Symptomatic corpus spongiosum defect in adolescents and young adults who underwent distal hypospadias repair during childhood.

INTRODUCTION AND OBJECTIVE: Several popular surgical techniques have been described for the repair of distal hypospadias; however, the role of repairing the corpus spongiosum was rarely discussed. Herein we review our experience with adolescents who underwent hypospadias repair during childhood. Their main complaints were partially or totally related to spongiosum deficiency, the surgical outcomes are also discussed. METHODS: Between 2007 and 2018, 25 patients aged between 13 and 28 years of age (median 19 years) were operated upon to repair the deficiency or absence of corpus spongiosum in addition to a Thiersch-Duplay urethroplasty. Their records indicated that the primary hypospadias repairs during childhood included MAGPI (N = 10) and TIPU (N = 9), in 6 patients the repair of the distal hypospadias was unknown. The main complaints were; abnormal urinary stream which patients described as spraying and/or dripping of urine (N = 10) and distal urethral swelling during voiding and dripping of urine post voiding (N = 15). Eight patients reported that they were treated for symptomatic recurrent urinary tract infections by their primary physicians. In 5 patients, the urethral wall was thin and covered with adherent epidermis only. In 20 patients, the laterally displaced spongiosum pillars were well-defined, 4 of whom exhibited mild chordee. In 14 patients the spongiosum pillars were mobilized and approximated using interrupted absorbable sutures. Four patients had spongiosum deficiency and urethral swelling resulting in mild diverticulum formation. The urethral wall was plicated and covered with the spongiosum and/or dartos flaps. In 4 patients the spongiosum pillars were fixed and could not be mobilized to provide a tension-free closure. In these cases, a dartos flap harvested from the scrotum, and used to cover the urethral wall and was sutured on either side to the spongiosum pillars. 12/25 patients underwent glandular contouring and/or meatoplasty simultaneously to improve the penile esthetics. RESULTS: The follow-up period varied between 18 months and 7 years (mean 3.5 years). 24/25 patients reported a normal steady urinary stream, absence of urethral swelling during voiding and none (22) or minimal (2) postvoid droplets of urine which soiled the underwear. One patient developed glans dehiscence and is voiding through a coronal meatus; he declined further surgery. None developed symptomatic urinary infection. The spongioplasty corrected the mild curvature in all 4 patients. CONCLUSIONS: Failure to recognize and/or correct the deficient corpus spongiosum during the repair of distal hypospadias during childhood may become symptomatic during adolescence however, the abnormality can be corrected successfully.

The adolescent glans penis: Functional and aesthetic issues following childhood hypospadias repair.

INTRODUCTION: As children with childhood hypospadias repairs transition into adolescence, the function and appearance of the genitalia acquire greater importance. For some, the direction and shape of the urinary stream can be embarrassing if abnormal, and the appearance of the glans penis and meatus are a concern as they develop the capacity for self-awareness. OBJECTIVE: Herein, we address the surgical correction and outcomes of urine spraying with or without fistulae, and cosmesis over 12 years. We also analyze if any specific prior repairs were more related to their complaints i.e. cosmesis, spraying, and/or fistulae. STUDY DESIGN: We retrospectively reviewed hypospadias revisions by a single surgeon over 12 years. We included adolescents and young adults who complained of abnormal urinary stream and/or aesthetic complaints. Patients then evaluated the post op result as very good, good, acceptable, or unsatisfactory. RESULTS: Of 542 patients who underwent revisionary procedures, 90 (16.6%) presented with complaints of urinary spraying, and appearance of the glans penis and/or meatus (see figure). Of these, 19 (21.1%) presented with aesthetic complaints alone, 37 (41.1%) presented with aesthetic complaints and spraying, and 34 (37.7%) presented with aesthetic concerns, spraying, and were noted to have urethral fistula either during preoperative examination or during surgery. 3/90 patients (3.3%) developed wound infection and dehiscence (one had a tubularized incised plate repair, another a Thiersch-Duplay repair, and the primary repair of the third patient was unknown). CONCLUSIONS: Adolescents and young adults who underwent hypospadias repair during childhood can return with concerns regarding functional and aesthetic abnormalities of the glans penis. Glans sculpting and meatal contouring may be utilized to normalize the urinary stream and achieve a normal aesthetic appearance of the glans penis. Surgeons should follow these patients through adolescence and into adulthood, because complications from hypospadias repairs acquire greater significance later and young adults seek to normalize their phalluses.

