The use of midurethral sling in the correction of low-stage cystoceles: a prospective randomized trial.

INTRODUCTION AND HYPOTHESIS: The objective was to assess whether midurethral slings (MUS) can improve both stress urinary incontinence (SUI) and cystoceles. MUS with anterior colporrhaphy (AC) as a treatment for SUI with cystocele is more invasive and carries greater risk than MUS alone. METHODS: This is a prospective randomized study involving women with stage 1 or 2 cystocele and SUI, who were > 21 years of age, who had had no previous surgery for SUI. Predominant SUI, symptomatic anterior pelvic organ prolapse, and informed consent were mandatory. Patients were randomized as to whether AC had been performed. The sling procedure was left to the surgeon's discretion: pubovaginal sling, tension-free vaginal tape, or trans-obturator tape. Success was defined as a negative stress test and no evidence of cystocele upon local examination. RESULTS: Ninety-eight patients were enrolled, 48 underwent MUS, and 50 underwent MUS and AC. Mean age ± SD was 44.96 ± 8.13 years. Baseline characteristics were similar. Operative time and blood loss were significantly higher in the MUS/AC group (p = 0.01 and 0.02 respectively). At 3 months, success was 79.1% and 77.8% in the MUS and MUS/AC groups respectively. This was maintained until 6 months (79.1% and 77.8% respectively). At 1 year, the results were comparable with success rates of 96.2% and 87.0% in the MUS and MUS and AC groups respectively. Symptom scores were comparable at 6- and 12-month evaluations. CONCLUSION: Midurethral slings correct symptomatic stage 1 or 2 cystoceles without the need for AC, which carries the risk of a significantly longer procedure and more significant blood loss.

Bladder function in children with posterior urethral valves: impact of antenatal versus postnatal diagnosis

ABSTRACT Purpose: Posterior urethral valves (PUVs) are the most common cause of congenital bladder obstruction in boys. Our aim was to assess the impact of early diagnosis and fulguration of PUVs on bladder function and compare their functional and urodynamic outcome with children who underwent delayed intervention. Materials and Methods: We retrospectively evaluated 153 patients who underwent primary valve ablation from two tertiary hospitals between 2001 and 2018. Patients have been divided into 2 groups, group 1 included 69 patients who were detected antenatally and underwent early fulguration of PUVs while group 2 included 84 children presented postnatally and underwent delayed valve ablation. The recorded data throughout follow-up in renal function tests, urodynamics and changes in the upper urinary tracts were evaluated and compared. Results: Median age at time of valve ablation was 10 days in group 1 and 7 months in group 2. The median follow-up period was 6.5 and 7 years in group 1 and 2, respectively. Chronic kidney disease (CKD) developed in 15 (22%) boys in group 1 while in group 2 it was observed in 31 (37%), p=0.04. While Q-max, mean bladder capacity and post-void residual (PVR) volumes were comparable in both groups, percent PVR was significantly higher in group 2 (3.27 vs. 1.44, p=0.002). Detrusor overactivity was slightly different in both groups (p = 0.07). Conclusions: Compared to delayed intervention, primary ablation of PUVs during the early neonatal life possibly provides the optimum chance to have optimum renal function without impact on bladder function.

Reporting and grading of complications after mid-urethral sling surgeries: Could the "Clavien-Dindo Classification" be adopted?

BACKGROUND: To construct a modified model for reporting and grading of postoperative complications after the mid-urethral sling (MUS) procedure based on the Clavien-Dindo classification. In addition, complications of three different types of MUS were compared. MATERIALS AND METHODS: A PubMed search for postoperative complication after MUS was carried out for the period between January 1990 and July 2018. Reported complications were stratified in a plate form designed in accordance with grades of the Clavien-Dindo classification. Then, the proposed model was applied on reported complications in 160 females who underwent three different procedures of MUS (transvaginal tape [TVT], transobturator tape [TOT], and autologous fascial sling) with a minimum follow-up of 24 months. RESULTS: The mean ± SD age at time of surgery was 46 ±â€Š7 years. TVT was carried out in 75 (47%) patients, TOT in 40 (25%), and fascial sling in 45 (28%). The total number of complications was 62 in 43 (26.8%) patients. The vast majority of complications were Grade I and Grade II 19 (12%) and 21 (13%) out of 160 patients, respectively. Transient postoperative voiding difficulty (Grade II) and de novo urgency (Grade II) were the most prevalent complications in the fascial sling method (15.4% for each), whereas transient thigh pain (Grade II) was the most frequently reported complication after TOT (10%). Life-threatening vascular injury (Grade IV-a) was a serious complication in TVT cases. CONCLUSIONS: Postoperative complications of the MUS could be graded according to Clavien's classification. The vast majority of complications were Graded I or II. TVT can cause serious life-threatening complications.

