URINARY INCONTINENCE - FROM CHILDHOOD ONWARDS.

Urinary incontinence (UI) is a condition that affects patients of all ages, starting with childhood. There are two peaks in its incidence, i.e., in childhood and another one in patients over 40 years of age, which increases continuously with patient age. It is a condition recognized by the World Health Organization as a set of diseases (International Classification of Diseases, ICD-10), and the International Classification of Functionality recognizes the associated extreme disablement. UI is a major health problem affecting the lives of an estimated 400 million persons worldwide. The global aging of the population will cause rise in the incidence of UI in the future. It is expected that UI itself will become a serious health and social burden for both patients and health service providers. UI can be an isolated problem, or it can be associated and/or aggravated by any associated disorder affecting the nervous system such as myelomeningoceles, Parkinson's disease or stroke. UI often affects the patient daily life, and it can have repercussions on their physical, financial, social, and emotional well-being. At last, it has a negative influence on their sexual health.

Latissimus dorsi free flap phalloplasty: a systematic review.

A phalloplasty is a complex genital reconstruction procedure of creating a neophallus. Several techniques to create a neophallus are described, based on different vascularized flaps, and each of them has its advantages and drawbacks. The aim of this study is to present musculocutaneous latissimus dorsi (MLD) flap as a viable option for total phalloplasty, with an interest in clinical outcomes and complications. A comprehensive literature review of all available reports about MLD flap phalloplasty was made. The following keywords were used on PubMed: latissimus dorsi musculocutaneous/myocutaneous free flap and phalloplasty. Research criteria revealed five articles and the results of 182 patients were analyzed. A total number of the patients, indications, operative technique, follow-up period, postoperative results, and complications were presented. In conclusion, MLD free flap presents a good choice for phalloplasty providing sufficient amount of tissue for safe implantation of penile prosthesis and successful penetrative sexual intercourse. The erogenous sensitivity is preserved with clitoris or glans penis incorporated into the base of the neophallus, and voiding in a standing position is achievable after urethral reconstruction. The main drawback is the lack of tactile sensation of the neophallus and the significant advantage is a well-concealed donor site.

Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery.

PURPOSE: Despite a variety of free flaps that have been described for creation of the neophallus in gender affirmation surgery, none present an ideal solution. We evaluated our patients and outcomes after gender affirmation phalloplasty using musculocutaneous latissimus dorsi free flap. METHODS: Between January 2007 and May 2017, 129 female transsexuals, aged 20-53 years (mean 24 years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages. RESULTS: The mean follow-up period was 43 months (ranged from 13 to 137 months). There were one partial and two total flap necrosis. The average size of the neophallus was 14.6 cm in length and 12.4 cm in girth. Total length of the reconstructed urethra during the first stage ranged from 13.4 to 21.7 cm (mean 15.8 cm), reaching the proximal third or the midshaft of the neophallus in 91% of cases. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively. CONCLUSION: Musculocutaneous latissimus dorsi flap is a good choice for phalloplasty in gender affirmation surgery. It provides an adequate amount of tissue with sufficient blood supply for safe urethral reconstruction and penile prosthesis implantation.

Single-stage repair of obliterated anterior urethral strictures using buccal mucosa graft and dorsal penile skin flap.

OBJECTIVE: To present a single-stage repair of obliterative urethral strictures by simultaneous use of a buccal mucosa graft and longitudinal dorsal penile skin flap. METHODS: Between February 2007 and October 2016, 51 patients with obliterative anterior urethral stricture underwent single-stage substitution urethroplasty. A buccal mucosa graft was harvested and fixed to the corpora cavernosa as the dorsal part of the neourethra, and a vascularized dorsal penile skin flap was created, transposed ventrally and sutured to the buccal mucosa graft to form ventral part of the neourethra. RESULTS: The follow-up period was 12-129 months (mean 49 months). The mean age of the patients was 48 years (range 15-71 years). The mean length of the obliterated urethral segment, measured during the operative procedure, was 5.2 cm. The etiology of strictures was: unknown, hypospadias and trauma in 19, 27 and five patients, respectively. Five patients were lost to follow up, and 46 patients were analyzed for the outcome. At the end of the follow-up period, recurrence of the stricture occurred in seven (15.2%) patients, whereas 39 (84.8%) patients did not develop stricture. An additional three (6.5%) patients developed fistula, resulting in overall successful voiding in 36 (78.3%) patients. CONCLUSIONS: A combined buccal mucosa graft and longitudinal dorsal penile skin flap could be a good choice for one-stage substitution urethroplasty in complex obliterative urethral strictures, with an acceptable complication rate.

