Penile Skin Flap Research Articles

Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap

To evaluate the clinical effect of single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap. We retrospectively reviewed the clinical database of 22 male patients with penile urethral stricture who received single-stage repair using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap from November 2015 to October 2018. All the cases had no complications, such as skin fistula. The causes of stricture included iatrogenic (14/22, 63.6%), inflammation (2/22, 9.1%) and idiopathic (6/22, 27.3%). A ventral urethrotomy was made in the segment of stricture and extended proximally and distally until the normal calibre urethra was encountered. The oral mucosa graft was secured to the corpus spongiosum in dorsal onlay fashion or underlying corpora cavernosum after resection of the severe scarred urethra. Then the prepared Orandi fasciocutaneous penile skin flap was secured to edges of corpus spongiosum or oral mucosa graft. A 16 F or 14 F Foley catheter was left in situ for a minimum of 3 weeks, at which time a urethrogram was performed to look for extravasation, and the urethroscopy was performed if necessary. Success was defined as an open urethra with Qmax≥15 mL/s and no need for further surgical intervention. all the 22 patients with a mean age of 52.6 (18-73) years underwent the combined tissue-transfer technique. The mean length of the penile urethral stricture was 5.3 (2.5-10.0) cm and the mean preoperative Qmax was 6.7 mL/s. the mean length of oral mucosa grafts and fasciocutaneous skin flaps were 5.5 (3.2-10.5) cm and 6.0 (3.5-11.0) cm, respectively. The mean operation time was 225 (150-420) minutes and the mean evaluated blood loss was 53 (20.0-110.0) mL. The grafts included buccal mucosa (19/22, 86.4%) and lingual mucosa (3/22, 13.6%). The mean postoperative Q max was 21.2 (15-32) mL/s. A case of skin fistula and 2 cases of recurrent stricture were found, so the technique success rate was 81.8% (18/22) at a mean follow-up of 20.5 (5-51) months. The perioperative complications included 2 cases of infection and skin necrosis, which healed well after conservative treatment. Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap appears to be an excellent option to repair penile urethral stricture with unsalvageable urethral plate and the penile skin is available. The present clinical series showed a successful rate of 81.8% (18/22).

Characteristics of the urethroplasty and our approach-Experience in patients with urethral stricture.

Urethral stricture is a common pathology with different etiologic factors in different age groups and societies. In our research, patients who underwent urethroplasty because of urethral stricture were evaluated in terms of etiology, localization, surgical technique and demographic characteristics. One hundred and sixty-three patients with a mean age of 53.43±16.5 years, operated between January 2008 and May 2016 because of urethral stricture were retrospectively included in the study. Diagnosis of the urethral stricture was established based on the complaints of the patient, results of urinalysis, urine culture, uroflowmetry, retrograde urethrography and/or voiding urethrography, and urethroscopy in case of need. Postoperative success for the patients was determined based on urinary flow rate and maximum flow rate of over 15 mL/sec were evaluated as success. Etiologic factors for urethral stricture included trauma in 40 (24.5%), urethral catheterization in 45 (27.6%), endoscopic procedure in 59 (36.2%), infection in 10 (6.2%), idiopathic etiologies in 9 (5.5%) out of 163 patients. Mean length of the stricture was 3.6±1.7 cm. While the indicated number of patients had buccal mucosa graft (n=73, 44.7%), penile skin flap (n=21, 12.8%), Heineke-Mikulicz repair (n=5, 3.0%), and end-to-end anastomosis (n=64, 39.1%). Mean follow-up period was 43.2±33.7 months. Buccal mucosa graft was applied as ventral (n=32, 43.8%), dorsal (n=22, 30.2%), and dorsolateral (n=14, 19.2%) onlay, and transventrally dorsal inlay (n=5, 6.8%) grafts. Average success rates were 83.5% (n=61/73) in buccal mucosa, 76.2% (n=16/21) in penile skin grafts; 85.9% (n=55/64) in end-to-end anastomosis and 80.0% (n=4/5) in Heineke-Mikulicz repair. Our assumption is that urethroplasty procedures have satisfactory long-term results, regardless of the location and size of the stenosis. According to our clinical experience, deciding on the most appropriate surgical technique by assessing each patient individually in experienced centers will increase success rates.

