Validation of Serbian Version of Dysfunctional Voiding Symptom Score (DVSS) Questionnaire.

OBJECTIVE: The aims of our study were to translate the dysfunctional voiding symptom score (DVSS) from English to Serbian; culturally adopt the items; assess the internal consistency and the test⁻retest reliability of DVSSSR in patients with dysfunctional voiding (DV); evaluate and test the construct and divergent validity of DVSSSR against demographic parameters (gender and education); and examine the level of explained variability for each item of DVSSSR against demographic parameters (gender and education). METHODS: The cross-sectional observational study included 50 patients with dysfunctional voiding aged 5 years and above. The DVSS questionnaire was translated from English into Serbian by the forward⁻backward method. Internal consistency was assessed with Cronbach α and test⁻retest reliability with intraclass correlation coefficient (ICC). For validity testing we performed construct and divergent validity analyses. RESULTS: There was excellent internal consistency for every item except for Item 6 (0.787) and Item 3 (0.864), where internal consistency was good. The observed test/retest ICC for average measures was more than 0.75 (excellent) for all DVSSSR items. Gender and educational level does not correlate significantly with each item of DVSSSR (p > 0.05). For divergent validity, there were no significant differences in mean values of each item of DVSSSR between genders and different levels of education (p > 0.05). Variability that can be explained for gender and educational level was below 10%. CONCLUSION: Translated DVSSSR is of adequate validity and reliability for assessing DV in children.

Efficacy of Magnetic Resonance urography in detecting crossing renal vessels in children with ureteropelvic junction obstruction.

INTRODUCTION: An aberrant or accessory crossing renal vessel (CV) leading to the lower pole of the kidney is the most common extrinsic cause of uretero pelvic obstruction(UPJ) obstruction in a child and young adolescent.There is still controversy regarding there functional significance in obstruction Preoperative identification of such vessels may influence surgical management. OBJECTIVE: First aim is to determine the value of magnetic resonance (MR) urography in detecting crossing vessels in children with UPJ obstruction,comparing the data with postoperative findings and the second one is to evaluate morphologic and functional parameters in these hydronephrotic kidneys. MATERIALS AND METHODS: Between June 2009 and December 2012 we retrospectively reviewed MR urography records of one hundred and nine children with unilateral hydronephrosis at the University Children's Hospital. 68 (62.4%) were male and 41 (37.6%) were female,median age was 6.5 ± 5.7. Of the total number of patients, 30 (27%) underwent pyeloplasty, while 79 (72.5%) did not. The age at surgery ranged from 0.3 to 18 years (median 6.6 years). The indication for surgery was based on standard criteria (obstructed renal transit time with or without altered renal function of vDRF < 40%), and did not depend on the presence or absence of a crossing vessel.Consensus reviewes of the MR urography studies were compared with surgical findings. RESULTS: A crossing vessel (CV) was found upon surgery in 9 (33%) of 30 kidneys.On MRU, there was no crossing vessel in 21 kidneys, confirmed at surgery in 18. A crossing vessel was detected with MRU in 9 kidneys and confirmed at surgery in 6. Thus, the sensitivity of MRU was 66.7%, the specificity was 85.7%, the positive predictive value was 66.7%, the negative predictive value was 85.7% and the accuracy was 80%. There was no statistically significant difference in the detection of crossing vessels between MR urography and surgery (p = 0.004 and p < 0.01 respectively). Overall, MRU and surgery showed good agreement (κ = 0.524). CONCLUSION: Based on our results we suggest that MR urography is a reliable and safe diagnostic tool to determine crossing vessels in selected children with UPJ obstruction. Thus, MRU can substitute for other imaging modalities and provide detailed information about the morphology and function of the affected kidney KEY WORDS: Children, Crossing renal vessels, Hydronephrosis, Ureteropelvic function obstruction.

Objective long-term evaluation after bladder autoaugmentation with rectus muscle backing.

