Reducing fistula rate in hypospadias repair: A comparative study between standard tubularized incised plate repair and incorporation of a layer of spongiosum tissue.

INTRODUCTION: The most prevalent complication in hypospadias repair is fistula formation. Adhering to the principle of providing urethroplasty coverage to mitigate fistula occurrence, we implemented a modification by integrating a spongiosum layer between the urethroplasty and the dartos flap. Our hypothesis posited that this approach would result in a reduced fistula formation rate. METHODS: This study is a comparative analysis involving patients under 18 years of age who underwent primary hypospadias repair. The cases were allocated into two groups. In the study group, in addition to performing tubularized incised plate (TIP) repair, a spongiosum layer harvested from both sides of the urethra was used to cover the urethroplasty (modification of the Y-to-I urethroplasty). The control group underwent a standard TIP repair. The primary outcome was to assess urethrocutaneous fistula formation. Secondary outcomes included evaluating the development of meatal stenosis and glans dehiscence, along with assessing cosmetic results by the Hypospadias Objective Penile Evaluation (HOPE) score. RESULTS: Overall, 154 hypospadias cases were included in the study. Eighty-seven patients (56%) were allocated to the study group, and 67 (44%) were allocated to the control group. Urethrocutaneous fistula developed in 3 (3.4%) and 11 (16.4%) patients in the study and control group, respectively (p = 0.006). Glans dehiscence occurred in 2 (2.3%) patients in the study group and 4 (6%) patients in the control group (p = 0.198). Meatal stenosis was observed in 4 (4.6%) patients in the study group and 5 (7.5%) patients in the control (p = 0.452). The mean HOPE score was 59 in both groups (p = 0.36). DISCUSSION: This study details our encounters with the novel modification and compares the results with standard TIP. Our data suggest that adding a layer of spongiosum tissue over the urethroplasty reduces the complication of urethrocutaneous fistula without increasing the occurrence of dehiscence, significant meatal stenosis, or compromising cosmetic outcomes. CONCLUSION: We advocate for implementing the described surgical modification as a viable option for hypospadias repair.

Preventing Rectourethral Fistula Recurrence With Gracilis Flap.

BACKGROUND: Rectourethral fistula (RUF) is an uncommon serious condition with various etiologies including neoplasm, radiation therapy, and surgery. Treatment for RUF remains problematic with a high recurrence rate. Although studies have suggested the recurrence rate of RUF is lower after surgical repair using a gracilis flap, outcomes have varied and the studies were small and inadequately controlled. Here, we compare outcomes of RUF repair with and without gracilis flap to evaluate its efficacy in preventing fistula recurrence and identify risk factors for recurrence. METHODS: We retrospectively reviewed patients who had undergone surgical repair for RUF between 2007 and 2018 at our institution and had at least 30 days of follow-up. Patient demographics, comorbidities, and surgical outcomes were recorded and compared for patients who had gracilis flap repair and those who did not (controls). Single variable logistic regression analysis was used to identify risk factors for recurrence. RESULTS: The gracilis group (n = 24) and control group (n = 12) had similar demographics and comorbidities. Fistula recurrence was far less frequent in the gracilis group (8% vs 50%, P = 0.009). There were no significant differences in other outcomes including length of hospitalization and surgical complications. When recurrent RUF was treated with a muscle flap (gracilis or inferior gluteus), 83% of the group had no additional fistula recurrence. In the control group, history of radiation ( P = 0.04) and urinary incontinence ( P = 0.015) were associated with fistula recurrence. CONCLUSIONS: We recommend using a gracilis flap for RUF repair given its association with lower recurrence without increased surgical complications.

Incised urethral diversion reduces the rate of fistula after one-stage hypospadias repair: a single-center retrospective controlled study.

