Urethral duplication II-A Y type with rectal urethra: ASTRA approach and tunica vaginalis flap for first stage repair

INTRODUCTION: Urethral duplication is a rare congenital anomaly affecting mainly boys. Generally, the duplication develops on the sagittal plane; the accessory urethra may run dorsally or ventrally to the orthotopic one. We present a patient with urethral duplication in which the orthotopic urethra was patent in the penile segment but atresic in the bulbar and prostatic segment. The patient had urinary flow from the rectum and the ectopic urethra could be well identified by anal examination. MATERIALS AND METHODS: Age at surgery was 13 months. The procedure consisted of an ASTRA (anterior sagittal trans-ano-rectal) approach for dividing the urethra and rectum and was successful to move the urethra up to the perineal area. The rectum was reconstructed and the patient placed into a lithotomy position. A urethral catheter inserted in the penile urethra oriented us were the atresic urethra in bulbar area started. The scrotum was opened in the middle and the distance between the two urethral stumps proximal and distal defined the extension of no urethral tissue that consisted of 5 cm. We opened the right scrotal space and a tunica vaginalis flap was obtained and attached to the bulbar tissue for a two-stage urethroplasty strategy. RESULTS: Patient had a nice healing and the tunica vaginalis was nicely incorporated to the adjacent tissue, having the two urethral stumps well delineated. CONCLUSIONS: ASTRA approach in combination with a two-stage urethroplasty with tunica vaginalis dorsal flap proved to be an excellent combination for a rare case of urethral Y duplication having the main urethra into the rectum.Universidade Federal de São Paulo (UNIFESP) Department of UrologyUNIFESP, Department of UrologySciEL

Elective appendicovesicostomy in association with monfort abdominoplasty in the treatment of prune belly syndrome

OBJECTIVE: To evaluate the role of elective appendicovesicostomy in association with Monfort abdominoplasty to avoid urinary tract infection (UTI) and renal damage in the post-operative follow-up of patients with prune belly syndrome. MATERIALS AND METHODS: We followed 4 patients operated in our institution (UNIFESP) (Monfort, orchidopexy and Mitrofanoff) and compared them to 2 patients treated similarly, but without an appendicovesicostomy, in a second institution (UFBA). We evaluated postoperative clinical complications, UTI and preservation of renal parenchyma. Patients were followed as outpatients with urinalysis, ultrasonography (US) and occasionally with renal scintigraphy. RESULTS: Mean follow-up was 23.5 months. Immediate post-operative course was uneventful. We observed that only one patient with the Mitrofanoff channel persisted with UTI, while the 2 patients used as controls persisted with recurrent pyelonephritis (> 2 UTI year). CONCLUSION: Our data suggest that no morbidity was added by the appendicovesicostomy to immediate postoperative surgical recovery and that this procedure may have a beneficial effect in reducing postoperative UTI events and their consequences by reducing the postvoid residuals in the early abdominoplasty follow-up. However, we recognize that the series is small and only a longer follow-up with a larger number of patients will allow us to confirm our suppositions. We could not make any statistically significant assumptions regarding differences in renal preservation due to the same limitations.Federal University of São Paulo Division of UrologyFederal University of Bahia Division of UrologyUNIFESP, Division of UrologySciEL

Histopathological evaluation of urethroplasty with dorsal buccal mucosa: an experimental study in rabbits

PURPOSE: Buccal mucosa is a widely accepted tissue for urethroplasty. The exact healing and tissue integration process, mainly the histological characteristics of dorsal buccal mucosa graft urethroplasty when used dorsally to reconstruct the urethral plate has not previously been assessed, and thus we developed an experimental model to address this question. MATERIALS AND METHODS: In 12 New Zealand rabbits (weight 2.5 kg) we surgically created a dorsal penile urethral defect. A buccal mucosa graft was sutured to the corpora and tunica albuginea, and the ventral urethra anastomosed to this new urethral plate. The animals were divided in three groups and sacrificed 1, 3 and 6 weeks after surgery (groups 1, 2 and 3). A retrograde urethrogram was obtained at autopsy in the last group and the penis analyzed histologically with hematoxylin-eosin and Masson's staining. RESULTS: The urethrograms showed no evidence of fistula or stricture. In group 1 the histopathological analysis showed submucosal lymph-mononuclear inflammatory edema, numerous eosinophils and squamous epithelium integrated into the adjacent urothelium. In group 2 there was no evidence of an inflammatory response but rather complete subepithelial hyaline healing, which was more marked in group 3. CONCLUSION: Healing of buccal mucosa grafts to reconstruct the urethral plate can be achieved by total integration of the squamous epithelium with the urothelium, maintaining the original histological properties of the graft with no fibrosis or retraction.Federal University of São Paulo Divisions of UrologyFederal University of São PauloUNIFESP, Divisions of UrologyUNIFESPSciEL

