Penile reconstruction after complete bladder exstrophy repair.

INTRODUCTION: The decreased penile length in patients born with bladder exstrophy (BE) results partly from pubic symphysis diastasis and the separation of the corporal bodies. Also, intrinsic shortening of anterior corporal compartment, residual penile dorsal curvature, and postsurgical scarred skin share in creation of short penile length. OBJECTIVE: The goal of this study was to look at whether adult men who had bladder exstrophy (BE) surgery as babies needed and benefited from penile reconstruction, which included penile lengthening and repair of any redo penile pathology that was present at the same time. STUDY DESIGN: We reviewed the records of 31 repaired BE patients with mean age of 21.4 ± 3.7 years. The patients complained of their dissatisfaction with short penile length, residual dorsal penile curvature, distal dorsal or hypospadiac urethral opening and scared penopubic skin. The penile lengthening was performed by sub-periosteal detachment of the corporal bodies from the pubic rami in all cases. In 8 patients full thickness dermal grafts were used to penile resurfacing after its lengthening. Twelve patients underwent coronal or glanular urethroplasty. Phalloplasty was performed in one patient using forearm free graft. RESULTS: Subjective evaluation by the patient reported satisfactory results in 25/31 (80.6 %). The degree of penile lengthening measured at 6 months and one year postoperatively showed increased length which varied between 50 % and 150 % of the preoperative penile length. DISCUSSION: We hypothesize that congenital causes, such as short anterior corporeal compartment, wide pubic rami diastasis, and short penile urethra, as well as iatrogenic causes, such as post-surgical peno-pubic scars, could account for the coexisting multifactorial causes of penile shortening in male adults with BE. Penile lengthening is permitted, in our opinion, provided that the crura from the pubic rami is carefully and partially mobilized. CONCLUSIONS: The short phallus, residual dorsal chordee and distal urethroplasty can be corrected successfully in the majority of patients. Adult males with BE may have short penis that requires another reconstructive stage. The short phallus, residual chordee and distal urethroplasty can be corrected` successfully in the majority of patients.

The long-term consequences of the hypospadias salvage repair issue.

PURPOSE: To present the long-term results of redo-hypospadias at our tertiary referral center following a failed prior repair. METHODS: One hundred sixty-four individuals with a history of unsuccessful repairs qualified for our retrospective cohort study. Our inclusion criteria were as follows: pre-operative data that was accessible, redo-hypospadias that was successfully repaired, and at least three years of follow-up at the last hospital visit. RESULTS: The mean patient age was 91.3 ± 21.1 months. The mean follow-up after successful repair was 41.3 ± 3.1 months. Ninety-two (group A) had one prior repair, and 72 (group B) had 2 or 3 repairs. Group A underwent six primary techniques: 32 underwent Onlay Island Flap (OIF), 10 underwent Mathieu, 12 underwent Tubularized Incised Plate Urethroplasty (TIPU), 8 underwent Urethral Mobilization (UM), and 34 underwent Buccal Mucosal Graft (BMG) { dorsal inlay Graft Urethroplasty (DIGU) in 4 and staged BMG in 30 patients}. In group B, four procedures were used: TIPU in 4, UM in 6, and BMG in 62 (staged BMG in 50 cases and DIGU in 12). CONCLUSIONS: The selected type of repair will depend on many factors, like residual healthy local skin and expertise. Safe techniques for repair of redo hypospadias after its 1st failure include TIPU, Mathieu, UM, OIF, and DIGU for distal varieties. After 2nd or 3rd repair DIGU, UM, and TIPU can be performed in distal types, while staged BMG can be applied for proximal ones.

Long term evaluation of continence after complete primary bladder exstrophy repair.

