Role of routine cystoscopy and cystography in exstrophy-epispadias complex.

OBJECTIVE: Our institutional protocol for the treatment of exstrophy-epispadias complex includes routine endoscopic and cystographic evaluation of the bladder with the child under general anesthesia. The protocols briefly described in the literature include a cystographic evaluation and the measurement of bladder capacity, but there are no reports on concurrent endoscopic findings and the value of examinations in this setting. Our objective is to evaluate the role and necessity of our management protocol by reviewing the findings in our patients' medical charts. STUDY DESIGN: Cystoscopies are performed in children with exstrophy-epispadias complex during the second year of life and then every 18 months until a capacity of 90 mL has been reached and bladder neck reconstruction, the last stage of modern staged repair, is performed. Patients referred from other institutions are evaluated on presentation. The examinations are performed by means of a pediatric cystoscope with the child under general anesthesia. Cystography is performed under a pressure of 30 cm/H2O. The contribution of the findings of these periodic evaluations vis-à-vis the surgical findings were studied. RESULTS: The medical charts of 49 patients who had been surgically treated for exstrophy-epispadias complex in our institution between 2000 and 2014 were reviewed. Thirty patients underwent at least one evaluation. Eighteen underwent serial examinations: four underwent two procedures, eleven underwent three procedures, and three underwent four procedures. The findings in eight cases were significant and they were treated on detection: bladder neck stricture (n = 5), bladder scar bridge (n = 2), and bladder stone (n = 1). Vesicoureteral reflux was present in all 30 patients, and high-grade reflux was present in 10 patients, of whom four had a bladder neck stricture. Fourteen of the 30 patients had a bladder capacity of 90 mL on the first evaluation, as did an additional eight children during later evaluations. Bladder capacity decreased below 90 mL in one child. Seven children did not reach the target capacity (Figure). CONCLUSION: Cystoscopic and cystometrographic evaluation of an exstrophic bladder allows early diagnosis of treatable bladder pathologies and monitoring of bladder capacity. It is a valuable tool in the follow-up period preceding bladder neck reconstruction.

Ventral plication for repair of pediatric dorsal penile curvature.

OBJECTIVES: To present the results of ventral plication for the repair of dorsal curvature. METHODS: A total of 33 patients (mean age 38 months, range 7 months to 15 years) with a dorsal curvature of >30 degrees degrees underwent ventral plication. A subcoronal incision was performed, followed by degloving of the skin to the penile base. The point of maximal curvature was noted and marked during an erection test. Two polypropylene 5-0 plication sutures were placed in the tunica albuginea of both corporeal bodies, just lateral and adjacent to the corpus spongiosum. Proper alignment and a straight penis were confirmed with a repeat erection test. The skin incision was closed with absorbable sutures. Surgical success was determined by parental and physician satisfaction with the final outcome during follow-up. RESULTS: No immediate or late complications (mean follow-up 25 months, range 3-65) developed. A straight penis was achieved in 28 of 33 patients (85%). Four patients with residual curvature did not require a second procedure, and the fifth patient successfully underwent reoperation using the same technique. CONCLUSIONS: The results of our study have shown that ventral plication is a simple and efficient technique for the repair of dorsal penile curvature.

Holmium laser ureteroscopic treatment of various pathologic features in pediatrics.

OBJECTIVES: To assess the outcome of pediatric patients treated by ureteroscopy for various pathologic findings. METHODS: A total of 31 children (median age 5 years, range 0.3 to 14) were ureteroscopically treated for ureteropelvic junction obstruction (UPJO) (n = 6, 1 primary and 5 secondary), ureteral strictures (n = 4), and calculi (n = 21). Miniscopes with a holmium laser were used for lithotripsy and ureterotomy. RESULTS: The average age in the UPJO group was 1.8 years (range 0.3 to 4), the operative time was 40 minutes (range 30 to 50), and the hospitalization was 1.2 days (range 1 to 2). A successful clinical and functional outcome was maintained after an average follow-up of 16 months (range 8 to 30). The 4 cases of ureteral stricture included two located in the middle ureter and two at the ureterovesical junction. No failures had occurred in this group after an average follow-up of 25 months (range 8 to 40). The calculi cases comprised 10 lower ureteral, 2 upper ureteral, and 9 renal stones, with an average stone burden of 11 mm (range 5 to 20). Three patients (14%) underwent preoperative stenting. Two patients (10%) required ureteral orifice dilation. Postoperatively, 4 patients (18%) had a ureteral catheter left in place, 15 (71%) had an internal stent with an externalized string, and 2 (10%) did not require drainage. The average operative time was 39 minutes (range 15 to 90), and the hospitalization was 1 day (range 0.5 to 2). All patients were rendered stone free. CONCLUSIONS: The results of our study have shown that the ureteroscopic approach in children with UPJO, ureteral strictures, and urinary calculi is safe and highly effective. Routine preoperative stenting and intraoperative ureteral dilation are not necessary. Stents with external strings were well tolerated and easily removed without anesthesia.

