Hipospadias: del diagnóstico ecográfico prenatal al manejo posnatal / Hypospadias: from prenatal ultrasound diagnosis to postnatal management

El hipospadias es la localización anormal del meato urinario y es la malformación de genitales externos más frecuentemente diagnosticada. El diagnóstico prenatal es posible mediante ecografía sistemática desde la semana 20 de gestación, siendo más fácil su diagnóstico en el tercer trimestre. Las formas leves suelen ser aisladas, familiares o asociadas a disfunción placentaria o restricción de crecimiento intrauterino, mientras que las formas más graves presentan hasta un 30% de asociación a defectos fetales, anomalías cromosómicas/genéticas o anomalías del desarrollo sexual. La tríada para el diagnóstico ecográfico prenatal consiste en curvatura ventral del pene, anomalía del prepucio dorsal y punta del pene roma. La valoración de la uretra durante la micción y el aspecto del chorro miccional son de gran utilidad para clasificar el defecto. Cuando se diagnostica hipospadias peneano o escrotal es aconsejable realizar una amniocentesis para estudio genético fetal y valorar otros signos de adecuada virilización, como el descenso testicular a partir de la semana 27. El seguimiento tras el parto debe ser multidisciplinario, incluyendo urólogo y endocrinólogo infantil. En hipospadias leves el pronóstico es bueno con reparación quirúrgica en el primer año de vida, pero las formas graves pueden presentar un reto mayor para su corrección funcional y estética.

Hypospadias refers to the abnormal location of the meatus; it is the most common genital malformation detected in the fetus and newborn. Prenatal diagnosis is feasible from 20 weeks onwards with routine ultrasound; however, it is easier to diagnose during the third trimester of pregnancy. Mild defects are usually isolated, familiar o related to placental disfunction or intrauterine growth restriction, while the severe hypospadias are associated to other fetal defects, genetic or chromosomal abnormalities or disorders of sex development. In about 30% of cases. The triad of ultrasound findings prenatally is ventral curvature of the penis, redundant dorsal foreskin and blunt distal penis. The identification of the urethra during the micturition and the direction of the urinary stream help in the classification of the defect. When severe hypospadias is detected, the recommendation is to perform genetic amniocentesis and search for other ultrasound findings related to poor virilization in the fetus, as testicular descent after 27 weeks of gestation. Postnatal follow up should be multidisciplinary including infantile urologist and endocrinologist. The prognosis in distal hypospadias is usually good following surgical repair, however in severe cases surgical interventions may be more challenging in order to obtain satisfactory outcome in terms of function and esthetic.

Double dartos flap layer in tubularized incised plate urethroplasty to prevent urethrocutaneous fistula in uncircumcised patients with distal hypospadias / 亚洲男科学杂志(英文版)

Urethrocutaneous fistula may complicate hypospadias repair. We noticed that double-layered preputial dartos flaps added to tubularized incised plate urethroplasty can reduce the risk of urethrocutaneous fistula. The aim of this study was to compare the outcomes of tubularized incised plate urethroplasty with double-layered preputial dartos flaps to with single-layered local fascial flaps in preventing urethrocutaneous fistula. A retrospective cohort study was conducted between January 2017 and December 2020 at Jordan University Hospital (Amman, Jordan). Boys who were aged between 6 months and 5 years, diagnosed with distal hypospadias, and not circumcised were included. The primary outcome was the occurrence of urethrocutaneous fistula in patients who underwent tubularized incised plate urethroplasty with a double-layered fascial flap. The results showed a total of 163 boys with distal hypospadias; among them, 116 patients underwent tubularized incised plate urethroplasty with a single-layered fascial flap, and 47 underwent tubularized incised plate urethroplasty with a double-layered fascial flap. The development of urethrocutaneous fistula was higher in the group receiving tubularized incised plate urethroplasty with a single-layered fascial flap than in the group receiving tubularized incised plate urethroplasty with a double-layered fascial flap after 1 month, 6 months, and 12 months (6.9% vs 0, 10.3% vs 0, and 5.2% vs 0, respectively), and the difference after 6 months was statistically significant (P = 0.02).

