Epispadias Repair Research Articles

Long-term Kidney Outcomes in Exstrophy-Epispadias Complex: How Patients Present as Adults

ObjectiveTo characterize kidney function in patients with exstrophy-epispadias complex (EEC) at time of presentation for adult urologic care. Materials and MethodsThis was a retrospective analysis of 23 patients (ages 18-57) with EEC who presented to a single tertiary care center from 2001-2020. Kidney function was evaluated based on calculated eGFR and presence of hydronephrosis on imaging. UDS data was used to evaluate the bladder. ResultsPatients had undergone a variety of different surgical techniques for exstrophy or epispadias repair prior to presentation to an adult urologist. We found that 10 of the 23 patients had evidence of CKD Stage II or higher at the time of presentation and 7 patients had evidence of hydronephrosis on imaging. There was urodynamics data available for 14 patients, of which 8 patients showed poor (≤15 ml/cmH2O) or intermediate (15-20 ml/cmH2O) bladder compliance. ConclusionIn conclusion, some patients with EEC have evidence of kidney dysfunction at time of presentation to an adult urologist. It is important to consider this when caring for patients with EEC as adults.

Implementation of a spinal anesthesia and sedation protocol that reliably prolongs infant spinal anesthesia: Case series of 102 infants who received spinal anesthesia for urologic surgery.

The use of spinal anesthesia in infants is seeing resurgence as an alternative to general anesthesia. Our primary aims are to describe our institution's experience introducing a spinal anesthesia and sedation protocol for infants undergoing urologic surgery, to describe methods of improving prolonged anesthesia, and to describe the failure rate of spinal anesthesia in these patients. Sedation was provided for some infants with intranasal dexmedetomidine±fentanyl. This is a retrospective case series examining infants aged 1-<14months who received spinal anesthesia for circumcision, orchiopexy, orchiectomy, hypospadias repair, or epispadias repair. The electronic medical record was reviewed and compared with unmatched historical controls who received general anesthesia. A total of 230 patients underwent a urologic procedure; 102 patients received spinal anesthesia and 128 received general anesthesia. Length of surgical time with spinal anesthesia ranged from 4 to 189minutes. The hospital length of stay was shorter in the spinal anesthesia group (median [IQR] of 5.3hours [4.3, 7.2]) compared to the general anesthesia group (17.1hours [15.6, 17.5]).The median bupivacaine dose was 0.75mg/kg [0.67, 0.85]. There was one case in which cerebral spinal fluid was unable to be obtained, and one case that required conversion to general anesthesia after surgery had started. There were no cases of apnea, bleeding, infection, or neurologic compromise. We describe the successful implementation of an infant spinal anesthesia and sedation protocol and a technique that uniquely provides prolonged surgical anesthesia with a low failure rate. We also report shorter anesthesia time, surgical time, and recovery room length of stay in patients who received spinal anesthesia compared to general anesthesia.

Management and outcome in dehisced exstrophy with a simplified bladder re-closure and further reconstruction

The traditionally accepted method of bladder re closure in dehisced exstrophy involves osteotomy assisted pubic bone approximation (PBA). Continent voluntary voiding is achieved in a small proportion of children sometimes after many operative procedures. We propose a simple yet reliable method of repair of the dehisced bladder using Rectus abdominis muscle flap (RAM) instead of PBA to bridge the inter-pubic gap, followed by concomitant or subsequent bladder augmentation (BA). The aim of this study is to assess the outcome of dehisced exstrophy, using a RAM flap assisted redo closure (without PBA) with concomitant or subsequent further reconstruction. This is a retrospective analysis of children who presented with dehisced exstrophy after repair in other institutions and who have undergone redo repair using RAM flap in two tertiary care centers from 2001 to 2019. The outcome of the redo closure and subsequent or concomitant further reconstruction as regards dryness, stability of the upper tracts and resolution of vesico ureteric reflux (VUR) was studied. Fifty five children (34 boys) underwent redo exstrophy repair for dehisced exstrophy using the RAM flap. Epispadias repair was performed concomitantly in 31 boys. In 26 children (group1) of mean age 12 months further surgery was deferred while in 29 children (group 2) of mean age 69 months underwent concomitant BA. Nine group 1 children underwent BA subsequently. Ureteric reimplantation was done at the time of BA in 54 ureters, 40 into the bladder plate and rest into the bowel segment of BA. 22 ureters were not reimplanted. Bladder neck surgery including 18 bladder neck closure and Mitrofanoff port for Clean Intermittent catheterization (CIC) were done along with BA. The RAM assisted bladder closure was event free and none needed redo operation. 35/38 augmented children are dry on Mitrofanoff CIC and one unaugmented boy voids normally. The upper tracts remain stable on ultrasound and VUR has resolved in 67/76 ureters. At current follow up, after a mean period of 53 months eGFR was normal in all except 3 who had initially presented with severe hydro uretero nephrosis. We present a simple and reliable method of repair of dehisced exstrophy using RAM flap with the feasibility of concomitant BA. Dryness was achieved with stable upper tracts in 36/39 children, 27 of them with a single reconstructive attempt.

