilated ureters.

One-stage total ureteral remodeling was done in a selected group of 64 megaureters in 44 children. Two new surgical techniques have been developed and utilized during the past six years. They were designed to preserve the ureteral blood supply and accomplish reconstruction of the whole ureter in one operation. The tapering in situ technique was utilized in 39 ureters and ureteral plication either alone or in conjunction with lower-third ureteral tapering in 25 ureters. These methods proved to be invaluable in the following selected cases: (1) massive ureteral dilatation and tortuosity due to vesicoureteral reflux or obstruction, (2) secondary operations following previous urinary diversion or unsatisfactory ureteral tailoring, (3) multiple obstructions within the same ureter, (4) transureteroureterostomy of dilated ureters, and (5) definitive surgery for dilated ipsilateral ureter of complete duplication.

Vaginal construction.

Construction of the vagina was performed in 5 46 XY, phenotypic female children, by utilizing a vascularized segment of ileum, which is folded and converted into a pouch, then placed between the rectum and bladder, and transplanted to the perineum. The neovaginal opening remained patent in all, mucus discharge decreased with time, and one teenager experienced a satisfactory sexual relationship.

Distal urethroplasty and glanuloplasty procedure: results of 512 repairs.

OBJECTIVES: We describe the distal urethroplasty and glanuloplasty (DUG) procedure, a modification of the Thiersch-Duplay method, and report indications, outcomes, and complications. METHODS: In all, 512 children with glanular, coronal, or subcoronal hypospadias variants underwent the DUG procedure. RESULTS: Follow-up demonstrated excellent functional performance and cosmetic appearance. Complications included 5 fistulae, 2 meatal stenoses, and 4 distal breakdowns of the distal neourethra. The incidence of complications requiring secondary procedures was 2.1% for the entire group. CONCLUSIONS: The DUG repair has allowed us to repair virtually all distal hypospadias variants using the Thiersch-Duplay method. The combined use of the Heineke-Mikulicz meatoplasty in patients with a stenotic meatus and the glanuloplasty as described by Zaontz has allowed the DUG repair to achieve excellent cosmetic and functional results.

Effect of nitroglycerin ointment on penile skin flap survival in hypospadias repair. Experimental and clinical studies.

The mobilization of penile neurovascular skin flaps is associated with vasospasm, which may result in ischemic necrosis. A prospective clinical trial of nitroglycerin was performed in 40 children undergoing hypospadias repair. Quantitative fluorescein studies were performed in another group of patients who underwent circumcision. These studies represent the first clinical application of nitroglycerin ointment in human subjects. Our preliminary data suggest that nitroglycerin ointment can enhance survival of skin flaps.

Endoscopic treatment of vesicoureteral reflux in children with neurogenic bladders.

Endoscopic subureteral injection of Teflon was performed in 12 children (20 ureters) with neurogenic bladders and vesicoureteral reflux (grades III-IV). Follow-up evaluation by ultrasonography and voiding cystourethrogram at three-month intervals up to two years revealed successful correction of the reflux in 70 percent of the ureters.

Primary obstructive megaureter in children.

Sixty-five cases of primary obstructive megaureter were retrospectively evaluated. The clinicoradiologic features of the abnormality are characteristic; however, a complete urologic workup is necessary to exclude the more common causes of ureteral dilatation. Treatment must be planned according to status of renal and ureteral functions. Surgical excision of the obstructive segment, reduction of ureteral caliber when indicated, and reimplantation achieved the best results in this series. A brief period of nephrostomy drainage prior to surgical remodeling of the lower ureter can be useful in selected cases. Conservative treatment of children with relatively few symptoms and slight ureteral dilatation is worthwhile.

MAGPI hypospadias repair: ambulatory versus inpatient surgery.

Over a one-year period, 96 consecutive children with distal hypospadias underwent mental advancement and glanuloplasty (MAGPI) for hypospadias repair. In a prospective study, 56 were operated on as inpatients, and 40 underwent repair as outpatients. It was determined that MAGPI can be performed safely and cost-effectively on an ambulatory basis.

Ureteropelvic junction obstruction during the first year of life.

Over the past three years, 28 children less than one year of age, were operated on for ureteropelvic junction obstruction. Our results demonstrate that congenital hydronephrosis most commonly presents antenatally, and that early postnatal correction can be performed safely. The high surgical success rate, with a relatively short hospital stay (3-4 days), is attributed to early diagnosis, when the pelviureteral tissues are relatively healthy and nephron maturation is at maximum. The practice of delaying surgical correction of an obstructed hydronephrotic kidney on the basis of "stable" renal function is unwarranted, since it denies such kidneys their full potential for recoverability.

Simultaneous repair of bilateral ureteropelvic junction obstruction.

Fifteen children with bilateral ureteropelvic junction obstruction underwent simultaneous repair as a single procedure. Dismembered pyeloplasty and ureterocalycostomy were the two procedures used. Ten were performed through anterior subcostal incisions. Posterior lumbotomy provided adequate exposure in 5 children and further contributed to shortened hospitalizations. The functional and anatomic results were excellent. Simultaneous bilateral pyeloplasty through posterior lumbotomy is a safe and cost-effective alternative to staged procedures for bilateral ureteropelvic junction obstruction.