Penopubic Epispadias Research Articles

Epispadias in boys with an intact prepuce

ObjectiveTo present an overview of the clinical presentation and pathological anatomy, and the results of surgical correction of 7 cases of epispadias with intact prepuce; a rare condition that has only occasionally been reported in literature. Patients and methodsA retrospective search was performed in the surgical and diagnoses database between 1991 and 2011. Seven cases of epispadias with intact prepuce were identified. Five presented as a webbed and buried penis, 1 as phimosis and 1 with suspicion for congenital anomaly of the genitalia. ResultsIn 3 of 7 cases, epispadias was suspected or diagnosed at first presentation and could be surgically corrected in the first intervention. In the other 4 cases, epispadias was discovered during surgery, requiring an additional intervention to perform epispadias repair in 3 cases. One boy was diagnosed with glandular, 3 with coronal, 1 with shaft and 2 with penopubic epispadias. Epispadias repair was successful with regard to cosmesis and erectile function. Five patients developed normal continence after surgery, 1 after intensive urotherapy. An under average penile length was the main reported problem during follow-up. ConclusionIn the diagnostic process for a concealed penis, the possibility of epispadias should be considered. If epispadias is suspected or confirmed, epispadias repair can occur in the first intervention, reducing the number of additional interventions. Epispadias with intact prepuce appears to have a better prognosis concerning urinary continence compared to classical epispadias.

Complete Penile Disassembly for Epispadias Repair in Postpubertal Patients

To present the outcomes of complete penile disassembly in 14 postpubertal patients. Complete penile disassembly is widely used for epispadias repair. From July 2001 to May 2008, a total of 14 postpubertal patients underwent complete penile disassembly epispadias repair. The median age at surgery was 18 years (range 14-34). Of the 14 patients, 3 patients had isolated penopubic epispadias (all with failure of previous repairs) and 11 had bladder exstrophy with no previous attempts at epispadias repair. Of the 11 patients with exstrophy, 6 had undergone previous cystectomy and rectal diversion and 5 had undergone bladder neck closure, ileocystoplasty, and creation of a continent outlet. A urethral stent was used only for patients with isolated epispadias. The first postoperative follow-up examination was at 6 weeks. Later, the patients were followed up every 3 months for 1 year. All patients had an orthotopic meatus. However, the short urethral plate was lengthened with a penile skin flap in 5 (36%) of the 14 patients to achieve an orthotopic meatus. No patient had glans/corporal ischemia. All patients had normal conical symmetric glans/corpora. Of the 3 patients undergoing redo surgery, 1 had sloughing of the distal neourethra and ended up with a coronal hypospadias. All 11 de novo patients had an orthotopic meatus with no fistula, stenosis, or dehiscence. All neourethras were easily calibrated with a 14F sound. All patients had normal straight erections with normal forward ejaculation. Complete penile disassembly is safe and effective surgery for epispadias repair in postpubertal patients. Lengthening of the urethral plate with a penile skin flap was required in one third of patients. The erection/ejaculatory functions were preserved in all patients.

Complete Penile Disassembly (CPD) for Epispadias Repair in Postpubertal Patients

Purpose CPD is widely utilized for epispadias repair. Herein, the outcome of such technique in 14 post pubertal patients is presented. Material and Methods Between July 2001 and May 2008, a total of 14 post pubertal patients underwent CPD epispadias repair. Mean age at surgery was 18.9 years (range 14-34). Eleven patients were born with bladder exstrophy. Six patients had previous cystectomy and rectal diversion with no epispadias repair. The remaining 5/11 exstrophy patients had bladder neck closure, ileocystoplasty and continent outlet. The remaining 3/14 patients had isolated penopubic epispadias and all underwent previous failed epispadias repairs. Urethral stent was used for patients with isolated epispadias. The first postoperative follow-up was at 6 weeks. Later patients were followed every 3 months for one year. Results All patients had an orthotopic meatus intra-operatively. However, the short urethral plate was augmented with a penile skin flap in 5/14(36%) patients. No patient had glans/corporal ischemia. All patients had normal conical symmetrical glans/corpora. One, redo, patient had sloughing of the distal neourethra and ended up with a coronal hypospadias. All the remaining 13/14 (93%) patients had orthotopic meatus with no fistula, stenosis, or dehiscence. All neourethras were easily calibrated with 14F sound. All patients had normal straight erections with normal forward ejaculation. Conclusions CPD is safe and effective for epispadias repair in post pubertal patients. Augmentation of the urethral plate with a penile skin flap is required in one third of patients. With careful dissection, the erection/ejaculatory functions are preserved in all patients.

