Comprehensive evaluation of grafting the preservable narrow plates with consideration of native plate width at primary hypospadias surgery.

INTRODUCTION: Dorsal inlay graft urethroplasty using inner-face preputial graft was described as an adjunct method to the classic tubularized incised plate (TIP) urethroplasty, aiming at reducing the risk of neourethral stenosis. OBJECTIVES: To evaluate the impact of dorsal inlay grafting of preservable narrow plates, in relation to native plate width. METHODS: Consecutive children with penile hypospadias with narrow plate (width < 8 mm) were evaluated prospectively between Jan 2014 and Jun 2018. Included cases were stratified into two groups: group A (plate width: 4 to <8 mm) and group B (plate width: < 4 mm). All cases were approached by TIP urethroplasty, with dorsal inlay grafting (inner-face prepuce). Cases with significant chordee (non-preservable plates), circumcised cases, and redo cases were excluded. RESULTS: A total of 104 hypospadias cases with narrow plates were included in this study. Among group A (n = 81), the need for postrepair urethral dilations was reported in two cases (2.5%) vs seven cases (30%) in group B (n = 23) (P-value < 0.001). Another two cases (2.5%) in group A developed urethrocutaneous fistulae vs three cases (13%) in group B (P-value = 0.0624). Surgical repair of the reported five cases with fistulae, revealed an ample neourethral wall; disclosing well-taken grafts in both groups. DISCUSSION: Few published studies evaluated grafting the incised plate in penile hypospadias. To the authors knowledge, this is the first study that selectively evaluated the impact of grafting narrow plates in relation to its native pre-incision width. CONCLUSIONS: According to the presented authors' experience, 4 mm width is the border line of clinical relevance that defines poor urethral plate. Grafting that plate failed to compensate for its native poor characteristics; however, it offered a valuable neourethral wall that proved indispensable when redo surgery deemed necessary, without adding grafting-related problems. Nevertheless, further extended comparative studies came across as a necessity to verify the long-term outcomes of grafting the incised poor plates.

Anatomical measurements of the urogenital sinus in virilized female children due to congenital adrenal hyperplasia.

BACKGROUND: Virilized females due to congenital adrenal hyperplasia represent the most common form of female disorders of sexual development. The anomaly therein is an external virilization to resemble male genitalia and a persistent urogenital sinus. OBJECTIVES: To study the anatomical details of the virilized female cases operated upon between 2011 and 2015. This anatomical description is presented to support the current surgical strategy of partial urogenital mobilization to correct this anomaly. METHODS: Thirty cases (presenting to a single tertiary center) were prospectively studied by genitography, cysto-urethroscopy, and operated upon via a single-stage feminizing genitoplasty. A single surgical team operated upon all cases. External virilization was assessed by the Prader classification. The internal anatomy was studied by measuring the length of the urethra proximal to the confluence, and the vertical depth of the vaginal-urethral confluence from the perineum. The correlation coefficients between the external virilization and the internal anatomical measurements were derived. RESULTS: The median age at surgery was 19 months (range 6-42 months). External virilization did not obviously correlate with the length of the proximal (prejunctional) urethra (r = -0.03, P = 0.5), or strongly with the depth of the vaginal-urethral confluence (r = 0.2, P = 0.2). The mean length of the proximal urethra was 22 mm (range 10-32 mm), and the mean vertical depth of the vaginal-urethral confluence from the perineum was 16 mm (range 8-31 mm). DISCUSSION: Due to limitations of the radiological and endoscopic evaluation, the accurate anatomical assessment of this condition may be challenging. In order to assess or compare the anatomy of these cases, there are two important points to address: (1) the length of the urethra proximal to the urogenital sinus, as this will impact the urinary outcome; and (2) the depth (level) of vaginal entry into the urogenital sinus, as this will affect the mobilization required to exteriorize the vagina. CONCLUSION: The degree of external virilization does not totally correlate with the internal anatomy. The depth of the vaginal-urethral confluence from the perineum is an indicator of the required mobilization for the current perineal approach. In 90% of cases in this age group (1-3 years old), this depth is ≤20 mm. This supports the current understanding that partial urogenital mobilization could be suitable for most cases Figure (Summary).

Transanal one-stage endorectal pull-through for Hirschsprung's disease: a multicenter study.

BACKGROUND/PURPOSE: Transanal endorectal pull-through (TEPT) is the latest development in treatment of Hirschsprung's disease (HD). This prospective study was designed to evaluate the safety and efficacy of 1 stage TEPT technique in the management of patients with HD. METHODS: One hundred forty-nine children (116 boys and 33 girls) aged 8 days to 14 years underwent 1 stage TEPT procedure over an 18-month period at 5 Egyptian academic pediatric surgical centers and affiliated hospitals. Median follow-up was 12 months (range, 3 to 21 months). These patients were evaluated with regard to age, sex, length of the aganglionic segment, intraoperative details, and postoperative functional results or complications. An electromyogram (EMG), endorectal ultrasound scan, and lower gastrointestinal (GI) motility studies were reserved for patients with postoperative problems with bowel control. RESULTS: Mean operating time was 120.2 +/- 27.8 minutes (range, 60 to 210 minutes). The average length of resected bowel was 26.8 +/- 12.4 cm (range, 15 to 45 cm). Thirteen patients required laparotomy because of extension of aganglionic segment beyond the sigmoid colon in 9, tear in the mesenteric vessels in 2, and difficulties in getting to the submucosal plane in 2. Three deaths (2%) occurred 3 days, 4 days, and 4 weeks postoperatively, respectively. Postoperative complications included transient perianal excoriation in 48 patients (30 were <3 months of age), enterocolitis (n = 26), anastomotic stricture (n = 7), recurrent constipation (n = 6), hypoganglionosis at distal end of pulled through segment (n = 2), cuff abscess (n = 3), anastomotic leak (n = 1), adhesive bowel obstruction (n = 1), and rectal prolapse (n = 1). Complete anorectal continence was noted in 35 of 42 (83.3%) children older than 3 years, whereas soiling and frequent accidents still occur in 7, who showed a steady improvement in their continence status. CONCLUSIONS: One-stage TEPT technique is both feasible and safe technique in properly selected children with rectosigmoid HD in all ages. The technique is easily learned and is associated with excellent clinical results.