Vojkan Vukadinovic

Onlay Island Flap Urethroplasty for Severe Hypospadias: A Variant of the Technique

A variant of the onlay island flap urethroplasty in severe hypospadias repair is described. The principles of the technique include mobilization of the urethral plate without dividing it, release of chordee, creation of a pedicle island flap on the dorsal penile skin with redundant vascularized tissue that is transposed to the ventral side of the penis by a buttonhole maneuver, and onlay of the flap to the mobilized urethral plate, covering all suture lines with a wide pedicle of flap. During the last 3 years this operation was performed in 92 patients 12 months to 19 years old with severe hypospadias. The complication rate was 5%.

Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair.

There are three different topics covered in the paediatric urology section in this issue. Authors from Belgrade describe how a dorsal dartos flap can be used to prevent fistula in the Snodgrass hypospadias repair. The use of extracorporeal pelvic floor magnetic stimulation in children with voiding dysfunction is described by authors from Seoul. And finally, authors from Antalya write about the impact of the location of the ureteric orifice on the efficacy of endoscopic injection to correct VUR.

PENILE DISASSEMBLY TECHNIQUE FOR EPISPADIAS REPAIR: VARIANTS OF TECHNIQUE

PURPOSE We present 2 variants of the penile disassembly technique for epispadias repair that refine some details of the Mitchell technique. In some cases the urethral plate retracts and shortens, and there may be poor vascularization at the most distal portion. In addition, when the neurovascular bundles of the separated hemicorporeal glanular bodies are intact, it is difficult to achieve excellent correction of dorsal chordee. MATERIALS AND METHODS Between 1995 and 1998 we performed the modified Mitchell technique in 11 boys 2 to 14 years old using 1 of 2 variants. For variant 1 the hemiglans and urethral plate remain connected by a small tissue bridge to avoid shortening the urethral plate and ensure a better blood supply. For variant 2 each corporeal body is dissected from the glans cap and neurovascular bundle to achieve complete mobility. This procedure enables ideal mobility of the corporeal bodies as well as curvature repair. When corporeal rotation was unsuccessful, we corrected persistent dorsal chordee using the Ransley corporotomy with corporostomy in 2 patients and with dermal grafting in 1. RESULTS Mean followup was 17 months (range 6 to 30). Dorsal curvature was corrected in all cases. Cosmetic appearance was good. Complications included meatal stenosis and urethral fistula in 1 case each. CONCLUSIONS Our variants of epispadias repair may be good alternatives to the Ransley and Mitchell complete penile disassembly techniques.

BLADDER AUTOAUGMENTATION WITH RECTUS MUSCLE BACKING

PURPOSE Bladder autoaugmentation is a procedure which includes detrusoromyotomy or detrusorectomy to release intact urothelium which than prolapses and increases bladder capacity and compliance. The prolapsed urothelium is usually covered with de-epithelialized pedicled colonic or gastric patch. We present our initial experience with bladder autoaugmentation using rectus muscle backing. MATERIALS AND METHODS Between August 1999 and December 2000 autoaugmentation was performed in 4 girls and 3 boys 4 to 11 years old (median age 8). All patients had neurogenic bladder with small capacity and poor compliance. The technique is performed using an extraperitoneal approach through either an inferior midline longitudinal or transverse incision. The procedure is started with a semi-filled bladder to find the right plane and then continues with an almost empty bladder to avoid severe injury of the prolapsed urothelium. Both rectus muscles are dissected from the anterior and posterior sheaths and sutured to detrusor edges. Urothelium is sutured to the muscle at several places to prevent its retraction and shrinkage. Thus, the bladder is fixed and hangs on rectus muscles, that is the anterior abdominal wall. RESULTS Followup was 10 to 25 months (median 16). Bladder capacity at 6 months postoperatively increased in all patients, and ranged from 162 to 368 ml. (median 266). All patients had clinical improvement, decreased hydronephrosis, no vesicoureteral reflux and better compliance. CONCLUSIONS Bladder autoaugmentation with rectus muscle backing is a safe and simple procedure. Rectus muscle is a good alternative to other backing materials.

Penoscrotal transposition with hypospadias: 1-stage repair.

A 1-stage surgical repair of penoscrotal transposition with hypospadias is described. The basic principles are correction of hypospadias with the best vascularized island penile skin flap used for a new urethra and 2 vascularized sliding skin flaps used for reconstruction of the penile skin, and transposition of the penis to the suprascrotal position in the area of the mons pubis, with mobilization plus midline testicular fixation (inter-orchiopexy) and scrotoplasty. This technique was applied in 42 patients 2 to 9 years old between 1986 and 1991. The complications were 2 urethral stenoses on the proximal anastomosis (1 was treated successfully by urethrotomy and 1 by an open operation) and 2 fistulas (successfully treated by surgery), while 2 patients required additional correction of penoscrotal transposition.

‘Pseudospongioplasty’ in the repair of a urethral diverticulum

To describe a technique for repairing urethral diverticula which includes neourethral reconstruction and increasing the mechanical support of the neourethra.

