Glanular closure during the tubularized incised plate procedure: a prospective randomized study

Hypospadias is reported in 1:200 live births. The introduction of the tubularized incised plate [TIP] procedure has revolutionized the treatment of hypospadias. The method of glanular closure during the TIP procedure, whether in single or double layers, has not been evaluated in the literature. To evaluate the optimal technique of glanular closure during the TIP repair of the distal hypospadias. Sixty-six infants and children with distal penile hypospadias were treated primarily with the TIP procedure. Age ranged between 9 months and 4 years with a mean age of 20.8 months at time of repair. Patients were randomly subdivided into two equal groups. In group A, the glans was repaired in a single layer, while in group B, the glans was closed in two layers. All cases were subjected to the same protocol of urethral stenting, penile bandage, and catheter removal by the third postoperative day. Both groups were followed up and compared with regard to the results of TIP repair and the incidence of complications. In group A, two cases developed glanular disruption versus none in group B. this was found statistically significant [p<0.05]. No statistical difference was found in between groups with regard to meatal stenosis, fistula formation, or in the overall cosmetic and functional outcomes. Medium-term follow up showed excellent results in 82.9% while good results were obtained in 17.2%. On the mid-term follow up, the TIP procedure continues to prove itself as the gold standard in treatment of the distal hypospadias. The double-layered glanuloplasty seems to hold an improved morbidity profile, with significantly lower glanular disruption rate, when compared to the single layered repair. Large-numbered studies are still needed to provide further evidence for the superiority of the double-layered glanuloplasty.

Management of arterial trauma of pediatric extremities [a report on 30 patients]

To review the diagnosis and treatment of children with upper and lower extremities arterial injuries and to evaluate the long-term outcome of long emgraft in pediatric aged group. A study of arterial trauma that needed surgery in children less than 13 years of age presented to Tanta University Hospital in the period from February 2001 to October 2005. Thirty [30] children were located who had arterial traumas distributed between lower extremity [20 cases] and upper extremity [10 cases]; exclusion criteria included isolated venous injuries, primary amputations. Clinical examination and duplex scanning were used for every patient at follow-up. Thirty children [24 boys and 6 girls] with an average age of 65 years [range, 3.5-13 years] were reviewed. The mechanisms of injury were blunt trauma in 20 patients [most of them were due to car accidents], penetrating injury in 10 cases. The most commonly injured arteries were 11 femoral, 6 popliteal, 5 brachial. An obvious delay in repair was evident in this series as 70% of cases [21 patients] were admitted to peripheral hospitals before reaching our center. Among 11 femoral injuries: 7 treated by long interposition graft [> 5cm] and 2 by femoropopliteal bypass to below knee segment. The material used for arterial repair were great saphenous vein [GSV] in 7 cases, the superficial femoral vein as an interposition graft in one case, and two parallel strips from contra-lateral GSV sutured together to obtain a wide lumen in another one In the popliteal segment: the use of intraluminal shunt and early fasciotomy to avoid ischemic nerve damage and decrease reperfusion injury, and then reconstruction with reversed saphenous interposition graft. Ligation of the bleeding infected pseudoaneurysm in the posterior tibial [1] and in the dorsalis pedis [1] was done. In the brachial: Three cases needed bypass either anatomical or extra-anatomical, and one in situ cephalic vein bypass, thrombectomy and dilatation through transverse arteriotomy was done in two cases. Saphenous interposition graft was done in 3 cases of the axillary and vein patch angioplasty in subclavian artery injury.. Most children had associated problems related to trauma especially bone fractures and soft tissue lacerations. Mortality rate in this series was 4 cases out of 30 cases [13.3%]. Delayed amputation needed for 3 cases [10%], two above knee amputations and one above elbow. At discharge all patients [22] had good distal pulse and functioning limb except one with brachial plexus injury. All patients advised to take aspocid 75 mg/daily. The patency of small diameter vein graft which was used as: long grafts in the remaining 12 cases, short graft or patch angioplasty in 5 cases were assessed. Only 12 patients completed the follow-up for 3 years. Duplex scanning showed no occlusion, non significant stenosis in two cases, no aneurysmal dilatation. Blunt trauma is more common than other causes in pediatric arterial injuries which masks the early diagnosis and makes the outcome poor. However, an aggressive vascular repair, innovative ideas, and expert vascular surgeon will allow limb salvage even in the presence of diagnostic delay. Invasive diagnostic studies have minimal role in these cases. Surgical repair can be performed in children and autogenous venous conduits are the best suitable bypass materials with patency and freedom from aneurysmal dilatation up to 3 years