V78 - Penile skin flap neourethra after radical penile amputation

V78 - Penile skin flap neourethra after radical penile amputation

04: Embryologic development of the external genitalia as it relates to vaginoplasty for the transgender woman

The objective of this video is to review the development of the external genitalia and to describe our technique for performing male to female vaginoplasty for the transgender woman. In this video, we review the development of the external genitalia for males and females. We then describe the penile inversion vaginoplasty technique that creates a neovagina using a proximal scrotal-perineal flap and a distal pedicled penile skin flap. We perform male-to-female vaginoplasty accounting for the homologous embryologic structures of the male and female external genitalia. With our technique, the neoclitoris is created from the glans of the penis, which developed from the genital tubercle, and would otherwise have developed into a clitoris in a biologic female. This ensures a sensate neoclitoris. The neovestibule is created from the urethra. Both the female vestibule and the male urethra developed from the endodermal lining of the urogenital sinus. The result is a functional neovestibule that provides moisture to the neovagina. Vaginoplasty allows transgender women to have external genitalia that are functional and congruent with their gendered self.

Buccal mucosal graft versus penile skin flap urethroplasty for long segment penile urethral stricture: a prospective randomized study.

IntroductionThe aim of this study was to analyze the outcomes of dorsolateral onlay buccal mucosal graft (BMG) and ventral onlay local penile skin flap (LPF) urethroplasty in the management of long segment penile urethral stricture (PUS).Material and methodsThrough a prospective study conducted between October 2014 and May 2018, 84 patients with long segment PUS were randomly assigned to receive either dorsolateral onlay BMG (Group 1 which included 42 patients) or ventral onlay PSF urethroplasty (Group 2 which included 42 patients). The success rate and surgical outcomes were compared in both groups.ResultsThe success rate was 92.9% in Group 1 and 85.7% in Group 2 (p = 0.5). Postoperative short segment urethral stricture at the site of proximal anastomosis was reported in 3 patients in Group 1. Six patients in Group 2 were considered as a treatment failure, 3 of them due to recurrence of long segment urethral stricture after 6 months, and 3 patients developed ring urethral stricture at the site of proximal anastomosis managed by direct vision internal urethrotomy.ConclusionsOn an intermediate term follow-up, dorsolateral onlay BMG and ventral onlay LPF provide similar success rates in penile urethroplasty, with essentially comparable postoperative morbidity. However, further studies with bigger sample sizes and longer follow-up periods may be required to determine subtle differences between both techniques.

Erectile dysfunction after urethroplasty.

IntroductionThe aim of this study was to analyze the influence of urethroplasty on sexual function.Material and methodsWe analyzed 75 operations: 41 anastomotic, 13 labial graft, 6 thigh skin mesh graft, and 15 penile skin flap urethroplasties. The severity of erectile dysfunction was assessed in the International Index of Erectile Function (IIEF5) questionnaire, preoperatively and at least 3 months after the surgery. The appearance of possible penile deformities was also evaluated postoperatively.ResultsThe etiology and location of the stricture had no impact on the erectile dysfunction in men with untreated urethral stricture. The difference in mean IIEF5 score before and after the first urethroplasty was not statistically significant (12.58 ±9.01 and 10.88 ±9.28; t(42) = 1.25, p = 0.220). The length of the stricture had no impact on the preoperative and postoperative IIEF5 score. Stricture in penile urethra caused a risk of postoperative penile curvature (p = 0.023).ConclusionsPatients with urethral stricture have a higher rate of erectile dysfunction than healthy men. Proper therapy should not negatively affect erectile function in a significant way, regardless of the length or location of the stricture, though it may have some influence on the penile anatomy.

