'Batman excision' of ventral skin in hypospadias repair, clue to aesthetic repair (point of technique).

OBJECTIVE: In the hypospadiac penis the ventral skin is poorly developed, while dorsal skin is redundant. The classical Byars' flaps are a way to use the excess dorsal skin to cover the penile shaft. The appearance after Byars' flaps however is not natural. We use a more natural looking skin allocation with superior aesthetic results. METHOD: The clue in this reconstruction is an inverted triangle shaped excision of ventral skin expanding over the edges of the hooded prepuce (which makes it look like Batman). After excision of the ventral skin it is possible to close the penile skin in the midline, thus mimicking the natural raphe. In case of preputial reconstruction the excised ventral skin makes the prepuce look more natural. CONCLUSION: The trend of further refining aesthetic appearance of the hypospadiac penis often neglects the penile skin reconstruction. A technique is presented by which the total penile appearances after surgery ameliorates due to better skin reconstruction.

Membrano-bulbo-urethral junction stenosis. Posterior urethra obstruction due to extreme caliber disproportion in the male urethra.

OBJECTIVE: Based on 4 cases of infravesical obstruction due to extreme caliber disproportion between the posterior urethra and the penile urethra, a pathophysiological mechanism for this dynamic obstruction is given and endoscopic treatment is described. SUBJECTS: Four cases of membrano-bulbo-urethral junction (MBUJ) stenosis, seen between September 1995 and April 1996, are described. Two boys had previous successful valve resection but still showed extreme ballooning of the posterior urethra. The other 2 boys showed bladder instability on urodynamics and the male variant of the spinning top urethra on voiding cystourethrography (VCUG). RESULTS: All cases were successfully treated by endoscopic incision at the 12 o'clock position of the kink between the posterior and the penile urethra which is seen when the full bladder is expressed. Disproportion in the posterior urethra, seen on VCUG, together with bad urinary flow measured on uroflowmetry raise the suspicion of MBUJ stenosis. CONCLUSION: Although rarely seen, extreme caliber disproportion in the male urethra can cause obstruction. Ballooning of the posterior urethra, caused by urethral valves, bladder instability resisted by voluntary sphincter contraction or congenital posterior urethral dilatation, creates an obstructive kink in the urethra comparable to some obstructions in ureteropelvic junction stenosis. If suspicion of such a form of obstruction arises, cystoscopy during pressure on the full bladder is mandatory in order to see the obstruction, descending as a membrane from the vault of the urethra.

The after-contraction in paediatric urodynamics.

OBJECTIVE: To evaluate the incidence and significance of the urodynamic registration of an after-contraction in the bladder of children. PATIENTS AND METHODS: In a prospective study, 250 children with a non-neurogenic voiding dysfunction (132 girls and 118 boys) were assessed for the occurrence of after-contractions during their video-urodynamic examination, and any filling-phase dysfunction noted. Twenty children in whom an after-contraction was recorded underwent additional voiding cystometry with three pressure transducers in the bladder (two microtip and one external transducer connected to a fluid-filled catheter). RESULTS: Of the 250 children, an after-contraction was registered in 84 (63 girls and 21 boys). Eighty of these had a filling-phase dysfunction; 51 had detrusor instability, 16 a hypersensitive bladder, six a low and seven a high compliance. Only four showed a normal cystometric pattern during filling. In the 20 children who underwent further study, the after-contraction was confirmed as a detrusor contraction, as it was registered simultaneously on three transducers of two types in 10 children and on two microtip transducers in another 10 children. CONCLUSION: The after-contraction is a frequent occurrence in children with voiding dysfunction, is related to bladder instability and is a genuine detrusor contraction.

Low-voltage coagulation for welding sutures watertight: an experimental study.

A rat model was developed to test the watertightness of sutures. In this model it was proved that welding by use of low-voltage coagulation current did not improve on the watertightness obtained with conventional skin suturing. The mean leak pressure after welding was about 4.2 cm H2O, i.e. statistically significantly lower than the mean leak pressure of the conventional suture, which is 14.1 cm H2O. Neither addition of protein solder nor an additional conventional suture improved these results. It is therefore concluded that low-voltage coagulation is unsuitable for welding tissues.