Urethral Plate Research Articles

Megameatus intact prepuce and associated anomalies

Objective: Megameatus intact prepuce is described as subset of megalourethra or distal hypospadias by several authors. Despite suggested different operative techniques, some authors prefer not to operate this variant of penile anomaly. We aimed to evaluate 31 patients operated due to megameatus intact prepuce and associated anomalies .
 Material and methods: Thirtyone patients operated between 2008-2018 for MIP were evaluated retrospectively. All data were collected from hospital records. Patient age, application reasons, raphe anomalies, associated genitourinary and extragenitourinary pathologies, operative techniques, and postoperative complications were analyzed. 
 Results: Mean age was 50 months (8-128 months). Ten of the patients had raphe anomalies. Genital raphe hyperpigmentation was seen in 1 patient, raphe deviation and bifurcated raphe was seen in6 and 3 patients respectively. Genitourinary anomalies were detected in 7 patients, bilateral undescended testes in 1 patient, penile chordee in 2 patients, ureteropelvic junction obstruction in 2 patients, penoscrotal web in 1 patient, nocturnal enuresis in one patient. Tubularized incised plate urethroplasty (TIPU) (n=5), tubularized urethral plate urethroplasty (TUPU)(n=16) and meatoplasty (n=10) were the operative techniques.
 Conclusion: . Co-occuring raphe anomalies should arise awareness of MIP among the clinicians who are engaged with the children’s medical conditions and also the possible anomalies especially in the societies which circumcision is not traditionally required. Further studies with large number series needed for better understanding of this pathology.

Spleno-adrenal fusion mimicking an adrenal metastasis of a renal cell carcinoma: A case report and embryological background

Foci of splenic tissue separated from the spleen can occur as a congenital anomaly. Isolated nodules of splenic tissue are called accessory spleens or spleniculli. However, nodules of splenic tissue can merge with other organs during embryonic development, in which case we speak of spleno-visceral fusions: most often, they merge with the tail of the pancreas (thus forming spleno-pancreatic fusion or an intrapancreatic accessory spleen), with the reproductive gland (i.e., spleno-gonadal fusion), or with the kidney (i.e., spleno-renal fusion). Our case report describes the fusion of heterotopic splenic tissue with the right adrenal gland, which was misinterpreted as a metastasis of a renal cell carcinoma. To the best of our knowledge, this is the first reported case of spleno-adrenal fusion. Spleno-visceral fusions usually represent asymptomatic conditions; their main clinical significance lies in the confusion they cause and its misinterpretation as tumors of other organs. We believe that the cause of retroperitoneal spleno-visceral fusions is the anomalous migration of splenic cells along the dorsal mesentery to the urogenital ridge, together with primitive germ cells, at the end of the fifth week and during the sixth week of embryonic age. This theory explains the possible origin of spleno-visceral fusions, their different frequency of occurrence, and the predominance of findings on the left side.

THE OUTCOME OF LONGITUDINAL DORSAL ISLAND FLAP FOR REPAIR OF HYPOSPADIAS IN CIRCUMCISED PATIENTS AND THOSE WITH FAILED PREVIOUS REPAIR

Patients with penoscrotal, proximal shaft and mid shaft hypospadias who were previously circumcised or patients with insufficient urethral plate such as those with severe chordee that cannot be corrected just by simple degloving, or failure of previous hypospadias repair, such patients represent a challenge for subsequent repair and appropriate procedure choice. The aim of this study is to assess the outcome of longitudinal dorsal island flap (LDIF) by both onlay and tubularized repair for patients with hypospadias who were previously circumcised or had poorly developed urethral plate. This prospective study was done on 36 patients who had penoscrotal, proximal and mid shaft hypospadias and were previously circumcised or had poorly developed urethral plate. Twenty four of them were operated upon by using onlay LDIF and 12 patients by using tubularized LDIF. Patients were followed-up for 12 months to look for any complication for these 2 types of surgeries and for assessing the functional outcome of the repair. The success rate for onlay LIDF was 75% and for tubularized LIDF was 58.33%. Overall complications occurred in 11 (30.55%) children. In conclusion, LDIF can be used successfully for repair of hypospadias in circumcised children or those with failed previous repair. Keywords: Hypospadias, LDIF, failed repair, tabularized incised plate urethroplasty