High grade persistent ventral curvature after multiple hypospadias surgery: how to correct?

ABSTRACT Introduction: A challenging situation in proximal hypospadias is the presentation of patients with successful urethroplasty but with persistent or recurrent ventral curvature (VC) after multiple hypospadias repair. Materials and Methods: We present a 13 year-old boy with 7 previous surgeries (long TIP, Duplay, meatoplasty) to treat hypospadias presenting with 60 degrees of VC, in spite of a well-accepted coronally neomeatus. We degloved the penis and artificial erection clearly appointed corporal disproportion causing curvature. We disconnected urethra from corpora. After excision of remnant fibrotic tissue, there was a residual curvature so a lenghtening corporoplasty with dermal graft from groin was performed. We have adjusted the urethral meatus position into a proximal penile shaft. We used a buccal mucosa graft placed in an inverted U-shape position planning a second stage urethroplasty (1). An indwelling silicone Foley tube was left for one week. The patient was discharged the day after surgery. Results: The aspect after corporoplasty proved satisfactory curvature correction. Patient had an excellent outcome and is scheduled for a second-stage after 6 months. Discussion: Snodgrass and Bush (2) reported that on 73 patients with an average of 2.7 operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50°. We do believe that some good results with minimal dorsal plicature may recur in adolescence and therefore when these procedures may be considered, they should be performed by classic Nesbit technique (3). Otherwise, the choice for primary ventral lengthening should be taken. Conclusion: Severe curvature associated with hypospadias should undergo a major procedure at early stage to avoid decompensation after dorsal plicature in adolescence. We had a very satisfactory result, the patient awaits the second stage procedure (Figure-1). Figure 1 End aspect after complete healing of buccal mucosa. Notice that penis is straight and second stage will be performed after 6 months of interval.

Application of the Mathieu combined tunnel technique for repairing glans dehiscence after failed hypospadias repair / 亚洲男科学杂志(英文版)

Repairing glans dehiscence after failed hypospadias repair is challenging for pediatric surgeons. Here, we introduced and evaluated a newly modified Mathieu technique, Mathieu combined tunnel (MCT), which involves multiple custom-designed flaps for the shortage of flap source material after repeated operations; we also constructed a tunnel to avoid the glans incision that may carry new risks of dehiscence. This retrospective study included 26 patients who were consecutively admitted to the First Affiliated Hospital of Sun Yat-Sen University (Guangzhou, China) for glans dehiscence repair after failed hypospadias repair from October 2014 to October 2020; sixteen patients underwent surgery using the MCT (MCT group) and ten patients underwent surgery using the tubularized incised plate (TIP) technique (TIP group). The operative time, blood loss, postoperative complications, normal urethral meatus rate, success rate, and Hypospadias Objective Penile Evaluation (HOPE) score were compared between the two groups. The MCT group achieved an overall satisfactory penile appearance and voiding function, with a higher rate of normal urethral meatus (15/16, 93.8%) and a lower rate of glans dehiscence (1/16, 6.2%), compared with the TIP group (70.0% and 30.0%, respectively). However, these differences were not statistically significant, possibly because of the limited number of patients (all P > 0.05). Mean postoperative HOPE scores were similar in the MCT group (mean ± standard deviation: 8.83 ± 0. 89) and TIP group (8.94 ± 0.57) (P > 0.05). No significant differences were found between the two groups in terms of blood loss and success rate, nor in the rates of various complications (e.g., fistula, urethral stricture, and glans dehiscence). In conclusion, the MCT technique appears to be feasible and reliable for repairing glans dehiscence after failed hypospadias repair.

A new option to prevent fistulas in anterior urethroplasty in patients with kippered urethra: the tunica vaginalis flap

ABSTRACT The objective of this study is describing a technique with the use of a tunica vaginalis flap (TVF) to cover the suture line during anterior urethroplasty in patients with kippered urethra due to chronic indwelling catheterization (CIC). We studied 5 patients (mean age=50.2) with a neurogenic bladder that developed urethral erosion after a long period of CIC. Foley catheter was removed on the 14th postoperative day. One patient developed wound infection and utethrocutaneous fistula, which was conservatively managed and after 12 months of follow-up all the patients didn't report difficulties in intermittent self-catheterization. In conclusion, a urethroplasty with TVF technique may be a viable method for repairing penile urethral erosions, but further studies are required with a bigger sample to confirm our results.