Buccal mucosa graft for simultaneous correction of severe chordee and urethroplasty as a one-stage repair of scrotal hypospadias (watch technique).

PURPOSE: Severe hypospadias repair still presents a great challenge. We evaluated a novel approach of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and new urethral plate creation, in combination with longitudinal dorsal island skin flap, as a one-stage repair of severe hypospadias. METHODS: Between July 2014 and September 2017, 26 patients (aged from 12 to 22 months) underwent scrotal hypospadias repair. Short and non-elastic urethral plate is divided. Buccal mucosa graft is harvested from the inner cheek, and designed in a special "watch" shape, with the spherical part in the middle and two rectangular parts on both sides. Tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" buccal mucosa with 6-8 "U-shape" stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally. Longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with buccal graft. Penile skin reconstruction is performed using available penile skin. RESULTS: The mean follow-up was 22 months (range from 9 to 46 months). Satisfactory results were achieved in 22 patients. Two urethral fistulas were successfully repaired by minor surgery after 3 months, while one meatal stenosis and one urethral diverticulum were successfully treated by temporary urethral dilation. There were no cases of residual curvature. CONCLUSION: Specially shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty could be a good choice for single-stage repair of scrotal hypospadias with severe curvature.

Total Phalloplasty With Latissimus Dorsi Musculocutaneous Flap in Female-to-male Transgender Surgery.

OBJECTIVE: To present our technique of musculocutaneous latissimus dorsi (MLD) free-flap total phalloplasty. This technically demanding female-to-male gender reassignment surgery consists of creating a neophallus from extragenital tissue. METHODS: The presented technique included: removal of internal and/or external female genitalia, creation of neophallus using latissimus dorsi free flap, clitoral incorporation into the neophallus, urethral lengthening, and insertion of testicular implants into the newly created scrotum. The MLD flap with proper dimension is harvested from nondominant side and tubularized. Microvascular anastomosis is done between thoracodorsal vessels and femoral artery and saphenous vein. Neophallus is positioned in adequate place. Urethroplasty is performed by combining different genital flaps that are harvested from anterior vaginal wall, urethral plate, and both labia minora and clitoral skin. Scrotoplasty is done by joining both labia majora with implantation of testicular implants. RESULTS: Operative time was 427 minutes with minimal blood loss. Both donor site and graft healed well, and the patient reports voiding well while standing. Penile prosthesis implantation as well as neophallic urethroplasty are planned for the second stage. CONCLUSION: Total MLD flap phalloplasty with urethral lengthening is a challenging and complex surgical procedure. This technique presents good variant for female transgenders with acceptable cosmetic outcome and enables good volume of neophallus, sexual arousal, and voiding while standing.

Repeated penile girth enhancement with biodegradable scaffolds: Microscopic ultrastructural analysis and surgical benefits.

Autologous tissue engineering using biodegradable scaffolds as a carrier is a well-known procedure for penile girth enhancement. We evaluated a group of previously treated patients with the aim to analyze histomorphometric changes after tissue remodeling and to estimate the benefits of repeated procedure. Between February 2012 and December 2016, a group of 21 patients, aged 22-37 (mean 28.0) years, underwent a repeated penile girth enhancement procedure with biodegradable scaffolds. Procedure included insertion of two poly-lactic-co-glycolic acid scaffolds seeded with laboratory-prepared fibroblasts from scrotal tissue specimens. During this procedure, biopsy specimens of tissue formed after the first surgery were taken for microscopic analysis. The mean follow-up was 38 months. Connective tissue with an abundance of connective tissue fibers, small blood vessels, and inflammatory cells were observed in all analyzed surgically removed tissue. Ultrastructural analysis of these tissue samples discovered the presence of large quantities of collagen fibrils running parallel to each other, forming bundles, with a few widely spread fibroblasts. In total, the mean values of flaccid and erect gain in girth after the second surgery were 1.1 ± 0.4 (range: 0.6-1.7) cm and 1.0 ± 0.3 (range: 0.6-1.5) cm, respectively. Microscopic evaluation of newly formed tissue, induced by autologous tissue engineering using biodegradable scaffolds, showed the presence of vascularized loose connective tissue with an abundance of collagen fibers, fibroblasts, and inflammatory cells, indicating active neovascularization and fibrinogenesis. The benefit of the repeated enhancement procedure was statistically significant.

