RESUMO
OBJECTIVES: To report the principles of penile resculpturing of different deformities caused by M. Peyronie: restoration of penile length, girth and shape with or without penile prosthesis implantation. METHODS: In the period between February 2007 and March 2009, we performed grafting surgery for M. Peyronie in 98 patients aged between 24 and 72 years (mean 52 years). Penile deformities were diferent: dorsal curvature in 54 (55%), lateral in 7 (7%), ventral in 11 (11%), and combined curvature in 21 (21%) associated corporal narrowing was present in 24 patients (24%). Four (4%) patients presented isolated penile shortening without other deformity. Isolated diffuse corporal narrowing without shortening was found in two (2%) patients. Severity of curvature ranges from 60 to 90 degrees, mean 72. Thirty one (31%) patients had associated ED. Surgical options for severe Peyronie's disease were: single grafting in 26 pts (26%), complex grafting including circular tunical incision in 36 pts (36%), and in patients with ED the same procedures combined with penile prosthesis implantation (37 pts, 38%). Surgical correction was based on measurement of the tunical defect and precise calculation of graft size and shape. Penile straightening and lengthening was achieved by equalizing of shortened penile side/s with the longest one (convex) and grafting. Penile width is reestablished with additional longitudinal incision/s and grafting; graft width is determined by measurement of difference in circumference between normal and narrowed part of the corpora. We used Intexen LP (AMS) as a grafting material in all cases. RESULTS: The mean follow-up was 15 months (6-25). Mean penile length gain without prosthesis was 2.8cm (1.5-4.2) and with prosthesis 3.2cm (2-4.5cm). Insuficient straightening was in 5 patients (>15 degree) where Neuro Vascular Bundle (NVB) was limiting factor. Twenty four patients reported hypoesthesia and reduced orgasmic sensitivity that recovered spontaneously after 3-6 months. De-novo ED occurred in 6 pts and progression of disease in 6 patients. Infection occurred only in one patient with penile prosthesis implantation. Overall patients' satisfaction was 95%. CONCLUSIONS: Complete tunical reconstruction in IPP can be performed as a safe procedure by transversal, longitudinal and circular grafting with or without simultaneous penile prosthesis implantation. Maximum penile length, girth and shape restoration can be achieved using geometrical calculation, regardless of type of deformity.
Assuntos
Induração Peniana/cirurgia , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Adulto JovemRESUMO
OBJETIVO: Informar sobre los principios de la cirugía reconstructiva de diferentes deformidades del pene causadas por la enfermedad de Peyronie: restauración de la longitud, perímetro y forma con o sin implante de prótesis de pene.MÉTODOS: En el período comprendido entre febrero 2007 y marzo de 2009, se realizó cirugía con par-che por enfermedad de Peyronie en 98 pacientes con edades comprendidas entre 24 y 72 años (media 52 años). Las deformidades en el pene eran diferentes: curvatura dorsal en 54 (55%) pacientes, lateral en 7 (7%), ventral en 11 (11%), y curvatura combinada en 21 (21%); 24 pacientes presentaban estrechamiento en el cuerpo cavernoso (reloj de arena) (24 %). Cuatro (4%) pacientes presentaban acortamiento de pene aislado, sin otras deformidades, y en dos (2%) pacientes se encontró un estrechamiento cavernoso difuso aislado sin acortamiento. La gravedad de la curvatura varió de 60º- 90º, media 72. Treinta y un (31%) pacientes pade-cían disfunción eréctil asociada. Las opciones quirúrgi-cas para los casos graves de enfermedad de Peyronie fueron: injerto simple en 26 (26%) pacientes, injertos complejos incluyendo incisión circular de la túnica albugínea en 36 (36%), y los mismos procedimientos en pacientes con disfunción eréctil combinados con implante de prótesis de pene en 37 pacientes (38%). La corrección quirúrgica se basó en la medición del defecto de la túnica y el cálculo preciso del tamaño del injerto y la forma. El enderezamiento y alargamiento del pene se logró, mediante la nivelación del lado/s acortados del pene con el más largo (convexo) y el injerto. El ancho del pene se restablece con incisión/es longitudinal/es adicionales e injertos; el ancho del injerto se determina mediante la medición de la diferencia en la circunferencia entre las partes normal y reducida del cuerpo cavernoso. En todos los casos, se utilizó InteXen LP (AMS) como material de injerto(AU)
