Suprapubic Skin Research Articles

Suprapubic skin as a skin graft donor site for micrograft application in vasculopaths

Suprapubic skin as a skin graft donor site for micrograft application in vasculopaths

V04-10 GENDER-AFFIRMING PHALLOPLASTY WITH ANTEROLATERAL THIGH FLAP

You have accessJournal of UrologyCME1 May 2022V04-10 GENDER-AFFIRMING PHALLOPLASTY WITH ANTEROLATERAL THIGH FLAP Ömer Acar, Alexi Millman, Luca Morgantini, Loren Schechter, and Ervin Kocjancic Ömer AcarÖmer Acar More articles by this author , Alexi MillmanAlexi Millman More articles by this author , Luca MorgantiniLuca Morgantini More articles by this author , Loren SchechterLoren Schechter More articles by this author , and Ervin KocjancicErvin Kocjancic More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: One of the options that can be employed within the context of gender-affirming masculinizing genital reconstruction is the anterior lateral thigh (ALT) flap. Our objective is to demonstrate our technique with ALT flap phalloplasty. METHODS: This is a 25-year-old trans male who desired to void in a standing position. Given the subcutaneous thickness of less than 1 cm in his thigh and concerns related to donor-site scarring, the shared decision was to proceed with phalloplasty with an ALT flap constructed in a “tube within a tube” technique. RESULTS: Acoustic Doppler followed by fluoro angiography to confirm perforator location helped outline the ALT flap. A suprapubic tube (SPT) was inserted under direct cystoscopic guidance. Anterior vaginal wall flap was mobilized and tubularized around the catheter. Clitoris was de-epithelialized. A semilunar suprapubic skin incision was made. Clitoris was sutured to the pubic periosteum. The remaining vaginal mucosa was ablated with electrocautery. Colpocleisis was completed using concentric stitches. The patient was then taken out of lithotomy position and the ALT flap was elevated. Dissection was performed to the intermuscular septum between the rectus femoris and the vastus lateralis. Descending branch of the lateral femoral circumflex artery was identified. The lateral femoral cutaneous nerve was dissected proximally. The flap was elevated on a single perforator and repeat fluorescence angiography confirmed intact perfusion. The urethra was reconstructed over an 18 Fr. council tip catheter and closed in a layered fashion. Methylene blue confirmed urethral integrity. Shaft skin was wrapped around the phallic portion of the urethra and closed in a layered fashion. The left ilioinguinal nerve was clipped for later coaptation with the lateral femoral cutaneous nerve. The flap was passed beneath the rectus femoris, sartorius, and then subcutaneously into the recipient site over the pubic symphysis. The anastomosis between the phallic urethra and elongated native urethra was performed over an 18 Fr. council tip catheter using interrupted stitches. Scrotoplasty was performed using labia majora flaps. The flap was then inset in a layered fashion. The donor site was closed by reapproximation and advancing the skin edges. A split-thickness skin graft was harvested from the thigh and applied over the donor site. The donor site was dressed with wound VAC. The procedure lasted 12 hours with an estimated blood loss of 550 ml. The patient was discharged on day 18. The urethral catheter was removed after a 30 days retrograde urethrogram (RUG). SPT was removed a month later. The patient initially voided without issues but then started to notice urine leakage through a phallic skin defect. RUG demonstrated distal phallic urethral stricture and a small urethrocutaneous fistula just proximal to it. The stricture was dilated with sounds. The patient was instructed to do intermittent self-calibration. Voiding improved, stricture did not recur and fistula healed spontaneously. No other urinary complications were encountered. CONCLUSIONS: ALT flap is a valid option for gender-affirming phalloplasty. It can be considered in patients with favorable body habitus who are concerned with donor-site scarring. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e369 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ömer Acar More articles by this author Alexi Millman More articles by this author Luca Morgantini More articles by this author Loren Schechter More articles by this author Ervin Kocjancic More articles by this author Expand All Advertisement PDF downloadLoading ...

