Congenital bladder diverticulum presenting as bladder outlet obstruction in infants and children.

PURPOSE: Congenital primary bladder diverticulum is a rare cause of infra-vesical obstruction. We present a series of 12 cases who presented with urinary retention secondary to a large primary bladder diverticulum. The aim is to high light the diagnostic difficulties and management issues of congenital bladder diverticulae. METHODS: We reviewed the case sheets of 12 patients with congenital bladder diverticulae who presented as lower tract obstruction with or without infection at a tertiary care centre in the last 10 years. All patients had urine examinations (complete microscopic with culture), serum creatinine, ultrasonography, intravenous urogram, voiding cystourethrogram with or without cystoscopy. The cases were managed by extravesical mobilization of diverticulae, diverticulectomy, and ureteric re-implantation. All patients (aged 1-36 months, mean 16.8 months) presented with retention of urine but 4 of them had symptoms of fever, tachycardia, abdominal distension and vomiting. Serum creatinine was normal in 10 out of 12 cases, but was high in two. Urine cultures grew Escherichia coli in 5 cases. Ultrasonography showed moderate to severe hydronephrosis on the left side in 5 cases, on the right side in 4 cases and bilateral in 3 cases but diverticulae could be located in only 8 cases. Intravenous urogram revealed hydrouretero-nephrosis in 9 cases, a poor functioning kidney with hydrouretero-nephrosis in 3 cases and bilateral hydrouretero-nephrosis in 3 cases. A Voiding Cystourethrogram confirmed the diagnosis in all cases. Vesicoureteric reflux (Grade 4-5) into the ipsilateral ureter was seen in 9 children of which it was bilateral in three cases. RESULTS: All children underwent extravesical diverticulectomy with re-implantation of the ipsilateral ureter in 9 cases, bilateral in 3 cases. All had an uneventful recovery except for one who had a suprapubic leak which healed on conservative treatment. Postoperative ultrasonograms showed mild hydronephrosis in 2 cases and micturating cystourethrograms revealed a grade III V-U reflux in one case which was managed conservatively. Patients are maintaining a sterile urine culture after a follow up of 6-36 months. CONCLUSION: Primary bladder diverticulum should be kept as a differential diagnosis in cases of bladder outlet obstruction in infants and children. A carefully done voiding cystourethrogram is the hallmark of diagnosis. Good results can be achieved by diverticulectomy and primary definitive repair with ureteric re-implantation even in infants.

Dog bite injuries of genitalia in male infant and children.

The aim of the study is to highlight genital dog bites in male infant and children in developing countries and their management. We managed three cases (9 months, 5 years, and 8 years) of genital dog bite between January 1997 and July 2008. Two had unprovoked stray dog bites and the third was bitten by his pet dog when disturbed during eating. Extent of injury varied from small-lacerated wound to near emasculation. Primary repair was done after thorough washing and debridement under antibiotic cover. In the 9-month-old male infant who was near emasculated, scrotum was closed with the available skin and a small penile stump was reconstructed after meatoplasty. Immunization against tetanus and rabies was done for all cases. Postoperative recovery was uneventful, and the wound healed primarily in all cases. Parents of the infant were asked for feminizing genitoplasty but they refused so they were advised for hormonal replacement and penile reconstruction at adolescence. Male children are the most common victims of genital dog bites. These injuries can be repaired primarily with good outcome provided strict cleaning, debridement, wound repair, antibiotic cover, and immunization is applied.

Preputial reconstruction and tubularized incised plate urethroplasty in proximal hypospadias with ventral penile curvature.

AIMS: Objective of this study was to assess the feasibility and results of preputial reconstruction and tubularized incised plate urethroplasty (TIP) in patients of proximal hypospadias with ventral penile curvature. MATERIALS AND METHODS: Twenty-seven patients of proximal hypospadias who underwent preputioplasty with TIP were evaluated retrospectively. Ventral curvature was corrected by mobilization of the urethral plate with the corpus spongiosum and the proximal urethra; dorsal plication was added according to the severity of curvature. Feasibility of preputial reconstruction was assessed by applying 3 stay sutures-the first to fix the skin at the corona, the second at the junction of the inner and outer preputial skin for pulling up the skin over the glans, and the third stay on penile skin at the level of the corona for retracting the skin. Preputial reconstruction consisted of a standard 3 layered re-approximation of the margins of the dorsal hood. RESULTS: Age of the patients varied from 10 months to 21 years with an average of 6 years and 4 months. Ventral curvature (mild 10, moderate 13, and severe 4 cases) was corrected by the mobilization of the urethral plate and spongiosum in 14 patients, 11 cases had mobilization of the proximal urethra in addition and 2 patients required single stitch dorsal plication with the above-mentioned steps. Two patients developed urethral fistula and 1 had preputial dehiscence. CONCLUSIONS: Preputioplasty with TIP is feasible in proximal hypospadias with curvature without increasing the complication rate. Postoperative phimosis can be prevented by on-table testing of the adequacy of preputial skin by 3 stay sutures.

Female hypospadias with vaginal stones: a rare congenital anomaly.

