Mohamed E. Dawaba

Factors affecting outcome of tubularized incised plate (TIP) urethroplasty: Single-center experience with 500 cases

PURPOSE To review our experience of tubularized incised plate (TIP) urethroplasty in children with hypospadias defects. METHODS Of 500 children (mean age 6 years) who received a TIP urethroplasty, 439 (87.8%) had primary hypospadias and 61 had one failed previous repair. The hypospadias defects were coronal in 110 (22%), distal penile in 261 (52.2%), midpenile in 78 (15.6%) and proximal in 51 (10.2%). Chordee was present in 98 (19.6%) patients. Presence of complications requiring re-operation and overall general appearance was recorded. RESULTS The mean (SD, range) follow-up was 34 (18, 7-77) months. Overall success rate was 81.4%. Re-operation was required in 93 patients (18.6%); for urethrocutaneous fistula in 47 (9.4%), complete disruption of the repair in 32 (6.4%) and meatal stenosis in 14 (2.8%). In univariate analysis, complications were significantly higher in stented repairs, posterior hypospadias, those with no neourethral coverage (spongioplasty), and repairs early in the study. The last three factors were the only significant independent risk factors in multivariate analysis. CONCLUSIONS TIP is a reliable method for treating both distal and proximal hypospadias and is suitable for both primary and re-operative cases with a low rate of complications. A significantly better outcome is achieved with distal hypospadias, covering the neourethra with the mobilized corpus spongiosum (spongioplasty) or a flap, and experience. Stenting of the repair, patient age, or previous failed repair has no statistically significant impact on outcome.

Prospective Study of the Long-Term Effects of Shock Wave Lithotripsy on Renal Function and Blood Pressure

PURPOSE We clarified the long-term effects of extracorporeal shock wave lithotripsy on renal function and blood pressure, and its relation to body mass index and type of lithotriptor. MATERIALS AND METHODS A total of 100 patients with a single radiopaque renal stone 2 cm or less in length were followed for 18 to 57 months (mean 43.6 +/- 13.8) after being stone-free by extracorporeal shock wave lithotripsy monotherapy using 2 lithotriptors. Mean patient age was 47.9 +/- 9.1 years (range 23 to 66). Nuclear scintigraphy using (99m)technetium-mercaptoacetyltriglycine was done for all patients before extracorporeal shock wave lithotripsy, as well as at the last followup visit to estimate glomerular filtration rate, clearance and split renal function. Blood pressure measurements were recorded at admission and at each followup visit. RESULTS Before extracorporeal shock wave lithotripsy treated side mean (99m)technetium-mercaptoacetyltriglycine clearance, glomerular filtration rate and split function were 146.22 +/- 59.48, 52.66 +/- 13.69 and 49.7 +/- 7.31, respectively. At the last followup visit they were 145.1 +/- 58.82 (p = 0.842), 54.85 +/- 15.75 (p = 0.114) and 49.96 +/- 8.68 (p = 0.577), respectively. Of 100 patients 18 were hypertensive before extracorporeal shock wave lithotripsy and 21 were hypertensive at the last followup visit. Mean diastolic blood pressure before extracorporeal shock wave lithotripsy was 80.2 +/- 6.2 vs 80.6 +/- 7.8 mm Hg (p = 0.674) at the end of followup. Mean systolic blood pressure before extracorporeal shock wave lithotripsy was 121.2 +/- 9 vs 121.55 +/- 10.2 mm Hg by the end of the study (p = 0.748). There were no statistically significant differences among body mass index groups or lithotriptor groups. CONCLUSIONS Extracorporeal shock wave lithotripsy is a safe procedure and has no significant long-term effects on renal function or blood pressure regardless of the type of machine used or body mass index.

Surgical management of failed pyeloplasty in children: Single-center experience

PURPOSE To evaluate the outcome of secondary surgical procedures for the management of failed pyeloplasty in children. MATERIALS AND METHODS Between 1996 and 2007, 590 cases of primary ureteropelvic junction (UPJ) obstruction underwent open dismembered pyeloplasty at our center. Of these patients, 18 (3%) with recurrent UPJ obstruction (14 males, 4 females; age range: 2-15 years) have undergone management of failed pyeloplasty. Secondary intervention was by open operative procedure in all cases. Clinical and radiological outcomes were assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow up. RESULTS Follow up ranged from 8 to 41 months (mean 28). The overall salvage rate was 89%. Secondary reoperative surgery was successful in 16 patients: dismembered pyeloplasty in 14 patients (78%) and ureterocalyceal anastomosis in 2 (11%). Nephrectomy was necessitated in 2 patients (11%). No perioperative complications were encountered. All patients showed stability of renal function on radiological follow up without evidence of obstruction and with no further symptoms. CONCLUSION Persistent UPJ obstruction after pyeloplasty is an uncommon complication. Secondary procedures have a very high success rate with excellent functional results. Nephrectomy is indicated in rare cases of severely deteriorated renal function.

Evaluation of a synchronous twin-pulse technique for shock wave lithotripsy: a prospective randomized study of effectiveness and safety in comparison to standard single-pulse technique.

To asses the efficacy and safety of bidirectional synchronous twin‐pulse extracorporeal shock wave lithotripsy (ESWL) compared with standard ESWL.