RESULTADOS: El seguimiento medio fue de 15 meses (6-25). El incremento de longitud del pene fue de 2,8 cm sin prótesis (1,5-4,2 cm) y 3,2 cm (2-4,5cm) con prótesis. En 5 pacientes (<15 grados), la corrección de la curvatura fue insuficiente, debido a que el haz neurovascular fue un factor limitante. Veinticuatro pacientes informaron de hipoestesia y sensibilidad orgásmica reducida que se recuperó espontáneamente al cabo de 3-6 meses. Seis pacientes presentaron una disfunción eréctil de novo y 6 pacientes progresión de la enfermedad. Sólo un paciente con implante de prótesis de pene sufrió infección. El índice de satisfacción general de los pacientes fue del 95%.CONCLUSIONES: La reconstrucción de la túnica albu-gínea completa en la enfermedad de Peyronie puede realizarse como un procedimiento seguro por medio de injertos transversales, longitudinales y circulares con o sin implante simultáneo de prótesis de pene. Se puede lograr, mediante el cálculo geométrico, la longitud máxi-ma del pene, el grosor y la recuperación de la forma, independientemente del tipo de deformidad(AU)
OBJECTIVES: To report the principles of penile re-sculpturing of different deformities caused by M. Peyronie: restoration of penile length, girth and shape with or without penile prosthesis implantation.METHODS: In the period between February 2007 and March 2009, we performed grafting surgery for M. Peyronie in 98 patients aged between 24 and 72 years (mean 52 years). Penile deformities were diferent: dorsal curvature in 54 (55%), lateral in 7 (7%), ventral in 11 (11%), and combined curvature in 21 (21%); associated corporal narrowing was present in 24 patients (24%). Four (4%) patients presented isolated penile shortening without other deformity. Isolated diffuse corporal narrowing without shortening was found in two (2%) patients. Severity of curvature ranges from 60 to 90 degrees, mean 72. Thirty one (31%) patients had associated ED. Surgical options for severe Peyronies disease were: single grafting in 26 pts (26%), complex grafting including circular tunical incision in 36 pts (36%), and in patients with ED the same procedures combined with penile prosthesis implantation (37 pts, 38%). Surgical correction was based on measurement of the tunical defect and precise calculation of graft size and shape. Penile straightening and lengthening was achieved by equalizing of shortened penile side/s with the longest one (convex) and grafting. Penile width is reestablished with additional longitudinal incision/s and grafting; graft width is determined by measurement of difference in circumference between normal and narrowed part of the corpora. We used Intexen LP (AMS) as a grafting material in all cases(AU)
RESULTS: The mean follow-up was 15 months (6-25). Mean penile length gain without prosthesis was 2.8cm (1.5-4.2) and with prosthesis 3.2cm (2-4.5cm). Insuficient straightening was in 5 patients (>15 degree) where Neuro Vascular Bundle (NVB) was limiting factor. Twenty four patients reported hypoesthesia and reduced orgasmic sensitivity that recovered spontaneously after 3-6 months. De-novo ED occurred in 6 pts and progression of disease in 6 patients. Infection occurred only in one patient with penile prosthesis implantation. Overall patients satisfaction was 95%. CONCLUSIONS: Complete tunical reconstruction in IPP can be performed as a safe procedure by transversal, longitudinal and circular grafting with or without simultaneous penile prosthesis implantation. Maximum penile length, girth and shape restoration can be achieved using geometrical calculation, regardless of type of deformity(AU)
Assuntos
Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Induração Peniana/diagnóstico , Induração Peniana/patologia , Induração Peniana/cirurgia , Pênis/anatomia & histologia , Pênis/patologia , Pênis/cirurgia , Disfunção Erétil/complicações , Disfunção Erétil/diagnóstico , Disfunção Erétil/cirurgia , Prótese de Pênis , Transplante/instrumentação , Transplante/métodos , Transplante , Ultrassonografia/instrumentação , Ultrassonografia/métodos , UltrassonografiaRESUMO