Does parental opinion differ from the health care team regarding cosmesis after hypospadias repair?

SUMMARY OBJECTIVE: Hypospadias is the most common malformation of the male genitalia. Surgical correction has traditionally focused on anatomic and functional outcomes, with less attention being paid to cosmetic results. Our purpose is to compare the cosmetic results of hypospadias repair among different groups of observers, namely the patient's family and the health care team, using photography and a simple rating scale. METHODS: Prospective observational study included 9 boys undergoing Snodgrass hypospadias repair. Photographs of the penis taken before, immediately after, and six months after surgery were assessed by a panel of 15 observers (parents and health care team) and a scale including three questions with diagrams for comparison with the pictures was used. Observers also assigned an overall postoperative score for the cosmetic result. RESULTS: Interobserver agreement was noted for the group of parents of other children with hypospadias regarding the shape of the glans (k=0.404; p=0.008) and for the group of pediatric surgeons regarding the degree of residual curvature (k=0.467; p=0.005). Two observers in the pediatrician group have indicated good performance in the assessment of residual curvature (k=0.609; P=0.024). In the overall assessment of cosmetic outcomes, the highest scores were assigned by observers in the parents group and in the pediatrician group, while the pediatric surgeons group has one of the lowest scores (p<0.001). CONCLUSIONS: Photography appears to be suitable for documenting corrections of hypospadias regarding penile curvature, and postoperative cosmetic result. Surgeons seem more concerned about cosmesis than parents.

Clinical evaluation of Compound Chamomile and Lidocaine Hydrochloride Gel for postoperative hypospadias in children / 中华男科学杂志

Objective@#To evaluate the clinical efficacy of Compound Chamomile and Lidocaine Hydrochloride Gel for postoperative hypospadias in children.@*METHODS@#From January to December 2020, we treated 116 children with distal hypospadias in the Department of Urology, Department of Pediatrics and the Seventh Medical Center of the PLA General Hospital, 58 by primary Snodgrass urethroplasty only (the control group) and the other 58 with Compound Chamomile and Lidocaine Hydrochloride Gel smeared on the penis postoperatively in addition (the trial group). We compared the operation time and postoperative pain score, edema regression and incidence of infection between the two groups, followed by statistical analysis using T test and Chi-square test.@*RESULTS@#All the operations were successfully completed by the same surgeon under general anesthesia. There were no statistically significant differences between the trial and control groups in age (［2.5 ± 0.8］ vs ［2.4 ± 0.6］ yr, P > 0.05) or operation time (［95.6 ± 14.5］ vs ［97.1 ± 15.2］ min, P > 0.05). No incision infection occurred in any of the cases. The pain scores at dressing removal were remarkably lower in the trial than in the control group at 2 hours (1.4 ± 1.0 vs 2.6 ± 1.3, P < 0.05), 24 hours (2.2 ± 1.3 vs 3.9 ± 1.6, P < 0.05), 48 hours (1.2 ± 0.7 vs 1.6 ± 0.9, P < 0.05) and 72 hours after surgery (2.5 ± 0.8 vs 3.7 ± 1.8, P < 0.05). Significantly more cases of edema regression were achieved in the trial than in the control group at 2 weeks postoperatively (35 vs 19, P < 0.05).@*CONCLUSIONS@#Compound Chamomile and Lidocaine Hydrochloride Gel can effectively relieve pain, reduce edema and accelerate edema regression after surgery in children with hypospadias, and therefore deserves wide clinical application.、.

Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias

ABSTRACT Introduction To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair. Material and methods Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated. Results Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream. Conclusions Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.