PURPOSE: Bladder autoaugmentation with rectus muscle backing is an efficient surgical technique for bladder augmentation. We evaluated long-term outcomes to determine the value of this procedure. MATERIALS AND METHODS: Between August 1999 and June 2004 autoaugmentation was performed in 16 girls and 7 boys 4 to 13 years old (median age 8). The indication was neurogenic bladder with small capacity and poor compliance due to myelomeningocele in 18 patients, tethered cord in 3 and sacral agenesis in 2. Detrusorectomy usually involved the whole upper half of the bladder. The prolapsed bladder urothelium was hitched to the 2 rectus muscles to prevent retraction and provide easier bladder emptying with voluntary muscle contractions. RESULTS: At the median early followup of 27 months (range 9 to 49) bladder volume had increased significantly in all 23 patients (median 338 ml, range 190 to 462). At the current median long-term followup of 134 months (range 94 to 159) bladder volume continued to be significant compared to median bladder capacity preoperatively (median 419 ml, range 296 to 552). Voluntary voiding was achieved in 14 patients without post-void residual urine. Nine patients used clean intermittent catheterization, of whom only 4 could not empty the bladder voluntarily and relied only on clean intermittent catheterization. CONCLUSIONS: Detrusorectomy with a rectus muscle hitch and backing is a minimally invasive, completely extraperitoneal, simple and safe procedure. However, the technique is indicated only in select cases without anterior abdominal wall anomalies.

[Warren shunt combined with partial splenectomy in children with extra-hepatic portal hypertension, massive splenomegaly and severe hypersplenism].

INTRODUCTION: Extra-hepatic portal vein obstruction (EHPVO) is one of the most often causes of portal hypertension in children. OBJECTIVE: Establishing the importance of shunt surgery in combination with partial spleen resection in selected pediatric patients with EHPVO, enormous splenomegaly and severe hypersplenism. METHODS: Distal splenorenal shunt (DSRS) with partial spleen resection was performed in 22 children age from 2 to 17 years with EHPVO. Indications for surgery were pain and abdominal discomfort caused by spleen enlargement, as well as symptomatic hypersplenism with leucopenia, thrombocytopenia and anemia. The partial spleen resection was performed by ligation of blood vessels to caudal two thirds of the spleen. After ischemic parenchymal demarcation transection with electrocautery LigaSure was performed with preservation of 20-30% of spleen tissue, and then Warren DSRS was created. Platelet and leucocytes counts and liver function tests were obtained before, one month and one year after surgery. Growth was assessed with SD scores (Z scores) for height, weight and body mass index at the time of surgery and one year later. RESULTS: In all patients postoperative period was without significant complications. Platelets and leucocytes counts were normalized. Patency rate of shunts was 100%. Two significant shunts stenosis were observed and successfully treated with percutaneous angioplasty. During the follow-up period (1 to 9 years) all patients were asymptomatic, with improved quality of life and growth. CONCLUSION: Results of our study indicate that shunt surgery with a partial spleen resection is an effective and safe procedure for patients with enormous splenomegaly and severe hypersplenism caused by EHPVO.

The role of clitoral anatomy in female to male sex reassignment surgery.

INTRODUCTION: Controversies on clitoral anatomy and its role in female sexual function still make clitoral reconstructive surgery very challenging. We evaluated the role of clitoral anatomic features in female to male sex reassignment surgery. MATERIAL AND METHODS: The study included 97 female transsexuals, aged from 18 to 41 years, who underwent single stage metoidioplasty between March 2008 and January 2013. The operative technique involved vaginectomy, the release of clitoral ligaments and urethral plate, urethroplasty by combining buccal mucosa graft and genital flaps, and scrotoplasty with insertion of testicle prostheses. Postoperative questionnaire was used to evaluate aesthetic, functional, and sexual outcome. RESULTS: The mean followup was 30 months. The mean length of the neophallus was 7 cm, compared to mean preoperative length of the hypertrophied clitoris of 3.3 cm. Complications occurred in 27.84% of all patients, related mostly to urethroplasty. Voiding while standing was achieved in all cases. None of the patients had problems in sexual arousal, masturbation, or orgasms. CONCLUSION: Accurate knowledge of the clitoral anatomy, physiology, and neurovascular supply is crucial for a successful outcome of female to male sex reassignment surgery. Our approach appears to ensure overall satisfaction and high quality of sexual life.

