Alex Brzezinski

URETHRAL DUPLICATION IN THE MALE: REVIEW OF 16 CASES

PURPOSE Urethral duplication is a rare congenital anomaly. The clinical presentation varies because of the different anatomical patterns of this abnormality. We describe our experience with 16 male patients with this anomaly. MATERIALS AND METHODS We retrospectively reviewed the records of 16 male patients treated for urethral duplication in the last 10 years. Age at presentation ranged from newborn to 8 years. Evaluation included ultrasound, voiding cystourethrography, retrograde urethrography and endoscopy. RESULTS A blind ending duplicated urethra (type I) was present in 4 patients, 2 independent urethras with distinct bladder necks (type IIA1) in 6, 2 urethras originating from a common bladder neck (type IIA2) in 4, and complete urethral and bladder duplication (type III) in 2. Six patients had associated vesicoureteral reflux. Duplication was an incidental finding at epispadias repair in 3 patients with bladder exstrophy, at hypospadias repair in 1 and at hydrocele repair in 1. One patient with bilateral dysplastic kidneys died in the newborn period. Surgical management included excision of the duplicated urethra in 8 cases and urethroplasty using a pedicle flap in 2, while surgical management was not required in 3. CONCLUSIONS Urethral duplication is a rare congenital anomaly with a variable clinical presentation. This pathological condition may easily be under diagnosed, especially in patients with other associated anomalies, such as hypospadias or bladder exstrophy. Surgical management should be planned individually according to the anatomical findings of the abnormality.

BLADDER EXSTROPHY ASSOCIATED WITH COMPLETE URETHRAL DUPLICATION: A RARE MALFORMATION WITH EXCELLENT PROGNOSIS

PURPOSE We report the association of complete urethral duplication and bladder exstrophy in 5 males, and describe the main characteristics to achieve diagnosis. MATERIALS AND METHODS From 1983 to 2000, 5 males with single bladder exstrophy and complete urethral duplication were seen at 3 institutions. Although bladder exstrophy was obvious at birth, only 1 patient had the preoperative diagnosis of associated urethral duplication. All patients were evaluated with abdominal ultrasound, voiding cystourethrogram after bladder closure and cystoscopy. RESULTS All patients were totally incontinent, including 4 after primary bladder exstrophy closure. Although it was initially unnoticed by the urologist, most patients had leakage from the tip of the penis during the Valsalva maneuver. In all cases bladder exstrophy was single and deeply situated in the pelvis with excellent elasticity. All patients had a normal sized penis with less severe dorsal chordee and conical shaped glans. The duplicate epispadiac urethra did not have a verumontanum. Only 1 of the 5 patients had the correct diagnosis made before primary closure of bladder exstrophy, while in the other 4 diagnosis of a duplicate ventral urethra was made at the time of epispadias or fistula repair. There were no other associated malformations. In all cases the dorsal epispadiac urethral plate was excised and bladder emptying occurred through the ventral urethra, which at cystoscopy had a normal verumontanum. Postoperatively, all patients became continent and voided with good flow through the ventral urethra and, as opposed to many cases of exstrophy and epispadias, had normal size and excellent cosmesis of the penis. CONCLUSIONS Complete urethral duplication is a rare variant of the exstrophy-epispadias complex. Patients with this anomaly present with a larger and more deeply situated bladder plate than classical exstrophy and a larger penis. A high index of suspicion is necessary to make a preoperative diagnosis. Excision of the dorsal urethral plate and maintenance of the ventral urethra are the treatment of choice, resulting in a continence and normal voiding.

LONG-TERM RESULTS OF PERCUTANEOUS ENDOPYELOTOMY IN THE TREATMENT OF CHILDREN WITH FAILED OPEN PYELOPLASTY

PURPOSE We reviewed our experience with the safety and long-term efficacy of percutaneous endopyelotomy in children with secondary ureteropelvic junction obstruction who previously underwent open pyeloplasty. MATERIALS AND METHODS Nine patients a median of 7 years old underwent endopyelotomy between June 1985 and July 1995. Anderson-Hynes pyeloplasty had previously been performed in all children. Antegrade endopyelotomy was done with a cold knife in conjunction with balloon dilation in some cases. Postoperative stenting lasted 6 weeks. RESULTS The median interval between pyeloplasty and endopyelotomy was 7.5 months. Mean operative time was 240 minutes. Percutaneous endopyelotomy was successful in 8 of the 9 patients. One patient who required repeat endopyelotomy after 4 years is presently well at 5 years of followup. Average followup was 5.6 years (range 2 to 10). There was a low morbidity rate, including 1 case of urinary tract infection, 1 of pneumonia and 1 that required blood transfusion. CONCLUSIONS Percutaneous antegrade endopyelotomy is a safe, effective and durable alternative for children who previously underwent unsuccessful pyeloplasty.

Orthoplasty in Epispadias

Orthoplasty (a term used in Europe to refer to chordee excision and penile straightening) in patients with epispadias has provided less than ideal results in the past. We propose a sequential stepwise approach for the assessment and correction of the corporeal deformity, incorporating dermal grafts on the dorsal aspect of the corpora cavernosa when necessary to achieve functional penile lengthening and straightening. Success, defined as significant improvement in functional penile length, a penis that dangles at 45 degrees below the horizontal and over-all improvement in cosmetic result, was achieved in 7 of 8 patients.