Urethrorectal Fistula Repair in Children: Urologic Perspective

OBJECTIVES We report our experience in the management of urethrorectal fistulae in children with emphasis on the complexity of this rare disease. PATIENTS AND METHODS A retrospective review was performed in cases that underwent repair of urethrorectal fistula at our center between 1997 and 2007. Records were reviewed for age, history, presentation, radiologic data, operative data, and condition at last follow-up. RESULTS Five children were managed for urethrorectal fistula. Their mean age was 6.8 years (range, 2 months-12 years). One case had congenital urethrorectal fistula and four had acquired fistulas including two after abdomino-perineal pull through for imperforate anus, one case post perineal urethroplasty, and another post repair of posttraumatic rectal tear. All patients presented with history of passing urine both through the rectum and the urethral meatus. We have three urinary diverted cases: one case in whom urinary and fecal diversions were performed and the remaining case was operated without diversion. Perineal approach was adopted in four procedures and abdomino-perineal approach in one. One patient required optical internal urethrotomy for anastomotic stricture at 6 months follow-up. CONCLUSIONS Urethrorectal fistula is a rare complication whether congenital or iatrogenic. Perineal repair is challenging, necessities meticulous dissection, adequate vascularity of the edges, and interposition of vascularized flaps and is potentially successful.

Retropubic bulbourethral sling in incontinence post-exstrophy repair: 2-year minimal follow up of a salvage procedure

Post‐exstrophy incontinence is a challenge because continence is difficult to achieve and more difficult to maintain. Feasibility and outcomes of a bulbourethral sling to treat post‐exstrophy incontinence is shown in this report.

Complete Primary Repair of Bladder Exstrophy: Critical Analysis of the Long-term Outcome

OBJECTIVE To demonstrate the long-term outcome of a contemporary series of 64 children who underwent complete primary repair of bladder exstrophy (CPRE) in a single tertiary referral center. MATERIALS AND METHODS Between 1998 and 2012, 64 children, 47 boys and 17 girls, were identified. Only 60 of the 64 cases were available for follow-up. The follow-up was done by renal bladder ultrasound and serum creatinine every 3 months and voiding cystourethrogram from 6 to 12 months postoperatively. Continence was defined as dryness ≥3 hours. RESULTS Median (range) follow-up is 14 years (from 5 to 19 years). Voided continence was achieved in 14 children (23%) after CPRE only. Additionally, 6 children were continent after bladder neck reconstruction (BNR) and 2 after bladder neck injection (BNI), raising the percentage of voided continence to 36%. The remaining 38 (64%) patients were using clean intermittent catheterization. All cases were continent at last assessment. The results of BNR or BNI were better in de novo than in redo cases (P <.05). The percentage of cases that needed augmentation ileocystoplasty in combination with multiple bladder neck procedures was lower in both female and de novo cases (P <.05). CONCLUSION The percentage of children with classic bladder exstrophy who underwent CPRE who will achieve continence with volitional voiding via the urethra is 36%. The continence results after BNR and BNI are better in de novo cases than in redo ones. Continence in female and de novo cases is more likely to be achieved with lower number of continence procedures.

Cloacal Duplication: Single-center Experience in the Management of a Rare Anomaly

Cloacal duplication is an exceedingly rare group of anomalies with a limited number of cases reported so far. The anomaly may be confined to partial bladder duplication or it may involve complete duplication of the urogenital tract, hindgut, spine, lower limbs, and vascular structures. Every case is unique and ought to be approached individually. By means of imaging studies and endoscopy, anatomic details should be carefully defined before endorsing surgical correction. A satisfactory outcome can be achieved in the majority of cases. In this report, we describe 3 girls with cloacal duplication, and review pertinent imaging and surgical management.

Perineal Hernia Is an Unusual Complication Post Perineal Bladder Neck Closure: A Case Report

Bladder neck closure (BNC) is the ultimate bladder neck reconstruction. If reconstruction fails, closure must be considered as it gives the highest continence rate. The vast majority of BNCs are performed through an abdominal approach (either transvesical or extravesical approach), but perineal approach remains an option for BNC with considerable success rate. Perineal hernia, which is defined as protrusion of abdominal contents through the perineal defect, is a very rare complication after urologic procedures. We report a case of perineal hernia post perineal BNC.

Primary Yolk Sac Tumor of the Prostate in a Child: Case Report

Extragonadal germ cell tumors comprise a rare entity of germ cell neoplasms. The central nervous system, mediastinum, and retroperitoneum are the most common locations. The prostate is a rare potential site, with only 7 cases reported in the literature to our knowledge. The diagnosis is on the basis of elevation of serum afetoprotein (AFP) level, characteristic histologic appearance, and positive immune-histochemical staining for AFP. Exclusion of a testicular primary, using physical and ultrasound examination, is critical before the diagnosis is made. The role of testicular biopsy has been debated. Microscopically, the tumor is composed of polygonal cells arranged in solid sheets, microcystic, papillary, or glandular structures. Tumor cells have eosinophilic cytoplasm, prominent nucleoli, and stain positive for AFP. The exceptional rarity of the disease, absence of reproducible treatment protocols in addition to lack of reference ranges for AFP in young children adds to the diagnostic and therapeutic conundrum of prostatic yolk sac tumor in children. Treatment is essentially multimodal entailing platinumbased chemotherapy and radical surgery. A survival advantage was noted with preoperative chemotherapy. Herein we report, to our knowledge, the first case of primary prostatic yolk sac tumor in a child who was treated with combination chemotherapy followed by radical prostatectomy. Unfortunately, the disease relapsed 17 months after the initial diagnosis and the patient eventually succumbed to the disease. Because of the dismal prognosis of the disease, a strict long-term follow-up including testicular surveillance for metachronous tumors is mandatory.