Single-staged male bladder exstrophy-epispadias complex reconstruction with pubic bone adaptation without osteotomy: 15-year single-center experience.

To represent the 15years' experience of an academic referral center for the reconstruction of bladder exstrophy-epispadias complex with a modified single-stage approach. Single-staged reconstruction techniques are commonly used for classic bladder exstrophy. However, combined bladder closure and epispadias repair have been taken into great consideration in patients with initially failed reconstruction or delayed primary closure. A total of 49 boys underwent 1-stage bladder and epispadias repair with pubic bone adaptation and without the application of pelvic osteotomy. The mean ± SD age at surgery was 5.23 ± 2.04months. Continence and social dryness were assessed in the follow-ups with 3months intervals for the first year and biannually thereafter. The mean ± SD of follow-up was 127.25 ± 71.32months. Urethrocutaneous fistula, stricture, wound infection, and hemiglans were developed in six distinct patients. However, no other major complications were noted. Three patients (6.1%) remained incontinent; while 32 (65.3%) children were socially continent and 14 (28.6%) children were waiting for toilet training. All the patients without previous failed closure were socially continent, while all incontinent patients had two failed closures in their history. No patient was rendered hypospadiac. Based on the experience of this institution, the application of single-stage reconstructive techniques can lead to continence, cosmetically pleasing appearance with promising outcomes, and reduction of overall operations, hospital stay and costs in the majority of cases as compared to multiple surgical procedures.

A case report on continent isolated male epispadias.

Epispadias is a rare congenital anomaly in which the urethral opening is on the dorsal surface of penis. Its incidence is 1 in 117000 newborn males and 1 in 484000 in newborn females. Its etiology is considered as because of failure of medial migration of mesenchyme between the ectodermal and endodermal layers of cloacal membrane due to premature rupture of cloacal membrane. Epispadias often presents as exstrophy epispadias complex, a wide spectrum of abnormalities that consist of classic bladder exstrophy, Epispadias and cloacal exstrophy. This case was not a part of exstrophy epispadias complex and it was an isolated continent epispadias which is extremely rare and it was managed with Cantwell Ransley epispadias repair technique.

Re: Use of Small Intestinal Submucosa for Corporal Body Grafting in Cases of Epispadias and Epispadias/Exstrophy Complex.

No AccessJournal of UrologyUrological Survey1 Jul 2020Re: Use of Small Intestinal Submucosa for Corporal Body Grafting in Cases of Epispadias and Epispadias/Exstrophy Complex Douglas A. CanningMD Douglas A. CanningDouglas A. Canning More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001049.04AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Re: Use of Small Intestinal Submucosa for Corporal Body Grafting in Cases of Epispadias and Epispadias/Exstrophy Complex." The Journal of Urology, 204(1), pp. 174–175 Reference 1. : Bladder exstrophy closure and epispadias repair. In: Rob and Smith’s Operative Surgery: Pediatric Surgery, 4th ed. Edited by . Boston: Butterworths 1988; pp 620–622. Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 204Issue 1July 2020Page: 174-175 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Douglas A. Canning More articles by this author Expand All Advertisement PDF downloadLoading ...

