Maternal and neonatal outcome of 100 consecutive triplet pregnancies.

The objective of this study is to determine the maternal and neonatal outcome of a large group of triplet gestations. A retrospective review of 100 triplet gestations managed and delivered between January 1992 and September 1999 by a single perinatal group is examined. These pregnancies were managed on an outpatient basis. Prophylactic interventions were not utilized. Ninety-six percent of the pregnancies had at least one complication, with preterm labor the most common. The median gestational age at delivery was 33 weeks (range 20.4 to 37, SD 4.1 weeks) with 14% of pregnancies delivering prior to 28 weeks' gestation. The corrected perinatal mortality rate was 97/1000. Minimal long-term morbidity was seen with delivery after 27 weeks' gestation. Pregnancy outcome did not vary with birth order or mode of conception. Triplet pregnancy is associated with a high rate ofantenatal complications. Favorable neonatal outcome can be obtained without the use of prophylactic interventions.

Nuchal translucency and its relationship to congenital heart disease.

Nuchal translucency refers to the normal subcutaneous space, observed on first trimester ultrasound evaluation, between the skin and cervical spine. Increased nuchal translucency is known to be associated with an increased risk of aneuploidy, particularly Trisomy 21, and recent studies have also identified increased nuchal translucency as a nonspecific marker for various genetic syndromes and multiple structural anomalies, to include congenital heart disease. This increased risk applies to euploid and aneuploid pregnancies and is directly related to the degree of nuchal translucency thickening. This article reviews the role of nuchal translucency as a screening tool for congenital heart disease.

Noncardiac thoracic anomalies.

FHT is a rare diagnosis that may be an isolated finding or associated with multiple fetal anomalies, congenital infection or isoimmunization. The natural history of the lesion is variable. The effusion may regress spontaneously; remain stable in size; or progress to involve both sides of the chest and produce fetal hydrops, pulmonary hypoplasia, and fetal or neonatal demise. Hydrops is associated with significant fetal mortality. Antenatal decompression of the hydrothorax with pleuroamniotic shunting or thoracocentesis may result in a significant decrease in perinatal morbidity and mortality. Persistent hydrothorax can usually be treated with noninvasive measures in the newborn period.

First trimester screening for structural fetal abnormalities: nuchal translucency sonography.

Nuchal translucency refers to the normal subcutaneous space, observed on first trimester ultrasound examination, between the skin and the cervical spine in the fetus. Increased nuchal translucency is known to be associated with an increased risk of aneuploidy, particularly Down syndrome. In addition to this association with aneuploidy, multiple studies have now identified increased nuchal translucency as a nonspecific marker of a wide range of fetal structural abnormalities, to include congenital diaphragmatic hernia, cardiac defects, and various genetic syndromes. The degree of nuchal translucency is directly related to the prevalence of fetal anomalies and may have prognostic significance, especially when found in association with other anomalies. The pathophysiology of increased nuchal translucency is uncertain but may be the result of cardiac failure or alterations in lymphatic drainage. Increased nuchal translucency may identify pregnancies that require further assessment, to include additional sonographic evaluation and possible fetal echocardiography. Further evaluation is required to assess the role of nuchal translucency screening in the general population.

Primary realignment of the disrupted prostatomembranous urethra.

Urethral scarring resulting in stricture formation can be avoided or minimized by proper treatment after injury. On presentation of the trauma patient, the possibility of such injury must be suspected and the urethra evaluated prior to any attempts at catheter placement. Diversion in all cases of posterior urethral injury should be by a suprapubic tube, with any urinary extravasation drained at the site of the injury. If the patient's general condition allows it, the disrupted urethra should be realigned by a catheter after the puboprostatic ligaments have been divided. These measures allow the prostate to return to the urogenital diaphragm without tension and in line with the distal urethra. Until the prostate is released, no amount of traction will reapproximate the urethra, and after it is released, traction is not necessary. The suprapubic catheter provides diversion, preventing further complications caused by urinary extravasation; urethral alignment minimizes subsequent stricture formation. When the stricture develops, if it is urodynamically significant, it can be repaired in 4 to 6 months. If one is fortunate, the stricture will be short and amenable to internal urethrotomy. If not, open reconstruction will be greatly facilitated by the attempts to guide the distracted ends of the urethra together.

Epithelioid sarcoma of the penis.

