Ahmed T. Hadidi

Early elective cesarean delivery before 36 weeks vs late spontaneous delivery in infants with gastroschisis

PURPOSE The aim of this study is to assess the value of early elective cesarean delivery for patients with gastroschisis in comparison with late spontaneous delivery. METHODS Analysis of infants with gastroschisis admitted between 1986 and 2006 at a tertiary care center was performed. The findings were analyzed statistically. RESULTS Eighty-six patients were involved in the study. This included 15 patients who underwent emergency cesarean delivery (EM CD group) because of fetal distress and/or bowel ischemia. The remaining 71 patients born electively were stratified into 4 groups. The early elective cesarean delivery (ECD) group included 23 patients born by ECD before 36 weeks; late vaginal delivery (LVD) group included 23 patients who had LVD after 36 weeks; 24 patients had LCD after 36 weeks because of delayed diagnosis that resulted in late referral; and 1 patient had early spontaneous vaginal delivery (EVD group) before 36 weeks. The mean time to start oral feeding, incidence of complications, and primary closure were significantly better in the ECD group than in the LVD group. The duration of ventilation and the length of stay were shorter in ECD group, but the difference was not statistically significant. CONCLUSION Elective cesarean delivery before 36 weeks allows earlier enteral feeding and is associated with less complications and higher incidence of primary closure (statistically significant).

The slit-like adjusted Mathieu technique for distal hypospadias

PURPOSE The aims of this study were to describe the slit-like adjusted Mathieu technique (SLAM) for distal and midpenile hypospadias and report the midterm follow-up. MATERIALS AND METHODS Between January 2005 and December 2009, the SLAM technique was performed in 923 patients. The key modification is the design of a converging incision and the technique of suturing. Patient age ranged between 4 months to 30 years (mean, 1.5 years). The records of 872 patients who maintained regular follow-up were reviewed. The technique was performed in all forms of distal hypospadias, regardless of the size of the glans or the degree of glans clefting. Cutaneous chordee was corrected by skin mobilization. Follow-up period ranged from 22 months to 6 years (mean, 38 months). A transurethral catheter was used for 1 to 3 days. RESULTS AND COMPLICATIONS Satisfactory results were obtained in 848 patients (97%). Fourteen patients developed fistulae. Four patients developed meatal stenosis. Six patients had wound dehiscence. CONCLUSIONS The SLAM technique is a reliable technique for correction of distal and midpenile hypospadias with persistent good results. It avoids the drawbacks of the classic Mathieu (a transverse rounded meatus that is not terminal). Multiple-layer closure and careful attention to technical details contributed to a 3% complication rate in primary distal hypospadias.

Development of the human male urethra: A histochemical study on human embryos

PURPOSE Controversy persists regarding the formation of human penile urethra. The classic fusion theory for the development of the spongy urethra and ectodermal ingrowth or endodermal transformation theories for the development of the glanular urethra do not explain the wide spectrum of anomalies seen in patients with hypospadias. This histological study was made to clarify the mechanism of urethral development. MATERIALS & METHODS 15 human male embryos ranging from 6 to 14 weeks were studied. The phalluses were examined microscopically and photographed. Tissues were prepared as serial histological sections and stained with haematoxylin and eosin and with special immuno-histochemical stains. RESULTS 1) The penile urethra: At 6 weeks of gestation, the urethral plate which is solid distally and partially grooved proximally becomes grooved distally and has fused proximally by 8 weeks. At 14 weeks of gestation; the urethral opening migrates only to the middle of the shaft. 2) The glanular urethra: At the 6th week of gestation, a solid epithelial plate reached the tip of the genital tubercle, and a glans cannot be identified. At the 7th week, a central vacuolation appears and the penile urethral groove does not reach the tip of the phallus. At the 8th week; coronal sulcus starts to appear, and a well defined blind central canal was evident in the 13th week. During the 14th week, the floor of the glanular canal degenerated to form a glanular groove. CONCLUSIONS Our observations suggest that the spongy urethra passes through 3 stages of development: a solid epithelial plate, deep urethral groove, and fused urethra. The glanular urethra passes through 4 developmental stages: a solid epithelial plate, a blind central canal, a deep glanular groove, and the floor from the preputial lamella. There was no evidence of ectodermal ingrowth. These observations raise serious questions to the current theories for human urethra development. Further studies on fresh human embryos are needed.

Double Y glanuloplasty for glanular hypospadias

PURPOSE A double Y glanuloplasty technique is described for the repair of glanular hypospadias with mobile meatus. MATERIALS Ninety-seven children with glanular hypospadias and mobile meatus were operated on using this technique in the period from January 2003 to January 2009. Mean age of patients was 12 (range, 4-60) months. RESULTS Patients were discharged home within 3 days. The operation resulted in a slit-like meatus. Follow-up ranged from 8 months to 6 years (mean, 45 months). Good cosmetic and functional results were obtained in 94 patients. Complications occurred in 3 patients (3%). Two patients experienced meatal stenosis. This was corrected using ventral meatotomy. One patient suffered from dehiscence of the wound and retraction of the meatus. The meatal retraction was corrected using a modified inverted Y Mathieu technique. CONCLUSIONS The double Y glanuloplasty technique is suitable for appropriately selected patients with glanular hypospadias and mobile meatus. It provides a cosmetically natural vertical slit at the tip of the glans.

