Should routine pyeloureterostomy be advocated in adult kidney transplantation? A prospective study of 283 recipients.

PURPOSE: Ureteroneocystostomy surgical techniques have been repeatedly debated in the medical literature, in contrast to pyeloureterostomy, which is merely considered a salvage procedure. We assessed urological complications and their management after routine pyeloureterostomy in adult kidney transplantation cases. MATERIALS AND METHODS: We performed a 2-center, uncontrolled, prospective study from January to December 2007. We compared results in 151 consecutive kidney transplantations with routine pyeloureterostomy (group 1) and in 129 procedures with extravesical anti-reflux ureteroneocystostomy (group 2). Perioperative ureteral stenting was done on demand in each group. Major complications included complex leakage, stenosis and surgical revision. Transient leakage or obstruction less than 15 days in duration were considered minor complications. RESULTS: Recipients in group 1 were more likely to undergo ureteral stenting on demand than those in group 2 (68.9% vs 21.7%). The incidence of overall complications was similar in groups 1 and 2 (9.3% and 13.2%, respectively, p = 0.15), although the major complication rate was higher in group 2. Group 1 recipients had a tendency to require long-term ureteral stenting more often. The only recipient with ureteral necrosis in group 1 was treated with surgical resection and repeat end-to-end ureteroureterostomy. In each group no graft was lost due to urological complications or their management. CONCLUSIONS: Routine pyeloureterostomy is a safe technique that may be a valuable alternative to ureteroneocystostomy for adult renal transplantation. It does not preclude further open re-intervention. Its main advantages include a significant decrease in the risk of surgical re-intervention, the opportunity to perform further endourological procedures on the allograft urinary system and the avoidance of vesicoureteral reflux.

Use of forearm free-flap phalloplasty in bladder exstrophy adults.

OBJECTIVE: To assess the long-term outcome and cosmetic results of forearm free-flap phalloplasty for correcting micropenis associated with bladder exstrophy in men. PATIENTS AND METHODS: From 1992 to 2000, six men with bladder exstrophy and unsatisfactory penile appearance underwent phalloplasty at our institution. The mean (range) follow-up was 113 (62-153) months. The surgical procedure consisted of a modified radial free-flap phalloplasty and prosthesis implantation. One-stage urethroplasty was electively performed according to the patient's voiding pattern. Early and late complications were recorded and quality of life after phalloplasty was assessed. RESULTS: The mean (range) age was 21.2 (17-26) years and flap survival was 100%. Two incontinent patients underwent immediate perineal urethrostomy. One sepsis occurred, requiring the removal of the penile prosthesis and a cutaneous continent urinary diversion; this patient was the only one to complain about the outcome. Two anastomotic urethral strictures were conservatively treated by endoscopic urethrotomy and only one patient underwent subsequent urethral self-dilatations. Five patients were very satisfied with the cosmesis of the neophallus and three patients reported having regular sexual intercourse. CONCLUSIONS: Although short, this series indicates the low incidence of early complications and the excellent long-term satisfaction with forearm free-flap phalloplasty in bladder exstrophy. Phalloplasty has potential indications when adult exstrophy patients are dissatisfied with the cosmetic appearance of their external genitalia or have unsatisfactory sexual intercourse.