Scrotal injuries during neonatal circumcision.

OBJECTIVE: To report very rarely encountered scrotal injuries during neonatal circumcision. Hospitals and physicians in the authors' country are mandated to report circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency room or the admitting department. This is believed to be the first case series describing scrotal injuries during ritual circumcision. PATIENTS AND METHODS: Reports of all circumcision complications between 2007 and 2014 were evaluated. Retrieved data on cases of scrotal injuries included patient's age, time between injury and hospital admission, nature of the injury, and administered treatment. RESULTS: Twelve of a total of 489 reports of circumcision injuries involved the scrotum (2.5%). All circumcisions were performed during the neonatal period, and the infants were admitted on the day of injury. The only related genital injury was significant shortage of penile skin reported in six patients. Scrotal exploration and skin closure in the operating room was undertaken in six cases, five under general anesthesia. Suture closure in the emergency department was performed in three patients, and the scrotal skin was left to heal with secondary intention in three other patients. Scrotal content injury that extended to the tunica vaginalis of the testis was noted in one exploration. DISCUSSION: The injuries sustained by the 12 study infants were mostly superficial and are not expected to cause long-term damage, although half of the patients required treatment under general anesthesia in the operating room or under sedation in the emergency department. While all reported patients emerged unscathed from the anesthetic procedures, the possible immediate complications of anesthesia as well as its long-term effects are not to be taken lightly, especially when treating a newborn. Further education of medical providers as well as performers of ritual circumcisions may help lower the risk of this rare injury as well as other more severe complications. CONCLUSION: Scrotal injury during neonatal circumcision is rare. While half of the 12 reported patients required exploration in the operating room, the injuries were mostly superficial and did not involve scrotal content, although they often involved extensive resection of penile skin.

Augmentation ureterocystoplasty: is it the preferred choice?

BACKGROUND: Various methods of urinary bladder augmentation have been attempted in order to try and achieve adequate bladder capacity, urinary continence, control urinary tract infection and preserve the upper urinary tract; however, long-term complications have been unavoidable. OBJECTIVE: To evaluate our experience with ureterocystoplasty as to whether it is the preferred method for bladder augmentation to achieve continence and preserve the upper urinary tract. DESIGN: Retrospective study. SETTING: Paediatric urology unit, Dana Children's hospital, Tel Aviv Medical Center (affiliated to the Sackler School of Medicine), Tel Aviv University. SUBJECTS: Four children; three girls, one boy, mean age 7.3, range (3-14) years. Two had neurogenic bladder due to occult spinal dysrraphism, the other two had non-neurogenic neurogenic bladder. The indications for surgery were urinary incontinence with recurrent urinary tract infections in all patients, one also had upper tract dilatation. INTERVENTIONS: All underwent augmentation ureteroplasty, two required nephrectomy due to non-functioning kidney, two required clean intermittent catheterizatiom postoperatively. MAIN OUTCOME MEASURES: Urinary continence, bladder capacity, vesicoureteral reflux, renal function tests, urinary tract infection rate and surgical complications encountered. RESULTS: In a mean follow-up period of 24 (6-46) months, all of the patients achieved urinary continence, two of the patients who have a normal bladder outlet are continent and void spontaneously with no residual urine. The other two patients are continent on clean intermittent catheterization. Only one episode of urinary tract infection was seen, none of the patients are currently on prophylactic antibiotics. The urinary bladder in all patients is spherical with good capacity and no vesicoureteral reflux was demonstrated. The upper urinary tracts are stable and the renal function tests are normal. CONCLUSION: Ureterocystoplasty is our preferred choice of bladder augmentation in patients with small, inelastic, poor compliant bladder with at least a moderately dilated ureter. Complications normally seen with enterocystoplasties are minimal.

Development of a large bladder calculus on sutures used for pubic bone closure following extrophy repair.

Bladder exstrophy is a rare congenital condition that occurs in 1 to 30,000 live births. Primary bladder closure is usually performed in the first days of life in conjunction with an iliac osteotomy in order to achieve a more secure bladder closure. We report a case of a large bladder stone with secondary right-sided hydronephrosis in a 3-year-old child who underwent exstrophy repair at the age of 7 months. During the exstrophy repair a no. 1 braided, polyester, non-absorbable suture was used to close the pubic bones and served as a nidus for intravesical stone formation. This case substantiates the lithogenic nature of non-absorbable sutures in contact with urine as well as the need for close post-operative follow-up in these patients.

Glide wires for delayed catheterization of severely obstructed ureters.

