Further experience with the double onlay preputial flap for hypospadias repair.

PURPOSE: Severe hypospadias can be safely and reliably repaired in 1 stage using island flaps of preputial skin. However, problems with conventional techniques include penile asymmetry resulting from rotation of the vascular pedicle around 1 side of the penile shaft and at times doubtful viability of the Byars flaps used for ventral skin coverage. We describe how some of these problems can be resolved using the double onlay preputial flap for hypospadias repair. MATERIALS AND METHODS: We reviewed the records of 47 children who underwent 1-stage double onlay preputial flap hypospadias repair at our institution between June 1994 and July 1998. Patient age ranged from 6 months to 9 years (mean 12.2 months). The urethral meatus was at the midshaft in 12 patients (25%), penoscrotal in 30 (64%) and perineal in 5 (11%). Chordee repair required dorsal plication in 29 patients, 7 of whom required an additional ventral incision of the tunica albuginea and tunica vaginalis autograft with preservation of the urethral plate to complete the repair. Scrotal transposition and bifid scrotum were repaired at the time of hypospadias repair in 9 patients. RESULTS: Followup was 3 to 47 months (mean 15.2 months). Complications requiring reoperation occurred in 12 patients (25%). In 8 (17%) boys a fistula developed, of whom 6 had perineal and 2 had penoscrotal hypospadias. Fistula closure was required in all patients. Successful closure was achieved with 1 procedure in 6 patients, required an additional fistula repair in 1 and remains to be determined in 1. Diverticula, meatal recession and persistent penile curvature requiring repeat dorsal plication occurred in 4 (9%), 2 (4%) and 2 (4%) patients, respectively. Revision for a bulky ventral skin strip was required in 1 boy (2%). All complications occurred in patients with the more proximal hypospadias. CONCLUSIONS: The double onlay preputial flap technique for hypospadias repair offers good cosmetic and functional results. Given the high incidence of penoscrotal and perineal hypospadias (75%) in our series complication rates are comparable or better than those of other techniques.

The outcome of artificial urinary sphincter placement after a mean 15-year follow-up in a paediatric population.

OBJECTIVE: To evaluate the long-term outcome in children who had an artificial urinary sphincter (AUS) placed, after a minimum of 10 years of follow-up. PATIENTS AND METHODS: The medical records of patients who had an AUS placed at the Children's Hospital of Michigan were reviewed and a telephone questionnaire was then completed by all patients with an AUS currently in place. RESULTS: Forty-seven children initially had an AUS placed between October 1978 and August 1986; medical records and follow-up were available for 32. After a mean follow-up of 15.4 years, 13 patients had had the AUS removed and 19 currently have an intact AUS. Erosion or infection was responsible for all AUS removals. Possible risk factors for AUS removal were prior AUS erosion, prior bladder neck surgery and a balloon pressure of >70 cmH2O. Eighteen of 19 patients with an intact AUS are dry and seven void volitionally. Revision was the most common reason for additional surgery, but the revision rate has decreased with the most current AS-800 model, to 0.03 revisions per patient-year. Of the 13 patients with an AS-800 model placed after 1987, nine have not required revision. Upper tract changes were mild and uncommon. CONCLUSION: The AUS is a durable and effective surgical option in the management of neurogenic urinary incontinence, and is the only reliable technique that can preserve volitional voiding. With technical improvements to the AUS and a longer follow-up, the revision rate has decreased. Causes of AUS removal may be preventable with improvements in surgical technique and patient selection. AUS placement should be considered as a first choice for the surgical management of neurogenic sphincteric incompetence.