Ali Tekin

Unexpected outcome of a modification of Bracka repair for proximal hypospadias: High incidence of diverticula with flaps.

INTRODUCTION Various graft and flap techniques have been proposed for urethral reconstruction in proximal hypospadias repair. The Bracka repair involving the transfer of inner prepuce like a Wolfe graft mostly results in satisfactory results besides a high fistula rate. AIM The aim was to decrease the high fistula rate with Bracka repair; we wanted to use the advantages of vascularized skin in the Bracka method. The aim of this study was to evaluate our results with this modification. STUDY DESIGN Our modification involves using a flap instead of a graft. In the first stage, chordee was corrected by transection of the urethral plate and dorsal midline plication when necessary. Instead of a graft as suggested by Bracka, inner preputial skin with ample blood supply was transferred and stitched to the denuded ventral penile surface. In the second stage after 6 months, this flap was tubularized in the Thiersch-Duplay fashion. Hospital records of patients who had undergone two stage modified Bracka repair between June 2007 and July 2012 were reviewed, including complaints, complications, and need for interventions. RESULTS Thirty-eight patients had undergone this operation. Four patients were lost to follow-up. The main complaint was obstructed urinary flow. Voiding symptoms were first attributed to urethral stenosis, but were, however, found to be due to diverticulum and vortex of the urine in the dilated urethra. Twenty-one patients (61%) had voiding problems and 10 patients (29%) had urinary tract infections. Fistula was observed in 23 and diverticula were observed in 24 patients. Of these, 16 patients had both fistula and diverticula. Only two patients (5%) were free of complications and totally satisfied with the operation, and 23 of the 34 patients had complications requiring intervention (Figure). DISCUSSION Inner preputial flaps used in proximal hypospadias repairs are prone to diverticula formation. They become redundant in time requiring reoperation, thus decreasing the success rate. Careful fixation of the flap to the corpora and allowing time for additional attachment of the urethral plate substitution through fibrotic activity could not overcome this complication. CONCLUSION Our modification of the Bracka technique using a flap for the plate resulted in a high rate of complications (in particular diverticulum formation) and was therefore abandoned. We recommend careful use of flaps in hypospadias surgery and long-term follow-up studies to evaluate actual functional and cosmetic results.

Parental Perception of Terminology of Disorders of Sex Development in Western Turkey

Objective: Disorders of sex development (DSD) is a nomenclature intended to defeat the discomfort of families and patients and has found worldwide usage. The aim of this study was to address the perception and usage of terminology among the parents of DSD patients in a tertiary center in western Turkey. Methods: The records of the DSD council (multidisciplinary team where each patient with DSD is discussed) between years 2008-2015 were reviewed retrospectively. Data including details of the management process, patient characteristics and follow-up details were noted. Then inquiries reflecting parental perception about terminology were implemented during clinical visits. Results: In total, 121 patients were evaluated in monthly meetings of the DSD council and 79 inquiries were completed. Fifty-one percent of the families admitted knowing the terms DSD, ambiguous genitalia, “dubious genitals” and intersex. However, only 2% preferred using DSD, 6% intersex and 14% ambiguous genitalia. Fifty-two percent of the parents used a disease name in Latin (mostly hypospadias) addressing the disorder. The offspring of 69% of the parents who were familiar with the name “dubious genitals” were diagnosed in the neonatal period. The preferred terminology used by parents was strongly associated with the terminology used most commonly in the medical speciality their child most often attended. Conclusion: Each country has its own social norms. We suggest therefore that local committees including medical professionals, patients and families should be employed to develop proper terminology.

Advice to the Families of the Pediatric Stone Former

Parents of the pediatric stone formers ask the physicians what they should give attention to or what the doctors recommend, in order to prevent the recurrence of stone disease. Answering these questions is always difficult in clinical practice. In this chapter we aim to clarify this relatively unexplored subject.

How Do I Get a Perfect Cosmetic Result After Circumcision

Circumcision is not an essential surgery and poor cosmesis is an underrecognized complication of it. Factors leading to poor cosmesis following circumcision are; impertinent tissue handling, insufficient hemostasis, using thick heavy sutures with long absorption time, failing to recognize anatomical diversities or abnormalities, excessive resection of prepuce, and too tight dressing.

Laparoskopik ve Robotik Pyeloplasti: Teknik İpuçları

İ kez 1990’lı yılların başlarında tarif edilen laparoskopik pyeloplasti günümüzde üreteropelvik bileşke obstrüksiyonunun (ÜPBO) tedavisinde en çok tercih edilen tedavi yaklaşımı olarak ön plana çıkmıştır (1). Her ne kadar endopyelotomi gibi endoskopik seçenekler daha az invaziv olsa da; bu yöntemlerin uzun dönemde başarısının düşüklüğü ÜPBO tedavisinde minimal invaziv pyeloplasti seçeneğini ön plana çıkartmaktadır (2). Literatürde farklı pyeloplasti teknikleri tanımlanmıştır. Biz, kliniğimizde, hem primer hem de sekonder pyeloplasti operasyonlarında yüksek başarı oranı nedeniyle sıklıkla Anderson-Hynes dismembered pyeloplasti tekniğini tercih etmekteyiz. Ancak çaprazlayan damar olmayan ve hidronefroz derecesi düşük olgularda Fengerplasti tekniği bir seçenek olabilir. Bununla birlikte, yüksek girişli bir üreterde ise Y-V plasti tercih edilebilir. Biz bu derlemede, laparoskopik ve robotik pyeloplasti olgularından edindiğimiz tecrübeye dayanarak meslektaşlarımıza bu operasyonlara yönelik bazı teknik ipuçlarını vermeyi amaçladık.