Angela D. Gupta

Radial Forearm Free Flap Phalloplasty for Penile Inadequacy in Patients with Exstrophy

PURPOSE Male patients with bladder and cloacal exstrophy are born with demure genitalia and often desire phalloplasty during late adolescence or early adulthood. Radial forearm free flap phalloplasty was used successfully for congenital aphallia in a few small series. We present a series of patients treated with phalloplasty using a radial forearm free flap after the repair of bladder and cloacal exstrophy. MATERIALS AND METHODS We reviewed the records of 10 patients who underwent radial forearm free flap phalloplasty between 2007 and 2012. Indications for phalloplasty were classic bladder exstrophy in 8 cases and cloacal exstrophy in 2. Nine patients underwent prior urinary diversion and 1 underwent urethroplasty at phalloplasty. In each case we reviewed the details of prior exstrophy repair, flap size, donor and recipient vessels, complications, need for subsequent surgeries and self-reported sensation. RESULTS The graft survived in all 10 patients. Short-term complications requiring surgical intervention developed in 2 patients. Five patients subsequently underwent placement of a penile prosthesis and 2 devices were removed secondary to erosion. All 10 patients reported protective sensation and erogenous sensation with ability to achieve orgasm at last followup. CONCLUSIONS Radial forearm free flap phalloplasty results in a sensate, cosmetic neophallus. No patient had long-term complications related to phalloplasty but complications related to penile prostheses continue to be a challenging aspect of phalloplasty. The long-term results of the forearm free flap are encouraging in this series of patients with bladder and cloacal exstrophy who desired phalloplasty.

Examining long term outcomes of Bladder Exstrophy: A 20 year follow up.

To examine long‐term quality‐of‐life, urinary continence and sexual function outcomes in patients diagnosed with bladder exstrophy (BE).

Coronary stent management in elective genitourinary surgery.

Whats known on the subject? and What does the study add?

Inflatable penile prosthesis technique and outcomes after radial forearm free flap neophalloplasty

The aim of this study was to describe the technical aspects and short-term outcomes of inflatable penile prosthesis (IPP) implantation after neophallus reconstruction at a single institution. Nine men with previously constructed radial forearm neophalli underwent IPP implantation. The etiologies of their penile anomaly were bladder exstrophy complex in five, disorder of sexual differentiation in two and genital obliteration secondary to ballistic trauma in two. Median follow-up was 9.6 months (range 1.5–139.7). The records for these patients were retrospectively reviewed and outcomes recorded. Mean age was 23.6 (range 18–31) years, and mean time interval from neophalloplasty to IPP implantation was 22.1 months (range 3–48). In all cases, 3-piece IPPs were employed, with eight of patients having one cylinder implanted in the native corporal body and extending into the neophallus. Mean surgical time was 222 min (range 142–409). Median length of implanted device was 22 cm. No intraoperative complications were observed. At the most recent follow-up, six patients (66.7%) had functional devices, with acceptable surgical outcomes. Three patients (33.3%) sustained device infections, and three (33.3%) sustained cylinder erosion. In three patients in whom neo-tunica albuginea were fashioned by ensheathing the cylinder with allograft human dermal tissue matrix, no erosions occurred. One patient underwent two revisions, the first for the associated erosion and infection and the second for genital pain, and was left with a semi-rigid prosthesis. IPP implantation affords the best opportunity for functionality for patients with a radial forearm free flap neophallus. Caution must be taken to ensure viability of the neophallus intraoperatively, and protocols to minimize the risk of infection should be followed. Fashioning neo-tunica albuginea using graft material may reduce risk of erosion.

Renal artery pseudoaneurysm after partial nephrectomy.

A 58-year-old woman with hypertension and cerebral aneurysm was referred to our institution upon diagnosis of a 3 cm right upper pole enhancing renal mass. Open partial nephrectomy was performed without excessive hemorrhage or entry into the renal collecting system. The final pathological diagnosis was stage I (pT1a), Fuhrman grade 2, clear cell (conventional) renal cell carcinoma with negative surgical margins. Abdominopelvic computerized tomography (CT) 4 months postoperatively revealed a well circumscribed 3 3.8 cm enhancing lesion at the surgical site unassociated with any hemorrhage or perinephric stranding (fig. 1). This lesion enhanced during the arterial phase, cleared rapidly and was unrelated to the collecting system which enhanced in its usual delayed diagnosis. Further evaluation with magnetic resonance imaging confirmed the lesion to be consistent with renal arterial pseudoaneurysm. Angiography and coil embolization of a distal feeding vessel were performed without damage to the proximal arterial tree (figs. 2 and 3). Pseudoaneurysm after partial nephrectomy is a rare but well documented complication with a reported incidence of 0.4% to as high as 12% in a

