Two-stage Urethroplasty Research Articles

About Surgical Correction of Urethral Stenosis: Urethroplasty

Objective The aim of our study has been to evaluate our results in the treatment of urethral stenosis through several surgical approaches of urethroplasty: the one-stage procedure by direct end-to-end anastomosis, the free dorsal onlay graft urethroplasty using buccal mucosa, and the two-stage urethroplasty. Methods Between February 2009 and January 2012, 53 patients were enrolled and analyzed for different types of urethral reconstruction. Results The procedures included direct end-to-end anastomosis in 26 patients (49%), 18 (34%) underwent a two-stage urethroplasty (Johansen's), in 9 a free dorsal onlay buccal mucosa urethroplasty was performed. At a mean follow-up of 17 months, we had an overall success rate of 95%. When stratified on the basis of the procedure performed, in the direct end-to-end anastomosis 98% of patients had no evidence of recurrent stricture, 96% of success rate was reached in the onlay buccal mucosa urethroplasty, and 91% in the two-stage procedure. Conclusions In patients with urethral strictures, urethroplasty has to be preferred with respect to urethrotomy, which is the cause of a high percentage of recurrence, and holds the risk of compromising the success of further surgical procedures of urethroplasty. Differently, several techniques of urethroplasty offer a high percentage of success rate until 95%, as showed by our results.

Two-stage urethroplasty with buccal mucosa

BJU InternationalVolume 109, Issue 1 p. 150-162 Two-stage urethroplasty with buccal mucosa Silke Riechardt, Corresponding Author Silke Riechardt Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, GermanyDr Silke Riechardt, Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany. e-mail: [email protected]Search for more papers by this authorMargit Fisch, Margit Fisch Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, GermanySearch for more papers by this author Silke Riechardt, Corresponding Author Silke Riechardt Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, GermanyDr Silke Riechardt, Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany. e-mail: [email protected]Search for more papers by this authorMargit Fisch, Margit Fisch Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, GermanySearch for more papers by this author First published: 09 December 2011 https://doi.org/10.1111/j.1464-410X.2011.10842.xCitations: 11 ILLUSTRATIONS by STEPHAN SPITZER, http://www.spitzer-illustration.com Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume109, Issue1January 2012Pages 150-162 RelatedInformation

The Cleveland Clinic experience with adult hypospadias patients undergoing repair: their presentation and a new classification system

hypospadias (56.4%) and the others had more proximal (bulbar) hypospadias (43.6%). • Voiding symptoms (such as dysuria, weak stream, spraying, urgency, frequency) were the most common presenting complaint (50.9%) and overall symptom (81.8%). About half of patients underwent a two-stage urethroplasty (52.7%). • Based on their history of repair, patients were divided into three categories: I, patients who have undergone continuous multiple surgeries for repair with significant scarring and tissue loss; II, delayed complications after an initially successful childhood repair; and III, no previous repair. Most patients were category I (58.2%); however, seven patients (12.7%) were category III. Balanitis xerotica obliterans (BXO) was more common in this subgroup compared with other categories (42.9% vs 8.3%, respectively, P = 0.037). In two of the three patients in category III with BXO, the stricture length was longer than 7 cm.

The Use of Topical Hyaluronic Acid and Silver Sulfadiazine (Altergen®) in Patients Undergoing Two-Stage Anterior Urethroplasty with Oral Mucosal Graft