Trigonal-sparing versus trigonal-involved Botox injection for treatment of idiopathic overactive bladder: A randomized clinical trial.

OBJECTIVE: To evaluate safety and efficacy of trigone-involved Botox injections in comparison with trigone-sparing injections in refractory idiopathic overactive bladder (OAB). MATERIALS AND METHODS: One hundred and three patients randomly received a 100-IU intradetrusal injection of Botox either sparing the trigone (52 patients) or involving the trigone (51 patients). Patients were prospectively evaluated at 1, 3, and 6 months. Efficacy was evaluated by 3-day voiding diaries, OAB symptom score (OABSS), and pressure flow study. Any complications were recorded. An ascending cystogram was done at 3 months for detection of vesicoureteral reflux. Urinary tract infection (UTI) was estimated on urine culture basis. Primary outcome was the difference of total OABSS at 3 months. RESULTS: The mean age ± SD was 34.3 ± 10 years (range 18-59 years). There was a reduction of episodes of all components of OAB in both groups in comparison with baseline by the end of the study but without significant difference between both groups. The trigonal-sparing group had less score of frequency compared with the trigonal-involved group throughout the study period (P < .05). There was no difference in OABSS at 3 months (1.5 ± 0.4 vs 1.6 ± 0.3, P .875). Two patients in the trigonal-involved group out of 51 (3.9%) were in need of clean intermittent catheterization because of voiding difficulty and a postvoid residual > 200 mL. There was a higher rate of UTI in the trigonal-involved group ranging from 5.6% up to 11.7% at each follow-up visit. No patient had reflux. CONCLUSION: Trigone injections are not superior to trigone-sparing injections. On the contrary, the incidence of UTI and voiding difficulty were higher. The concept of reflux induced by trigonal injection has not been proven.

How correlated is BOO with different objective parameters commonly used in evaluation of BPH: a prospective study.

OBJECTIVES: The use of non-intubated uroflowmetry, PVR, prostate volume, and I-PSS are the most commonly used tools for the evaluation of patients with BPH. In this prospective study, we elucidated the correlation between BOO as rated by pressure-flow study in men with LUTS attributed to BPH and those parameters. METHODS: Over a period of 2 years 460 men above the age of 45 years old (mean age 60.46 ± 9.4) were prospectively included in this study. Symptoms were evaluated using the International Prostate Symptom Score, and digital rectal examination, prostate-specific antigen, and transrectal ultrasound were done. The urodynamic evaluation included uroflowmetry, filling cystometry, and voiding cystometry with the plotting of pressure-flow study according to Lin-PURR (Schäfer's nomogram). The correlation coefficient was calculated between these variables. RESULTS: The correlation of other objective parameters with total score was not much better. The Spearman's correlation coefficient were - 0.09, 0.07 and - 0.1 for prostate weight, post voiding residual urine and maximum free flow rate respectively. Correlations between Schäfer's grade and Qmax, PVR and prostate volume were found to be weak to fair correlation (r values were - 0.4, 0.18, and 0.39 respectively). CONCLUSION: Objective non-invasive parameters most commonly used in the evaluation of men with LUTS attributed to BPH have limited correlation with obstruction, as diagnosed by pressure flow nomogram.

Retropubic bulbourethral sling in incontinence post-exstrophy repair: 2-year minimal follow up of a salvage procedure.

