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Corporal grafting for severe hypospadias - a single institutional experience with three different techniques
ESPU Meeting 2007 hypospadias respectively. TP significantly decreased PR mRNA levels in both females and males.
CONCLUSIONS This study provides in-vivo evidence that PRs are highly expressed in developing GTs
S49 with an increasing manner until birth implying that the GT is sensitive to the effects of estrogenic and progestogenic endocrine disruptors during fetal life. In addition to their opposing morphological effects, EE and TP lead to opposing effects on PR expression. These findings suggest that progesterone plays an
important role in GT development, although the physiological role remains to unknown.
# S09-3 (PP)
DISTAL PENILE REMODELLING WITH COMPOSITE GRAFT (DPRCG) FOR NEOGLANS RECONSTRUCTION Wee Yan CHIA Gleneagles Intan Medical Centre, Paediatric Surgery, Kuala Lumpur, MALAYSIA
PURPOSE To describe the technique of distal penile remodelling with a composite graft (DPRCG) for neoglans reconstruction following traumatic penile glans loss
MATERIAL AND METHODS Four boys had a neoglans reconstruction following traumatic loss of the glans penis. Two of them suffered glans loss following hypospadias repair; one had an avulsion injury of the glans while the other suffered an inadvertent excessive circumcision. After the distal penis was degloved, it was remodelled to simulate the glans and coronal sulcus; and the neocoronal sulcus grafted with skin from the buccal mucosa while the neo-glans was
grafted with full thickness post auricular skin. The distal penile remodelling was initiated with a circumferential distally based fascial flap raised along the line of the proposed coronal sulcus. This flap was then rolled over the distal part of the penis and sutured distally to simulate the bulky part of the glans just distal to the coronal sulcus. After completion of neoglans and neo-coronal sulcus grafting, the penile skin was re-attached to the neocoronal sulcus to complete a ‘circumcised look’ in the immediate post operative period.
RESULTS All four boys completed their neoglans reconstruction which resulted in
a reasonably normal ‘circumcised look’ in the immediate post operative period. After a follow-up period of between 17 to 39 months, two patients had partial loss of the differentiation between the glans and coronal sulcus. All four boys maintain their ability for erection.
CONCLUSIONS Distal penile remodelling with composite graft (DPRCG) partially helps in the restoration of a normal looking circumcised penis and is useful for neoglans reconstruction.
# S09-4 (PP)
CORPORAL GRAFTING FOR SEVERE HYPOSPADIAS - A SINGLE INSTITUTIONAL EXPERIENCE WITH THREE DIFFERENT TECHNIQUES Mark P. CAIN, MD, FAAP, Jeffrey A. LESLIE, Anthony J. CASALE, Martin KAEFER and Richard C. RINK James Whitcomb Riley Hospital for Children, Indiana University, Division of Pediatric Urology, Indiananpolis, USA
PURPOSE
MATERIALS AND METHODS
Correction of severe chordee by corporal body grafting has been successfully performed using a variety of grafts and biomaterials. To date there has been no large single institutional experience comparing the various techniques. We report our outcomes comparing small intestinal submucosa (SIS), tunica vaginalis (TV), and dermal grafts (DG) used for correcting chordee at the time of first stage hypospadias repair.
A retrospective chart review was conducted including all patients that underwent two stage hypospadias repair from 1985 to 2006 with corporal body grafting at the first stage. Age at time of surgery, residual chordee at the time of the second stage, and the need for additional placation or chordee correction at the second stage was recorded.
RESULTS A total of 71 patients were identified, with a median age at initial corporal grafting of 10 months, and median time between first
and second stage of 7.6 months. DG were used in 29, TV in 21, and SIS in 20 patients. One patient had both SIS and TV grafts placed. Complications requiring corporal plication at the time of the second stage occurred with one DG and one SIS graft for minor residual ventral chordee. One patient that had 4-ply SIS developed severe fibrosis required graft excision and regrafting with TV. No single layer SIS grafts had complications. No patient has demonstrated residual chordee after second stage hypospadias repair.