A simple procedure for management of urethrocutaneous fistula after hypospadias repair

Objective The treatment of urethral fistula is quite challenging. We tried to evaluate the results of a simple procedure in urethral fistula repair. Background A urethrocutaneous fistula is a common complication of urethroplasty. These fistulae may be caused by a variety of factors and occur in different sizes at various sites of the previous repair. Materials and methods A variety of methods have been described in the literature for the repair of urethrocutaneous fistulae with variable results. In this study of 25 cases, we have successfully repaired urethrocutaneous fistulae using perifistula non-hair-bearing penile skin flaps for their closure in the period spanning from January 2005 to December 2015. The operation consists of the creation of perifistula non-hair-bearing penile skin-based flap after marking the site. It was created with one side being kept large as compared with the other side in any direction. We mobilized the flap and the larger sized flap was folded over the tube just like a hat of a box and sutured it with the other side of the flap. We did it in only midpenile and proximal fistulas, irrespective of the size of the fistulas, whether they were small, medium or large sized. We included recurrent as well as fistula after primary repair. Results The mean age of patients was 6 years. We have successfully repaired all urethrocutaneous fistulae using our protocol with a success rate of 100%. Conclusion Flap technique is an appropriate procedure for repair of midshaft and proximal urethral fistulae of any size.

Single-stage repair of obliterated anterior urethral strictures using buccal mucosa graft and dorsal penile skin flap.

To present a single-stage repair of obliterative urethral strictures by simultaneous use of a buccal mucosa graft and longitudinal dorsal penile skin flap. Between February 2007 and October 2016, 51 patients with obliterative anterior urethral stricture underwent single-stage substitution urethroplasty. A buccal mucosa graft was harvested and fixed to the corpora cavernosa as the dorsal part of the neourethra, and a vascularized dorsal penile skin flap was created, transposed ventrally and sutured to the buccal mucosa graft to form ventral part of the neourethra. The follow-up period was 12-129months (mean 49months). The mean age of the patients was 48years (range 15-71years). The mean length of the obliterated urethral segment, measured during the operative procedure, was 5.2cm. The etiology of strictures was: unknown, hypospadias and trauma in 19, 27 and five patients, respectively. Five patients were lost to follow up, and 46 patients were analyzed for the outcome. At the end of the follow-up period, recurrence of the stricture occurred in seven (15.2%) patients, whereas 39 (84.8%) patients did not develop stricture. An additional three (6.5%) patients developed fistula, resulting in overall successful voiding in 36 (78.3%) patients. A combined buccal mucosa graft and longitudinal dorsal penile skin flap could be a good choice for one-stage substitution urethroplasty in complex obliterative urethral strictures, with an acceptable complication rate.

Changing Trends in Reconstruction of Complex Anterior Urethral Strictures: From Skin Flap to Perineal Urethrostomy

ObjectiveTo evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade. MethodsWe retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management. ResultsAmong 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%). ConclusionOver a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps.