Ureterocele fenestration with holmium laser in neonates.

AIM: To evaluate the effectiveness of holmium-laser fenestration of intravesical ureteroceles in neonatal period. MATERIAL AND METHOD: We retrospectively analyzed the results of the holmium-laser puncture in ten neonates with intravesical ureterocele, between September 2013 and September 2016. Laser probe was placed through the cystoscope to the lowest and medial portion of the ureterocele, near the bladder floor. Few punctures (4 to 8) were made, until ureterocele has been collapsed. RESULTS: Mean duration of general anesthesia was 16 minutes (range, 10-24) and duration of hospitalization was 1-3 days (mean, 1.3 days). There weren't complications regarding endoscopic treatment. There was the need for retreatment in one (10%) patient. Obstruction was found in one (10%) patient on ultrasound after one month. After three months there was no obstruction on ultrasound in any patient. In patients in whom VCUG was performed, vesicoureteral reflux was not found three months after the surgery. DISCUSSION: The relief of the obstruction, prevention of the vesicoureteral reflux and the urinary tract infection are the reasons for the immediate treatment in the neonatal period. In that way, the preservation of renal function is enabled. The reason for laser fenestration was better endoscopic control of the extensibility of the ablation. The moment of ureterocele collapsing can be visualized directly. CONCLUSIONS: Holmium-laser fenestration is a minimally invasive, highly effective and safe kind of treatment for ureterocele in neonatal period with minimal complication rate. Further clinical studies with a greater number of patients will offer more reliable information regarding this procedure. KEY WORDS: Fenestration, Holmium-laser, Neonates, Ureterocele.

Laser-puncture Versus Electrosurgery-incision of the Ureterocele in Neonatal Patients.

PURPOSE: To compare the holmium-laser puncture and electrosurgery-incision in neonates with intravesical ureterocele. MATERIALS AND METHODS: We retrospectively analyzed the results of laser-puncture of ureterocele (LP group) in 12 patients (mean age 9.8 days, range 4-28) and electrosurgery-incision in 20 patients (ES group) (mean age 10.2 days, range 6-28), treated at our institution. Patients had their records reviewed for preoperative findings, endoscopic procedure description, and postoperative outcomes. RESULTS: There was the need for retreatment in one (8.3%) patient in LP group and in four (20%) patients in ES group (P = .626). Duration of general anesthesia in LP and ES groups was 16 (range, 10-24) minutes and 15 (range, 10-20) minutes, respectively (P = .355). There was no statistically significant difference in terms of hospitalization (LF group one day, ES group 1.35 days) (P = .286). Complications were not found in LP group. There were two (10%) patients with pyelonephritis after the treatment in ES group (P = .516). After one month, obstruction was observed on ultarsound examination in one (8.3%) and two (10%) patients, respectively. After three months, obstructionwas not found in any patient in both groups. After six months, vesicoureteral reflux was found in one (8.3%) patient after laser-puncture of the ureterocele and in 13 (65%) patients after electrosurgery-incision (P = .003). CONCLUSION: Both laser-puncture and electrosurgery-incision endoscopic techniques are highly effective in relieving the obstruction. There is no significant difference regarding hospitalization, need for retreatment and the occurrence of complications. The incidence of de novo vesicoureteral reflux is significantly lower in patients treated with holmium-laser, as well as the need for upper pole partial nephrectomy.

Ileal vaginoplasty as vaginal reconstruction in transgender women and patients with disorders of sex development: an international, multicentre, retrospective study on surgical characteristics and outcomes.

OBJECTIVE: To describe the surgical outcomes of ileal vaginoplasty in transgender women and patients with disorders of sex development (DSD). PATIENTS AND METHODS: Transgender women and patients with DSD, who underwent ileal vaginoplasty at the VU University Medical Center Amsterdam, University Hospital Trieste, University Hospital Essen, and Belgrade University Hospital, were retrospectively identified. A chart review was performed, recording surgical technique, intraoperative characteristics, complications, and re-operations. RESULTS: We identified a total of 32 patients (27 transgender and five non-transgender), with a median (range) age of 35 (6-63) years. Ileal vaginoplasty was performed as the primary procedure in three and as a revision procedure in the remaining 29. The mean (sd) operative time was 288 (103) min. The procedure was performed laparoscopically (seven patients) or open (25). An ileal 'U-pouch' was created in five patients and a single lumen in 27. Intraoperative complications occurred in two patients (one iatrogenic bladder damage and one intraoperative blood loss necessitating transfusion). The median (range) hospitalisation was 12 (6-30) days. Successful neovaginal reconstruction was achieved in all. The mean (sd) achieved neovaginal depth was 13.2 (3.1) cm. The median (range) clinical follow-up was 35 (3-159) months. In one patient a recto-neovaginal fistula occurred, which lead to temporary ileostomy. Introital stenosis occurred in four patients (12.5%). CONCLUSION: Ileal vaginoplasty can be performed with few intra- and postoperative complications. It appears to have similar complication rates when compared to sigmoid vaginoplasty. It now seems to be used predominantly for revision procedures.

