Samir Orabi

Post-traumatic posterior urethral stricture in children: How to achieve a successful repair

OBJECTIVE Complex post-traumatic posterior urethral strictures in children constitute a major challenge to the pediatric urologist. Surgical repair depends primarily on the length of the urethral obliteration. Resection with end-to-end anastomosis is the usual procedure in the face of a short segment stricture. Transpubic urethroplasty and substitution urethroplasty are currently used to treat extensive and complex urethral strictures. We present our experience of the management of children presenting with post-traumatic posterior urethral stricture. PATIENTS AND METHODS Fifty boys with a mean age of 9 years (6-13) with obliterative urethral stricture were operated on during May 1999 to August 2006. Short posterior urethral stricture was treated by excision and end-to-end anastomotic urethroplasty in 40 boys. Long posterior urethral stricture was managed by combined inferior pubectomy in three, transpubic urethroplasty in four and tubed penile fasciocutaneous flap in three. RESULTS With a mean follow-up of 4.5 years (6 months-7 years), all children who underwent perineal anastomotic urethroplasty were successfully repaired. Transpubic urethroplasty was associated with a re-stricture in one child 6 years following the repair. In the group repaired by tubed fasciocutaneous flap, we encountered a distal anastomotic stricture accompanied by a huge proximal diverticulum which needed revision in one child, and another diverticulum with multiple stones in another who was treated successfully. CONCLUSION Anastomotic urethroplasty in children is feasible with good results. Proper evaluation is needed to choose the best surgical technique for each patient. Tubed fasciocutaneous flap carries the highest complication rate.

Progressive hair coil penile tourniquet syndrome: multicenter experience with 25 cases

OBJECTIVE Penile hair tourniquet syndrome is an uncommon syndrome characterized by progressive penile strangulation by a hair tie. Complications reported include urethrocutaneous fistula, complete urethral transection, penile gangrene, and penile amputation. Prevention of such major complications depends on awareness of the etiology and presence of a high index of suspicion for early diagnosis. PATIENTS AND METHODS Twenty-five children presenting with different degrees of hair coil penile strangulation syndrome have been operated on in the period from 2000 to 2007 in 2 tertiary care centers in the city of Alexandria. Eighteen boys had complete transection of the urethra at the coronal sulcus. Seven boys had partial transection of the ventral wall of the urethra at the coronal sulcus. Repair of the penis was done in all children in a single stage. RESULTS The mean age of boys is 3 years and 9 months (2-5 years). The mean follow-up is 20.7 (6-48) months. Urethral catheter was left for a mean of 5.5 (4-7) days. In the mean follow-up period, we had 4 complications in the form of 2 tiny urethrocutaneous fistulas and 2 anastomotic urethral strictures. The fistulae were closed surgically after the primary surgery by 1 year in the 2 cases, with no recurrence. Urethral strictures were managed by endoscopic visual urethrotomy, with no recurrence. CONCLUSION Penile tourniquet syndrome can cause serious penile complications. Awareness of this rare syndrome can help in preventing such complications. Being familiar with the surgical reconstruction guarantees high success rate.

Corporeal Body Grafting Using Buccal Mucosa for Posterior Hypospadias With Severe Curvature

PURPOSE Severe penile curvature correction by corporeal body grafting has been successfully performed using various grafts and biomaterials. We present our initial experience with buccal mucosa as a free corporeal graft to correct severe penile curvature as part of a multistage approach to posterior hypospadias repair. MATERIALS AND METHODS A total of 12 children with a mean age of 6.2 years (range 4 to 8) with posterior hypospadias and severe ventral chordee (greater than 45 degrees) necessitating ventral grafting underwent correction using buccal mucosa. Preoperative androgen supplement was given when penile and glanular size was significantly small for age. Buccal mucosa was harvested from the inner side of the cheek or the lower lip. The harvested graft was defatted, fashioned and fixed to the ventral corporeal defect. The pre-grafting penile angle, immediate post-grafting angle and penile angle at 6 months were assessed. RESULTS All children had penoscrotal or perineal hypospadias, 4 had partial androgen insensitivity syndrome and 1 underwent multiple previous failed repairs. Androgen was given preoperatively in 3 children. After chordee release and urethral plate transection the penile angle was between 45 and 80 degrees. Mean graft length and width was 2.5 and 1.6 cm, respectively. All children had a straight penis at the end of the procedure and none required additive dorsal plication. At the last followup at 12 months all children had a straight penis except 2 with mild curvature (less than 10 degrees). No complications were noted with this technique. CONCLUSIONS Preliminary results of the novel use of buccal mucosa as a corporeal graft for severe chordee appear satisfactory. Longer term followup is needed to further document these data.