Fast-track surgery concepts for congenital urogenital anomalies.

AIM: To investigate the possibility of fast-track surgery concepts in pediatric urology department as a single center study model of a developing country. MATERIAL OF STUDY: The study included 1620 patients surgically treated at the pediatric urology department, from 2009 to 2011. According to the congenital anomalies, all patients were classified in one of four groups: I - testicular anomalies (197 patients); II - external genital anomalies (453); III - upper urinary tract anomalies (801) and IV - associated anomalies (169). We analyzed the total duration of stay in the hospital of all patients among all treating doctors concerning the anomaly. RESULTS: Statistically significant difference in total length of hospitalization of all patients in Group I was noted in Doctors 1 and 5 (F=10.36** for F0.05;5;12=3.11 and F0.01;5;12=5.06), as well as in the Group II (F=17.01** for F0.05;5;12=3.11 and F0.01;5;12=5.06). Statistical analysis was not possible to be performed in groups III and IV because of lack of the patients. DISCUSSION: Analyzing the length of hospitalization of the patients treated at the urology department, all doctors showed the tendency to shorten the total length of hospitalization in patients of all groups. Majority of the studies carried out on pediatric urology departments in developed countries, showed that over 50% of children were successfully treated using fast-track surgery concept. CONCLUSIONS: Modern methods of surgical management and anesthesia allow decrease of hospitalization length, financial savings to the healthcare system and better comfort for patients.

Epispadias repair after failed surgery in childhood.

INTRODUCTION: Redo surgery in failed epispadias presents a great challenge. Our aim was to present a radical approach for correction of penile deformities as well as urethral reconstruction in patients after failed epispadias repair. MATERIALS AND METHODS: Between January 2006 and January 2011, 13 patients, aged 13 to 22 years, underwent redo surgery due to failed epispadias repair in childhood. All patients presented with severe dorsal curvature and short urethra. First stage included penile disassembly technique with complete separation of corporal bodies, urethral dissection, and transposition and subtotal glans mobilization. Residual dorsal curvature was corrected by tunical incision and grafting of the defect. Short urethra was dissected and transposed ventrally with opening at the base of the penis. Penile entities were reassembled in normal anatomical relationship. Penile body was covered using available vascularized skin flaps. After 6 months, second stage was performed and included reconstruction of the penile urethra using buccal mucosa graft and scrotal hairless skin flap. RESULTS: Follow-up ranged from 12 to 60 months (mean 33 months). Acceptable outcome is achieved in all the patients. Complete penile lengthening and straightening is obtained in 10 out of 13 patients. Mild curvature is noted in three patients without consequences. Satisfactory sexual activity was reported from nine patients. One patient developed fistula that was closed after 4 months, whereas all other patients reported normal voiding with no difficulties. CONCLUSIONS: Redo surgery of failed epispadias is very demanding procedure. Radical approach in these cases is necessary for complete repair of all penile deformities with satisfactory postoperative outcome.

[Possibilities of fast track surgery principles in the treatment of congenital urological anomalies].

