SELECTED ABSTRACTS

Pediatric Urology

046

Repair in Two Stages - the Best Option for Patients with Severe Primary Hypospadias

N. JOHAL*, T. NITKUNAN†, A. QTEISHAT†, K.J. O?MALLEY* and P.M. CUCKOW*
*Great Ormond Street Hospital; †Institute of Urology, London, UK

INTRODUCTION

The repair of severe hypospadias represents a major surgical challenge. After initial enthusiasm for single stage procedures, many paediatric urologists have turned to the alternative two-staged approach after experiencing disappointing results. This alternative approach has been advocated by Bracka and arises out of procedures originally described by Clouthier, Duplay and Turner Warwick. One surgeon?s experience in primary hypospadias repair is reported.

PATIENTS

Between 7/98 and 6/03, 104 boys underwent a two-staged reconstruction of which 62 were primary repairs. Indications for staged repair included: proximal meatus [mid-shaft (18 patients), peno-scrotal (23), or perineal (2)], severe chordee [31 pts], poor glans groove and BXO. Inner prepuce was the graft of choice. Mean age was 37.6 months at completion of surgery and mean follow-up was 30 months.

RESULTS

All grafts took well and none of the 62 required revision. One patient developed a haematoma. Maturation of the graft for at least 6 months ensured the best conditions for second stage closure. Parents described the cosmetic and functional results as ?good? or ?excellent? in 85% of cases after completion of surgery. Complications included partial glans dehiscence (3 pts), residual mild ventral curvature (3), and meatal stenosis (3).

CONCLUSIONS

Two-staged repair has proved a reliable and reproducible technique with a low complication rate in a difficult cohort of hypospadias patients. Inner preputial skin grafts take very successfully on the ventral surface of the penis and splitting the glans enables a slit-like meatus to be achieved in most cases. Excellent cosmetic results can be anticipated.

047

The Island Tube and Island Onlay Hypospadias Repairs Offer Excellent Long-Term Outcomes a 14-year Follow-Up

H.M. SNYDER, A.R. SHUKLA and R.P. PATEL
Children?s Hospital of Philadelphia, Philadelphia, USA

INTRODUCTION

We have utilized an inner preputial flap as a transverse island tube (IT) for the one-stage repair of proximal hypospadias when the urethral plate cannot be preserved and as an island onlay flap (IO) when the urethral plate can be preserved for over 20 years at our institution. We report long-term follow-up and an outcome comparison of these two techniques.

PATIENTS AND METHODS

We retrospectively reviewed our records for all patients that underwent proximal hypospadias repair with either the IT or IO procedure between 1980 and 1990 by one surgeon. We randomly contacted these former patients, blinded to the surgeon, to undergo a long-term outcomes review, follow-up examination, and uroflowmetry.

RESULT

Patient information could be retrieved for a total of 73 patients that underwent an IT or IO procedure during the defined time interval. We were able to contact 49 of these former patients and 30 patients agreed to participate. The IT and IO repairs were performed on 14 and 16 boys with proximal hypospadias, respectively, at a mean age of 16.8 months. At a mean follow-up of 14.2 years for both groups (144 to 253 months), two boys in the IT group (14.2%) and none having IO had developed a fistula requiring repair. Distal stenosis requiring meatoplasty occurred in 1 and 2 patients in the IT and IO groups, respectively. Urolflowmetry in 11 patients in the IT group and 14 patients in the IO groups showed mean maximal flow rates (Q_max) of 17.3 mL/s and 21.8 mL/s (P = 0.343), and mean post-void residuals (PVR) of 5.0 mL/s and 2.36 mL/s, respectively (P = 0.249).

CONCLUSIONS

Unlike other forms of substitution urethroplasty, vascularized flaps based on preputial skin appear to be unique in that they do not have a long-term stricture rate. The IT and IO repairs provide excellent longterm cosmetic and functional results. As the IT does have a higher incidence of postoperative complications, we have continued to extend our application of the IO to more proximal hypospadias repairs with continued success.

048

Is Real Complete Disassembly Technique Lengthen Epispadiac Penis?

S. PEROVIC and M. DJORDJEVIC
Department of Urology, 11000 Belgrade, Serbia

INTRODUCTION

Penile disassembly for epispadias repair was first described by Mitchell. We developed technique which is based on total separation of corpora cavernosa from glans cap, neurovascular bundles and urethral plate to obtain totally free corporeal bodies for straightening and lengthening procedures.

MATERIALS AND METHOD

During the period from October 1995 to March 2003, the technique was performed on 19 patients, aged 2 days to 39 years. Penile disassembly includes complete separation of the corporeal bodies from glans cap with neurovascular bundles and urethral plate. Neurovascular bundles, short urethral plate and dorsal chordee could be limiting factors for penile lengthening. Complete mobility of separated corpora cavernosa is achieved only after mobilization of the neurovascular bundles up to the pubic bones. If urethral plate is short it must be divided. Dorsal chordee is corrected by grafting of dorsal side in order to avoid penile shortening. The tips of the corporeal bodies are fixed to the most distal part of the hemiglanses cap using Ushaped suture. Proximally, each corpora cavernosa is fixed to the penile base skin to avoid postoperative retraction of the lengthened penis. Penis is reassembled into normal anatomical relationships.