Outcome Analysis of Isolated Male Epispadias: Single Center Experience With 33 Cases

We review our results with isolated male epispadias repair, comparing the Cantwell-Ransley and Mitchell-Bagli procedures in regard to continence status and postoperative complications. We reviewed the charts of 33 patients presenting with isolated epispadias (glanular in 3, penile in 9, penopubic in 21) between 1994 and 2005. Of the 21 patients with penopubic epispadias Cantwell-Ransley repair was performed in 14 and Mitchell-Bagli repair was done in 7. Mean patient age at epispadias repair was 16.8 months (range 12 to 24) and 19.3 months (9 to 42) for the Cantwell-Ransley and Mitchell-Bagli operations, respectively. After epispadias repair in the Mitchell-Bagli group 4 of 6 patients (67%) became continent vs 0 of 13 in the Cantwell-Ransley group (p <0.01). Bladder neck repair was performed in 11 of 13 children (85%) who underwent a Cantwell-Ransley repair. Of these 11 boys 6 became continent. Hence, 3 of the 5 patients who failed the first bladder neck repair underwent a second bladder neck repair with augmentation cystoplasty to achieve dryness (dry more than 4 hours). The other 2 patients are on clean intermittent catheterization and have 2 to 4-hour dry intervals. After undergoing a Mitchell-Bagli epispadias repair 2 patients (33%) remained incontinent and went on to receive endoscopic injection of bulking agent to become dry. Mean followup was 70 months (range 10 to 120) for Mitchell-Bagli repair and 80 months (21 to 144) for Cantwell-Ransley repair. At last followup 13 of 17 children (76%) with penopubic epispadias were completely dry or had dry intervals greater than 4 hours. Among the 21 patients 10 (48%) had complications, of whom 8 were in the Cantwell-Ransley group (57%) and 2 were in the Mitchell-Bagli group (29%). Similar urinary continence rates can be achieved for male penopubic epispadias with both surgical techniques, at the expense of more bladder neck repairs following the Cantwell-Ransley procedure.

Mitchell′s technique for epispadias repair: Our preliminary experience

<b>Aim:</b> We present here experience of a single surgeon with Mitchell's procedure for correction of epispadias.<br><b> Materials and Methods:</b> Nine boys (mean age 5½ years, range 9 months to 16 years) underwent Mitchell's repair in Department of Pediatric Surgery over a period of 5½ (September 1999 to March 2005) for correction of epispadias. Six of these patients had come for the second stage of exstrophy-epispadias repair after primary bladder closure; the other three had incontinent penopubic epispadias. <br><b> Results:</b> The penis was cosmetically acceptable as regards to size, glans shape and peno-pubic angle in all the patients. However, there was a high incidence of penopubic fistula (44%). These patients with penopubic fistula also required postoperative urethral dilatations, at times repeated. One of the common factors to these subset patients was their younger age when Mitchell's urethroplasty was performed. <br><b> Limitations:</b> The series is descriptive in nature, short in numbers and does not provide statistical comparison of Mitchell's procedure with the previously done procedures. <br><b> Conclusions:</b> Mitchell's complete penile disassembly technique for epispadias repair is more acceptable anatomical procedure that results in near-pendulous penis. However, when performed at young age, it is fraught with the complication of penopubic fistula similar to that as seen with Cantwell-Ransley's procedure. Mitchell's procedure creates a hypospadiac meatus initially and the meatal advancement is required as for any other distal penile/coronal hypospadias.

A ventral rotational skin flap to improve cosmesis and avoid chordee recurrence in epispadias repair.

To describe a technical modification that facilitates dorsal skin closure, improves cosmesis and eliminates chordee recurrence secondary to contracture of the dorsal penile skin in the repair of epispadias. Eleven patients with penopubic epispadias (mean age 1.8 years) had the epispadias repaired using a modified ventral penile skin flap. Four patients had isolated epispadias and seven had had a previous primary closure of bladder exstrophy. Nine patients underwent the Cantwell-Ransley technique, leaving the meatus in a glanular position. Two patients were repaired using the penile disassembly technique of Mitchell and Bägli, because they had a short urethral plate. A ventral island skin flap was fashioned, starting at the base of the penis. Dissection was carried ventrally into the scrotum to allow for adequate dorsal flap transposition. The flap was rotated laterally to shift the suture line from the midline and to cover the dorsal aspect of the penis with untouched penile shaft skin. Redundant ventral foreskin was discarded. All patients had an uneventful course after surgery. Dorsal penile skin was viable in every case and no patient developed recurrence of chordee or a urethrocutaneous fistula. The cosmetic result was excellent in all patients. Dorsal skin closure using lateral rotation of ventral penile skin flap improves cosmesis after epispadias repair and eliminates the recurrence of chordee secondary to midline dorsal scarring.