One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals.

BACKGROUND: Female-to-male gender-confirmation surgery (GCS) includes removal of breasts and female genitalia and complete genital and urethral reconstruction. With a multidisciplinary approach, these procedures can be performed in one stage, avoiding multistage operations. AIM: To present our results of one-stage sex-reassignment surgery in female-to-male transsexuals and to emphasize the advantages of single-stage over multistage surgery. METHODS: During a period of 9 years (2007-2016), 473 patients (mean age = 31.5 years) underwent metoidioplasty. Of these, 137 (29%) underwent simultaneous hysterectomy, and 79 (16.7%) underwent one-stage GCS consisting of chest masculinization, total transvaginal hysterectomy with bilateral adnexectomy, vaginectomy, metoidioplasty, urethral lengthening, scrotoplasty, and implantation of bilateral testicular prostheses. All surgeries were performed simultaneously by teams of experienced gynecologic and gender surgeons. OUTCOMES: Primary outcome measurements were surgical time, length of hospital stay, and complication and reoperation rates compared with other published data and in relation to the number of stages needed to complete GCS. RESULTS: Mean follow-up was 44 months (range = 10-92). Mean surgery time was 270 minutes (range = 215-325). Postoperative hospital stay was 3 to 6 days (mean = 4). Complications occurred in 20 patients (25.3%). Six patients (7.6%) had complications related to mastectomy, and one patient underwent revision surgery because of a breast hematoma. Two patients underwent conversion of transvaginal hysterectomy to an abdominal approach, and subcutaneous perineal cyst, as a consequence of colpocleisis, occurred in nine patients. There were eight complications (10%) from urethroplasty, including four fistulas, three strictures, and one diverticulum. Testicular implant rejection occurred in two patients and testicular implant displacement occurred in one patient. CLINICAL IMPLICATIONS: Female-to-male transsexuals can undergo complete GCS, including mastectomy, hysterectomy, oophorectomy, vaginectomy, and metoidioplasty with urethral reconstruction as a one-stage procedure without increased surgical risks and complication rates. STRENGTHS AND LIMITATIONS: To our knowledge, this is the largest cohort on this topic so far, with good surgical outcomes. Limitations include lack of selection or exclusion criteria and lack of other studies with a simple approach. For this reason, the technique should be studied further and compared with other techniques for female-to-male surgery before it can be recommended as an alternative procedure. CONCLUSIONS: Through a multidisciplinary approach of experienced teams, one-stage GCS presents a safe, viable, and time- and cost-saving procedure. Complication rates do not differ from reported rates in multistage surgeries. Stojanovic B, Bizic M, Bencic M, et al. One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals. J Sex Med 2017;14:741-746.

Gastric tube esophageal reconstruction in children with esophageal atresia and caustic stricture Study of clinical value based on 25 single-center. Centre experience.

AIM: The aim of this study was estimation of clinical value of gastric tube esophagoplasty in children based on one single center experience. METHODS: Forty-nine patients with diagnosis of EA (n=22) and caustic esophageal injury (n=27) had undergone reverse gastric tube esophagoplasty during 25 years at our institution. Almost all EA patients received initially gastrostomy and cervical esophagostomy. Majority of CS patients had initially repeated dilatation therapy. Demographics, preoperative features (initial condition, initial treatment and nutritional status) and postoperative features (leakage, stenosis, nutritional status and disease-specific symptoms) were retrospectively reviewed and analyzed. Mean follow up time was 8.2 years. RESULTS: Of 49 patients, 2 patients died and gastric tube failed in one patient. The most common complications were anastomotic leak (52%) and anastomotic stricture (47,8%). Disease-specific symptoms (dysphagia and reflux symptoms) with important clinical manifestations were observed in 10.87% of patients. Preoperatively, all patients were eutrophic. One year after operation 96% of patients stayed eutrophic and two EA patients were malnourished. CONCLUSION: The most common complications such as anastomotic leak and anastomotic stricture may be considered benign. Postoperative nutrition, as good indicator of the procedure's adequacy, for the majority of patients is satisfactory. Gastric tube esophagoplasty is an appropriate alternative for esophageal replacement in children. KEY WORDS: Children, Gastric tube, Esophagoplasty.