The GUD technique: glandar urethral disassembly. An alternative for distal hypospadias repair

ABSTRACT Introduction We present an alternative procedure for distal hypospadias consisting of urethral mobilization and partial glandar disassembly, namely GUD (glandar urethral disassembly) technique. Materials and Methods A subcoronal circumcision exposes distal dysplastic urethra. We incise the Buck´s fascia on both sides of urethra releasing it partially from the corpora. We keep a thin bridge of urethral plate to the glans and disassembly almost completely the glans from the corpora, except for the bridge. The glans is incised creating two wide wings that are extremely mobile. The urethra is mobilized, advanced and sutured to the tip of the glans. The glans wings embrace the distal urethra producing a conical glans. Discussion The concept of urethral mobilization has been reported and popularized by Koff in the literature to correct distal hypospadias. One of the limitations of this procedure is the risk of urethral retraction due to extensive proximal dissection. We got inspiration from Mitchell and Bagli' s work of penile disassembly in epispadias to develop the GUD concept. We adopt minimal urethral mobilization mainly in glandar/proximal penile shaft and complete deconstruction of the glans, detaching the corpora from the glans and rotating the wide glans wings to embrace the urethra. Therefore we avoid suture urethroplasty and refurbish the glans to a better conical shape. Conclusion We are convinced that this operation can be regarded as a genuine alternative to distal hypospadias (coronal and subcoronal) but should not be addressed to midshaft forms.

Laringoespasmo reflejo en cirugía urológica pediátrica / Reflex laryngospasm in pediatric urologic surgery

Introducción: El laringoespasmo es una complicación temida por los anestesiólogos. Se asocia a broncoespasmo, hipoxia, arritmias, aspiración del contenido gástrico y paro cardiaco. Es más frecuente en neonatos y lactantes. Está estrechamente vinculado al tipo de cirugía y consiste en un cierre intenso y prolongado de la glotis en respuesta a la estimulación glótica directa o refleja. Objetivo: Describir el tratamiento del laringoespasmo parcial reflejo en un paciente pediátrico durante una intervención urológica. Presentación del caso: Paciente de 18 meses de edad al cual se le realiza meatotomía. Durante la cirugía presenta laringoespasmo parcial reflejo tratado con maniobras físicas. Sin la necesidad de usar medicamento ni vía área mecánica. Conclusiones: Las maniobras utilizadas son seguras y efectivas en el tratamiento del laringoespasmo reflejo sin la necesidad de abordar la vía aérea ni uso de medicamentos, se lograron resultados satisfactorios con una relación riesgo beneficio a favor del paciente(AU)

Introduction: Laryngospasm is a complication feared by anesthesiologists. It is associated with bronchospasm, hypoxia, arrhythmias, aspiration of gastric contents, and cardiac arrest. It is more common among neonates and infants. It is closely related to the type of surgery and consists in an intense and prolonged closure of the glottis in response to direct or reflex glottic stimulation. Objective: To describe the management of reflex partial laryngospasm in a pediatric patient during a urological intervention. Case presentation: 18-month-old patient who received meatotomy. During surgery, he presented reflex partial laryngospasm managed with physical maneuvers, without the need to use medication or the mechanic airways ventilation. Conclusions: The maneuvers used are safe and effective for the management of reflex laryngospasm without the need to address the airway or using of medications. Satisfactory outcomes were achieved with a risk-benefit ratio in favor of the patient(AU)

Comparison of continuous eversion and inverting subepithelial suture in transverse preputial island flap urethroplasty in proximal hypospadias repair: A retrospective study