OBJECTIVE: Failure to retrogradely catheterize an obstructed ureter may require a nephrostomy. We describe an endoscopic technique to catheterize a severely obstructed ureter when the obstruction does not permit passage of a ureteral catheter over a wire. METHODS: Using a cystoscope, a wire is passed beyond the obstruction. When the attempt to insert a ureteral catheter over the wire fails, the wire is left in place, fixed externally to a Foley catheter. A second attempt to insert a ureteral catheter is carried out 24-48 h later. RESULTS: The procedure was performed in 5 patients. Ureteral catheterization, which was initially impossible, was performed successfully and without complications. CONCLUSIONS: Maintaining a wire in place over a short period of time facilitates a subsequent ureteral catheterization.

Loss of urethrovaginal septum as a complication of exstrophy closure in girls.

PURPOSE: The aim of this study was to report complications involving paraexstrophy skin flaps in the female bladder exstrophy closure. MATERIALS AND METHODS: Bladder exstrophies in three female patients were initially closed using paraexstrophy skin flaps, with an osteotomy being performed in only 1 patient. A dehiscence occurred in all, and a reclosure was performed at a mean of 10 (range: 7-18) months after the initial closure. RESULTS: Two patients underwent successful reclosure and are awaiting bladder neck reconstruction. The third patient, who had complete procidentia, had a bladder which failed to grow after successful reclosure and underwent augmentation cystoplasty. CONCLUSIONS: Closure of bladder exstrophy in female patients using paraexstrophy skin flaps can be associated with an increased complication rate and should be used judiciously in the exstrophy patient.

Penile length in adulthood after exstrophy reconstruction.

PURPOSE: We attempted to determine whether the penis in adulthood after exstrophy reconstruction is short because of a congenital defect in the size of the corpora cavernosa. MATERIALS AND METHODS: Pelvic magnetic resonance imaging was performed on 10 men who underwent exstrophy reconstruction in childhood, and 10 age and race matched controls. Measurements of penile and pelvic anatomy were compared. RESULTS: The corpora cavernosa in men after exstrophy reconstruction were shorter than normal. Dividing total corporeal length into an anterior and posterior segment revealed that the anterior segment was short but the posterior segment attached to the pubic ramus was normal. However, the diameter of the posterior corporeal segment was greater than in controls. Although diastasis of the symphysis pubis increased the intersymphyseal and intercorporeal distances, the angle between the corpora cavernosa was unchanged, presumably because the corporeal bodies were separated in a parallel fashion. CONCLUSIONS: After exstrophy reconstruction the penis is short in adulthood, at least partially due to a congenital deficiency of corporeal tissue. Since diastasis of the pubic symphysis and chordee decrease penile visibility, approximation of the pubic symphysis and procedures to straighten the penis may improve cosmesis. However, because the corpora cavernosa are short, after exstrophy reconstruction the penis will always be shorter than normal in adulthood.

The outcome of patients with classic bladder exstrophy in adult life.

PURPOSE: We determined the outcome of 20 older adult bladder exstrophy patients regarding urinary continence, sexual function, fertility and psychosocial integration. MATERIALS AND METHODS: A total of 16 men and 4 women completed an anonymous questionnaire and the charts were reviewed for medical history. RESULTS: Of 9 patients who void spontaneously 6 are dry for 4 hours and 3 for 2 hours. Among the remaining 11 patients 5 are dry on clean intermittent catheterization, 3 who had undergone uterosigmoidostomy are dry for more than 4 hours and 3 had an incontinent stoma. Four men and 2 women are married, including 2 men and 1 women who had a total of 7 children. Ten of 16 men (63%) reported that they ejaculate a few cubic centimeters in volume, 3 ejaculate only a few drops and 3 have no ejaculation (2 of whom underwent cystectomy). Semen analyzed in 4 patients (3 with azoospermia and 1 with oligospermia) and average volume of ejaculate was 0.4 cc (range 0.2 to 1). All women reported regular and normal menstrual periods. A total of 15 patients experienced normal erections that were described as satisfactory by 8 and not satisfactory by 6 due to a small penis, with dorsal chordee in 1. Of the 16 men 12 (75%) experienced satisfactory orgasms while 10 had participated in sexual intercourse with complete partner satisfaction in 9. Half of the men and all women describe intimate relationships as serious and longterm. Of the 20 patients 15 (75%) achieved a high level of education. CONCLUSIONS: Bladder exstrophy patients generally achieve good results but the fertility of most men is in doubt.

Current management of bladder exstrophy.

This article describes in detail the modern management of the patient born with classic bladder exstrophy. Also, new techniques of prenatal diagnosis and pelvic fixation to secure the initial or secondary closure are discussed. Last, management of the failed closure and the bladder not suitable for closure are described and outlined. A successful initial closure of the infant born with bladder exstrophy is the single most important determinant in the eventual development of continence in the exstrophy patient.

