Alan P. Dickson

Antenatally detected pelvi-ureteric junction obstruction: concerns about conservative management.

To review the conservative management of antenatally detected pelvi‐ureteric junction (PUJ) obstruction in children.

An objective assessment of the results of hypospadias surgery

To compare the cosmetic result of tubularized incised‐plate urethroplasty (Snodgrass method) with that of two established techniques, the meatal‐based flap and onlay island flap repair.

The Malone antegrade colonic enema procedure : outcome and lessons of 6 years' experience

Abstract The successful management of faecal incontinence can dramatically improve the quality of life of affected children. The introduction of the non-refluxing, catheterisable appendico-caecostomy provides the opportunity to treat previously resistant patients. Over a 6-year period, 29 children had a Malone antegrade continent stoma for enema administration (MACE). Incontinence was related to spina bifida in 12 children, ano-rectal anomaly in 12, Hirschprungs disease in 2, followed excision of a pelvic tumour in 2, and was secondary to intractable chronic constipation in 1. The conduit was fashioned from the appendix (20), a caecal tube (8), or a gastric tube (1). Surgical complications were stomal stenosis (11), wound infection (1), anastomotic leak (1), MACE stoma prolapse (1), and a pressure sore (1). Colonic irrigation was achieved with washouts of saline (24), saline plus phosphate (4), and saline plus Picolax (1). Twenty-three patients have complete control of bowel function, but 4 still soil. Two remain incontinent, 1 of whom is still being instructed. One child subsequently had a colostomy, but still uses the MACE stoma. Successful bowel management requires motivation, dedication, commitment, and the input of a clinical nurse specialist. The MACE is a relatively straightforward operative procedure that provides an effective washout technique that is acceptable to both parents and children.

Antenatal diagnosis of bladder/cloacal exstrophy: challenges and possible solutions.

OBJECTIVE To identify the pitfalls in accurate antenatal diagnosis of bladder exstrophy (BE) and cloacal exstrophy (CE), and thus understand the challenges for antenatal counselling. METHODS A prospectively maintained bladder exstrophy database of antenatal and live born referrals for BE/CE was used to identify patients. Data were collected about the antenatal scan findings and the outcome of pregnancy. RESULTS Between 2003 and 2009, 40 new babies with BE/CE were referred and of them 10 had an antenatal diagnosis. Five patients did not have a diagnosis despite suspicious findings noted on antenatal scans and another three had a wrong diagnosis of BE/CE. Of the 16 referrals with antenatal suspicion of BE/CE, 5 opted for termination. At the 20-week scan, it was possible to identify the gender of the fetus in 3/16 cases only. CONCLUSIONS Only a quarter of the babies born with BE/CE had received an antenatal diagnosis. Raising awareness about the condition amongst radiographers, and facilitating further scanning by a specialist fetal management unit if suspicious findings are noted, is crucial for improving the rate of detection. An antenatal diagnosis may not be reliable, and difficulty in identifying gender at the 20-week scan adds to the complexity of antenatal counselling. Magnetic resonance imaging and karyotyping may provide additional helpful information.

Oral Mucosa Graft for Repair of Hypospadias: Outcomes at Puberty

PURPOSE Oral mucosa graft has been used in the treatment of hypospadias for the last 15 years. We assessed the long-term outcome of oral mucosa grafts for urethral substitution in hypospadias surgery at our institution. MATERIALS AND METHODS We retrospectively reviewed patients who underwent oral mucosa graft for hypospadias between 1994 and 2002. Data collected included indications, site of oral mucosa graft, complications and long-term outcomes. Followup information was obtained from the last clinical contact. RESULTS A total of 37 patients underwent oral mucosa graft consisting of an onlay graft (30), urethral tube (5) or 2-stage Bracka type procedure (2). Of the patients 26 had undergone at least 1 previous operation for hypospadias. Following oral mucosa graft 10 patients had an early surgical complication requiring reoperation, including fistula (7), urethral stricture (2) and tortuous urethra (1). Three of the 5 patients (60%) with tubed grafts had complications. Long-term followup was available in 30 patients, of whom 28 are now postpubertal and 2 are peripubertal. One patient required redo urethroplasty for obstructive balanitis xerotica obliterans in the grafted urethra. Five patients have varying degrees of meatal stenosis, with only 2 requiring intervention to date. CONCLUSIONS Oral mucosa graft has a significant associated early complication rate of fistula and stricture, with 27% of cases requiring further surgery. However, the majority of oral mucosa grafts have stable urethral outcomes at puberty.

The management of bladder exstrophy: the Manchester experience.