INTRODUCTION: Autologous tissue engineering with biodegradable scaffolds is a new treatment option for real penile girth enhancement. AIM: The aim of this article is to evaluate tissue remodeling after penile girth enhancement using this technique. METHODS: Between June 2005 and May 2007, a group of 12 patients underwent repeated penile widening using biodegradable scaffolds enriched with expanded autologous scrotal dartos cells. Clinical monitoring was parallel to histological investigation of tissue remodeling. During second surgical procedure, biopsies were obtained 10-14 months after first surgery (mean 12 months, N=6) and compared with those obtained after 22-24 months (mean 23 months, N=6), and control biopsies from patients who underwent circumcision (N=5). Blind evaluation of histomorphometrical and immunohistochemical finding was performed in paraffin sections. MAIN OUTCOME MEASUREMENTS: Penile girth gain in a flaccid state ranged between 1.5 and 3.8 cm (mean 2.1 ± 0.28 cm) and in full erection between 1.2 and 4 cm (mean 1.9 ± 0.28 cm). Patients' satisfaction, defined by a questionnaire, was good (25%) and very good (75%). RESULTS: In biopsies obtained 10-14 months after first surgery, highly vascularized loose tissue with collagen deposition associated with small foci of mild chronic and granulomatous inflammation surrounding residual amorphous material was observed. Fibroblast-like hyperplasia and small vessel neoangiogenesis occurred intimately associated with the progressive growth of vascular-like structures from accumulation of CD34 and alpha-smooth muscle actin-positive cells surrounding residual scaffold-like amorphous material. Capillary neoangiogenesis occurred inside residual amorphous material. In biopsies obtained after 22-24 months, inflammation almost disappeared and tissue closely resembled that of the dartos fascia of control group. CONCLUSIONS: Autologous tissue engineering using expanded scrotal dartos cells with biodegradable scaffolds is a new and promising method for penile widening that generates progressive accumulation of stable collagen-rich, highly vascularized tissue matrix that closely resemble deep dartos fascia.
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Implantes Absorvíveis , Pênis/cirurgia , Engenharia Tecidual , Alicerces Teciduais , Actinas/metabolismo , Adulto , Antígenos CD34/metabolismo , Biópsia , Capilares/metabolismo , Fibroblastos/metabolismo , Seguimentos , Humanos , Antígeno Ki-67/metabolismo , Masculino , Músculo Liso/metabolismo , Neovascularização Fisiológica , Satisfação do Paciente , Pênis/irrigação sanguínea , Pênis/patologia , Transplante AutólogoRESUMO
Urethral duplication and megalourethra are very rare anomalies and their concomitant presence is extremely rare, with only a few published cases. We present a complex case of complete urethral duplication with dorsal megalourethra that was severely stenotic in its bulbar part and meatus, with the ventral urethra atretic distally and dilated proximally. Both the corpus spongiosum and the cavernosum were missing. He had associated upper urinary tract abnormalities. Urethral patency was restored successfully by meatoplasty, staged buccal mucosa graft urethroplasty, and tailoring of the megalourethra. This report is unique regarding the use of a buccal mucosa graft for urethral reconstruction in patients with associated urethral duplication and megalourethra.
Assuntos
Anormalidades Múltiplas , Uretra/anormalidades , Anormalidades Múltiplas/diagnóstico , Anormalidades Múltiplas/cirurgia , Humanos , Recém-Nascido , MasculinoRESUMO
OBJECTIVES: To report our experience of treating severe penile injuries with different causes and treatments, as penile trauma presents a difficult physical and psychological problem, and the type and extent of injury varies from mild to severe, sometimes even with total amputation. PATIENTS AND METHODS: We analysed retrospectively 43 patients (mean age 28 years, range 5-52 years) with severe penile injuries referred to us from March 1999 to August 2007. The causes of penile injuries differed, including iatrogenic trauma (20), traffic accidents (11), burns (three), self-amputation (two), ritual circumcision (two), penile fracture (two), gunshot trauma (two) and electrocution (one). The management required a wide variety of surgical techniques tailored to each patient depending on the type and extent of injury. RESULTS: The mean (range) follow-up was 47 (10-108) months. The aesthetic and functional results, including satisfactory sexual intercourse were good in 35 patients. There were complications in seven patients; infection after implanting an inflatable penile prosthesis in one, protrusion of a semirigid prosthesis in one, urethral complications (one stenosis and two fistulae) in three and partial skin flap necrosis in two. CONCLUSIONS: Severe penile injuries should be treated on an individual basis, applying different techniques. However, treatment can be effective and safe only in specialized centres.