Proximal hypospadias with small flat glans: the lateral-based onlay flap technique

PURPOSE The lateral-based onlay (LABO) technique for patients with proximal hypospadias associated with flat glans and report of the follow-up. MATERIALS AND METHODS Between January 2004 and December 2010, the LABO technique was performed in 107 patients. The principle is to use the lateral foreskin adjacent to the glans as the onlay flap. Patient age ranged between 8 months and 2 years (mean, 11 months). The records of 98 patients who maintained regular follow-up were reviewed. All the patients had proximal hypospadias with flat or incomplete cleft glans and did not have a deep chordee. Follow-up period ranged from 12 months to 8 years (mean, 32 months). A transurethral silastic catheter was used for 7 days. RESULTS AND COMPLICATIONS Satisfactory results were obtained in 93 patients (95%). Two children developed fistula, 2 developed glans dehiscence, and 1 child had skin prolapsing from the meatus that required excision. CONCLUSIONS The LABO technique is a reliable technique for patients with proximal hypospadias in the absence of a deep chordee. It has particular value in patients with small or flat glans. With multiple layer closure and careful attention to technical details, a low complication rate (5%) was achieved in correcting this type of proximal hypospadias.

Buried penis: Classification surgical approach

PURPOSE The purpose of this study was to describe morphological classification of congenital buried penis (BP) and present a versatile surgical approach for correction. MATERIALS AND METHODS Sixty-one patients referred with BP were classified into 3 grades according to morphological findings: Grade 1-29 patients with Longer Inner Prepuce (LIP) only, Grade II-20 patients who presented with LIP associated with indrawn penis that required division of the fundiform and suspensory ligaments, and Grade III-12 patients who had in addition to the above, excess supra-pubic fat. OPERATIVE APPROACH A ventral midline penile incision extending from the tip of prepuce down to the penoscrotal junction was used in all patients. The operation was tailored according to the BP Grade. All patients underwent circumcision. Mean follow up was 3 years (range 1 to 10). RESULTS All 61 patients had an abnormally long inner prepuce (LIP). Forty-seven patients had a short penile shaft. Early improvement was noted in all cases. Satisfactory results were achieved in all 29 patients in grade I and in 27 patients in grades II and III. Five children (Grades II and III) required further surgery (9%). CONCLUSIONS Congenital buried penis is a spectrum characterized by LIP and may include in addition; short penile shaft, abnormal attachment of fundiform, and suspensory ligaments and excess supra-pubic fat. Congenital Mega Prepuce (CMP) is a variant of Grade I BP, with LIP characterized by intermittent ballooning of the genital area.

Functional urethral obstruction following tubularised incised plate repair of hypospadias

PURPOSE To report functional urethral obstruction (FUO) following the tubularised incised plate (TIP) procedure for hypospadias repair and its management. MATERIALS AND METHODS Between January 2003 and December 2010, 263 patients were referred with complications following TIP repair and who were reviewed on regular follow up after further correction. One hundred and twenty-nine of these patients presented with persistent obstructive voiding signs and symptoms in spite of apparently successful calibration or dilatation, 32 presented with persistent stenosis, and 97 with recurrent fistula. The mean age at surgery was 2.9 years (range 1-4). The complications were corrected using 1 of 2 techniques: modified Mathieu (112) and lateral onlay flap (17). The mean follow-up was 4 years (range 1-9). RESULTS The obstructive symptoms were corrected with a single procedure in 120 (93%). Nine patients (7%) developed complications in the form of fistula (7 patients) and glanular dehiscence (2 patients) that were corrected successfully in a second operation. CONCLUSIONS The incised urethral plate may heal forming a deep narrow groove resulting in FUO. Patients with FUO present with obstructive voiding symptoms in spite of successful calibration or dilatation. These symptoms disappear after reconstruction of a wide fully epithelised neo-urethra.

Reply to Dr. Snodgrass’ letter to the editor

My paper that Dr. Snodgrass alluded to reports the experience with 129 patients who presented with obstructive urethral symptom/signs following tubularized incised plate repair of hypospadias. These children had the following in common: 1) No obstructive problems before hypospadias surgery. 2) They all had TIP technique to repair their hypospadias. 3) The ability to pass an 8 Fr catheter without difficulty (excluding anatomical stenosis or stricture). 4) These obstructive symptoms resolved completely after reconstruction of a new wide urethra. Fistula and stenosis are well recognized complications after any technique used for hypospadias repair. The standard approach to exclude stenosis is to pass an 8 Fr catheter [1] through the new urethra in children less than 4 years. If the catheter passes without difficulty, this means that the child has no stenosis. This was true before the introductionof theTIP technique.Nowadays, theauthor andmanyother surgeons that perform hypospadias repair encounter many children following the TIPwho complain of FUOdespite the ability to pass an 8 Fr catheter. We have a commitment to our children and our colleagues to report this complication and techniques to correct it successfully. The author will respond systematically and objectively to each point that Dr. Snodgrass mentioned in his letter to the editor: