Three-dimensional Computed Tomography Scan of the Pelvic Bone in Isolated Epispadias: Analysis Before Surgical Correction.

OBJECTIVE: To determine intrapelvic angles and distances in pure epispadias patients and compare them to normal values. METHODS: Using three-dimensional computed tomography, 17 intrapelvic dimensions (8 angles and 9 distances) were measured in 26 patients with pure epispadias (21 boys and 5 girls). These values were compared to normal values obtained from 6 patients (5 boys and 1 girl) who underwent either pelvic or abdominopelvic computed tomography for purposes unrelated to their bony pelvis. RESULTS: Significant differences were observed in five angles (sacroiliac joint angle, S1 tilt angle, sacral curvature, superior-inferior rotation of the pelvis, and pubococcygeal angle; P-value=.016, .044, .011, .020, and .001, respectively); these show less sacral rotation toward the axial plane, more sacral curvature, inferior rotation of the pelvis, and sacroiliac joints' rotation toward the coronal plane in epispadias compared to controls. Also, two distances (pubic diastasis and anterior segment length of the pelvis; P-value=.002 and .012, respectively) had significant differences, showing wider pubic diastasis and shorter anterior segment in epispadias. However, the differences between other intrapelvic angles and distances were not statistically significant between the two groups. CONCLUSION: In addition to the explanations hypothesized for the embryology of the exstrophy-epispadias complex, there can be other etiologies for both epispadias and bladder exstrophy to explain the differences between bony anatomies of the pelvis in these patients.

Factors Affecting Transperitoneal Robot-Assisted Laparoscopic Radical Prostatectomy.

Objectives: To evaluate the impact of body mass index (BMI), preoperative risk classification, previous inguinal herniotomy, and abdominal operations on several steps of robot-assisted radical prostatectomy (RARP) and lymph node (LN) involvement. Methods: A total number of 225 consecutive patients were included in the study who underwent transperitoneal RARP by 1 surgeon. We defined the following parameters as dependent variables: duration of prostatectomy, duration of pelvic lymphadenectomy, incision to suture time, console time, number of dissected LNs and number of positive LNs for metastasis. We assessed the impact of the following covariates using univariate nonparametric and multivariate analysis: BMI, preoperative D'Amico risk classification, history of inguinal herniotomy, and previous abdominal operations. Results: We observed a statistically significant difference among our three BMI groups (<25, ≥25 and <30, and ≥30 kg/m2) regarding pelvic lymphadenectomy and LN metastasis. Moreover, among the three risk groups (low, intermediate, and high) duration of prostatectomy, pelvic lymphadenectomy, and LN metastasis were statistically different. Previous abdominal operations have been also demonstrated to significantly influence the pelvic lymphadenectomy. In addition, our multivariate model proved the impact of our covariates on pelvic lymphadenectomy. Conclusions: Our findings highlight the impact of BMI and preoperative risk on various steps of RARP. We revealed longer duration of pelvic lymphadenectomy and more nodal yield in patients with higher BMI and high-risk disease. Therefore, we suggest that BMI and risk classification according to D'Amico should be taken into account while a RARP is being planned.

Gigantic Suprapubic Lymphedema: A Case Study.

We present the first case study of idiopathic gigantic suprapubic lymphedema and buried penis treated with puboscrotal reconstruction in a patient with initial extreme obesity after an extensive weight reduction (120 kg). Massive localized lymphedema of the suprapubic region should be differentiated from the scrotal type. Severe lymphedema could not resolve on its own and weight reduction does not seem to be helpful in such cases.

Combination of calcium hydroxyapatite and autologous blood for endoscopic treatment of vesicoureteral reflux in children.

OBJECTIVE: To report the results of endoscopic correction of vesicoureteral reflux (VUR) with concomitant injection of pure calcium hydroxyapatite (CaHA) and autologous blood. PATIENTS AND METHODS: Records of patients who underwent endoscopic correction of VUR using concomitant injection of CaHA and autologous blood from 2008 through 2010 were retrospectively reviewed. Data regarding patients' demographics, preoperative VUR grades, febrile urinary tract infections, complications of procedure, postoperative VUR grades and cure rates were collected. Voiding cystourethrography was performed 3 months postoperatively. RESULTS: Total number of 23 children (9 girls and 14 boys) with 40 refluxing ureters were included. The mean age of children was 1.9 ± 0.97 (SD) years. Reflux grades were II to IV in 14, 11 and 15 renal refluxing units (RRUs), respectively. The mean follow-up period was 44 months. VUR was successfully treated in 87.5% of RRUs after three injections. Significant statistical difference was found between VUR grades before and after the first, second and third injections (p < 0.001, p = 0.001 and p = 0.011, respectively). Moreover, there was a significant difference between primary reflux grade and treatment success (p = 0.031). Febrile UTI was resolved in 85% of patients (17 of 20 patients with febrile UTI) after endoscopic treatment which shows significant improvement (p < 0.001). The procedure was uneventful in all patients, and no obstruction was reported during the follow-up period. CONCLUSION: Concomitant injection of pure CaHA without any additives (hyaluronic acid, etc.) and autologous blood can be an effective, repeatable and cost-benefit approach for the management of children suffering VUR with a success rate of 87.5% after three injections.

