Dorsal inlay inner preputial graft repair versus ventral-only preputial graft repair in primary distal penile hypospadias with narrow urethral plate.

Background: Tubularized incised plate (TIP) is the most common technique used for distal hypospadias repair with good outcome but with a high rate of urethral stricture. Inner preputial-free graft can be used as an inlay graft in the incised area of the narrow urethral plate, also can be used as an onlay graft for urethroplasty in hypospadias repair to avoid this complication. Patients and Methods: A comparative prospective randomized study was conducted on two groups of hypospadias patients with narrow urethral plate. Group A: dorsal inlay inner preputial graft repair was performed (grafted TIP [G-TIP]) and Group B: ventral onlay preputial graft repair was performed. The assessment of outcome and hypospadias objective scoring evaluation (HOSE) score was done at 2 weeks and 6 months. Results: Group A included 55 patients for whom dorsal inlay inner preputial graft repair was performed (G-TIP), and Group B which was planned to be conducted on 55 patients using onlay preputial graft (onlay graft) but was terminated after 15 cases due to high failure rate (33%). Group A showed better success rate 96% and better HOSE score (score 16) at 2 months and 6 months 83.6% and 88.2% versus 26.7% and 33.3% in Group B. Postoperative complications showed a statistically significant difference; glans dehiscence (3.6% vs. 40%), wound infection (1.8% vs. 33.3%), and skin sloughing (3.6% vs. 26.7%) in Groups A and B, respectively. Conclusion: G-TIP is a good technique for the management of distal hypospadias with narrow urethral plate with good success rate, cosmetic outcome, and with less complications compared to onlay graft.

Evaluation of erectile function after anastomotic vs substitutional urethroplasty for bulbar urethral stricture.

OBJECTIVE: To evaluate erectile function (EF) after anastomotic (AU) vs substitutional urethroplasty (SU) for bulbar urethral stricture. PATIENTS AND METHODS: This was a prospective comparative non-randomised clinical study conducted in the Department of Urology, Benha University Hospital, between September 2015 and September 2018, involving 34 male patients with urethral stricture. Preoperatively, all the patients completed the International Index of Erectile Function (IIEF)-15 (EF Domain) to establish baseline sexual function. AU was performed in 21 patients and SU in 13. The IIEF-15 (EF Domain) was administered again at 3- and 6-months postoperatively and compared to the preoperative results. RESULTS: A total of 34 patients were included in the study, 21 in the AU group with a stricture length of ≤3 cm, and 13 in the SU group with a stricture length of >3 cm. All patients were sexually active preoperatively. In the AU group, seven patients developed erectile dysfunction (ED) at 3-months postoperatively, with four of them improving during the subsequent 3 months, but three had persistent ED at 6-months postoperatively. In the SU group, two patients developed ED at 3-months postoperatively and they improved during the subsequent 3 months. In the AU group, the mean IIEF-15 (EF Domain) score was 27.6 preoperatively, which decreased to 25.6 at 6-months postoperatively; however, this was statistically insignificant (P = 0.10). While in the SU group, the mean IIEF-15 (EF Domain) score was the same before and at 6 months after SU at 27.2 (P = 1.0). CONCLUSION: At 6-months postoperatively, there was no statistically significant impact of urethroplasty for bulbar urethral stricture on erectile function.Abbreviations: AU: anastomotic urethroplasty; ED: erectile dysfunction; EF: erectile function; IIEF: International Index of Erectile Function; SU: substitutional urethroplasty.

Chronological Changes In Uroflowmetry After Hypospadias Repair: An Observational Study.

AIM: Urinary flow after urethroplasty is of paramount importance. The aim of this study is to evaluate the progression of uroflowmetry (UF) parameters after different distal and proximal hypospadias repair techniques. METHODS: In this cohort study, cases that underwent primary hypospadias repair at our institution between March 2010 and December 2018 were included when uncomplicated, asymptomatic and toilet-trained. UF findings and post void residual were described after each specific technique. RESULTS: In all, 88 patients were eligible. Time to last UF ranged from 35 to 138 months postoperatively. Significant increase started 36 months after distal tubularized incised plate urethroplasty (TIP) and afterwards than Mathieu technique. While was noticed 24 and 36 months after Onlay technique and proximal TIP, respectively; however, TIP showed steady significant increase atall time intervals. Duckett repair exhibited insignificant change in maximum flow rate (Qmax) values, buccal mucosal graft (BMG) and inner preputial graft (IPG), significant increase in the Qmax values after 6 and 24 months, respectively, then remained steady high. Transposed preputial flap (TPF) showed significant increase at 6-12 months only, then remained steady lower than the other two techniques. Obstructed flow was 37% after distal TIP, 30% after Mathieu, 25% after proximal TIP, 66.7% after Duckett repair, and 33.3% after TPF. There were no obstructed cases after BMG and IPG. DISCUSSION: Improvement by time varied between techniques. After repair most cases are below the 50th percentile, implying that the reconstructed urethra is not functioning as a normal urethra. Staged repair for proximal hypospadias is preferable to a heroic one-stage procedure. CONCLUSION: Choice of the surgical technique for hypospadias repair had impact on the improvement of Qmax values. TIP improved 36 months postoperatively. However, for proximal cases staged graft repair had earlier improvement and higher Qmax values than proximal TIP and Onlay techniques.