OBJECTIVE: Urethrocutaneous fistula is the most prevalent complication after hypospadias repair. The aim of this study was to evaluate whether incised urethral diversion was superior to traditional transurethral diversion in minimizing complications. PATIENTS AND METHODS: We retrospectively collected and analyzed 113 cases with proximal penile or penoscrotal hypospadias that were repaired by one-stage transverse preputial island flap urethroplasty between January 2016 and January 2020. Of those cases, 60 used incised urethral diversion (group A), whereas the remaining 53 were managed by transurethral diversion (group B) for urinary drainage after surgery. Postoperative complications in both groups were assessed for fistula, urethral diverticulum, meatal stenosis, wound infection, and distal urethral breakdown. RESULTS: Fistula was reported in 2 patients (3.3%) in group A, while it was observed in 15 patients (28.3%) in group B (p < 0.001). Wound infection occurred in one patient (1.7%) in group A, compared with six patients (11.3%) in group B (p < 0.05). The incidence rates of distal urethral breakdown were 1.7% (1/60) and 11.3% (6/53) for group A and group B, respectively (p < 0.05). One patient (1.7%) in group A and three patients (5.7%) in group B had a meatal stenosis (p > 0.05). There were two patients who developed urethral diverticulum in either group (p > 0.05). CONCLUSIONS: The use of incised urethral diversion for urinary drainage had an advantage over transurethral diversion in one-stage hypospadias repair with respect to the post-operational fistula occurrence, wound infection, and distal urethral breakdown.

Efficacy of additional tunica vaginalis flap coverage for protecting against urethrocutaneous fistulas in tubularized incised plate urethroplasty: A prospective, randomized controlled trial.

PURPOSE: We compared the protective effect of additional tunica vaginalis flap coverage combined with a dartos flap against urethrocutaneous fistulas in tubularized incised plate (TIP) urethroplasty in a randomized controlled trial. MATERIALS AND METHODS: This prospective, randomized controlled trial in a single tertiary center enrolled 50 patients in whom it was feasible to perform single TIP urethroplasty between 2016 and 2017. Consecutive children were randomly allocated to study group A (additional tunica vaginalis flap coverage, n=25) or control group B (dartos-only coverage, n=25). All patients were examined in the outpatient clinic at 1, 3, 12, and 24 months. Postoperative cosmetic outcomes were evaluated by surgeons and parents using the Pediatric Penile Perception Scale questionnaire. RESULTS: In group B, 1 of 25 patients (4.0%) developed an urethrocutaneous fistula within 12 months. An additional two cases of fistula were found in all proximal-type hypospadias patients at 24 months in the same group without statistical significance (p=0.07). The penile cosmetic satisfaction rate was not significantly different between the groups according to scores on the Pediatric Penile Perception Scale. CONCLUSIONS: Our randomized controlled trial did not show a significant decrease in the incidence of or a significant slowing of the progression of postoperative fistulas after TIP urethroplasty by the use of additional tunica vaginalis coverage. A tunica vaginalis flap is not routinely recommended but could have a selective role in proximal-type TIP urethroplasty with deficient dartos and subcutaneous tissue to cover the neourethra.

Preoperative Topical Estrogen Treatment vs Placebo in 244 Children With Midshaft and Posterior Hypospadias.

PURPOSE: Urethral fistula and dehiscence are common after hypospadias surgery. Preoperative androgens have been considered to reduce these complications although this consideration is not evidence-based. Dermatologists have reported the benefits of topical estrogens on skin healing. We investigated whether the preoperative use of topical promestriene could reduce healing complications in hypospadias surgery. Our primary objective was to demonstrate a reduction of healing complications with promestriene vs placebo. Impact on reoperations and other complications, clinical tolerance, bone growth, and biological systemic effects of the treatment were also considered. METHODS: We conducted a prospective, randomized, placebo-controlled, double-blind, parallel group trial between 2011 and 2015 in 4 French centers. One-stage transverse preputial island flap urethroplasty (onlay urethroplasty) was selected for severe hypospadias. Promestriene or placebo was applied on the penis for 2 months prior to surgery. The primary outcome was the presence of postoperative urethral fistula or dehiscence in the first year postsurgery. For safety reasons, hormonal and anatomical screenings were performed. RESULTS: Out of 241 patients who received surgery, 122 patients were randomized to receive placebo, and 119 patients received promestriene. The primary outcome was unavailable for 11 patients. Healing complications were assessed at 16.4% (19/116) in the placebo vs 14.9% (17/114) in the promestriene arm, and the odds ratio adjusted on center was 0.93 (95% confidence interval 0.45-1.94), P = 0.86. CONCLUSIONS AND RELEVANCE: Although we observed an overall lower risk of complications compared to previous publications, postsurgery complications were not different between promestriene and placebo, because of a lack of power of the study or the inefficacy of promestriene.

Use of a Split Pedicled Gracilis Muscle Flap in Robotically Assisted Vaginectomy and Urethral Lengthening for Phalloplasty: A Novel Technique for Female-to-Male Genital Reconstruction.

