Warren Snodgrass

Tubularized, Incised Plate Urethroplasty for Distal Hypospadias

A technique is described for correction of distal hypospadias with minimal chordee by tubularizing the urethral plate. The key step is deep longitudinal incision of the plate, which allows for tubularization without the need for additional flaps. The resultant neourethra is functionally adequate and an excellent cosmetic result with a vertically oriented meatus is achieved. A total of 16 boys underwent the procedure with no case of meatal stenosis or fistula occurring during a median followup of 22 months.

THE IMPACT OF TREATED DYSFUNCTIONAL VOIDING ON THE NONSURGICAL MANAGEMENT OF VESICOURETERAL REFLUX

PURPOSEnWe evaluated the impact of dysfunctional voiding on the nonsurgical management of vesicoureteral reflux in toilet trained children.nnnMATERIALS AND METHODSnThe study population comprised 107 girls and 21 boys 3 to 10 years old who were diagnosed with vesicoureteral reflux during evaluation for urinary tract infection or dysfunctional voiding. Dysfunctional voiding was identified prospectively on the basis of typical symptoms. All patients with a urinary tract infection received antibiotic prophylaxis and oxybutynin was prescribed for all those with dysfunctional voiding. Girls with dysfunctional voiding who had no history of urinary tract infection were also given daily antibiotic prophylaxis.nnnRESULTSnOf the 128 patients 51 girls and 15 boys had dysfunctional voiding. Reflux spontaneously resolved in 27 of the 44 evaluable girls (61%) with normal and 19 of the 42 (45%) with dysfunctional voiding. A breakthrough urinary infection developed in 18 girls (43%) with versus only 5 (11%) without dysfunctional voiding (p = 0.001). No boys had a breakthrough infection.nnnCONCLUSIONSnDespite anticholinergic therapy and antibiotic suppression 43% of the girls with dysfunctional voiding in whom reflux may otherwise have resolved spontaneously had a breakthrough urinary infection leading to surgery.

DOES TUBULARIZED INCISED PLATE HYPOSPADIAS REPAIR CREATE NEOURETHRAL STRICTURES

PURPOSEnBoys in whom hypospadias was repaired by tubularized, incised plate urethroplasty were evaluated to determine whether dorsal incision of the urethral plate results in strictures of the neourethra.nnnMATERIALS AND METHODSnPostoperative followup of the initial 72 patients was reviewed and then attempts were made to contact these boys for delayed assessment more than 1 year after surgery. Periodic neourethral calibration was routinely done during year 1 postoperatively and at delayed followup. Urethroscopy was performed for a decreased urinary stream or during anesthesia for other procedures. Uroflowometry was done at the delayed assessment of toilet trained boys.nnnRESULTSnThe urethra was calibrated in 85% of the patients with no strictures noted. Urethroscopy in 10% of the boys demonstrated a healthy appearing neourethra. Uroflowometry was possible in 34% of the toilet trained patients with all results within the 95% confidence levels of standard curves for age.nnnCONCLUSIONSnThe dorsal relaxing incision of tubularized, incised plate hypospadias repair did not result in neourethral strictures.

Histology of the urethral plate: Implications for hypospadias repair

PURPOSEnWe define the histology of the urethral plate in boys with hypospadias.nnnMATERIALS AND METHODSnSubepithelial biopsies of the urethral plate were obtained in 17 boys, including 13 with distal and 4 with penoscrotal hypospadias. Ventral penile curvature was noted in 5 cases. Specimens were evaluated by 7 light microscopy after hematoxylin and eosin staining.nnnRESULTSnAll biopsies demonstrated well vascularized connective tissue comprised of smooth muscle and collagen. There was no evidence of fibrous bands or dysplastic tissue.nnnCONCLUSIONSnThe urethral plate consists of epithelium overlying connective tissue. We found no histological evidence of fibrous cords historically considered responsible for chordee.

Long-term followup of the hematuria-dysuria syndrome.

PURPOSEnThe hematuria-dysuria syndrome is the most common reported complication of gastrocystoplasty. We reviewed our cases of gastrocystoplasty to determine the long-term incidence and significance of the syndrome.nnnMATERIALS AND METHODSnWe performed a retrospective study of 78 patients who underwent gastrocystoplasty at our institution between July 1989 and October 1994. A total of 72 of the 78 cases were evaluated within the last year to elicit symptoms of the hematuria-dysuria syndrome.nnnRESULTSnSpina bifida and bladder exstrophy were the most common diagnoses of patients undergoing gastrocystoplasty. There were 3 (4%) patients who required medications on a continuous basis to control symptoms of the hematuria-dysuria syndrome. However, using broad criteria 17 (24%) patients would be categorized as having the syndrome. Of these patients 9 did not require any medications and 4 occasionally took medications to control symptoms. A significant increase in the incidence of the hematuria-dysuria syndrome was detected in those cases with a sensate compared to those with an insensate urethra.nnnCONCLUSIONSnThe hematuria-dysuria syndrome is a clinically significant problem at long-term followup in a small percentage of patients treated with gastrocystoplasty. The lowest incidence is in those children with an insensate urethra who are continent. When symptoms occur they are easily treated in the majority of cases. We believe that gastrocystoplasty remains a viable option in the armamentarium of bladder augmentation.