Laser lithotripsy in the treatment of renal stones in children. A single-center experience.

AIM: To evaluate the effectiveness and safety of laser lithotripsy in the treatment of renal stones in children in a single center. MATERIAL AND METHODS: We retrospectively analysed patients (n=36) who were treated with laser nephrolithotripsy (LL group) between 2011 and 2014. We compared those results with results of pneumatic nephrolithotripsy in patients (n=32) who were treated from 2007 to 2011 (PL group). The patients were evaluated in respect of gender, age, stone location, stone size, complications and stone-free rate. RESULTS: The duration of anesthesia, the need for retreatment, the mean hospitalization and the occurrence of minor complications (perirenal haematoma, urinoma, minimal ureteral perforation) were significantly lower in LL group (p < 0.05). We found statistically significant difference in stone-free rate between two groups - stone-free rate was significantly higher in LL group (LL: 94.4% vs. PL: 62.5%) (p < 0.05). DISCUSSION: Analyzing the stone-free rate after lithotripsy and the occurrence of complications, it is shown that the laser lithotripsy is more efficient than pneumatic lithotripsy and that endoscopic procedure proved safer, in terms of complications. Majority of the studies showed different successful rate after laser lithotripsy for stones located in the kidney. In particular cases, there is the need for ureteral orifice dilatation and ureteral stent insertion. CONCLUSIONS: Laser endoscopic lithotripsy is minimally invasive, effective and safe surgical procedure for the treatment of renal stones in children with minimal complication rate. The effectiveness is partially limited to stones in lower pole calices of the kidney. KEY WORDS: Laser lithotripsy, Urolithiasis, Ureterorenoscopy.

International multicentre psychometric evaluation of patient-reported outcome data for the treatment of Peyronie's disease.

OBJECTIVE: To compare patient-reported outcomes (PROs) of surgical correction of Peyronie's disease (PD) with the Nesbit procedure, plaque incision and grafting, and the insertion of a malleable penile implant after surgical correction of penile curvature. PATIENTS AND METHODS: We performed a retrospective review of men who underwent surgical correction of PD between January 2010 and December 2012 at six international centres. Treatment-related PROs and satisfaction were evaluated with a non-validated questionnaire. RESULTS: The response rate to the questionnaire was 70.9%, resulting in a study cohort of 206 patients. The Nesbit procedure, plaque incision with grafting, or implantation of a malleable penile prosthesis was performed in 50, 48, and 108 patients, respectively. Overall, 79.1% reported a subjective loss of penile length due to PD preoperatively (range 2.1-3.2 cm). Those patients treated with a malleable penile implant reported the greatest subjective penile length loss, due to PD. A subjective loss of penile length of >2.5 cm resulted in reduced preoperative sex ability. Postoperatively, 78.0%, 29.2% and 24.1% patients in the Nesbit, grafting, and implant groups reported a postoperative, subjective loss of penile length (range 0.4-1.2 cm), with 86.3%, 78.6%, and 82.1% of the patients in each group, respectively, being bothered by the loss of length. CONCLUSIONS: Penile length loss due to PD affects most patients. Further penile length loss due to the surgical correction leads to bother among the affected patients, irrespective of the magnitude of the loss. The Nesbit procedure was associated with the highest losses in penile length. In patients with PD and severe erectile dysfunction, a concomitant lengthening procedure may be offered to patients to help overcome the psychological burden caused by the loss of penile length.

An overview of neovaginal reconstruction options in male to female transsexuals.

Transsexualism is a complex condition in which the person experiences the inconsistency between the desired gender and their biological gender. Absence of the vagina is devastating in male to female transsexuals. Creation of the neovagina is the main surgical problem in these patients. Historically, beginnings of the neovaginal creation have their roots in the treatment of Mayer-Rokitansky syndrome and conditions such as cloacal anomalies, certain intersex disorders, vaginal malignancies, or severe vaginal trauma, but have more recently found great purpose in male to female sex reassignment surgery. Many operative procedures have been described but none is ideal. Therefore, the search for new, improved solutions continues. In neovaginoplasty reconstruction of the vulvovaginal complex is performed in its entity. The gold standard in neovaginal reconstruction in male to female sex reassignment surgery is penile skin inversion technique with or without scrotal flaps, which enables adequate sensation of the neovagina, good neovaginal depth, good erotic sensitivity of the neclitoris, and esthetically acceptable labia minora and maiora.