A Novel Suction-Irrigation Cannula-Guided Hydrophilic Tip Guidewire Technique of Intraoperative Ureteral Stent Placement During Robot-Assisted Radical Prostatectomy

Background: Patients with large median lobe, history of pelvic radiotherapy, or transurethral resection of the prostate are on the verge of ureteral orifice (UO) injury during robot-assisted radical prostatectomy (RARP). Not all aforementioned patients require ureteral stent placement. Intraoperative findings justify whether to proceed with ureteral stent placement or not. Previously described techniques of intraoperative stent placement involve use of transurethral cystoscopy or suprapubic skin incision, which makes procedure further difficult especially with robotic arms in place.1 Herein, we describe a simple and efficacious method Suction-Irrigation cannula-Guided Hydrophilic Tip guidewire (SIGHT) technique for intraoperative ureteral stent placement. Technique: The case shown here is a 64-year-old gentleman with Gleason 8 prostate cancer and opted for RARP. After division of bladder neck, the interior of the bladder was routinely inspected and the UOs were found too close to the bladder margins. The decision was made to proceed with bilateral ureteral stents placement. To facilitate stent placement, bladder margin is held up using 4th arm of the robot. The bedside assistant inserted laparoscopic suction irrigation cannula from 5 mm assistant trocar. Cannula tip was held a couple of centimeters away from respective UO. A 0.038 Inch diameter, 150 cm long hydrophilic straight tip guidewire is fed into the abdomen through shaft of the cannula. The surgeon on console (A.T.) places the wire into UO and feeds it proximally until the resistance is met. The bedside assistant (R.B.) then feeds the stent over the wire into the abdomen, and the surgeon threads the stent over the wire. The assistance held back-tension on the wire. A pusher is then guided over the wire in similar manner and stent is advanced until distal end of the stent is seen. The wire is pulled out by the bedside assistant, and the distal end of the stent is confirmed with use of robot and secure inside the bladder. Surgery proceeded as usual. Stent placement was verified postoperatively by plain kidney, ureter and bladder radiograph. Patient was discharged next day. Catheter removal was done at postoperative day 7. Ureteral stents were removed under local anesthesia in the office at 4 weeks postoperative visit without complication. Conclusions: Our SIGHT technique is safe, effective, and easily adaptable method for intraoperative ureteral stent placement during robotic procedures. It avoids intraoperative cystoscopy or suprapubic skin incision or use of additional guidewires thereby saving time during which patient is under anesthesia during surgery. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music Source:www.epidemicsound.com Copyright: Author owns copyright/license for the music used in the video. A.T. has served as a site-PI on pharma/industry-sponsored clinical trials from Kite Pharma, Lumicell Inc., Dendreon, and Oncovir Inc. He has received research funding (grants) to his institution from Department of Defence, National Institute of Health, Axogen, Intuitive Surgical, Arthur M. Blank Family Foundation, and other philanthropy. A.T. has served as an unpaid consultant to Roivant Biosciences and advisor to Promaxo. He owns equity in Promaxo. Rest of the authors do not have conflict of interests. Runtime of video: 3 mins 21 secs