S50
CONCLUSIONS
ESPU Meeting 2007 associated with proximal hypospadias we have demonstrated successful outcomes
with SIS, tunica vaginalis or dermal grafts with no significant differences in results.
In a large group of children requiring corporal grafting for severe chordee # S09-5 (O)
URETHRAL DUPLICATION WITH CHORDEE e SURGICAL MANAGEMENT Joseph ORTENBERG MD, FAAP, Michael L. RITCHEY MD, FAAP* and Anthony A. CALDAMONE MD, FAAPy LSUHSC / Children’s Hospital, Dept of Urology, New Orleans, USA - * Mayo Clinic, Dept of Urology, Scottsdale, USA - y Brown University/Rhode Island Hospital, Dept of Urology, Providence, USA
BACKGROUND Urethral duplication may be evident at birth or may present later in childhood with a double urinary stream, or infection.
METHODS In a retrospective review at 3 institutions, 13 cases of urethral duplication were identified between 1987-2004, ranging in age from 1 day to 14 years. Evaluation consisted of radiographic imaging, intraoperative urethroscopy and artificial erections. The urethral configuration,
meatal position, presence of chordee and any associated anomalies were assessed.
RESULTS All boys were identified with a double meatus of which 54% had epispadias and 15% had hypospadias with a relatively normal position of the anomalous meatus. Voiding cystography or a retrograde urethrogram was beneficial to classify these lesions. Vesicoureteral reflux or ureteral ectopia was present in 15 of boys. According to the classification proposed by Effman e 15% of boys were Type II A1 and the balance were Type II A2. Operative management consisted of
dorsal urethrectomy, often with release of suspensory ligament, in order to fully resect the extra urethra, as well as chordeelysis or ventral penile plication in 69% of patients. Surgical techniques will be reviewed. Surgery was uniformally successful with follow eup of 10 months16 years.
CONCLUSIONS Dorsal urethrectomy is curative for urethral duplication with concomitant chordeelysis or plication. Surgery should ideally be accomplished during infancy, as genital resconstructive surgery is best tolerated in this age group.
# S09-6 (PP)
COMPARATIVE ANALYSIS OF TUBULARIZED INCISED PLATE VS. ONLAY ISLAND FLAP URETRHOPLASTIES FOR PENOSCROTAL HYPOSPADIAS Luis BRAGA, Joao PIPPI SALLE, Sumit DAVE, Armando LORENZO, Walid FARHAT, Antoine KHOURY and Darius BAGLI Hospital for Sick Children, Urology, Toronto, CANADA
PURPOSE
MATERIAL AND METHODS
To review our experience with penoscrotal hypospadias (PSH), comparing the results of TIP vs. transverse island flap ONLAY urethroplasties.
A retrospective review of consecutive patients with PSH was performed. 1657 boys underwent hypospadias repair at our institution from 1998 to 2006. 75 comprised
our study population: 35 children underwent a TIP repair, and 40 had an ONLAY procedure. Degree of chordee, type of chordee repair, complications, available uroflowmetry in toliet trained-pts., and number of re-operations were compared between the 2 groups.
Variables
TIP n ¼ 35 (%)
ONLAY n ¼ 40 (%)
p
Preop severe chordee (> 45o) Dorsal plication Mean catheter duration (days) Overall complication Fistula/Breakdown Fistula location (proximal) Recurrent chordee Average flow rate Flattened shape curve PVR >30% expected blad capac # pts with >2 re-operations
7 (20) 19 (54.3) 8.5 (7-10) 21 (60) 18 (51.4) 13/18 (72.2) 2 (5.7) 3.1 to 13.2 16/24 (66.6) 2/24 (8.3)
18 (45) 27 (67.5) 10.3 (7-14) 18 (45) 10 (25) 2/10 (20) 5 (12.5) 3.0 to 16.0 7/21 (33.3) 0/21 (0)
0.02
2 (5.7)
7 (17.5)
NS 0.01 0.02
<0.01
CONCLUSIONS This study provides in-vivo evidence that PRs are highly expressed in developing GTs
S49 with an increasing manner until birth implying that the GT is sensitive to the effects of estrogenic and progestogenic endocrine disruptors during fetal life. In addition to their opposing morphological effects, EE and TP lead to opposing effects on PR expression. These findings suggest that progesterone plays an
important role in GT development, although the physiological role remains to unknown.