Endoscopic treatment of urinary incontinence in pediatric patients: 2-year experience with dextranomer/hyaluronic acid copolymer.

We investigated the effectiveness of dextranomer/hyaluronic acid copolymer (dextranomer microspheres in sodium hyaluronan solution) as a treatment for urinary incontinence due to sphincter incompetence in children and adolescents. Patients with urinary incontinence due to neurogenic and structural causes were given a transurethral injection of dextranomer/hyaluronic acid copolymer to increase bladder outlet resistance. Patients were assessed at 1, 3, 6, 12 and 24 months after injection using a validated questionnaire, 1-hour pad test, ultrasonography, cystography and cystometry. Patients who remained incontinent were offered repeat injections of dextranomer/hyaluronic acid copolymer up to a maximum of 3 injections. A total of 16 patients 8 to 22 years old were treated with dextranomer/hyaluronic acid copolymer, including 3 with neurogenic bladder, 8 with bladder exstrophy after 3-stage reconstruction, 4 with penopubic epispadias and 1 with urogenital sinus. Mean volume injected was 2.8 ml. (range 1.8 to 4.0) and mean number of injections received was 2.3 per patient. Dry time interval increased by 43 minutes (p <0.05) and functional bladder capacity increased by 34 ml. (p <0.05) at 6 months after treatment compared with pretreatment values. Improvement in both parameters was maintained at 12 months. At 6 and 12 months of followup 12 (75%) and 8 (50%) patients reported improvements in daytime and nighttime dryness, respectively. A slight decrease in continence parameters was observed in the 13 patients who completed the 24-month followup. No adverse events were reported and no upper urinary tract deterioration was observed as a consequence of endoscopic treatment within the 2-year followup period. Use of dextranomer/hyaluronic acid copolymer as a bulking agent to increase bladder outlet resistance improves symptoms in children and adolescents with incontinence of neurogenic and nonneurogenic origin.

Endoscopic Treatment of Urinary Incontinence in Pediatric Patients: 2-Year Experience with Dextranomer/Hyaluronic Acid Copolymer

ABSTRACTPurpose: We investigated the effectiveness of dextranomer/hyaluronic acid copolymer (dextranomer microspheres in sodium hyaluronan solution) as a treatment for urinary incontinence due to sphincter incompetence in children and adolescents.Materials and Methods: Patients with urinary incontinence due to neurogenic and structural causes were given a transurethral injection of dextranomer/hyaluronic acid copolymer to increase bladder outlet resistance. Patients were assessed at 1, 3, 6, 12 and 24 months after injection using a validated questionnaire, 1-hour pad test, ultrasonography, cystography and cystometry. Patients who remained incontinent were offered repeat injections of dextranomer/hyaluronic acid copolymer up to a maximum of 3 injections.Results: A total of 16 patients 8 to 22 years old were treated with dextranomer/hyaluronic acid copolymer, including 3 with neurogenic bladder, 8 with bladder exstrophy after 3-stage reconstruction, 4 with penopubic epispadias and 1 with urogenital sinus. M...

Evolution of male epispadias repair: 16-year experience.

We review our experience during the last 16 years, adopting different surgical approaches for epispadias repair, and compare the results of complete penile disassembly technique with perineal muscular complex reassembly since 1995 with previous repairs. From 1984 to 1999, 58 epispadias repairs were performed in 53 male patients 3 days to 13 years old, including 18 with primary penopubic epispadias, 35 with bladder exstrophy and 5 treated with secondary genito-urethroplasty after previous repairs of the exstrophic complex. Cases were divided into 2 periods of the surgical procedure. Different techniques succeeded in 41 patients in the first decade (group 1) while the complete penile disassembly with perineal muscular complex reassembly technique was used in 17 patients during the last 5-year period (group 2). Results of both groups were compared, and Fisher's exact test was used for statistical analysis. Of the 41 group 1 cases complications (mostly fistula and/or urethral stenosis) in 21 (51%) required 1 or multiple operations. Continence was never achieved with urethroplasty alone. Cosmetic appearance of the phallus was not satisfactory in 23 cases (29%) and urethral catheterization was difficult in 8 (19%). Of the 17 group 2 cases only 2 complications (11%) occurred (1 fistula and 1 distal urethral stenosis). Dry intervals or voluntary continence was achieved in 6 of the 10 patients with exstrophy and in all but 1 with epispadias without bladder neck surgery. The penis had a satisfactory cosmetic appearance and no dorsal chordee with an easily catheterizable urethra was noted. The complication rate was significantly different in the 2 groups (Fisher's exact test p = 0.0042). The complete penile disassembly with perineal muscular complex reassembly technique, with deeper positioning of the urethra in the perineal musculature, seems to guarantee a significant step forward in functional epispadias repair.

