Use of jejunal serosal patch and pyloric exclusion in the management of complex duodenal injury.

BACKGROUND: Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of Emergency Surgery and American Association for the Surgery of Trauma favour a primary repair for less-complex injuries, but the management of more complex duodenal trauma remains controversial with varying techniques supported, including pyloric exclusion, omental or jejunal patch closure, gastrojejunostomy and pancreatoduodenectomy. We describe the techniques used in one case of complex duodenal trauma. TECHNIQUE: The duodenum is approached via a standard laparotomy with Kocherisation. Primary repair of the duodenal perforations is performed using a 3/0 polydioxanone suture (PDS), followed by mobilisation of a loop of mid-jejunum against the area of duodenal trauma over the primary repair as a jejunal serosal patch. The antimesenteric jejunal serosal border is sutured to the serosa of the duodenum (serosa only) using a 3/0 PDS. Pyloric exclusion is then performed through an anterior gastrostomy, to control the volume of gastric juice entering the duodenum. The pylorus is sutured closed using an absorbable suture followed by closure of the anterior gastrostomy using a GIA stapling device.

In-vivo regeneration of bladder muscular wall with whole decellularized bladder matrix: A novel hourglass technique for duplication of bladder volume in rabbit model.

OBJECTIVE: To determine histological aspects of decellularized bladder graft to achieve a double-sized bladder by novel hourglass technique; using rabbit models. METHODS: Sixteen rabbit bladders were decellularized and underwent laboratory investigations. After making a laparotomy incision and exposure of bladders in another 16 rabbits (partial detrusor myomectomy), they were separated into two groups. The fundus of the decellularized scaffold was anastomosed to the fundus of the native bladder via the serosal layer, and the omentum and a double-J stent were placed in the decellularized bladder by no direct contact with the urine (Group A, n=8). In group B (n=8), the bladder was augmented applying the decellularized bladder that was in contact with the urine. After 6 months, the omentum was brought out of the neck of the engineered bladder and the anastomosis was opened. Biopsies were taken at 1, 3, and 9 months postoperatively. RESULTS: Cell removal with preservation of extracellular matrix structure was confirmed in decellularized bladders. Histological examination after 1 month demonstrated few cells at the border of the grafts. After 3 months, the region of the graft was indistinguishable from the natural bladder with continuity of transitional epithelium of natural bladder on the decellularized grafted scaffolds. The organization of muscle layers was similar to native bladder muscle layers after 9 months. IHC staining markers were highly expressed after 9 months. Interestingly, bladders had a high fibrosis grade in group B compared with hourglass technique. CONCLUSION: We confirmed that decellularized bladder may be a reliable scaffold and viable material for bladder augmentation.

Surgical treatment of Peyronie's disease with autologous tunica vaginalis of testis.

BACKGROUND: To investigate the feasibility and safety of surgical treatment for Peyronie's disease (PD) by excising and repairing plaque using autologous tunica vaginalis of testis. METHODS: From March 2007 to December 2012, total 19 patients with PD underwent surgical treatment at our center. All patients had significant phallocampsis during erection. All patients complained of decreased sexual function. During the operation, the fibrotic plaque was excised and neurovascular bundle (NVB) was spared. A size-matching autologous tunica vaginalis of testis was harvested as the graft and patched to the defect. All patients received follow up every 3 months in the first year and 6 months in the following years. Data on sexual function before and after the operation was collected and compared. RESULTS: All operations were completed successfully without serious complications. The mean operative time was 74 min. The mean size of excised plaque was 3.0 cm(2). Postoperative pathological studies revealed the fibroplastic hyperplasia of excised tissue. All patients had satisfactory correction of penile appearance. The erectile penile length between pre- and post-operation didn't show significant difference. Postoperative intercourse satisfaction and overall satisfaction measured by IIEF-5 were significant improved. CONCLUSIONS: Our surgical treatment is feasible and safe for patients with PD. It can effectively improve the penile cosmetic appearance and patients' intercourse/overall satisfaction on sexual life.