Modified Snodgrass Repair for Hypospadias: Outcome at a General Surgical Unit

Background: Hypospadias occurs in around one in 200-300 male live births and is the most common congenital abnormality of the urethra. There are three characteristic features; Firstly the external meatus opens on the underside of the penis or the perineum, secondly the ventral aspect of the prepuce is poorly developed ('hooded prepuce') and thirdly there is usually a ventral deformity of the erect penis (chordee). Many methods have been used to repair hypospadias. We worked on Modified Snodgrass repair for mid-shaft and distal hypospadias in a General Surgical Unit. Objective: To study the outcome of Modified Snodgrass Repair with respect to outcome and post operative complications like fistulas, disruption, meatal stenosis, residual chordae ,penile torsion and infections.Material and Methods: All patients with hypospadias according to exclusion and inclusion criteria admitted to Surgical B unit of Saidu Teaching Hospital from 1st January 2015 to 21st December, 2019 were entered in the study. U shape incision was made around the urethral plate. Urethral incisions were extended to the mid-glans. Urethral plate was incised in center upto midglans. After tubularization of urethral plate and circumferential incision proximal to coronal sulcus from each edge of urethral plate, the penile skin was degloved upto or near to penoscrotal junction depending upon extent of chordee. Neourethra was formed and covered by Dorsal Dartos facial flap which was slit in the centre and brought out to ventral surface by passing the glans through the slit. The child was followed after a week to change dressing and after 10 days to remove catheter and then after one month and three months for checking complications and outcome.Results: Total of 100 subjects were included in study,(67%) having anterior and (43%) having middle hypospadias. Mean age was 3.7 years. Complications were recorded in 21% of patients. Urethro cutaneous fistula in 9%, Total disruption in 1%, Infections in 5%, Meatal stenosis in 2% ,Catheter blockage in 2% and penile torsion occurred in 2% of patients. 97% cases had good cosmetic shape. The fistulas were repaired after 6 months in two layers and had satisfactory results.Conclusion: A properly performed Modified Snodgross repair can be performed in General Surgical Unit with reasonable efficacy if expertise is available

Challenging proximal hypospadias repairs: An evolution of technique for two stage repairs

Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars' flaps. A single institution, retrospective, cohort study of consecutive two-stage, primary, proximal hypospadias repairs performed from 2007 to 2017 was conducted. Patients with <6 months follow-up and incomplete operative reports were excluded. Risk of complications (fistula, dehiscence, diverticulum, meatal stenosis, stricture) were evaluated following urethroplasty and stratified by first-stage repair technique. As technique refinements have been made since 2012, comparisons between two temporal subgroups (those who underwent repair in 2007-2012 and in 2013-2017) were made. 78 of 127 patients met inclusion criteria. Overall complication rate was 47% (Summary Table). Median follow-up was 25.4 months (range 6.4-128.5 months) after urethroplasty. Pedicled preputial flaps (hazards ratio [HR] 0.30; 95% Confidence Interval [CI] 0.14-0.65) and inlay grafts (HR 0.32; 95% CI 0.11-0.95) were associated with lower complication risks compared to Byars' flaps (Summary Table). Median time to complication was significantly shorter for Byars' flaps (5.7 months) than for inlay grafts (40.6 months) and pedicled preputial flaps (79.2 months) by Kaplan Meier analysis. Temporal subgroup comparisons showed that overall complication rates decreased from 70% to 31% (p=0.001), but differences in complication rates by first-stage technique were not statistically significant. In our cohort, repairs with Byars' flaps had the highest complication rate, which is consistent with our observations that urethras tubularized from Byars' flaps lack appropriate backing and are hypermobile and irregular. To overcome these shortcomings, modifications were made to our approach to two-stage proximal hypospadias repairs with the use of inlay grafts and pedicled preputial flaps quilted to the underlying corporal bodies to optimize the stability of the urethral plate. Our preliminary results are promising. Approach to the first stage of two-stage repairs affects outcomes. Pedicled preputial flaps and inlay grafts were associated with lower complication risks than Byars' flaps. Refinement of technique and patient selection may have resulted in fewer complications in the short term. However, long-term follow-up is needed.

MANAGEMENT OF ANTERIOR HYPOSPADIAS, OUR EXPERIENCE WITH SNODGRASS REPAIR TECHNIQUE MARDAN MEDICAL COMPLEX MARDAN TEACHING HOSPITAL

OBJECTIVE: To report on the short-term outcomes of anterior hypospadias tabularized incised plate urethroplasty,as reported by Snodgrass.MATERIAL AND METHODS: From January 2014 to December 2016, patients with anterior hypopadiaswithout chordae were the subjects of this research, which took place at the Mardan Medical Complex surgical department in Mardan. The research had 56 patients ages 3 to 13 years, with a mean age of 5.1. Anterior distal shafthypospadias with a healthy urethral plate was an inclusion criterion, while chordae and a history of prior surgery wereexclusion criteria. A new urethra was created around a size 6 to 8 Fr stent after the full length of the urethral platewas cut along the midline. Subdartos fascia covered the newly formed urethra. In every instance, sufratullae were usedfor pressure dressing.RESULTS: During the investigation, there were three complications: six cases (10.7%) of urethrocutaneous fistuladevelopment, four cases (7.1%) of meatal stenosis, and two cases (3.5%) of glandular dehiscence. In our research, theoverall rate of problems was 21.42%.CONCLUSIONS: For anterior hypospadias, the Snodgrass treatment has outstanding functional and estheticoutcomes. Comparing this operation to others, the incidence of complications is modest.KEYWORDS: Distal Hypospadias, Snodgrass repair.