Pedicled preputial island flap for double functions in hypospadias surgery.

OBJECTIVE: To use the prepuce for double functions one as a second layer for the neourethra to decrease the incidence of urethrocutaneous fistula and the second as a skin covering for the ventral aspect of the penis. MATERIAL AND METHODS: From January 2013 to December 2016, 37 cases of hypospadias with mild to moderate chordee were included in this study. The cases with ventral penile skin defect were managed by tubularized incised plate urethroplasty (TIPU) using pedicled preputial flap. Recurrent cases, cases with severe chordee which necessitated division of the urethral plate, and cases with penoscrotal hypospadias were excluded from this study. RESULTS: Thirty-seven cases of hypospadias aged 9-60 months with a mean age of 24.8 months were included in this study. Coronal (n= 9 cases; 24.3%), distal penile (n=11; 29.9%), and midpenile hypospadias (n= 17; 45.9%) were detected in respective number of patients. Postoperative complications consisted of external meatal stenosis (n=2; 8.1%), and one case with urethrocutaneous fistula. Skin necrosis was not reported in this study. Follow-up visits were performed at 1, 3 and 6 months which showed good cosmetic appearance that was accepted by their parents. CONCLUSION: This technique was beneficial in decreasing the rate of skin necrosis, as it keeps the blood supply to the preputial skin intact, and decreases the incidence of urethrocutaneous fistula.

Management of refractory idiopathic overactive bladder: intradetrusor injection of botulinum toxin type A versus posterior tibial nerve stimulation.

INTRODUCTION: To compare the safety and efficacy of posterior tibial nerve stimulation (PTNS) versus an intradetrusor injection of botulinum toxin type-A (BTX-A) 100 U in the management of refractory idiopathic overactive bladder (OAB). MATERIALS AND METHODS: We randomized 60 patients with refractory idiopathic OAB to receive an intradetrusor injection of BTX-A 100 U or PTNS. We assessed the patients at baseline, 6 weeks, 3 months, 6 months, and 9 months, and determined their clinical symptoms, overall OAB symptom score, urgency score, quality-of-life score, and urodynamic study parameters. RESULTS: The two patient groups had similar baseline characteristics. After treatment, the patients in the BTX-A group had significant improvements in all parameters compared to their baseline values. Patients in the PTNS group initially had significant improvements in all parameters, but by 9 months, this was no longer true for most parameters. In general, the improvements were more significant in the BTX group, especially at 9 months. In the BTX-A group, two patients (6.6%) needed clean intermittent catheterization; 3 patients (2 women and 1 man; 10% of patients) had mild hematuria, and 2 patients (6.6%) had urinary tract infections (UTIs). In the PTNS group, local adverse effects included minor bleeding spots and temporary pain. CONCLUSIONS: Intradetrusor injection of BTX-A and PTNS are both effective to manage refractory idiopathic OAB. BTX-A is more effective than PTNS and is also durable, minimally invasive, reversible, and safe, but it also has more side effects.

A Critical Analysis of Stented and Unstented Tubularized Incised Plate Urethroplasty Through a Prospective Randomized Study and Assessment of Factors Influencing the Functional and Cosmetic Outcomes.

OBJECTIVE: To compare, functionally and aesthetically, stented and unstented tubularized incised plate urethroplasty (TIPU). In addition, predictors of repair success were investigated. MATERIALS AND METHODS: One hundred ten children with distal hypospadias were included in this study. The length and width of the urethral plate (UP) and transverse glans diameter (TGD) were measured. Patients were randomized into two groups: stented and unstented TIPU. Postoperative assessment of pain was done using Face, Legs, Activity, Cry, Consolability (FLACC) scale, and cosmetic outcome was evaluated using hypospadias objective scoring evaluation. Uroflow was assessed at 6 months in toilet-trained boys. Complications were graded by the Clavien classification system. RESULTS: In 93 cases, Face, Legs, Activity, Cry, Consolability score, hospital stay, and dressing time were in favor of the unstented group, whereas hypospadias objective scoring evaluation score and uroflow parameters were comparable. TGD and UP width varied significantly between successful and failed cases. Cutoff values of 13.5 mm and 8.5 mm for TGD and UP width, respectively, are required for successful outcome. Acute urinary retention was 12.8% after unstented repair. Detrusor spasm was 47.8% after stented and 8.5% after unstented repair. In both groups, urethrocutaneous fistula of 5.4%, glanular dehiscence of 1.1%, and meatal stenosis of 5.4% were found in cases with small TGD and narrow UP. CONCLUSION: Unstented TIPU evades the associated drawbacks of the stent along with lower postoperative pain, hospital stay, and dressing time. Even without a postoperative stent, the complication rate in infants with distal hypospadias is low, and short-term functional and aesthetic outcomes were not compromised.

