Koyanagi urethroplasty for proximal hypospadias: A stage procedure?

OBJECTIVE: To report experience and technical refinements with the Koyanagi urethroplasty for proximal hypospadias. METHODS: A retrospective study was conducted between 2004 and 2017. Medical records of patients treated by the Koyanagi technique were investigated. The penile ventral skin was closed either with a Byars flap or using an "Ombredanne's chasuble" (OC). The cohort was divided chronologically into two groups of the same number of patients (early -E- and late experience group-LEG-). Demographics, anatomical findings and surgical outcomes were compared between groups using univariate analysis. A logistic regression was performed to assess factors associated with the occurrence of a postoperative urethrocutaneous fistula or urethroplasty dehiscence (UD). RESULTS: The Koyanagi urethroplasty was performed in 67 patients, 33 in the EEG and 34 in the LEG. The overall surgical complication rate was 64.2% (n=43), including 42 fistula or UD, higher in the EEG (81.8%) than in the LEG (44.1%, P<0.01). However, in the LEG, patients underwent the surgery older and the use of OC more frequent. After multivariate analyses, factors associated with a postoperative fistula or UD were the year of surgery (OR=0.71 [0.53-0.96] P=0.02), the age at surgery (OR=1.11 [1.01-1.22], P=0.03); contrary to the skin coverage method or the stenting duration (P>0.05). An urethral stenosis occurred in 1 patient (1.5%). At last follow-up, 64.2% of patients required a further procedure and 80.6% of urethral meatus were glandular. CONCLUSION: In this study the complication rate, particularly the urethrocutaneous fistula, remained high. Urethral stenosis, were rare but the follow-up was too short to clearly identified them. Considering as a 2 stage procedure koyanagi uretroplasty allows to obtain finally good results. LEVEL OF EVIDENCE: III.

Repeated detrusor injection of botulinum toxin A for neurogenic bladder in children: A long term option?

AIMS: Evaluation of repeated (at least 4) intra-detrusor injections of toxin botulinum A (IDI-TBA) for neurogenic bladder in a pediatric cohort. METHODS: Patients who underwent at least 4 IDI-TBA between 2005 and 2017 for neurogenic bladder related issues were included (detrusor overactivity and low compliance). Clinical and cystometric data were collected before and after the first injection and after the last injection. The primary endpoint was the proportion of patients with non-abnormal cystometry (no detrusor overactivity and normal compliance). Secondary outcomes were the evolution of the observed bladder capacity/expected ratio, surgical complications and acquired kidney impairment. RESULTS: From the 832 patients referred to our institution for neurogenic bladder, 48 underwent IDI-TBA, and 17 at least 4 injections. Among them, a total of 95 procedures were performed (median per patient 5 [4-8]). While the first injection had a significant effect for 82.3% patients, the last injection improved the medical condition for only 53.0% cases. The bladder capacity ratio, initially 36.1%, increased to 80.3% after the first injection but decreased to a level of 57.1% at last. After a median follow-up of 57 [34-102] months, no severe complications were reported but 11.8% of patients presented with repeated pyelonephritis. A bladder augmentation surgery was finally indicated for 35.3% cases. CONCLUSIONS: Despite a low complication rate and impressive cystometric results after the first injection, IDI-TBA efficacy decreased with time and repetition. These findings prone a long-term follow-up and a "à-la-carte" management of this specific population depending on the long-term response to IDI-TBA.

[Flexible ureterorenoscopy and laser lithotripsy for upper urinary tract stones in neurologic patients with severe motor disability]. / L'urétérorénoscopie souple avec fragmentation laser dans le traitement des calculs du haut appareil urinaire chez les patients atteints d'une maladie du système nerveux avec un handicap moteur sévère.

OBJECTIVE: The study's objective was to evaluate the effectiveness and morbidity of flexible ureterorenoscopy and laser lithotripsy for upper urinary tract stones in patients with a nervous system pathology including severe motor disability. METHODS: Between 2006 and 2013, we retrospectively analyzed 83 flexible ureterorenoscopy to treat 63 kidneys in 42 patients. Stone free (SF) kidneys defined as an absence of stones on computerized tomography, renal ultrasound, X-ray or direct ureterorenoscopy, were considered a surgical success. Complications were classified according to the Clavien-Dindo system. RESULTS: Success rates were 49.2 %, 57.1 % and 58.7 %, respectively after first, second and third flexible ureterorenoscopy procedure. Clearance after one procedure was achieved in 64.3 % of cases involving less than 20mm stones. No major complication (Clavien-Dindo>2) was described (0 %). Complication rates were 44.7 %, with 31.6 % Clavien-Dindo 2. The main complication was urosepsis, which occurred in 27.6 % of cases. CONCLUSION: Flexible ureteroscopy and laser lithotripsies for upper urinary tract stones in neurologic patients with severe motor disability are associated with a lower success rate and some frequent low grade complications compared to overall population. In clinical practice, the indications of flexible ureterorenoscopy for these patients seem restricted. LEVEL OF EVIDENCE: 5.

The radical soft-tissue mobilization (Kelly repair) for bladder exstrophy.

UNLABELLED: The radical soft-tissue mobilization (RSTM) technique has been proposed as an alternative for staged reconstruction of bladder exstrophy. In this video, we demonstrate the successive steps of this technique. METHODS: A newborn male with classic bladder exstrophy underwent bladder closure without pelvic osteotomies at birth; he then underwent RSTM at 1 year of age. TECHNIQUE: Mobilization: The RSTM involved simultaneous intra-pelvic and perineal dissection, aiming at full mobilization of potential urethral sphincter striated structures, levatores ani muscles, pudendal pedicles and corpora cavernosa from their attachment on the pubic bones. From the perineal approach, a periosteum incision was performed on the antero-medial aspect of the pubic bones, and the periosteum was peeled from the ischio-pubic ramus, lifting the corpora from the bone and providing control on the pudendal pedicles. The attachments of all striated muscular structures on the lower aspects of the posterior corpora (transverse perinei, bulbo-spongiosus, ischio-cavernosus muscles) were released to allow adequate re-approximation around the reconstructed urethra. Reconstruction: After ureteric reimplantation, a funnel-shaped cervicoplasty was performed and continued by urethroplasty over an 8-Fr catheter. The muscular structures mobilized from the corpora and the bones were wrapped around the neo-urethra, which was transposed ventrally in the scrotal position, creating a temporary hypospadiac urethrostomy. After abdominal wall closure, the corpora were then de-rotated, and secured to the neo-symphisis with non-absorbable sutures, and the penile skin shaft was reconstructed. RESULTS: At the 12-month follow-up, the boy was asymptomatic, still in nappies, with non-dilated upper-tracts on renal ultrasound, and dryness intervals of 90 min. CONCLUSION: Radical soft-tissue mobilization allows a tension-free bladder-neck reconstruction, and may favour development of physiological continence mechanisms independent of the inevitable pubic symphisis re-enlargement. Creation of temporary hypospadias is most often needed to maximize penile length. This technically demanding procedure requires thorough knowledge of detailed anatomy of the bladder exstrophy pelvis, as demonstrated in this video.