This investigative pilot study was conducted with the objective of evaluating the therapeutic effect of a cream containing hyaluronic acid (HA) and silver-sulfadiazine (Altergen®, IBSA Farmaceutici Italia, S.r.l.) in adult patients undergoing two-stage urethroplasty using an oral mucosal graft for anterior urethral strictures due to failed hypospadias repair. We used a cream (Altergen®) containing the following active ingredients: 100 g HA, 0.20 mg sodium salt, and 1 g silver-sulfadiazine. During the period of January 2009 - May 2010, 40 patients, mean age 24 years, who had undergone hypospadias surgery during childhood were enrolled in the study, according to some inclusion and exclusion criteria (age >18 years, with the absence of diabetes, neurovascular disease, lichen sclerosus or other dermatological lesions). All 40 patients had navicularis or penile urethral strictures and underwent two-stage urethroplasty using an oral mucosa graft. Post-operatively, 20 patients (50%) were treated with a cream containing HA and silver-sulfadiazine (Altergen®) and 20 patients (50%) were treated using a standard topical treatment (iodopovidone 10% gel). All patients underwent a follow-up at 6, 15, 30, 60 and 120 days after surgery. Out of the 20 patients treated with the HA and silver-sulfadiazine-containing cream (Altergen®), 18 (90%) showed good and complete healing of the graft implant 30 days after surgery. Of the 20 patients not treated with the HA and silver-sulfadiazine-contaning cream (Altergen®), 13 (65%) showed good and complete healing of the graft implant 30 days after surgery. These results were constant in all follow-ups in both patient groups. In patients who underwent a navicularis or penile two-stage oral mucosal graft urethroplasty, the use of a HA and silver-sulfadiazine-containing cream was associated with a higher success rate of the graft implant and a lower incidence of post-surgical complications compared to the controls.

101 TOTAL PHALLOPLASTY USING MUSCULOCUTANEOUS LATISSIMUS DORSI FLAP - EXPERIENCE IN 92 PATIENTS

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery1 Apr 2011101 TOTAL PHALLOPLASTY USING MUSCULOCUTANEOUS LATISSIMUS DORSI FLAP - EXPERIENCE IN 92 PATIENTS Rados Djinovic, Sasa Tomovic, Salvatore Sansalone, Marko Milosavljevic, Vladislav Pesic, Nikola Stanojevic, and Miodrag Lazic Rados DjinovicRados Djinovic Belgrade, Yugoslavia More articles by this author , Sasa TomovicSasa Tomovic Belgrade, Yugoslavia More articles by this author , Salvatore SansaloneSalvatore Sansalone Rome, Italy More articles by this author , Marko MilosavljevicMarko Milosavljevic Belgrade, Yugoslavia More articles by this author , Vladislav PesicVladislav Pesic Belgrade, Yugoslavia More articles by this author , Nikola StanojevicNikola Stanojevic Belgrade, Yugoslavia More articles by this author , and Miodrag LazicMiodrag Lazic Belgrade, Yugoslavia More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.166AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We present total phalloplasty in children and adults using latissimus dorsi free flap for creation of large neophallus that allow easy performance of urethroplasty and prosthesis implantation. METHODS In the period from April 1999 to January 2010 total phalloplasty is performed in 92 patients aged between 10 and 46 yr (mean 34 yr). Indications were: congenital anomalies (9), iatrogenic injury (7) or accidental (6) trauma and transsexualism (71 patients). The flap is harvested on subscapular artery, vein and thoracodorsal nerve. Neophallus is created on site, transferred to the pubic region and anastomozed with femoral artery, saphenous vein and ilioinguinal nerve. Two-stage urethroplasty is performed in 77 patients using only buccal mucosa alone (12) or combined with split thickness skin graft (65). Donor site was closed directly in 23 patients, while in the remaining 4 split thickness skin graft was used. Inflatable prsthesis was implanted in 31 and semi-rigid in 43 pts. RESULTS Follow-up was 9 months to 11 years. Penile size varied from 13 to 19 cm in length and from 12 to 15 cm in circumference. Total flap necrosis occurred in 2 and partial in 3 patients. The donor site healed good in 34 pts, acceptably in 53, while in the remaining 12 mild to moderate moderate scarring occured. Two urethral dehiscences, 11 uretrocutaneous fistulas and 13 urethral stenosis developed that were successfully treated surgically. Function of implanted penile prostheses is satisfactory. CONCLUSIONS Musculocutaneous latissimus dorsi flap provides excellent neophallus size, good aesthetic appearance, easy implantation of penile prosthesis and urethroplasty. It can be also used successfully in pediatric population. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e43 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rados Djinovic Belgrade, Yugoslavia More articles by this author Sasa Tomovic Belgrade, Yugoslavia More articles by this author Salvatore Sansalone Rome, Italy More articles by this author Marko Milosavljevic Belgrade, Yugoslavia More articles by this author Vladislav Pesic Belgrade, Yugoslavia More articles by this author Nikola Stanojevic Belgrade, Yugoslavia More articles by this author Miodrag Lazic Belgrade, Yugoslavia More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urethroscopic Holmium: YAG Laser Ablation of Large Urethral Stone after Two-Stage Urethroplasty

Hairball in a urethral diverticulum has rarely been reported. These hairballs are usually formed in the diverticulum coated with a hair bearing epithelium and can lead to urinary obstruction or infection. Using laser is a safe way to ablate such stones.

Urethroplasty for Strictures After Phallic Reconstruction: A Single-Institution Experience

BackgroundTreatment recommendations for strictures after phalloplasty are lacking. ObjectiveOur aim was to evaluate the outcome of urethroplasty for strictures after phalloplasty and to provide treatment recommendations based on this experience. Design, setting, and participantsOne hundred and eighteen urethroplasties were performed in 79 patients. Mean patient age was 37.6 yr. Mean follow-up was 39 mo. InterventionDifferent types of urethroplasty were used: meatotomy, Heineke-Mikulicz principle (HMP), excision and primary anastomosis (EPA), free graft urethroplasty (FGU), pedicled flap urethroplasty (PFU), two-stage urethroplasty (TSU), and perineostomy followed by urethral reconstruction (PUR). MeasurementsStricture recurrence was defined as the need for additional instrumentation or surgery. Results and limitationsMean stricture length was 3.6cm. Stricture location was at the meatus, phallic urethra, anastomosis, fixed part, and different locations in 18, 28, 48, 15, and 9 urethroplasties, respectively. Stricture recurrence was observed in 44 urethroplasties (41.12%). Stricture recurrence rate for meatotomy, HMP, EPA, FGU, PFU, TSU, and PUR was 25%, 42.11%, 42.86%, 50%, 40%, 30.3%, and 61.9%, respectively. ConclusionsThe main stricture location after phalloplasty is the anastomosis between the phallic and the fixed part. Urethroplasty for strictures after phalloplasty is associated with a relatively high recurrence rate. Trial registrationEC UZG 2007/434.

The Cleveland Clinic experience with adult hypospadias patients undergoing repair: their presentation and a new classification system

• To characterize and categorize adults with hypospadias who presented to our clinic with urethral stricture and fistula to better clarify the presentation, history and intraoperative findings in this heterogeneous group and to better describe the natural history of this anomaly in adulthood. • A retrospective chart review was performed on adults with hypospadias who underwent urethroplasty for urethral stricture, urethrocutaneous fistula, and/or hypospadias repair at Cleveland Clinic between 1993 and 2009. All procedures were performed by a single staff surgeon (K.W.A.). • The charts were reviewed for site of hypospadias, presenting complaint, overall symptoms, history of repair and type of surgery performed. • Fifty-five adult patients were identified. Median age was 37 years (range: 18-72). About half of the patients had distal (glanular/subcoronal or pendulous) hypospadias (56.4%) and the others had more proximal (bulbar) hypospadias (43.6%). • Voiding symptoms (such as dysuria, weak stream, spraying, urgency, frequency) were the most common presenting complaint (50.9%) and overall symptom (81.8%). About half of patients underwent a two-stage urethroplasty (52.7%). • Based on their history of repair, patients were divided into three categories: I, patients who have undergone continuous multiple surgeries for repair with significant scarring and tissue loss; II, delayed complications after an initially successful childhood repair; and III, no previous repair. Most patients were category I (58.2%); however, seven patients (12.7%) were category III. Balanitis xerotica obliterans (BXO) was more common in this subgroup compared with other categories (42.9% vs 8.3%, respectively, P= 0.037). In two of the three patients in category III with BXO, the stricture length was longer than 7 cm. • Adults with hypospadias represent a heterogeneous group. More than half of adults with complications related to hypospadias have had multiple operations (category I) representing one of the most difficult challenges to the reconstructive urologist. • Roughly 30% of patients undergo an initially successful repair in childhood with recurrent problems in adulthood (category II), suggesting that the outcomes of repair may not be as durable as estimated by studies with shorter-term follow-up. • Finally, BXO is over-represented in men with hypospadias who have not previously undergone repair, which contradicts the previous suggestion that the risk of BXO is related to the use of skin grafts/flaps from previous repairs and suggests that there may be an increased risk of severe stricture disease in patients who have never undergone corrective surgery for this anomaly.

Urethroplasty for urethral strictures: Quality assessment of an in‐home algorithm

To evaluate the outcome of different techniques of urethroplasty and to assess the quality of an in-home algorithm. Two hundred fifty-two male patients underwent urethroplasty. Mean patient's age was 48 years (range 1-85 years). Data were analyzed for the failure rate of the different techniques of urethroplasty. An additional analysis was done based on an in-home algorithm. Median follow up was 37 months (range: 6-92 months). Global failure rate was 14.9%, with an individual failure rate of 11.7%, 16.0%, 20.7% and 20.8% for anastomotic repair, free graft urethroplasty, pedicled flap urethroplasty and combined urethroplasty, respectively. In free graft urethroplasty, results were significantly worse when extrapreputial skin was used. Anastomotic repair was the principle technique for short strictures (83.3%), at the bulbar and posterior urethra (respectively 50.8 and 100%). Free graft urethroplasty was mainly used for 3-10 cm strictures (58.6%). Anastomotic repair and free graft urethroplasty were more used in case of no previous interventions or after urethrotomy/dilation. Pedicled flap urethroplasty was the main technique at the penile urethra (40.7%). Combined urethroplasty was necessary in 41 and 47.1% in the treatment of, respectively, >10 cm or panurethral/multifocal anterior urethral strictures and was the most important technique in these circumstances. Two-stage urethroplasty or perineostomy were only used in 2% as first-line treatment but were already used in 14.9% after failed urethroplasty. Urethroplasty has good results at intermediate follow up. Different types of techniques must be used for different types of strictures.

Two-Staged Urethroplasty: Buccal Mucosa and Mesh Graft Techniques

The purpose of this study was to describe indications, the operative technique and results of the two-staged buccal mucosa (BM) and mesh graft urethroplasty for treatment of urethral strictures. Between 3/1993 and 12/1999, urethral reconstructions were performed in 267 consecutive patients (group I), including 68 mesh graft urethroplasties (25 %) and 30 BM urethroplasties (12 %). Between 1/2000 and 8/2004, additional 249 urethroplasties were performed: Of those, 12% were mesh graft and 50% BM urethroplasties (group II). In patient group I, stricture recurrence was found to be the main complication of both procedures (BM 17 %, mesh 16 %). However, erectile dysfunction and curvature only occurred in the mesh graft group with 4% and 9 %, respectively. Patient satisfaction was high in both groups (BM 96.7%, mesh 83.3%). Between 1/2000 and 8/2004 (group II) the number of BM urethroplasties increased to 50%, whereas the number of mesh graft urethroplasty decreased (12%). More than 80% of the patients were satisfied with the results. Long strictures with severe spongiofibrosis represent an indication for two staged urethro-plasty (BM and mesh graft). Excellent results can be achieved with both techniques with a similar rate of complications. The mesh graft technique remains the last option for a complex patient group.

Clinical Outcome and Quality of Life Assessment in Patients Treated With Perineal Urethrostomy for Anterior Urethral Stricture Disease

We performed a quality of life assessment for patients treated with perineal urethrostomy for anterior urethral stricture disease. We retrospectively reviewed 173 patients (median age 55 years) who underwent perineal urethrostomy (from 1978 to 2007) as part of a plan for a staged urethroplasty repair for a complex anterior urethral stricture. The perineostomy was made using flap urethroplasty. The clinical outcome was considered a failure when postoperative instrumentation was needed. A questionnaire was used to evaluate patient quality of life and satisfaction. Stricture etiology was unknown in 50.3% of the cases, lichen sclerosus in 17.3%, catheter in 13.3%, instrumentation in 8.7%, failed hypospadias repair in 4.6%, trauma in 4.1% and infection in 1.7%. Stricture length was 1 to less than 2 cm in 1.2% of cases, 2 to less than 3 cm in 3.5%, 3 to less than 4 cm in 12.1%, 4 to less than 5 cm in 13.8%, 5 to less than 6 cm in 7.5%, greater than 6 cm in 4.1% and panurethral in 57.8%. Of 173 patients 91 (52.6%) underwent prior urethroplasty. Median followup length was 62 months (range 12 to 361). Of 173 cases 121 (70%) were successful and 52 (30%) were failures, requiring revision of the perineostomy. Of 173 patients 135 (78%) were satisfied with the results obtained with surgery, 33 (19.1%) were very satisfied, 127 (73.4%) with a median age of 57 years (range 23 to 85) refused to do the second stage of urethroplasty and 46 (26.6%) with a median age of 47.5 years (range 27 to 72) are currently on a waiting list for the second stage of urethroplasty. Perineostomy is a necessary procedure for patients with complex urethral pathology and satisfaction rates are high.

Histological evaluation of an alternative method of neophalloplasty based on two lower abdominal skin flaps and simultaneous buccal mucosa graft in the ventral surface of the neophallus (two-stage urethroplasty): Experimental study in rabbits

To evaluate, in an experimental study in rabbits, a new model of neophalloplasty based on two lower abdominal skin flaps and ventral buccal mucosa graft for planned two-stage urethroplasty procedure. Sixteen rabbits were operated and divided into four equal groups which were sacrificed at 2, 4, 8 and 12 weeks. The inflammatory pattern, presence of sub-epithelial fibrosis and epithelial changes in the grafted area were evaluated histologically. There were no deaths and no dehiscence of the wound was seen. One animal in the 2-week group developed an ulcer in the grafted area. We found minimal contracture of the neophallus, but this was not statistically significant between groups. Buccal mucosa graft showed good uptake in all groups, with vascular support from subcutaneous tissue of the flaps. The grafted area developed epithelial metaplasia, showing a decrease in cell layers with time, with disappearance of the sub-epithelial papillae and appearance of stratum granulosum and keratinization of the epithelial graft surface. A decrease in sub-epithelial fibrosis with replacement of immature by mature (eosinophilic) collagen was found. In the later groups was also observed an important decrease in inflammatory response, and the chorion of the grafted area presented a dilated capillary network, indicating that the process of neoangiogenesis was effective. Buccal mucosa displayed histological integration in the abdominal flaps with epithelial metaplasia in all groups. The surgical aspect of the neophallus was cosmetically acceptable, with minimal contracture.

Lingual Mucosal Graft Urethroplasty for Anterior Urethral Reconstruction

ObjectiveEvaluate the use of lingual mucosal graft (LMG) in anterior urethral strictures. MethodsFrom January 2001 to December 2006, 29 men (mean age, 48.5 yr) with anterior urethral strictures underwent graft urethroplasty with LMG. The mean length of stricture was 3.6cm. Patients with bulbar, penile, or bulbopenile strictures received one-stage dorsal free graft urethroplasties. In patients with failed hypospadias repair we performed a two-stage urethroplasty. Criteria for successful reconstruction were spontaneous voiding with no postvoid residual urine and no postoperative instrumentation of any kind. Clinical assessment included the donor site morbidity. ResultsMean follow-up was 17.7 mo. One-stage bulbar and penile urethroplasties without meatal involvement had an 81.8–100% success rate. Bulbopenile urethroplasties were successful in 60% of the cases, whereas one-stage urethral reconstructions in patients with meatal involvement were successful in 66.6%. The two cases of two-stage urethral reconstruction with LMG and buccal mucosal graft after failed multiple hypospadias repairs were unsuccessful. The overall early recurrence rate was 20.7%. Patients with the graft harvested from the tongue reported only slight oral discomfort at the donor site and difficulty in talking for 1 or 2 d. ConclusionsThe mucosa of the tongue, which is identical to the mucosa of the rest of the oral cavity, is a safe and effective graft material in the armamentarium for urethral reconstruction with potential minor risks of donor site complications. LMG may be used alone for short strictures (<5cm) or in combination with buccal mucosa when longer grafts are needed.

The modified Koyanagi hypospadias repair for the one-stage repair of proximal hypospadias

Perineal and penoscrotal hypospadias were often managed by two-stage urethroplasty with variable results and significant number of these may need third surgery. Though modified Koyanagi one-stage repair has a learning curve, it has all the advantages of two-stage repair. The aim was to review the results of modified Koyonagi repair from the literature and our own centre experience.

General considerations in hypospadias surgery

Nonsystemic review of the literature was done for timing of surgery, preoperative evaluation and plan, anesthesia, suture materials, magnification, tissue handling, stent and diversion problems, intra and postoperative care, dressing, and follow-up protocol. The best time for hypospadias repair is between 6 and 18 months. Preoperative evaluation in proximal hypospadias includes hormonal and radiological examination for intersex disorders, as well as for upper tract anomalies along with routine evaluation. General anesthesia is a rule but local blocks help in reducing the postoperative pain. Magnification, gentle tissue handling, use of microsurgical instruments, and appropriate-sized stent for adequate period help in improving the results. Hormonal stimulation is useful to improve growth and vascularity of urethral plate and decrease the severity of chordee in poorly developed urethral plate with severe curvature. Urethral plate preservation urethroplasty with spongioplasty is the procedure of choice in both proximal and distal hypospadias. Algorithms are proposed for management of hypospadias both with curvature and without curvature. Two-stage urethroplasty has its own indications. A good surgical outcome may be achieved following basic surgical principles of microsurgery, fine suture materials, choosing one or two-stage repair as appropriate, proper age of surgery, and with good postoperative care. Future of hypospadiology is bright with up coming newer modalities like laser shouldering, robotics, and tissue engineering.

Musculocutaneous Latissimus Dorsi Free Transfer Phalloplasty in Children and Adolescents

Purpose Total phalloplasty in children generates a great dilemma concerning indications as well as neophallic size. Evaluating long-term results of total phalloplasty using different flaps with poor results regarding penile size, we developed a technique using a latissimus dorsi free flap in children with micro or absent penis and difficult psychological problems. Material and methods In the period from April 2001 until June 2006, total phalloplasty was performed in 14 patients aged between 10 and 18 years. Indications were micropenis (3), intersex (1), small penis after epispadias (6) or hypospadias repair (1) and absent penis after epispadias repair (2) or trauma (1). Musculocutaneous latissimus dorsi free flap was harvested with a long pedicle, transferred to the recipient area and anastomosed to the femoral artery, saphenous vein and ilioinguinal nerve. Two-stage buccal mucosa urethroplasty was performed in 8 patients, while in the remaining 6 it was not indicated due to a different urinary diversion. An inflatable penile prosthesis enveloped in the vascular graft was implanted in 4 and a semirigid in 1 adolescent patient. Results Follow-up was from 5 to 66 months (mean: 23 months). Penile size was 13 to 16 cm in length and 10 to 14 cm in circumference. There was no partial or total flap necrosis. The donor site was closed directly with a good outcome in 5 and satisfactory in 6 patients, while in the remaining 3 a split-thickness skin graft was used with an unsatisfactory aesthetic appearance. All inflatable penile prostheses function normally. A remarkable improvement of the psychological status was noted in all children. Conclusions Phalloplasty in children is indicated in selected cases in order to diminish profound psychological trauma due to body dysmorphia. A musculocutaneous latissimus dorsi flap is our technique of choice that enables the formation of a neophallus in children with size as in adults.

Outcome of dorsal onlay buccal mucosa substitution urethroplasty in long strictures of anterior urethra

Background: The surgical treatment of adult anterior urethral strictures is constantly evolving. Controversy exists over the best means of reconstructing the anterior urethra. Methods: Twelve patients underwent buccal mucosal urethroplasty for long segment anterior urethral stricture between 2003 and 2005. Eleven patients with a salvageable urethral plate were treated with one stage dorsal onlay urethroplasty, using a perineal or circumcoronal incision. One patient with a severely scarred urethral plate underwent two-stage urethroplasty. Results: At a mean follow up of 14.2 months (range 2 to 26) one (8.3%) patient had short recurrent stricture, which was treated with optical urethrotomy. The mean maximal urine flow rate improved from 8.3 ml/sec to 18.1 ml/sec after the surgery. There were no donor site complications. All patients had a normal slit like meatus and none had chordee or erectile dysfunction. Conclusion: In long stricture of anterior urethra, dorsal onlay buccal mucosa urethroplasty provides excellent intermediate term results with a normal, wide caliber urethra.