MP35-16 SURGICAL MANAGEMENT OF URETHRO-CUTANEOUS FISTULA ORIGINATING FROM THE ANTERIOR URETHRA IN ADULT MEN OVER A 10 YEAR PERIOD

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I (MP35)1 Apr 2020MP35-16 SURGICAL MANAGEMENT OF URETHRO-CUTANEOUS FISTULA ORIGINATING FROM THE ANTERIOR URETHRA IN ADULT MEN OVER A 10 YEAR PERIOD Nikki Jeffery*, Anastasia Frost, Simon Bugeja, Stella Ivaz, Mariya Dragova, Angelica Lock, Daniela Andrich, and Anthony Mundy Nikki Jeffery*Nikki Jeffery* More articles by this author , Anastasia FrostAnastasia Frost More articles by this author , Simon BugejaSimon Bugeja More articles by this author , Stella IvazStella Ivaz More articles by this author , Mariya DragovaMariya Dragova More articles by this author , Angelica LockAngelica Lock More articles by this author , Daniela AndrichDaniela Andrich More articles by this author , and Anthony MundyAnthony Mundy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000879.016AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethro-cutaneous fistula (UCF) originating from the anterior urethra in adult men is an uncommon presentation. We describe our experience in managing this problem. METHODS: We reviewed our prospective database to identify all cases of UCF repair in adult men over a 10 year period (May 2009 to May 2019), where the UCF originated from the anterior urethra. RESULTS: Our unit performed 59 surgeries for UCF repair in 55 patients (n = 52 referred from elsewhere). Most patients had a single fistulous tract (n = 43). The UCF tracked to the following locations: glans (n = 6), corona/subcorona (n = 17), distal shaft (n = 15), mid shaft (n = 11), proximal shaft (n = 7), penoscrotal (n = 7), perineum (n = 7). The causes of UCF included: prior hypospadias repair (n = 33), Prince Albert piercing (n = 5), circumcision injury (n = 6), other iatrogenic trauma (n = 4), idiopathic bulbar stricture (n = 4), prior epispadias repair (n = 2), Fournier’s gangrene (n = 1). Lichen sclerosus was present in 10 patients. Urethral stricture was present in 22 patients. Prior attempts at UCF repair had been made elsewhere in 10 patients (n = 5 with > 1 prior attempt). The surgical technique used for UCF repair depended on: i) presence of concomitant urethral stricture; ii) status of hypospadias or epispadias repair; iii) UCF size; iv) UCF location; v) quality of local tissue. Patients with no concomitant urethral stricture and no hypospadias failure were usually suitable for simple UCF excision and layered closure with dartos interposition (n = 18). Other techniques were typically used for larger UCF associated with poor quality local tissue: reopening of circumcision scar with degloving to mobilise dartos for interposition (n = 2), scrotal dartos interposition (n = 1), penile skin onlay flap (n = 1), scrotal skin onlay flap (n = 1), right inner thigh skin flap (n = 1). Patients with associated urethral stricture or failed hypospadias or epispadias repair required urethroplasty to deal with their UCF and its underlying cause (n = 31). Follow-up was available for 48 patients (n = 5 lost to follow-up, n = 2 died). Surgery was successful in 42 patients (86%) with minimum 3 months follow-up (mean 19 months). A second attempt at UCF repair was made in 4 patients with 2 successes, 1 failure and 1 lost to follow-up), giving overall success in 44 patients (94%). CONCLUSIONS: UCF originating from the anterior urethra in adult men can be managed surgically with excellent outcomes, even in re-operative cases. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e518-e518 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nikki Jeffery* More articles by this author Anastasia Frost More articles by this author Simon Bugeja More articles by this author Stella Ivaz More articles by this author Mariya Dragova More articles by this author Angelica Lock More articles by this author Daniela Andrich More articles by this author Anthony Mundy More articles by this author Expand All Advertisement PDF downloadLoading ...