EVOLUTION OF MALE EPISPADIAS REPAIR: 16-YEAR EXPERIENCE

We review our experience during the last 16 years, adopting different surgical approaches for epispadias repair, and compare the results of complete penile disassembly technique with perineal muscular complex reassembly since 1995 with previous repairs. From 1984 to 1999, 58 epispadias repairs were performed in 53 male patients 3 days to 13 years old, including 18 with primary penopubic epispadias, 35 with bladder exstrophy and 5 treated with secondary genito-urethroplasty after previous repairs of the exstrophic complex. Cases were divided into 2 periods of the surgical procedure. Different techniques succeeded in 41 patients in the first decade (group 1) while the complete penile disassembly with perineal muscular complex reassembly technique was used in 17 patients during the last 5-year period (group 2). Results of both groups were compared, and Fisher's exact test was used for statistical analysis. Of the 41 group 1 cases complications (mostly fistula and/or urethral stenosis) in 21 (51%) required 1 or multiple operations. Continence was never achieved with urethroplasty alone. Cosmetic appearance of the phallus was not satisfactory in 23 cases (29%) and urethral catheterization was difficult in 8 (19%). Of the 17 group 2 cases only 2 complications (11%) occurred (1 fistula and 1 distal urethral stenosis). Dry intervals or voluntary continence was achieved in 6 of the 10 patients with exstrophy and in all but 1 with epispadias without bladder neck surgery. The penis had a satisfactory cosmetic appearance and no dorsal chordee with an easily catheterizable urethra was noted. The complication rate was significantly different in the 2 groups (Fisher's exact test p = 0.0042). The complete penile disassembly with perineal muscular complex reassembly technique, with deeper positioning of the urethra in the perineal musculature, seems to guarantee a significant step forward in functional epispadias repair.

Epispadias repair using the Mitchell technique

Purpose: The results of epispadias repair using Mitchell's technique in nine patients is analyzed and the advantages of the procedure discussed. Methods: Nine boys aged between 6 weeks and 6 years underwent epispadias repair between November 1996 and March 1998 (Penopubic epispadias, inferior vesical fissure, and midpenile epispadias, one patient aach; exstrophy epispadias complex, six patients). Eight patients had first attempt at repair of epispadias. Two patients had closure of exstrophy and epispadias at one stage. Results: At a mean follow-up of 10 months, all children had a conical glans, eight patients had ventral orthotopic meatus, and one had coronal hypospadiac meatus. Minor penopubic fistula developed in one patient. Six patients had downward angled penis, and three had horizontal penis in a flaccid state. All children were observed to have good erections during sleep. Conclusions: Mitchell's technique of epispadias repair allows an anatomic reconstruction of the penis with superior cosmetic and functional results. Long-term follow-up studies are necessary to evaluate the genital functions.

Penopubic epispadias repair in adulthood: Surgical and functional outcome with modified Cantwell-Ransley procedure

Isolated primary penopubic epispadias is a rare anomaly with a reported incidence of one in 11,700 males. It is unusual for patients with this anomaly to present for the first time in adulthood due to the fact that the clinical presentation is striking at birth. The hallmark of surgical repair is the reconstruction of a functionally and cosmetically appealing genitalia as well as proper citing of the neomeatus. Several surgical procedures for complete epispadias have been described in the literature, but the modified Cantwell-Ransley technique and the Mitchell-Bagli repair (complete penile disassembly) are the most widely used. We report a case of a 25-year-old man who presented to our facility for the first time for surgical treatment. The patient underwent the modified Cantwell-Ransley procedure based on surgeon's preference and expertise. The delay in presentation was a thing of concern to us as it is well-known that boys born with epispadias suffer poor self-image as they grow older and become aware of their genitalia. Following a successful modified Cantwell-Ransley procedure our patient's self-esteem, confidence, and sexual appeal greatly improved. We, therefore, conclude that surgical procedures such as the Cantwell-Ransley repair are appropriate even in cases presenting late in adulthood.