Scrotal Hitch Procedure to Prevent Apical Necrosis of Scroto-perineal Flap for Urethroplasty

To present our experience with scrotal hitch technique to prevent necrosis of apex of scroto-perineal flap during two staged open urethroplasty for long segment complex anterior urethral strictures. Over the past 6 years, 22 patients underwent two-staged urethroplasty at our institution. All the strictures were laid open during first stage along with scrotal hitch. The stitch was removed after 7 days. The flap was healthy in all 22 patients at the time of second stage. Neo-meatal stenosis was not seen in any of the patients. One patient had local site collection, which was cured by topical antibiotics. This technique is simple, cost effective, which minimizes the drag over the flap by the shaft of the Foley catheter and thus prevents its pressure necrosis. The technique is particularly helpful in cases of thick, bulky scrotum and does not cause any morbidity, instead allows for early, comfortable ambulation and obviates the need of cumbersome scrotal supportive dressings.

Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children

Objective Total phalloplasty is rarely performed in children due to the mutilation involved and the dilemma concerning neophallic size in children. We present a musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children with difficult psychological problems. Materials and methods Total phalloplasty was performed in eight boys aged between 10 and 15 years. Indications were small penis after failed epispadias repair (4), micropenis (3) and intersexuality (1). A musculocutaneous latissimus dorsi free flap was harvested with thoracodorsal artery, vein and nerve. The flap was transferred to the pubic region and anastomosed to the femoral artery, saphenous vein and ilioinguinal nerve. Two-staged urethroplasty was performed in five patients using buccal mucosa, while in the remaining three a Mitrofanoff channel had been created previously. An inflatable penile prosthesis was implanted in two cases after puberty. Results Follow-up was from 6 to 53 months (mean: 29 months). Penile size varied from 13 to 16 cm in length and from 10 to 12 cm in circumference. No flap necrosis, either partial or total, was noted. The donor site healed acceptably in four cases while in the remaining four moderate scarring occurred. Function of the penile prostheses is satisfactory. Psychological status is significantly improved in all children. Conclusion Phalloplasty in childhood is indicated to prevent profound psychological problems related to body dysmorphia. The musculocutaneous latissimus dorsi flap is a possible choice for phalloplasty in children that enables good neophallic size as in adults. We recommend this surgery to be performed before puberty to ensure optimal psychosexual pubertal development.

The treatment of complex urethral stricture greater than 8 cm long

To evaluate the selection of different procedures and the feasibility for the treatment of long segment urethral stricture. Seventy-six patients with complex urethral stricture greater than 8 cm long underwent different procedures of urethroplasty. Of them various mucosa grafts urethral reconstruction were adopted in 42 cases (colonic mucosal graft, n = 26; buccal mucosal graft, n = 10; bladder mucosal graft, n = 6); One-stage pedicle flaps urethroplasty in 20; two-stage urethroplasty of Johanson procedure in 12; and penile urethra-prostatic urethra anastomosis, three-stage urethroplasty in 2. In early followed up (within 6 months postoperatively), 67 patients (88%) voided well and complications developed in 10. Among the 70 patients who lasted more than 1 year after operation, 51 cases were followed up. Forty-four patients voided well, and complications developed in 8. Of the 8 cases urethral restructure developed in 2 (18%) for pedicle flaps urethroplasty, 2 for colonic mucosal urethroplasty (9%), 1 for buccal mucosal graft (1/7), 1 for bladder mucosal graft (1/3); penile chordee in 2 (2/5), and one of them was accompanied by hair bearing neourethra for two-stage urethroplasty of Johanson procedure. Colonic mucosal and buccal mucosal grafts urethroplasty are feasible procedures for the treatment of long segment urethral stricture, and Colonic mucosal graft urethroplasty may be considered when more conventional procedures fail or complicated urethral strictures greater than 10 cm long.