The contribution of preconditioning hyperbaric oxygen for complex re-operative surgery of bladder exstrophy and epispadias. A case study of 11patients.

INTRODUCTION: Multiple surgeries on patients born with bladder exstrophy and epispadias (BEE) especially when complicated by postoperative infections results in varying degrees of scarring of the tissues and decreased vascularity. When further surgery for these patients is contemplated the tissue ischemia may result in poor healing and additional complications. Problem wounds due to arterial insufficiency mainly in diabetic ulcers and following therapeutic radiation are commonly treated with hyperbaric oxygen therapy (HBOT). It was hypothesized that the pathologic features of severe fibrosis and tissue ischemia in repeat BEE surgery are similar to those of post radiotherapy patients and would therefore benefit from HBOT. OBJECTIVES: Examine the role of preconditioning and postoperative adjunctive hyperbaric oxygen therapy in repeat surgery of complex cases of bladder exstrophy and epispadias who underwent multiple failed surgical repairs (6-10 operations). STUDY DESIGN: Review of the records of selected eleven patient (9 males and 2 females), the ages varying between 2 and 30 years, 9 patients were born with bladder exstrophy and 2 with epispadias. All patients underwent multiple surgeries often complicated by postoperative wound infection and break down of their repairs. They were referred by other experienced surgeons for further correction of abnormalities which included recurrent abdominal wall hernias following wound dehiscence and repeat repairs of the scarred and deformed genitalia (figure) following multiple surgical failures. For this high morbidity group of patients, the protocol which was adopted included pre-operative 20 dives of HBOT at 1.5 for the young child and 2 atmospheric pressures for the older patients followed by 5-10 dives postoperatively. RESULTS: All patients tolerated the HBO without side effects, and all achieved a satisfactory surgical outcome of the repairs of the large recurrent abdominal hernias, and reconstruction of the external genitalia (figure). Postoperative evaluation was conducted by the parents or patient and the surgeon using a modified scoring system. 3/11 encountered minor complications, suture tracks (2 pts.) and hypertrophic scar which faded over one year (1 pt) CONCLUSIONS: Preconditioning HBO may be utilized as an adjunctive treatment and preventive strategy to activate the protective mechanisms of neovascularization which would reduce the potential morbidity and improve wound healing of compromised and less vascularized tissues of selected patients born with BEE who endured multiple surgical complication.

Outcome of penile lengthening of adolescents and young adults born with bladder exstrophy and epispadias.

BACKGROUND: The decreased penile length in patients born with BE results partly from pubic symphysis diastasis and the separation of the corporal bodies, which causes a shortened penis as the corporal length is lost in traversing the distance between the pubic rami. However, in some cases there is an intrinsic penile abnormality and dorsal chordee. Furthermore, multiple surgeries has in some cases, resulted in cutaneous and subcutaneous scarring, which contributed to the problem of the short phallus and dorsal tethering to the abdominal wall (figure). OBJECTIVE: Herein we evaluated the outcome of penile lengthening, repair of penile upward tethering to the abdominal wall and dorsal curvature in males born with bladder exstrophy and epispadias (BEE). STUDY DESIGN: We reviewed the records of 34 patients (11-29 years old) born with BE (31pts.) and epispadias (3 pts.). The parents and/or the young men were referred because of their dissatisfaction with and complains of short penile length, and upward tethering/chordee. The penile lengthening was achieved by detaching the corporal bodies from the pubic rami and suturing the corporal bodies as reported by Johnston (figure) However, in 11 patients who had had multiple surgeries the periosteum was incised and the corporal dissection was performed subperiosteally to protect the erectile tissues. In 16 pts dermal grafts of the dorsal corporal wall was performed to correct the dorsal curvature. 13 patients underwent single stage augmentation urethroplasty. RESULTS: Surgical complications were encountered in 4 pts (11.7%). Subjective evaluation by the patient and/or parents reported satisfactory and/or very satisfactory results in 31/34 (91%). The degree of penile lengthening measured at 6 months and one year postoperatively showed increased length which varied between 50% and 150% of the preoperative penile length. CONCLUSIONS: As children born with BEE transition to adolescence and adulthood, the external genitalia acquire greater importance. The short phallus and/or dorsal chordee and/or upwards tethering can be corrected successfully in the majority of patients.

