A different approach to distal hypospadias repair: The GUD (glandular urethral disassembly) technique.

INTRODUCTION: Distal hypospadias represent the most frequent clinical presentation of hypospadias. In spite of more than 300 techniques available, there is not an ideal approach. We have proposed an alternative procedure based on the combination of minor urethral mobilization and major glans deconstruction and partial disassembly from the corpora, the GUD technique. We want to present our clinical experience with the procedure and describe it in detail. METHODS: The technique consists of disconnecting the spongious tissue and the distal urethra from the corpora and detaching partially the glans as well, from 2 to 10 o'clock. The glans is opened in midline and the procedure combines cranially mobilization of urethra with caudal and medial rotation of glans wings to refurbish the glans correcting the hypospadia without urethroplasty. RESULTS: We have treated 164 patients with distal hypospadia. Median age at the surgery was 22.4 months (1-184 months). The meatal position after penile degloving was coronal at 108 cases, subcoronal at 54 and 2 patients presented megameatus and intact foreskin. Three patients (1.8%) had mild penoscrotal transposition in addition to hypospadia. Twenty-eight patients were treated as a secondary repair (17%). We found complications in 6 patients (3.6%) consisting of five fistulas (3%) and three glans dehiscence (1.8%). Two patients had both complications. Follow up was 21 months (1-42 months) and the median follow-up time was 18 months. DISCUSSION: We acknowledge that this procedure is intended only to distal hypospadias (coronal and subcoronal). We stress that the GUD procedure can be performed irrespectively of any urethral plate "quality" as it does not require a minimum glans width as the TIP repair. Moreover, there is no need for preoperative testosterone treatment. The absence of suture and urethroplasty minimizes the risk of coronal fistulas after surgery. CONCLUSIONS: We believe that this procedure is a viable alternative to distal hypospadias repair.

In utero myelomeningocele repair: The natural history of patients with incontinent pattern (sphincteric deficiency: leakage below 40 CMH20).

INTRODUCTION: Since 2011 we have been following prospectively myelomeningocele patients treated in utero with particular interest to patients with sphincter weakness/deficiency. We investigated the changes of bladder pattern and upper urinary tract with time in children who underwent in utero repair and had low-pressure incontinence based on urodynamic evaluation (UE). MATERIALS AND METHODS: From the 120 patients in our database, 117 had at least one UE. Of these, 30 were classified as incontinent when leaking at low pressure (<40 cmH20). We reviewed clinical evaluation, urinary tract ultrasound, voiding cystourethrography (VCUG), and other UE parameters at first and last evaluation. RESULTS: We found 30 cases (25.64%). Mean age at initial evaluation was 4.97 months followed by UE done initially at mean age of 5.73 months. Follow-up was 28.4 months. Febrile urinary tract infection has been found in four patients (13.3%), hydronephrosis in four patients, and bladder neck thickening in three (10%). The VCUG showed vesicoureteral reflux in three cases (3/27, 11.1%). A total of 90% of patients had detrusor overactivity with mean maximum detrusor pressure (33.37 cmH20). Only 16.67% of patients showed normal bladder capacity. From the 30 patients, 23 had at least two UE. We noticed a change of bladder pattern as follows: six patients became of high-risk pattern, five normal, and two with underactive bladder pattern. The average interval between the first and last UE was 25.5 months (median: 15 months). CONCLUSION: We concluded that 43.47% of patients with low DLPP have kept the incontinent pattern. If the initial LPP was below 30 cmH20, 70% remained with the incontinet pattern.