# S09-3 (PP)
DISTAL PENILE REMODELLING WITH COMPOSITE GRAFT (DPRCG) FOR NEOGLANS RECONSTRUCTION Wee Yan CHIA Gleneagles Intan Medical Centre, Paediatric Surgery, Kuala Lumpur, MALAYSIA
PURPOSE To describe the technique of distal penile remodelling with a composite graft (DPRCG) for neoglans reconstruction following traumatic penile glans loss
MATERIAL AND METHODS Four boys had a neoglans reconstruction following traumatic loss of the glans penis. Two of them suffered glans loss following hypospadias repair; one had an avulsion injury of the glans while the other suffered an inadvertent excessive circumcision. After the distal penis was degloved, it was remodelled to simulate the glans and coronal sulcus; and the neocoronal sulcus grafted with skin from the buccal mucosa while the neo-glans was
grafted with full thickness post auricular skin. The distal penile remodelling was initiated with a circumferential distally based fascial flap raised along the line of the proposed coronal sulcus. This flap was then rolled over the distal part of the penis and sutured distally to simulate the bulky part of the glans just distal to the coronal sulcus. After completion of neoglans and neo-coronal sulcus grafting, the penile skin was re-attached to the neocoronal sulcus to complete a ‘circumcised look’ in the immediate post operative period.
RESULTS All four boys completed their neoglans reconstruction which resulted in
a reasonably normal ‘circumcised look’ in the immediate post operative period. After a follow-up period of between 17 to 39 months, two patients had partial loss of the differentiation between the glans and coronal sulcus. All four boys maintain their ability for erection.
CONCLUSIONS Distal penile remodelling with composite graft (DPRCG) partially helps in the restoration of a normal looking circumcised penis and is useful for neoglans reconstruction.
# S09-4 (PP)
CORPORAL GRAFTING FOR SEVERE HYPOSPADIAS - A SINGLE INSTITUTIONAL EXPERIENCE WITH THREE DIFFERENT TECHNIQUES Mark P. CAIN, MD, FAAP, Jeffrey A. LESLIE, Anthony J. CASALE, Martin KAEFER and Richard C. RINK James Whitcomb Riley Hospital for Children, Indiana University, Division of Pediatric Urology, Indiananpolis, USA
PURPOSE
MATERIALS AND METHODS
Correction of severe chordee by corporal body grafting has been successfully performed using a variety of grafts and biomaterials. To date there has been no large single institutional experience comparing the various techniques. We report our outcomes comparing small intestinal submucosa (SIS), tunica vaginalis (TV), and dermal grafts (DG) used for correcting chordee at the time of first stage hypospadias repair.
A retrospective chart review was conducted including all patients that underwent two stage hypospadias repair from 1985 to 2006 with corporal body grafting at the first stage. Age at time of surgery, residual chordee at the time of the second stage, and the need for additional placation or chordee correction at the second stage was recorded.
RESULTS A total of 71 patients were identified, with a median age at initial corporal grafting of 10 months, and median time between first
and second stage of 7.6 months. DG were used in 29, TV in 21, and SIS in 20 patients. One patient had both SIS and TV grafts placed. Complications requiring corporal plication at the time of the second stage occurred with one DG and one SIS graft for minor residual ventral chordee. One patient that had 4-ply SIS developed severe fibrosis required graft excision and regrafting with TV. No single layer SIS grafts had complications. No patient has demonstrated residual chordee after second stage hypospadias repair.