V09-09 THE RICHARD GRADY MONSPLASTY

INTRODUCTION AND OBJECTIVE: Classic bladder exstrophy in the female results in an exstrophic bladder and urethra, an anterior introitus with a bifid clitoris, and short labia minora. During closure, the lower abdominal wall is closed and the bifid clitori are brought into close apposition, but are often not completely closed to prevent injury to the clitoral bodies. The lower abdominal wall is often under tension, leading to gradual spreading of the distance between the clitoral bodies. We demonstrate a vertical z plasty closure to provide a 2-layer closure of the mons that decreases tension and improves cosmetic appearance of the female external genitalia by creating a clitoral hood. METHODS: This technique was developed as part of an international collaboration focused on the repair of bladder exstrophy and epispadias. After closure of the lower abdominal fascia, 2 lateral incisions are made just superior to the clitoral bodies. The inferior edges of these incisions are re-approximated in the midline in a subcuticular fashion with absorbable monofilament suture, thus forming the deep, posterior ledge of the skin closure. Next, the superior cut edges are re-approximated in a similar fashion, creating the superior/outer ledge of the mons. This closure is then extended and joined with the abdominal skin closure. RESULTS: This technique has been used as an adjunct in newborn primary closures and in older patients who present for cosmetic revision. The extension of the mons to create a clitoral hood eliminates the appearance of a protruding bifid clitoris. There have been no wound infections, skin breakdowns, or early clitoral separations. CONCLUSIONS: The vertical Z-plasty closure of the mons creates a more normal appearance of the external genitalia of girls with bladder exstrophy and epispadias by developing a clitoral hood, while also providing a robust, multi-layer closure that decreases tension and the risk of wound dehiscence. Source of Funding: None

Urethral duplication in male children: A study of 12 cases

PurposeTo present our experience in urethral duplication focusing on detailed surgical management. MethodsWe retrospectively reviewed the records of 12 male patients treated for urethral duplication between 2005 and 2017. Evaluations included ultrasound, retrograde urethrography, cystoscopy, and voiding cystourethrography. ResultsThe age at presentation ranged from birth to 11 years. All 12 cases were classified using the Effmann classification. Case 1–4 patients with type I underwent excision of the dorsal accessory urethra by stripping technique. In case 5 patient(type IA) with two adjacent apical urethras, the septum was opened to form a single channel. Case 6 patient with type IB underwent visual internal urethrotomy near bulbous urethra to combine urethra into one channel. Five patients classified as type II (one with a type IIA1, and four with type IIA2 urethras). Urethral duplication was incidentally found during epispadias repair in case 7 patient with type IIA1, which was corrected by ventral plication, and excision of the dorsal epispadial urethra with stripping technique just below pubic bone. Case 8 patient with type IIA2 also required dorsal urethral excision with stripping technique. The two Y-type patients (case 10, 11) underwent urethrourethrostomy with a single-stage buccal mucosa tube graft, followed by repetitive surgeries owing to urethral stricture. One type III patient presented with penile inflammation and suprapubic pain, and underwent excision of both the dorsal urethra and nonfunctional anterior bladder. ConclusionsUrethral duplication requires individualized surgical approaches based on the anatomical and functional characteristics. Because prognosis is variable depending on type and accompanied anomalies, these should be taken into account when planning a comprehensive workup and surgical management. Level of evidenceLevel IV.

Penile Disassembly in Complete Primary Repair of Bladder Exstrophy: Time for Re-evaluation?

To explore a series of classic bladder exstrophy (CBE) cases referred to the authors' institution where primary closure with penile disassembly epispadias repair was complicated by penile injury. The penile disassembly technique is frequently combined with bladder closure in patients with CBE undergoing the complete primary repair of exstrophy (CPRE). Penile disassembly has been posited as a risk for penile injury by ischemic mechanisms. A prospectively-maintained institutional database of 1337 exstrophy-epispadias complex patients was reviewed for CPRE cases referred to the authors' institution, and those with injury to the penis were identified. The location, extent of injury, and subsequent management is reported. One hundred and thirteen male CBE patients were referred after prior CPRE. Twenty-six (20%) were identified with penile loss and reviewed. Eighty-one percent were closed in the neonatal period, and 54% had a pelvic osteotomy. Median follow-up time was 9.9 years (range 0.6-21.3). Of 26 patients with penile loss, 77% had unilateral loss and in 23% had bilateral loss involving the glans and/or one or both corpora cavernosa. Three patients were successfully managed with myocutaneous neophalloplasty. Complete penile disassembly during bladder exstrophy closure may lead to penile injury. This major complication questions the continued application of complete penile disassembly in the reconstruction of bladder exstrophy.