Degloving and realignment--simple repair of isolated penile torsion.

OBJECTIVES: To present the results of repairing congenital or acquired penile torsion by means of a simple surgical procedure that does not involve resection of corporeal tissue. METHODS: Forty-six circumcised patients (mean age 27 months, range 6 to 119) presented with isolated penile torsion of a greater than 30 degree rotation. The surgical technique involved degloving the penile skin to the penoscrotal junction. Residual torsion was corrected using 5-6/0 polyglactin absorbable suture applied to the desired 12-o'clock position of the penile skin adjacent to the glans and to a location counter to the direction of the torsion in the degloved penile skin sleeve. A wedge of loose ventral penile skin was usually resected. The resultant tightening of the skin allowed for proper alignment of the penis and better cosmesis. The rest of the circumferential incision was closed using the same suture material. The success of the procedure was evaluated according to physician and parental satisfaction with the final outcome. RESULTS: Thirty-seven patients were available for follow-up (mean 31 months, range 8 to 68). Satisfactory results were achieved in 35 (95%) of the 37 patients; the other 2 had residual torsion. Complications were minor and consisted of postoperative fever and a subcutaneous hematoma in 1 patient that resolved with conservative treatment. CONCLUSIONS: The degloving and realignment procedure is a simple technique that may be applied safely and successfully in most cases of penile torsion.

[Endoscopic injection of dextranomer/hyaluronic acid for vesico-ureteral reflux--preliminary results].

BACKGROUND: Endoscopic injection is a minimal invasive treatment for vesico-ureteral reflux, an alternative for prophylactic antibiotics or open surgery. Concerns of safety were raised regarding traditional injectable materials used in the past. The recently introduced dextranomer/hyaluronic acid is a new biocompatable substance. Its safety and efficacy has been investigated and demonstrated. OBJECTIVES: To report our preliminary results with the endoscopic injection of dextranomer/hyaluronic acid. METHODS: Twenty nine pediatric patients of mean age 58 months (range 6-144) underwent endoscopic treatment. A total of 42 refluxing ureteral units were treated. Reflux grade was 2, 3, and 4 in 10, 24, and 8, respectively. The procedure was performed under general anesthesia, using a 9.5FR pediatric cystoscope and a semi-rigid needle. The substance was injected submucosally at the 6-o'clock position of the ureteral orifice. A mean of 0.87 ml of the substance was injected (range: 0.6-1.2). In the latter part of the series we injected a minimum of 1 ml for each ureter. During follow-up, ultrasonography and a voiding cystography were performed after 1 and 3 months respectively. RESULTS: Vesico-ureteral reflux resolved in 32/42 (76%) of the ureters. The rate of success was 10/10 (100%), 19/24 (79%) and 4/8 (50%) in reflux grades 2, 3, and 4, respectively. De-novo contralateral reflux was noted in 5 patients. A single complication occurred: acute venous bleeding originating in the injection site, which was managed endoscopically. CONCLUSIONS: Endoscopic injection of dextranomer/ hyaluronic acid is a safe and effective treatment. We recommend the injection of 1 ml, the entire volume available for each ureter.

Megameatus intact prepuce hypospadias variant: application of tubularized incised plate urethroplasty.

OBJECTIVES: The characteristics of the megameatus intact prepuce (MIP) hypospadias variant present a unique challenge to surgeons. Dissatisfaction with the results of conventional repair methods led to the emergence of several alternative surgical approaches, including the glanular approximation (GAP) and pyramid procedures. The application of tubularized, incised plate (TIP) urethroplasty has not been documented in this setting. METHODS: Twenty-four patients (mean age 18.5 months, range 6 to 60) presented with MIP. They had all been circumcised. The meatus was glanular in 6, coronal in 15, and distal shaft in 3 patients. Glanular MIP was repaired by meatal advancement and glanuloplasty (n = 2) or the GAP technique (n = 4). Coronal MIP was repaired by the GAP (n = 7) or TIP urethroplasty (n = 8), and distal shaft MIP was repaired by TIP urethroplasty (n = 3). Stents or catheters were used only with TIP urethroplasty. The mean follow-up period was 40 months (range 8 to 80). RESULTS: Satisfactory cosmetic and functional results were achieved in 20 patients (83%). The other 4 patients included 1 patient who underwent GAP and meatoplasty and 3 of the 11 patients who underwent TIP urethroplasty, of whom 2 underwent meatoplasty and 1 simple local repair of a urethrocutaneous fistula without the need for urethral reconstruction. CONCLUSIONS: The success rates for all selected techniques were satisfactory. TIP urethroplasty can be successfully used in the more severe, proximal forms of MIP.