Gender-Affirming Phalloplasty with Anterolateral Thigh Flap

ABSTRACT Introduction Anterior lateral thigh (ALT) flap is one of the options that can be employed within the context of gender-affirming masculinizing genital reconstruction. Objective Herein, we demonstrate our technique with ALT flap phalloplasty. Methods This is a 25-year-old trans male who desired voiding in standing position. Given the quality of his thigh skin (subcutaneous thickness <1cm) and concerns related to donor-site scarring, the shared decision was to proceed with phalloplasty with ALT flap constructed in a “tube within a tube” technique. Results The ALT flap was designed and outlined using acoustic Doppler followed by fluorescence angiography to confirm perforator location. A suprapubic tube (SPT) was inserted under direct cystoscopic guidance. Anterior vaginal wall flap (6cm x 3cm) was liberated. Vaginal flap was tubularized around the urethral catheter. Clitoris was de-epithelialized. A semilunar suprapubic skin incision was made. Clitoris was sutured to the pubic periosteum. Remaining vaginal mucosa was ablated with electrocautery. Colpocleisis was completed using concentric stitches. Then, he was taken out of lithotomy and the ALT flap was elevated. Subfascial dissection was performed to the intermuscular septum between the rectus femoris and the vastus lateralis. Descending branch of the lateral femoral circumflex artery was identified. Lateral femoral cutaneous nerve was dissected proximally. Flap was elevated on a single perforator and repeat fluorescence angiography confirmed intact perfusion. Urethra was reconstructed over an 18 Fr. council tip catheter and closed in a layered fashion. Urethral integrity was tested with methylene blue. Shaft skin was wrapped around the phallic portion of the urethra and closed in a layered fashion. The left ilioinguinal nerve was clipped for later coaptation with lateral femoral cutaneous nerve. The flap was passed beneath the rectus femoris, sartorius and then subcutaneously into the recipient site over the pubic symphysis. The anastomosis between the phallic urethra and elongated native urethra was performed over an 18 Fr. council tip catheter using interrupted stitches. Scrotoplasty was performed using labia majora flaps. Flap was then inset in a layered fashion. Donor site was closed by reapproximation and advancing the skin edges. A split thickness skin graft was harvested from the thigh and applied over the donor site. Donor site was dressed with wound VAC. The procedure lasted 12 hours with an estimated blood loss of 550ml. Patient was discharged to a skilled nursing facility on day 18. Urethral Foley catheter was removed in a month after documenting patency on retrograde urethrogram (RUG). SPT was removed a month later. He initially voided well but then started to notice weakening in stream and urine leak through phallic skin defect. RUG demonstrated distal phallic urethral stricture and a small urethrocutaneous fistula just proximal to it. Stricture was dilated with sounds. Patient was instructed to do intermittent self-calibration. Voiding improved, stricture did not recur and fistula healed spontaneously. No other urinary complications were encountered. Conclusions ALT flap remains a valid option for gender-affirming phalloplasty. It can be considered in patients with favorable body habitus who are concerned with donor-site scarring. Disclosure No

Increase apparent penile length by cryolipolysis in the reduction of male suprapubic fat.

The buried or hidden penis in adults is troublesome in males, whereas the length of the penile shaft is buried under the skin surface of the suprapubic fat to a degree that reveals the concept of a little penis. We aimed to assess a new modality of treatment to increase the apparent penile length by using the cryolipolysis in the reduction of male suprapubic fat as a noninvasive procedure. This prospective study was performed on 46 male patients complaining of buried short apparent small size penis. All patients were subjected to full medical history, body mass index and examination of penile (length, size and abnormalities). The measures of the apparent penile length from the skin to the tip of the glans penis and suprapubic skin fold thickness using (adipometer) were recorded before the three consecutive suprapubic cryolipolysis sessions. The mean apparent stretched penile length at session 1, 2 and 3 were 12.1±0.5cm, 12.66±0.48 and 12.88±0.72, respectively, with a statistically significant increase between three sessions (p<.001), whereas the mean skin fold suprapubic fat at session 1, 2 and 3 was 2.99±0.49cm, 2.37±0.48 and 2±0.37, respectively, with a statistically significant decrease (p<.001). The cryolipolysis of suprapubic fat is a safe, effective, noninvasive and applicable procedure that successfully decreases the suprapubic fat in males and increases the apparent length of the buried penises.

Isolated penile injury in boys: Accident, negligence, or abuse?

Aim:The aim of the study was to highlight the etiology, spectrum of presentation, and management of isolated penile trauma in boys.Methods:A retrospective review of boys treated for isolated penile trauma between January 2015 and June 2019 at a tertiary-level hospital.Results:Nine children were admitted over 4½ years. Etiology: The mechanism of penile injury (PI) was penile hair tourniquet (n = 5), postcircumcision (n = 2), dog bite (n = 1), and scald injury (n = 1). Extent of injury includes complete urethral transection at corona (n = 4); loss of urethral plate in a case of hypospadias (n = 1); complete loss of glans (n = 1); penile transection at corona (n = 1); total penile amputation (n = 1); and deep partial-thickness burns of penile shaft and adjacent suprapubic skin (n = 1). Management: One patient absconded. The remaining patients were managed as follows: calibration of urethral meatus (n = 1); penile burn was managed with dressing and antibiotics; coring of glans with urethral end–end anastomoses (n = 4); Bettocchi's quadrangular lower abdominal flap phalloplasty (n = 1); and Bracka's staged urethroplasty (n = 1). Complications include wound infection following trauma (n = 4), postsurgical infection (n = 3), urethrocutaneous fistula (n = 2), and reapplication of penile hair tourniquet (n = 1).Conclusion:Isolated PI in boys is not uncommon. Most are preventable if the parents are apprized and watchful. The clinician should also be vigilant regarding child maltreatment. A staged approach tailored to the type of injury provides a satisfactory outcome.