Assuntos
Doenças do Pênis/cirurgia , Pênis/lesões , Pênis/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Adolescente , Adulto , Criança , Pré-Escolar , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Doenças do Pênis/etiologia , Prótese de Pênis , Procedimentos de Cirurgia Plástica/efeitos adversos , Estudos Retrospectivos , Índices de Gravidade do Trauma , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Adulto JovemRESUMO
INTRODUCTION: Metoidioplasty represents one of the variants of phalloplasty in female transsexuals. Its main characteristic is that it is a one-stage procedure. It involves lengthening and straightening of hypertrophied clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses. AIM: Our aim is to describe our technique and highlight its advantages. METHODS: Between September 2002 and April 2007, 82 female transsexuals, aged 18-54 years (mean age 31) underwent one-stage metoidioplasty. Clitoris is lengthened and straightened by division of clitoral ligaments and short urethral plate. Urethroplasty is done with combined buccal mucosa graft and genital skin flaps. Scrotum is created from labia majora in which two testicle prostheses are inserted. Simultaneously, female genitalia are removed. MAIN OUTCOME MEASURES: Patients' personal satisfaction about sensitivity and length of neophallus, possibility to void in standing position, real length of reconstructed urethra as well as complication rate comparing to other published data. RESULTS: The median follow-up was 32 months (range 14-69). The mean neophallic length was 5.7 cm (range 4-10). Voiding in standing position was reported in all patients, while dribbling and spraying were noticed in 23 cases and solved spontaneously. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients reported preserved sensation and normal postoperative erection. Testicle prostheses rejection was not observed in any of the patients. CONCLUSIONS: Metoidioplasty is a single-stage and time-saving procedure. It could be an alternative to total phalloplasty in female transsexuals who do not wish to have sexual intercourse. Also, it represents a first step in cases where additional augmentation phalloplasty is required.
Assuntos
Clitóris/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Transexualidade/cirurgia , Adolescente , Adulto , Órgãos Artificiais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Pênis , Retalhos Cirúrgicos , Adulto JovemRESUMO
PURPOSE: Different tubular structures have been used to create cutaneous catheterizable continent urinary stomas. The most common complication is stomal stenosis on the cutaneous end of the tubes. We present a variant of stomal stenosis repair that uses a buccal mucosa graft. MATERIALS AND METHODS: Between January 2000 and March 2006 stenotic stomal repair was performed in 10 patients between 3 and 17 years old (mean age 6). A Mitrofanoff channel was created from a bladder tube in 4 patients, from appendix in 3, from ileum in 2 and from the ureter in 1. The procedure involved the removal of scar tissue and the creation of well vascularized dermal beds by skin de-epithelialization (epidermis removal). After that we formed 2 elliptical dermal flaps. Two elliptical buccal mucosa grafts were quilted to the recipient bed (the dermal flap) and anastomosed with the mucosa of the normal part of the channel. The flaps were joined, tubularized and sutured to the skin. An indwelling catheter was left in the channel for 2 weeks. Postoperatively the buccal mucosa was wetted with saline solution for 4 consecutive days. RESULTS: Followup was between 12 and 39 months (mean 22). There was no partial or total graft necrosis. None of the patients experienced repeat stenosis. The stoma was visible (uncovered) and the esthetic appearance was satisfactory in all patients. CONCLUSIONS: Repair of Mitrofanoff stomal stenosis using a buccal mucosa graft is a minor procedure. It is a good salvage procedure that excludes the need to create a new channel.
Assuntos
Mucosa/transplante , Retalhos Cirúrgicos , Estomas Cirúrgicos , Adolescente , Cateterismo , Bochecha/cirurgia , Criança , Pré-Escolar , Constrição Patológica , Feminino , Humanos , Masculino , Estomas Cirúrgicos/efeitos adversosRESUMO
Wang and colleagues described the use of fasciocutaneous flap based on deep inferior epigastric perforator (DIEP) vessels for vaginal reconstruction. They presented four patients with congenital vaginal agenesis and one with vaginal tumor. The rhombus-shaped abdominal flap was designed according to the location of deep inferior epigastric vessels perforators. The size of the flap ranged from 9 x 12 to 11 x 12 cm. The flap was elevated without underlying muscle, dissecting perforators together with the pedicle-deep inferior epigastric vessels up to their origin. The fully mobilized flap was tabularized, transposed paravesically to the previously prepared vaginal bed, and anastomosed to vaginal introitus. Primary donor-site closure was accomplished in all patients with conspicuous scars. All flaps survived and the authors reported a normal appearance of external genitalia with sufficient neovaginal depth and width. During the short follow-up (6-14 mo), two patients reported satisfactory sexual intercourse.
