Akihiro Shimotakahara

Tubularized incised plate urethroplasty with dorsal inlay graft prevents meatal/neourethral stenosis: a single surgeon's experience

BACKGROUND/PURPOSE Snodgrass tubularized incised plate urethroplasty (SUP) is versatile and has good cosmesis. However, postoperative meatal/neourethral stenosis (M/N-S) is common enough for some surgeons to add a dorsal inlay graft (DIG) harvested from the inner prepuce and sutured to cover the longitudinal midline incision of the urethral plate. This is the first formal assessment of the effectiveness of DIG for preventing M/N-S. METHODS We reviewed the medical records of 100 consecutive SUP cases performed by a single surgeon between 2003 and 2010 comparing SUP + DIG (S + D group, n = 50) with SUP - DIG (S - D group, n = 50). Mean follow-up was 3.6 years. Data were analyzed statistically using the χ(2), 2-way ANOVA, and Mann-Whitney tests, with P < .05 considered significant. RESULTS Severity of hypospadias and type of SUP were similar. Mean age at SUP was 3.3 years in S + D and 3.6 years in S-D (P = NS). There were 4 complications in the S + D group: urethrocutaneous fistula (n = 3) and neourethral stenosis without diverticulum (n = 1). There were 15 complications in the S-D group : meatal stenosis (n = 2), neourethral stenosis with or without diverticulum (n = 6), urethrocutaneous fistula (n = 7) (P < .01). M/N-S was significantly less in the S + D group (1 vs 8; P < .05). CONCLUSIONS We strongly recommend that DIG be performed routinely during SUP.

Intraoperative measurement of rectourethral fistula: prevention of incomplete excision in male patients with high-/intermediate-type imperforate anus

INTRODUCTION We report a novel technique to measure the length of the rectourethral fistula (RUF) in male patients with high-/intermediate-type imperforate anus during laparoscopically assisted anorectal pull-through (LAARP) to prevent incomplete excision. METHOD During LAARP for RUF in 5 male patients (mean age, 4.6 months; prostatic in 3, bulbar in 2), the RUF was dissected carefully close to the urethra and opened; and a fine catheter with 10-mm calibrations was inserted by the laparoscopic surgeon until it was seen to emerge at or near the verumontanum by another surgeon performing cystoscopy. The laparoscopic surgeon then measured the distance from the point where dissection was ceased at the rectal end to the urethral orifice. The RUF was dissected free from the prostate for exactly this length, tied, and excised; and colon pull-through was performed to finish LAARP. RESULT Rectourethral fistulae ranged from 5 to 15 mm and were much longer than expected. All dissections were uncomplicated without any injury to the urethra, and postoperative courses were unremarkable. At mean follow-up of 11 months, urination is normal in all without evidence of residual fistula. CONCLUSION Knowing the exact length of the RUF facilitates safe and complete excision in an otherwise blind situation.

Comparison of anorectal angle and continence after Georgeson and Peña procedures for high/intermediate imperforate anus

AIM The anorectal angle (AA) influences defecation after pull-through (PT) for imperforate anus (IA). We compared postoperative AA and continence after Georgesons laparoscopy-assisted colon PT (GPT) and Peñas posterior sagittal anorectoplasty (PSARP) for high/intermediate-type IA. METHODS We reviewed 33 high/intermediate-type IA cases (20 GPTs and 13 PSARPs) prospectively. All had colostomy initially as neonates. Anorectal angle was measured as the angle between the rectum and the anal canal on barium enema. A fecal continence evaluation questionnaire (FCEQ) consisting of 5 parameters (frequency of defecation, staining/soiling, perianal erosion, anal shape, and requirement for medication; maximum score = 10) was evaluated in 28 cases (15 GPTs and 13 PSARPs) followed up for more than 3 years. RESULTS Mean age at PT was similar (6.6 months for GPT and 6.3 months for PSARP; P = not significant). There was no significant difference in mean AA. The FCEQ scores for GPT were generally higher throughout the study and significantly better from 3 years postoperatively (P < .05). CONCLUSIONS We are the first to confirm that effective AA similar to PSARP can be achieved after GPT, although FCEQ would suggest that GPT has less detrimental functional impact.

Intraoperative endoscopy during choledochal cyst excision: extended long-term follow-up compared with recent cases

INTRODUCTION We routinely perform intraoperative endoscopy (IOE) of the intrahepatic bile duct (IHBD) and intrapancreatic bile duct (IPBD) with a pediatric cystoscope during excision of choledochal cyst (CC). Here we compare extended long-term follow-up patients with a series of recent cases. METHODS We compared 25 CC patients treated over the past 5 years (group 1) with 69 CC patients treated between 1986 and 1998 and followed up for more than 10 years (group 2), focusing on stone formation. RESULTS In group 1 (mean follow-up, 2.6 years) IOE identified IHBD debris in 7 (28%) of 25 and IPBD protein plugs in 9 (36%) of 25. In group 2 (mean follow-up, 14.6 years) IOE identified IHBD debris in 11 (16%) of 69 and IPBD protein plugs in 17 (25%) of 69. There was no relation between type of CC and incidence of IHBD debris or IPBD protein plugs. The incidence of postoperative stones to date is 0% in group 1 and 2.9% in group 2, rates far lower than those reported in the literature. CONCLUSIONS We attribute our lower incidence of stones directly to IOE and recommend that it be performed routinely during cyst excision. It is simple, is effective, and improves outcome.