Case report of sigmoid colon perforation and colocutaneous fistula due to retropubic midurethral sling placement for stress urinary incontinence

BackgroundSigmoid bowel perforation is a very rare and serious complication of the retropubic tension-free vaginal tape (TVT) procedure for female stress urinary incontinence. The complication can be avoided with the use of the correct manipulation technique.Case presentationA 75-year-old female patient underwent a retropubic TVT procedure in the local hospital for the treatment of stress urinary incontinence. The procedure was smooth. Two weeks after surgery, the patient began to complain of fever and bloody, purulent discharge from the left suprapubic skin wound. During a 4-month period after surgery, she was admitted to the local hospital 4 times for similar infection symptoms. The infections were temporarily controlled with antibiotic administration. The reason for the refractory infection of the left suprapubic skin wound was not identified until a foreign TVT mesh was found in the sigmoid colon via a colonoscopy. We diagnosed that the TVT mesh caused a sigmoid colon perforation that led to colocutaneous fistula. An exploratory laparotomy revealed that the TVT tape perforated into and out of the sigmoid colon. An 8-cm long left part of mesh was removed. Two ruptures of sigmoid colon were mended without the need for bowel resection. At the 4-years follow-up after laparotomy, the patient was doing well and still continent.ConclusionsUrologists and gynecologists should be aware of the possibility of colon bowel injury in SUI patients with prior sling surgeries. Patient having recurrent suprapubic cutaneous infection may have high degree of suspicion of colon injury after TVT sling. The passage of the retropubic space procedure should be slow and always along the pubic bone according to the anatomy.

Genetic variants in glutamine metabolic pathway genes predict cutaneous melanoma-specific survival.

Glutamine dependence is a unique metabolic defect seen in cutaneous melanoma (CM), directly influencing the treatment and prognosis. Here, we investigated the associations between 6025 common single-nucleotide polymorphisms (SNPs) in 77 glutamine metabolic pathway genes with CM-specific survival (CMSS) using genotyping datasets from two published genome-wide association studies (GWASs). In the single-locus analysis, 76 SNPs were found to be significantly associated with CMSS (P < .050, false-positive report probability < 0.2 and Bayesian false discovery probability < 0.8) in the discovery dataset, of which seven SNPs were replicated in the validation dataset and three SNPs (HAL rs17676826T > C, LGSN rs12663017T > A, and NOXRED1 rs8012548A > G) independently predicted CMSS, with an effect-allele attributed adjusted hazards ratio of 1.52 (95% confidence interval = 1.19-1.93) and P < .001, 0.68 (0.54-0.87) and P = .002 and 0.62 (0.46-0.83) and P = .002, respectively. The model including the number of unfavorable genotypes (NUGs) of these three SNPs and covariates improved the five-year CMSS prediction (P = .012) than the one with other covariates only. Further expression quantitative trait loci (eQTL) analysis found that the LGSN rs12663017 A allele was significantly associated with increased messenger RNA (mRNA) expression levels (P = 8.89 × 10 -11 ) in lymphoblastoid cell lines of the 1000 Genomes Project database. In the analysis of the genotype tissue expression (GTEx) project datasets, HAL rs17676826 C and NOXRED1 rs8012548 G alleles were significantly associated with their mRNA expression levels in sun-exposed skin of the lower leg (P = 6.62 × 10-6 and 1.37 × 10-7 , respectively) and in sun-not-exposed suprapubic skin (P < .001 and 1.43 × 10-8 , respectively). Taken together, these genetic variants of glutamine-metabolic pathway genes may be promising predictors of survival in patients with CM.