PD63-11 CHANGING TRENDS IN RECONSTRUCTION OF COMPLEX URETHRAL STRICTURES: FROM SKIN FLAP TO PERINEAL URETHROSTOMY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III1 Apr 2018PD63-11 CHANGING TRENDS IN RECONSTRUCTION OF COMPLEX URETHRAL STRICTURES: FROM SKIN FLAP TO PERINEAL URETHROSTOMY Joceline Fuchs, Nabeel Shakir, Maxim McKibben, Jeremy Scott, Boyd Viers, Travis Pagliara, and Allen Morey Joceline FuchsJoceline Fuchs More articles by this author , Nabeel ShakirNabeel Shakir More articles by this author , Maxim McKibbenMaxim McKibben More articles by this author , Jeremy ScottJeremy Scott More articles by this author , Boyd ViersBoyd Viers More articles by this author , Travis PagliaraTravis Pagliara More articles by this author , and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2971AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although tissue transfer operations such as buccal mucosal graft (BMG) and penile skin flaps are commonly used for complex urethroplasty cases, outcomes for reconstruction of severe strictures can be unreliable. We report our evolving approach to reconstruction of complex strictures over the last decade. METHODS We retrospectively reviewed a large series of complex urethral reconstruction cases comparing three techniques: a) BMG, b) penile skin flap or c) perineal urethrostomy (PU) at a tertiary center (2007-2017) with ≥ 6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management. RESULTS Among 1129 stricture cases, 406 complex strictures were identified for this analysis (median length 4.6 cm). Reconstruction was most commonly performed using BMG urethroplasty (242/406, 59.6‰), followed by penile skin flap (85/406, 20.9‰) and PU (79/406, 19.5‰). PU use has increased steadily and significantly over the past decade, rising from 4.3‰ of case volume in 2008 to 38.7‰ of urethral reconstruction cases in 2017 (p=0.01). Over time, the proportion of complex reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized (Figure). Over a median follow-up of 52.0 months, 18.7‰ (76/406) patients failed at a median of 13.9 months. Success rates were higher following PU (92.7‰) compared to BMG and skin flaps (76.0‰ and 78.3‰, respectively) (p<0.01) despite PU patients being older (mean age 61.4 yr), having longer strictures (5.6 cm) and more commonly having LS (20.2‰). LS patients are increasingly managed with PU in our practice, with PU performed in 58.3‰ (14/24) of complex LS cases over the last 3 years, with the exception of young men who are more likely to choose attempted repair using BMG (median age BMG 46.5 yr vs. PU 60.4 yr). CONCLUSIONS Over a decade of a urethral reconstructive practice, PU is increasingly utilized for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1218 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Joceline Fuchs More articles by this author Nabeel Shakir More articles by this author Maxim McKibben More articles by this author Jeremy Scott More articles by this author Boyd Viers More articles by this author Travis Pagliara More articles by this author Allen Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V10-01 NOVEL VAGINOPLASTY TECHNIQUE: INVERSION OF PENILE SKIN AND USE OF SCROTAL GRAFT WITHOUT SACROSPINAL FIXATION

You have accessJournal of UrologyFemale Pelvic Medicine1 Apr 2018V10-01 NOVEL VAGINOPLASTY TECHNIQUE: INVERSION OF PENILE SKIN AND USE OF SCROTAL GRAFT WITHOUT SACROSPINAL FIXATION Ervin Kocjancic, Hari Vigneswaran, Laurel Sofer, Jorge Jaunarena, David Whitehead, Luca Morgantini, and Loren Schechter Ervin KocjancicErvin Kocjancic More articles by this author , Hari VigneswaranHari Vigneswaran More articles by this author , Laurel SoferLaurel Sofer More articles by this author , Jorge JaunarenaJorge Jaunarena More articles by this author , David WhiteheadDavid Whitehead More articles by this author , Luca MorgantiniLuca Morgantini More articles by this author , and Loren SchechterLoren Schechter More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2657AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The current gold standard in vaginoplasty for gender confirmation is the penile skin inversion technique. The three main challenges of this surgery are: maximal vaginal length, prevention of neovaginal prolapse and optimal cosmetic appearance. We present this video is to show our technique for vaginoplasty using scrotal graft and a modified dissection that prevents neovaginal prolapse, avoiding sacrospinal fixation. METHODS The patient was prepped in lithotomy position. A full–thickness skin graft was harvested from the scrotum, encapsulated, defatted, and sutured over a vaginal dilator. Scroto-perineal flap and penile flaps were designed and elevated, and the penis was degloved. Bilateral orchiectomy was performed. The vaginal cavity was then created using both blunt and sharp dissection with the aid of the Lowsley retractor allowing to fit a 15 x 4cm vaginal dilator. The neoclitoris was fashioned from the dorsal glans penis and dissected on the dorsal neurovascular pedicle incorporating Buck's fascia. The bulbospongiosus and ischiocavernosus muscles were resected, and the corpus spongiosum was separated from the corpora cavernosa, completely dissecting the latter. The spongiosa from the urethral bulb was then resected. Neurovascular bundle of glans was plicated and then sutured to the rectus fascia. The urethra was shortened and spatulated ventrally to create a neomeatus. The penile skin flap was then sutured to the scrotal perineal flap in a layered fashion. The scrotal skin graft was sutured to the penile flap with multiple W-plasties. The distal portion of the urethra is then used to create the vestibulum. An incision was made in this portion of the urethral plate to expose the neoclitoris. Two penrose drains were placed in the vagina. The labia majora were then closed in a layered fashion. The vagina was packed with two Sulfamylon–soaked vaginal packs and lubricating jelly. RESULTS The case took 360 minutes. EBL was 200 mL. Vaginal packing was removed on day 5, and patient was discharged on day 6. Final vaginal length was 13cm.Out of our 46 cases in the last two years, only one morbidly obese patient experienced a degree of neovaginal prolapse. CONCLUSIONS The combination of perineal flap and scrotal graft allows for a significant lengthening of the neovaginal cavity.The extended dissection of the recto-prostatic space, up to the level of the pouch of Douglas, allows for omission of sacrospinal fixation, thus reducing the risk of damage to the pudendal neurovascular bundle. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1072 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Ervin Kocjancic More articles by this author Hari Vigneswaran More articles by this author Laurel Sofer More articles by this author Jorge Jaunarena More articles by this author David Whitehead More articles by this author Luca Morgantini More articles by this author Loren Schechter More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Twin penile skin flap, is it the answer for repair of long anterior urethral strictures?

ObjectiveTo present our twin ventral penile skin flap technique for the management of complex long anterior urethral strictures not caused by lichen sclerosis (LS), with evaluation of surgical outcome and complications. Patients and methodsWe retrospectively reviewed patients diagnosed with long complex anterior urethral strictures who were all referred to Ain Shams University hospital and operated on by three reconstructive surgeons. The surgical procedure was carried out as follows: exposure of the urethra through a ventral longitudinal penile skin incision and another perineal incision; two ventral longitudinal dartos-based penile skin flaps are used for urethral augmentation as onlay flaps. Clinical data were collected in a dedicated database. Preoperative, intraoperative, and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed. ResultsBetween January 2012 and February 2015, 47 patients diagnosed by urethrograms as having long anterior urethral strictures, with a mean (SD, range) length of 17.56 (2.09; 14–21) cm, were managed by twin penile skin flap repair. Four patients were lost to follow-up, thus 43 patients constituted the study cohort. The mean (range) follow-up period was 31 (22–36) months. The overall success rate was 95.35% (41/43). At 12-months postoperatively, the 41 successful cases had a mean (SD, range) peak urinary flow rate of 20.26 (3.06, 14–25) mL/s and American Urological Association Symptom Score of 5.6 (1.85, 3–8). Postoperative complications included urethrocutaneous fistula in three patients (6.97%), mild sacculation of the flap in seven patients (16.52%), post-micturition dribbling in 34 patients (79.07%), decreased penile girth in two patients (4.65%), and chordae of <15° with no need for repair in three patients (6.97%). ConclusionsIn the presence of a favourable urethral plate and ample non-hirsute penile skin, one-stage twin penile skin flap urethroplasty provides excellent results for non-LS related complex strictures, with minimal acceptable complications. It proved to be especially efficient in circumcised patients.

Management of long segment anterior urethral stricture (≥ 8cm) using buccal mucosal (BM) graft and penile skin (PS) flap: outcome and predictors of failure.

ABSTRACTPurposeTo evaluate the surgical outcome and predictors of failure of substitution urethroplasty using either dorsal onlay buccal mucosal (BM) graft or ventral onlay penile skin flap (PS) for anterior urethral stricture ≥ 8cm.Patients and methodsBetween March 2010 and January 2016, 50 patients with anterior urethral stricture ≥ 8 cm were treated at our hospital. The surgical outcome and success rate were assessed. The predictors of failure were analyzed using multivariate analysis. Failure was considered when subsequent urethrotomy or urethroplasty were needed.ResultsDorsal onlay BM graft was carried out in 24 patients, while PS urethroplasty in 26 patients. There was no significant difference between both groups regarding patients demographics, stricture characteristics or follow-up period. One case in the BM group was lost during follow-up. Stricture recurrence was detected in 7 (30.4%) patients out of BM group while in 6 (23.1%) patients out of PS group (p value= 0.5). No significant differences between both groups regarding overall early and late complications were observed. Occurrence of early complications and the stricture length were the only predictors of failure in univariate analysis, while in multivariate analysis the occurrence of early complications was only significant.ConclusionOn short-term follow-up, both dorsal onlay BM graft and ventral onlay PS flap urethroplasty have similar success rates. However, BM graft has a potential advantage to reduce operative time and is also technically easier. The surgeon should avoid early local complications as they represent a higher risk for failure.

