Can a graft be placed over a flap in complex hypospadias surgery? An experimental study in rabbits

ABSTRACT Purpose: To develop a rabbit experimental study to test the hypothesis that surgical repair of hypospadias with severe ventral curvatures might be completed in one stage, if a graft, such as buccal mucosa, could be placed over the tunica vaginalis flap used in corporoplasty for ventral lengthening, with the addition of an onlay preputial island flap to complete the urethroplasty. Materials and methods: The experimental procedure with rabbits included a tunica vaginalis flap for reconstruction of the corpora after corporotomy, simulating a ventral lengthening operation. A buccal mucosa graft was placed directly on top of the flap, and the urethroplasty was completed with an onlay preputial island flap. Eight rabbits were divided into 4 groups, sacrificed at 2, 4, 8 and 12 weeks postoperatively, and submitted to histological evaluation. Results: We observed a large number of complications, such as fistula (75%), urinary retention (50%) and stenosis (50%). There were two deaths related to the procedure. Histological evaluation demonstrated a severe and persistent inflammatory reaction. No viable tunica vaginalis or buccal mucosa was identified. Conclusions: In this animal model, the association of a buccal mucosa graft over the tunica vaginalis flap was not successful, and resulted in complete loss of both tissues.

Rapid intraoperative tissue expansion with Foley catheter in a challenging cripple Hypospadias

Failed hypospadiass cases may result in hypovascular, scarred penis with residual penile chordee and leave the patient with minimal residual skin for penile resurfacing and urethroplasty. Local tissue expansion has become a good alternative to provide skin for penis by using expanders however they require long periods of time for expansion. Besides, rapid tissue expansion was also described in different tissues. We used rapid intraoperative expansion technique by using a Foley catheter in a failed hypospadias case who had minimal residual skin secondary to infection and we concluded that rapid intraoperative tissue expansion with Foley catheter is an effective, feasible reconstructive method for easy dissection and penile resurfacing in failed hypospadiass cases.

Duplicación rectal extrofiada asociada a malformación anorrectal y transposición pene-escrotal con hipospadias perineal: Reporte de un caso clínico / Exstrophy of rectal duplication associated with anorectal malformation and penoscrotal transposition with perineal hypospadias: A case report

Se presenta el caso de un paciente masculino quien requirió tratamiento por agenesia anorrectal con fístula rectouretral y transposición pene-escrotal con hipospadias perineal, acompañados de una masa perineal. La tumoración perineal se encontró íntimamente adherida y en continuidad al recto, lo que la hace compatible con una duplicación rectal extrofiada. La reconstrucción quirúrgica de la anomalía se realizó en etapas hasta lograr resultados funcionales y estéticos aceptables.

We present the case of a male patient who required treaatment due to anorectal agenesis with recto urethral fistula and penoscrotal transposition with perineal hypospadias, associated with a perineal tumor. The perineal tumor was found strongly adhered and contiguous to the rectum which makes it compatible with an exstrophy of rectal duplication. Surgical reconstruction of the birth defect was performed in stages until acceptable biological function and esthetic results were obtained.

Meatobalanoplastia asociada a movilización de uretra para corregir hipospadias distales / Meatobalanoplastia associated with mobilization of the urethra to correct distal hypospadias

Objetivo: Demostrar que la meatobalanoplastia asociada a movilización, por liberación parcial o total de la uretra (MEBAMU) es una conducta técnico quirúrgica funcional y estéticamente útil para corregir hipospadias distales.Material y Métodos: 63 de 81 niños de entre 8 y158 m. de edad (promedio 37,4 m. mediana 25 m.) operados por el mismo cirujano entre los años 2000 y 2007 cumplieron con los criterios de inclusión. Es un estudio clínico prospectivo de tipo experimental, con controles históricos. Los detalles técnicos son descriptos minuciosamente. 15 (23,8%) eran hipospadias balánicas, 26 (39,7%) coronales y 22 (36,5%) subcoronales. 9 pacientes habían sido operados previamente, 8 con otras técnicas y 1 con la misma técnica. De acuerdo con las necesidades, en 18 pacientes la uretra se iberó parcialmente y en 45 totalmente (13 en un corto trayecto y 32 extensamente) . El seguimiento promedio fue de 33 m (6 a 99m). A 30 niños de 2 a 14 años de edad (Promedio 75,2 m) se les realizó uroflujometría, 36,6 m promedio después de operados. El análisis estadístico se realizó con software de SAS que considera un error de tipo I del 5% (alfa=0.05%). La comparación entre los grupos, cuando las variables fueron numéricas se realizó mediante el test de Wilcoxon Sun Run. Las variables nominales (cualitativas) mediante test de Chi cuadrado o Fisher Exact test. Resultados: Preponderó la liberación parcial de la uretra en las formas balánicas y la total en las coronales y subcoronales (p<0,01). 5 pacientes (7,9%) se complicaron, 2 fístulas y 3 estenosis. De los 9 pacientes con cirugías previas, 7 evolucionaron satisfactoriamente.