INTRODUCTION: Urogenital congenital anomalies are among the most common congenital anomalies and very frequent pathology in paediatric urology. Health care systems strive to shorten the duration and reduce the costs of hospitalization, while maintaining treatment effectiveness. OBJECTIVE: To evaluate the duration of hospital stay of surgically treated patients with congenital urogenital anomalies and estimate the possibility of using fast track surgery principles in paediatric urology in the local settings of a developing country. METHODS: Retrospective non-randomized study included 552 patients who had been surgically treated at the Urology Department of the University Children's Hospital, during 2010. In line with their congenital anomalies, all patients were classified in one of four groups: I--upper urinary tract anomalies (252 patients); II--genital anomalies (164 patients); III--testicular anomalies (76 patients) and IV--associated anomalies (60 patients). We analyzed the total duration of stay as well as pre- and post-operative stay in the hospital. RESULTS: The average duration of hospitalization was 4.7 +/- 4.0 days. Patients with testicular anomalies stayed for the shortest period (2.3 +/- 1.9 days) (p < 0.01) and patients with associated anomalies stayed in the hospital the longest (6.5 +/- 4.7 days) (p < 0.01). CONCLUSION: Modern methods of surgical treatment allow reduction of hospitalization, financial savings to the healthcare system and greater comfort for patients. Our results showed that this is also possible to apply in our environment.

"Hanging" of the buccal mucosal graft for urethral stricture repair after failed hypospadias.

PURPOSE: Urethral stricture is the second most common complication of hypospadias repair after urethrocutaneous fistula. Usually more than 1 procedure is needed for correction due to a lack of available tissue after previous repairs. We evaluated 1-stage urethral stricture management after hypospadias repair using a ventral buccal mucosal graft. We describe the importance of graft hanging and coverage. MATERIALS AND METHODS: From August 2004 to April 2009, 15 patients 9 to 17 years old underwent urethral stricture repair after failed hypospadias surgery. Mean time after primary surgery was 7.2 years (range 4 to 13). Vascularized periurethral tissue around the stenotic part of the neourethra was dissected. The urethra was opened ventrally and a buccal mucosal graft of appropriate size was inserted to allow urethral augmentation. Using several U stitches the graft was anchored to the surrounding periurethral tissue to prevent its folding and retraction. Recurrent chordee in 12 patients and secondary vesicoureteral reflux in 3 were also corrected at this time. RESULTS: Mean followup was 37 months (range 17 to 73). Successful results were confirmed in all patients by urethrography and uroflowmetry. One urethral fistula was corrected 3 months later by minor surgery. Recurvature did not develop in this group. There was no recurrent reflux in endoscopically treated patients. CONCLUSIONS: Ventral buccal mucosal grafting is a simple, safe option for urethral stricture repair. Hanging the graft to periurethral tissue is important for its survival and to prevent postoperative folding and retraction.

Minimally invasive inguinal technique for the management of duplex ureteric anomaly.

OBJECTIVE: To present outcomes of a minimally invasive inguinal technique for the separation of the distal part of ureters in duplex systems and for the extravesical ureteroneocystostomy of only the pathologically involved ureter. MATERIALS AND METHODS: From November 2001 to February 2007, we performed extravesical reimplantation of only the involved ureter in 21 duplex systems, of which 14 were refluxing (megaureters) and seven had obstruction of the ureterovesical junction. The mean (range) age of the patients was 39 (17-59) months. In seven patients, ureterocutaneostomy (of the involved ureter only) was performed first, with reimplantation 3-6 months later, after the diameter of the ureter had decreased, to ensure safe reimplantation. The mean (range) postoperative follow-up was 28 (12-47) months. RESULTS: Postoperative voiding cysto-urethrograms (VCUGs) and magnetic resonance imaging (MRI), showed an absence of vesico-ureteric reflux (VUR) or obstruction in the ureters of the first 10 patients. In the remaining 11 patients, there was no ultrasound detectable dilatation, but symptomatic urinary tract infection developed in two of these patients. Subsequent VCUG and MRI results showed no obstructions or VURs. CONCLUSION: Our results showed that the minimally invasive inguinal approach to separation of ureters in duplex systems and single ureteroneocystostomy of only the pathologically involved ureter represents a viable treatment option.

Combined buccal mucosa graft and dorsal penile skin flap for repair of severe hypospadias.