How do asymptomatic toilet-trained children void following tubularized incised-plate hypospadias repair?

PURPOSE : To evaluate the functional outcome in the form of urinary flow rates in asymptomatic children following uncomplicated tubularized incised plate urethroplasty (TIPU) hypospadias repair. METHODS : We reviewed the records of children who underwent TIPU at our institution between April 1997 and September 2007 and included only asymptomatic toilet-trained children who had an uncomplicated postoperative course and had undergone uroflometry not less than 1 year postoperatively. Unfavourable voiding parameters were either a plateau curve, a peak flow below the 5th percentile range in nomogram or a post-void residual (PVR) more than 20% of the total functional capacity of the bladder. Uroflowmetry findings were analyzed against variables, including the surgeon, the severity of hypospadias, the presence of a hypoplastic urethra, the use of double layer closure, the performance of a spongioplasty and the use of a stent. Serial uroflowmetries, when available, were compared with respect to the initial flow study. RESULTS : In total, 59 patients were eligible for the study. The mean age at surgery was 2.4 years. Hypospadias was distal penile in 50 (85%) and mid and proximal penile in 9 (15%). Mean follow-up was 3.3±2 (1-9.5) years. The uroflow curve was bell-shaped in 18 (30%), interrupted in 8 (14%), slightly flattened in 27 (46%) and plateau in 6 (10%). Flow rate nomograms revealed that 40 (68%) were above the 20th percentile, 10 (17%) were below the 5th percentile and 9 (15%) were between these ranges. PVR was >20% of the pre-void volume in 9 children (15%). No patient demonstrated all three unfavourable parameters together. The groups of children with unfavourable functional voiding parameters were compared to the children with favourable parameters specifically with respect to the possible predictors of outcome. Follow-up uroflometry in 17 patients showed improvement in the flow curve, flow rate and PVR with significant improvement of maximum urinary flow rate (Qmax) and PVR values. CONCLUSIONS : Asymptomatic, urodynamic abnormalities were observed in our study following uncomplicated TIPU repair. These abnormalities were not related to the variation of the technique among surgeons. Spontaneous improvement has been noted on serial flow studies.

The role of preoperative prophylactic antibiotics in hypospadias repair

INTRODUCTION We sought to determine whether the use of preoperative antibiotics is effective in reducing postoperative wound infections and urinary tract infections (UTI) in hypospadias repair. METHODS We retrospectively reviewed all hypospadias repairs performed at the Montreal Childrens Hospital between March 2009 and September 2012. All types of primary hypospadias repairs and redo cases were included. Patients with no adequate follow-up or with missing records of antibiotics were excluded. Preoperative antibiotics were given in the form of cefazolin (50 mg/kg intravenously) when appropriate. Postoperative oral antibiotics were administered as decided by the pediatric urologist. Primary outcomes included postoperative wound infection and UTI. Secondary outcomes included the need for reoperation of hypospadias due to urethrocutaneous fistula, meatal stenosis, urethral stricture and wound dehiscence. RESULTS In total, 157 cases of hypospadias repair were reviewed; of these 7 were excluded due to lack of follow-up. Of the remaining 150 patients, 62 received preoperative antibiotics and 88 did not. The groups were well-matched for age, hypospadias characteristics, type of repair and repair of curvature. The group that received preoperative antibiotics had a significantly higher number of stented cases (82% vs. 52% of the non-preoperative antibiotic group). Two cases of wound infection were reported (1 in the pre-operative antibiotic group and 1 in the non-preoperative antibiotic group). There was no symptomatic UTI or culture-demonstrated UTI in either group. Moreover, there was no statistically significant difference between the 2 groups in terms of primary outcomes. The complication rate was 11% (17/150 repairs) and all patients needed reoperation. This studys important limitations include the rarity of studied end points combined with the small sample and the retrospective nature of our study. CONCLUSION Our findings do not support the routine use of preoperative antibiotics in hypospadias repair.

Dye-assisted lymphatic-sparing laparoscopic varicocelectomy in children

INTRODUCTION The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques. MATERIALS AND METHODS Twenty-five consecutive LSLVs were performed on children with a mean age of 15 years over a 4-year period. Varicocele grade was 3 in 21 cases and grade 2 in 4. Indications for intervention were hypotrophy in 12, pain in 11 cases and family preference in 2. A scrotal injection of lymphatic dye was utilized to spare at least one lymphatic and the remaining spermatic vessels were divided. RESULTS Lymphatic sparing was accomplished in all cases. Operative time varied from 30 to 140 min (mean 85 ± 26). No perioperative complications were noted. On average follow-up of 13 months a residual varicocele was noted in 2 cases, with no hydrocele and resolution of pain. Mean testicular volume difference diminished from 33% pre to 18% postoperatively. CONCLUSION This multi-surgeon experience demonstrates that dye-assisted LSLV is easily accomplished with promising results. It appears that preservation of a single spermatic lymphatic vessel is sufficient, although in some cases a second dye injection is required to visualize the lymphatics.