Current Referral Patterns and Means to Improve Accuracy in Diagnosis of Undescended Testis

OBJECTIVES: The goals were to determine current referral patterns for boys suspected of having undescended testis (UDT) and to identify factors to assist primary care providers in distinguishing retractile testes from UDTs on the basis of history, physical examination, or imaging findings. METHODS: By using a standardized history assessment, visual inspection of the scrotum for symmetry, physical examination, and review of previously obtained imaging findings, we performed a prospective observational study with consecutive patients referred to a pediatric urologist for evaluation of UDT. RESULTS: Of 118 boys, 51 (43%) had descended testes, 60 (51%) had UDTs, and 7 (6%) had initially indeterminate findings. Boys with UDT were referred at a median age of 43.3 months. Patients referred at <1 year or >10 years of age were significantly more likely to have UDT than were those referred at 1 to 10 years of age. History of UDT at birth, prematurity, and scrotal asymmetry strongly increased the risk of UDT. Genital ultrasonography had been performed for 25% of patients, incorrectly indicating UDT for 48%. CONCLUSIONS: Most boys were referred well beyond the recommended age of <12 months for orchiopexy. Only one-half of the patients had UDT, with most errors in diagnosis being made for boys 1 to 10 years of age, which suggests difficulty distinguishing UDT from retractile testis. Positive birth history findings, prematurity, and scrotal asymmetry predicted UDT and can be used by primary care physicians in their assessment before referral. Genital ultrasonography did not distinguish UDTs from retractile testes.

A simplified Kropp procedure for incontinence

PURPOSEnA simplified Kropp bladder neck reconstruction was done to achieve urinary continence.nnnMATERIALS AND METHODSnA total of 23 patients with an incompetent bladder neck underwent the procedure, including 22 with a neurogenic bladder secondary to myelodysplasia and 1 with bladder exstrophy. The bladder neck operation was incorporated into comprehensive lower tract reconstruction that included simultaneous augmentation cystoplasty in 20 patients, ureteroneocystostomy in 6 and appendicovesicostomy in 6.nnnRESULTSnOf the 23 patients 21 (91%) are continent. Complications included difficult catheterization in boys and new onset vesicoureteral reflux.nnnCONCLUSIONSnThis operation is easily performed and effective for achieving continence.

VAGINAL CALCULI SECONDARY TO PARTIAL VAGINAL OUTLET OBSTRUCTION IN PEDIATRIC PATIENTS

Vaginal calculi are classified as primary or secondary and they are rare, especially in children. Primary vaginal calculi are believed to originate from the stasis of urine in the vagina without an obvious nidus, whereas secondary vaginal calculi are the result of crystallization of urinary constituents around a foreign body in the vagina. The 2 previously described children with vaginal calculi had primary stones. Eton noted a large struvite stone associated with an ectopic ureter draining into the vagina of a 7-year-old child. Bissada and Hanash removed a struvite calculus from a 12-year-old patient with urinary incontinence secondary to spina bifida. We recently treated 2 children with primary vaginal stones associated with partial vaginal outlet obstruction.

Recent advances in understanding/management of hypospadias

Hypospadias is the second most common birth anomaly, affecting 1 of every 300 males. The abnormal position of the urinary opening, and associated downward curvature of the penis in some cases, potentially impact both urinary and sexual function. Modern surgical correction most often involves tubularization of the urethral plate, those tissues which normally should have completed urethral development. This article discusses recent progress in hypospadias repair. Prospective data collection in consecutive patients promotes better understanding of both patient and technical factors that influence surgical complications. Patients with a proximal urinary opening near or within the scrotum, those failing prior to repairs, and/or those with a small glans diameter have increased likelihood for urethroplasty complications. Quality review of reliable data led to two layer urethroplasty covered with tunica vaginalis in proximal repairs, significantly reducing postoperative fistulas. Neither preoperative androgens used to grow a small diameter glans, nor a change in sutures used to approximate the glans wings reduced wound dehiscence, but a recent technical modification of the glansplasty with more extensive dissection before suturing has. The observation that reoperation increases risk for further complications three-fold suggests the less common proximal repairs and reoperations should be subspecialized so that designated surgeons can gain greater expertise. In addition, surgeons performing hypospadias repair must better define the complications that occur so that scientific reporting of outcomes becomes more standardized. Standardized objective means to assess results are also needed so that surgeons performing different repairs can compare outcomes.

TRIAMCINOLONE TO PREVENT STENOSIS IN MITROFANOFF STOMAS

After Mitrofanoff first reported in 1980 that appendix or ureter could be used as a channel from the abdominal wall to the bladder for intermittent catheterization, the so-called Mitrofanoff principle found widespread application in lower urinary tract reconstruction. Its success partially depends on the narrow conduit, which allows easy passage of catheters without kinking. However, the small caliber of Mitrofanoff conduits preferentially derived from the appendix enhances the risk of stomal stenosis. In fact, stenosis is the most frequent problem in continent catheterizable stomas, occurring in an average of 13% of patients. Spatulation of the appendix2 with or without advancement of a V flap3 may decrease the incidence of this complication but does not completely prevent it. Patients with stenosis require dilation or surgical revision to facilitate catheterization. Furthermore, it has been our experience that stenosis recurs despite previous revision with V flaps. Our cases of stomal stenosis that developed after appendicovesicostomy have been associated with hypertrophic scar formation. We report the administration of triamcinolone injected parastomally as an adjunct to surgical revision to prevent recurrent stenosis. CASE REPORTS