Using a serosal trough for fashioning a continent catheterizable stoma: technique and outcomes.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Continent urinary diversion with bladder augmentation is an established method of providing urinary continence in children with bladder exstrophy, who are not suitable candidates or have a failed bladder neck reconstruction. Sub-mucosal implantation of the tubularized catheterizable stoma (usually the appendix) into the reservoir, with backing typically provided by either the bladder musculature or colonic taenia, is safe and highly effective in these children. In some cases of classic bladder exstrophy and in the majority of patients with cloacal exstrophy, the ileum is used for enterocystoplasty and therefore there is no taenia to back the implanted catheterizable channel. This study describes the steps for providing a reliable flap-valve mechanism for the continent catheterizable channel using the serosal trough technique. OBJECTIVES: To evaluate the efficacy and potential complications of the serosal-trough (ST) technique for the implantation of a continent catheterizable stoma (CCS) during enterocystoplasty. To describe the surgical technique and provide detailed illustrations. PATIENTS AND METHODS: Using an institutional review board-approved departmental database, children with bladder exstrophy, born after 1990, were selected, and patients who had undergone urinary diversion with a CCS created using the ST technique were identified. Demographic and technical characteristics, as well as the eventual clinical outcomes, were retrospectively reviewed. RESULTS: A total of 135 patients with urinary diversion were identified, of whom 26 (13 males) had undergone CCS implantation using the ST technique. Patients included 14 classic exstrophies, 10 cloacal exstrophies, and two epispadias. The appendix and tapered ileum were used for the creation of a CCS in 11 and 15 patients, respectively. The median (range) age at creation of a CCS was 10.7 (4.4-17.4) years. At the time of CCS creation, 21 patients underwent initial enterocystoplasty, four had repeat augmentations, and one had a CCS on a previously augmented bladder. Ileum (mean length 18 cm) was used in 24/25 augmentations and was selected owing to lack of redundant sigmoid in 52% of patients and intraoperative surgeon preference in the remaining cases. In one case of cloacal exstrophy, a hindgut remnant was used. In 24 (92%) cases, initial CCS resulted in complete continence of the catheterizable channel. After a median (range) of 2.5 (0.2-7.5) years' follow-up all patients were dry via intermittent catheterization. The CCS failed at postoperative months 6 and 21 and required complete revision in two cases. CONCLUSIONS: Using a ST to provide a strong backing for a catheterizable channel is an excellent option when a channel must be placed in the ileum, hindgut, or in an area of augmentation where muscular backing is not available. The ST technique provides a reliably catheterizable tunnel, durable continence mechanism and a good success rate when creating a CCS in combination with a urinary diversion.

Use of a duodenal serosal patch in the repair of a colon rupture in a female Solomon Island eclectus parrot.

Case Description-A 444-g (0.98-lb) 4-year-old sexually intact female Solomon Island eclectus parrot (Eclectus roratus solomonensis) was referred and evaluated for a suspected colonic obstruction. Clinical Findings-The parrot had a 3-day history of not passing feces and lack of appetite following treatment of dystocia that included percutaneous collapse of the egg and manual removal of egg fragments via the cloaca. During this procedure, a tear in the cloacal mucosa developed. The tear was repaired via a midline cloacotomy. Although clinically stable at the time of referral, the parrot became lethargic and bradycardic and had delayed crop emptying. Treatment and Outcome-A midline celiotomy and cloacotomy were performed to relieve the colonic obstruction, during which the severely distended colon ruptured. The colonic defects were closed in a simple interrupted pattern, and a serosal patch was applied by use of the adjacent duodenum. The bird recovered uneventfully from anesthesia and was passing voluminous feces with mildly increased effort within 1 hour after surgery. At 3 weeks after surgery, the parrot was passing feces with no increase in effort and had a normal appetite. Clinical Relevance-Application of a duodenal serosal patch for repair of a colon rupture was successful in this parrot. Gastrointestinal obstruction is rare in birds, but should be considered in birds that have regurgitation, decreased fecal production, and gastrointestinal dilation. Because birds lack an omentum, serosal patching with adjacent duodenum should be considered as a viable option in avian surgery.

Macroscopic and histological evaluation of tunica vaginalis dorsal grafting in the first stage of Bracka's urethroplasty: an experimental study in rabbits.