Long-term unexpected single polyprolene suture complication following traditional pubovaginal sling: Suprapubic skin fistula

Long-term unexpected single polyprolene suture complication following traditional pubovaginal sling: Suprapubic skin fistula

Clear cell papulosis: report and review

A 12-month-old boy presented with three months of asymptomatic hypopigmented flat-topped papules on the suprapubic skin and lower abdomen. Emollients and topical steroids offered no improvementand the patient was referred to the dermatology department. Shave biopsy revealed a papillated epidermis with scattered solitary mononuclearclear cells at all levels of the epidermis and an overlying basket weave orthokeratosis. The cells were epithelioid with increased amphophilic cytoplasm. Immunohistochemical staining was positive for CK7,CEA, and CAM5.2 and negative for S100, CD1a, and Mart-1. These findings were consistent with clear cell papulosis. No treatment was recommended as these lesions were asymptomatic. However, yearlyfollow up was recommended given the resemblance of these cells to those of Paget disease. Review of the literature demonstrates a total of 31 biopsy confirmed cases with AE1, CEA, and EMA positivity and S100negativity as the most consistent staining properties. A recent retrospective review of 19 cases documents long term follow-up of at least six years and up to 21 years. The results suggested a tendency toward selfresolution and an absence of malignant progression, supporting the benign nature of these lesions.

28: Management of intravesical mesh and incisional pain after midurethral sling placement

The objective of this video is to demonstrate the laparoscopic excision of an intravesical midurethral sling with concurrent removal of the sling arm through a suprapubic skin incision. This video describes the excision of both intravesical midurethral sling and incisional pain temporally related to the same surgical procedure. The patient described is a 48 year old who underwent Lynx retropubic midurethral sling placement at an outside facility. Review of her operative note revealed the fact that there was gross hematuria with bladder drainage after sling placement, however cystoscopy demonstrated no evidence of bladder injury. One week later, she developed a large hematoma and underwent evacuation, with an incision made through her left suprapubic incision. She presented to our practice 10 months later with urgency, frequency, recurrent urinary tract infections, and left sided incisional pain. Physical examination revealed significant tenderness and nodularity along her left suprapubic incision. Cystoscopy demonstrated a 2 cm intravesical portion of the midurethral sling penetrating the left dome of the bladder. The decision was made to proceed with laparoscopic removal of the intravesical mesh and complete removal of the left sided sling arm through a small suprapubic incision. Management of both intravesical midurethral sling and incisional pain is able to be accomplished using a laparoscopic approach with extraction through prior suprapubic incision.

Is Striae Gravidarum related to Cesarean Scar and Peritoneal Adhesions?

Objective:To evaluate the relationship between striae gravidarum (SG) score and abdominal scar characteristics together with intraperitoneal adhesion (IPA) grades of patients who were hospitalized for second cesarean delivery.Methods:A total of 145 consecutive women undergoing scheduled cesarean section (CS) in a tertiary level maternity hospital between November 2013 and January 2014 were included in the study. All women had transverse suprapubic skin incision due to the previous CS and none of them had a history of vaginal delivery. Patients were classified according to the SG status, as women with no SG: Group-1(n=53), mild SG: Group-2(n=27) and severe SG: Group 3(n=65). Groups were compared between themselves with regard to various sociodemographic properties, cesarean scar characteristics and IPA scores.Results:No significant difference in the length, width and color of the scar was detected among groups. While flat scar was the most prominent form of scar, the elevated scar was significantly more frequent in Group-1 compared to other groups (p=0.009). IPA grades were 0 or 1 in 77.3% of Group-1, 81.3% of Group-2 and 76% of Group-3. There was no significant difference in IPA scores between groups (p=0.884). After combining CS scar characteristics (flat, depressed and elevated) and SG status [SG (+) or SG (-)], we found no significant difference between the groups in terms of IPA severity.Conclusion:Striae gravidarum (SG) was found to be associated with scar characteristics, but not associated with the severity of intraperitoneal adhesion (IPA).

No incision and tension-free vaginal sling for stress urinary incontinence: The role of knotless barbed suture

Midurethral mesh sling is the most performed incontinence procedure. This hypotheses propose knotless barbed suture could be positioned as a tension-free trans-vaginal sling under the mid-urethra without vaginal incision. Knotless suture sling support and stabilize mid-urethra when intraabdominal pressure increase. This procedure is designed to replace midurethral mesh sling operation, aiming at reducing complications. It is completed in a similar way with retropubic mesh sling procedure, and less invasive. This involve the passage of fine needle from suprapubic skin to midurethral vaginal wall, and knotless suture passing through in fine needle as a U shape. The foundational promises for this hypothesis pertain to two clinical facts: midurethral sling procedure is a gold standard treatment, and the knotless suture offer superior tissue holding or fixation strength originated from the unique barbed design.

