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Re: Hypospadias Repair With Tubularized Incised Plate: Does the Obstructive Flow Pattern Resolve Spontaneously?
PEDIATRIC UROLOGY
1435
Re: Ventral Corporal Body Grafting for Correcting Severe Penile Curvature Associated With Single or Two-Stage Hypospadias Repair C. Miguel, G. Rafael, D. Joshi, B. Y. Yuval and L. Andrew Division of Pediatric Urology, Miami Children’s Hospital and Jackson Memorial Hospital, University of Miami, Miami, Florida J Pediatr Urol 2011; 7: 289 –293.
Purpose: The literature on small intestinal submucosa for chordee correction in children is scarce. We reviewed our experience with 1 ply SIS for ventral corporal body grafting in cases of severe ventral penile curvature associated with proximal hypospadias in children. Materials and Methods: From 04 –2001 to 12–2007, 58 boys with proximal hypospadias and severe ventral curvature underwent single layered SIS graft to the corporal bodies to correct chordee. In 43 patients the surgery was done in the first stage of a planned 2-stage procedure. Fifteen patients underwent a 1-stage chordee correction with SIS and tubularized transverse preputial flap urethra. Results: Mean follow-up was 4.8 years. A straight phallus with good cosmesis was achieved in 57/58 patients. In 51/58 patients an artificial erection was performed in the operating room as part of a second stage procedure or for complications associated with the one stage urethroplasty. One patient needed a second procedure to correct the curvature (chordee was over-corrected and needed a ventral Nesbitt plication). In fifteen patients that underwent a 1-stage genital reconstruction, the neourethral meatus was left in the lower part of the glans in 8 patients and at the coronal sulcus in 7. Conclusions: Corporal body grafting with single layer SIS is a viable option for correction of severe chordee associated with corporal body disproportion. SIS is a material with reliable results, easy availability and no donor site associated morbidity. As a result of penile elongation with a graft, simultaneous island flap urethroplasty became difficult in many patients. Editorial Comment: This is a large series of boys with severe hypospadias treated with single layered, small intestinal submucosa graft to corporeal bodies. Of 58 patients 57 had excellent straightening. The remaining case actually was overcorrected and required ventral correction. No patient underwent dorsal plication. There did not seem to be SIS contraction associated with single ply SIS, possibly because the authors routinely oversized the graft by 20%. Postoperative curvature was recorded following artificial erection during the second stage procedure in all but 7 patients. In these patients erection was documented by parent reports or patient self-assessment. In this large series single ply SIS seemed effective for the correction of curvature, obviating the need for dorsal plication and presumably increasing the effective penile length in these patients who are at risk for considerable shortening associated with proximal hypospadias. Douglas A. Canning, M.D.
Re: Hypospadias Repair With Tubularized Incised Plate: Does the Obstructive Flow Pattern Resolve Spontaneously? M. Andersson, M. Doroszkiewicz, C. Arfwidsson, K. Abrahamsson and G. Holmdahl Department of Pediatric Urology, Queen Silvia Children’s Hospital, Sahlgrenska Academy, Gothenburg, Sweden J Pediatr Urol 2011; 7: 441– 445.
Objective: The aim of this prospective study was to evaluate whether urinary flow improves with time after tubularized incised plate (TIP) repair. Patients and Method: Between 1999 and 2003, primary TIP was performed in 126 boys. In patients old enough (48 boys, mean age at surgery 46 months, range 18 –103), uroflowmetry was performed 1 year and 7 (median, range 3–10) years post surgery. Miskolc nomograms were used to compare results from the two follow ups (Q(max) in relation to voided volume and age). Results: Eleven boys had symptoms of obstruction resulting in intervention. For the other 37 boys, the mean Q(max) was 13.6 ⫾ 5.6 ml/s 1 year postoperatively (mean voided
1436
UROLITHIASIS/ENDOUROLOGY
volume 107 ⫾ 43 ml) and 49% had flows below the 5th percentile. Seven years postoperatively the mean Q(max) was 19.0 ⫾ 8.1 ml/s (mean voided volume 235 ⫾ 112 ml) and 32% had flows below the 5th percentile. In the group with flows below the 5th percentile at 1 year, all improved and 28% improved to above the 25th percentile. Proximal hypospadias was more often associated with obstructive flow than distal (75%/75% compared to 43%/21% 1/7 years postoperatively). Conclusion: We found spontaneous improvement (P ⫽ 0.00022) 7 years after TIP repair, although many boys still had a Q(max) in the low normal or obstructive range. Editorial Comment: The authors reviewed flow rates at 1 year and 7 years following tubularized incised plate urethroplasty. Of 126 boys 48 underwent uroflowmetry at 1 year and 7 years. Of these boys 11 had symptoms of obstruction, resulting in intervention. These results suggest that while half of patients had flows below the fifth percentile at 1 year, only 32% had flows below the fifth percentile by year 7. From this study it is clear that an obstructed flow pattern develops in a large proportion of boys following hypospadias repair. It is encouraging that this process seems to improve in a proportion of patients but it is still worrisome that a large proportion persists with obstructed flow even after 7 years. A hypospadic urethra needs to be oversized, particularly if the reconstructed defect is long. A normal urethra dilates during voiding, resulting in a greater cross-sectional area through which the urine flows. Following a major hypospadias repair, particularly perineal hypospadias, scarring occurs, which limits the normal dilatation of the urethra during voiding. This scarring may result in a relatively diminished plateau-shaped urinary stream in many cases, as this article suggests. Therefore, our job is to study each patient carefully postoperatively, including following patients for an adequate period to ensure that their bladder remains healthy and stable. A normal flow rate is hard to achieve following hypospadias repair. Douglas A. Canning, M.D.