Penile prosthesis implantation and tunica albuginea incision without grafting in the treatment of Peyronie's disease with erectile dysfunction.

We evaluated penile prosthesis implantation with tunica albuginea-relaxing incisions without grafting in the treatment of Peyronie's disease associated with erectile dysfunction. Between April 2005 and June 2011, 62 patients underwent surgery due to severe Peyronie's disease associated with erectile dysfunction. Malleable and inflatable penile prostheses were inserted in 49 and 13 cases, respectively. Penile prostheses were inserted into the corpora cavernosa using the standard ventral approach. After lifting the neurovascular bundle, the tunica albuginea was incised and opened at the plaque region to correct the deformities and to lengthen the penis. Subsequently, the wide neurovascular bundle was replaced, and all incisions of the tunica albuginea were covered to prevent corporal grafting. In the median follow-up of 35 months (range 14-82 months), the penis was completely straightened in 59 (95%) patients. Numbness of the glans, which the patients found initially upsetting, decreased or disappeared spontaneously 3-6 months later. Penile prosthesis implantation with tunica albuginea incisions is a viable alternative in the treatment of Peyronie's disease because the extensive dissection of the neurovascular bundle allows a good approach to the plaque and provides excellent covering of the incised tunica albuginea without additional grafting.

Treatment for failed epispadias repair presenting in adults.

PURPOSE: We evaluated the results of 1-stage and multistage penile reconstruction in adults with complications after multiple failed epispadias repairs. MATERIALS AND METHODS: A total of 23 adults underwent penile disassembly for repeat epispadias repair from February 2006 to June 2011. Median age at surgery was 27 years (range 17 to 41). Surgical treatment included penile disassembly with complete straightening and lengthening of the penis, followed by urethral reconstruction. The corpora cavernosa were completely separated from the glans cap with the neurovascular bundles and from the urethra. The urethra, which was short in all cases, was divided at the glans level. Penile straightening and lengthening were achieved by tunica albuginea incision and grafting. The urethra was reconstructed 3 to 6 months later using combined buccal mucosa graft and genital skin flaps. Success was defined as a functional penis without urethral fistula or stricture, or residual chordee as well as a cosmetically acceptable penile appearance. RESULTS: Mean followup was 33 months (range 14 to 78). Of the patients 19 had a completely straightened and lengthened penis. Improved length of the erect penis was 2.7 to 6.6 cm. In 4 patients mild curvature developed without the need for additional correction. Urethral fistula in 3 cases was repaired 6 months after urethroplasty in 2, while it closed spontaneously in 1. All 21 sexually active patients reported good erectile function. CONCLUSIONS: Adults with complications after childhood epispadias repair are still a difficult population to treat. A radical surgical approach must be used to achieve a successful outcome.

Epispadias repair after failed surgery in childhood.

INTRODUCTION: Redo surgery in failed epispadias presents a great challenge. Our aim was to present a radical approach for correction of penile deformities as well as urethral reconstruction in patients after failed epispadias repair. MATERIALS AND METHODS: Between January 2006 and January 2011, 13 patients, aged 13 to 22 years, underwent redo surgery due to failed epispadias repair in childhood. All patients presented with severe dorsal curvature and short urethra. First stage included penile disassembly technique with complete separation of corporal bodies, urethral dissection, and transposition and subtotal glans mobilization. Residual dorsal curvature was corrected by tunical incision and grafting of the defect. Short urethra was dissected and transposed ventrally with opening at the base of the penis. Penile entities were reassembled in normal anatomical relationship. Penile body was covered using available vascularized skin flaps. After 6 months, second stage was performed and included reconstruction of the penile urethra using buccal mucosa graft and scrotal hairless skin flap. RESULTS: Follow-up ranged from 12 to 60 months (mean 33 months). Acceptable outcome is achieved in all the patients. Complete penile lengthening and straightening is obtained in 10 out of 13 patients. Mild curvature is noted in three patients without consequences. Satisfactory sexual activity was reported from nine patients. One patient developed fistula that was closed after 4 months, whereas all other patients reported normal voiding with no difficulties. CONCLUSIONS: Redo surgery of failed epispadias is very demanding procedure. Radical approach in these cases is necessary for complete repair of all penile deformities with satisfactory postoperative outcome.