Prenatal Diagnosis of Concomitant Accessory Scrotum and Diphallia in the Accessory Tissues: Case Report.

A case of accessory scrotum with duplicated penis (diphallia) in a male fetus is reported because of its rarity. This case is presented with proved negative androgen receptors in the accessory genitalia. The results of excisional surgery as well as immunostaining for androgen receptors in the resected specimens are presented as well. The outcomes of prenatal ultrasonography, clinical examination of the infant, and pathologic findings of the resected accessory genitalia are also discussed.

Intermittent voiding per urethra as an indicator of cutaneous vesicostomy malfunction.

PURPOSE: To present a new approach for management of cutaneous vesicostomy (CV) prolapse, with special emphasis on normal appearing vesicostomy may be malfunctioning. To introduce the application of temporary stoma-free drainage as a diagnostic and therapeutic tool. MATERIALS AND METHODS: From December 2000 to September 2006, 66 children (61 males and 5 females) with CV were studied. The mean age at vesicostomy was 7 months (range 1-30), and the main underlying disease was posterior urethral valves (in 45 children, 68%). Indications for CV included significant hydroureteronephrosis (HUN) and recurrent urinary tract infection. Patients were followed up for complications and were treated based on our institutional approach. All patients with persistent upper tract dilatation and micturition per urethra underwent temporary bladder (via stoma) free drainage. Patients with stomal stenosis were managed either by a revision surgery or by simple dilatation and intermittent catheterization. Purse string suturing was applied in mucosal prolapses as the first choice. RESULTS: The complications were observed in 21 patients (31%), including twelve stomal stenosis, nine severe mucosal prolapses, and two recurrent urinary infections. HUN and significant voiding per urethra persisted following initial CV in 19 out of 66 patients (29%), eleven of which having normal appearing CVs. Seventeen of these patients were managed by temporary stoma-free drainage (accompanied by purse string suturing in mucosal prolapse), and two patients with severe stenosis underwent surgical revision. Temporary stoma-free drainage improved HUN in 94% of patients (16 of 17). CONCLUSIONS: Voiding per urethra is an indicator of CV malfunction, and temporary stoma-free drainage can be a diagnostic and therapeutic option in such children. A seemingly open CV may still be malfunctioning, and ureterovesical or intravesical obstructions should be considered if HUN does not improve following temporary stoma-free drainage.

Urethral hydrodistension for management of urethral hypoplasia in prune belly syndrome: long-term results.

PURPOSE: The aim of the study was to evaluate the efficacy and safety of urethral hydrodistension for management of urethral hypoplasia in prune belly syndrome (PBS). METHODS: During a 10-year period, 7 infants with PBS and urethral hypoplasia presented either with open urachus or surgically created urinary diversion referred to our hospital. Five milliliters of normal saline was pushed via a 22-gauge plastic angiocatheter into the urethra with simultaneous finger pressure on the perineum to occlude the proximal urethra that was repeated with higher volumes of the solution (up to 20 mL). The procedure was continued until a 6F or 8F feeding tube catheter confirmed the urethral patency. Hydrodistension was repeated in 3-month intervals till complete patency was confirmed by imaging. RESULTS: Median age of the infants was 6 (1-8) months. All urethral hydrodistension were successful after 1 to 3 sessions. Follow-up imaging studies showed significant improvement in all patients except one. Natural and surgically created urinary diversions were closed in 6 infants. CONCLUSIONS: The hydrodistension create an equal and constant pressure into the urethral wall without any urethral damage. This technique can be considered along with the other available methods for management of urethral hypoplasia in selected cases of PBS.

Posterior urethral valve in a child presenting as recurrent epididymo-orchitis.

Epididymo-orchitis is an uncommon complication of posterior urethral valve. A four-year-old boy was admitted because of right-sided epididymo-orchitis. Scintigraphy of the scrotum showed increased uptake of radiotracer on the right side. The posterior urethral valve was disclosed by voiding cystourethrography. Ablation of the valve and antibiotic therapy made the patient free of symptoms.

The urethral valve of Guérin and lacuna magna: clinical presentations and urodynamic findings.