Erectile dysfunction in patients undergoing multiple attempts at hypospadias repair: Etiologies and concerns

One-third of adult patients presenting for the repair of persistent penile defects after failing multiple hypospadias repair attempts during childhood will complain of erectile dysfunction (ED). The goal of this paper is to identify possible etiological causes of its onset. Five selection criteria were used for entrance into the study: 1) Patients had to have failed≥three prior hypospadias repair attempts. 2) Present for evaluation between 18 and 40 years of age. 3) No known congenital or medical anomaly could be present that could have predisposed to erectile dysfunction. 4) Sexual history inventory for men (SHIM-5 score) completed. 5) All patients with moderate to severe ED (SHIM scores≤16) underwent psychological screening; individuals with good quality spontaneous or self-stimulated erections, experiencing major life events, or had documented psychological problems were excluded from the study. One hundred consecutive patients meeting these criteria were assessed. We evaluated multiple factors to discern if they were associated with the onset of ED: the initial location of the urethral meatus, if a corporoplasty was performed, the type of corporoplasty used, if the urethral plate was divided or resected, the use of a ventral corporal graft, the total number of open reparative procedures performed before referral, the number of direct visual internal urethrotomies (DVIU) performed, the length of a urethral stricture at the time of the referral and whether lichen sclerosus was present. Statistical evaluations used chi-square analysis, two-tailed t-tests, or a logistic regression model where indicated, p-values < 0.05 were considered significant. 37% (37/100) of our patients complained of moderate to severe ED (SHIM score ≤16). Statistical analysis comparing patients with ED to those without ED (63%:63/100), revealed patients with ED were older, median age 34yrs (range 20-40) vs 26yrs (range 18-40) p=0.0212, had undergone division of the urethral plate 70.3% (26/37) vs 47.6% (30/63), p=0.0276, had placement of a ventral corporal graft, 24% (8/33) vs 1.5% (1/67), p=0.0003 or had undergone repetitive DVIU's to manage urethral stricture disease, median number 4 (range 0-15) vs 0 (range 0-6), p<0.0001, see table. The early onset of ED in patients that failed multiple attempts at hypospadias repair in childhood is associated with advancing age, division of the urethral plate, and prior ventral corporal grafting. Especially significant is the association of ED to the use of repetitive internal urethrotomy to manage urethral stricture disease.

The GUD technique: glandar urethral disassembly. An alternative for distal hypospadias repair.

ABSTRACTIntroduction We present an alternative procedure for distal hypospadias consisting of urethral mobilization and partial glandar disassembly, namely GUD (glandar urethral disassembly) technique.Materials and Methods A subcoronal circumcision exposes distal dysplastic urethra. We incise the Buck´s fascia on both sides of urethra releasing it partially from the corpora. We keep a thin bridge of urethral plate to the glans and disassembly almost completely the glans from the corpora, except for the bridge. The glans is incised creating two wide wings that are extremely mobile. The urethra is mobilized, advanced and sutured to the tip of the glans. The glans wings embrace the distal urethra producing a conical glans.Discussion The concept of urethral mobilization has been reported and popularized by Koff in the literature to correct distal hypospadias. One of the limitations of this procedure is the risk of urethral retraction due to extensive proximal dissection. We got inspiration from Mitchell and Bagli’ s work of penile disassembly in epispadias to develop the GUD concept. We adopt minimal urethral mobilization mainly in glandar/proximal penile shaft and complete deconstruction of the glans, detaching the corpora from the glans and rotating the wide glans wings to embrace the urethra. Therefore we avoid suture urethroplasty and refurbish the glans to a better conical shape.Conclusion We are convinced that this operation can be regarded as a genuine alternative to distal hypospadias (coronal and subcoronal) but should not be addressed to midshaft forms.

