Effects of extensive mobilization and tension anastomosis in anorectal reconstruction (experimental study).

PURPOSE: Anorectoplasty and pull-through procedure can be performed with extensive mobilization or tension anastomosis, which can compromise bowel blood perfusion. We aimed to analyze the hypoxia biomarker values and histopathological findings in both conditions to correlate the occurrence of anal stenosis and defecation disorders in experimental models. METHODS: We created anorectal reconstruction models with impaired vascularization of the anorectum (group I) and tension anastomosis (group II) in rats. A third group of animals underwent sham operation (group III) and another as controls (group IV). Hypoxia biomarker values were assessed in all groups. The histopathological changes on the postoperative days 3 and 35, anal stenosis and defecation disorders on day 35 were compared. RESULTS: Hypoxia biomarker values confirmed postoperative ischemia in groups I-III compared to control. Group I and II rats had a similarly pronounced ischemia with histopathologic changes in the anorectum on the postoperative day 3 and accompanied by severe fibrosis on day 35. Compared to the sham operation, both groups showed defecation disorders with significant anal stenoses. CONCLUSION: Extensive rectal mobilization to about the same extent as tension anastomosis has a major impact on postoperative rectal ischemia, resulting in severe fibrotic changes in the anorectum and defecation disorders in the long term.

A closer look at iatrogenic hypospadias.

Almost all surgical repair techniques for hypospadias include dissection of the glans penis, and covering the neo-urethra with the glans tissue circumferentially. Surprisingly, the presence of the "septum glandis" in the ventral midline has been overlooked for decades. A careful examination of six patients with iatrogenic hypospadias (IH) revealed direct indications of the septum glandis. All patients were treated with long-term urethral catheterisation in the paediatric intensive care unit due to neurologic and/or metabolic diseases. The glans was disrupted in all patients due to ventral midline compression of the urethral catheter, which resulted in a tear in the septum glandis. A remnant of the septum glandis was clearly observed in patients with an incomplete tear. Further injuries caused tear in the frenulum and corpus spongiosum, exposed the glanular urethra and made its vertical elliptical shape, the "fossa navicularis", visible. Intact contours of the separated glans wings were observed in all patients. The glans wings merge ventrally in the midline, but are separated by a fine connective tissue (septum glandis) in conjunction with the frenulum, which is involved in the formation of the ventral wall of the glanular urethra. IH provides further insight into the structural anatomy of the normal human glans and glanular urethra.

Enteric Duplication Cysts in Children: A Single-Institution Series with Forty Patients in Twenty-Six Years.

PURPOSE: The purpose of the study was to evaluate our experience with enteric duplication cysts in 40 children during the past 26 years, while assessing the variability of their presentations and to propose an algorithm for surgical management. METHODS: We retrospectively analysed sex, age, clinical presentations, duplication site, surgical treatment, presence of ectopic tissue, complications, associated anomalies, and prognosis of 40 patients with gastrointestinal tract duplications who were surgically treated in our clinic. RESULTS: Overall, there was a predominance of boys (28 males, 70 %; 12 females, 30 %). The presenting symptom was vomiting in 23 patients, rectal bleeding in 11 patients, abdominal mass in 10 patients, abdominal pain in 9 patients, constipation in 6 patients, cough in 2 patients, and respiratory distress in 2 patients. In 30 patients, a complete excision of the cyst with additional segmental intestinal resection and anastomosis was performed. Cystectomy was performed in seven patients, while complete excision of the cyst with additional wedge resection was performed in two. A Wrenn procedure (mucosectomy) was performed in one patient. CONCLUSION: Due to the variability in the site of enteric duplications, a wide range of presenting symptoms can exist, which is challenging for diagnosis. In children with a diagnosis of acute abdomen, enteric duplication cysts should be considered, and these children should be further investigated for additional skeletal, urogenital, and gastrointestinal system pathologies. Surgical treatment depends on the site and type of the cyst.

The Glanular-Frenular Collar (GFC) technique: Dual approach to hypospadias reconstruction.