Augmentation ureterocystoplasty could be performed more frequently

PURPOSE Megaureter represents the ideal tissue for bladder augmentation but to date ureterocystoplasty has been used only in select cases. We demonstrate that ureterocystoplasty can be used more frequently by dividing the megaureter and using its distal part for bladder augmentation and proximal part for reimplantation into the bladder. This technique can be performed as a 1 or 2-stage procedure. MATERIALS AND METHODS From November 1995 to October 1998 ureterocystoplasty was performed in 16 patients 3 to 12 years old (mean age 6.6). In 9 cases with impaired renal function loop cutaneous ureterostomy had been previously done to preserve and improve renal function. In the remaining 7 cases bladder augmentation and simultaneous ureteroneocystostomy were performed without cutaneous ureterostomy. Ureterocystoplasty was done extraperitoneally. This distal part of megaureter was used for bladder augmentation and the proximal part was implanted into the bladder using extravesical detrusor tunneling ureteroneocystostomy in a majority of cases. RESULTS Followup ranged from 12 months to 4 years (mean 2.8). The new increased bladder capacity ranged 296 to 442 ml. (mean 371) in both groups. Compliance was improved in all cases with a decrease in the number of clean intermittent catheterizations daily, and there was no further worsening of renal function. Vesicoureteral reflux was noted in 3 patients without clinical symptoms. CONCLUSIONS Megaureter presents the ideal tissue for bladder augmentation. Division of the ureter and use of its distal part for augmentation is always possible. Augmentation ureterocystoplasty performed this way can be done more frequently.

Detrusorectomy With Rectus Muscle Hitch and Backing

PURPOSE Bladder autoaugmentation is a procedure that includes detrusoromyotomy or detrusorectomy with an aim to release intact urothelium, which then prolapses and increases bladder capacity and compliance. Covering of the prolapsed urothelium usually is done by using deepithelialized pedicled colonic or gastric patch. The authors present their first experiences with detrusorectomy using rectus muscle for hitch and backing. METHODS Between August 1999 and February 2002, autoaugmentation was performed in 19 patients (12 girls and 7 boys) aged 4 to 12 years (median, 8). All patients had a neurogenic bladder with small capacity and poor compliance. Detrusorectomy usually involves the whole upper half of the bladder to achieve regular shape of the huge prolapsed urothelium. Both rectus muscles are dissected from their anterior and posterior sheaths. Urothelium is sutured to the muscle at several points to prevent its retraction and shrinkage. This way, bladder is fixed and hanged on rectus muscles. RESULTS Follow-up was 6 to 35 months (median, 21). The new bladder capacity was increased in all patients and ranged from 190 to 411 ml (median, 313). All patients had clinical improvement and better compliance. CONCLUSIONS Detrusorectomy with rectus muscle hitch and backing is a safe and simple procedure. However, long-term results are needed to define value of this procedure.

The Role of Clitoral Anatomy in Female to Male Sex Reassignment Surgery

Introduction. Controversies on clitoral anatomy and its role in female sexual function still make clitoral reconstructive surgery very challenging. We evaluated the role of clitoral anatomic features in female to male sex reassignment surgery. Material and Methods. The study included 97 female transsexuals, aged from 18 to 41 years, who underwent single stage metoidioplasty between March 2008 and January 2013. The operative technique involved vaginectomy, the release of clitoral ligaments and urethral plate, urethroplasty by combining buccal mucosa graft and genital flaps, and scrotoplasty with insertion of testicle prostheses. Postoperative questionnaire was used to evaluate aesthetic, functional, and sexual outcome. Results. The mean followup was 30 months. The mean length of the neophallus was 7 cm, compared to mean preoperative length of the hypertrophied clitoris of 3.3 cm. Complications occurred in 27.84% of all patients, related mostly to urethroplasty. Voiding while standing was achieved in all cases. None of the patients had problems in sexual arousal, masturbation, or orgasms. Conclusion. Accurate knowledge of the clitoral anatomy, physiology, and neurovascular supply is crucial for a successful outcome of female to male sex reassignment surgery. Our approach appears to ensure overall satisfaction and high quality of sexual life.

Surgical treatment of cloacal anomalies

Abstract From 1989–1998 14 patients were treated with cloacal anomalies: 5 typical cloacas (PC), 5 posterior cloacas, and 4 cloacal exstrophies (CE); 12 underwent surgery. Four typical cloacas were resolved with posterior sagittal anorectovagino-urethroplasty (PSARVUP), whereas in the 5th total urogenital mobilization (TUM) was used. Three PCs were managed with transanorectal TUM and 2 with anterior TUM without opening the anal canal and rectum (without a protective colostomy). Two CEs were treated with atypical procedures. Two patients with CE died without surgery and 2 died after surgery due to complex associated anomalies. During postoperative follow-up of 1–8 years, 5 children had voluntary bowel movements and no soiling while the others had soiling with or without enemas; 1 had stress incontinence; 3 were on clean intermittent catheterization due to neurogenic bladder and were dry.PSARVUP provides a satisfactory result if there is no sacral anomaly. TUM makes this operation easier to perform. In patients with a PC it is sometimes possible using TUM to separate the urinary from the genital tract and remove the accessory urethra without opening the anus and rectum.