Analysis of the effect about tubularized urethral plate disassembly for one-stage midshaft epispadias repair in infant

Objective To evaluate the safety and efficacy of tabularized urethral plate disassembly for epispadias repair in infant. Methods From January 2016 to September 2018, 10 boys aged between 18 to 36 months old with mishaft epispadias were included. The main complaint was that the urethral opening was found on the dorsal side of the penis. Preoperative cystography revealed that 3 of them had unilateral vesicoureteral reflux (Grade Ⅰ), and white blood cells in routine urinary in all 10 patients were negative. Physical examination: the penis is short and flat, the width is 17-25 mm, average is 20.7 mm, the penis curvature is 15°-30°, average is 21.5°, and the urethral opening located on the dorsal side of the penis. The anesthesia method was selected for tracheal intubation, intravenous anesthesia combined with caudal anesthesia, and the surgical position was supine position. The surgical method: one stage of tabularized urethral plate disassembly urethroplasty: during the operation, the penile curve was corrected by free urethral plate and penile degloving. Two of them were unsatisfied with the correction of the curvature, and the ventral tunica folded was applicate. To avoid urethral plate ischemia, attention should pay to blood supply protection. The two corpus cavernosum are separated in the root, and the urethra is completely displaced to the ventral side of the cavernous body. The ventral side of the urethral under glans is shaped into a fissured that conforms to the anatomy. The prognosis and surgical choice of the midshaft epispadias were discussed combined with literature. Result The operation time was 130-200 min with an average of 157 mins. Intraoperative hemorrhage 5-30 ml, average is 16 ml, 1 case of glans skin was black one day after surgery, with enhanced dressing change. After 1 month, the glans was local atrophy and scar formation. No skin incision infection case. After discharge from the hospital, the follow up through the internet and outpatients for 3-40 months, average is 21 months, 2 cases with urethral fistula, more surgery to repair the fistula successfully after 6 months. The penile curvature was corrected in 8 cases, and the residual curvature of 2 cases was about 10-15°, which was temporarily observed. Patients with unilateral vesicoureteral reflux preoperatively, they still suffered from vesicoureteral reflux in the 6-12 months regular review after surgery without any intervention due to white blood cell was negative in urine routine. All cases had urinary patency and no cases with urethral stricture. Conclusion Tubularized urethral plate disassembly is a effective and simple procedure that can correct the midshaft epispadias in infant. Key words: Epispadias; Prognosis; Penis

Staged Male Bladder Exstrophy Repair

This chapter details the latest surgical advances and outcomes in the modern surgical management of male classic bladder exstrophy to include patient selection for closure, operative considerations, newborn primary bladder and posterior urethral closure, early epispadias repair, bladder neck reconstruction with an antireflux procedure, and postoperative management. It highlights how to achieve the primary objectives of (1) a secure abdominal closure, (2) reconstruction of a functional and cosmetically acceptable penis, and (3) urinary continence with the preservation of renal function. In addition, it addresses the most common pitfalls and challenges encountered when accomplishing each of the major surgical interventions. This review contains 3 figures, 5 tables, and 47 references. Key Words: Congenital defect, Bladder exstrophy, Epispadias, Reconstruction, Urinary Continence, Magnetic Resonance Imaging, Pain management, Pelvic osteotomy

Use of small intestinal submucosa for corporal body grafting in cases of epispadias and epispadias/exstrophy complex