Recurrent ventral curvature after proximal TIP hypospadias repair

Most boys with proximal hypospadias have ventral curvature (VC) which must be straightened while preserving the urethral plate to use TIP repair. That is usually done by dorsal plication (DP). However, we reported recurrent VC was commonly found after DP in boys with proximal urethroplasty complications, and have diagnosed VC in patients similarly straightened by WS. We reviewed our proximal TIP patients and now report their recurrent VC. We used a prospectively-maintained database to identify all patients with proximal TIP by WS and document recurrent VC. Penile straightening was primarily done by midline DP using 5-0 or 6-0 polypropylene, and/or other maneuvers including combinations of urethral plate elevation off the corpora, mobilization of the urethra to the external sphincter, and ventral corporotomies. Recurrent VC was suspected by a characteristic 'hunched-over' appearance and resistance to lifting the glans cephalad (Figure), and confirmed in all cases by artificial erection intraoperatively. 58 of the 77 patients with follow up had VC straightened. Recurrent VC was diagnosed in 26%. It was suspected during this review in another 10% who had recurrent urethroplasty complications which we now know often indicate VC, or urethral plate elevation with no treatment for corporal disproportion. This recurrent VC was objectively measured in nearly half those diagnosed, averaging 52 (30-75). It was diagnosed before puberty in all cases. There was no difference in recurrent VC in those managed with DP alone versus those straightened by DP and/or other maneuvers. The finding that 1 of every 4 patients had recurrent VC after proximal TIP, and that as many as 1 of every 3 might have had that complication, is concerning. During most the study the extent of VC was visually estimated, and most patients were thought to have <45° with no tension on the UP after straightening. We reported 70% of patients operated elsewhere for proximal hypospadias and presenting with urethroplasty complications had recurrent VC≥30° following earlier DP. In that series, in the current patients, and in an earlier report by Braga etal., an intact urethral plate correlated with increased risk for recurrent VC. Despite our improved ability to diagnose recurrent VC, we have not found it in boys who underwent STAG repair with urethral plate transection. Recurrent VC after proximal TIP repair occurred in at least 1 of every 4 patients despite DP and/or additional maneuvers to straighten the penis while preserving the urethral plate. Accordingly, we now only perform proximal TIP when there is little (<30°) or no VC.

Narrow urethral plate augmentation in anterior and middle hypospadias repair: Onlay flap VS. Inlay graft. A prospective randomized comparative study

The measurement of the urethral plate width (as an objective parameter) and its effect of this width on the results of tubularized incised plate urethroplasty (TIPU) have been reported in two series and both authors reported that a urethral plate width<8mm is associated with higher complication rates. The augmentation of the urethral plate either by dorsal inlay graft urethroplasty (DIGU) or Onlay flap has been compared with the original TIPU in different degrees of hypospadias with better surgical results in augmented cases. To evaluate the surgical results of longitudinal Onlay preputial flap (LOF) vs (DIGU) techniques in augmentation of the narrow urethral plate. Primary anterior and middle hypospadias cases with narrow urethral plates were randomly allocated into two groups; group one operated by DIGU and group two operated by (LOF). The Success rate, individual complication rate, and operative times were compared. 39 cases completed the study. No significant differences in patients' characteristics were detected. In the DIGU group, one case (5.3%) complicated with fistula and glandular dehiscence wherein in the LOF group, 7 cases (35%) Complicated with 5 fistulae, 2 glanular dehiscences, one flap loss, one diverticulum (p= .02). No significant differences in the rates of individual complications. Variables affecting the success of hypospadias repairs are many. Urethral plate quality is an important variable among these variables. The definition of urethral plate quality is usually subjective. In the DIGU group, only 1/19 (5.3%) case had two complications, fistula and glandular dehiscence. Mouravas etal., in their comparative study between TIPU and G-TIP without mention of urethral plate width reported a significant reduction of the overall complications and urethral stenosis without significant reduction in fistula rate. In their G-TIP group, only 2 cases out of 24 (8.3%) were complicated with one fistula and one glandular dehiscence where in the TIPU group, 7 cases (30.4%) were complicated with one glandular dehiscence and 6 cases with urethral stenosis. In the LOF group, fistula in 5/20 cases (25%) was the commonest complication followed by glandular dehiscence in 2 cases (10%). Diverticulum and flap loss occurred in one case for each (5%). In the multivariate analysis of 474 patients' cohort by Spinoit etal., there were no significant differences between the risk of re-intervention after TIP and Onlay flap in anterior and middle hypospadias (25.8% vs. 18.8%), and (22.2% vs. 20%) respectively. Our data suggest that augmentation of the narrow urethral plate with DIGU has a better surgical outcome than with LOF. No significant difference in cosmetic outcomes detected.

A comparative study of two-stage versus single-stage repair of severe Hypospadias

Background: The main aim of hypospadias repair is to preserve the urethral plate whenever possible. This study was undertaken to compare the outcome of repair of severe hypospadias with moderate chordee by single-stage Snodgrass with two-stage repair with dermal graft corporoplasty. Methods: This prospective cross-section study was done in the Department of Urology, Chalmida Anand Rao Institute of Medical Sciences, Bommakal, Karimnagar. The selection of the patients the type of surgery was based on the type of case. A total of n=31 patients were operated for severe hypospadias out of which n=14 single surgeries and n=17 two-staged surgeries were performed. Results: N=25 patients were found with a moderate degree of chordee. No complications were found in n=11(78.57%) in single-stage repairs and two-stage repairs n=15(88.23%) were without complications the p values were found to be 0.012 which is significant. HOSE scores Erection correction was better in two staged surgeries as compared to single-stage repairs with p values &lt;0.001 which is considered significant. Conclusion: We can conclude that the repair of severe hypospadias with moderate chordee by two-staged repair showed better outcomes as compared to single-stage repair. The incidence of postoperative complications is also lesser with two-staged repairs. However, the choice of the procedure must be based on the type of hypospadias, choice of patients and economical constraints.