The authors describe the technique of robotic vaginectomy, anterior vaginal flap urethroplasty, and use of a longitudinally split pedicled gracilis muscle flap to recreate the bulbar urethra and help fill the vaginal defect in female-to-male gender-affirming phalloplasty. Vaginectomy is performed by means of the robotically assisted laparoscopic transabdominal approach. Concurrently, gracilis muscle is harvested and passed through a tunnel between the groin and the vaginal cavity. It is then split longitudinally, and the inferior half is passed into the vaginal cavity; it is inset into the vaginal cavity. Following urethroplasty, the superior half of the gracilis flap is placed around the vaginal flap to buttress this suture line with well-vascularized tissue. From May of 2016 to March of 2018, 16 patients underwent this procedure. The average age of the patients was 35.1 ± 8.8 years, average body mass index was 31.4 ± 5.5 kg/m, and average American Society of Anesthesiologists class was 1.8 ± 0.6. The average length of surgery was 423.6 ± 84.6 minutes, with an estimated blood loss of 246.9 ± 84.9 ml. Patients were generally out of bed on postoperative day 1, ambulating on postoperative day 2, and discharged to home on postoperative day 3 (average day of discharge, 3.4 ± 1.4 days). At a mean follow-up time of 361.1 ± 175.5 days, no patients developed urinary fistula at the urethroplasty site. The authors' use of the longitudinally split gracilis muscle in first-stage phalloplasty represents a novel approach to providing well-vascularized tissue to achieve both urethral support and closure of intrapelvic dead space, with a single flap, in a safe, efficient, and reproducible manner. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Retardation of Preputial Wound Healing in Rats with Hypospadias Induced by Flutamide.

Objective: The aim of this study was to identify a theoretical support for the prevention of urethral fistula following hypospadias repair, by comparing the preputial wound healing process in Sprague-Dawley (SD) rats with and without hypospadias induced by flutamide. Methods: Fifteen pregnant SD rats were randomly divided into three groups. These rats in one group received the androgen receptor antagonist flutamide (25 mg/kg/day) from gestation days 11-17, to establish a rat model of hypospadias for further study of the molecular mechanisms of the hypospadias etiology. The pregnant rats in the control groups were not administered flutamide. The pups from the control and experiment groups underwent an incision on the dorsal prepuce on postnatal day 25 and were sacrificed on postoperative days 3, 7, and 14 to collect penis samples. The penis morphology was examined in all groups. Subsequently, transforming growth factor ß1 (TGF-ß1), α-smooth muscle actin (α-SMactin), and signal transducers and activators of the transcription 3 (STAT3) expression levels in the different groups were measured at the indicated time points postoperatively using qRT-PCR and Western blot. Results: There was less regeneration of the subcutaneous tissue in hypospadias rats than in the sham-operated group (P < 0.05) on postoperative day 3. No differences were found in the regeneration of the subcutaneous tissue between these groups on postoperative days 7 or 14. Additionally, there were no differences in the epithelial cell regeneration between the control and the hypospadias groups at any postoperative timepoint. Moreover, the expression levels of TGF-ß1, α-SMactin, and STAT3 were all significantly lower in hypospadias group than that in the sham-operated group (P < 0.05). Conclusion: The results from the present work suggest that preputial wound healing is retarded in rats with hypospadias induced by flutamide and that this retardation might result from multi-gene regulation.

Colpectomy Significantly Reduces the Risk of Urethral Fistula Formation after Urethral Lengthening in Transgender Men Undergoing Genital Gender Affirming Surgery.

PURPOSE: We assessed the effect of performing colpectomy before (primary) or after (secondary) gender affirming surgery with single stage urethral lengthening on the incidence of urethral fistula in transgender men. MATERIALS AND METHODS: We retrospectively reviewed the charts of all transgender men who underwent gender affirming surgery with urethral lengthening between January 1989 and November 2016 at VU University Medical Center. Patient demographics, surgical characteristics, fistulas and fistula management, and primary and secondary colpectomy were recorded. Descriptive statistics were calculated and incidence rates were compared. RESULTS: A total of 294 transgender men underwent gender affirming surgery with urethral lengthening. A urethral fistula developed in 111 of the 232 patients (48%) without colpectomy and in 13 of the 62 (21%) who underwent primary colpectomy (p <0.01). Secondary colpectomy resulted in 100% fistula closure when performed in 17 patients with recurrent urethral fistula at the proximal urethral anastomosis and the fixed part of the neourethra. CONCLUSIONS: Primary colpectomy decreases the incidence rate of urethral fistulas. Secondary colpectomy is also an effective treatment of fistulas at the proximal urethral anastomosis and the fixed part of the neourethra.

