Recurrent chordee in 59 adolescents and young adults following childhood hypospadias repair.

BACKGROUND: As children transition to adolescence, penile curvature may recur several years, sometimes, decades later. Herein we review our experience with a group of symptomatic patients, their surgical repairs and outcome. MATERIAL & METHODS: Reviews were done on the charts of 59 symptomatic adolescents aged 14-21 years who presented with recurrent penile curvature, causing either sexual dysfunction or significant deformity and had undergone surgical correction between 2000 and 2017. Their initial hypospadias repairs were: TIP & dorsal midline plication (28), Tiersch-Duplay (T-D) urethroplasty and Nesbit dorsal repair [9], prepuce mucosal island onlay and Nesbit repair [6], Two-stage Byar repair and ventral dermal graft (3 patients). 13/59 patients were repaired elsewhere, and their records were unavailable. Surgical correction included one stage dorsal replication and skin detethering (32patients), one-stage urethral mobilization and corporal/dermal grafts (12patients), staged corporal/dermal graft and skin coverage followed by urethroplasty (Grafted TIP) 8-12 months later (15patients), and 11/59 had urethral fistula, which were repaired concomitantly. RESULTS: 55 out of 59 patients were followed up for 6-48 months (median 30 months) by periodic office visits, and 2-4 weeks in 4 patients whose subsequent follow up was by email. Of the 55 patients, 53 healed well, and 2patients developed wound breakdown and scarring, which resulted in mild recurrent curvature but to a lesser degree than preoperatively. The other 4 patients who corresponded by email were pleased with the surgical outcome. Of the total 59 patients, 28 reported satisfactory sexual activity. None of the patients who had corporal/dermal grafts reported erectile abnormalities. CONCLUSIONS: Recurrent curvature in adolescents following hypospadias repair, may be caused by peri-urethral and skin fibrosis and/or disproportionate growth of the relatively hypoplastic ventral corporal wall or the reconstructed urethra. Surgical correction of symptomatic patients by dorsal shortening or ventral lengthening procedures depends on the degree of curvature following skin degloving of the penis. We have been recommending to parents of children born with proximal hypospadias who had what appeared to be a good surgical result to follow up after puberty.

Safety and Effectiveness of SAF-R, a Novel Patient Positioning Device for Robot-Assisted Pelvic Surgery in Trendelenburg Position.

PURPOSE: We found current robotic positioning devices to be inadequate and cumbersome. Furthermore, we realized there were no premarket well-designed studies to prove their safety and efficacy. In this prospective pilot study, we aimed to investigate the safety and effectiveness of a novel patient-positioning device (SAF-R) to secure the patient in Trendelenburg (T-burg) position for robot-assisted pelvic surgery. PATIENTS AND METHODS: Sixteen patients undergoing robot-assisted pelvic operation in T-burg position were enrolled. Patients were positioned using SAF-R board. Pressure sensor mats were used for real-time monitoring of the contact pressures and contact area on the shoulders and calves throughout the surgery. Data collection included patients' body mass index (BMI), time needed for positioning, total time in the T-burg position, contact pressure and contact area readings from the sensor mats, and the patient shifting distance on the table. Patients were also followed for 1-month postoperatively for any position-related adverse event. RESULTS: The median age of the patients was 56.5 years with median BMI of 27.3. The median positioning time was 6 minutes, duration of T-burg position was 3.5 hours, and patient shift on the table was 1 cm. The contact pressure over the shoulders was in the safe range (< 80 mm Hg) before and at the end of the surgery in all cases (right: 13.12 ± 1.12 vs 20.25 ± 1.56 mm Hg, left: 12.84 ± 1.05 vs 19.60 ± 1.09 mm Hg, p = 0.001). The changes in the mean contact pressure over the calves and the mean contact area for the shoulders and calves during the T-burg position were not significantly different. No significant position-related complication was detected during follow-up. CONCLUSIONS: SAF-R surgical board is a safe, reliable, and timesaving positioning device for patients undergoing robotic pelvic surgery in the T-burg position.