High single scrotal-incision orchidopexy as the standard technique in infants aged 6-24 months.

OBJECTIVE: To prospectively investigate the effectiveness of high single scrotal-incision orchidopexy (HSSIO) for palpable undescended testis (PUDT) in infants aged 6-24 months. PATIENTS AND METHODS: From March 2012 to July 2014, 46 age range-restricted (6-24 months) infants with 57 PUDT underwent HSSIO after obtaining written consent from their parents. The exclusion criteria were ectopic, retractile testes and recurrent cases. All infants were examined before surgery in the outpatient department and after anaesthesia induction immediately before surgery. All infants had general anaesthesia with a caudal block. The operative time, intraoperative and postoperative complications, and follow-up of the infants at 0.5, 3 and 6 months were recorded and analysed. RESULTS: The mean (SD; range) operative time was 23.45 (3.28; 18-29) min. A hernia sac was found in 39 (68.4%) UDTs. For postoperative complications, only one infant developed a scrotal haematoma that was managed conservatively. The procedure was successful in 56/57 PUDT (98%). An auxiliary procedure was needed in one case, to obtain more length of the cord by extension of the incision to the external ring. CONCLUSION: HSSIO is a safe and feasible technique, with many benefits, and as such should be considered as the standard technique for orchidopexy in infants aged 6-24 months.

Standard versus tubeless mini-percutaneous nephrolithotomy: A randomised controlled trial.

OBJECTIVE: To prospectively compare the outcome of standard mini-percutaneous nephrolithotomy (SmPCNL) versus tubeless mini-percutaneous nephrolithotomy (TmPCNL) as primary treatments of renal stones. PATIENTS AND METHODS: In all, 80 patients with a solitary radio-opaque renal stone and candidates for PCNL were selected. The patients were randomly divided into two groups of 40, one group treated with SmPCNL and the other with TmPCNL. Patients and stone characters, as well as operative and postoperative data of both groups were compared and statistically analysed. RESULTS: There was no significant difference between the two groups for patient demographics and stone characteristics. There was no statistically significant difference between the two groups for the mean operative time, mean postoperative drop in haemoglobin, mean postoperative urine leakage, mean hospital stay, and stone-free rate. The mean (SD) postoperative dose of analgesia was statistically significantly higher in the SmPCNL group compared with the TmPCNL group, at 112.5 (48.03) versus 48.8 (43.5) mg, respectively. CONCLUSION: Both procedures are safe and effective for managing renal stones, without any significant difference between the two procedures; however, the postoperative analgesic requirement is significantly higher in SmPCNL.

Laparoscopic ureterolithotomy; which is better: Transperitoneal or retroperitoneal approach?

OBJECTIVE: This was a prospective study to compare the outcome of laparoscopic transperitoneal ureterolithotomy (LTU) with laparoscopic retroperitoneal ureterolithotomy (LRU) as a primary treatment for a large stone in the proximal ureter. MATERIAL AND METHODS: A total of 24 patients with a solitary, large (>1.5 cm), and impacted stone in the proximal ureter was selected and randomly divided into two groups. The first group included 13 patients who were treated by LTU, and the second group included 11 patients who were treated by LRU. Patient demographics and stone characteristics as well as the operative and postoperative data of both groups were compared and statistically analyzed. RESULTS: There was no significant difference between the two groups regarding patient demographics and stone characteristics. The mean operative time was significantly shorter in the LTU group than in the LRU group [116.2±21.8 min vs 137.3±17.9 min, respectively (p=0.02)]. The mean time to oral intake was significantly longer in the LTU group than in the LRU group [21.2±4.9 h vs 15.5±2.8 h, respectively (p=0.002)]. There was significant higher rate (27.3%) of changing to open surgery in LRU (p=0.04). The stone-free rate was significantly higher in the LTU group than in the LRU group [100% vs. 72.8%, respectively (p=0.03)]. There was no statistically significant difference between the two groups regarding the mean blood loss, mean hospital stay, mean analgesia dose, blood transfusion rate, postoperative fever, and stone migration during surgery. CONCLUSION: Both approaches of laparoscopic ureterolithotomy are effective in treating large impacted stones in the proximal ureter. LTU has significantly shorter operative time and lower rate of open conversion but has a significantly longer time to oral intake.