Transverse Preputial Island Flap for Hypospedias Repair: A Study in A Tertiary Level Hospital

Introduction: Hypospadias continues to be a challenging problem for reconstructive surgeon. As urethral plate preservation got an important role, transverse preputial island flap (TPIF) urethroplasty is one of the preferred technique for sub-coronal and distal penile hypospadius. Methods: This study was conducted at urology department, DMCH, from February, 2014 to June, 2017 where 15 patients underwent TPIF urethroplasty. Inner preputial flap with its pedicle was developed and separated from the dorsal penile skin which was sutured to the urethral plate in an onlay manner over a stent by running suture. Glanuloplasty and meatoplasty was done and skin closed.SPC was done in every cases. Dressing was checked on 5th POD, stent was removed after 03 weeks. SPC was removed 2 to 3 days after satisfactory voiding. All patients were followed up at 6th and 12th week. Results: Among the 15 patients age range was 2-14 years and mean age. Sub-coronal in 4 and distal penile was in 11 patients. Following TPIF urethroplasty wound disruption was noted in one patient for that glans closure was done successfully. There was no meatal stenosis and urethrocutaneous fistula in follow up. Regarding cosmetic outcome 12 were good, 2 were acceptable and 1 was poor. Conclusion: Success rate of TPIF urethroplasty in case of sub-coronal and distal penile hypospadias is excellent. Cosmetic outcome should be considered most challenging and with experience of surgeons this aspect will be improved. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.43-47

Identification of risk factors associated with numerous reoperations following primary hypospadias repair

Complications remain the top evaluation priority subsequent to hypospadias repair. Complications vary in further management, and usually require one or more reoperations. Patients and/or their parents concern not only with the success rate of reoperation, but also with the risk of numerous reoperations. To identify the risk factors associated with numerous reoperations following primary hypospadias repair. Data were collected retrospectively from patients who underwent reoperations for complications following primary hypospadias repair at a single institution from August 2008 to October 2017. A total of 507 patients required reoperations following 2754 primary hypospadias repairs. Eventually, 486 patients were eligibly included with a median age of 2.2 years. The median follow-up period was 6.5 years. Preserved urethral plate urethroplasty for primary repair (including Snodgrass, Onlay and Mathieu techniques) was performed in 307 (63.2%) patients, Duckett technique was performed in 121 (24.9%) patients, and staged urethroplasty (including staged Duckett, Byars and Bracka techniques) was performed in 58 (11.9%) patients. The complications included 302 fistulas, 108 dehiscence, 50 urethral strictures, 18 meatal stenosis, 38 diverticula, 24 mild recurrent ventral curvature and 23 severe recurrent ventral curvature. A total of 363 (74.7%) patients needed 1 reoperation, 87 (17.9%) needed 2 reoperations, 19 (3.9%) needed 3 reoperations, and 17 (3.5%) needed >3 reoperations. Ordinal logistic regression demonstrated that severe recurrent ventral curvature, urethral stricture, dehiscence and primary staged hypospadias repair increased the risk of numerous reoperations, with odds ratios of 75.991-fold, 36.967-fold, 11.765-fold and 3.074-fold, respectively. In contrast, diverticulum decreased the risk, with an odds ratio of 0.443-fold. Our data demonstrated significant heterogeneity in the risk of numerous reoperations for each complication. Severe recurrent ventral curvature conferred the highest risk of numerous reoperations, followed by urethral stricture, dehiscence. In additional, our data showed an increased risk of numerous reoperations following primary staged repairs. Identification the risk factors confers advantages in the assessment of postoperative outcomes and anticipation of future reoperations. Severe recurrent ventral curvature, urethral stricture, dehiscence and primary staged hypospadias repair were associated with numerous reoperations following primary hypospadias repair.