RESUMO
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.
Assuntos
Prepúcio do Pênis/transplante , Hipospadia/cirurgia , Mucosa Bucal/transplante , Retalhos Cirúrgicos , Seguimentos , Humanos , Lactente , Masculino , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Urológicos Masculinos/métodosRESUMO
PURPOSE: Surgical anatomy of the epispadiac penis is still not fully described. Using our complete disassembly technique, we discovered some anatomical features of epispadiac penis that may have significant impact on surgical outcome. MATERIALS AND METHODS: A total of 52 patients 2 days to 19 years old (mean age 43 months) underwent primary repair of epispadias between October 1996 and December 2006. After complete penile disassembly, ie full mobilization of the corporeal bodies, neurovascular bundles and urethral plate, reassembly of the penile entities was done. The urethral plate is tubularized and ventralized. The corporeal bodies are straightened and lengthened by 2 transverse incisions and grafting, joined medially and fixed to the glans cap. The glans is reconstructed, and the neurovascular bundles are moved dorsally and joined. The skin is reconstructed using different local flaps. RESULTS: Investigating the anatomical features of the epispadiac penis, we discovered several distinguishing features. The corporeal bodies are separated and triangular in shape. They represent the main substrate of dorsal curvature due to the significant disproportion in length between the long ventral and short wedge-shaped dorsal sides. The length of the neurovascular bundles is determined by their course-they are longer if they overlie the ventral side of the corpora and shorter if positioned over the dorsal side. The skin between the scrotum and penis has characteristics similar to penile skin. A good functional and esthetic outcome was achieved in 46 patients. Erection and glanular sensitivity were preserved in all patients. There was no necrosis of the glans or corporeal bodies. Complications included urethral fistula in 4 patients, stenosis in 2 and mild residual curvature in 2. CONCLUSIONS: New insights into the anatomical features of the epispadiac penis can have a significant impact on surgical outcomes.
Assuntos
Epispadia/patologia , Epispadia/cirurgia , Pênis/patologia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Dissecação , Epispadia/fisiopatologia , Humanos , Lactente , Recém-Nascido , Masculino , Ereção Peniana/fisiologia , Pênis/fisiopatologia , Resultado do TratamentoRESUMO
OBJECTIVES: To report our experiences of vaginal sacrospinous ligament fixation after vaginoplasty in male transsexual patients with the aim of preventing its postoperative prolapse. METHODS: From August 1997 through November 2005, a total of 62 male transsexual patients (mean age 26 years, range 18 to 58) underwent sacrospinous ligament fixation for neovaginal prolapse during male-to-female sex reassignment surgery. The neovagina was created from a penile skin tube flap combined with a urethral flap. A deep and wide perineal cavity between the urethra, bladder, and rectum was created by dissection of the tendineous center and rectourethral muscle. The right pararectal space was opened by penetrating the right pararectal fascia (rectal pillar) and right ischial spine was palpated. Using the ischial spine as a prominent landmark, the sacrospinous ligament was palpated. Long-handled Deschamps ligature was used to pierce the ligament medially to the ischial spine. Vaginopexy to the sacrospinous ligament was performed, and the neovagina was placed deep in the perineal cavity. RESULTS: The median follow-up was 32 months (range 7 to 102). Sacrospinous ligament fixation was successfully performed in all patients. The mean vaginal length was 10.7 cm (range 9.5 to 16). Of the 62 patients, 42 (76%) were able to have normal sexual intercourse. The appearance of the neovagina was aesthetically acceptable in 52 patients. In 3 cases, a minor bulge of the anterior vaginal wall was easily resolved by simple excision. CONCLUSIONS: Vaginal sacrospinous fixation is feasible in male transsexuals for neovaginal prolapse prevention. However, extensive experience with male pelvic surgery is required to avoid possible complications.