Fertility and sexuality issues in congenital lifelong urology patients: male aspects.

PURPOSE: To review existing literature about fertility and sexuality of boys born with complex congenital genitourinary anomalies. METHODS: A Pubmed review was performed in December 2018 to identify the most relevant original manuscripts regarding male complex congenital conditions affecting the urogenital system in male patients including spina bifida (SB), bladder exstrophy-epispadias complex (BEEC) and hypospadias. A comprehensive review was drafted exploring sexual dysfunction from a medical, psychosexual, surgical and reproductive point of view during transition from childhood (or adolescence) to adulthood. RESULTS: About 75% of men with SB have erectile dysfunction (ED) (Gamé et al. in Urology 67(3):566-570, 2006; Diamond et al. in 58(4):434-435, 1986). Most SB patients have impaired sexual development mainly due to diminished self-esteem, dependence on caregivers and lack of privacy (Blum et al. in Pediatrics 88(2):280-285, 1991). Men with BEEC have fewer intimate relationships than women because of the greater difficulties with issues regarding their genitalia and sexual activities (Deans et al. in Am J Obstet Gynecol 206(6):496.e1-496.e6, 2012). However, a good quality of life is achievable with the effective use of coping strategies (Deng et al. in Transl Androl Urol 7:941, 2018; Rikken et al. in BMC Womens Health 18(1):163, 2018; Friedler et al. in Reprod Biomed Online 32(1):54-61, 2016). Chordee occurs in 25% of all hypospadias patients. More severe hypospadias is related to a greater risk for complications. The long-term sexual quality of life (QoL) in men who underwent hypospadias surgery is influenced by a lot of factors. Therefore, an interactive and dynamic biopsychosocial model of sexual QoL was proposed. CONCLUSIONS: The care of patients with congenital urologic conditions becomes a challenge especially in the period of 'transition'. The goal of follow-up is a holistic management viewed from a medical, psychosexual, surgical end reproductive point. All patients should be asked for specific urinary, fecal or sexual concerns.

Fertility and sexuality issues in congenital lifelong urology patients: female aspects.

PURPOSE: With advances in treatment modalities and medical knowledge, girls with congenital urologic disorders are living well into adulthood. Although, sexual and reproductive function in this population is still poorly understood. The aim is to review existing literature about fertility and sexuality in women with congenital genitourinary disorders, including spina bifida (SB), bladder exstrophy-epispadias complex (BEEC) and congenital adrenal hyperplasia (CAH). METHODS: This review represents the joint SIU-ICUD (Société Internationale d'Urologie-International Consultation on Urological Disease) consultation on congenital lifelong urology. The results of this analysis were first presented at a joint consultation of the SIU and ICUD at the 2018 SIU annual conference in Seoul, South Korea. Appropriate experts were asked to write specific sections regarding sexuality and reproductive function in female patients with these complex congenital urogenital disorders. Each expert performed their own literature review which was reviewed by GDW, AFS, Hadley M. Wood and Dan Wood. Expert opinion was obtained where data are non-existent. RESULTS: Only about half of the individuals with SB express a satisfactory sex life. In women with BEEC, cosmetic concerns surrounding genital appearance and function may increase psychological distress, including severe depression, suicide and sexual dysfunction. Professional health care is key for improving self-esteem and to interact in the biopsychosocial model of the quality of life. Patients with SB and BEEC should be informed about all the potential risks and difficulties before, during and after pregnancy. Screening for pelvic organ prolapse is important as it can exacerbate their already existing sexual dysfunction, difficulties achieving pregnancy and challenges with clean intermittent catheterization. CONCLUSIONS: Lifelong multidisciplinary follow-up and management are complex but necessary. As these patients grow into their adolescence, they may have the desire to become involved in personal relationships and have sexual interactions. Their healthcare team needs to be increasingly sensitive to these aspects.