OBJECTIVES: Urethral reconstruction in severe hypospadias presents a great challenge. We have designed a method of combining a longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in most severe hypospadias. METHODS: Between January 2003 and March 2007, 17 patients (aged from 9 to 23 months) underwent severe hypospadias repair (13 penoscrotal and 4 scrotal hypospadias). Short urethral plate was divided in all cases and remaining curvature repaired by dorsal plication. We harvested and fixed a buccal mucosa graft to the ventral side of corpora cavernosa to be the first half of a neourethra. A longitudinal dorsal island skin flap was created and buttonholed ventrally. We sutured it together with the buccal mucosa graft to form the neourethra. We fixed the abundant flap pedicle laterally to cover all suture lines of the neourethra. We performed penile skin reconstruction using available penile skin. RESULTS: The mean (range) follow-up was 25 (7 to 58) months. We achieved satisfactory, functional, and aesthetic results in 14 patients. In 3 cases urethral fistula (2) and distal stricture (1) required secondary treatment. CONCLUSIONS: Combined longitudinal island skin flap and buccal mucosa graft could be a good choice for urethral reconstruction in most severe hypospadias repairs.

[Positional installation of contrast cystography: a new approach in the diagnosis of vesicoureteral reflux].

INTRODUCTION: Positional installation of contrast cystography (PIC cystography) represents a new method to identify vesicoureteral reflux (VUR) that is unrevealed by standard diagnostic procedures. It is performed by radiological examination of the vesicoureteral junction during cystoscopic installation of the contrast medium at the ureteral orifice. OBJECTIVE: We studied the significance of PIC cystography to demonstrate VUR that failed to be revealed by standard voiding cystourethrography (MCUG), as well as the degree of the correlation of such a finding with endoscopic appearance and the position of the ureteral orifice (UO). METHOD: The aim of the paper was to analyze a sample of 5 children (4 girls and 1 boy), aged 6-15 years (mean 9.8 years) with recurrent febrile urotract infections, complicated with scarring changes of the renal parenchyma and normal findings on MCUG. The grade of VUR demonstrated by PIC cystography was classified using the standard hydrodistensional scale. RESULTS: All 5 patients had VUR, disclosed by PIC cystography, of whom in 4 it was unilateral and in one bilateral. Of 5 patients, 4 had VUR grade I and one grade II. All the children with VUR detected by PIC cystography also had evident cystoscopic abnormalities in the position and/or configuration of the ureteral orifice at the same side, while at the side with normal finding on PIC cystography, the endoscopic finding was also within normal limits. CONCLUSION: PIC cystography is the method of choice in the confirmation of VUR as the cause of recurrent urotract infection and its complications in children with a normal finding on standard MCUG. In all our patients with VUR verified by PIC cystography, at the same side we also revealed endoscopic changes in the position and/or configuration of UO.

Lymphangioma scroti.

Lymphangiomas are congenital malformations of the lymphatic system. We report a 10-year-old boy with lymphatic malformation of the scrotum, which presented as a multiloculated scrotal mass associated with edema of the left thigh and left cryptorchidism. Histopathologic examination showed scrotal lymphangioma cavernosum. Ultrasonography was of major importance for the preoperative diagnosis and to determine the extent of the scrotal lesion. Scrotal lymphangiomas are very rare. It is important to consider them in boys with a cystic scrotal mass in order to avoid misdiagnosis, improper treatment and recurrences.

Omphalocele associated with gastroschisis defect covered with skin.

Omphalocele and gastroschisis are distinct malformations in many aspects. Anatomical and pathologic findings in both conditions are usually typical and very frequent. Unusual clinical presentations of some cases may contribute to clearing up questions about the embryological origins of gastroschisis and omphalocele. We describe a rare case of omphalocele associated with gastroschisis defect covered with skin.

Refluxing megaureter for the Mitrofanoff channel using continent extravesical detrusor tunneling procedure.