Assuntos
Ligamentos/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Transexualidade/cirurgia , Prolapso Uterino/prevenção & controle , Vagina/cirurgia , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prolapso Uterino/etiologiaRESUMO
OBJECTIVE: To present total phalloplasty in children and adults using a musculocutaneous latissimus dorsi (MLD) free flap to create a large neophallus, that allows easy urethroplasty and implantation of a prosthesis. PATIENTS AND METHODS: From April 1999 to January 2006, 16 patients (mean age 24 years, range 10-34) had a total phalloplasty; the indications were congenital anomalies of the penis in 12, iatrogenic in two and accidental penile trauma in two. The MLD flap is mobilized on a subscapular artery and vein, and a thoracodorsal nerve. The neophallus is created on-site and after dividing the neurovascular pedicle, transferred to the pubic region, where it is anastomosed with the femoral artery, saphenous vein and ilio-inguinal nerve. The donor site was closed directly in 15 patients while in one a split-thickness skin graft was used to cover the defect. In the following stages, two- or three-stage buccal mucosa urethroplasty was used in 11 patients; a penile prosthesis was implanted in seven. RESULTS: The mean (range) follow-up was 31 (12-74) months; the penis was 14-18 cm long and 11-15 cm in circumference. There was no partial or total flap necrosis; the donor site healed satisfactorily in 13 patients while in the remaining three there was moderate scarring. The patency of the urethra was good in all patients. Two urethrocutaneous fistulae developed; one closed spontaneously and the other was successfully treated with minor surgery. The function of the implanted penile prostheses was satisfactory in all patients. CONCLUSIONS: The MLD flap allows the creation of a neophallus of good size and with a good aesthetic appearance; it allows urethroplasty and safe implantation of a penile prosthesis, and it can also be used in children.
Assuntos
Satisfação do Paciente , Prótese de Pênis , Pênis/cirurgia , Retalhos Cirúrgicos , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Adolescente , Adulto , Criança , Humanos , Masculino , Pênis/fisiologia , Transplante de Pele/métodosRESUMO
PURPOSE: We present our results with botulinum-A toxin transperineal pelvic floor/external sphincter injection combined with behavioral and biofeedback reeducation in children with voiding dysfunction who had been resistant to previously applied therapies. MATERIAL AND METHODS: Eight boys and 12 girls between 7 and 12 years old (mean age 9) with recurrent urinary tract infection, an interrupted or fractional voiding pattern and high post-void residual urine in whom behavioral, short biofeedback and alpha-blocker therapies had failed were included in the study. They were treated with botulinum-A toxin at a dose of 50 to 100 U. Botulinum-A toxin was injected transperineally into the pelvic floor and/or external sphincter in all patients. In boys the sphincter was localized endoscopically before injection (endoscopically assisted transperineal approach). Behavioral and biofeedback reeducation started 15 days after injection. RESULTS: Followup was between 9 and 14 months. All patients were without urinary tract infection and fever, while 5 were still on chemoprophylaxis. Six months after treatment residual urine decreased in 17 of 20 patients by 0 to 130 ml (mean +/- SD 45.75 +/- 32.17 ml, t = 6.360, p <0.001). Nine patients reestablished a normal voiding curve and 8 showed improvement. Three did not manifest any significant improvement. In 1 girl transitory incontinence resolved spontaneously within 48 hours. There were no other complications. CONCLUSIONS: The effect of botulinum is transitory. However, it can break the circle of detrusor-sphincter dyssynergia and the period when it is sustained can be used for retraining the patient in normal voiding. At this moment botulinum-A toxin is one of last options in refractory cases of voiding dysfunction.