INTRODUCTION: Continence after bladder exstrophy (BE) repair remains a major debatable challenge to pediatric urologists, together with the lack of standard definitions and long-term results in large series. OBJECTIVE: We assessed the long-term urinary continence in 142 toilet-trained cases after one (1-) stage of complete primary repair of bladder exstrophy (CPRE) and consequent procedures to achieve this goal in a single tertiary referral center. STUDY DESIGN: The current retrospective study included 123 boys and 19 girls with BE that were repaired by (1-) stage CPRE. The Mean age at (BE) repair was 9.5 ± 2.6 weeks. Complete penile disassembly (CPD) was used for epispadias repair in 42 (34.1%) and modified Cantwell-Ransley repair (MCR) was used in 81 (65.9%) boys. Bilateral anterior transverse innominate osteotomies (ATIO) were applied in all. Urinary continence was expressed in terms of the dry interval (DI). Continence procedures were afforded if CPRE failed to achieve DI ≥ 3 h (hrs.), those were in the form of endoscopic bladder neck injection (BNI), bladder neck reconstruction (BNR), and bladder neck closure (BNC) with catheterizable stoma. RESULTS: The mean age at follow up was 12.1 ± 5.2 years. DI ≥ 3 h was gained in 23 (16.2%) after CPRE alone, while complementary post-CPRE continence procedures were required to reach this goal in the remaining patients. Deflux injection was reported in 10 (7%), CIC in 8 (5.6%), BNR in 32 (22.5), and BNC with catheterizable stoma alone in 37 (26.1%), or with Charleston pouch in 32 (22.5%). DISCUSSION: We think that ≥3 h DI with voiding represents an appropriate definition of continence after BE repair. According to the results in the current series, we think that successful anatomical closure of BE is achievable, but the functional outcome in terms of continence and its evaluation is tricky. Results of continence were reported to change with age of the child, and it is difficult to evaluate both before toilet training age and long-term follow up. CONCLUSIONS: Long-term follow up of CPRE with bilateral ATIO alone or with BNI results in ≥3 h DI in a few cases; BNR after CPRE can provide a good chance for continence; otherwise, BNC with catheterizable stoma is a valid option.

Does primary urethral realignment improve the outcome of pediatric pelvic fracture urethral injury? A randomized controlled trial.

OBJECTIVE: To assess the efficacy of primary urethral realignment in the prevention of urethral stenosis and in simplifying delayed urethroplasty after complete pelvic fracture urethral injury in male children. METHODS: This randomized comparative trial included 40 boys <18 years with complete pelvic fracture urethral injury. The initial management was a primary urethral realignment in 20 boys and suprapubic cystostomy alone in the remaining 20 boys. The boys who underwent primary urethral realignment were assessed regarding the development of urethral stenosis. Boys who needed to be delayed urethroplasty in the two groups were compared regarding urethral defect length, intraoperative details, postoperative outcomes, number of procedures, and time to achieve normal voiding. RESULTS: Although 14 (70%) patients were able to void after primary urethral realignment, all of them developed urethral stenosis and needed delayed urethroplasty. No statistically significant difference between the two groups was found regarding urethral defect length, intraoperative details, and postoperative outcomes. Patients in the primary urethral realignment group underwent significantly more procedures (p < 0.001) and took a significantly longer time to achieve normal voiding (p = 0.002). CONCLUSION: Primary urethral realignment is neither able to prevent urethral stenosis nor effective in simplifying later urethroplasty after complete pelvic fracture urethral injury in male children. It exposes the patients to more surgical procedures and a prolonged clinical course.

A randomised trial comparing transurethral to percutaneous cystolithotripsy in boys.

OBJECTIVE: To compare the efficacy and morbidity of transurethral cystolithotripsy (TUCL) and percutaneous CL (PCCL) in the management of bladder stones in male children. PATIENTS AND METHODS: A total of 100 boys, aged <14 years with a single bladder or urethral stone of <30 mm, were randomised into two equal groups. Initial diagnostic urethro-cystoscopy and push back of urethral stones were done for patients in both groups. Patients in Group A had TUCL, while those in Group B had PCCL through a 20-F sheath using a 12-F nephroscope. The two groups were compared regarding preoperative criteria, intraoperative details, and postoperative outcomes. RESULTS: The patients in this study had a median (range) age of 36 (4-144) months and stone size of 10 (5-26) mm. There was no statistically significant difference between the two groups for preoperative criteria. The assigned procedure was successful in 48 (96%) patients in Group A and 49 (98%) in Group B (P = 1). Complications were encountered in 11 (22%) patients in Group A and five (10%) in Group B (P = 0.171). The median (range) operative time was 21.5 (4-90) min in Group A and 13 (5-70) min in Group B (P < 0.001). In all, 47 (94%) stones needed disintegration in Group A vs 22 (44%) in Group B (P < 0.001). CONCLUSION: Both techniques have comparable success and complications rates. However, PCCL has a shorter operative time and less need for stone disintegration.