PURPOSE: We present a variation on the continent procedure using the refluxing megaureter for the Mitrofanoff channel, and its results. MATERIALS AND METHODS: The Mitrofanoff procedure using the refluxing megaureter was performed in 35 patients (valve bladder syndrome 15, neurogenic bladder 10, non-neurogenic bladder 10) between 1995 and 2001. Mean patient age was 5.9 years. In 5 patients the distal segment of the megaureter was used after nephrectomy, and in 30 patients the proximal segment of the megaureter was simultaneously reimplanted unilaterally. The distal segment of the megaureter was inserted under the detrusor close to the native hiatus, pulled through the tunnel between the unresected detrusor and the mucosa, and subsequently brought to the abdominal wall. The ureterovesical junction was left intact. RESULTS: In all of our patients we obtained sufficient length and good vascularization of both ureteral segments. Satisfactory tunnel length was achieved in 29 patients. In 6 cases the tunnel was elongated by dissection of the detrusor. Median followup was 37 months. Three patients had development of stenosis at the stoma level, which resolved with minimal revision at the ureter-skin level. Minimal leakage occurred in 3 patients, all of whom were successfully treated with anticholinergics. On routine followup no patient had signs of reflux recurrence in the reimplanted ureter. CONCLUSIONS: The results of our variant procedure expand the number of patients who may benefit from use of the ureter for the Mitrofanoff channel.

Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair.

OBJECTIVE: To evaluate the importance of urethral covering using vascularized dorsal subcutaneous tissue for preventing fistula in the Snodgrass hypospadias repair. PATIENTS AND METHODS: The study included 67 children (aged 1-11 years) who had hypospadias repaired between April 1998 and May 2003, including 51 with distal and 16 with midshaft hypospadias. In all children, a standard tubularized incised-plate urethroplasty was followed by reconstruction of new surrounding urethral tissue. A longitudinal dartos flap was harvested from excessive dorsal preputial and penile hypospadiac skin, and transposed to the ventral side by a buttonhole manoeuvre; it was sutured to the glans wings around the neomeatus, and to the corpora cavernosa over the neourethra. Thus the neourethra was completely covered with well-vascularized subcutaneous tissue. RESULTS: At a mean (range) follow-up of 21 (6-65) months, the result was successful, with no fistula or urethral stenosis, in all 67 children. CONCLUSION: We suggest that urethral covering should be part of the Snodgrass procedure. A dorsal well-vascularized dartos flap, buttonholed ventrally, is a good choice for preventing fistula. Redundancy of the flap and its excellent vascularization depends on the harvesting technique.

[Effect of treatment of lower urinary tract dysfunction on occurrence of urinary tract infections in children with vesicoureteral reflux]. / Uticaj lecenja disfunkcije donjeg urotrakta na ucestalost urinskih infekcija kod dece sa vezikoureternim refluksom.

Correlation between lower urinary tract dysfunction, urinary tract infection (UTI) and vesicoureteral reflux (VUR) is complex and well known. The impact of lower urinary tract dysfunction treatment on frequency of UTI in children with VUR was assessed in our study. Lower urinary tract dysfunction was diagnosed in 32 girls and 4 boys; 19 (53%) of them had VUR in 24 kidney units. All patients were on chemo-prophylaxis and were advised how to restore regular voiding and assume normal posture, in order to reach an optimal relaxation of the pelvic floor during voiding. Eight patients (42%) with signs of hyperactive bladder and/or small bladder capacity were administered anticholinergic-oxybutynin (0.2 mg/kg of body weight). Eleven patients (58%) with sign of bladder-sphincter dysfunction and/or residual urine volume over 20% were treated by alfa-blocker-alfuzosin (0.1 mg/kg of body weight). Four children with constipation were advised to use fiber-rich diet. During 12-mount follow-up, none had febrile UTI, and 7 (37%) had 1 to 3 UTI without temperature. In conclusion, conservative treatment of VUR should include chemo-prophylaxes, lower urinary tract dysfunction treatment, and treatment of constipation, what was confirmed by our study as well.

'Pseudospongioplasty' in the repair of a urethral diverticulum.