Complications of circumcision in Israel: a one year multicenter survey.

BACKGROUND: In Israel, virtually all children undergo circumcision in the neonatal period. Traditionally, it is commonly performed by a "Mohel" (ritual circumciser) but lately there is an increasing tendency among the educated secular population to prefer a medical procedure performed by a physician and with local anesthetic injection. OBJECTIVES: To evaluate the outcome of this procedure and to compare the complication rate following circumcisions performed by ritual circumcisers and by physicians. METHODS: In 2001, of the 19,478 males born in four major medical centers in Israel 66 had circumcision-related complications. All the children were circumcised in non-medical settings within the community. The patients were medically evaluated either urgently due to immediate complications or electively in outpatient clinics later on. Upon the initial assessment a detailed questionnaire was filled to obtain data regarding the procedure, the performer, and the subsequent complications. RESULTS: All the circumcisions were performed during the early neonatal period, usually on day 8 of life (according to Jewish law). in 55 cases (83%) it was part of a ritual ceremony conducted by a ritual circumciser (Mohel), while in 11 babies (17%) physicians were involved. Acute bleeding after circumcision was encountered in 16 cases (24%), which required suturing in 8. In addition, we found two cases of wound infection and one case of partial amputation of glans penis in which the circumcision was performed by a ritual circumciser. Among the late complications, the most common was excess of skin in 38 cases (57%); 5 children (7.5%) had penile torsion and 4 children (6%) had shortages of skin, phimosis and inclusion cyst. The overall estimated complication rate of circumcision was 0.34%. CONCLUSIONS: Complications of circumcision are rare in Israel and in most cases are mild and correctable. There appears to be no significant difference in the type of complications between medical and ritual circumcisions.

Salvage Mathieu urethroplasty: reuse of local tissue in failed hypospadias repair.

OBJECTIVES: To report our experience with Mathieu urethroplasty for revision of hypospadias repairs. Mathieu perimeatal-based flap urethroplasty remains a popular technique more than seven decades after its description for single-stage hypospadias repair. The excellent results of primary distal hypospadias repair are well documented, but reports of the results using the technique as a salvage procedure are sparse. The reuse of local tissue may be hampered by the presence of scar tissue and reduced vascularity. METHODS: A total of 40 patients underwent salvage urethral reconstruction. Of the 40 patients, 34 (mean age 70 months, range 11 to 216) underwent salvage Mathieu urethroplasty. All patients underwent surgery at least 6 months after the previous surgery. One, two, and three or more prior procedures had been performed in 22, 6, and 6 patients, respectively. The mean follow-up period was 29 months (range 1 to 84). In 6 patients, local tissue was scarred and immobile, and they underwent the procedure using buccal mucosal grafts. RESULTS: Satisfactory functional and cosmetic results after the initial procedure were achieved in 25 patients (74%). Two patients underwent reoperation for repair of meatal stenosis, and 5 (15%) underwent simple repair of fistula without the need for urethral reconstruction. Two patients underwent reoperation at other medical centers and were lost to follow-up. Overall, cure was achieved in 32 (94%) of the 34 patients. CONCLUSIONS: Mathieu urethroplasty is an efficient technique for salvage hypospadias repair. Patient selection is the key to successful repair. Despite the effects of previous surgery, local tissue of adequate quality to facilitate repair exists in most patients.

Midline dorsal plication technique for penile curvature repair.

PURPOSE: Most penile curvature repair techniques involve excision of the tunica albuginea and mobilization of the neurovascular bundles. Recent neuroanatomical studies of the neurovascular bundles have demonstrated the distribution of nerve fibers and identified the 12 o'clock position as the only nerve-free position. We present the results of penile curvature repair with the midline dorsal penile plication technique. MATERIALS AND METHODS: A total of 45 penile plication procedures were performed in 43 pediatric patients, of whom 39 had mild to moderate and 4 had severe curvature. Eight patients had previously undergone penile curvature repair. After the induction of an artificial erection test a 4 or 5-zero polypropylene plication suture was placed at the point of maximal curvature at the 12 o'clock position. RESULTS: Of patients with mild to moderate curvature 97% underwent a successful initial procedure. Satisfactory results were achieved in only 2 of the 4 patients with severe curvature. Two of the 3 initial failures were successfully reoperated using the same technique. The procedure was successful in all 8 patients who had previously undergone operation for curvature repair. CONCLUSIONS: Midline dorsal penile plication is a safe, simple to perform procedure that achieves excellent results in patients with mild to moderate curvature. It is a useful technique in patients in who previous repairs have failed. We suggest other repair techniques for severe curvature.