AIMS: Post-exstrophy incontinence is a challenge because continence is difficult to achieve and more difficult to maintain. Feasibility and outcomes of a bulbourethral sling to treat post-exstrophy incontinence is shown in this report. METHODS: A retropubic bulbourethral sling was applied to male patients with incontinence post-exstrophy-epispadius repair. The study included children with total (continuous) incontinence who underwent multiple previous anti-incontinence procedures, ranging from bladder neck injection to bladder neck reconstruction. Preoperative assessment includes urinalysis, renal US, VCUG, 1-hr pad test and urodynamics. The bulbourethral sling applied is made of polypropylene and is suspended by 4 pairs of nylon sutures, to support the bulbar urethra within its covering muscles with the sutures tied on the rectus muscles. Continence was evaluated as well as adverse events. RESULTS: Seventeen children, (median age 8.7 years) completed 24-month of follow up. All had CPRE. Five children (29.27%) were dry. Four micturated through the urethra and one by catheterizing his cutaneous stoma every 3-4 hr. In none, PVR exceeded 10% of expected capacity. Four children underwent re-tightening 1-4 weeks after removal of urethral catheter. Perineal wound dehiscence occurred in one, perineal/suprapubic pain in seven and epididymo-orchitis in one child. CONCLUSION: The current technique is promising for difficult cases of incontinence after CPRE. It is safe, as no serious adverse events occurred during follow up period. It is economic and re-tightening is easy to perform. Neurourol. Urodynam. 35:497-502, 2016. © 2015 Wiley Periodicals, Inc.

Management of refractory OAB in the non-neurogenic patient.

Overactive bladder (OAB) is one of the most common bothersome urological diseases. It also has a negative economic impact. Pathophysiology entails changes in neurogenic and myogenic factors, as well as urinary biomarkers such as nerve growth factor (NGF) and prostaglandins (PGs). With symptoms from OAB-Dry to OAB-Wet, the urodynamic pattern of OAB bladder is often characterized by idiopathic detrusor overactivity with lower threshold of sensation, diminished compliance and capacity. Treatment ranges from a combination of behavioral modifications (BM)/ pelvic floor muscle training (PFMT) to combinations of antimuscarinics, Botox injection, nerve stimulation and augmentation cystoplasty. Herein, a contemporary review on the different aspects of management of refractory OAB in patients without neuropathic disorders is presented.

Detrusor after contractions in men with lower urinary tract symptoms: Myth or reality?

OBJECTIVES: To study after contractions in men with lower urinary tract symptoms (LUTS) related to bladder outlet obstruction (BOO), in the absence of neuropathy, and to verify whether it is associated with the severity of symptoms or certain filling and voiding variables. PATIENTS AND METHODS: Of 380 patients with LUTS and who were assessed using urodynamic studies, we retrospectively analysed those who had after contractions (ACs). Bladder overactivity was diagnosed as any increase in the detrusor pressure of <2-s duration during the filling phase, and an AC was diagnosed as any increase in the detrusor pressure of ⩾2 s after the end of the voiding phase and complete cessation of flow. The presence of ACs was then assessed in relation to different components of the International Prostate Symptom Score (IPSS), using a two-tailed Levene's test, and to filling and voiding cystometry variables, using Mann-Whitney-Wilcoxon Rank test. RESULTS: In all, 373 of the 380 patients were included (seven had invalid voiding cystometry); ACs were detected in 51 (13.9%). There was no statistical significance for associations between AC and any of the variables assessed, including individual questions of the IPSS, detrusor overactivity, cystometric capacity, compliance, maximum urinary flow rate (Qmax), detrusor pressure at Qmax or the maximum detrusor voiding pressure. CONCLUSION: ACs detected on voiding cystometry of men with LUTS attributed to BOO do not seem to be related to symptoms, or filling and voiding variables.

TVT versus TOT, 2-year prospective randomized study.