Management of ischemic tissues and skin flaps in Re-Operative and complex hypospadias repair using vasodilators and hyperbaric oxygen.

INTRODUCTION: Repeated and multiple surgeries for hypospadias result in varying degrees of scarring and hypovascularity of penile tissues which may result in poor healing and increasing complication rates with each additional repair. Vasodilator agents such as Nitroglycerine (NTG) can be helpful in the immediate postoperative period to improve flap viability. Hyperbaric oxygen therapy (HBOT) has well-established benefits to promote angiogenesis and wound healing. We hypothesized that NTG and HBOT, methods to promote blood flow and wound healing, would provide better outcomes in redo hypospadias surgeries and reduce complication rates; and, that HBOT and NTG would provide better outcomes compared to NTG alone. OBJECTIVES: Herein, the authors review the results of their strategy of the past 5.5 years in managing these compromised hypovascular tissues using 2% NTG and HBOT for redo surgery of hypospadias. STUDY DESIGN: Between 2014 and 2019, 82 patients (2-24 years old) exhibiting varying degrees of scarring of skin and subcutaneous tissues underwent re-operative repair of hypospadias complications following failed surgeries (3-9 operations, average 5.5 failed previous repairs). There were two groups of patients: Group I (49 patients) received trimodal therapy consisting of NTG, HBOT, and local steroids. The patients were examined every 3 weeks and every 3 months thereafter. The postoperative site was photographed by the parents or by the older patient prior to each visit. Group II (33 patients) received NTG and local steroids, but not HBOT for various reasons. RESULTS: In Group I: 44/49 (88.8%) of the repairs were successful. The complications in this group included a distal repair breakdown (n = 2) and urethral fistula (n = 3). In Group II, a successful outcome was noted in 23/33 (69.6%). The follow up of the 78 patients who completed their repairs varied between 5 months and 4 years. Results are highlighted in the table. DISCUSSION: In accordance to previously published data, the study results further support promising outcomes of application of NTG and HBOT to improve flap viability. Limitations include non-randomization of our treatment groups resulting in a retrospective evaluation of our protocol; and, the intrinsic heterogeneity of our patient population, previous surgical repairs, and scar tissues. CONCLUSIONS: The proposed treatment of combining NTG and HBOT appears to result in reversal of tissue hypoxia and improved wound healing. This preliminary report shows improved outcomes with less morbidity in a group of patients with multiple hypospadias surgical failures and it warrants further application in a larger number of patients.

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.

Advances in bladder substitution and creation of neobladders in children.

Cystectomy and urinary bladder substitution are rare in children but may be necessary in some cases of bladder exstrophy, in the setting of malignancy, or in other settings in which the bladder is severely dysfunctional. This article details advances in surgical techniques in creating continent urinary diversions in this specialized pediatric population.

Metanephric Adenoma in the Pediatric Population: Diagnostic Challenges and Follow-up.

OBJECTIVE: To discuss the presenting features, imaging findings, and recommended management of patients with Metanephric adenoma (MA) focusing on the diagnostic challenges and indications for follow up. MATERIALS AND METHODS: In this case report, we present a case of a 10-year-old female with MA who eventually underwent nephron sparing surgery with a partial nephrectomy. We performed a literature review of previous cases of metanephric adenoma and their respective management and follow-up. RESULTS: Renal ultrasound demonstrated a heterogeneous, echogenic mass measuring 3.8 cm at the upper pole of the right kidney. Further investigations consisted of computed tomography scan, magnetic resonance imaging, and magnetic resonance angiography. The patient underwent robotic-assisted partial nephrectomy. The immunohistochemical staining pattern, gross, and microscopic appearance of the lesion were consistent with the diagnosis of MA. The combination of CK7, EMA, and S-100 negativity and WT1 and CD57 positivity is considered characteristic of metanephric adenoma as described in the literature. CONCLUSION: MA is a rare benign tumor and especially in the pediatric population can cause significant concern over a possible malignant lesion. Although, no follow-up recommendations currently exist in cases of completely resected MA, we standardly perform postoperative surveillance. Although Metanephric Adenoma is difficult to diagnose preoperatively, given the advances in nephron sparing surgery and the utilization of nonionizing radiation modalities for follow up, we can manage these patients safely and with lower morbidity by preserving renal parenchyma.