Determination of substance overdose in two Iranian centers: comparison between opioids and non-opioids.

Recently, new trend toward non-opioid substances is observed in Iran. This is, therefore, to compare overdose of opioids and non-opioids origin. We performed this investigation to provide more detailed information so that preventive actions are taken in future. Over 18 month, 1876 individuals with opioid (opium, heroin, compact-heroin, buprenorphine and opiates) or non-opioid (MDMA (ecstasy), LSD, hashish and cocaine) overdose were selected. They have been compared regarding sex, age, reason of overdose, method of substance use, occupation, marital status, history of addiction in parents/siblings, duration of hospital admission and educational level. There were 1782 and 94 persons with opioid and non-opioid, respectively. Inhalation was the method of choice and women were found to have more tendencies to hallucinogens rather opioids. Moreover, use of non-opioids was observed more in individuals with university education and moreover in whom none of whose parents/siblings was addict. Policies should be planned by the governments to prevent further addictions especially to non-opioids.

Comparison of hysterosalpingography and laparoscopy in infertile Iranian women with tubal factor.

OBJECTIVE: Mechanical factors are responsible for approximately 30% of female infertility and various methods such as transvaginal ultrasonography, hysterosalpingography (HSG), hysteroscopy and laparoscopy have been used to investigate these factors. The aim of this study was to evaluate if HSG alone can be accurately used, compared with laparoscopy in order to reduce health care costs in high medical standard setting in infertile women with tubal factor METHODS: Retrospectively medical records of women admitted to a local Iranian hospital were selected. Records of those who underwent both HSG and laparoscopy were studied. Afterwards, the findings were compared in regard to tubal obstruction. RESULTS: A total number of 181 records was included into the study By both methods, 99 women were evaluated to have normal findings, and 37 women - abnormal findings, i.e. 136 of 181 (75%) HSG reports were accurate in reference to laparoscopy However there were 3 patients with abnormal fallopian tubes that were not detected by HSG and, moreover; 42 patients with normal tubes which were reported as abnormal by HSG. The calculated sensitivity and specificity of HSG in our study were 0.92 and 0.70, respectively CONCLUSION: Although laparoscopy is considered as the reference standard in infertility workup, HSG can be performed first and, therefore, the use of laparoscopy should be limited to cases suspected for etiologies other than intratubal, such as endometriosis and peritubal adhesions.

Use of biodegradable plates and screws for approximation of symphysis pubis in bladder exstrophy: applications and outcomes.

OBJECTIVES: To investigate the feasibility of biodegradable plate and screws for the tension-free internal fixation of the symphysis pubis in patients with bladder exstrophy, with a particular emphasis on pelvic bone changes as seen on 3-dimensional computed tomography. METHODS: A total of 11 children with bladder exstrophy underwent surgical repair with biodegradable plate and screw fixation (mean age 4.13 years). Of the 11 patients, 6 had a history of failed bladder closures and pelvic osteotomies, 1 had failed bladder closure, and 4 had no such history. All 11 children underwent single-stage classic bladder closure. Subsequently, the symphysis pubis was fixed by placing a biodegradable miniplate and screws. The patients remained in leg bandages for 2 weeks. The follow-up period was 6-50 months (average 30.1). Three-dimensional pelvic bone computed tomography was performed initially and at 6 months postoperatively. RESULTS: All 11 children had an uneventful postoperative period, except for a superficial infection at the site of the suprapubic tube in 1 patient. The mean hospital stay was 13.4 days. The plate remained in situ, and no further surgery was needed to remove it. Pelvic 3-dimensional computed tomography revealed a 35.48 ± 1.50 mm, 20.06 ± 1.97 mm, and 10.73° ± 0.84° decrease in pubic diastasis, intertriradiate distance, and iliac wing angle at 6 months postoperatively, respectively. Significant improvement was seen in the patients' urinary continence and gait compared with the preoperative values. At the final follow-up visit, 6 patients were socially dry. CONCLUSIONS: Internal fixation of the pubic arch using biodegradable plates as a biocompatible alternative to current metal fixation system offers intriguing potential for early exstrophy management. This adds a layer of security to the pubic closure, in addition to the current surgical armamentarium for bladder exstrophy.

Urethral triplication and urethrovasal reflux in 5-day-old male infant.

To present the case of a 5-day-old male infant referred to our clinic with complaints of huge swollen testes, recurrent urinary tract infection, and diarrhea. The imaging studies and surgical assessments revealed a urethrorectal fistula and 2 nonfunctional urethras. Cutaneous vesicostomy was performed urgently to avoid additional renal infection. At the age of 6 months, the anterior anal insertion was repaired by perineal access. Eventually, urethral reconstruction was performed when the boy was 3 years old. The patient was asymptomatic at the last follow-up examination without additional urinary tract infections. The combination of urethrovasal reflux and congenital urethral triplication, consisting of urethrorectal fistula, has not been previously reported.