INTRODUCTION: The Glanular-Frenular Collar (GFC) technique has evolved since it was first described in 2017. The technique involves reconstruction of the septum glandis, which has been overlooked in the history of hypospadias, and formation of the frenulum, creating the ventral wall of the glanular urethra without dissecting the glans, leaving room for the formation of the navicular fossa. MATERIAL AND METHODS: We present a case of distal hypospadias corrected with the GFC technique and demonstrate the important steps of the surgical technique. RESULTS: The aesthetic result corresponded to the normal anatomy of the glans and frenular triangle, and the functional result showed a free and wavy shape of urine that resembled the normal flow from the urethra. DISCUSSION: In the normal anatomy of the penis, the wings of the glans are separated ventrally by the septum glandis and the frenulum. The navicular-shaped glanular urethra and its vertical, elliptical opening are covered by the fibroelastic septum glandis, unlike the penile urethra, which is surrounded by the corpus spongiosum. CONCLUSION: Reconstruction of hypospadias should include the formation of a septum glandis, frenulum, and navicular fossa. The GFC technique demonstrates the importance of a dual surgical approach for glanular and penile urethra reconstruction.

Looking beyond the dartos fascia and tunica vaginalis: reviewing the stance of common adjuvant covering biomaterials in hypospadiology.

Hypospadias, one of the commonest congenital anomalies in boys, can have a spectrum of clinical presentation based on the location of the meatus and the presence of chordee. The surgical repair of hypospadias involves great precision, especially in proximal varieties and redo/complex cases of hypospadias. Hypospadiologists have put in tremendous efforts to improve the outcomes of these children. The utilization of adjuvant biomaterials is one such effort that has gained significant attention over the recent years. Biomaterials are used to cover the urethral suture line in instances where the ideal covering agents (dartos fascia and tunica vaginalis) are unavailable. We reviewed the mechanism of action, current stance, and advantages/disadvantages of three commonly used adjuvant agents, i.e. autologous platelet concentrates, tissue glues, and acellular dermal matrixes. Although individual studies have highlighted the therapeutic benefits of these adjuvants, the available literature has a limited level of evidence. Moreover, it is believed that the application procedure of these covering agents needs to be scrutinized in future studies. In addition, it is suggested that the application of any covering agent right up to the meatus is non-anatomical and redundant. Well-designed randomized controlled trials with a uniform application procedure and comparing different covering agents need to be conducted in the future before any definite conclusion is drawn.

Anatomical modeling of the foreskin for the reconstruction of glanular hypospadias.

The normal development of the glanular urethra is closely related to the normal development of the foreskin. A ventral deficit in the foreskin results with the failure to develop the septum glandis and frenulum, which also form the ventral wall of the glanular and subcoronal urethra. Here we present the anatomical modeling of the foreskin in order to obtain a mucosal collar for the reconstruction of the glanular hypospadias with the GFC technique (Glanular-Frenular-Collar), which can also be used for various purposes to reconstruct the urethra in hypospadias.

"Fossa navicularis" and "septum glandis": A "flow-control chamber" for the male urethra?

A clear understanding of the normal anatomy of the glanular urethra is essential for anatomical reconstruction of the male urethra. In hypospadias surgery, tubularization of the neourethra over a catheter or stent has been the standard method for decades. However, the male urethra is not a tubular structure with uniform configuration and diameter by forming a fossa (navicularis) in the glans penis. We recently investigated the structural anatomy of the glanular urethra using magnetic resonance imaging (MRI). We have shown that the male urethra does not have a uniform tubular structure and not covered by the corpus spongiosum to the end. The glanular urethra that forms the "fossa navicularis" has a wider caliber than the proximal urethra. Its vertical elliptical shape resembles a laterally compressed slit-like passage. The fossa navicularis is covered by a thin layer of fibrous tissue ("septum glandis") which is an extension of tunica albuginea of the corpus cavernosum and the corpus spongiosum. Our hypothesis is based on the results of MRI of the glanular urethra and the basic principles of fluid dynamics. We analyzed the flow dynamics of urine on this particular component of the urethra in terms of shape and structural properties. Because of its wider caliber than the proximal urethra, the glanular urethra (fossa navicularis) should cause an increase in pressure and a decrease in velocity of the urine flow. The navicular shape of the fossa and its elliptical external opening (the meatus) should allow urine to be expelled at higher flow rates and at opposite angles at the upper and lower corners which make the wave-like shape of the urine. It can be said that the changes in the volumetric form, pressure and velocity, as well as the wave-like shape of the urine flow are caused by the "fossa navicularis" covered by the "septum glandis". We propose that the "fossa navicularis" and "septum glandis" play a role as 'flow control chamber" in controlling the flow of the urine exiting the urethra, which must be taken into account for successful functional reconstruction of hypospadias.