The Role of Human Acellular Dermis in Preventing Fistulas After Bladder Neck Transection in the Exstrophy-epispadias Complex.

OBJECTIVE: To evaluate human acellular dermis (HAD) as an adjunct during bladder neck transection (BNT) by comparing surgical outcomes with other types of tissue interposition. METHODS: A prospectively maintained institutional database of exstrophy-epispadias complex (EEC) patients was reviewed for those who underwent a BNT with at least 6 months follow-up. The primary outcome was the occurrence of BNT-related fistulas. RESULTS: In total, 147 EEC patients underwent a BNT with a mean follow-up time of 6.9 years (range 0.52-23.35 years). There were 124 (84.4%) classic exstrophy patients, 22 (15.0%) cloacal exstrophy patients, and 1 (0.7%) penopubic epispadias patient. A total of 12 (8.2%) BNTs resulted in fistulization, including 4 vesicoperineal fistulas, 7 vesicourethral fistulas, and 1 vesicovaginal fistula. There were 5 (22.7%) fistulas in the cloacal exstrophy cohort and 7 (5.6%) fistulas in the classic bladder exstrophy cohort (P = .019). Using either HAD or native tissue flaps resulted in a lower fistulization rate than using no interposed layers (5.8% vs 20.8%; P = .039). Of those with HAD, the use of a fibrin sealant did not decrease fistulization rates when compared to HAD alone (6.5% vs 8.8%, P = .695). There was no statistical difference in surgical complications between the use of HAD and native flaps (8.6% vs 5%, P = .716). CONCLUSION: Use of soft tissue flaps and HAD is associated with decreased fistulization rates after BNT. HAD is a simple option and an effective adjunct that does not require harvesting of tissues in patients where a native flap is not feasible.

Urethral Complications After Transgender Phalloplasty: Strategies to Treat Them and Minimize Their Occurrence.

Radial forearm free flap phalloplasty (RFFP) is the current standard of care for most FTM gender confirmation surgeries. This procedure is associated with a rate of urethral stricture as high as 51%, which falls only to 23-35% even among the most experienced contemporary surgeons. While some modifications have been proposed to combat this high complication rate, it still remains a major source of lasting morbidity. The method involves literature review of RFFP literature. Lowest stricture rates are found when neourethra is made with a long, meticulously constructed tube of well-vascularized perivaginal/periurethral and labia minora tissue. In cases of urethral stricture, urethroplasty is required in 94-96% of patients. Surgery should be delayed until all acute inflammation has subsided. Urethroplasty is technically challenging and fails in up to 50% of cases. Repeated surgery or salvage urethral exteriorization procedures, which can leave the patient with lifelong perineal urethrostomy, are often required. Patient and physician knowledge regarding the high burden and poor treatment options for urethral stricture after phalloplasty is incomplete, and patient acceptance of this reality is crucial for honest understanding of the potential complications of this increasingly common but extremely complex surgery. Clin. Anat. 31:187-190, 2018. © 2018 Wiley Periodicals, Inc.

Buck's fascia repair with glanuloplasty in hypospadias surgery: A simple approach with excellent outcome.