Tratamento de hipospádia distal pela técnica de snodgrass / Treatment of distal hypospadias for snodgrass technique

Introdução: hipospádia é uma malformação congênita que se caracteriza pela localização ectópica do meato uretral e a anomalia genital mais comum no sexo masculino. Dentre as formas de apresentação a distalrepresenta 70% dos casos. O tratamento é estritamente cirúrgico, associado às complicações significativas que o tornam um desafio. Objetivo: avaliar o resultado cirúrgico no tratamento da hipospádia distal no serviço de cirurgia pediátrica do HIJG.Métodos: estudo prospectivo, observacional, com seguimento pós-operatório de 90 dias. Resultados: no período de março de 2006 a maiode 2007, 50 pacientes portadores de hipospádia distal foram submetidos à uretroplastia pela técnica de Snodgrassno HIJG. A média de idade foi de 4,08 anos (6m - 14anos). O tempo de retirada da sonda uretral no pós-operatório foi em média de 11,28 (7 - 20) dias e a moda de 7 dias. As intercorrências no pós-operatório ficaram assim distribuídas: sangramento de meato uretral (60%), dor na ferida operatória (40%). As complicações ocorridas foram: estenose de meato uretral (6%) e fístula uretrocutânea (10%). O aspecto cirúrgico foi considerado satisfatório em 48 dos pacientes (96%). Conclusão: A taxa complicação foi de 16% e a aparênciado trato genital externo foi considerada normal na grande maioria dos casos.

Background: hypospadia is a congenital anomaly characterized by ectopic location of the urethral meatus. It’s the most common anomaly of male genitalia. Among its forms of presentation, the distal form responds for 70% of the total. The treatment of this anomaly is strictly surgical, associated with significant complications which may interfere in the results. Objective: evaluate the surgical result of the treatment of distal hypospadia in the Joana de Gusmão Children’s Hospital, Florianópolis, Brazil. Method: prospective study, observational, with postsurgical follow-up of 90 days.Results: in the period of March 2006 and May 2007, 50 patients with distal hypospadia where submitted toSnodgrass uretroplasty. The average age was 4,08 years (6 months to 14 years). The removal of the urethralcatheter in the post-surgical period occurred in mean time of 11,28 (7 - 20) days and its mode was 7 days. Thepost-operative problems where: bleeding from urethral meatus (60%), pain in the operatory wound (40%). Thecomplications where: urethral meatus stenosis (6%) and urethra-cutaneous fistula (10%). The surgical aspect wassatisfactory in 48 patients (96%).Conclusions: the complication rate was 16% and the appearance of the external genital tract was satisfactory in the majority of the patients.

Additional malformations in femoral hypoplasia: unusual facies syndrome.

This syndrome comprises of bilateral femoral hypoplasia and unusual facies comprises of short nose with broad tip, elongated philtrum, thin upper lip, small lower jaw, cleft palate and antimongolian slant of palpebral fissure. Etiology is idiopathic, sporadic, few families have been reported to have autosomal dominant inheritance. We report a case with the additional finding of unilateral complete aplasia of femur, encephalocele, complete cleft lip, bilateral absence of 5th metatarsal and toe and hypospadias. The mode of inheritance appears to be sporadic mutation in this case.

Repercusiones urológicas de la malformación anorrectal alta / Urological repercussions of high anorectal anomaly

Se revisaron los casos de 64 pacientes con diagnóstico de malformación anorrectal alta con el fin de identifiar la incidencia y los tipos de malformaciones urológicas que acompañan, así como su diagnóstico y tratamiento, ademas de las repercusiones en el curso clínico de los mismos. Se encontró que 42 por ciento presentaban una o más de estas malformaciones, y que destacaban el reflujo vesicoureteral (55 por ciento), la vejiga neurogénica (25.9 por ciento) y la agenesia renal (18.5 por ciento). El diagnóstico oportuno fue realizado en menos de mitad en 60 por ciento de los casos. Fueron cinco en promedio las operaciones por paciente para su reconstrución. Cinco pacientes desarrollaron insuficiencia renal crónica. Se concluye que las malformaciones urológicas acompañantes representan una causa significativa de morbimortalidad. Se recomiendan la realización de ultrasonido renal y uretrocistograma en forma oportuna y la atención de estos pacientes en un centro especializado.

Developmental anomalies associated with hypospadias.

Hundred and thirty patients with hypospadias were studied between 1983 and 1990, with an aim of analysing the associated anomalies in these patients. Urogenital anomalies were observed in 30% and extra-urogenital anomalies were noted in 16%. Undescended testis was the most frequently seen anomaly, having been noted in 6.9% of 130 cases. Vesico-ureteral reflux was present in 5.4% and inguinal hernia in 3.8%. The incidence of these anomalies increased in proportion to the severity of penile deformity. The present article emphasizes the need for systemic urological and endocrinal examination, especially in severe cases of hypospadias.