Urolithiasis/Endourology Re: Are Stone Protocol Computed Tomography Scans Mandatory for Children With Suspected Urinary Calculi? E. K. Johnson, G. J. Faerber, W. W. Roberts, J. S. Wolf, Jr., J. M. Park, D. A. Bloom and J. Wan Department of Urology, University of Michigan Medical Center, Ann Arbor, Michigan Urology 2011; 78: 662– 666.
Objective: To examine the clinical utility of noncontrast-enhanced computed tomography (NCCT) in pediatric patients with urolithiasis who progressed to surgery. Although NCCT is routine for the evaluation of adult patients with suspected urolithiasis, its routine use in the pediatric population is tempered by concern about radiation exposure. Methods: We conducted a retrospective chart review of all pediatric patients who had undergone surgery for urinary stones from 2003 to 2008 at our institution. The imaging modalities used, surgery type, stone composition, 24-hour urinalyses, and relevant predisposing conditions were characterized. Results: A total of 42 pediatric patients (24 males and 18 females) were treated during the 6-year period. The average age was 11.3 ⫾ 5.3 years (range 2.7–25.4), and the most common treatment modalities were shock wave lithotripsy (28%) and ureteroscopy (22%). A discernible risk factor or cause of urolithiasis was absent in 21 patients (47%). A review of imaging studies found 38 with stones visible on ultrasonography and/or abdominal plain film. A total of 21 patients underwent NCCT, in addition to ultrasonography and/or abdominal plain
1435
Re: Ventral Corporal Body Grafting for Correcting Severe Penile Curvature Associated With Single or Two-Stage Hypospadias Repair C. Miguel, G. Rafael, D. Joshi, B. Y. Yuval and L. Andrew Division of Pediatric Urology, Miami Children’s Hospital and Jackson Memorial Hospital, University of Miami, Miami, Florida J Pediatr Urol 2011; 7: 289 –293.
Purpose: The literature on small intestinal submucosa for chordee correction in children is scarce. We reviewed our experience with 1 ply SIS for ventral corporal body grafting in cases of severe ventral penile curvature associated with proximal hypospadias in children. Materials and Methods: From 04 –2001 to 12–2007, 58 boys with proximal hypospadias and severe ventral curvature underwent single layered SIS graft to the corporal bodies to correct chordee. In 43 patients the surgery was done in the first stage of a planned 2-stage procedure. Fifteen patients underwent a 1-stage chordee correction with SIS and tubularized transverse preputial flap urethra. Results: Mean follow-up was 4.8 years. A straight phallus with good cosmesis was achieved in 57/58 patients. In 51/58 patients an artificial erection was performed in the operating room as part of a second stage procedure or for complications associated with the one stage urethroplasty. One patient needed a second procedure to correct the curvature (chordee was over-corrected and needed a ventral Nesbitt plication). In fifteen patients that underwent a 1-stage genital reconstruction, the neourethral meatus was left in the lower part of the glans in 8 patients and at the coronal sulcus in 7. Conclusions: Corporal body grafting with single layer SIS is a viable option for correction of severe chordee associated with corporal body disproportion. SIS is a material with reliable results, easy availability and no donor site associated morbidity. As a result of penile elongation with a graft, simultaneous island flap urethroplasty became difficult in many patients. Editorial Comment: This is a large series of boys with severe hypospadias treated with single layered, small intestinal submucosa graft to corporeal bodies. Of 58 patients 57 had excellent straightening. The remaining case actually was overcorrected and required ventral correction. No patient underwent dorsal plication. There did not seem to be SIS contraction associated with single ply SIS, possibly because the authors routinely oversized the graft by 20%. Postoperative curvature was recorded following artificial erection during the second stage procedure in all but 7 patients. In these patients erection was documented by parent reports or patient self-assessment. In this large series single ply SIS seemed effective for the correction of curvature, obviating the need for dorsal plication and presumably increasing the effective penile length in these patients who are at risk for considerable shortening associated with proximal hypospadias. Douglas A. Canning, M.D.