AIM Bladder exstrophy (BE) is a severe congenital malformation with life-long implications. This article discusses the current surgical management and describes the development of the nationally commissioned bladder exstrophy service in Manchester, UK. METHODS Outcome of BE surgery in Manchester was retrospectively reviewed. A Medline search was also undertaken and the published outcomes reviewed for the Modern Staged Repair of Bladder Exstrophy (MSRE), the Complete Primary Repair of Exstrophy (CPRE), and Radical Soft-Tissue Mobilisation (RSTM). RESULTS Sixty-seven infants with BE were treated in the period 2000-2012. Twenty-six infants underwent primary closure during the neonatal period, and in twenty-one this was successful. The remaining forty-one infants underwent delayed closure, and all were successful. Twenty-six children underwent MSRE, and continence with urethral micturition was achieved in sixteen (62%) (ten alone and six with urethral clean intermittent catheterisation). A further five (19%) are continent following bladder neck closure, cystoplasty, and continent diversion. Seven (26%) of the twenty-six patients are completely dry overnight. Twenty infants underwent primary ureteric reimplantation, and none have renal scarring. By contrast, renal scarring (unilateral n=fourteen; bilateral n=five) was found in nineteen of thirty-seven infants who did not undergo reimplantation. CONCLUSIONS Specialised experience has allowed demonstrable improvement in bladder exstrophy outcomes throughout the period of the study.

Construction of a Natural Looking Inverted Umbilicus for Bladder Exstrophy

PURPOSE Most attempts to create an umbilicus in the exstrophy abdomen eventually leave the end result of a flat scar rather than an inverted structure. We describe a technique that allows the creation of a better looking inverted umbilicus. MATERIALS AND METHODS A total of 19 patients between 5 days and 7 years old underwent umbilicoplasty. At the apex of the vertical midline wound the skin and superficial fascia are elevated off the anterior rectus sheath well beyond the top of the skin incision. The skin edge at the most superior apex of the wound is sutured to the linea alba, thereby inverting the skin and fixing it to the sheath. Two skin flaps based superiorly are cut from the margin of the inverted skin. The flaps are then rotated medial and sutured to the linea alba to form the base of the new umbilicus. The superficial fascia inferior to the umbilicus is opposed and the skin edges are approximated. RESULTS A total of 18 patients had bladder exstrophy and 1 had cloacal exstrophy. Of the patients 11 underwent bladder/cloacal exstrophy closure, 3 underwent epispadias repair, 3 underwent bladder neck repair, and 2 underwent bladder augmentation and continent cutaneous diversion. Mean +/- SD followup was 6 +/- 4 months. The technique allowed the creation of an inverted umbilicus in all patients. None experienced infection or dehiscence. The cosmetic result obtained was excellent and durable. CONCLUSIONS We recommend the creation of an inverted umbilicus in the exstrophy population at bladder closure or later in life if umbilicoplasty is required.

Multiple urethral anomalies: Anterior urethral diverticulum, posterior urethral valves, and distal hypospadias

We report an infant with antenatally detected bilateral hydroureteronephrosis and a penile cyst who was eventually diagnosed with an anterior urethral diverticulum (AUD), subcoronal hypospadias, and posterior urethral valves (PUV) after birth. To our knowledge, there are no reports where all three anomalies have been found to coexist. As per urethral catheterisation was difficult, cystoscopy-guided catheterisation was performed. On retracting the complete foreskin, a subcoronal hypospadias was identified. The AUD was resected partially, and during a cystoscopy for completion of AUD resection, a dilated anterior urethra was found collapsed, and thin PUV were identified and divided. He remains well at nine months with an improving renal cortical thickness. The vesicoureteric reflux had resolved.

Uro-genital bleeding in pre-menarcheal girls: dilemmas of child abuse

Uro-genital bleeding in pre-menarcheal girls always raises concerns regarding child abuse. There are serious social issues involved; however, before labeling it as sexual abuse, all efforts must be made to rule out an organic pathology. We recently encountered two young girls of Afro-Caribbean origin who presented with vaginal bleeding with concerns from referring physicians about child/sexual abuse. On examination both had a rare condition of urethral prolapse. One of them underwent four-quadrant excision and the other was treated conservatively with urethral catherization.

Rectus sheath tunnels for continent stomas.

Continent stoma rectus sheath tunnel (CSRST) has been used in antegrade colonic enema (ACE) and urinary continent cutaneous diversion (UCCD) stomas to reduce leakage and to support a straight track for the continent conduit. All patients that underwent CSRST between 1995 and 2005 were identified and their case notes retrospectively reviewed. Patients were divided into two groups: the ACE group and the UCCD group. Demographic data, age at surgery and complications including stenosis and leakage were recorded. Forty patients underwent CSRST between 1995 and 2005. The mean age and standard deviation (SD) at surgery was 6.8 (2.1) years. Eighteen patients underwent ACE with a mean (SD) follow-up of 7.6 (3.1) years. No patient has faecal leakage. No patient had stomal revision, but one patient (5.5%) required an indwelling gastrostomy button to maintain patency. Twenty-two patients underwent UCCD with a mean (SD) follow-up of 8.1 (2.8) years. No patient developed urinary leakage. Two patients (9%) required revision of the stoma and one (4.5%) required an indwelling catheter because of recurring stomal stenosis. CSRST prevents stoma leakage. Revision surgery rate after CSRST is low, particularly after ACE reconstruction.