OBJECTIVE: To evaluate the use of tunica vaginalis as a dorsal free graft in the first stage of Bracka's urethroplasty in a rabbit animal model using macroscopic and histological analysis. MATERIAL AND METHODS: Surgery was performed on 16 rabbits, divided into four groups of four according to the number of weeks after surgery at which they were killed (2, 4, 8 and 12 weeks). The penile urethra was removed and only the ventral aspect of the urethra was reconstructed using a tunica vaginalis free graft dorsally fixed in the corpora cavernosa. Epithelial, inflammatory and fibrotic changes in the graft were evaluated macroscopically then histologically at the point when each rabbit group was killed. RESULTS: Macroscopic evaluation showed good graft uptake with minimal retraction (P > 0.05). Histological evaluation showed a reduction in the inflammatory process during the first 4 weeks, after which inflammation stabilized. The mesothelium was partially healed at 2 and 8 weeks with a metaplasia defined by a stratified squamous, non-keratinized lining. The grafted area was thinner than the surrounding penile skin and similar to urothelial native epithelium. CONCLUSION: Tunica vaginalis used as a free graft placed dorsally on the corpora cavernosa in the first stage of Bracka's urethroplasty shows good tissue integration and develops into a stratified non- keratinized epithelium (metaplasia) without significant retraction, despite exposure to the external environment.

Comparison between gallbladder serosal and mucosal patch in duodenal injuries repair in dogs.

BACKGROUND: One of the most challenging problems in clinical surgery is management of an extensive duodenal injury. In its management, there are limitations in using jejunal serosal patch and other conventional methods in specific conditions. This study was performed to compare treatment of large duodenal defects by a gallbladder serosal patch and the gallbladder mucosal patch in a dog as an animal model. METHODS: A duodenal defect (2 cm, about 50% of the total circumference) was created in the second portion of the duodenum in eight dogs. The animals were divided into two equal groups, with group 1 undergoing serosal patch repair and group 2 undergoing mucosal patch repair. The macroscopic and microscopic healing features of the gallbladder serosal and mucosal patch were compared. RESULTS: None of the dogs died due to surgical complications. The whole grafted area was covered by neomucosa at the end of the third week in all animals with the gallbladder serosal patch (group 1). In this group, the scar was small; no significant narrowing of lumen was noted and serosal healing was uniformly complete. In histological examination, a complete coverage of the gallbladder serosal patch by neomucosa consisting of columnar epithelium with short villous formations was observed. In mucosal patch models (group 2), complete epitheliazation, mild fibrosis, and incomplete repair were visible. In histological examination, severe inflammation was noticed too. CONCLUSION: In patients with multiple trauma affecting upper gastrointestinal tracts, use of the gallbladder serosal patch method is easy and reliable. So it may be considered in the surgical management of large duodenal defects, which cannot be repaired by available conventional methods.

Dorsal tunica vaginalis graft plus onlay preputial island flap urethroplasty: experimental study in rabbits.

OBJECTIVE: To assess the use of tunica vaginalis graft plus onlay preputial island flap in urethral reconstructive surgery in rabbits through histopathology. MATERIAL AND METHODS: We developed an experimental model of urethroplasty that resembles one-stage complex hypospadias surgery with divided urethral plate. The tunica vaginalis graft is dorsally placed to recreate the urethral plate and the internal preputial island flap is placed onlay to complete the urethroplasty. Sixteen animals were divided into four equal groups and sacrificed at 2, 4, 8 and 12 weeks after surgery, the penis being sent for histopathological evaluation. RESULTS: There were no deaths related to the procedure or wound breakdown; all rabbits voided spontaneously after surgery. Two urethrocutaneous fistulae were found. Microscopically, good tissue integration was observed, the tunica vaginalis mesothelium was gradually replaced by a more stratified epithelial lining, similar to the urothelial lining of the native urethra. The stratified squamous non-keratinized lining of the internal preputial island flap also changed into a thinner epithelial lining with only 4-5 cell layers. Two urethral diverticula were found. CONCLUSION: A tunica vaginalis graft placed dorsally plus an onlay internal preputial island flap was shown to be a successful technique for urethroplasty in an animal model.

Corporeal grafting for severe hypospadias: a single institution experience with 3 techniques.

PURPOSE: Correction of severe chordee by corporeal body grafting has been successfully performed using various grafts and biomaterials. We report a single institution comparison of our experience using small intestinal submucosa, tunica vaginalis and dermal grafts at stage 1 hypospadias repair. MATERIALS AND METHODS: A retrospective chart review was performed of the records of all patients who underwent staged hypospadias repair from 1985 to 2006 with corporeal body grafting at stage 1 with small intestinal submucosa, tunica vaginalis or dermal grafts. Age at grafting, time between stages, residual chordee at stage 2 repair and the need for additional plication or chordee correction at stage 2 were recorded. RESULTS: A total of 71 patients were identified with a median age of 10 months at stage 1 repair and a median of 7.6 months between stages 1 and 2 repair. Dermal grafts, tunica vaginalis and small intestinal submucosa grafts were used in 29, 21 and 20 patients, respectively. One patient received a combination of small intestinal submucosa and tunica vaginalis. None of the patients receiving tunica vaginalis graft required any further correction of chordee. One patient with a dermal graft and 1 receiving small intestinal submucosa required Nesbit plication at stage 2 repair for minor ventral chordee. One patients receiving small intestinal submucosa showed severe fibrosis at the graft site, requiring excision and repeat grafting with tunica vaginalis. This patient has been previously described. The 2 patients with small intestinal submucosa related complications had 4-ply grafts. We have seen no complications associated with 1-ply small intestinal submucosa. At limited followup we have not seen residual chordee after stage 2 repair. CONCLUSIONS: In a large group of children requiring corporeal grafting for severe chordee we observed successful chordee correction with 1-ply small intestinal submucosa, tunica vaginalis or dermal grafts.

Technique of anterior urethroplasty using the tunica albuginea of the corpora cavernosa.

OBJECTIVE: To describe a technique of anterior urethroplasty using the tunica albuginea of the corpora cavernosa. METHODS: We performed this technique on 99 male patients with anterior urethral stricture with follow-up at 6, 12 and 18 months. We assessed preoperative and postoperative patient satisfaction rate based on symptoms along with preoperative and postoperative urethrograms, urethrosonographies and uroflowmetry and labelled outcomes as good, fair and poor. RESULTS: Good and fair results were considered successful. The overall success rate was 95.9%. In our series of patients, the overall success rate of urethroplasty remained the same at 6 months, but decreased to 94.9% at 12 months and 88.1% at 18 months. CONCLUSION: These observations show that anterior urethroplasty by using the tunica albuginea of the corpora cavernosa produced satisfactory results and is comparable with the other techniques of urethroplasty. The merits of using the tunica albuginea for urethroplasty are local availability of tissues, so that there is no need to use anatomically and structurally dissimilar distant tissue such as the buccal mucosa, preputial, penile, or scrotal skin or Teflon grafts. It can be used in our area where most of the patients come with dyskeratotic changes in their buccal mucosa.

The tunica vaginalis dorsal graft urethroplasty: initial experience.

INTRODUCTION: Nowadays, buccal mucosa grafts are the most successful method to reconstruct bulbar urethral strictures. Dorsal placement of the graft has been recently proposed, allowing the graft to be spread fixed on the tunica albuginea of the corporal bodies overlying the stricture. The dorsal graft is ingenious and represents a useful addition to the surgical armamentarium, since it offers a better chance for graft take than does the spongiosum when the urethra is diseased and poorly vascularized. We developed an additional reconstructive option using tunica vaginalis grafts, placed dorsally, for the treatment of anterior urethral strictures. SURGICAL TECHNIQUE: A total of 11 patients with anterior urethral strictures were treated with a tunica vaginalis graft urethroplasty. The surgical technique was done as described by Barbagli. The urethra was dissected from the corpora cavernosa and rotated 180 degrees. The dorsal urethral surface was exposed and fully opened. Both the distal and proximal lumina were calibrated. The tunica vaginalis graft was sutured, splayed and quilted over the corpora cavernosa using 6-0 PDS running stitches. The left side of the urethral mucosa was sutured to the graft using 6-0 PDS sutures. A 18F silicone Foley catheter was inserted at this point. The urethra was rotated back to its original position and sutured laterally to the right side of the graft. At the end of the procedure, the graft was completely covered by the urethra. With a follow-up ranging from 7 weeks to 5 months, all patients were voiding well (uroflowmetry > 14 mL per second). CONCLUSION: This initial experience in 11 patients indicates that tunica vaginalis dorsal graft urethroplasty may be considered within the reconstructive armamentarium of genitourinary surgeons.