A novel technique to construct a neo-scrotum out of preputial skin for agenesis and underdeveloped scrotum.

INTRODUCTION: Congenital scrotal agenesis (CSA) is an extremely rare condition with fewer than 10 cases reported in the literature. These patients are often further complicated by undescended testicles as well as systemic developmental disorders. Herein, we report our experience and an innovative surgical technique for creation of a neo-scrotum in three children. MATERIALS AND METHODS: We evaluated the records of three children in our database who were labeled as having an absent (1 patient) or severely underdeveloped scrotum (2 patients). Patients were aged 6, 14, and 16 months. All patients were uncircumcised, and the decision was made to create a neo-scrotum using the foreskin. The prepuce was harvested on a pedicle of dartos and transposed over the perineal cleft to create a neo-scrotal pouch. The flap was allowed to heal for 12-14 weeks, at which time the orchidopexy was performed. RESULTS: The follow-up to the surgery was 5 years, 3 years, and 6 months, respectively. There were no instances of flap necrosis, dehiscence, or wound infection. The three children had a capacious, aesthetically pleasing scrotal sac, which in all cases accommodated both testicles. CONCLUSION: In our experience, a well-vascularized preputial skin flap rotated to the perineum based on its ventral dartos pedicle provides an excellent source of tissue for creation of a neo-scrotum. We believe that the esthetic outcome of our technique rivals that of other reported techniques.

Prepuce sparing: Use of Z-plasty for treatment of phimosis and scarred foreskin.

INTRODUCTION AND OBJECTIVES: The desire to preserve the prepuce is often based on cultural norms. Recently, the concept of "genital autonomy" has been invoked to delay circumcision (or any genital altering procedure) until the individual reaches maturity and can make his or her own decision. However, some uncircumcised boys develop one or more episodes of balanitis resulting in scarring of the prepuce and pathologic phimosis which is difficult to treat. Herein we report on the management of severe phimosis and preputial scarring using preputial Z-plasties. MATERIALS AND METHODS: We reviewed the records of 28 patients, aged 3-12 years who underwent prepuce-sparing surgery within the previous 5 years with a minimum follow-up of 6 months. All patients were uncircumcised, with severe phimosis defined as a tight, pinpoint opening. All patients failed to respond to 6-10 weeks of betamethasone treatment. All parents requested preservation of as much of the foreskin as possible. RESULTS: All patients healed satisfactorily, without infection, hematoma, or flap necrosis. One child developed mild scarring which responded to local steroid application. At follow-up evaluation, ranging from 6 to 24 months, the prepuce was fully retractable in all patients (Fig.). CONCLUSIONS: Excision of the scarred preputial ring results in a circular suture line, which is in essence a straight line, curved and connected at each end, and this is likely to contract over time. The principle of Z-plasty can be exploited to elongate and interrupt the straight line, preventing contracture thus widening and sparing the prepuce.

Management of 220 adolescents and adults with complications of hypospadias repair during childhood.

OBJECTIVE: The goal of hypospadias repair is to achieve normal voiding and good penile cosmesis with minimal complications. Some urethroplasties deteriorate from childhood to adolescence and late stage failures have been reported. We report our experience with adult patients who have had a previous repair during childhood and present with a late complication. METHODS: We reviewed the records of 220 patients aged 15-39 years old with a history of hypospadias repair who presented to our clinic. Forty-five patients with chordee, 39 with urethral strictures, 11 urethral fistulae, five with hairy urethras, three with urethral diverticula, and 117 patients with an abnormal glans or subterminal meatus were repaired. RESULTS: Median follow-up was 14 months. Two patients had persistent chordee. Island skin flap urethroplasty afforded one patient with a urethral fistula and another with a recurrent urethral stricture, while the buccal mucosa group had one fistula which healed spontaneously and two recurrent strictures. For the patients undergoing glanular repairs, seven had dehiscence or breakdown of the repair. All other operations were successful. CONCLUSION: Complications of childhood hypospadias repair may present later in life as some urethroplasties deteriorate with time. We now recommend to parents of children with repaired proximal hypospadias to come for follow-up as their child transitions to adolescence.