RESULTS

Follow up was from 6 months to 8 years (mean 3.6 years). Dorsal curvature was corrected in all cases with satisfactory penile length.

CONCLUSION

Good results in urethroplasty and penile straightening are not sufficient to consider successful epispadiac repair. Final successful outcome depends on the penile length as well. Our technique represents an advance in lengthening of epispadiac penis.

049

Total Phallic Construction for Micropenis

D.J. RALPH and A.N. CHRISTOPHER
Institute of Urology, London, UK

INTRODUCTION

This paper describes the management of micropenis by total phallic construction.

PATIENTS AND METHODS

Seven men, with a mean age of 25 years, who had had multiple operations for micropenis in childhood are included. The original diagnoses were exstrophy/epispadias (n = 3), pseudohermaphrodite (n = 1), androgen insensitivity (n = 1), bilateral orchidectomy (n = 1) and androgen deficiency following chemo-radiotherapy (n = 1). The phallus was fashioned using a forearm free flap in six patients and an abdominal flap in one patient. To maintain erogenous sensation, the glans penis was incorporated into the ventral surface of the neophallus in all cases. A phallic urethra was formed in four patients. A neo-glans has been fashioned in four patients and an inflatable AMS 700CX penile prosthesis inserted in five patients.

RESULTS

All patients are very satisfied with the cosmetic appearance of the phallus and the four patients with a urethral reconstruction can void standing and are dry. All penile prostheses are in a good position with four patients having regular sexual intercourse. Multiple complications and subsequent revision operations were needed to obtain these results. Anastamotic urethral strictures were revised in three of four patients, and prosthesis revision was needed in three patients due to poor cylinder position (n = 2) or to infection (n = 1). Wound infections occurred in three patients.

CONCLUSION

Total phallic construction for micropenis can change the life of young men by allowing them to stand to void and to have sexual intercourse. The long-term results are excellent but patients must be warned of the high complication rates.

050

Psychosocial and Sexual Function in the Young African Adult with True Intersex

S. GARG, C.M. JAYACHANDRAN, P. MADHUVRATA, S. UNDRE and S.K. GARG
Hammersmith Hospital, London, UK

METHODS

Fifty-five cases of ambiguous genitalia were studied prospectively over a 10-year period.

INTRODUCTION

A high incidence of true intersex is seen amongst the West African population. 60% present post puberty making management difficult. Our aim was to establish guidelines for the management of post pubertal true intersex in West Africa. Investigations performed were including buccal smear, urinary ketosteroids, semen analysis, urogenitogram, urethroscopy, pelvic laparotomy and gonadal biopsy.

RESULTS

Fifteen of 25 patients with true intersex presented after puberty. Histology showed 53% ovotestes, 30% ovaries, and 17% testicles. Twelve were living as males, seven of whom had a uterus and fallopian tube and were offered gender reassignment though none of them opted for it. The three living as females had well developed uterus and fallopian tubes Gonads appropriate to the assigned gender were retained. Mastectomy and hypospadias repair was performed in the males. Three of the five males without any female genital organs achieved normal libido, penetration and ejaculation. Of the seven males with female genital organs, one reported psychosocial problems and only one reported normal libido and penetration without ejaculation. All three females had vaginoplasty. One achieved pregnancy, and one became sexually active.

CONCLUSIONS

Psycho-social aspects are prime considerations in gender assignment. In male patients with functional female genital organs better sexual function maybe possible by reassigning gender. Male to female reassignment in post-pubertal patients is not socially acceptable in West Africa. The absence of well developed mullerian structures predicts male sexual function.

051

Does the Type of Lithotriptor Used Affect Treatment Outcome in Paediatric Urinary Tract Calculi?

A.R. RAZA, S.A. MOUSSA, G.S. SMITH and D.A.T. TOLLEY
Western General Hospital, Edinburgh, UK

INTRODUCTION

ESWL is well established in the treatment of urinary tract calculi in children. We report our experience with two different lithotriptors.

PATIENTS AND METHODS

Retrospective case note and X-ray review of children undergoing lithotripsy with the Wolf Piezolith (2300) 1988?98 and Dornier Compact Delta electromagnetic lithotriptor 1999?present. Kub ± ultrasound of renal tract performed 1?3 months post ESWL to assess stone-free status.

RESULTS

122 children: (140 renal units) m:f 82:40, age 11 months-15 years (mean 7.7 years). 28 (23%) urological/congenital abnormality, 7 (6%) metabolic abnormalities, 92% stones unilateral (left = right). Wolf Piezolith (2300): 102 renal units (75 GA sessions), stone size range 3?110 mm (mean = 27 mm) overall ancillary procedure rate 8%. stone free % for stones <20 mm (79%), for stones >20 mm and complex calculi (42%). Compact Delta: 38 renal units (40 GA sessions), stone size range 3?35 mm (mean = 20 mm), overall ancillary procedure rate 7%, stone free % for stones <20 mm (87%), for stones >20 mm and complex calculi (41%). The overall complication rate (both lithotriptors) was 26%. 9 children developed steinstrasse with 4 (44%) requiring ancillary procedures for clearance.

CONCLUSION

There was no significant difference in stone free, ancillary procedure or complication rates between the lithotriptors although the percentage requiring ga sessions was higher with the Compact delta. There was a significant decrease in stone free rate for both lithotriptors as stone complexity and burden increased.