Fire in the Operating Room During Hypospadias Repair

Fire in the operating room (OR) is a very distressful and shocking occurrence with potential dramatic consequences. Despite safety rules and rigorous recommendations, such unintentional events do occur every so often. Notably, the vast majority of cases have been reported in the adult population, with very few pediatric cases described to date. Herein, we report on a 16-month-old boy undergoing reconstructive surgery for penoscrotal hypospadias, who experienced an OR fire most likely related to the use of alcohol-based solution ignited by monopolar electrocautery

Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures

OBJECTIVES: Since the resurgence in the use of buccal mucosa (BM) in substitution urethroplasty in the late 1980s and early 1990s, there has been controversy as to which surgical technique is the most appropriate for its application. METHODS: The authors performed an updated literature review. Several centres have published widely on this topic, and the points considered include the use BM in dorsal onlay grafts, ventral onlay grafts, and tubularised grafts and the role of two-stage procedures. RESULTS: In experienced hands, the outcomes of both dorsal onlay grafts and ventral onlay grafts in bulbar urethroplasty are similar. The dorsal onlay technique is, however, possibly less dependent on surgical expertise and therefore more suitable for surgeons new to the practice of urethroplasty. The complications associated with ventral onlay techniques can be minimised by meticulous surgical technique, but in series with longer follow-up, complications still tend to be more prevalent. In penile urethroplasty, two-stage dorsal onlay of BM (after complete excision of the scarred urethra) still provides the best results, although in certain circumstances a one-stage dorsal onlay procedure is possible. In general, ventral onlay of BM and tube graft procedures in the management of penile strictures are associated with much higher rates of recurrence and should therefore be avoided. CONCLUSIONS: In experienced hands the results of the ventral and dorsal onlay of BM for bulbar urethroplasty are equivalent. Two-stage procedures are preferable in the penile urethra, except under certain circumstances when a one-stage dorsal onlay is feasible

Arterial anatomy and arteriographic diagnosis of arteriogenic impotence

One hundred twenty-six bilateral selective arteriographic examinations of the iliopudendal vascular tree were performed after comprehensive multidisciplinary evaluation in patients with chronic erectile dysfunction. Best imaging results were obtained by performing the arteriography under epidural anesthesia after intracavernous injection of a vasoactive drug combination. The arteriography is mandatory prior to revascularization procedures. It is further indicated in primary erectile dysfunction and posttraumatic erectile failure. The importance of cavernosography and selective arteriography in primary erectile dysfunction is stressed. Increasing knowledge about the influence of vasoactive drugs on penile hemodynamics has led to its application in diagnosis and therapy of erectile dysfunction. Pharmacocovernosography, Doppler-ultrasound of penile arteries after intracavernous injection of a vasoactive drug combination, and pharmacoarteriography are refined techniques to prove a vascular etiology of erectile dysfunction. The results of the morphologic studies of the vascular system are correlated with functional testing of erectile capacity by intracavernous application of a papaverinephentolamine drug combination

Outcome and refinements of gender confirming surgery

Introduction Gender dysphoria is a state in which the individual shows strong and persistent identification with the opposite sex. After thorough diagnostic assessment, the treatment includes gender confirming surgery (GCS). The efficacy and benefit of GCS has been advocated to effectively resolve the patient’s gender dysphoria as well as improve quality of life and psychosocial functioning. The aim of the studies described here was to assess surgical techniques, complications, quality of life and functional outcomes of GCS. Patients and Methods Study I is a retrospective study ofsurgical outcomes for patients who underwent male-tofemale (MtF) GCS over a 14-year period (n=205). Study II describes a prospective study (n=80) of vaginal depth after vaginoplasty performed using solely penile skin for intra vaginal lining. Factors predicted to correlate with poor outcomes were analyzed using a multivariate regression model. Study III is a prospective study (n=193) examining patient-reported outcomes on health-related quality of life. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1,3 and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population. Study IV is a cohort study (n=22) of the sensitivity of the neoclitoris and its patient-reported functionality. Tactile and vibratory sensitivity was measured with the Semmes-Weinstein monofilaments and the Bio-Thesiometer vibratory measurement device, respectively. A body image questionnaire was provided to patients and the patients were asked about orgasm, pain and general satisfaction with the surgery. Results In study I, the most common short-term complications were bleeding (11%) and infection (10%). Other complications, such as wound dehiscence (2%), rectovaginal fistula (2%), pulmonary embolus (2%) and deep vein thrombosis (0%), were rare. In study II, the average neovaginal depth was 10.2 cm (range 1 -16 cm). Noncompliance with dilation protocol (p<0.001) and postoperative complications (p=0.01) were associated with decreased vaginal depth. Neither circumcision nor age affected the outcome of vaginal depth. In study III, transgender women reported significantly lower quality of life in most dimensions when compared to the general population. One year postoperatively, there was a trend towards higher scores compared to the preoperative measurement point; however, these scores then declined. In study IV, the average pressure threshold for the neoclitoris was 12.5 g/mm2 and the average vibratory threshold was 0.3 µm. The vast majority of the study participants could reach orgasm (86%), and reported satisfaction with having undergone GCS (86%). Conclusions MtF GCS can be performed with a low rate of major complications. Using solely penile skin is sufficient to create the vaginal lining, although adhering to a dilation protocol is crucial to attaining sustained vaginal depth. Quality of life among MtF patients compared to the general population is improved one year after GCS, but then declines. The sensate neoclitoris has a protective tactile sensation, gives the patient erogenous sensitivity and the ability to reach orgasm in the majority of patients. Over all, the vast majority of patients who undergo MtF GCS are satisfied

Revision of perineal urethrostomy using a meshed split-thickness skin graft

Perineal urethrostomy is considered to be the last option to restore voiding in complex/recurrent urethral stricture disease. It is also a necessary procedure after penectomy or urethrectomy. Stenosis of the perineal urethrostomy has been reported in up to 30% of cases. There is no consensus on how to treat a stenotic perineal urethrostomy, but, in general, a form of urinary diversion is offered to the patient. We present the case of a young male who underwent perineal urethrostomy after urethrectomy for urethral cancer. The postoperative period was complicated by wound dehiscence with subsequent complete obliteration of the perineal urethrostomy. Revision surgery was performed with reopening of the obliterated urethral stump and coverage of the skin defect between the urethra and the perineal/scrotal skin with a meshed split-thickness skin graft. To date, this patient is voiding well and satisfied with the offered solution