Outcome analysis of severe chordee correction using tunica vaginalis as a flap in boys with proximal hypospadias.

PURPOSE: There is ongoing controversy regarding optimal treatment for severe ventral curvature. It has been suggested that ventral corporeal lengthening may be associated with recurrent curvature and erectile dysfunction. To further assess these issues we reviewed our experience with ventral penile lengthening for correcting the severe ventral curvature associated with proximal hypospadias. MATERIALS AND METHODS: We reviewed the records of 38 boys with severe hypospadias and congenital ventral curvature greater than 45 degrees who were treated at our institution from 1995 to 2004 with placement of a flap or graft in the corporeal bodies to straighten the phallus. Of the patients 21 had perineal and 17 had penoscrotal hypospadias, including 22 with associated penoscrotal transposition and/or bifid scrotum and 6 with ambiguous genitalia. Testosterone stimulation before surgery was given in 11 children at surgeon discretion. RESULTS: Median age at surgery was 15 months. The urethral plate was divided in 94.7% of patients. A tunica vaginalis flap was used alone in 23 cases and associated with dura, pericardium or small intestinal submucosa in 8, 2 and 1, respectively. The remaining 4 patients underwent ventral grafting alone, including lyophilized dura in 1, pericardium in 1 and dermis in 1. Urethral reconstruction was achieved by the transverse island flap technique or 1 of its modifications in 34 children. Four boys underwent a 2-stage procedure. Followup available on 35 of 38 patients was 1 to 11 years (median 5.3). Recurrent ventral curvature in 5 of 35 patients was mild in 1 and clinically significant, requiring re-intervention, in 4. Four of 9 patients (44.4%) who underwent corporeal grafting with lyophilized dura had recurrent ventral curvature vs 1 of 23 (4.3%) who had a tunica vaginalis flap (chi-square 5.14, p = 0.02). At last followup straight erections were documented by patients and/or parents in 30 of 35 children (85.7%). CONCLUSIONS: The short-term outcome of ventral penile lengthening using tunica vaginalis flap alone for correcting severe chordee is favorable with a 95% success rate. Dural grafts were associated with a higher risk of recurrent ventral curvature compared to tunica vaginalis flaps. Although most of our patients were not yet adults, when chordee and erectile dysfunction may become apparent, we believe that tunica vaginalis flap repair is a good option for correcting severe ventral curvature.

The tunica vaginalis dorsal graft urethroplasty: initial experience

INTRODUCTION: Nowadays, buccal mucosa grafts are the most successful method to reconstruct bulbar urethral strictures. Dorsal placement of the graft has been recently proposed, allowing the graft to be spread fixed on the tunica albuginea of the corporal bodies overlying the stricture. The dorsal graft is ingenious and represents a useful addition to the surgical armamentarium, since it offers a better chance for graft take than does the spongiosum when the urethra is diseased and poorly vascularized. We developed an additional reconstructive option using tunica vaginalis grafts, placed dorsally, for the treatment of anterior urethral strictures. SURGICAL TECHNIQUE: A total of 11 patients with anterior urethral strictures were treated with a tunica vaginalis graft urethroplasty. The surgical technique was done as described by Barbagli. The urethra was dissected from the corpora cavernosa and rotated 180 degrees. The dorsal urethral surface was exposed and fully opened. Both the distal and proximal lumina were calibrated. The tunica vaginalis graft was sutured, splayed and quilted over the corpora cavernosa using 6-0 PDS running stitches. The left side of the urethral mucosa was sutured to the graft using 6-0 PDS sutures. A 18F silicone Foley catheter was inserted at this point. The urethra was rotated back to its original position and sutured laterally to the right side of the graft. At the end of the procedure, the graft was completely covered by the urethra. With a follow-up ranging from 7 weeks to 5 months, all patients were voiding well (uroflowmetry > 14 mL per second). CONCLUSION: This initial experience in 11 patients indicates that tunica vaginalis dorsal graft urethroplasty may be considered within the reconstructive armamentarium of genitourinary surgeons.