PURPOSE: To evaluate in a comprehensive way TVT in comparison with TOT, the results of a single-center RCT are presented. Many studies addressed efficacy and safety of TVT and TOT. METHODS: Women included were adults having predominant SUI with positive stress test. They were randomized to get either TVT (Gynecare(®)) or TOT (Aris(®)). All women were seen 1 week, 3, 6, 12, 18, and 24 months. RESULTS: Seventy-one women completed 2-year follow-up. Median age was 47 (range 33-60 years). Mean ± SD BMI in TVT group was 34 ± 5 while in TOT group was 32 ± 5 kg/m(2). POP of any degree was seen in 50 % (35 women). At 1 year, pad test-negative women were 31 and 29 for TVT and TOT, respectively. At 2 years, figures became 28 in TVT group and 27 in TOT. At 1 year, UDI 6 and IIQ 7 decreased by 78.5 and 81 % for TVT and by 69 % and 75 % for TOT group. At 2 year, comparable percentages were 73 and 79 % for TVT and 69 and 82 % for TOT. Fifteen unique patients had adverse events, 10 of them had TOT. CONCLUSIONS: Both tapes have similar efficacy, regarding cure of incontinence. TVT is more effective, albeit insignificantly, than TOT at 2 years. However, serious adverse events were more frequent with TVT, yet TOT has more unique adverse events.

Urinary tract infection before and after mid-urethral slings: culture-proven diagnosis and analysis of risk factors.

OBJECTIVES: To study prevalence of UTI in women with SUI before and after mid-urethral slings based on culture-proven diagnosis. MATERIALS AND METHODS: Clean catch midstream urine samples were collected and sent for agar culture in 150 patients before and on follow-up after mid-urethral slings visit. Degree of agreement between culture-proved UTI and clinically suspected was assessed. In addition, risk factors for UTI were analyzed. RESULTS: Preoperative culture was positive in 9 (6%) patients, 7 of them were asymptomatic. UTI was primarily diagnosed in 39 (26%) patients suggested by symptoms. No bacterial growth was detected at first postoperative day. There were 6 out of 62 (9.7%) patients who had positive urine cultures at follow-up visits, all of them were symptomatic. Eleven (18%) patients were diagnosed as UTI, based on clinical suspicion. CONCLUSION: In contrast to UTI before surgery, asymptomatic UTI is unlikely to happen after mid-urethral sling.

Repair of vesicovaginal fistula: Single-centre experience and analysis of outcome predictors.

OBJECTIVES: Data from 80 patients with a vesicovaginal fistula (VVF) were collected and analysed, to define the probable factors affecting the outcome of surgery. PATIENTS AND METHODS: In a retrospective study, the records of 80 women with a mean (SD) age of 35.8 (9) year were assessed; 40% of the VVF occurred after abdominal hysterectomy, 30% after Caesarean section, 15% after difficult vaginal delivery and 11.25% after forceps vaginal delivery. Fifteen women (18%) had a previous failed repair. The median duration of the VVF was 11.5 months. RESULTS: Of the 80 VVF, 41 were high, 30 were low, four combined high and low and five were at the bladder neck. Nine cases had multiple openings on pan-endoscopy. An abdominal approach was used in 54 patients, vaginal in 20 and a combined approach in six. The median (SD) catheter duration was 14 (3.9) days. Ureteric stents were left in 59 patients. At a mean (SD) follow-up of 33.02 (65.7) months, the VVF was cured in 65 (81%) patients. Univariate analysis of variables possibly affecting the success of surgery showed that the duration of VVF, surgical approach, previous repair and position of the VVF were significant factors. Only previous intervention and surgical approach maintained significance in multivariate analysis. CONCLUSION: An abdominal approach seems to give superior results. Previous failed repair had a significant negative effect on success. An earlier repair (<6 months) is associated with higher success rates.

Retropubic bulbourethral sling for post-prostatectomy male incontinence: 2-year followup.