The Ovary-Sparing Laparoscopic Excision of a Benign Teratoma

Purpose: We demonstrate complete excision of a benign ovarian teratoma and combine the benefits of laparoscopy with ovary preservation and avoidance of tumor spillage. Case History: A 9-year-old female presented with 2 months of intermittent right lower quadrant abdominal pain. Physical examination was unremarkable with no palpable abdominal mass. Pelvic ultrasonography revealed an enlarged right ovary with no evidence of torsion on duplex scan. MRI revealed a calcified, 3.5 cm mass within the right ovary, consistent with a teratoma. Tumor marker blood studies, including beta-HCG, alpha-fetoprotein, and CA-125, were negative. Procedure: General anesthesia was administered. The patient was placed in Trendelenburg position with the monitor at the foot of the bed. Three 5-mm laparoscopic ports were placed, one for the 5-mm, 30° camera at the umbilicus and one each in the lower quadrants for dissection instruments. A 12-mm port was placed in the skin crease, directly above the ovary, for the endocatch bag. The abdomen was insufflated with carbon dioxide to 13-mm Hg pressure. Initial inspection revealed a normal-appearing abdomen, a normal contralateral ovary, and the serosa of the enlarged right ovary appeared intact. The dissection began at the pelvic edge by dividing the peritoneal attachments between the adnexal structures and the pelvic side wall with the harmonic scalpel. It proceeded toward the point between the bladder and the epigastric vessels. The ovarian and iliac vessels and ureter were avoided. The dissection extended under the adnexa. The ovary reached the 12-mm port without tension. It was placed in an endocatch bag to prevent spillage in case of rupture and carefully pulled through the 12-mm port site. The hydroplane technique of saline injection with a 30-gauge needle under the ovary serosa allowed dissection of the teratoma from normal ovarian tissue. The serosa was opened and the teratoma circumferentially excised.1,2 The preserved ovary serosa was closed with running suture of 3–0 chromic catgut. The adnexa were replaced in the abdominal cavity in the correct orientation. The abdomen was desufflated and port sites were closed. Results: The pathology analysis revealed a benign 3.0 cm teratoma, completely excised with intact margins and no immature elements. No complications occurred. The operative time was 70 minutes. The patient was discharged on postoperative day 2. Conclusion: We demonstrate complete excision of a benign ovarian teratoma and combine the benefits of laparoscopy with ovary preservation and avoidance of tumor spillage.3 For patients with negative tumor markers, an MRI with a teratoma contained in the ovary and a tumor diameter less than 5 cm are appropriate. The distance between bladder and epigastric vessels may limit the size of lesion that can be brought through the abdominal wall along the suprapubic skin crease. The hydroplane technique reveals a consistent plane between teratoma and normal ovary. However, this technique is also suitable for lesions where malignancy is suspected. The risk of suspicious histology, tumor rupture, and spillage increases with tumor diameter. In general, these risks increase with lesions more than 5 cm in diameter.4 Therefore, we promote the use of the endocatch bag. No competing financial interests exist. Runtime of video: 4 mins 55 secs

The Relationship between Rostral Retraction of the Pannus and Outcomes at Cesarean Section.

Objective Maternal obesity presents several challenges at cesarean section. In an effort to routinely employ a transverse suprapubic skin incision, we often retract the pannus in a rostral direction using adhesive tape placed after induction of anesthesia and before surgical preparation of the skin. We sought to understand the association between taping and neonatal cord blood gases, Apgar scores, and time from skin incision to delivery of the neonate. Study Design This is a retrospective study, performed using prospectively collected anesthesiology records with data supplemented from the patients' medical records. Singleton pregnancies with morbid obesity (body mass index [BMI] > 40 kg/m(2)) between 37 and 42 weeks of gestation who delivered via nonurgent, scheduled cesarean delivery under regional (spinal, combined spinal-epidural, or epidural) anesthesia between March 2007 and March 2013 were identified. Maternal demographics including BMI, comorbidities, type of anesthesia, time intervals during the surgery, cord gas results, and Apgar scores were collected. The relationship between taping and blood acid-base status, Apgar scores, and interval from skin incision to delivery was investigated using appropriate statistical tests. Results There were 2,525 (27.5%) cesarean deliveries out of 9,189 total deliveries. Applying the described inclusion/exclusion criteria, 141 patients were identified (33 taped and 108 nontaped). There was no significant difference in BMI between the taped (51.9 kg/m(2)) and nontaped groups (47.4 kg/m(2)), p > 0.05. There was no difference in type of anesthesia (p > 0.05). The only significant difference between the taped and not-taped groups was the presence of chronic hypertension in the taped group (p = 0.03). There were no significant differences in cord blood gas values, Apgar scores, or skin incision to delivery interval (p > 0.05 for all outcomes). Conclusions Taping of the pannus at cesarean section is a safe intervention that is not associated with adverse neonatal outcomes. Furthermore, over a set of parturients with BMI > 40 kg/m(2), it does not hasten skin incision to delivery time.