OBJECTIVES: To describe a technique for repairing urethral diverticula which includes neourethral reconstruction and increasing the mechanical support of the neourethra. PATIENTS AND METHODS: Between February 1995 and May 2000, 267 patients with proximal hypospadias underwent a one-stage penile skin longitudinal flap urethroplasty. The overall postoperative complication rate was 20%; a diverticulum formed in 24 patients (9%) and in all it was repaired. Diverticulectomy was carried out by de-epithelialization of excess diverticular skin, so that two subcutaneous vascularized tissue wings could be created. After re-establishing distal urethral patency and neourethral closure, the de-epithelialized diverticular wings were folded and overlapped to form a mechanical support for the neourethral ventral wall; this procedure was termed 'pseudospongioplasty'. RESULTS: There were no recurrences of diverticulum or any fistula formation. The only complication was urethral stenosis in two cases, which was successfully resolved by internal urethrotomy. CONCLUSION: Re-establishing patency and providing mechanical support are essential when repairing a urethral diverticulum. Our technique with pseudospongiosal tissue reconstruction during the repair represents a good alternative or addition to other techniques.

Detrusorectomy with rectus muscle hitch and backing.

PURPOSE: Bladder autoaugmentation is a procedure that includes detrusoromyotomy or detrusorectomy with an aim to release intact urothelium, which then prolapses and increases bladder capacity and compliance. Covering of the prolapsed urothelium usually is done by using deepithelialized pedicled colonic or gastric patch. The authors present their first experiences with detrusorectomy using rectus muscle for hitch and backing. METHODS: Between August 1999 and February 2002, autoaugmentation was performed in 19 patients (12 girls and 7 boys) aged 4 to 12 years (median, 8). All patients had a neurogenic bladder with small capacity and poor compliance. Detrusorectomy usually involves the whole upper half of the bladder to achieve regular shape of the huge prolapsed urothelium. Both rectus muscles are dissected from their anterior and posterior sheaths. Urothelium is sutured to the muscle at several points to prevent its retraction and shrinkage. This way, bladder is fixed and hanged on rectus muscles. RESULTS: Follow-up was 6 to 35 months (median, 21). The new bladder capacity was increased in all patients and ranged from 190 to 411 ml (median, 313). All patients had clinical improvement and better compliance. CONCLUSIONS: Detrusorectomy with rectus muscle hitch and backing is a safe and simple procedure. However, long-term results are needed to define value of this procedure.

Enlargement and sculpturing of a small and deformed glans.

PURPOSE: We present 2 techniques of enhancement and sculpturing of a small and/or deformed glans. MATERIALS AND METHODS: The small glans in primary or re-do hypospadias repair was enhanced by longitudinal double-faced island flaps incorporated onto the ventral side of the glans between the glans wings. The deformed glans, of small or normal size (with normal urethra or well functioning neourethra), was enlarged and sculptured by injection of hydrogel. Between May 1997 and March 2002, 27 patients underwent glans enhancement and sculpturing. Small deformed glans occurred after failed hypospadias repair in 10 patients, penile trauma in 3, hemangioma sclerozation in 2, primary hypospadias in 8 and normally developed penile body in 4. A double-faced island flap was performed in 14 patients, glans was enhanced by hydrogel injection in 9 and both procedures were performed in 4. RESULTS: Mean followup was 34 months for the double-faced flap technique 17 months for hydrogel injection. Satisfactory enlargement and esthetic appearance were achieved in 13 of the 14 patients who underwent the double-faced flap technique and 1 required surgical correction. Of the 9 patients who underwent either single or multistage hydrogel injection 8 had good results and 1 required partial removal of hydrogel after hypercorrection. The combination of these 2 techniques provided satisfactory results in all 4 cases. CONCLUSIONS: Enlargement and sculpturing of a small deformed glans are challenging and difficult. A double-faced island flap and/or injection of hydrogel resolves this problem satisfactorily.