BACKGROUND: Hypospadias is a common problem encountered in surgical practice and its repair is challenging because of various complications. Urethro-cutaneous fistula is the most common postoperative complication (incidence of 0-33%). Different types of intermediate protective layers have been used in attempts to decrease UCF formation; however, no single surgical technique is ideal. OBJECTIVE: The aim of this study was to compare use of dartos fascia and Buck's fascia as intermediate layers in prevention of the formation of UCF. STUDY DESIGN: This was a prospective, comparative study conducted over a period of 2 years from January 2014 to December 2015. Patients with primary hypospadias without or with mild ventral penile curvature were included in the study. Patients were categorised into two groups, A and B, with alternate patients assigned to each group. Patients in group A underwent Snodgrass repair with urethroplasty by two-layer subepithelial closure and dartos tissue as an intermediate layer. Patients in group B underwent a urethral repair followed by Buck's fascia repair as intermediate layer and glanuloplasty after excision of a triangular skin strip on either side of the urethral plate. Patients were followed at regular intervals for a minimum of 6 months and complications were noted. RESULTS: Over a period of 2 years, 160 patients were included in the study: 80 patients in group A and 80 patients in group B. The age of patients ranged from 1 year to 4.6 years, with a mean age of 1.8 years. Postoperative complications are listed in the summary table. DISCUSSION: A protective intermediate layer between the neourethra and the skin can be used to reduce fistula formation. We describe a technique of urethroplasty using Buck's fascia as intermediate layer and glanuloplasty, with excellent results. Buck's fascia over the corpora spongiosum which is deficient ventrally in hypospadias is not completely absent, and can be easily used to cover the neourethra, needs minimal dissection and hence vascularity of tissues is preserved (summary Fig.). We used this Buck's fascia as a second protective layer over the neourethra in an attempt to decrease UCF formation, and compared it with use of dartos fascia. In our study, UCF occurred in 2.5% of patients in the Buck's fascia group and 12.5% of patients in the dartos group, a statistically significant difference. We believe that the native Buck's fascia lateral to spongiosum is a more appropriate, natural, and strong layer to cover the neourethra. CONCLUSION: Use of Buck's fascia as an intermediate layer along with glanuloplasty is simple and very effective in preventing UCF formation and glanular dehiscence. We recommend the use of Buck's fascia as an intermediate layer to cover the neourethra to reduce incidence of postoperative complications and improve results.

A new material to prevent urethral damage after implantation of artificial devices: an experimental study

ABSTRACT Objective To validate the application of the bacterial cellulose (BC) membrane as a protecting barrier to the urethra. Materials and Methods Forty female Wistar rats (four groups of 10): Group 1 (sham), the urethra was dissected as in previous groups and nothing applied around; Group 2, received a 0.7cm strip of the BC applied around the urethra just below the bladder neck; Group 3, received a silicon strip with the same dimensions as in group 2; Group 4, had a combination of 2 and 3 groups being the silicon strip applied over the cellulosic material. Half of the animals in each group were killed at 4 and 8 months. Bladder and urethra were fixed in formalin for histological analysis. Results Inflammatory infiltrates were more intense at 4 months at lymphonodes (80% Grade 2), statistically different in the group 2 compared with groups 1 (p=0.0044) and 3 (p=0.0154). At 8 months, all samples were classified as grade 1 indicating a less intense inflammatory reaction in all groups. In group 2, at 8 months, there was a reduction in epithelial thickness (30±1μm) when com-pared to groups 1 (p=0.0001) and 3 (p<0.0001). Angiogenesis was present in groups 2 and 4 and absent in group 3. In BC implant, at 4 and 8 months, it was significant when comparing groups 4 with 1 (p=0.0159). Conclusion BC membrane was well integrated to the urethral wall promoting tissue remodeling and strengthening based on morphometric and histological results and may be a future option to prevent urethral damage.

A new material to prevent urethral damage after implantation of artificial devices: an experimental study.

OBJECTIVE: To validate the application of the bacterial cellulose (BC) membrane as a protecting bar-rier to the urethra. MATERIALS AND METHODS: Forty female Wistar rats (four groups of 10): Group 1 (sham), the urethra was dissected as in previous groups and nothing applied around; Group 2, received a 0.7cm strip of the BC applied around the urethra just below the bladder neck; Group 3, received a silicon strip with the same dimensions as in group 2; Group 4, had a combination of 2 and 3 groups being the silicon strip applied over the cellulosic material. Half of the animals in each group were killed at 4 and 8 months. Bladder and urethra were fixed in formalin for histological analysis. RESULTS: Inflammatory infiltrates were more intense at 4 months at lymphonodes (80% Grade 2), statistically different in the group 2 compared with groups 1 (p=0.0044) and 3 (p=0.0154). At 8 months, all samples were classified as grade 1 indicating a less intense inflammatory reaction in all groups. In group 2, at 8 months, there was a reduction in epithelial thickness (30±1µm) when com-pared to groups 1 (p=0.0001) and 3 (p<0.0001). Angiogenesis was present in groups 2 and 4 and absent in group 3. In BC implant, at 4 and 8 months, it was significant when comparing groups 4 with 1 (p=0.0159). CONCLUSION: BC membrane was well integrated to the urethral wall promoting tissue remodeling and strengthening based on morphometric and histological results and may be a future option to prevent urethral damage.

