Proximal hypospadias repair using the koyanagi-hayashi technique. A review of 15 cases.

BACKGROUND: Several surgical approaches or modifications of existing techniques have been described for the repair of hypospadias. In Sub-Saharan Africa, a two-stage approach is the preferred option in proximal cases with severe penile curvature. OBJECTIVE: The authors describe their experience with one-stage repair of proximal hypospadias with severe penile curvature using the Koyanagi-Hayashi technique. METHODOLOGY: Three hundred and ten patients were seen at the outpatient clinic from November 2009 to November 2015. All patients aged between 2 and 17 years with a confirmed diagnosis of proximal hypospadias and operated according to the Koyanagi-Hashashi technique were included in the study. RESULTS: The mean age at diagnosis was 6.7 ± 4.35 years (81 months). The level of the hypospadias was penile in 60%, scrotal 33.5%, and posterior in 6.6% of cases. The most common complications after primary repair were partial breakdown of the urethroplasty (44.8%), urethra-cutaneous fistula (3.3%), dehiscence of the glanuloplasty (22.2%), and recurrent penile curvature (11.1%). DISCUSSION: The high psychological implication of this condition in children and adolescents at the time of diagnosis in our context was a major weakness of our study. However, it turned out to be an advantage as the patients could be involved in the decision-making in as much as the previous gender was taken into consideration. CONCLUSION: A one-stage repair approach as described by Koyanagi-Hayashi also provides good aesthetic and functional outcome. It thus stands out as an alternative even in our African setting.

Mixed gonadal dysgenesis in Yaoundé: A preliminary experience about three cases.

UNLABELLED: Mixed gonadal dysgenesis is characterised by unilateral chromosomal abnormality, which is probably the result of anaphase lag during mitosis. The 45, XO/46, XY karyotype is the most common form of mosaicism involving the Y chromosome. It is a rare clinical entity with a worldwide incidence of 1.5/10,000 live births. Its epidemiology in Sub-Saharan Africa is not known. This study reports experience in the management of 3 cases at the Yaounde Gynecologic-Obstetric and Paediatric Hospital. From November 2009 to November 2014, 3 cases were successfully managed at our institution. RESULTS: All patients presented with asymmetrical gonadal differentiation. On one side of the body, a poorly-developed testicular gonad and on the other side a gonadal streak. A persistent Mόllerian remnant was equally found in the 3 cases. Management of mixed gonadal dysgenesis should be done in tertiary health care centres. A multidisciplinary team approach is recommended.

A case report of Cowper's syringocele in an 18-months old infant at the Yaoundé Gynaeco-Obstetric and Pediatric Hospital.

Syringocele or dilatation of the duct of the bulbo-urethral (Cowper's) gland is usually of congenital origin but can be acquired. It is a very rare deformity, <10 cases have been reported in literature. The main objective is to describe an additional case of syringocele of Cowper's glands and review the literature. An 18-month-old infant presented with a history of acute urinary retention 3 days after birth and a cystostomy was done. Voiding cystourethrogram was normal and cystourethroscopy showed a syringocele. Endoscopic incision was performed in our patient with satisfactory results. No complications were noted. Syringocele or cystic dilatation of Cowper's gland duct usually has a congenital aetiology. Diagnosis is confirmed by endoscopy. Treatment is by marsupialisation in the urethra by endoscopy. Syringocele is a rare pathology usually congenital. It should be suspected in all case of lower urinary tract obstruction in children.

Our experience of proximal hypospadias repair using the Cloutier-Bracka technique at the Gynaeco-Obstetric and Paediatric Hospital, Yaounde-Cameroon.

BACKGROUND: In parts of Africa, routine circumcision is practised and sometimes even on children with hypospadias. The lack of preputial foreskin renders urethroplasty more difficult and often requires to use of a mucosal graft as described by Bracka. OBJECTIVE: The authors describe their experience of hypospadias repair using Bracka's technique. MATERIALS AND METHODS: Over a period of 5 years, 100 cases of proximal hypospadias were operated in our institution. All patients aged 0-18 years who had already been circumcised were included in this study. RESULTS: The outcome of the 12 cases operated according to Bracka's technique was analysed. The mean age was 11.5 years. The ectopic meatus was penoscrotal in three cases, scrotal in one case and perineal in eight cases. After reconstruction, the new meatus was sutured at the top of the glans in one case, at the prepuce in seven cases and at the penile midshaft in one case. The main complications noted were surgical site infection, wound dehiscence, residual chordee and urethrocutaneous fistula. No neourethral stenosis nor uretrocele was recorded. DISCUSSION: The buccal mucosal graft urethroplasty as described by Bracka is associated with a lower risk of meatal strictures compared to other free mucosal grafts. The buccal mucosa is easier to harvest and causes less scarring than bladder mucosa. CONCLUSION: Repair of severe hypospadias remains a challenge for paediatric surgeons. The functional and cosmetic outcomes depend on the choice of the donor site for the graft and objective assessment of successful reconstruction criteria during follow-up.

Psychoanalytic theory and the problem of creativity.

The current crisis of psychoanalysis also involves studies of various forms of creativity. After having pointed out the need for distinction between clinical-empirical theory and hypothetical theory (such as metapsychology) the author identifies and summarizes a number of trends of investigation as reported in our literature: libidinal-energetic, contenutistic (unconscious fantasies), anthropomorphic (of the ego), aggression-reparation, phenomenological, and object-relationship approaches. The role played by metapsychological concepts (the author, in agreement with those who consider them unacceptable, discusses some of the most well-known criticisms), and the confusion between theoretical levels are responsible for having made the psychoanalytical contribution entirely unsatisfactory at a higher explanatory level and for having hindered adequate reorganization of data of an empirical nature. After having examined several elements involved in creativity (symbolism, role of pathology and body experience, etc.), the author outlines a personal theoretical hypothesis of the structural type as a basis for the establishment of a clinical-empirical theory which, as regards research on creativity too, may constitute the chief field of investigation for psychoanalysis.

[Psychoanalytic proposals for a clinical theory]. / Proposte psicoanalitiche per una teoria clinica.

The principle that increasing the collection of data through an exchange of clinical experience means scientific progress for psychoanalysis is criticized: this can be achieved only by adopting new theories or paradigms. Freudian metapsychology in an unsatisfactory theory because instead of explaining clinical data, it contrasts them but an exclusively empirical theory would limit psychoanalysis. The Author suggests to adopt and develop a structural paradigm. The concept of structure is utilized at neurophysiological level, at psychological structures level and finally in the structuralistic analysis of psychoanalytical multiple narratives. Three types of theories are considered clinically: descriptive, comprehensive (of multiple aims and meanings) and genetic. The articulation of comprehensive and genetic theories with the hypothetical theory level represented by psychological structures is being sought. This different theoretical approach will also involve differences at technical level and the Author deals with this latter aspect by referring to interpretations, transference dreams and pathology.