Bladder reconstruction using scaffold-less autologous smooth muscle cell sheet engineering: early histological outcomes for autoaugmentation cystoplasty.

OBJECTIVE: To investigate the feasibility of a new approach for cystoplasty using autologous smooth muscle cell (SMC) sheet and scaffold-less bladder tissue engineering with the main focus on histological outcomes in a rabbit model. MATERIALS AND METHODS: In all, 24 rabbits were randomly divided into two groups. In the experimental group, SMCs were obtained from the bladder muscular layer, labelled with PKH-26, and seeded on temperature-responsive culture dishes. Contiguous cell sheets were noninvasively harvested by reducing the temperature and triple-layer cell-dense tissues were constructed. After partial detrusorectomy, the engineered tissue was transplanted onto the urothelial diverticulum. The control group underwent partial detrusorectomy followed by peritoneal fat coverage. At 2, 4, and 12 weeks the rabbits were humanely killed and haematoxylin and eosin, Masson's trichrome, cluster of differentiation 34 (CD34), CD31, CD3, CD68, α-smooth muscle actin (α-SMA), picrosirius red, and pentachrome staining were used to evaluate bladder reconstruction. RESULTS: At 2 weeks after SMC-sheet grafting, PKH-26 labelled SMCs were evident in the muscular layer. At 4 weeks, 79.1% of the cells in the muscular layer were PKH-positive cells. The portion of the muscular layer increased in the experimental group during the follow-up and was similar to normal bladder tissue after 12 weeks. α-SMA staining showed well organised muscle at 4 and 12 weeks. CD34+ endothelial progenitor cells and CD31+ microvessels increased continuously and peaked 4 and 12 weeks after grafting, respectively. CONCLUSION: In the present study, we show that autologous SMC-sheet grafting has the potential for reliable bladder reconstruction and is technically feasible with a favourable evolution over the 12 weeks following implantation. Our findings could pave the way toward future bladder tissue engineering using the SMC-sheet technique.

Single-stage subsymphyseal cystoscopic-guided bladder neck plication and urethrogenitoplasty in female epispadias: presentation of long-term follow-up.

OBJECTIVE: • To investigate the feasibility of an endoscopic technique as a guide to evaluate bladder outlet resistance during bladder neck plication (BNP) for treatment of female epispadias. PATIENTS AND METHODS: • The postoperative outcomes with long-term follow-up of 10 girls with epispadias were reviewed (four had a previous history of bulking agent injection into the BN). • After taking a skin flap from the area between the crura of the bifid clitoris, subsymphyseal dissection was continued to the BN. • Under cystoscopic guidance, BNP was performed using absorbable sutures (two cases) or non-absorbable sutures (eight) aiming to attain a smooth closure of the BN during gradual withdrawal of the cystoscope. • Finally, urethrogenitoplasty was accomplished by urethral reconstruction with tubularization of the inter-clitorial flap followed by monsplasty and approximation of the two hemi-clitorises. RESULTS: • The mean (range) follow-up was 9.1 (5-15) years. • After primary surgery seven of the 10 girls were continent and all could void normally. • Of the three failed cases (including two that underwent BNP using absorbable suture), two became dry after injection of bulking agent into the BN and the remaining girl underwent BN reconstruction; she was socially continent at the final follow-up. • Ultimately, all 10 girls were socially continent, including six who were completely dry. • Urodynamic studies showed an increase in mean bladder capacity (P < 0.001) and a significant time-dependent improvement of the leak-point pressure and maximum urinary flow rate. CONCLUSIONS: • The present series suggests that single-stage subsymphyseal urethrogenitoplasty together with cystoscopic-guided BNP for management of female epispadias is reliable and effective with definite advantages. • The high success rate and safety of the procedure are important factors for the introduction of this method as a valid option for treatment of this rare congenital anomaly.