PURPOSE: Post-prostatectomy incontinence is usually due to sphincter damage as a complication of prostatectomy but may result from other causes. The intermediate term outcome of the retropubic bulbourethral sling is presented. MATERIALS AND METHODS: Included in study were 40 men with post-prostatectomy incontinence who used 5 or greater pads daily for protection. All patients had undergone prostatectomy, including transurethral resection in 17, holmium laser enucleation in 3, and open retropubic and radical prostatectomy in 12 and 8, respectively. Preoperatively voiding cystourethrogram and urodynamics were done in all men as applicable. A bulbourethral sling was prepared from polypropylene mesh. Suspension was achieved using size zero nylon sutures to fix the mesh in front of the rectus sheath. Patients were followed at 1 week, 3 and 6 months, and semiannually thereafter. RESULTS: Median incontinence duration was 3 years (range 0.5 to 14). Concomitant surgery was done in 11 men (27.5%), 34 (85%) were dry at 24-month followup and 10 (25%) underwent retightening at 3 to 6 months. Urodynamics showed no significant change in filling or voiding parameters. The increase in maximum urethral closure pressure and functional urethral length was not statistically significant. CONCLUSIONS: The described retropubic bulbourethral sling is a viable option for severe male incontinence with a satisfactory cure rate at intermediate followup. It is adjustable and cost-effective.

Minimum 2-year follow-up of mid-urethral slings, effect on quality of life, incontinence impact and sexual function.

INTRODUCTION AND HYPOTHESIS: In this study, the impact of mid-urethral slings (MUS) on incontinence-related distress, quality of life and sexual function is assessed at a minimum 2 years. METHODS: Patients received either a pubovaginal sling (PVS) or a tension-free vaginal tape (TVT). The Arabic translation of urogenital distress inventory (UDI)-6, incontinence impact questionnaire (IIQ)-7, and short form Female Sexual Function Index (FSFI) were administered at baseline and 24 months. RESULTS: Sixty three women with a mean age of 47.8 years were included in this study. A median follow-up was done after 54 ± 21.9 months. Thirty nine women had PVS while 24 had TVT. Cure was defined as a significant decrease in UDI-6 and a negative stress test at 200 ml, which was found to be 93.65% and 95.2%, respectively. Overall, UDI-6 decreased from a mean preoperative value of 68.1 ± 16.9 to 27.6 ± 18.3 (p < 0.0001). IIQ-7 decreased from 70 ± 19 to 24 ± 20.8(p < 0.0001). The difference between pre- and postoperative values was insignificant. CONCLUSION: An MUS gives a cure rate of over 93% at a median follow-up of 54 months. A significant decline in UDI-6 and IIQ-7 is evident after surgery. Sexual function, as measured by the FSFI, was not significantly affected.

Novel technique for the treatment of stress urinary incontinence. Early experience.

OBJECTIVE: To evaluate the efficacy of in situ anterior vaginal wall sling, reinforced with polypropylene mesh, in the treatment of stress urinary incontinence (SUI). METHODS: Seventeen patients with mean age of 51.29 years (range: 27-73) underwent surgery for SUI from August 2006 to August 2007 at Osmaniye State Hospital, Osmaniye, Turkey. Two out of 17 patients gave history of previous anti-incontinence surgical intervention, while the remaining were primary cases. In situ anterior vaginal wall sling, reinforced with semi-size monofilament polypropylene tape (size of the mesh was similar to size of in situ sling), was used as an anti-incontinence procedure. The mean follow-up period was 9.29 months (range: 4-16). RESULTS: In-situ anterior vaginal wall sling reinforced with polypropylene mesh was successful in 16 (94.1%) patients, 14 of them were cured, and 2 had clinical improvement. There was no report of preoperative urethral, bladder, or bowel injury. One patient developed postoperative urinary retention that resolved after decreasing the tension of the suspension sutures, and one patient had suprapubic wound sepsis treated by oral antibiotics and anti-inflammatory drugs. No postoperatively significant post-voiding residue was detected. CONCLUSION: The early results of this technique are encouraging. It is easy to learn, economical, with a good success rate. Urethral erosion is less likely to occur due to the presence of intervening vaginal mucosa. In the future, a prospective study recruiting a larger number of patients undergoing this technique with long-term follow-up is recommended.

Effect of detethering on bladder function in children with myelomeningocele: Urodynamic evaluation.