Male epispadias is a rare congenital urogenital anomaly in which the meatus is ectopically located along the dorsal midline of the penile shaft. In cases associated with severe curvature, functional and cosmetic outcomes could be accomplished by lengthening the shorter dorsal surface with the use of corporal grafting. Various graft materials have been used in the past for hypospadias repair including tunica vaginalis, dermis, and small intestinal submucosa (SIS). The use of SIS grafting for corporoplasty during epispadias repair has rarely been described in the literature. To report the experience in the management of dorsal corporal body grafting using SIS in children with severe penile curvature due to epispadias. The authors retrospectively reviewed the charts of all patients with epispadias or bladder exstrophy/epispadias complex and severe dorsal chordee (>40°) who underwent epispadias repair with single-layer SIS for corporal body grafting. Clinical variables, surgical technique, and outcomes were analyzed. A total of nine consecutive patients underwent staged epispadias repair with dorsal corporal single-layer SIS grafting (summary figure). Of these, four (44.4%) had primary penopubic epispadias, one (11.1%) had mid-shaft epispadias, and four (44.4%) had bladder exstrophy/epispadias complex. The mean age at surgery was 13.4±6 months. After phalloplasty with SIS grafting, there were no reported complications related to the graft during the post-operative period or follow-up visits. Although traditional techniques for epispadias repair allow some degree of corporal lengthening, they also result in abrupt medial rotation of the corporal bodies leading to torqueing and potential unsatisfactory cosmetic results. In contrast, the authors use single-layer SIS for corporal body grafting, and this study technique results in a more gradual inward rotation thus allowing more anatomical accuracy. Furthermore, an advantage of the use of SIS over other grafting materials is that there is no need to harvest an autologous graft such as tunica vaginalis or dermis. Epispadias repair using single-layer SIS corporal body grafting is an effective, safe, and feasible method, which provides satisfactory cosmesis and correction of dorsal curvature in congenital epispadias in children. Furthermore, a more normal penis appearance, without a decrease in the corporal length or diameter, is achieved with this technique.

Male Epispadias Repair Surgical and Functional Results with Modified Cantwell-Ransley Procedure / Case Series Study

Male Epispadias Repair Surgical and Functional Results with Modified Cantwell-Ransley Procedure / Case Series Study

Complete penile disassembly in epispadias repair.

To report current results of complete penile disassembly technique in epispadias repair. In ten years, we have preformed 31 complete penile disassembly for proximal epispadias repair. Twenty-four patients had epispadias after primary repair of bladder exstrophy and 7 isolated penopubic epispadias. The age of the patients ranged from 10months to 6years (median 3years). The shortening of urethral plate was found in 30 patients (97% of cases), and this shortening varied between 6 and 16mm. However, in one patient we found a lengthening of the urethral plate of 8mm. The narrowing of urethral plate was found in all patients, and this narrowing varied between 30 and 50% of the width of the plate. Postoperative complications encountered in our patients were dominated by fistulas and dehiscence, particularly in patients who had bladder exstrophy-epispadias complex. After dehiscence and fistulas repair, the cosmetic results were satisfying in 25 patients (80.5% of cases) with conical glans and meatus in orthotopic position without any necrosis of the glans. However, the urinary continence ≥ 1h was observed in 6 patients (19% of cases) and only 3 patients (9.7% of cases) had a urinary continence ≥ 3h. The mean follow-up was 61 months. The complete penile disassembly remains one of the best techniques for epispadias repair. However, we noticed a reappearance of the dorsal curvature of the penis in a large number of patients treated for isolated epispadias and the impact of this technique on urinary incontinence remains uncertain.

Editorial Comment

The authors present an unusual series of patients with complaints of persistent suprapubic pain. The report details their presumptive explanation for the etiology of the discomfort and a successful treatment regimen. This observation gives urologists a reasonable plan for management of symptomatic suprapubic fluid collections in males with a history of bladder exstrophy and/or epispadias repair.

Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy

Penile ischemic injury is a reported catastrophic complication after complete primary repair of exstrophy (CPRE). Aiming to improve the bladder exstrophy-epispadias repair outcomes, the study institution adopted a modified staged exstrophy repair to incorporate the advantages of CPRE by avoiding concurrent epispadias repair and adding bilateral ureteral re-implantation and bladder neck tailoring (staged repair of bladder exstrophy with bilateral ureteral re-implantation [SRBE-BUR]) at the initial repair. It was hypothesized that such modifications minimize penile complications and prevent upper tract deterioration while enhancing bladder resistance and consequent capacity. Here, a comparative series of outcomes between CPRE and SRBE-BUR is reported. A retrospective cohort study including all exstrophy-epispadias male neonates managed in the study institution from January 2000 to December 2014 was performed. Patients were divided into those who underwent CPRE-BUR (group 1) and SRBE-BUR (group 2) (Figure). Baseline characteristics, peri-operative data, and long-term surgical outcomes were collected and analyzed for between-group comparison. Fisher exact and Mann-Whitney U tests were performed for statistical analysis. A total of 21 eligible patients were included: 10 in group 1 and 11 in group 2. Baseline characteristics were comparable. Two patients in group 1 had intra-operative penile ischemic injury (one with subsequent penile tissue loss), whereas none of the group 2 patients had intra-operative complications. No significant difference between the groups was noted for operative time; however, significantly lesser blood loss was noted in group 2. Comparable long-term surgical outcomes such as additional surgical intervention, urinary continence, bladder capacity, vesicoureteral reflux, hydronephrosis and recurrent urinary tract infections (UTIs) were noted. In addition, although subjective, better penile length and cosmesis were achieved by staging the repair (Figure). The SRBE with bilateral ureteral re-implantation is a safe alternative for the repair of the exstrophy-epispadias repair as it prevents the catastrophic complication of penile tissue loss, while having comparable long-term outcomes with the CPRE. Delaying epispadias repair avoids penile injury besides possible improvement of its overall cosmesis.

Is there a shortening of the urethral plate in complete penile disassembly used in epispadias repair, and what is its impact on the final outcomes?

PurposeTo assess the importance of shortening of the urethral plate that occurred with complete penile disassembly technique in epispadias repair and its impact on cosmetic and functional results (on urinary incontinence). MethodsFrom January 2009 to December 2016, 26 boys underwent complete penile disassembly technique for proximal epispadias repair. Twenty-one patients had epispadias after primary repair of bladder exstrophy, and 5 patients had isolated penopubic epispadias. The age of the patients ranged from 11 months to 6 years (median 3 years). ResultsAfter disassembling the penis in three parts, the shortening and narrowing of urethral plate were found in all patients; the shortening varied between 2 and 16 mm. However, in isolated epispadias, the urethral plate is easily extensible. The cosmetic results (after dehiscence and fistulas repair) were found to be satisfactory in 24 patients with conical glans and meatus in the orthotopic position without any necrosis of the glans. However, 18 patients (81.8% of cases) who initially had a bladder exstrophy presented a dehiscence or fistula. The urinary continence ≥ 1 h was observed in 5 patients (19% of cases), and only 3 patients (11.5% of cases) had a urinary continence ≥ 3 h. ConclusionsThe complete penile disassembly procedure restores the normal anatomy of the penis. Despite the shortening and narrowing of the urethral plate, the cosmetic results were good in the majority of patients. However, its functional outcomes on urinary incontinence, particularly for epispadias with bladder exstrophy, remain uncertain.