OBJECTIVE: To highlight the unusual and late presentation of the rare congenital urethral anomaly of female hypospadias and its management. PATIENTS AND METHODS: We report on four cases (aged 18-65 years; mean 34 years and 3 months) of female hypospadias; two presented with urinary incontinence, recurrent UTI since birth and dyspareunia, and two were diagnosed during catheterization following retention of urine. One of the younger patients had vaginal stones. We reached the diagnosis by catheterization, voiding cysto-urethrogram and panendoscopy. A periurethral vaginal flap urethroplasty was performed in three layers with excellent results in three cases, and one patient was managed conservatively. RESULTS: Results were excellent in the three cases treated surgically. Patients were continent after urethroplasty and were happy to pass urine in a stream with complete emptying of the bladder for the first time in their life. Two of them had fertility problems due to urogenital septal defects and are undergoing appropriate treatment. CONCLUSIONS: Vaginal voiding leads to urinary stagnation in the vagina causing urinary pseudo-incontinence and vaginal stones. Early diagnosis requires a high index of suspicion.

Correction of penile torsion by mobilization of urethral plate and urethra.

OBJECTIVE: To assess the feasibility of correction of torsion by mobilization of the urethral plate with the corpus spongiosum and the proximal urethra. PATIENTS AND METHODS: Of 27 cases of congenital penile torsion, 18 had hypospadias, seven were chordee without hypospadias, and two were isolated penile torsion. Age of patients varied from 2 to 26 years (mean 6 years, 8 months). Correction of torsion was performed: (1) penile skin de-gloving; (2) mobilization of the urethral plate with the corpus spongiosum up to the corona; (3) mobilization of the proximal urethra up to the perineum; and (4) mobilization of the hypoplastic urethra/urethral plate into the glans. Tubularized incised plate urethroplasty with spongioplasty was done in cases of hypospadias, as compared to spongioplasty alone in cases of chordee without hypospadias. RESULTS: Degree of torsion varied from 45 to 180 degrees (mean 68.70); 74% of the patients had left and 26% had right penile torsion. Correction of torsion was possible by penile de-gloving (4%), mobilization of urethral plate and spongiosum (26%), mobilization of proximal urethra (22%), and mobilization of urethral plate/hypoplastic urethra with spongiosum into glans (48%). CONCLUSIONS: Extended urethral mobilization corrected penile torsion in almost all cases. The technique is simple, safe, reproducible and effective for correction of both torsion and chordee.

A new algorithm for management of chordee without hypospadias based on mobilization of urethra.

OBJECTIVE: To assess the feasibility of chordee correction by mobilization of urethra with corpus spongiosum, and define the guidelines for management of chordee without hypospadias. PATIENTS AND METHODS: We reviewed 25 cases of chordee without hypospadias, managed in 1992-2005. Age of patients ranged from 3 to 28years (mean 14.4years). Chordee correction was performed on a case-by-case basis by skin de-gloving, mobilization of divergent corpus spongiosum, mobilization of hypoplastic urethra, mobilization of proximal urethra up to bulbar urethra, dorsal plication and division/resection of hypoplastic urethra with main emphasis on mobilization of urethra, and confirmed by Gittes test. RESULTS: Chordee correction was possible by mobilization of urethra after penile degloving in 76% of cases and dorsal plication after urethral mobilization in 8%. Only 16% required division/resection of hypoplastic urethra. None of them had residual chordee in follow-up period of 6months-3years (mean of 26months). After fistula repair and internal urethrotomy in one patient each, a second surgery had 100% success. CONCLUSIONS: We propose an algorithm based on mobilization of urethra that defines the etiology and guidelines for the management of chordee without hypospadias.

Single-stage perineal urethroplasty for continence in female epispadias: a preliminary report.

OBJECTIVES: To evaluate the results of single-stage new technique of perineal urethroplasty with double breasting of the urethra and bladder neck and sphincteroplasty in female patients with epispadias. METHODS: We have treated 4 patients with severe female epispadias (male/female ratio 6:1) since 1991. They presented at the age of 3, 11, 12, and 23 years. Perineal urethroplasty with double breasting, sphincteroplasty, and genitoplasty was done in 3 cases. Cohen's cross-trigonal reimplantation with bladder neck reconstruction was done in the fourth patient who had an ectopic ureter, but the patient required perineal urethroplasty and genitoplasty because of partial incontinence. The urethral plate and bladder neck was mobilized from the surrounding tissue to the bladder neck. A urethral mucosal strip of about 5 to 10 mm was denuded from the bladder neck to the end of urethral plate on one lateral edge, and the urethral plate and urethral mucosa was tubularized over a 12F catheter. Urethroplasty was done with double breasting of the urethral muscle margins starting from inside the bladder neck downward to the neomeatus with corporoplasty, sphincteroplasty, and genital reconstruction. RESULTS: Of the 4 patients, 3 were fully continent during the day with a dry interval of 4 to 5 hours. One of the 3 patients was partially continent and had nocturnal enuresis, which responded to anticholinergic. The fourth patient with bladder neck reconstruction was partially incontinent initially but became continent after perineal urethroplasty. CONCLUSIONS: Our technique of one-stage perineal urethroplasty increases the urethral and bladder neck resistance, as well as the bladder capacity, all factors important for continence. This is a simple and effective method for the development of both continence and cosmesis in female epispadias repair.