ABSTRACT Introduction: Transverse preputial island flap urethroplasty (TPIFU) is one of the most frequently performed technique for single-stage repair in proximal hypospadias. It was reported that the subepithelial urethroplasty would obviously decrease urethrocutaneous fistula (UF) complication after proximal TIP. But in the process of TPIFU, it had not been reported yet. Objective: We reviewed our experience to evaluate and compare the effect of continuous eversion suture (CES) versus continuous inversion subepithelial suture (CIS) on complication rates in the TPIFU. Material and methods: A retrospective review of all patients operated with CES and CIS in our institution between January 2017 and Jun 2017 was performed. Results: A total of 161 patients were enrolled in the research. Patients were followed up for 12~17 months. Total success rate was 73.9% (119/161). No statistically difference was found between the two groups with regard to age of patients (P=0.097), catheter size (P=0.52), time of catheterization (P=0.47), length of neourethra (P=0.20), non-urethral comorbidity (P=0.44) and post-operative infection (P=1.0). The overall postoperative complications had no statistically difference between the two groups (P=0.067). There were no statistically significant differences in the incidence of urethra-cutaneous fistula (UF) (OR=0.07, 95% CI: -0.24~0.037, P=0.22), urethral diverticulum (UD) (OR=0.026, 95% CI: -0.16~-0.056, P=0.323), urethral stricture (US) (OR=0.081, 95% CI: -0.15~0.15, P=1.0) and breakdown of urethral repair (BU) (OR=0.02, 95% CI: -0.118~-0.044, P=1.0). Discussion: The comparison of two group's postoperative complications was feasible because there were no statistically differences among perioperative variables. It seemed as if continuous inversion subepithelial suture would promote healing. However, it indicated that the overall success rate and the incidences of UF, UD, US and BU complications had no statistically difference between groups. It might be accounted for the subtle differences of techniques changing the process of establishing prime and side branches vascularization. Conclusions: The CIS technique had no significantly different effect on the four complications rates when compared with CES in TPIFU. Thus, CES and CIS could be randomly adopted in TPIFU as personal preference.

Our tubularized incised plate urethroplasty Repair. Results for Hypospadias Surgery

Background: The Tubularized Incised Urethral Plate (TIP) urethroplasty is a widely accepted technique among urologists and heavily used in their centers. This technique was developed by Snodgrass in 1994 for repairing varied degrees of hypospadias. Aim: This paper aims at analyzing and evaluating our early experience and the outcomes of using TIP urethroplasty technique. Therefore, the results have to be assessed in a large series. Methods: In this prospective study, 95 patients with varying hypospadiac meatus levels who experienced the procedure of TIP. During the entire sampling period, patients had varying degrees of hypospadias ranging from glanular to penoscrotal (glanular 2, coronal/subcoronal 37, distal shaft 30, mid-shaft 10, proximal shaft 5 and penoscrotal 11). Results: The overall success rate of TIP procedure repair of hypospadias was 87.4%; whereas the overall reoperation rate was 12.6%. The highest percentage was for those with failed previous repair (secondary). The average duration of the procedure was 58.6±18.4 minutes. Nearly a third of the patients developed one or more postoperative major complication. The total rate of fistula was 12.6%, with "10.6% in primary distal, 15.9% in primary proximal and 20% in secondary repair". Sixteen cases had a mild degree of "meatal stenosis" (16.8%), but all were managed by simple dilatation at the office or at home using 8 F feedingtube. Conclusion: The outcomes demonstrated that the TIP procedure is a quick, safe and reliable technique. Additionally, it can provide excellent cosmoses and function with few complications and acceptable reoperation rate.

Prevalence and surgical management of pubic hypertrophy in hypospadias patients: results from a high-volume surgeon

ABSTRACT Introduction: Pubic hypertrophy, defined as an abnormal and abundant round mass of fatty tissue located over the pubic symphysis, is frequently underestimated in patients with hypospadias. We examined the prevalence of this condition, as well as the outcomes associated with its surgical treatment. Material and methods: Within 266 hypospadias patients treated at our clinic, we assessed the prevalence of pubic hypertrophy, and we schematically described the surgical steps of pubic lipectomy. Multivariable logistic regression (MLR) tested for predictors of pubic hypertrophy. Finally, separate MLRs tested for predictors of fistula and any complications after pubic lipectomy. Results: Of 266 hypospadias patients, 100 (37.6%) presented pubic hypertrophy and underwent pubic lipectomy. Patients with pubic hypertrophy more frequently had proximal hypospadias (44 vs. 7.8%), disorders of sex development (DSD) (10 vs. 0.6%), cryptorchidism (12 vs. 2.4%), and moderate (30°-60°) or severe (>60°) penile curvature (33 vs. 4.2%). In MLR, the location of urethral meatus (proximal, Odds ratio [OR]: 10.1, p<0.001) was the only significant predictor of pubic hypertrophy. Finally, pubic lipectomy was not associated with increased risk of fistula (OR: 1.12, p=0.7) or any complications (OR: 1.37, 95% CI: 0.64-2.88, p=0.4) after multivariable adjustment. Conclusions: One out of three hypospadias patients, referred to our center, presented pubic hypertrophy and received pubic lipectomy. This rate was higher in patients with proximal hypospadias suggesting a correlation between pubic hypertrophy and severity of hypospadias. Noteworthy, pubic lipectomy was not associated with increased risk of fistula or any complications.