Challenges in salvaging urinary continence following failed bladder exstrophy repair in a developing country.

INTRODUCTION: The management of urinary incontinence following failed bladder exstrophy repairs is not well defined, some surgeons recommend urinary diversion, others would pursue reconstructive surgery. OBJECTIVE: Herein we review our experience with various strategies for management of urinary incontinence and their outcome in 61 patients born with bladder exstrophy who failed their initial repairs. We also examine the impact of diverse factors in making the surgical decision for patients with limited resources in a developing country. MATERIAL AND METHODS: Between 1981 and 2014, 61 incontinent patients (age 3-18 years) born with bladder exstrophy were referred for secondary or tertiary repair. In nine children the bladder was exposed following wound dehiscence and 52 had had one or more attempted repairs resulting in contracted bladders. The primary treatment included: re-closure and bilateral iliac osteotomy in five patients (group 1); urinary diversion in Mainz II pouch in 15 patients (group 2); and 41 patients (group 3) underwent bladder augmentation and bladder neck reconstruction (31 patients) or bladder substitution and cystectomy (10 patients). RESULTS: In group 1, three out of five patients were voiding with dry intervals. One child was dry between catheterization, and one was incontinent and underwent Mainz II diversion. All 16 patients with Mainz II pouch were continent of urine and stool. Of the 41 patients in group 3, follow-up was available for 34 patients, of whom 31 (91%) were dry between catheterization. However, additional surgery was performed in 15/34 (44%). Malignant changes were noted in 2/26 cystectomy specimens. DISCUSSION: The quality of the bladder plate may deteriorate following failed bladder exstrophy surgeries. A few selected cases who had maintained a relatively healthy bladder plate were candidates for re-closure with osteotomy. Other surgical options included complex reconstruction with catheterizable channel, and internal urinary diversion. In this series the following factors were considered: a) pre-operative bladder biopsy to rule out pre-cancerous lesions, b) counseling the parents about possible additional surgeries after bladder augmentation or continent reservoir, and c) patients' geographic and socio-economic status. CONCLUSIONS: Children born with bladder exstrophy are best treated at pediatric centers with expertise in their management. The exstrophied bladder should be protected and covered with non-adherent plastic wrap to prevent mucosal irritation and ulceration by the diaper. However, following failed surgeries the majority of incontinent patients can be salvaged to become continent/dry. It would appear that the Mainz II internal diversion offers a reasonable surgical option for selected patients, especially for females and those who have endured multiple surgical failures.

Resurfacing the Penis of Complex Hypospadias Repair ("Hypospadias Cripples").

PURPOSE: After the creation of a neourethra in a "hypospadias cripple," resurfacing the penis with healthy skin is a significant challenge because local tissue is often scarred and unusable. We reviewed our experience with various strategies to resurface the penis of hypospadias cripples. MATERIALS AND METHODS: We retrospectively reviewed the records of 215 patients referred after multiple unsuccessful hypospadias repairs from 1981 to 2014. In 130 of 215 patients we performed resurfacing using local penile flaps using various techniques, including Byars flaps, Z-plasty or double Z-plasty, or a dorsal relaxing incision. Of the 215 patients 85 did not have adequate healthy local penile skin to resurface the penis after urethroplasty. Scrotal skin was used to resurface the penis in 54 patients, 6 underwent tissue expansion of the dorsal penile skin during a 12 to 16-week period prior to penile resurfacing, 23 underwent full-thickness skin grafting and another 4 received a split-thickness skin graft. RESULTS: Of the 56 patients who underwent fasciomyocutaneous rotational flaps, tissue expansion or a combination of both approaches 54 (96.4%) finally had a successful outcome. All 6 patients who underwent tissue expansion had a successful outcome without complications and were reported on previously. All 23 full-thickness skin grafts took with excellent results. All 4 patients who underwent fenestrated split-thickness skin grafting had 100% graft take but secondary contraction and ulceration were associated with sexual activity. CONCLUSIONS: In our experience scrotal skin flaps, tissue expansion of the dorsal penile skin and full-thickness skin grafts serve as reliable approaches in resurfacing the penis in almost any hypospadias cripple lacking healthy local skin.