Modified Penile Augmentation by Dermal-Fat Graft in Post-Hypospadias Adults

Although a considerable part of patients desire further improvement in penile size after hypospadias repairs, penile augmentation is only considered in patients with congenital penile hypoplasia or acquired penile retraction. Modified penile augmentation by free dermal-fat graft is introduced to satisfy these patients and improve surgical safety. From April 2012 to December 2014, a total of 15 male adults after hypospadias repairs, aged 18-24 years, underwent modified penile augmentation which involved girth enhancement by a free dermal-fat graft and penile elongation (suprapubic skin advancement-ligamentolysis). A specially designed tunneling instrument was introduced to facilitate pericavernous thickening without degloving. Outcome evaluation was mainly based on objective penile measurements and results of the Male Genital Image Scale. With 6 months' follow-up, all patients had achieved excellent cosmetic results, with a significant average dimensional increase of 1.53 ± 0.23 cm in flaccid girth and 1.67 ± 0.24 cm in flaccid length. No erection deficiencies or urinary fistula occurred. Patients' perception of male genitalia improved postoperatively, with the average MGIS score rising from 31.73 ± 4.86 to 40.20 ± 4.54. This modified technique is safe and effective in enlarging penile size. The use of the specially designed tunneling instrument simplifies penile girth enhancement, avoiding unnecessary trauma to the neo-urethra and neurovascular bundle. It is confirmed that physical dimensional enhancement does contribute to improving their underestimation of penile size. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Erect penile dimensions in a cohort of 778 Middle Eastern men: establishment of a nomogram.

Accurate data regarding the size of the erect penis are of great importance to several disciplines working with male patients, but little high-quality research exists on the subject, particularly in different ethnic groups and for erect penis size. The aim of this study was to create a nomogram of erect penile dimensions in a large sample of Middle Eastern men. A retrospective cohort study of 778 men (mean age 43.7; range 20-82) attending urological outpatient clinics in Saudi Arabia was conducted. Exclusion criteria were age under 18 years, a presenting complaint of small or short penis, Peyronie's disease or complaint of congenital curvature, clinical hypogonadism, and previous penile surgery or trauma. Three erect penile dimensions following induction of erection using intracavernosal injection of Quadrimix. Mean patient body mass index (BMI) was 29.09 (standard deviation [SD] 5.76). The mean suprapubic skin-to-penile tip erect length was 12.53 cm (SD 1.93); the mean erect length from the symphysis pubis to the penile tip was 14.34 cm (SD 1.86); and the mean erect shaft circumference was 11.50 cm (SD 1.74). A nomogram was constructed and statistical analysis performed, demonstrating a weak negative correlation between BMI and erect penile length measured from the suprapubic skin (r = -0.283, P < 0.000) but not from bone to tip, and a weak negative correlation between age and both erect penile length measurements (skin to tip r = -0.177, P < 0.0005; bone to tip r = -0.099, P = 0.006). A nomogram for Middle Eastern men can be used as a standard when advising men with small penis anxiety. The importance of measuring erect size and allowing for infra-pubic fat interference in measurement is emphasized. We envisage that this tool can be used to educate and reassure concerned men about the size of their penises.

A new, simple operative approach for bilateral inguinal hernia repair in girls: A single transverse supra-pubic incision.