Urinary Catheterization: a Paradigm Shift in Difficult Urinary Catheterization.

BACKGROUND: The urinary catheter is an ancient device for urinary drainage in patients. Placement of a urethral catheter is a common medical procedure that may have led to morbidity and mortality. Urethral catheterization is commonly performed by a nurse. Difficult catheter placement generates urology consultation. Difficult catheterization with a vision-guided urinary catheter may provide expedited and successful catheter placement by nursing personnel. METHODS: A PubMed.gov and Ovid Medline search for articles on history of urinary catheter, difficult urinary catheterization, iatrogenic urethral injury, iatrogenic urethral injury and CAUTI, management of iatrogenic urethral injury, and techniques for urinary catheter placement was performed. RESULTS: The history of urinary catheters is reviewed. Technical advances in the last century are discussed. Indications for catheter placement are included. Outcomes and cost of complications of urinary catheters are discussed relative to present practice quality standards. Review of difficult urinary catheterization management algorithms developed with urological catheter improvements during the last decade is analyzed. Educational and technological advances to improve outcomes of urinary catheter use are addressed. CONCLUSIONS: Provider attention to issues of urinary catheterization is enhanced by education and additional skills for catheterization. Physician and nurse providers can use current technology with preparation to improve the catheterization care of patients.

Characteristics Associated With Urethral and Rectal Gonorrhea and Chlamydia Diagnoses in a US National Sample of Gay and Bisexual Men: Results From the One Thousand Strong Panel.

BACKGROUND: Gay and bisexual men are at elevated risk for Neisseria gonorrhoeae and Chlamydia trachomatis (GC/CT). Rectal GC/CT symptoms may be less obvious than urethral, increasing opportunities for undiagnosed rectal GC/CT. METHODS: A US national sample of 1071 gay and bisexual men completed urethral and rectal GC/CT testing and an online survey. RESULTS: In total, 6.2% were GC/CT positive (5.3% rectal, 1.7% urethral). We calculated adjusted (for education, race, age, relationship status, having health insurance, and income) odds ratios for factors associated with rectal and urethral GC/CT diagnoses. Age was inversely associated with urethral and rectal GC/CT. Compared with white men, Latinos had significantly greater odds of rectal GC/CT. Among men who reported anal sex, those reporting only insertive sex had lower odds of rectal GC/CT than did men who reported both insertive and receptive. There was a positive association between rectal GC/CT and number of male partners (<12 months), the number of anal receptive acts, receptive condomless anal sex (CAS) acts, and insertive CAS acts. Compared with those who had engaged in both insertive and receptive anal sex, those who engaged in only receptive anal sex had lower odds of urethral GC/CT. The number of male partners (<12 months) was associated with increased odds of urethral GC/CT. CONCLUSIONS: Rectal GC/CT was more common than urethral and associated with some demographic and behavioral characteristics. Our finding that insertive CAS acts was associated with rectal GC/CT highlights that providers should screen patients for GC/CT via a full range of transmission routes, lest GC/CT go undiagnosed.

Reanastomosis uretro vesical por extraccion accidental de sonda vesical tras prostatectomia radical / Urethrovesical redo anastomosis after accidental removal of the urethral catheter after radical prostatectomy

No disponible

Management of anorectal malformation without ligation of fistula: an approach preventing posterior urethral diverticula.

OBJECTIVE: The posterior urethral diverticulum is a common urologic complication requiring reoperations in anorectal malformation cases (ARM). We present a series of 24 cases of male ARM managed without ligation of fistula. MATERIAL AND METHODS: A prospective study was conducted between July 2010 and June 2012 including male neonates with ARM, where rectobladder neck and rectoprostatic fistula were approached by the abdominal route. The fistulous tract was dissected to the distal-most possible length and was excised flush with the urethra without its ligation. A per-urethral catheter was placed in situ. A record was made of any features of urinary leak and a micturating cystourethrogram was performed at the 1-year of follow-up. RESULTS: Twenty-four cases of ARM, 16 with rectobladder neck fistula and eight cases with rectoprostatic fistula were included. Of these, 12 had single-stage primary abdominoperineal pull-through and 10 were managed by primary posterior sagittal anorectoplasty. Two cases with colostomy during the neonatal period were managed by laparoscopic assisted anorectoplasty at 6 months. None of the cases had a urinary leak during the postoperative period. All had a normal micturating cystourethrogram at 1 year. CONCLUSIONS: The approach of dividing fistula without ligation may prevent posterior urethral diverticula, but larger long-term follow-up studies are needed.