Repair of hypospadias with severe chordee using a long, wide, U-shaped flap that preserves ventral penile tissues intact for second-stage urethroplasty.

PURPOSE The aim of the study was to report a new technique for repairing hypospadias with severe chordee (HSC). METHODS Our new technique involves making a long, wide, U-shaped incision on the ventral penis from the coronal sulcus to very distal to the meatus and dissecting to create a flap (U-flap). During dissection, the urethra is divided just proximal to the meatus. After release of chordee, the U-flap is returned to the ventral penile shaft and sutured in place. A buttonhole made distally in the U-flap is anastomosed to the cut end of the urethra to create a neomeatus. Snodgrass urethroplasty is performed 6 to 18 months later. We have treated 11 patients with HSC (mean age, 22.3 months) using this technique. RESULTS Postoperatively, all U-flaps were viable. The neomeatus appeared to be more proximal because the penis was straighter. Urethroplasty using the central part of the U-flap was uncomplicated by scar tissue and successful in all cases. After a mean follow-up of 15.7 months, all patients have satisfactory penises without stenosis or diverticulum, although 1 had fistula. CONCLUSION Our U-flap technique allows the ventral penis to be preserved intact without scarring for second-stage urethroplasty and as a result is well suited for treating HSC.

The benefit of stay sutures during thoracoscopic esophagoesophagostomy in patients with esophageal atresia: a technical report

We report on technical modifications we developed for thoracoscopic esophagoesophagostomy in patients with esophageal atresia. They are: (1) placing stay sutures along the edges of the atretic esophagi and exteriorizing them through the thoracic wall to expose the luminal surfaces of the esophagi nicely and relieve tension on the anastomosis; (2) leaving 1/5 of the length of the distal and proximal ends of the atretic esophagi intact before placing the stay sutures, to avoid retraction of the mucosa into the lumen; (3) making the diameter of the proximal esophagus 1.5–2 times larger than the diameter of the distal esophagus to make the shape of the anastomosis more streamlined without notching.

Treves' field pouch hernia: our experience and literature review.

Treves’ field pouch hernia (TFPH) is an unusual type of congenital internal hernia. Although eight cases of TFPH have been reported in the English literature, they were seldom diagnosed preoperatively with high mortality rates. We describe a 12-year-old girl with TFPH diagnosed as an internal hernia on computed tomography and confirmed laparoscopically, and review the literature.

Activating transcription factor 3 is not up-regulated in hypospadias patients in Japan

Background: The aetiology of hypospadias is largely uncharacterized. Some of the researchers have advocated that activating transcription factor 3 (ATF3), an oestrogen-responsive transcription factor, is up-regulated in patients with hypospadias. The purpose is to evaluate the universality of this fact; we studied the expression of ATF3 protein in prepuce tissue obtained from hypospadias and phimosis patients living in metropolitan Tokyo. Materials and Methods: Prepuce tissue was obtained from outer foreskin at the time of surgery, quickly prepared for paraffin-embedded sectioning and stained immunohistochemically for ATF3. Two researchers blindly evaluated immunoreactivity and scored it semi-quantitatively as nil = 0, weak = 1, or strong = 2, to give a final staining intensity score (SIS). Subjects were 18 hypospadias patients and 17 phimosis patients (as controls) who had surgery between January, 2009 and March, 2010. Results: All subjects lived in metropolitan Tokyo, Japan. Mean ages at surgery were 2.9 ± 1.0 and 3.9 ± 2.4 years, respectively (P > 0.05). SIS was not statistically different between hypospadias patients (1.4 ± 0.5) and controls (1.5 ± 0.5), (P > 0.05). Conclusions: Our data suggest that ATF3 is not highly associated with hypospadias in metropolitan Tokyo. Differences in ethnicity might have influenced our results.

Modified Snodgrass tubularized incised plate urethroplasty prevents fistula formation in hypospadias

Urethrocutaneous fistula is a common complication after redo urethroplasty for hypospadias, or urethroplasty for patients with thin urethral plate. We modified Snodgrass’ tubularized incised plate urethroplasty (STIPU) by stripping the most superficial skin from both sides of the U-shaped incision to expose more subcutaneous tissue along the suture line. Our modified STIPU would appear to be effective in preventing postoperative urethrocutaneous fistula formation in redo urethroplasty for hypospadias, and urethroplasty for patients with thin urethral plate.

Collis–Nissen fundoplication using a computer-powered right angle linear cutting stapler in children

We reviewed our clinical experience of using a computer-powered right angle linear cutter (CPRALC) for Collis–Nissen fundoplication (CNF) in three children with gastroesophageal reflux (GER) or failed Nissen associated with short esophagus. Case 1 was a 13-month-old female with persistent GER after type-C esophageal atresia repair. Case 2 was a 2-year-old female with dysphagia secondary to fundic wrap migration after laparoscopic Nissen. Case 3 was a 3-year-old male with post type-C esophageal atresia repair, dysphagia secondary to fundic wrap migration after open Nissen. All had short esophagus confirmed pre- or intra-operatively. After the esophagus was mobilized, Collis vertical gastroplasty was performed using CPRALC parallel to the lesser curve to elongate the esophagus. Nissen fundoplication was performed loosely around the neo-esophagus. There were no intra- or post-operative complications, although case 3 still has mild dysphagia, requiring dilatation. This is the first report of CNF performed using CPRALC in children. It would appear to be safe and effective for treating children with GER or failed Nissen associated with short esophagus.