A CASE OF NEO-MEATAL STENOSIS AFTER PENECTOMY FOR PENILE CANCER, REPAIRED BY BLANDY PERINEAL URETHROSTOMY

Surgical resection is the standard treatment for the management of localized penile cancer and a neo-urethral meatus is generally created on the penile stump or perineum. Neo-urethral meatus is often stenosed and requires repeated transurethral manipulations such as dilation and urethrotomy. These procedures are generally futile and are associated with poor quality of life. Here, we report a case of penile cancer that developed a neo-meatal stenosis after total penectomy, which was subsequently salvaged by perineal urethrostomy using Blandy technique. A 72-year-old male who was diagnosed with localized penile cancer, underwent total penectomy and creation of neo-meatus on the perineum. Neo-meatus stenosis had developed in the patient and he received repeated urethral dilations without any success. Finally, when the patient was unable to void, he was referred to us for the amelioration of meatal stenosis through the placement of a suprapubic catheter. Because the condition of the residual bulbar urethra was adequate and its length was enough, we planned to create a non-transecting perineal urethrostomy by Blandy technique. An inverted U-shaped perineal incision was made, and a skin flap was created. The scarred neo-meatus and spongiofibrosis at the distal bulbar urethra were completely excised. The residual bulbar urethra was exposed, and a longitudinal ventral incision of 4 cm was made. The edge of the bare urethral mucosa and tunica albuginea of the corpus spongiosum were sutured by 4-0 PDS for hemostasis. The apex of the U-shaped skin flap was brought to the proximal margin of the urethrotomy and a tension-free anastomosis was created between the skin flap and the urethral plate. Thereafter, the skin of the perineum was sutured to the open longitudinal urethrotomy. The patient started to void on the 5th day post-surgery. The subject could void without the help of any intervention and did not require any instrument, sixteen weeks after the surgery.

Tubularized Reconstructed Plate Urethroplasty: An Alternative Technique for Distal Hypospadias Repair

OBJECTIVETo report current results of a new surgical technique, tubularized reconstructed plate urethroplasty (TRPU) in distal hypospadias repair which allows the tubularization of urethral plate without incision or grafting. METHODSThis study is a prospective single surgeon series. Between January 2019 and March 2020, total of 158 patients underwent hypospadias repair, and 29 selected patients had TRPU procedure. Demographic data, duration of follow-up, complications were recorded. A vertical incision is made starting from halfway up the glans. This incision creates a diamond like defect which enables wedge removal of a segment of spongiosum tissue from the base of urethral plate extending to the hypospadiac meatus. Vertical incision is closed horizontally. The urethral plate is stretched and loosened from the base and re-secured into its bed using quilting stitches. Reconstructed urethral plate ensures the required width to allow the formation of neourethra of adequate circumference, followed by a formal glansplasty. RESULTSPreoperative glans width was 13.4 ± 0.9 mm, urethral plate width was 6.1 ± 0.9 mm. Mean postoperative follow-up period was 13.6 months. All patients had successful functional outcome and cosmetically satisfying appearance. None of the patients required meatal calibration. The total complication rate was 3.4%. CONCLUSIONNative urethral plate itself is used as a natural flap to increase the surface area of the urethral plate in this new perspective of urethroplasty method. We believe that TRPU procedure provides an alternative approach for the formation of neourethra and it is a successful and relatively simple procedure with low complication rates, good cosmetic results and promising successful functional short-term outcome.

Complete Urethral Duplication With Epispadias in a Young Man: A Case Report

A 25 year male patient presented with the complaints of passage of urine through two openings on his penis, with deformities of penis since birth. After birth his parents noticed, when he micturates, urine comes through an opening on the proximal part of dorsal surface of penis in addition to the opening on the tip of glans penis. The penis is also a bit deformed and dorsal part of corona glandis is bifid. No treatment for the anomaly was taken. At puberty his testes, scrotum and other secondary sexual characteristics developed normally. He feels sexual attractions to opposite sex and experiences nocturnal emissions periodically. His penis erects on sexual stimulations, but bends upwards and at the peak of excitement orgasm also occurs and semen comes through the ventral orthotopic opening only. General physical examination was unremarkable, but external genitalial examination, shows, two external urethral meatus – one small pit like opening at the normal orthotopic position on the tip of glans penis and another on the dorsal surface of proximal penile shaft with epispadias and exposed urethral plate distal to this.. He had also dorsal chordee and ventral hooding with dorsal bifid glans penis. He had normally developed scrotum with normal both testes . Corpora cavernosa are developed but separated proximally. Spongiosa also developed and orthotopic anterior urethra can be palpated. Other systemic examinations revealed no abnormalities. Routine investigations like urine R/E, C/S, S.creatinine, blood sugar, CBC were normal. X-ray KUB revealed small separation of pubic symphysiis. USG of whole abdomen with KUB revealed significant PVR (77cc) with features of cystitis (sediments in bladder) with no other abnormality. RGU and MCU revealed duplicated urethra –with an accessory urethra arising from bladder neck, runs above the orthotopic one along the shaft terminating at the proximal part of dorsal penile shaft. The lower orthotopic urethra is normal with no stricture or abnormality except narrowing of the distal anterior urethra and external opening. Cystogram shows normal bladder with no VUR or divarticula except thickend wall. Urethrocystopic examination after dilatation of stenosed EUM of orthotopic (ventral) urethra showed normal anterior and posterior urethra containing sphincter and verumotanum and prostatic urethra opening into the bladder neck. Then cystoscope passed through the dorsal epispadiac urethra , which showed a less developed urethra, opening into the protruding bladder neck. Urinary bladder and ureteric orifices were normal . Then excision of accessory epispadiac urethra and the urethral plate done as high as possible near to bladder neck, followed by correction of chordee by ventral plication and repair of bifid corona glandis. He had an uneventful recovery ,though having a residual dorsal chordee, which was corrected by a second operation after 18 months, when excision of residual stump of accessory dorsal urethra followed by dermal graft repair of dorsal corporal body done. Bangladesh Journal of Urology, Vol. 21, No. 1, January 2018 p.48-51