A combined vertical and horizontal pelvic osteotomy approach for primary and secondary repair of bladder exstrophy.

PURPOSE: We describe a new combined horizontal and vertical pelvic osteotomy procedure for bladder exstrophy. MATERIALS AND METHODS: A total of 36 patients with the bladder exstrophy complex underwent this procedure during a 3-year period (8 primary and 18 secondary bladder closures, and 6 at bladder neck reconstruction). RESULTS: There were no instances of dehiscence and only a minor bladder prolapse in 1 patient with cloacal exstrophy. Two patients had a transient femoral nerve palsy and there was 1 superficial pin infection. Urological complications included symptomatic urinary tract infections in 5 patients, acute epididymitis in 1 and bladder calculi in 2. CONCLUSIONS: This new osteotomy procedure is of great benefit in initial or repeat closure of bladder exstrophy and may help in eventually achieving continence.

The multiple reoperative bladder exstrophy closure: what affects the potential of the bladder?

OBJECTIVES: To define the possible cause of failure and the eventual potential of the bladder in 23 exstrophy patients, who underwent more than two failed prior attempts at closure. METHODS: Twenty-three patients were selected from the exstrophy data base who had two or more prior closures. Eighteen patients had undergone 2 previous closures and 5 patients 3 previous closures for either complete dehiscence or significant prolapse. At the time of initial closure, 19 patients did not have an osteotomy. At secondary closure, 10 underwent osteotomy while at third closure 5 had an osteotomy. At the time of reclosure at our institution all underwent an osteotomy. RESULTS: Reoperative repair at our institution was successful in all patients. Six patients achieved a bladder size suitable for bladder neck reconstruction and of them 3 are dry. The bladder size was inadequate in 9 patients and 8 are being monitored for possible bladder growth. CONCLUSIONS: Tension-free closure with osteotomy and immobilization are important factors both in an initial or any subsequent closure. The chance of obtaining an adequate bladder capacity for bladder neck plasty and eventual continence, following multiple reclosures, is markedly diminished.

Bladder exstrophy from childhood into adult life.

Exstrophy of the bladder is rare and the incidence of bladder exstrophy is calculated to be from 1 per 30,000 to 50,000 live births with male to female ratio ranging from 1.5-5 to 1(1-4). It was found that persistence or overgrowth of the cloacal membrane on the lower anterior abdominal area, prevents normal mesenchymal ingrowth. This causes divergence of the lower abdominal muscular structures and forces the genital ridges to fuse caudal to the cloacal membrane. The stage of ingrowth of the urorectal septum at the time of rupture determines whether one will produce an exstrophic urinary tract alone (classic bladder exstrophy or epispadias) or cloacal exstrophy with the hindgut interposed between the hemibladders.

Ureteral bladder augmentation using the lower pole ureter of a duplicated system.

Megaureters of nonfunctioning renal segments in a duplex system are commonly available for use in reconstructive procedures secondary to high-grade reflux, ectopic ureter, ectopic ureterocele, or obstructive megaureter. The use of megaureters subtending a nonfunctioning lower pole renal segment for bladder augmentation in 2 patients is reported.

Acute scrotum caused by Henoch-Schönlein purpura, with immediate response to short-term steroid therapy.

The authors report a case of acute scrotum caused by Henoch-Schönlein purpura. It involved bilateral swelling of the epididymis and testes, which was documented by scrotal ultrasonography and which responded immediately to systemic steroid treatment.

Concealed umbilical stoma: description of a modified technique.

PURPOSE: We describe a technique for creating a concealed umbilical stoma. MATERIALS AND METHODS: The base of the umbilicus is used as a superiorly based skin flap that is incorporated into the spatulated stoma. Six patients have undergone diversion using this technique. The stoma was constructed from appendix in 4 cases, stomach in 1 and tapered ileum in 1. RESULTS: All patients achieved an easily catheterizable hidden umbilical stoma, are dry on clean intermittent catheterization and have had no stomatitis or peristomal hernia. CONCLUSIONS: This technique for creating a concealed umbilical stoma preserves the native appearance of the umbilicus and combines a superior cosmetic result with an easily catheterizable stoma.

Submucosal bladder neck injections of glutaraldehyde cross-linked bovine collagen for the treatment of urinary incontinence in patients with the exstrophy/epispadias complex.