We described the clinical presentations, radiological findings, urodynamic patterns and endoscopic management in a series of patients with symptomatic lacuna magna (LM). The medical records of 14 boys diagnosed as LM were reviewed, retrospectively. The presence of LM was first diagnosed based on clinical history, physical exam, and radiological findings; then confirmed by urethroscopy. Urodynamic study was performed in 10 boys before and after the procedure. Transurethral incision and fulguration of the valve was performed in all patients. The mean (range) age of patients was 3.1 years (6 months to 8 years). The boys presented with dysuria (n = 9), postvoid dribbling (n = 4), hematuria (n = 3), bloody spotting (n = 3), enuresis (n = 4), and glanular irritation and pain (n = 6). The post-operative period was uneventful in all patients. The symptoms were relieved and repeat radiological exam showed complete resolution of LM in all children by the 3rd post-surgical month. Before the procedure, main urodynamic abnormalities in children were high P(detmax) and detrusor instability that significantly improved within 3-6 months after treatment. Despite evidence suggesting that a LM is a frequent, normal anatomical variant, the valve may cause symptoms such as intermittent hematuria, dysuria, and bloody spotting of underwear. The lesion may be associated with obstructive urodynamic patterns in some children. Endoscopic treatment of patients effectively relieves the symptoms and corrects the urodynamic abnormalities.

Management of multiple failed repairs of the phallus using tissue expanders: long-term postpubertal results.

PURPOSE: We present the long-term results of our experience with application of tissue expanders for phallic reconstruction in patients with a history of multiple surgical repairs. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 16 patients who underwent penile tissue expansion for treatment of failed phallic reconstruction. The patients were 5 to 22 years old (mean age 9.9) at the time of the procedure. The original diagnoses were congenital adrenal hyperplasia (1 patient), partial penile amputation (1), epispadias (3) and proximal hypospadias (11). We used different shapes and numbers of tissue expanders according to the estimated skin augmentation requirement for final reconstructive surgery. The injection port was placed at the suprapubic area lateral to the penile base, with a small incision between the anticipated expander pouch and the reservoir. Penile tissue expanders were inflated by injections after 1 to 2 weeks postoperatively. Definitive reconstructive surgery was then planned and the tissue expander was removed at penile reconstruction at 2 to 11 months (mean 4.6) after implantation. RESULTS: Only 1 tissue expander was removed due to erosion. However, sufficient expanded skin was available for urethral reconstructions and penile skin coverage in all patients (100%). There were 2 cases of overlying penile skin redness, which resolved with temporary balloon deflation. Two patients had urethrocutaneous fistulas, which were successfully repaired later. Two additional patients required meatal dilation/urethromeatoplasty for meatal stenosis. These complications were corrected within 1 year postoperatively. After a long-term followup of 3 to 10 years (mean 6.5) as patients progressed through puberty, only 3 had mild chordee. At the end of followup acceptable cosmetic and functional results were achieved in 13 patients (81%). CONCLUSIONS: Tissue expansion is associated with few complications and good cosmetic results for phallic reconstruction in patients with minimal residual skin available for additional reconstructive efforts after repeated surgeries.

Buccal mucosal graft in repeat urethroplasty.

INTRODUCTION: Our aim was to evaluate the efficacy of a tubed buccal mucosal graft in repeat urethroplasty for patients with urethral stricture and failed previous operations. MATERIALS AND METHODS: Ten patients (aged 12 to 47 years) with urethral stricture were entered into the study. All had a history of failed previous urethroplasties, and 5 had failed internal urethrotomies, too. Repeat urethroplasties were performed by excising the fibrous tissue around the stricture; buccal mucosa was then harvested from the inner cheek, made into graft tubing, and interposed into the defect. The patients were followed at 1, 6, and 12 months. RESULTS: The procedure was technically successful in all the patients. The mean operative time was 150 minutes. The stricture sites were in the posterior urethra in 8 and the anterior urethra in 2 patients. The mean urethral defect length was 4.9 cm. The primary etiology was pelvic fracture in 7 patients. Strictures recurred postoperatively in 3 patients, all of whom had a urethral defect longer than 5 cm, and 2 of whom had more than 1 previous failed urethroplasties (compared with 1 out of 7 in the successful cases). Urinary flow rate increased significantly (from 0 to 10.4 +/- 7.33 mL/s) postoperatively (P = .018). Longer strictures produced significantly poorer graft urethroplasty outcomes (P = .001). CONCLUSION: Urethroplasty with buccal mucosal grafts is tough, resilient, easy to harvest, and leaves no scar. It appears to be an optimal substitute for anterior and posterior urethral strictures longer than 3 cm.