Redo hypospadias repair by a single surgeon after failed hypospadias surgeries: Experience from a developing country

Background: Hypospadias surgeries are often complicated with fistulas, meatal stenosis and disruptions. We report our series of redo surgeries for failed primary repairs. Methods: We prospectively observed all the redo hypospadias repairs done by the principal author between 2013 and 2017. Thiersch-Duplayurethroplasty was done if the urethral plate was adequately wide and intact; tubularized incised plate (TIP) urethroplasty was performed if the urethral plate was intact but, narrower than 8 mm; 2 stage procedures were done with oral mucosal graft (OMG) if the urethral plate was deficient or scarred with significant chordee. Result: There was a total of 31 patients. Age ranged from 18 months to 15 years (mean 8.05 ±4.27 years). Sixteen (51.61%) patients underwent only one surgery, 10 (32.26%) patients underwent 2 surgeries, 2 patients (6.45%) underwent 3 surgeries, and 3 patients (9.68%) underwent 4 surgeries prior to presenting to us before our redo surgeries.We had performed TIP urethroplasty in 16 (51.61%) patients, meatal based flap urethroplasty in 12 (38.71%), OMG followed by urethroplasty in 2 (6.45%), and repair of urethra-cutaneous (UC) fistula in 1 (3.23%) patient. Ten (32.26%) Complications occurred in 8 (25.80%) patients. Unsuccessful repair was noted in 03 (9.67%) patients (UC fistula 1, glans dehiscence with UC fistula 1, and glans dehiscence 1). Conclusion: Thiersch-Duplay and TIP repair can be successfully performed in redo hypospadiassurgeries with acceptable complication rate. OMG graft can be reserved for cases with gross scarring of the urethral plate. Keywords: Failed hypospadias repair; Tubularized incised plate urethroplasty; Thiersch-Duplay; Outcome

A RARE CASE OF PRIMARY MEDIASTINAL CHORIOCARCINOMA IN A YOUNG MALE

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Choriocarcinoma is a trophoblastic tumor that can be gestational or secondary choriocarcinoma and non-gestational or primary choriocarcinoma (PCC). Mediastinal choriocarcinoma without a detectable primary is an extremely rare tumor with an annual incidence rate of 2.1 cases per 100,000 males. We present a case of primary mediastinal choriocarcinoma in a young male patient. CASE PRESENTATION: A 18-year-old male presented with cough, shortness of breath, high grade fever, night sweats for 2 weeks. Physical examination revealed bibasilar crackles and right upper quadrant tenderness. Labs showed elevated WBC, LFTs, ESR, CRP and LDH. Chest radiology showed bilateral lung masses with mediastinal and periaortic lymphadenopathy. CT chest abdomen and pelvis showed innumerable diffuse bilateral lung masses, large anterior mediastinal lymph nodes and small periaortic and paratracheal lymph nodes. MRI brain showed numerous supratentorial and infratentorial nodules. Infectious workup was negative. Ultrasound of testicle was negative for testicular mass. B-HCG were 699,181 mIU/ml but AFP was 0.7 ng/ml. CT guided biopsy of lung mass confirmed poorly differentiated stage 3C choriocarcinoma. Patient did not respond to different regime of chemotherapy and unfortunately passed away from multiorgan failure. DISCUSSION: PCC preferentially involves midline structures including central nervous system, pineal body, mediastinum, retroperitoneum, lung, and liver. Median age of occurrence is between 15 to 35 years. In PCC, arrest of gonadal cell migration happens somewhere along the urogenital ridge, where they remain dormant until an unknown stimulus causes them to develop into a tumor. Common presentations are dry cough, hemoptysis and dyspnea. It presents as a rapidly growing non-cavitating well-defined anterior mediastinal mass. Tumor cells release B-HCG, which is used as a tumor marker for diagnosis, staging and monitoring. Immunohistochemical staining is positive for both HCG and CAM 5.2. PCC is an aggressive angioinvasive tumor that metastasizes to the lung and brain. Early diagnosis is difficult due to its rare presentation and atypical symptoms. Diagnosis is made by high serum B-HCG and presence of mononuclear trophoblasts intermixed with syncytiotrophoblasts in biopsy. Unlike germ cell tumor, mediastinal choriocarcinoma has very poor prognosis. Bleomycin, etoposide and cisplatin regimen are being used as standard first line chemotherapy. CONCLUSIONS: Some studies showed an improved survival rate up to 2 years with surgery and chemotherapy. Considering poor prognosis more research needs to be done to explore newer chemotherapy/immunotherapy to improve survival rate. Reference #1: Zhang, S., Gao, H., Wang, X.-A., Liang, B., Li, D.-W., Shao, Y., & Jiang, S.-J. (2014, September). Primary choriocarcinoma in mediastinum with multiple lung metastases in a male patient: A case report and a review of the literature. Reference #2: Oncology, D. of. (n.d.). Male primary mediastinal choriocarcinoma with diffuse... : Medicine. Retrieved from https://journals.lww.com/md-journal/Pages/articleviewer.aspx?year=2019&issue=07120&article=00069&type=Fulltext DISCLOSURES: No relevant relationships by Miguel Conde, source=Web Response No relevant relationships by Hameeda khan, source=Web Response No relevant relationships by Pooja Raju, source=Web Response No relevant relationships by Ehsen Rao, source=Web Response No relevant relationships by Aditi Saha, source=Web Response