Proximal hypospadias with severe chordee: single stage repair using corporeal tunica vaginalis free graft.

PURPOSE: We report the results of corporeal tunica vaginalis free graft for single stage correction of severe chordee in children with proximal hypospadias. MATERIALS AND METHODS: A total of 18 children with proximal hypospadias and severe chordee underwent tunica vaginalis free graft for correction of chordee and urethroplasty. The graft was anastomosed to the ventral surface of the corpus cavernosum to correct severe penile curvature without dorsal plication of the corpus cavernosum. Single stage urethroplasty was then performed. In cases where the urethral plate was too short for urethral reconstruction a transverse preputial island flap was used for single stage urethroplasty. If the incised urethral plate did not have a well vascularized and supple appearance or the prepuce was not sufficient for phallic coverage, we transected the urethral plate and staged urethroplasty was done. RESULTS: Mean followup was 27.5 months. In 13 patients ventral chordee was corrected using tunica vaginalis free graft without transecting the urethral plate, and urethroplasty was performed in 1 stage. In 3 patients the urethral plate was transected and a transverse preputial island flap was used for single stage urethroplasty. In 2 patients the urethral plate was transected and interposed with dermal graft and tunica vaginalis free graft, followed by staged urethroplasty. There was mild residual chordee in 2 cases. One child had a urethrocutaneous fistula at 2 weeks postoperatively, and 1 presented with obstructive pattern uroflowmetry due to meatal stenosis. CONCLUSIONS: In this preliminary report the majority of patients with proximal hypospadias and severe chordee were successfully treated with single stage repair using tunica vaginalis free graft for correction of severe chordee.

Crural tunica albuginea autograft for corporoplasty: an experimental animal study of hemodynamic, histopathological, and molecular effects in the long term.

INTRODUCTION: Correction of penile deformity caused by Peyronie's disease by a variety of grafts varies in success. A long-term follow-up shows a significant number of graft scarring and erectile dysfunction. The clinical success of autologous crural tunica albuginea graft (TAG) has not resulted in wide application. AIM: To identify in healthy baboons the limitations and merits of autologous crural TAG over 1 year in a way difficult to pursue in humans. METHODS: Under general anesthesia, eight sexually active adult baboons underwent pharmacological cavernosometry (CM) and cavernosography. TAG from crus was implanted in the distal penile shaft. After 6 months, six animals were reevaluated and two were sacrificed, and the penises were excised. After 1 year, the remaining six animals were evaluated and sacrificed. The TAG and underlying corpus cavernosum (CC) were examined histologically and by Western blot analysis for nitric oxide synthase (NOS), neuronal (nNOS), endothelial (eNOS) and inducible (iNOS) isoforms, and transforming growth factor-beta1 (TGF-beta1). MAIN OUTCOME MEASURES: Sexual activity, CM, cavernosography, histopathology, and Western blot analysis. RESULTS: All animals resumed normal sexual activity 1 month postsurgery. Cavernous pressure was comparable before, at 6 months, and 1 year after surgery. A cavernovenous insufficiency developed in four animals at 6 months, and ceased in two at 1 year. Penile angulation (<20 degrees) was seen in three animals at 6 months, and an additional two at 1 year. Histologically, TAG was indistinguishable from the adjacent tunica with no fibrosis. In CC, iNOS and nNOS decreased at 1 year, whereas there was no change in TGF-beta1 levels. In TAG, there was no significant change in TGF-beta1 and eNOS levels, but there was a significant decrease in iNOS at 1 year. CONCLUSION: Autologous free TAG is associated with normal sexual activity, minimal hemodynamic changes, excellent histological outcome, and no rise in iNOS or TGF-beta1. However, cavernovenous insufficiency, mild penile angulation, and decreased nNOS persisted at 1 year.