Three-dimensional anatomy of the pelvic bone in bladder exstrophy: comparison between patients managed with osteotomy and pubic symphysis internal fixation using metal plates.

OBJECTIVES: To compare intrapelvic osseous dimensions in classic bladder exstrophy patients who underwent pelvic osteotomy and pubic symphysis internal fixation, using metal plates without osteotomy by defining intrapelvic angles and distances using three-dimensional computed tomography scan (3D-CT). METHODS: Fourteen exstrophy patients who were operated with osteotomy (OST) and 19 patients who had undergone pubic approximation using metal plates (PLT) were enrolled in this study. 3D-CT was performed to measure 8 intrapelvic angles and 9 distances. In addition, a 3D-CT image of control group of 14 age- and sex-matched patients and the preoperative data of 12 cases (6 patients in each group) were considered to compare the bony aspects of exstrophy patients before and 6 months after surgery. RESULTS: Sacroiliac joint angle, pubococcygeal angle, ischiopubic angle, pubic diastasis, and inter-triradiate distance were different from controls in both techniques. Iliac wing angle, however, was at near normal values in PLT group. The result of before-after comparison revealed significant changes in iliac wing angle, sacroiliac joint angle, and pubic diastasis in both groups. CONCLUSIONS: Our study suggests that internal fixation of pubic arch using metal plates in bladder exstrophy may be as effective as the currently accepted osteotomy-containing techniques from the standpoint of intrapelvic osseous dimensions and angles. Modification of our new pubic approximation technique is essential to better recapitulate the anatomy of the normal bony pelvis.

Biodegradable mini plate and screw: a secure method for internal fixation of symphysis pubis in animal model of pubic diastasis.

OBJECTIVES: To investigate short-term results of symphysis pubis reapproximation in a simulated animal model of pubic diastasis using biodegradable plate and screw, in comparison with animals with no fixation, in terms of inflammatory reaction, histologic changes, and three-dimensional pelvic bone CT (3D-CT) scan. METHODS: Fifteen male goats were divided in 3 groups and underwent midline pubic symphysiotomy. In GI (n = 6), the pubes were brought together with sutures through the bone and fixed by placing a biodegradable plate and screws. In GII (n = 3), symphysis was brought together by inserting sutures. Animals' pubes received no fixation in GIII (n = 6). Three-dimensional CT scan was performed, after 3 months in GII, and at the third and sixth months in GI and GIII. Furthermore, tissue-implant interface was examined for tissue reaction and implant degradation. RESULTS: Pelvic bone 3D-CT scan in the biodegradable group revealed characteristic differences in pubic diastasis, iliac wing angle, and inter-triradiate distance compared with GII and GIII. Decreases of 21.8 +/- 0.7 mm, 7.28 +/- 0.4 mm, and 7.43 +/- 1.5 degrees were observed in pubic diastasis, inter-triradiate distance, and iliac wing angle, respectively, in biodegradable group in comparison with GIII in the sixth month. Neither clinical nor histologic evidence of inflammation due to insertion of biodegradable system was reported. CONCLUSIONS: Pubic bone adaptation with biodegradable plate and screws is a safe and reliable procedure for secure anterior pubic fixation in bladder exstrophy. Easy intraoperative handling, no long-term traction, biocompatibility, and no disturbance in skeletal growth are important prerequisites for introduction of this method of pubic approximation into clinical practice.

Hypospadias repair and glans augmentation using a modified Mathieu technique.

PURPOSE: To describe a modification in Mathieu (perimeatal-based flap urethroplasty) technique that incorporates glans augmentation into the procedure and is applicable for hypospadias patients with small glans and shallow urethral grooves. PATIENTS AND METHODS: Fifty-four children with primary hypospadias and small glans underwent either the new double-faced Mathieu (DF-Mathieu) technique (33 patients) or tubularized incised plate (TIP) procedure (21 patients). DF-Mathieu perimeatal-based skin flap was meant to cover the distance from urethral orifice to the tip of the glans and flip back to fill the gap between glans wings. Patients were followed up for 20 months (12-30). TIP group underwent the conventional procedure. RESULTS: The mean age in DF-Mathieu and TIP group was 43.1 and 39.8 months, respectively. Post-operative results in DF-Mathieu group revealed one urethral fistula and no urethral break down or necrosis. In TIP group, there were one glans fistula (4.7%) and one meatal stenosis (4.7%). Overall success rate was 97% in DF-Mathieu and 90.5% in TIP operation. After 6 months, all DF-Mathieu patients had slit-like meatus and their cosmetic results were satisfactory. CONCLUSION: Double-faced Mathieu technique seems applicable in patients with shallow urethral grooves when TIP procedure may increase the risk of complications. Unlike its predecessor, this technique eliminates the tension on glans wing sutures and the risk of subsequent neo-urethral break down.