During the last 7 years 19 patients underwent 33 transurethral injections of glutaraldehyde cross-linked bovine collagen into the bladder neck for stress incontinence. Of the 15 patients 14 have classic bladder exstrophy, 3 have complete male epispadias and 2 have cloacal exstrophy. The procedure was performed after a Young-Dees-Leadbetter bladder neck reconstruction in 15 patients and before it in 4. Injections were repeated in 10 patients after a mean of 12 months. After a mean followup of 26 months (range 9 to 84) improvement of continence was noted in 10 of 19 patients (53%) of whom 4 have significant improvement. Of the 8 patients whose condition failed to improve after collagen injections 6 underwent additional successful surgery to achieve urinary continence. Of the 10 patients who underwent repeated collagen injections 9 (90%) had additional improvement. Although there were no complications related to the injected collagen itself, postoperative complications developed in 2 patients. Submucosal injection of collagen to the bladder neck is simple and safe, and has a reasonable success rate. Thus, it may be used to improve continence in patients with the exstrophy/epispadias complex who lack full control after appropriate reconstructive surgery.

Applications of osteotomy in the cloacal exstrophy patient.

During the last 18 years we treated 22 patients with cloacal exstrophy of whom 13 were referred for further treatment after initial treatment elsewhere. One patient underwent cystectomy with ileal conduit urinary diversion soon after birth and 9 of the remaining 21 underwent initial closure without osteotomy. Of these 9 patients significant complications developed in 8 (89%) after bladder closure, including dehiscence in 6 (1 underwent 2 unsuccessful closures), a vesicocutaneous fistula and postoperative ventral hernia in 1, and bladder prolapse in 1. In contrast, complications developed in only 2 of the 12 patients (17%) who underwent osteotomy at the time of initial closure, including bladder dehiscence in 1 and significant prolapse in 1. Patients who underwent osteotomy and those who did not were similar in terms of the size of omphalocele, presence of myelomeningocele and time of primary closure. We also found that osteotomy or failed closure has no effect on the eventual continence of cloacal exstrophy patients. While osteotomy is not the only variable involved in successful cloacal exstrophy closure, our results indicate the need for osteotomy in these patients to increase the success rate at the time of initial bladder closure.

The Cantwell-Ransley epispadias repair in exstrophy and epispadias: lessons learned.

OBJECTIVES: We evaluated our experience with the Cantwell-Ransley epispadias repair to determine the lessons that have been learned with the increased experience and follow-up. METHODS: A total of 75 boys (60 with bladder exstrophy and 15 with complete epispadias) underwent a Cantwell-Ransley epispadias repair at our institute in the last 6 years. Primary repair was performed in 58 boys (45 with exstrophy and 13 with epispadias), and secondary repair was performed after prior failed closure in 17 boys (12 at the secondary exstrophy closure, 3 with exstrophy, and 2 with complete epispadias). RESULTS: At a mean follow-up of 28 months, all patients had a horizontal or downward angled penis while standing. The incidence of urethrocutaneous fistulas in the immediate postoperative state was 21% and at 3 months was 15%. The incidence of urethrocutaneous fistulas was no more in those patients in whom paraexstrophy skin flaps were used at anterior closure than in those in whom the urethral plate was left intact. Two patients developed a urethral stricture at the proximal anastomotic area, and 4 patients had minor skin separation of the dorsal penile skin closure. Catheterization or cystoscopy, or both, has been performed in 60 patients and revealed an easily negotiable urethral channel in all. CONCLUSIONS: The Cantwell-Ransley epispadias repair offers a straighter urethra, better correction of chordee and cosmesis, and a lower fistula rate in the exstrophy or epispadias patient.

Criteria for the prenatal diagnosis of classic bladder exstrophy.

OBJECTIVE: To define ultrasonographic criteria for the prenatal diagnosis of classic bladder exstrophy. METHODS: Forty-three prenatal ultrasound scans were studied from 25 pregnancies in which live delivery of an infant with classic bladder exstrophy occurred. The diagnosis of bladder exstrophy could be made retrospectively in 29 prenatal studies from 17 pregnancies. The time of the fetal ultrasound varied from 14-36 weeks' gestation (mean 23). The diagnosis of bladder exstrophy was made before delivery in only three cases. RESULTS: Five factors associated with bladder exstrophy were identified: 1) The bladder was not visualized on ultrasound in 12 of 17 cases (71%); 2) a lower abdominal bulge representing the exstrophied bladder was seen in eight of 17 cases (47%); 3) a small penis with anteriorly displaced scrotum was identified in eight of 14 males (57%); 4) the umbilical insertion was low set in five of 17 cases (29%); and 5) abnormal widening of the iliac crests was seen in three of 17 cases (18%). CONCLUSION: The prenatal diagnosis of bladder exstrophy should be considered any time the bladder is not visualized or any of the aforementioned factors are noted.