AIM OF WORK: To study the effect of detethering of the cord on urodynamic changes in patients with myelomeningocele. MATERIALS AND METHODS: We retrospectively reviewed the urodynamic data of 37 patients. In all of them myelomeningocele primary repair was carried out. The patients were divided into two groups: (1) those who underwent detethering of the cord and (2) those who did not. Neurourological examination, filling cystometry, assessment of bladder management, and fecal continence were studied in all patients. RESULTS: Eleven (29.7%) out of 37 patients underwent detethering of the cord. The mean age at presentation was 10.1 ± 4 and 10.8 ± 7 years in groups 1 and 2, respectively (P 0.7). Nocturnal and diurnal enuresis was found in 45% of group 1, while it was found in 69% of group 2. Fecal soiling was detected in 18% in group 1 and in 38.5% in group 2. Mean bladder capacity was 210 ± 125 cc and 199 ± 120 cc for groups 1 and 2, respectively (P 0.8). Uninhibited detrusor contractions were noticed in nine patients (82%) of group 1 and in 21 patients (81%) of group 2. Delta det LPP was lower in group 1 (35 ± 19 cm H(2)O) than in group 2 (46 ± 40 cm H(2)0). CONCLUSION: Detethering of the cord had a positive impact on patients with myelomeningocele in terms of lowering of det LPP and accordingly decreasing the risk of upper tract deterioration.

Endoscopic excision of an eroding calcified mesh sling, 10 years after primary surgery.

Management of urethral erosion typically entails two options: sling incision (in the early postoperative period) or excision of the suburethral part of the sling (urethrolysis). This paper describes a different endoscopic technique. A forty-year-old woman with a synthetic sling implanted 10 years prior presented with persistent lower urinary tract symptoms. A kidney ureter bladder X-ray showed a stone at the level of the bladder neck. Disintegration of the stone revealed eroding mesh embedded in the urethral wall. Complete resection of the mesh using an electrocautery knife was performed. Two months since the procedure, the patient has had an uneventful course. Both vaginal and urethral walls are intact, and she is capable of normal voiding with some stress incontinence. Although it is unusual, a sling eroding the urethra is a diagnosis that needs to be considered even 10 years after surgery. Endoscopic management is feasible and can be successful.

Urethral pressure measurement in stress incontinence: does it help?

INTRODUCTION AND OBJECTIVES: The resting urethral pressure profile (UPP), used for the assessment of women with stress incontinence, is routine in many urodynamic units. It is time- and effort-consuming, and its diagnostic value is controversial, as well as its value in the prediction of outcome of anti-incontinence surgery. Herein, we assessed its value in the prediction of the outcome of surgery. PATIENTS AND METHODS: Sixty women were randomized to fascial sling or TVT. Urodynamics were performed preoperatively, 6 months and annually thereafter. After filling and voiding cystometry, resting UPP was performed while sitting. Automated catheter pulling, at a rate of 1 mm/s, was adopted. Averaged readings were obtained. Comparison of maximum urethral closure pressure (MUCP) in success and failure, as well as in sling and TVT, was performed, utilizing ANOVA. RESULTS: Preoperative MUCP and functional urethral length (FUL) were 72.9 +/- 27.9 cmH2O and 2.4 +/- 0.7 cm. At last follow-up, they were 71.1 +/- 20.7 cmH2O and 2.7 +/- 0.7 cm, respectively. The differences between sling and TVT as regards value of MUCP and FUL were not significant. The relationship of the outcome of surgery and UPP parameters showed no statistical difference. No significant effect was shown for the success of surgery, duration of follow-up, and interaction of outcome and time over MUCP (P = 0.82, 0.56 and 0.69, respectively) or FUL (P = 0.82, 0.11 and 0.67, respectively). CONCLUSION: The routine use of resting UPP has no added value in terms of the prediction of success of incontinence surgery. It does not help with follow-up and adds to the time and cost of the examination.

Dorsal dartos flap in Snodgrass hypospadias repair: how to use it?