Neuro-Orthopedic Manifestations of the Omphalocele Exstrophy Imperforate Anus Spinal Defects Complex

PURPOSE The omphalocele-exstrophy-imperforate anus-spinal defects complex is a severe multisystem congenital defect. To comprehensively care for these patients one must appreciate the neurological and orthopedic impact on the overall health of the child. MATERIALS AND METHODS We retrospectively reviewed the medical records of 73 children with omphalocele-exstrophy-imperforate anus-spinal defects who were treated at our institution, identifying neurological and orthopedic anomalies, ambulatory ability and voiding status. RESULTS No neurological data were available on 5 patients. Of the remaining 68 patients 9 had no spinal anomaly, 57 had spina bifida, 1 had hemivertebrae and 1 had coccygeal hypoplasia. We further classified the 47 spina bifida cases as spina bifida occulta in 6, meningocele/lipomeningocele in 12, myelomeningocele/lipomyelomeningocele in 24 and sacral agenesis in 6. Of the patients with spina bifida 35 had cord tethering. Commonly identified orthopedic anomalies were vertebral malformation in 59 patients, scoliosis in 25, clubfoot in 14 and limb length discrepancy in 8. Ambulatory status in 62 patients of walking age revealed that 37 ambulated fully, 15 ambulated with devices, 2 ambulated minimally with devices and 8 were wheelchair bound. Continence data were available on 61 closed cases. Of these patients 26 were incontinent, including 3 with conduit diversion, 1 with ureterostomy and 1 with vesicostomy. A total of 35 patients were socially continent, of whom 30 catheterized via a continent abdominal stoma and 5 voided/catheterized via the urethra. CONCLUSIONS Early evaluation for neurosurgical and orthopedic anomalies is vital in these children. Despite the high incidence of spinal pathology most patients ambulate without assistance. Few children with omphalocele-exstrophy-imperforate anus-spinal defects achieve continence via the urethra. Vigilant followup is necessary to identify potentially correctable conditions.

Management of Primary Squamous Cell Carcinoma at the Mucocutaneous Junction of an Ileal Conduit

c c s t c d s o T w o 1 c s r e a m c u t c t c 5 w m m m c s s t v s Primary tumors arising from ileal conduit urinary diversions are exceedingly rare, despite having been routinely performed since the 1950s. Cases f adenocarcinoma within the ileal conduit have been eported in published studies, but a secondary maligancy at the level of the mucocutaneous junction has not een described. We report a case of peristomal squamous ell carcinoma 27 years after cystoprostatectomy and ileal onduit diversion for transitional cell carcinoma of the ladder and review the data on peristomal malignancies.

Unusual Presentation of a Mullerian Remnant in an Infant with Recurrent Epididymo-orchitis

Mullerian duct remnants result from incomplete regression, a defect that occurs during sexual differentiation. Ninety percent of patients with mullerian remnants also have an associated disorder of sexual differentiation such as hypospadias. Presenting signs and symptoms are recurrent bladder infection, perineal pain, dysuria, or infertility. The purpose of this case report is to recount an unusual presentation of a mullerian duct remnant with recurrent epididymo-orchitis and to discuss the embryology, diagnosis, and management of this condition.

Does benign prostatic hyperplasia treatment with alpha-blockers affect prostate cancer risk?

Purpose of reviewTo determine whether alpha-blockers, commonly used for the treatment of benign prostatic hyperplasia, are associated with prostate cancer risk. Recent findingsAlpha-blockers have been associated with a reduced risk of prostate cancer aggressiveness in some observational studies and an increased risk in other studies. However, this relationship is complex as different alpha-blockers have divergent effects in laboratory studies and there are many confounders in daily practice such as differential screening practices. SummaryBoth benign prostatic hyperplasia and prostate cancer are common conditions in the aging male population, such that an interaction between alpha-blockers and prostate cancer risk is clinically relevant. Prospective evidence is necessary to establish a definitive link.

Using a serosal trough for fashioning a continent catheterizable stoma: Technique and outcomes

Continent urinary diversion with bladder augmentation is an established method of providing urinary continence in children with bladder exstrophy, who are not suitable candidates or have a failed bladder neck reconstruction. Sub‐mucosal implantation of the tubularized catheterizable stoma (usually the appendix) into the reservoir, with backing typically provided by either the bladder musculature or colonic taenia, is safe and highly effective in these children. In some cases of classic bladder exstrophy and in the majority of patients with cloacal exstrophy, the ileum is used for enterocystoplasty and therefore there is no taenia to back the implanted catheterizable channel. This study describes the steps for providing a reliable flap‐valve mechanism for the continent catheterizable channel using the serosal trough technique.