Substitution urethroplasty for anterior urethral stricture repair: comparison between lingual mucosa graft and pedicled skin flap

Objectives: The aim of this study was to compare the effectiveness and outcomes of lingual mucosa graft (LMG) urethroplasty versus pedicled skin flap (PSF) urethroplasty in the repair of anterior urethral strictures.Materials and methods: A retrospective study in one urological center examined 293 male patients with anterior urethral strictures who received substitution urethroplasty from 2006 to 2015. Of these, 199 patients received PSF urethroplasty and 94 received LMG urethroplasty. The causes of stricture included catheter damage, transurethral instrumentation, trauma, infection, tumor and radiotherapy. Strictures caused by lichen sclerosus, hypospadias repair or failed urethroplasty were excluded. The success rate of PSF versus LMG in different urethra positions was analyzed.Results: Overall, PSF and LMG had similar success rates (83.4% vs 85.1%, p = 0.713). In distal penile urethra, penile skin flaps and LMG achieved similar success rates (87.7% vs 82.1%, p = 0.297), but in proximal penile urethra, scrotal flaps had relatively low success rates (69.0% vs LMG 83.3%, p = 0.345) and in bulbar urethra, perineal skin flaps had significantly lower success rates than LMG (66.7% vs 92.3%, p = 0.036).Conclusion: Lingual mucosa is a good material for the repair of urethral defects and achieves results similar to or even better than those of PSF. Scrotal skin and perineal skin had lower success rates.

Use of Bipedicled Dorsal Penile Flap With Z Release Incision: A New Option in Redo Hypospadias Surgery

To solve the challenge in redo hypospadias surgery, we tried to use a bipedicled dorsal penile flap with a Z release incision in failed hypospadias cases and reported the outcome. Thirty male children with 3 or 4 previous unsuccessful hypospadias surgeries were included in our study. Our technique was done after at least 6 months from the last surgery. A flap of the dorsal penile skin was preserved and the skin lateral to the flap was dissected on each side. A small opening was done in the dartos proximal to flap. The glans was withdrawn through this opening with a ventral transposition of the flap. Z-plasty was used to compensate for the deficient dorsal skin; the Z-plasty had 3 limbs and all were made of equal length. The mean age of the patients was 5.4 ± 1.8 years and the mean follow-up was 2.1 ± 0.7 years. The technique was successful in 80%. Reoperation was required in 3 cases; all cases were managed using a 2-stage buccal mucosal graft. A small fistula at the coronal level developed in 2 cases but closed spontaneously within 1 month. All patients were voiding well and had a vertically oriented meatus at the tip of the glans and satisfactory cosmetic results. Repair of failed hypospadias using a bipedicled dorsal penile skin flap with Z release incision is a safe and simple procedure offering high success rates.