A case of epithelioid sarcoma of the penis is reported with a review of the current treatment modalities. A new method of reconstructing the penis involved with malignancy is presented. Pertinent literature is cited. Cases of epithelioid sarcoma should be published to improve the understanding of the potential of different treatments available. This case represents the fifth epithelioid sarcoma of the penis reported in the literature.

Management of urethral stricture disease.

With the advent of modern tissue transfer techniques, most cases of urethral reconstruction can be approached with confidence that an excellent functional and cosmetic result is probable. The authors present a logical approach to urethral stricture disease predicated on the anatomy of the stricture disease. Only those procedures believed to offer a maximal chance of success are offered to the patients. Should a patient present with complex stricture disease, initially a flap procedure would be employed.

New concepts in phallic reconstruction.

Over the past four years we have performed total phallic reconstructions in 12 patients. Six patients underwent reconstruction following trauma, 3 were female-to-male transsexuals, and 3 had micropenis deformities. These reconstructions were one-stage microsurgical tissue transfers that included urethral reconstruction and coaptation of erogenous nerves. The surgical indications, techniques, and results are discussed.

Posterior urethral injuries associated with pelvic fractures.

The types of fracture of the bony pelvis are categorized, and a system for diagnosis and treatment is recommended which should prevent many strictures and make those which do develop, easier to repair secondarily. This system of treatment should reduce trauma to the nerves and blood vessels.

Clitoromegaly and megalourethra in idiopathic female intersex.

Idiopathic female intersex can present with a varying phenotypic expression but generally includes clitoromegaly in association with either urogenital and/or cloacal anomalies. Additionally, absence of corporeal bodies may exist, resulting in either a markedly enlarged empty phallus or a megalourethra if developmental anomalies of the urogenital sinus occur in association with corporeal agenesis. Herein we report 2 cases to illustrate the spectrum of this disorder.

Surgical correction of urethral prolapse.

Since prolapse of the female urethra is the result of inadequate pelvic attachment we believe treatment should be reduction of the herniated urethra and fixation of the bladder and urethra to the posterior surface of the symphysis and rectus abdominis muscles.

Utricular configuration in hypospadias and intersex.

To evaluate the incidence and significance of an enlarged prostatic utricle in hypospadiac patients without underlying intersex 44 patients with the meatus located in the perineum, penoscrotal junction or proximal two-thirds of the penis were evaluated with cystourethroscopy immediately before the operation. There was an abnormally enlarged utricle in 57 per cent of the perineal, 10 per cent of the penoscrotal and none of the penile hypospadias and intersex revealed a high incidence of enlarged utricle or the presence of a vagina masculinus. Utricular enlargement in itself doses not indicate intersexuality but careful cystoscopic examination of its vault needs to be undertaken, searching for a cervix. An enlarged utricle can be a manifestation of delayed mullerian duct regression or decreased androgenic stimulation of the urogenital sinus.

Free full thickness skin graft urethroplasty: current technique.

We present details of our current techniques for skin graft urethroplasty. We believe that careful attention to the details of these operative techniques is important to their success. The changes from our previous reports include: 1) preparation of patch grafts with rounded ends, 2) preparation of tube grafts with fishmouth spatulation, 3) fixation of the stent catheter to the anterior abdominal wall, 4) leaving a stent catheter inlying for 2 weeks and replacing with a smaller catheter if a voiding cystourethrogram shows extravasation, 5) fixation of the graft during preparation by dermatome adhesive, 6) irrigation of the wound with irrigant before closure and 7) urodynamic flow study for non-invasive postoperative followup.

Utricular configuration in hypospadias and intersex.

To evaluate the incidence and significance of an enlarged prostatic utricle in hypospadiac patients without underlying intersex 44 patients with the meatus located in the perineum, penoscrotal junction or proximal two-thirds of the penis were evaluated with cystourethroscopy immediately before the operation. There was an abnormally enlarged utricle in 57% of the perineal, 10% of the penoscrotal and none of penile hypospadiacs, for an over-all incidence of 14%. Concurrent analysis of a series of phenotypic male patients with hypospadias and intersex revealed a high incidence of enlarged utricle or the presence of a vagina masculinus. Utricular enlargement in itself does not indicate intersexuality but careful cystoscopic examination of its vault needs to be undertaken, searching for a cervix. An enlarged utricle can be a manifestation of delayed müllerian duct regression or decreased androgenic stimulation of the urogenital sinus.