PURPOSE: To introduce new technique for covering neourethra with dorsal dartos subcutaneous tissue in Snodgrass hypospadias repair. MATERIAL AND METHODS: The study included 26 patients with primary hypospadias, aged 2-22 years (average 7.86), operated from June 2002 to August 2006. Of the patients, 21 had distal, 3 midshaft and 2 penoscrotal hypospadias. The standard technique of tubularized incised plate (TIP) with double-layer covering of the neourethra by subcutaneous tissue was used in all cases of reconstruction. The mean follow-up period was 4.5 months (range 3-12 months). RESULTS: Successful result of a normal-looking penis without fistula was achieved in all patients. One patient had meatal stenosis (3.84%) at the early postoperative period which was corrected by urethral dilatation of the external meatus at an interval of up to 2 months postoperatively. CONCLUSION: Our technique represents a reasonable option for utilizing dorsal dartos subcutaneous tissue in TIP urethroplasty. The neourethra is covered symmetrically with a double layer of well-vascularized tissue and the penis is kept without rotation. Redundancy of the flap and its excellent vascularization depend on the harvesting technique. Further follow-up and a larger number of patients are needed before a final conclusion can be made.

Standard Snodgrass technique in conjunction with double-layer covering of the neourethra with dorsal dartos flap is the therapy of first choice for hypospadias.

PURPOSE: To evaluate the validity of the standard tubularized incised plate (TIP) urethroplasty technique for different kinds of hypospadia. MATERIALS AND METHODS: From June 2002 to December 2003 and from March 2006 to October 2007 38 patients aged 1-22 years (average 7.34) were operated using the concept of TIP urethroplasty. The hypospadiac meatus were subcoronal in 28 patients (73.68%), midshaft in six (15.78%), and penoscrotal in four (10.52%). Standard TIP urethroplasty in conjunction with double-layer covering of the neourethra with dorsal dartos flap were used in the primary cases (28 patients). In the secondary cases (four patients) and in boys who were circumcised before admission (six patients), modified TIP urethroplasty was used. The mean periods of hospitalization and follow-up were 0.92 days and 4.19 months, respectively. RESULTS: No fistulas were observed in boys who underwent primary reconstruction using standard TIP urethroplasty. Fistulas were observed in two patients (5.26%)-one patient with penoscrotal hypospadias who underwent two-stage repair and another who was circumcised before admission. One patient had meatal stenosis at the early postoperative period which was corrected by dilatation of the external meatus at intervals up to 2 months postoperatively. CONCLUSION: Standard TIP urethroplasty with double-layer covering of the neourethra with dorsal subcutaneous tissue is the procedure of choice for treatment of primary cases of distal/midshaft hypospadias. This technique seems suitable for reconstruction of proximal, secondary, and even complicated hypospadias.

A novel technique of bulbourethral sling for post-prostatectomy incontinence.

OBJECTIVE: The treatment of post-prostatectomy incontinence (PPI) can be challenging. Although many injectable materials have been used to treat this problem, the results are at best unsatisfactory. Fixation of an artificial urinary sphincter has been the gold standard of care for patients with PPI for many years. In the last decade there has been a revival of male sling techniques, involving either a fixed or dynamic compressive effect. Herein, a technique for the correction of PPI is described which involves minimal incursion of exogenous material and has excellent cost-effectiveness. MATERIAL AND METHODS: A total of 23 patients underwent a bulbourethral sling procedure using mesh suspended from the anterior abdominal wall for the management of PPI. The technique is performed under spinal anesthesia and utilizes knitted polypropylene mesh, which is fastened by three pairs of sutures. A modified Stamey needle is used for transferring nylon sutures to the suprapubic wound. The sutures are tied in front of the rectus sheath, utilizing intraoperative urodynamic guidance. A 12 F suprapubic tube is utilized as a pressure channel for monitoring vesical pressure and sling tension. RESULTS: Twenty patients were completely dry at the last follow-up, one was greatly improved and in two the treatment was considered a failure. The median follow-up period was 9 months (range 6-24 months). No urethral erosion has been reported thus far. Morbidity in the form of perineal pain and limited ambulation in the first few days after surgery were reported. Five patients had scrotal and penile numbness which continued for an average of 3 months. CONCLUSIONS: The mesh sling technique described herein is efficient and cost-effective. It yielded promising results in this study, which involved a short-term follow-up period and a limited number of patients. More cases are being enrolled and a study involving a longer follow-up period is underway.