Background:Inguinal hernia repair remains one of the most common operations performed by pediatric surgeons. We described a new surgical approach for treating bilateral inguinal hernias in girls through a small single transverse supra-pubic incision.Materials and Methods:A new approach was performed on female children 12-years-old and younger with bilateral inguinal hernias between January 2005 and April 2012.Technique:A single transverse suprapubic incision (1-1.5 cm) was made. Using sharp and blunt dissection bilateral hernias were exposed and repaired using a standard high ligation.Results:Ninety-nine girls with a preoperative clinical diagnosis of bilateral inguinal hernia were included. Median age was 2 years (range: 1 month to 12 years). All patients underwent general anesthesia. Median operative time was 12 minutes (range 5-22). There were no intra-operative complications or misdiagnosis. Two patients had bilateral sliding hernias and the remainder had indirect hernias. Post-operatively two patients developed non-expanding small hematomas, both treated non-operatively without sequelae. There were zero hernia recurrence and median follow-up was 5 years (range: 1-8 years) on 99% of patients.Conclusion:We described a new, safe, simple, and rapid approach for bilateral inguinal hernia repair in female pediatric population. A single transverse suprapubic skin incision was adequate for exposing both inguinal regions with excellent postoperative results.

‘Minimum-incision’ endoscopically assisted transvesical prostatectomy: Surgical technique and early outcomes

ObjectiveTo describe the surgical technique and report the early outcomes of a ‘minimum-incision’ endoscopically assisted transvesical prostatectomy (MEATP) for managing benign prostatic obstruction secondary to a large (>80g) prostate. Patients and methodsIn a prospective feasibility trial, 60 men with large benign prostates underwent MEATP. The baseline and postoperative evaluation included the International Prostate Symptom Score (IPSS), a measurement of maximum urinary flow rate (Qmax), and the postvoid residual (PVR) urine volume. The adenoma was enucleated digitally through a 3-cm suprapubic skin incision, and haemostasis was completed with endoscopic coagulation of the prostatic fossa. Perioperative complications were recorded and stratified according to the modified Clavien–Dindo score. ResultsThe mean (SD, range) prostate weight estimated by ultrasonography was 102.9 (15.4, 80–160)g, the operative duration was 52 (8, 40–65)min, the haemoglobin loss was 2.1 (1, 0.4–5)g/dL, the catheterisation time was 5.2 (1.3, 4–9)days, and the hospital stay was 6.2 (1.4, 5–10)days. There were 21 complications recorded in 16 (27%) patients, and most (86%) were of grades 1 and 2. The most frequent complications were bleeding requiring a blood transfusion (8%), and prolonged drainage (5%). There was a significant improvement at 3months after surgery in the IPSS (8.6 vs. 21.6, P<0.001), Qmax (19.5 vs. 7.7, P<0.001), and PVR (15.8 vs. 83.9mL, P<0.001). ConclusionMEATP is feasible, safe and effective. Comparative studies and long-term data are required to determine its role in the surgical treatment of large-volume BPH.

Chirurgie cosmétique de l’appareil génital masculin

To describe the indications and results of techniques to change the appearance of the penis for aesthetic reasons. Provide recommendations concerning cosmetic surgery of the male genitalia. We have selected from Medline Database, articles published between 1990 and 2011. Forty articles have been selected excluding papers reporting populations less than five cases per type of procedure. There is no consensus on the size below which it is justifiable to accept or attempt to modify the size of the penis. Length of the penis in maximal tension less than 9.5 cm or 10 cm in erection can be considered as an acceptable limit, in a patient who suffers from it. The assessment of men asking for penile enlargement must include a psychosexological or psychiatric evaluation, looking for a dysmorphophobia or another psychiatric condition. Penile extenders under medical control must be the first-line treatment option for patient seeking penile lenghtening procedure when justified. In case of failure, three techniques can be used alone or in combination: penile lengthening by section of the suspensory ligaments and suprapubic skin advancement, lipectomy of Mons pubis and scrotal webbing section. The results are modest, the rate of complications significant and satisfaction low. Girth enlargement techniques by injection of autologous fat give inconsistent aesthetic results and satisfaction rates are low. All other techniques remain experimental. Cosmetic surgery of the penis is associated with a high risk of forensic exposure and surgery should be only proposed after a multidisciplinary consensus, followed by a time of reflection given to the patient after full disclosure. Applications for the purpose of reconstruction surgery after trauma or consequences of cancer treatment are justified.