Combination of clonidine-bupivacaine in caudal epidural anesthesia for hypospadias surgery in children: prospective, randomized, blind study / Associação clonidina-bupivacaína na anestesia peridural caudal para cirurgia de hipospádia em crianças: estudo prospectivo, randomizado, encoberto

Abstract Background and objectives: The combination of clonidine with local anesthetic administered for epidural anesthesia via caudal route seems to improve the quality of postoperative analgesia, but with conflicting results. This study compared the postoperative analgesia of three different doses of clonidine combined with bupivacaine in caudal epidural anesthesia in children undergoing hypospadias repair. Methods: Eighty children aged 1-10 years, candidates for surgical repair of hypospadias, were randomly divided into four groups of 20 patients to receive general anesthesia combined with caudal epidural anesthesia with bupivacaine 0.165% alone or in combination with 1, 2 or 3 µg.kg- 1 of clonidine. The primary outcome was morphine consumption in the first 24 h postoperatively. Mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, time to awakening, pain severity (FLACC scale), level of sedation (RAMSAY), duration of analgesia, and occurrence of adverse effects were also compared. Results: Intraoperatively, there was no difference between groups regarding mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, and time to awakening. Postoperative morphine consumption and pain severity were similar between groups, but the group receiving clonidine (3 µg.kg-1) had lower heart rate and higher sedation level than the group receiving bupivacaine alone. Conclusions: The combination of clonidine at doses of 1, 2 or 3 µg.kg-1 with bupivacaine 0.16% via caudal epidural route did not alter the consumption of morphine in the early postoperative period of children undergoing hypospadias repair.

Resumo Justificativa e objetivos: A associação de clonidina ao anestésico local administrado por via peridural caudal parece melhorar a qualidade da analgesia pós-operatória, mas com resultados conflitantes. Este estudo comparou a analgesia pós-operatória de três diferentes doses de clonidina associada à bupivacaína na anestesia peridural caudal em crianças submetidas à correção de hipospádia. Método: Oitenta crianças entre um e dez anos, candidatas à correção cirúrgica de hipospádia, foram divididas, aleatoriamente, em quatro grupos de 20 pacientes para receber anestesia geral associada à anestesia peridural caudal com bupivacaína 0,166% isolada ou associada a 1, 2 ou 3 µg.Kg-1 de clonidina. Como desfecho principal avaliou-se o consumo de morfina nas primeiras 24 horas de pós-operatório. Compararam-se também pressão arterial média, frequência cardíaca, concentração expirada de sevoflurano, tempo de despertar da anestesia, intensidade da dor pela escala FLACC, nível de sedação (Ramsay), tempo de duração da analgesia e ocorrência de efeitos adversos. Resultados: No transoperatório, não houve diferença entre os grupos quanto à pressão arterial média, frequência cardíaca, concentração expirada de sevoflurano e ao tempo de despertar. No pós-operatório, o consumo de morfina e a intensidade da dor foram similares entre os grupos, mas o grupo que recebeu 3 µg.Kg-1 de clonidina apresentou menor frequência cardíaca e maior sedação do que o grupo que recebeu somente bupivacaína. Conclusões: A associação de clonidina nas doses de 1, 2 ou 3 µg.Kg-1 à bupivacaína 0,166% por via peridural caudal não alterou o consumo de morfina no pós-operatório imediato de crianças submetidas à correção de hipospádia.