Assuntos
Toxinas Botulínicas Tipo A/administração & dosagem , Fármacos Neuromusculares/administração & dosagem , Incontinência Urinária/tratamento farmacológico , Criança , Eletromiografia , Feminino , Humanos , Injeções Intramusculares , Masculino , Diafragma da Pelve , Radiografia , Uretra/diagnóstico por imagem , Bexiga Urinária/diagnóstico por imagem , Incontinência Urinária/diagnóstico por imagem , Incontinência Urinária/fisiopatologia , Micção , UrodinâmicaRESUMO
OBJECTIVES: The Snodgrass technique presents the procedure of choice for distal hypospadias. Fistula formation is the most common complication with various rates. We evaluated the importance of a urethral covering using vascularized dorsal subcutaneous tissue for fistula prevention. METHODS: Our study included 126 patients, aged 10 months to 16 years, who underwent hypospadias repair from April 1998 through June 2005. Of the patients, 89 had distal, 30 had midshaft and 7 had penoscrotal hypospadias. All patients underwent standard tubularized incised plate urethroplasty, which was followed by reconstruction of new surrounding urethral tissue. A longitudinal dorsal dartos flap was harvested and transposed to the ventral side by the buttonhole manoeuvre. The flap was sutured to the glans and the corpora cavernosa to completely cover the neourethra with well-vascularized subcutaneous tissue. RESULTS: Mean follow-up was 32 (6-87) months. A successful result without fistula was achieved in all 126 patients. In six patients, temporary stenosis of the glandular urethra occurred and was solved by dilation. CONCLUSIONS: A urethral covering should be performed as part of the Snodgrass procedure. A dorsal well-vascularized dartos flap that is buttonholed ventrally represents a good choice for fistula prevention. Redundancy of the flap and its excellent vascularization depend on the harvesting technique.
Assuntos
Fístula/prevenção & controle , Hipospadia/cirurgia , Retalhos Cirúrgicos , Procedimentos Cirúrgicos Urogenitais/métodos , Adolescente , Criança , Pré-Escolar , Seguimentos , Humanos , Lactente , MasculinoRESUMO
OBJECTIVE: Total phalloplasty is rarely performed in children due to the mutilation involved and the dilemma concerning neophallic size in children. We present a musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children with difficult psychological problems. MATERIALS AND METHODS: Total phalloplasty was performed in eight boys aged between 10 and 15 years. Indications were small penis after failed epispadias repair (4), micropenis (3) and intersexuality (1). A musculocutaneous latissimus dorsi free flap was harvested with thoracodorsal artery, vein and nerve. The flap was transferred to the pubic region and anastomosed to the femoral artery, saphenous vein and ilioinguinal nerve. Two-staged urethroplasty was performed in five patients using buccal mucosa, while in the remaining three a Mitrofanoff channel had been created previously. An inflatable penile prosthesis was implanted in two cases after puberty. RESULTS: Follow-up was from 6 to 53 months (mean: 29 months). Penile size varied from 13 to 16 cm in length and from 10 to 12 cm in circumference. No flap necrosis, either partial or total, was noted. The donor site healed acceptably in four cases while in the remaining four moderate scarring occurred. Function of the penile prostheses is satisfactory. Psychological status is significantly improved in all children. CONCLUSION: Phalloplasty in childhood is indicated to prevent profound psychological problems related to body dysmorphia. The musculocutaneous latissimus dorsi flap is a possible choice for phalloplasty in children that enables good neophallic size as in adults. We recommend this surgery to be performed before puberty to ensure optimal psychosexual pubertal development.
RESUMO
OBJECTIVE: To assess the early disclosure and treatment of meatal stenosis after hypospadias repair, using calibration of the neourethral meatus at regular intervals to detect stenosis, and to assess the curative effects of dilatation with topical corticosteroids. PATIENTS AND METHODS: Between 2001 and 2003, 83 boys (median age 19 months, range 12-28) had a proximal hypospadias repair using a tubularized skin island-flap urethroplasty. The neourethra was calibrated every 7-15 days with newly designed small and fine metal sounds (5-12 F) for 3 months starting 7-10 days after surgery. The patients with meatal stenosis were treated by dilatation using topical 0.05% betamethasone cream daily (twice per day) for 3 months. RESULTS: The mean (range) follow-up was 29 (12-37) months; 19 patients who developed early stenosis were treated by dilatation with topical steroids. After treatment, 14 neourethras were passable with a minimum sound of 10 F at regular 6-12 months assessments. Stenosis persisted in five patients who did not respond to the treatment; of these, a diverticulum developed in one and a fistula in two. All patients with permanent complications were re-operated. There were no adverse effects in any of the patients treated with topical 0.05% betamethasone cream. CONCLUSION: Early calibration and dilatation of the neourethra after hypospadias repair is a useful method for the early disclosure and treatment of meatal stenosis. The newly designed sounds made calibration/dilatation less unpleasant and more acceptable for the patient. Topical corticosteroids improved scar elasticity, which facilitated dilatation and prevented the formation of meatal stenosis.