Critical Application of Adult Nephrolithometric Scoring Systems to Children Undergoing Mini-Percutaneous Nephrolithotomy.

Objective: To evaluate and compare the ability of the Guy's stone score (GSS), the S.T.O.N.E. nephrolithometry, and the Clinical Research Office of the Endourology Society (CROES) nomogram to predict the outcome of mini-percutaneous nephrolithotomy (MPNL) in children, and to identify which of the predictors involved in these scoring systems can separately affect this outcome. Patients and Methods: All children younger than 14 years who had MPNL in our center over a period of 3 years were included prospectively. Bivariate analyses were done to evaluate the associations of the three scoring systems and the predictors composing them with single-session stone clearance and complications. Receiver operating characteristic (ROC) curve analyses of the three scoring systems were conducted to evaluate and compare their abilities to predict the outcomes. Decision curve analyses for the three scoring systems were conducted to evaluate the clinical benefit of using each of them to predict stone clearance. Results: We consecutively enrolled 92 renal units in 89 children with a median age of 9.5 years. Single-session stone clearance was achieved in 76 (82.6%) renal units. Complications occurred with 19 (20.7%) procedures. Stone multiplicity (p = 0.043), staghorn stone (p = 0.007), prior stone treatment (p < 0.001), number of calices involved (p = 0.006), stone burden (p = 0.003), GSS (p < 0.001), S.T.O.N.E. nephrolithometry (p = 0.012), and CROES nomogram (p < 0.001) had significant associations with stone clearance. Only stone attenuation was significantly associated with complications (p = 0.031). For prediction of stone clearance, CROES nomogram demonstrated the greatest area under the ROC curve and the greatest net benefit on decision curve analyses. Conclusions: For children undergoing MPNL, CROES nomogram is the best to predict stone clearance. However, none of the studied scoring systems predicted complications efficiently.

Comparative Application of Different Substaging Techniques for Non-Muscle Invasive Urothelial Carcinoma.

To evaluate the diagnostic performance and clinical significance of 4 systems of substaging cases with non-muscle invasive urothelial bladder carcinoma. In addition 4 cutoff measures were evaluated for prediction of muscularis-mucosa invasion. Four substaging systems were applied to 57 NMIBC cases to assess which of these reported methods correlates best with recurrence and progression. On univariate regression analysis patients having tumor size more than 3 cm, solid tumor architecture, high grade, substage B, substage T1e, substage ROL 2 and Tumor depth more than 1 mm were associated with higher recurrence. On multivariate analysis all the four substaging systems, tumor size, grade and tumor type had significant prognostic value for recurrence. Regarding progression only the metric substaging method was associated with tumor progression (p = 0.04). However, on univariate and multivariate regression analysis none of the substaging systems showed prognostic significance and only solid tumor architecture and CIS had significant prognostic value for tumor progression. The ROC curve analysis showed that 1 mm depth of invasion had the best accuracy for detection of muscularis-mucosa invasion (80.2%). Using 1 mm cutoff in measuring the depth and 0.5 mm for the diameter of infiltration may provide clinically relevant information to guide a more personalized therapy for NMIBC. Inclusion of both measures in addition to other histopathologic variables may aid in the development of a scoring system.

Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. II. Urological Self-Inflicted Harms: 1. Unintentional Patient's Side-Inflictor Urological Injuries.