An unusual presentation of urethral duplication presenting with chronic bladder retention, left scrotal transposition and left renal agenesis

ABSTRACT Introduction and objective Urethral duplication is a rare congenital anomaly, with roughly 200 cases reported in the literature (1). It is more frequent in males, with few cases reported in females. The clinical presentation differs according to the anatomical variant present. The duplication most commonly occurs in the sagittal plane with one urethra located ventrally and the other dorsally (2). Usually the ventral urethra is the more functional of both. Duplications occurring in the coronal plane are quite rare and they are usually associated with bladder duplication (3). The purpose of this paper was to present a video of a boy with an unusual urethral duplication form. Materials and Methods Patient was born premature due to oligohydramnios at 7 months-gestational age and he has initial diagnosis of hypospadia. Since then, he presented at least 7 febrile UTI and mother complained of difficult micturition and a presence of a mass at lower abdomen. Patient was referred to our institution and we identified urethral duplication with a glandar and scrotal meatus, palpable bladder and left penile-hemiscrotum transposition. US and CT-scan showed left kidney agenesis and overdistended bladder. VCUG and retrograde urethrography showed duplication, presence of contrast in the seminal vesicles and complete catheterizing of both urethras was not possible. Results The topic urethra was dysplastic and not patent to a 4Fr plastic tube so we were unable to access it endoscopically. We performed initially a Mitrofanoff procedure to allow CIC and treat chronic retention. Six months later, we assessed both urethras surgically and concluded that dorsal urethra was dysplastic after 3cm still in the penile area and scrotal urethra was not possible to be catheterized. We excised the ventral urethra because of dribbling complaints up to bulbar area and reconstructed the scrotal transposition, keeping the topic urethra for cosmetic issues. Patient had excellent outcome, performs CIC every 4 hours and has not presented further UTI episodes. Discussion and conclusion The urethral duplication is an anomaly that has multiple anatomical presentations. There are several theories about the etiology, but none can explain all types of presentations. There is also more than one rating available, and the Effmann classification is the most detailed. The case exemplifies this varied spectrum of anatomic urethral duplication. It resembles the urethral duplication type IIa-Y, however, ventral urethra meatus was located in penoscrotal area and both urethras were at least partially hypoplastic/dysplastic associated with obstruction and bladder retention. In determining how to best manage a patient with Y-type urethral duplication, the caliber and quality of the orthotopic urethra must first be assessed. Published reports suggest that best outcomes are those using the ventral duplicated urethra for the reconstruction (4). In this case, none of urethras were functional and a supravesical outlet channel had to be provided. The treatment of this condition requires an individualized planning and a vast technical knowledge of reconstructive surgery.

Uso de mucosa prepucial en la estenosis uretral e hipospadia, Hospital Nacional Guido Valadares de Timor Oriental / Uso de mucosa prepucial na estenose e hipospadia da uretra, Hospital Nacional Guido Valadares de Timor Oriental / Using preputial mucosa in urethral stricture and hypospadias, at National Hospital Guido Valadares East-Timor

Se presentó un caso intervenido en el servicio de Urología del Hospital Nacional "Guido Valadares" de Timor Oriental, con diagnóstico de retención completa de orina, insuficiencia renal aguda obstructiva posrrenal, hidronefrosis bilateral y estenosis uretral e hipospadia, con el objetivo de demostrar el uso de la mucosa prepucial para las hipospadias que concomitan con estenosis uretral. La conducta quirúrgica consistió en una uretroplastia con mucosa prepucial. Se logró la reconstrucción total de la uretra afectada, con buenos resultados finales estéticos y funcionales. El uso de la mucosa oral fue de gran utilidad en el manejo del paciente(AU)

A case was presented in the Department of Urology of Guido Valadares National Hospital in East Timor, diagnosed with complete retention of urine, post renal, obstructive and acute renal failure, bilateral hydronephrosis and urethral stricture and hypospadias, in order to demonstrate the use of prepucial mucosa for hypospadias that concomitan with urethral stricture. The surgical treatment consisted urethroplasty with preputial mucosa. Total reconstruction of the affected urethra was done with good aesthetic and functional outcomes. The use of oral mucosa was very useful in patient management(AU)