Differences in early career operative experiences among pediatric urologists

Previous research suggests that pediatric urologists feel well trained by their fellowship for cases encountered early in their career. We questioned the complexity and diversity of cases new pediatric urologists were actually performing. The aim was to identify the frequency with which newly trained pediatric urologists are performing various procedures, investigate which factors are associated with case complexity and diversity, and evaluate for differences between male and female surgeons. Case logs of urologists from July 30, 2007, to June 30, 2013, initially applying for the certifying examination who self-identified as pediatric urologists were reviewed. Data points included cases/dates, and surgeon demographics. An in-depth analysis was performed on 51 index cases from the 71 included pediatric urologists, for which a level of complexity was assigned. Compared with the bottom volume quartile, surgeons in the top quartile performed more cases of minimal (115.9±8.7 vs. 51.7±8.7, p<0.001), moderate (31.1±2.7 vs. 10.1±1.0, p<0.001) and significant (10.8±1.9 vs. 2.0±0.4, p<0.001) complexity. More than 90% logged circumcisions, orchiopexies, and inguinal hernia repairs, while less than 1.5% logged open nephroureterectomies or complete male epispadias repair. Surgeons submitted at least one of 17.2±0.5 (range 5-28) unique codes. The figure presents the percentage of current procedural terminology (CPT) codes performed by each urologist. Surgeons with the least case diversity performed a higher percentage of low-complexity cases, and lower percentages of moderate and complex cases (p<0.001). Males, comprising 60.6% of urologists, performed more cases than females (342.9±30.9 vs. 229.1±18.1, p=0.007), averaging more cases of minimal (95.0±6.6 vs. 73.3±4.6, p=0.018) and significant (6.7±1.0 vs. 2.8±0.5, p=0.005) complexity. There was no difference in cases of moderate complexity (22.0±1.9 vs. 18.1±2.1, p=0.201). In general, pediatric urologists should expect to perform many minor cases when they enter practice. Women are entering urology in increasing numbers. In our study, female urologists performed fewer cases. This could have implications for the workforce, which in urology in general is expected to decrease. Case diversity and degree of complexity vary among newly trained pediatric urologists. The urologist with the greatest case diversity never performed 45% of the 51 analyzed CPT codes, while the one with the least case diversity never performed 90% of the codes. Male surgeons performed more operations, particularly those of minimal and significant complexity. The variability in operative experience reinforces the importance of continuing education and mentorship after completion of fellowship.

MP25-02 PENILE DISASSEMBLY IN EXSTROPHY: TIME TO REEVALUATE?

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II1 Apr 2018MP25-02 PENILE DISASSEMBLY IN EXSTROPHY: TIME TO REEVALUATE? Matthew Kasprenski, Mahir Maruf, John Jayman, Karl Benz, Jason Michaud, Emily Dunn, and John Gearhart Matthew KasprenskiMatthew Kasprenski More articles by this author , Mahir MarufMahir Maruf More articles by this author , John JaymanJohn Jayman More articles by this author , Karl BenzKarl Benz More articles by this author , Jason MichaudJason Michaud More articles by this author , Emily DunnEmily Dunn More articles by this author , and John GearhartJohn Gearhart More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.839AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Epispadias repair, using the complete penile disassembly technique, is frequently combined with primary bladder closure in patients with classic bladder exstrophy (CBE). Yet, penile disassembly has been posited as a risk for penile injury by ischemic mechanisms. Herein, the authors present all CBE cases referred to their institution where primary closure with penile disassembly epispadias repair was complicated by penile injury. METHODS A prospectively-maintained institutional database of 1311 exstrophy-epispadias complex patients was reviewed for complete primary repair of CBE cases referred to the authors' institution, and those with injury to the penis were identified. The location, extent of injury, and subsequent management is reported. Triplanar magnetic resonance imaging (MRI) of the pelvis with volumetric analysis was used for penile compartment quantification. RESULTS Of the 170 CBE patients referred after a prior complete primary repair, 22 (13%) were identified with penile loss. A majority (82%) were closed in the neonatal period, and 55% had a pelvic osteotomy. Eight patients (38%) had a failed primary closure. Median follow-up time was 10 years (range 3-21). Penile injury was often unilateral (82%), and involved the glans and/or corpora cavernosa. MRI of the pelvis confirmed anterior corporal deficiency that resulted from primary closure. Three patients were successfully managed with myocutaneous neophalloplasty between the ages of 15 and 16 years old. CONCLUSIONS As a part of the primary bladder closure, penile disassembly for epispadias repair may lead to penile ischemia. In addition to reconstructive planning, MRI may be used to quantify penile injury. CBE patients with penile injury can be managed with myocutaneous phalloplasty. Because of the soft tissue loss with complete penile disassembly, it may be time to reevaluate the application of this technique in the reconstruction of bladder exstrophy. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e326 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Matthew Kasprenski More articles by this author Mahir Maruf More articles by this author John Jayman More articles by this author Karl Benz More articles by this author Jason Michaud More articles by this author Emily Dunn More articles by this author John Gearhart More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...