Comparative Study Between Tubularized Incised Urethral Plate and Tubularized Incised Plate with Preputial Graft in Hypospadias Repair

Background: Hypospadias is a common congenital anomaly, affecting approximately 1 of 300 live male births making hypospadias the second most common birth defect in boys after cryptorchidism. there are more than 100 techniques for urethral reconstruction among these techniques the tubularized incised urethral plate (TIP) which was proposed by Snodgrass in 1994 has been the most popular technique for the repair of primary hypospadias. Objective: To study the difference between tubularized incised urethral plate and tubularized incised plate with preputial graft in hypospadias repair. Patient and methods: This prospective randomized study included sixty patients suffering from hypospadias who was admitted to the urology department of Menoufia and Kafr El-Sheikh University Hospitals from December 2018 to June 2020 which were randomized into two groups; group I underwent the classic TIP repair and group II underwent TIP repair with inlay preputial graft. Operative details, postoperative complications were reported also uroflowmetry was done for all cases at the 3rd and 6th months postoperatively. Results: There was no significant difference between both techniques regarding the postoperative complications and overall success rate (P 0.718) which were 83.3% and 86.7% in A and B respectively. The uroflowmetry at 3rd month postoperatively showed no significant groups difference in Q max between both groups (p >0.05) while there was a significant improvement in Q max in the 6th month in the grafted group (p. 0.001) Conclusion: despite both the classic TIP repair and TIP with preputial graft were comparable according to the overall success rate and postoperative complications the grafted TIP was more superior to classic TIP in the functional outcomes which were assessed by the uroflowmetry (Q max).

Comparative Study Between Tubularized Incised Urethral Plate and Tubularized Incised Plate with Preputial Graft in Hypospadias Repair

Background: Hypospadias is a common congenital anomaly, affecting approximately 1 of 300 live male births making hypospadias the second most common birth defect in boys after cryptorchidism. there are more than 100 techniques for urethral reconstruction among these techniques the tubularized incised urethral plate (TIP) which was proposed by Snodgrass in 1994 has been the most popular technique for the repair of primary hypospadias. Objective: To study the difference between tubularized incised urethral plate and tubularized incised plate with preputial graft in hypospadias repair. Patient and methods: This prospective randomized study included sixty patients suffering from hypospadias who was admitted to the urology department of Menoufia and Kafr El-Sheikh University Hospitals from December 2018 to June 2020 which were randomized into two groups; group I underwent the classic TIP repair and group II underwent TIP repair with inlay preputial graft. Operative details, postoperative complications were reported also uroflowmetry was done for all cases at the 3rd and 6th months postoperatively. Results: There was no significant difference between both techniques regarding the postoperative complications and overall success rate (P 0.718) which were 83.3% and 86.7% in A and B respectively. The uroflowmetry at 3rd month postoperatively showed no significant groups difference in Q max between both groups (p >0.05) while there was a significant improvement in Q max in the 6th month in the grafted group (p. 0.001) Conclusion: despite both the classic TIP repair and TIP with preputial graft were comparable according to the overall success rate and postoperative complications the grafted TIP was more superior to classic TIP in the functional outcomes which were assessed by the uroflowmetry (Q max).