Transpubic posterior urethroplasty via perineal approach in children: A new technique *

OBJECTIVE To evaluate a new technique of transpubic urethroplasty via perineal approach for management of pelvic fracture urethral distraction defects (PFUDD) in children. METHODS Of 78 children undergoing posterior urethroplasty for PFUDD, 12 (15.4%) had a short urethra that could not bridge the gap (>5 cm) for a tension-free anastomosis. Age ranged from 5.2 to 12 years (median = 8.5 years). The median distraction defect length was 4.8 cm (range 3.7-6.4 cm). For the latter group, the new technique of transpubic posterior urethroplasty via perineal approach was performed. The first follow-up visit was scheduled 1 month after suprapubic catheter removal. Radiological studies and uroflowmetry were repeated at 6-month intervals for 1 year and once yearly thereafter. RESULTS Patients were followed up for a period of 6 months to 5 years with a mean of 2.7 years. Mean operative time was 2.5 h (range 1.9-3.2 h) with a mean blood loss of 200 ml (range 50-640 cc) and the mean hospital stay was 4 days. All 12 children had a good urinary stream over the follow-up period; 3/12 (25%) developed stress urinary incontinence that resolved within 6 months postoperatively; 9/12 (75%) complained of (retracted) short penis. CONCLUSIONS Transpubic urethroplasty via perineal approach is a feasible technique for management of complex PFUDD in children, and presents many advantages over other routes.

Laparoscopic re-implantation of refluxing ureter in children: A feasibility study

Abstract Objective: To report our initial experience in the application of laparoscopy in the management of children with unilateral vesico-ureteric reflux (VUR) using the laparoscopic extravesical transperitoneal approach following the Lich–Gregoir technique, and to evaluate the results and benefits of this technique for such patients. Patients and methods: Between February 2013 and August 2014, 17 children [13 girls and four boys, with a median (range) age of 60 (24–120) months] presented with recurrent febrile urinary tract infections and were diagnosed with unilateral VUR. They underwent transperitoneal extravesical laparoscopic ureteric re-implantation following the Lich–Gregoir technique. Postoperatively abdomino-pelvic ultrasonography was done at 1 month after surgery and voiding cystourethrography (VCUG) at 3 months after surgery, and in cases with persistent VUR or de novo contralateral VUR another VCUG was done at 6 months after surgery. Results: The median (range) operative time was 90 (80–120) min and the postoperative hospital stay was 2 (2–5) days. Intraoperative and postoperative complications were minimal. Patients were followed-up for a median (range) of 6 (3–21) months. All the children had complete resolution symptomatically and on VCUG, without further intervention. Conclusions: The laparoscopic extravesical transperitoneal approach for ureteric re-implantation, following the Lich–Gregoir technique, is feasible and very effective in the management of VUR. Prospective randomised studies are eagerly awaited to define the benefits of this technique to patients, as well as to determine the cost-effectiveness of this approach.

9 PELVIC FRACTURE URETHRAL INJURIES IN CHILDREN AND OLDER PATIENTS

INTRODUCTION AND OBJECTIVES: The subject of pelvic fracture urethral injuries usually has been discussed including children and older patients together. In this study we attempted to learn if pelvic fractures and associated urethral injuries in children and older patients differ. METHODS: A total of 203 consecutive male patients, 2 to 80 years old (mean 31), with fracture of the bony pelvis were enrolled in this study. All patients were entered into a prospective protocol including documentation of age, type of pelvic fracture, and presence of urethral injury and its type. The urethral injury was classified as complete rupture, partial rupture, and urethral stretch which refers to an elongation of the intact posterior urethra. All 203 patients underwent radiographic examination of the pelvis while retrograde urethrography was performed in 194 patients. As was confirmed later, 8 of the other 9 patients had no urethral injury and 1 had sustained partial urethral rupture. In analyzing our data patients were categorized as being children up to 15 years old(43 patients, group 1) or older patients (160 patients, group 2). RESULTS: Of fractures involving the ischiopubic rami, the less serious fractures including single and ipsilateral rami fractures were more common in older patients (47 versus 32%, p 0.05). On the other hand, the more serious fractures including straddle (fractures of all 4 ischiopubic rami) and Malgaigne’s (fracture of both ischiopubic rami with disruption of ipsilateral sacroiliac joint) fractures were more common in children (56 versus 24%, p 0.05). Fractures not involving the ischiopubic rami were more common in older patients (29 versus 12%, p 0.05). Urethral injury was more common in children than in older patients (30 versus 24%). Whereas the incidence of partial urethral injury was similar in both groups, stretching of an intact posterior urethra was more common in older patients (32 versus 8%) and complete rupture was more common in children (69 versus 42%). In 3 children with partial rupture, the injury involved the prostatic urethra and bladder neck. CONCLUSIONS: The young boy who sustains a pelvic fracture is much more unfortunate than the older patient who receives the same bone injury. Certain characteristics set him apart from an older patient. First; the pelvic fracture is more liable to be one of the serious fractures that cause a higher incidence of urethral injury. Second; urethral injury is more likely to be a complete rupture with a higher incidence of stricture formation. Third; urethral injury may implicate the bladder neck which increases the risk of urinary incontinence.