[Biodegradable catheters for fistula prevention in hypospadias. Experimental preliminary study]. / Sondas biodegradables para la prevención de las fístulas de hipospadias. Estudio preliminar experimental.

INTRODUCTION: Continuous technical innovations are not enough to resolve the high incidence of fistula after hypospadias repair. A urethral catheter-tutor made of reabsorbable polymeric biomaterial (RPB) which could be left in situ long enough could reduce the complications. TARGET: To investigate in an animal model differents RPB to be used in urology. METHODOLOGY: CRL Wistar rats, males, divided into 5 equal groups according to the used polymers: polylactide; lactic-coprolactone copolymer; lactic-glycolic copolymer; simulated; control silicones. Three individuals were sacrificed per group at 4th, 10th and 16th week. In all animals (exceptuating the simulated group), biomaterial was fixed to the bladder wall bylaparotomy. Animals remained in individual housing and kept under daily control of hematuria during the first 15 days and weekly weight and urine control for pH and lactate. After being slaughtered, remaining polymer was collected for chemical analysis and bladder tissue for hystologic study. RESULTS: There was no mortality, hematuria nor other clinical signs. The bladder wall showed a mild foreign body reaction. The values of lactate and pH in urine did not reach toxic levels. Lactic-glycolic was totally reabsorbed by the 10th week and had the lowest degree of calcification. Polylactide and lactic-coprolactone remained intact. CONCLUSION: The model of urinary bladder has proven useful for studying the degradation of bioresorbable polymers. The analyzed polymers have spent long time to be reabsorbed, so we will have to study new others.

Incidence of genital warts in adolescents and young adults in an integrated health care delivery system in the United States before human papillomavirus vaccine recommendations.

BACKGROUND: Information on genital wart incidence in adolescents and young adults before human papillomavirus (HPV) vaccination is important for understanding the impact of the vaccine on the epidemiology of this early outcome of HPV infection. METHODS: The study population included 11- to 29-year-old enrollees of Northern California Kaiser Permanente between July 1, 2000, and July 1, 2005, before the availability of the HPV vaccine. We identified genital warts with an algorithm combining genital wart-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes (078.10, 078.11, and 078.19) with physician-recorded anatomic locations. We calculated sex- and age-specific incidence rates of genital warts and described the specific anatomic location of presentation, as well as recurrences of genital warts. RESULTS: We identified 1,682 cases of genital warts among 181,264 individuals. The incidence rate was highest among women (6.3/1000 person-years) and men (2.9/1000 person-years) aged 20 to 24 years old. Among women (n = 96,792), 63.4% of the 1240 incident genital wart cases occurred on the vulva and 21.1% on the cervix. Among men (n = 84,472), 91.6% of the 442 incident genital wart cases did not have a specific anatomic location recorded. Most people with an incident genital wart diagnosis (87.2%) did not have a recurrence during the observation period. CONCLUSIONS: Our study found that the incidence of genital warts was highest among persons aged 20 to 24 years using a unique method to identify the location of the wart. Information on incidence of genital warts before vaccine use provides baseline data that can be used to measure HPV vaccine impact.

Surgical treatment and prevention of recurrence of urethral calculi associated with hairballs after urethroplasty.

OBJECTIVES: To evaluate technical aspects and outcome of preventing urethrocutaneous fistula and calculi recurrence in surgical treatment of urethral calculi associated with hairballs after urethroplasty. PATIENTS AND METHODS: Sixteen patients who had urethral calculi associated with hairballs after urethroplasty underwent urethrolithotomy and trimming and epilation of the neourethra. While operating, we made a staggered incision of the skin and urethra, carefully sutured the urethral incision, and covered it by well-vascularized tissue. A tube-in-tube stent method was performed on the latter 12 patients for better drainage of the exudates that accumulated in the urethra. RESULTS: All calculi were successfully removed. Surgical site infection occurred in the last one of the former 4 patients and resulted in an urethrocutaneous fistula. There were no other complications. All patients were followed up for 2-7 years; no urethral stenosis or recurrence of calculi was observed, and remarkable reduction of urethral hair was obtained. CONCLUSIONS: Urethrolithotomy and trimming and epilation of the neourethra seem to be appropriate treatments for urethral calculi associated with hairballs after urethroplasty. Full attention should be paid to fistula prevention.