Application of combined penile and scrotum skin flap in reoperation for failed hypospadias repair

Objective To explore the application of combined penile and scrotum skin flap in the reoperation process for operation failure cases with hypospadias. Methods A retrospective analysis was performed with the inclusion of 15 failure cases with hypospadias who received combined penile and scrotal skin flap treatment for reoperation from January 2013 to December 2015 in the First Affiliated Hospital of Guangxi Medical University.These cases aged from 7 to 15 years old, with a median age of 10.2 years old.Among them, a 3rd operation was performed in 4 cases, 4th operation in 5 cases, 5th operation in 4 cases, and 6th operation in 2 cases.The procedure of Onlay island flap urethroplasty+ tubularized incised plate (Onlay+ TIP) urethroplasty was performed in 4 patients, and the other 11 cases were treated with urethral mouth basal vascular skin tube urethroplasty (Mathieu)+ TIP urethroplasty.F8 or F10 silicone balloon catheter were used as stent in new urethra, outer dressing after operation was replaced every 2 to 3 d, the outer dressing was demolished 6-8 d after operation. Results All patients were followed up after surgery until March 20, 2016, the follow-up time was 4-26 months.In these 15 patients, the success rate of operation was 86.7%(13/15 cases), among them, 3 cases were success and 1 case was failed in Onlay+ TIP group, and 10 cases were success and 1 case was failed in Mathieu+ TIP group.The patients with successful operation were with beautiful appearance of the penis, normal position of the meatus urinarius and normal urination.No peristome of urethra, urethrovaginal fistula or urethral diverticulum was found after surgery.However, urethral cracking of the glans of penis appeared in 2 operation failed patients, and the orificium urethrae externum was low-set, and urethroplasty was needed 1 year postoperatively. Conclusions For some failure cases with hypospadias showing suitable anatomy conditions, Onlay+ TIP or Mathieu+ TIP combined with penile and scrotal flap may be a good choice for the completion of reoperation. Key words: Hypospadias; Urethroplasty; Reoperation

The Selection of Procedures in One-stage Urethroplasty for Treatment of Coexisting Urethral Strictures in Anterior and Posterior Urethra

To explore selection of the procedures in one-stage urethroplasty for treatment of coexisting urethral strictures in the anterior and posterior urethra. Between 2008 and 2014, a total of 27 patients with existing strictures simultaneously at anterior urethra and posterior urethra were treated in our hospital. Two types of procedures were selected for treatment of the anterior urethral strictures. A penile skin flap and the lingual mucosa were used for augmented urethroplasty in 20 and 7 cases, respectively. Three types of procedures, namely, non-transecting end-to-end urethral anastomosis (n = 3), traditional end-to-end urethral anastomosis (n = 17), other grafts substitution urethroplasty, including pedicle scrotal skin urethroplasty (n = 2), and lingual mucosal graft urethroplasty (n = 5), were utilized in the treatment of posterior urethral strictures. The patients were mean followed up 30 months with an overall success rate of 88.9%. The majority of the patients exhibited wide patent urethras on retrograde urethrography and the patients' urinary peak flow ranged from 14.2 to 37.9 ml/s. Complications developed in 3 patients (11.1%). Of the 17 patients who underwent traditional urethral end-to-end anastomosis, urethral strictures occurred in 2 patients at 4 and 6 months after the operation. These patients achieved a satisfactory voiding function after salvage pedicle scrotal skin urethroplasty. A urethral pseudodiverticulum was observed in another patient 9 months after pedicle penile flap urethroplasty; and after a salvage procedure, he regained excellent voiding function. Synchronous anterior and posterior strictures can be successfully reconstructed with a combination of substitution and anastomotic urethroplasty techniques.

The Surgical Learning Curve for One-stage Anterior Urethroplasty: A Prospective Single-surgeon Study

BackgroundThe learning process for one-stage anterior urethroplasty has never been addressed before. ObjectiveTo evaluate the surgical learning curve for one-stage anterior urethroplasty. Design, setting, and participantsData from 641 consecutive patients treated with one-stage urethroplasty for urethral stricture were collected prospectively. All the procedures were performed by a single surgeon between 1994 and 2014. InterventionOne-stage anterior urethroplasty using substitute tissues. Outcome measurements and statistical analysisThe outcome was treatment failure, defined as any postoperative instrumentation needed including dilation. Surgeon experience was coded as the total number of one-stage urethroplasties performed by the surgeon before the operation. Multivariable Cox regression analysis was used to evaluate the association between surgeon experience and treatment failure. Covariates consisted of age, body mass index, smoking history (no, yes, ex-smoker), diabetes history (no or yes), previous surgical treatments (no or yes), stricture length, and stricture site (bulbar, penile, panurethral). Results and limitationsOverall, 546 patients (85%) were treated with one-stage oral mucosa urethroplasty; penile skin or skin flap was used in 95 patients (15%). Median follow-up among patients who did not experience surgical failure was 69 mo (interquartile range: 35–118). The failure-free survival at 5 yr was 77% (95% confidence interval [CI], 74–81). At multivariable analysis, surgeon experience was significantly associated with a lower probability of treatment failure (hazard ratio per 20 procedures: 0.98; 95% CI, 0.97–0.99; p=0.008). The surgical learning curve appeared lengthened, without reaching a plateau even after 600 procedures. ConclusionsIn this single-surgeon analysis, surgical experience has a significant impact on the probability of treatment success for one-stage urethroplasty. Better results are achieved only after a long learning curve that may not be justifiable for late-career and low-volume surgeons. Patient summaryThe probability of surgical success after one-stage urethroplasty is importantly influenced by surgeon experience. Better results are achieved only after a very long learning process.

Skin cover in epispadias repair by dorsal transposition of a ventral island flap: a modification of the Pippi Salle technique

To describe a technique for a reliable and cosmetic skin cover for epispadias repair. This is achieved using a ventral flap of prepuce and the penile skin. This is a modification of the technique described by Pippi Salle, who wrapped the penile shaft with the same flap, from one side with a resultant suture line on to the contralateral side of the penis. Thirty-five children (18 with pure epispadias and 17 with exstrophy epispadias complex) who underwent epispadias repair by the described technique in our hospital were reviewed. In our technique, a ventral flap of prepuce and penile skin, as described by Pippi Salle, is developed and a button hole is made in the dartos fascia. This button hole is utilized to deliver the shaft ventrally which effectively brings the flap onto the dorsal aspect of the penis. The skin flap is then wrapped in toto around to provide a complete cover on the penile shaft with suture line on the ventral aspect. All the 35 children had satisfactory skin cover with a scarless dorsum of penis. Two children had immediate post-operative ventral suture line breakdown, one requiring resuturing and the other healed spontaneously. The 'button hole' technique with dorsal transposition of the prepuce and skin flap effectively prevents the dorsal scar contracture by completely avoiding a longitudinal suture line dorsally. On the other hand, the healed ventral suture line is continuous with the scrotal midline raphe, giving a natural look. The overall result is a sturdy repair with a cosmetic appearance of the penis.

AB024. The penile dermal flap* for defect reconstruction in Peyronie’s disease (PD) deformities

ObjectiveGenerally speaking, historically, two main types of surgical treatments have been used to straighten penis deformity in Peyronie’s disease (PD)*: viz. (I) plication procedures; and (II) assorted graft materials to close defects in the tunica albuginea after plaque/deformity excision/release. Many different techniques have been described under each category. Curiously, flaps* (cf. free grafts), which are widely used in many other surgical applications, have hardly been tried in PD. The first description of a pedicled, epidermis-free, dermal penile skin flap for covering the tunica albuginea defect after plaque incision/excision in PD was made by this author in 1992 at the Milan ISSM meeting. In 1994, at the Singapore ISSM meeting, the penile dermal flap operation was awarded the ISSM’s prestigious biennial Herbert Newman award for best paper in original clinical research in the field of sexual health. In this talk, attention is drawn to the biological and cost advantages of having and using biological auto flaps, and it’s operative technique, advantages and long term results. S. KRISHNAMURTI: ‘Penile dermal flap for defect reconstruction in Peyronie’s disease: operative technique and four years’ experience in 17 patients.’ Int J Impotence Res (1995) 7, 195-208.’ In this presentation, the operative technique in both, circumcised and uncircumcised Peyronie’s disease patients will be shown with slides and videos.MethodsOperative technique video and PPT slides to be shown.ResultsPresented in body of talk.ConclusionsWhen available, simple, autologous local pedicled flap ideal material for PD defect closure.