Re: Hypospadias Repair With Tubularized Incised Plate: Does the Obstructive Flow Pattern Resolve Spontaneously? M. Andersson, M. Doroszkiewicz, C. Arfwidsson, K. Abrahamsson and G. Holmdahl Department of Pediatric Urology, Queen Silvia Children’s Hospital, Sahlgrenska Academy, Gothenburg, Sweden J Pediatr Urol 2011; 7: 441– 445.
Objective: The aim of this prospective study was to evaluate whether urinary flow improves with time after tubularized incised plate (TIP) repair. Patients and Method: Between 1999 and 2003, primary TIP was performed in 126 boys. In patients old enough (48 boys, mean age at surgery 46 months, range 18 –103), uroflowmetry was performed 1 year and 7 (median, range 3–10) years post surgery. Miskolc nomograms were used to compare results from the two follow ups (Q(max) in relation to voided volume and age). Results: Eleven boys had symptoms of obstruction resulting in intervention. For the other 37 boys, the mean Q(max) was 13.6 ⫾ 5.6 ml/s 1 year postoperatively (mean voided
1436
UROLITHIASIS/ENDOUROLOGY
volume 107 ⫾ 43 ml) and 49% had flows below the 5th percentile. Seven years postoperatively the mean Q(max) was 19.0 ⫾ 8.1 ml/s (mean voided volume 235 ⫾ 112 ml) and 32% had flows below the 5th percentile. In the group with flows below the 5th percentile at 1 year, all improved and 28% improved to above the 25th percentile. Proximal hypospadias was more often associated with obstructive flow than distal (75%/75% compared to 43%/21% 1/7 years postoperatively). Conclusion: We found spontaneous improvement (P ⫽ 0.00022) 7 years after TIP repair, although many boys still had a Q(max) in the low normal or obstructive range. Editorial Comment: The authors reviewed flow rates at 1 year and 7 years following tubularized incised plate urethroplasty. Of 126 boys 48 underwent uroflowmetry at 1 year and 7 years. Of these boys 11 had symptoms of obstruction, resulting in intervention. These results suggest that while half of patients had flows below the fifth percentile at 1 year, only 32% had flows below the fifth percentile by year 7. From this study it is clear that an obstructed flow pattern develops in a large proportion of boys following hypospadias repair. It is encouraging that this process seems to improve in a proportion of patients but it is still worrisome that a large proportion persists with obstructed flow even after 7 years. A hypospadic urethra needs to be oversized, particularly if the reconstructed defect is long. A normal urethra dilates during voiding, resulting in a greater cross-sectional area through which the urine flows. Following a major hypospadias repair, particularly perineal hypospadias, scarring occurs, which limits the normal dilatation of the urethra during voiding. This scarring may result in a relatively diminished plateau-shaped urinary stream in many cases, as this article suggests. Therefore, our job is to study each patient carefully postoperatively, including following patients for an adequate period to ensure that their bladder remains healthy and stable. A normal flow rate is hard to achieve following hypospadias repair. Douglas A. Canning, M.D.
Urolithiasis/Endourology Re: Are Stone Protocol Computed Tomography Scans Mandatory for Children With Suspected Urinary Calculi? E. K. Johnson, G. J. Faerber, W. W. Roberts, J. S. Wolf, Jr., J. M. Park, D. A. Bloom and J. Wan Department of Urology, University of Michigan Medical Center, Ann Arbor, Michigan Urology 2011; 78: 662– 666.
Objective: To examine the clinical utility of noncontrast-enhanced computed tomography (NCCT) in pediatric patients with urolithiasis who progressed to surgery. Although NCCT is routine for the evaluation of adult patients with suspected urolithiasis, its routine use in the pediatric population is tempered by concern about radiation exposure. Methods: We conducted a retrospective chart review of all pediatric patients who had undergone surgery for urinary stones from 2003 to 2008 at our institution. The imaging modalities used, surgery type, stone composition, 24-hour urinalyses, and relevant predisposing conditions were characterized. Results: A total of 42 pediatric patients (24 males and 18 females) were treated during the 6-year period. The average age was 11.3 ⫾ 5.3 years (range 2.7–25.4), and the most common treatment modalities were shock wave lithotripsy (28%) and ureteroscopy (22%). A discernible risk factor or cause of urolithiasis was absent in 21 patients (47%). A review of imaging studies found 38 with stones visible on ultrasonography and/or abdominal plain film. A total of 21 patients underwent NCCT, in addition to ultrasonography and/or abdominal plain