Use of human acellular dermal matrix during classic bladder exstrophy repair.

INTRODUCTION: The extent of the abdominal wall defect in people with classic bladder exstrophy (CBE) varies, and can be extensive. In this study, human acellular dermis (HAD) was used to bridge the fascial gap, as an alternative to osteotomy, to support a fascial repair of the abdominal wall, and as a filler in selected cases of CBE. OBJECTIVE: To demonstrate the efficacy of the employed techniques of using HAD within the bladder exstrophy population. MATERIALS AND METHODS: The medical records of six males, born with CBE, and who had abdominal wall defects were reviewed. Two children, aged 6 and 8 years old, were referred from overseas with unrepaired bladder exstrophy plates and large abdominal wall defects (8 cm and 12 cm wide). Both had their bladders reconstructed, placed within the pelvis, and HAD was used to replace the absent abdominal wall (bridged repair) without the use of pelvic osteotomy. In three other patients, HAD reinforced the native fascial repair (bolster repair). In three patients, HAD also served as a filler for the abdominal depression that was present following initial staged repair. Where HAD was used for bridged or bolster repair, the edges of the allograft were extended 2-3 cm circumferentially beyond the perimeter of the abdominal wall defect. RESULTS: All six patients healed well, without evidence of abdominal wall hernias at 1-3 years postoperatively. Functionally, each patient regained an appropriate level of abdominal wall strength. Two children successfully underwent a secondary procedure through the bridged allograft repair, as each required bladder neck reconstruction and bilateral ureteral reimplantation through the reconstructed abdominal wall. Continence was achieved in these two patients, with one child voiding at 2-hourly intervals and the second at 3-hourly intervals. One patient developed a urethral-cutaneous fistula, distant to location of the allograft. There were no associated wound complications. CONCLUSIONS: In this series of patients born with classic bladder exstrophy, HAD acted as a biologic scaffold and allowed native cellular ingrowth and tissue remodeling. It served as an alternative to pelvic osteotomy in older patients with unrepaired CBE. The material reinforced a weak or potentially suboptimal fascial repair and filled a tissue gap, resulting in improved aesthetics. Given its ease of preparation and the lack of significant morbidity associated with its use, combined with the functional and esthetic results in the present series, HAD may be considered during delayed reconstruction of abdominopelvic tissues in people born with CBE.

Split-cuff nipple technique of ureteral reimplantation in children with thick-walled bladders due to posterior urethral valves.

OBJECTIVE: To describe a novel technique of ureteral reimplantation in patients with thick-walled bladders, which addresses the technical challenges and high failure rates seen in this population. METHODS: From 1997 to 2012, 45 megaureters were reimplanted in 26 children aged 2-11 years. Key surgical modifications included ureteral trough creation within the detrusor, formation of a distal ureteral split-cuff nipple, reliance on transureteroureterostomy (TUU) when the bladder would not support the reimplantation of 2 ureters, performance of psoas vesicopexy, and judicious utilization of ureteral stump augmentation in patients undergoing TUU. Follow-up ranged from 1 to 12 years. RESULTS: Seven patients underwent unilateral and 4 underwent bilateral ureteral reimplantation; TUU was performed in 15. Psoas vesicopexy was performed in 22 patients. Voiding cystourethrography showed no reflux in all children who underwent vesicopexy. Reflux resolved in 6 of 8 bilaterally reimplanted ureters; 2 of 8 had improved reflux that later resolved with Deflux injection. No ureters obstructed. Hydronephrosis improved in 32 of 45 renal units and remained stable in 13. Seven patients continue to develop bacteriuria. Five have developed renal failure. CONCLUSION: In our experience, a long ureteral trough combined with a split-cuff nipple technique for reimplanting megaureters into thick-walled bladders yields improved results over conventional submucosal tunneling, effectively eliminating or improving reflux and preventing obstruction. TUU and psoas vesicopexy proved useful adjuncts in creating adequate intravesical trough length. The risk for continued bacteriuria and renal failure due to limited renal reserve, however, remain notable in this group.