S50
CONCLUSIONS
ESPU Meeting 2007 associated with proximal hypospadias we have demonstrated successful outcomes
with SIS, tunica vaginalis or dermal grafts with no significant differences in results.
In a large group of children requiring corporal grafting for severe chordee # S09-5 (O)
URETHRAL DUPLICATION WITH CHORDEE e SURGICAL MANAGEMENT Joseph ORTENBERG MD, FAAP, Michael L. RITCHEY MD, FAAP* and Anthony A. CALDAMONE MD, FAAPy LSUHSC / Children’s Hospital, Dept of Urology, New Orleans, USA - * Mayo Clinic, Dept of Urology, Scottsdale, USA - y Brown University/Rhode Island Hospital, Dept of Urology, Providence, USA
BACKGROUND Urethral duplication may be evident at birth or may present later in childhood with a double urinary stream, or infection.
METHODS In a retrospective review at 3 institutions, 13 cases of urethral duplication were identified between 1987-2004, ranging in age from 1 day to 14 years. Evaluation consisted of radiographic imaging, intraoperative urethroscopy and artificial erections. The urethral configuration,
meatal position, presence of chordee and any associated anomalies were assessed.
RESULTS All boys were identified with a double meatus of which 54% had epispadias and 15% had hypospadias with a relatively normal position of the anomalous meatus. Voiding cystography or a retrograde urethrogram was beneficial to classify these lesions. Vesicoureteral reflux or ureteral ectopia was present in 15 of boys. According to the classification proposed by Effman e 15% of boys were Type II A1 and the balance were Type II A2. Operative management consisted of
dorsal urethrectomy, often with release of suspensory ligament, in order to fully resect the extra urethra, as well as chordeelysis or ventral penile plication in 69% of patients. Surgical techniques will be reviewed. Surgery was uniformally successful with follow eup of 10 months16 years.
CONCLUSIONS Dorsal urethrectomy is curative for urethral duplication with concomitant chordeelysis or plication. Surgery should ideally be accomplished during infancy, as genital resconstructive surgery is best tolerated in this age group.
# S09-6 (PP)
COMPARATIVE ANALYSIS OF TUBULARIZED INCISED PLATE VS. ONLAY ISLAND FLAP URETRHOPLASTIES FOR PENOSCROTAL HYPOSPADIAS Luis BRAGA, Joao PIPPI SALLE, Sumit DAVE, Armando LORENZO, Walid FARHAT, Antoine KHOURY and Darius BAGLI Hospital for Sick Children, Urology, Toronto, CANADA
PURPOSE
MATERIAL AND METHODS
To review our experience with penoscrotal hypospadias (PSH), comparing the results of TIP vs. transverse island flap ONLAY urethroplasties.
A retrospective review of consecutive patients with PSH was performed. 1657 boys underwent hypospadias repair at our institution from 1998 to 2006. 75 comprised
our study population: 35 children underwent a TIP repair, and 40 had an ONLAY procedure. Degree of chordee, type of chordee repair, complications, available uroflowmetry in toliet trained-pts., and number of re-operations were compared between the 2 groups.
Variables
TIP n ¼ 35 (%)
ONLAY n ¼ 40 (%)
p
Preop severe chordee (> 45o) Dorsal plication Mean catheter duration (days) Overall complication Fistula/Breakdown Fistula location (proximal) Recurrent chordee Average flow rate Flattened shape curve PVR >30% expected blad capac # pts with >2 re-operations
7 (20) 19 (54.3) 8.5 (7-10) 21 (60) 18 (51.4) 13/18 (72.2) 2 (5.7) 3.1 to 13.2 16/24 (66.6) 2/24 (8.3)
18 (45) 27 (67.5) 10.3 (7-14) 18 (45) 10 (25) 2/10 (20) 5 (12.5) 3.0 to 16.0 7/21 (33.3) 0/21 (0)
0.02
2 (5.7)
7 (17.5)
NS 0.01 0.02
<0.01