Foi apresentado um caso no Departamento de Urologia do Hospital Nacional "Guido Valadares" de Timor Oriental, com diagnóstico de retenção urinária completa, insuficiência renal aguda obstrutiva pós-renal, hidronefrose bilateral e estenose e hipospádia uretral, para demonstrar a utilização da mucosa prepucial para hipospádia que coincide com estenose uretral. O procedimento cirúrgico consistiu em uma uretroplastia com mucosa prepucial. A reconstrução total da uretra afetada foi alcançada, com bons resultados estéticos e funcionais finais. O uso da mucosa oral foi muito útil no manejo do paciente(AU)

Patologias genitais masculinas em cirurgia pediátrica de manejo / Outpatient pediatric surgery of male genital pathologies

Objetivos: Diagnosticar e manejar patologias comuns do trato genital masculino. Métodos: Revisão da literatura do ano de 2011 ao 2017 em base de dados PubMed. Resultados: Hipospádia é a localização anômala do meato uretral. Seu diagnóstico é clínico. As indicações cirúrgicas são anormalidades funcionais e estéticas. Fimose é descrita como impossibilidade de retração do prepcio para exposição da glande peniana, sendo um evento fisiológico quando apresenta resolução espontânea. Nos casos patológicos, o tratamento é primeiramente realizado com corticoide tópico. Se falha, o tratamento é cirúrgico. Hidrocele é o acúmulo de líquido na bolsa escrotal. O diagnóstico é clínico e por transiluminação escrotal. A maioria dos casos regride espontaneamente até os 24-36 meses. A cirurgia é considerada padrão-ouro para hidrocele comunicante na criança. Criptorquidia é a falha na migração do testículo até a bolsa escrotal. Seu diagnóstico é clínico, através da palpação testicular bilateral. Caso os testículos não estejam presentes na bolsa escrotal até os 6 meses de idade, a cirurgia é imprescindível, pelo risco de infertilidade e malignização. Conclusões: É essencial que o médico generalista saiba reconhecer tais condições com o intuito de iniciar prontamente o tratamento adequado, evitando suas complicações.

Aims: Diagnose and manage common pathologies of the male genital tract. Methods: Literary review of the last 6 years in the PubMed database. Results: Hypospadia is an anomalous location of the urethral meatus. The diagnosis is clinical. Surgical indications are functional and aesthetic abnormalities. Fimosis is described as impossibility of retraction of the foreskin to expose the penile glans, it is a physiological event when it presents spontaneous resolution. In pathological cases, treatment is first performed with topical corticosteroids. If it fails, the treatment is surgical. Hydrocele is the accumulation of fluid in the scrotal sac. The diagnosis is clinical and scrotal transillumination. Most cases regress spontaneously up to 24-36 months. Surgery is considered gold standard in cases of communicant hydrocele in children. Cryptorchidism is the failure of the migration of the testis to scrotal sac. The diagnosis is clinical through bilateral testicular palpation. If the testicles are not present in the scrotal sac until 6 months of age, surgery is essential, due to the risk of infertility and malignancy. Conclusions: It is imperative that the general practitioner knows how to recognize such conditions in order to promptly initiate appropriate treatment, avoiding complications.

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.

A wet dressing for male genital surgery: A phase II clinical trial

ABSTRACT Purpose: This study was to confirm the safety and efficacy of BC dressing when used in surgical male wound healing at the urogenital area. Methods: Open, non-controlled clinical study of phase II. A total of 141 patients, among those children, adolescents and adults with hypospadias (112), epispadias (04), phymosis (13) and Peyronie's disease (12) that had a BC dressing applied over the operated area after surgery. A written informed consent was obtained from all participants. Study exclusion criteria were patients with other alternative treatment indications due to the severity, extent of the injury or the underlying disease. The outcomes evaluated were efficacy, safe and complete healing. The costs were discussed. Results: In 68% patients, the BC dressing fell off spontaneously. The BC was removed without complications in 13% of patients at the outpatient clinic during the follow-up visit and 17% not reported the time of removal. In 3% of the cases, the dressing fell off early. Complete healing was observed between 8th and 10th days after surgery. The BC dressings have shown a good tolerance by all the patients and there were no reports of serious adverse events. Conclusion: The bacterial cellulose dressings have shown efficacy, safety and that can be considered as a satisfactory alternative for postoperative wound healing in urogenital area and with low cost.

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.