INTRODUCTION: Unintentional self-inflicted injuries mainly refer to those injuries which are inflicted by the patient himself with benign intentions. In urology, they may vary and result in significant morbidities. PATIENTS AND METHODS: A retrospective search of our patients' data records for the reported cases of patient's side-inflictor urological injuries during the period July 2006 - June 2016 was made. Each case was studied for age, gender, primary diagnosis, injury inflictor, involved organ, motivating factor, mechanism, diagnosis, management, and final outcome. RESULTS: Of more than 55,000 urological procedures, 26 patients (0.047%) were involved in unintentional patient's side-inflictor urological injuries. The age range was 8-76 years and included 23 males and 3 females. Fifteen patients (57.7%) had urological disorders before the injury. They could be differentiated into direct organ involvement injuries (53.8%) and catheter involvement injuries (46.2%). External male urogenital organs were involved in 69.3% of cases which were diagnosed on physical examination. The inflictor of the injury was the patient himself, a relative, and another patient in 73.1, 19.2, and 7.7% of cases, respectively. Motivating factors were relief of painful conditions (34.6%), psychiatric disorders (38.5%), and sexual purposes (27%). Final outcomes were short-term harm, long-term harm, and permanent disability in 50, 11.5, and 38.5% of cases, respectively. CONCLUSION: Unintentional patient's side-inflictor urological injuries are very rare events and mainly involve the external male urogenital organs under different motivating stressors. They could be differen-tiated into direct organ and catheter manipulation injuries with variable final outcomes from mild short-term harms to permanent disabilities.

Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. VI. Unusual Events in Urolithiasis: 1. Long-Standing Urethral Stones without Underlying Anatomical Abnormalities in Male Children.

OBJECTIVES: The study aimed to present our center's experience with long-standing urethral stones in male children with normal urethra. MATERIALS AND METHODS: Retrospective search of our center data was done for the cases of long-standing urethral stones with normal urethra in male children during the period July 2001 - June 2016. Demographic and clinical data were studied. RESULTS: Of more than 54,000 urolithiasis procedures, 17 male children (0.031%) were operated for long-standing urethral stones with normal urethra. In 14 cases (82.4%), residence was rural and parental education levels were low or none. All children were regularly prompted voiding with a history of difficulty or dysuria. All the stones lodged in the posterior urethra with an approximate mean duration of 2 months. The mean stone size of 11.29 ± 3.88 mm and rough surfaces in 88.2% of cases represented the main predisposing factors. Major complications included rectal prolapse in 1 case and vesicoureteral reflux in 3 cases. Endoscopic push-back was followed by disintegration in 76.5% or cystolithotomy in 17.7%, while it failed in 1 case that was treated by cystolithotomy. CONCLUSIONS: Long-standing urethral stones in male children with normal urethra are very rare misdiagnoses. Stone topography and sociocultural factors predisposed to their lodgments and negligence. Endoscopic treatment is the best approach.

Does the site of the orthotopic neobladder outlet matter? A prospective randomized comparative study.

BACKGROUND: To compare the results of urethral anastomosis to a button hole and to the lowest part of the anterior suture line during orthotopic neobladder substitution. METHODS: From January 2012 to December 2015, 87 consecutive male patients with invasive bladder cancer underwent radical cystectomy and Hautmann ileal neobladder. Patients were randomly divided into two groups; group I (44 patients), the outlet was created as a button-hole at the most dependent part of the pouch, group II (43 patients), the lowest 1 cm of the anterior suture line of the pouch was left open as an outlet. Patients were randomly assigned to either group using computer-generated random numbers (JMP, Version 12.0.1; SAS Institute, Cary, NC, USA) via a sealed envelope. The functional outcomes of both groups were compared especially at the urethro-enteric anastomosis. RESULTS: There were no intraoperative complications. Early postoperative complications occurred in 9 patients (5 in group I and 4 in group II, p = 0.484). Prolonged urinary leakage persisted for 11 and 14 days in 2 patients in group I and 10 and 16 days in 2 patients in group II. Delayed postoperative complications occurred in 11 patients (5 [12.5%] in group I and 6 [15.6%] in group II) (p = 0.711). Three patients developed urethro-enteric strictures (2 in group I and 1 in group II) (p = 0.571). CONCLUSION: The "non-hole" technique of urethral anastomosis was not associated with a significant increase in the complication rate when compared to the commonly performed "hole" technique.