Cloacal Exstrophy: a complex disease

Introduction Cloacal exstrophy is a rare occurrence with an incidence of 1:200,000 to 1:400,000 live births. It represents one of the most challenging reconstructive endeavors faced by pediatric surgeons and urologists. Aside from the genitourinary defects, there are other associated anomalies of the gastrointestinal, musculoskeletal and neurological systems that require a multidisciplinary approach when counseling anxious parents. Material and Methods We present a video of a patient with cloacal exstrophy treated with 21 days of life. Surgery consisted of separation and tubularization of the cecal plate from the exstrophied bladder halves and colostomy construction. The bladder was closed primarily and umbilical scar reconstructed and used for ureteral and cistostomy drainage. A urethral catheter was used to guide bladder neck tubularization. A final epispadic penis was obtained and planned for further repair in a second step. Results The patient had an initial uneventful postoperative course and immediate outcome was excellent. The bladder healed nicely but patient presented with abdominal distension in the 5th day of postoperative setting requiring parenteral nutrition. The distal colon persisted with lower diameter although non obstructive, but causing difficulty for fecal progression. Continuous colostomy dilatation and irrigation were required. Conclusions Approximating the bladder halves in the midline at birth and primary bladder closure is a viable option, intestinal transit may be a issue of concern in the early postoperative follow-up.Universidade Federal de São Paulo (UNIFESP) Division of UrologyUNIFESP, Division of UrologySciEL

A new extra-abdominal channel alternative to the mitrofanoff principle: experimental and preliminary clinical experience

INTRODUCTION: The appendix is the gold-standard channel for the Mitrofanoff principle in pediatric urology, but the search for alternatives is justified considering it may not be available or preferably used for colonic stomas (Malone antegrade continence enema). The aim of this study is to report on technical feasibility of a new approach for creating catheterizable channels in a rabbit model and to present our preliminary clinical experience. MATERIAL AND METHODS: We configured a tube from two rectangular skin flaps 1x4 cm opposite each other in the middle line of the lower inferior abdomen. The channel was anastomosed to the bladder dome with embedding sutures to create a valvular mechanism. The experimental study consisted of 12 rabbits, divided in 4 groups according to the sacrifice schedule at 2, 4, 8 and 12 weeks. At 30th postoperative day, an urodynamic evaluation was performed to record continence of the stoma. A histological analysis of the specimens stained with hematoxylin-eosin, Masson trichrome and Picrosirius red was also done in group 2 (sacrifice at 4 weeks postoperatively). We used this method in 3 patients with congenital non-neurogenic bladder disease presenting with massive residual volumes without compliance deficits. RESULT: The technique proved feasible in all animals, 9 of 12 could be easily catheterized and underwent urodynamic study. No stoma leakage was observed in 7 animals at high bladder pressures (> 50 cm H20) and only 2 animals had some leakage at 40 cm H20. Urodynamics performed through the stoma showed urethral leakage at 20 cm H20, therefore demonstrating the efficacy of the valvular mechanism. Histological analysis confirmed good integration between the tube and the bladder. Mean follow-up of the clinical series (3 patients) was 7.2 months. Two patients remained continent up to 4 hours, whereas 1 patient had some leakage after 2 hours. CONCLUSION: We were able to confirm feasibility of a new extra-abdominal channel based on the Mitrofanoff principle and successfully reproduced the method in a clinical setting. Follow-up was short and long term results are required before any conclusive judgment can be made.Federal University of São Paulo Department of UrologyUNIFESP, Department of UrologySciEL

SOIL RESPIRATION AND BULK DENSITY UNDER ORGANIC AND CONVENTIONAL FARMING SYSTEMS

The aim of this study was to evaluate, in the field, the soil respiration and bulk density under conventional and organic farming plots. The evaluations were made in different plots established as conventional farming system and organic farming system with six, nine, twelve, fifteen, eighteen and twenty one months old. Plots were replicated four times and in each subplot were evaluated soil respiration, bulk density and porosity. The soil respiration was significantly greater in organic farming system with fifteen, eighteen and twenty-one months old as compared with conventional farming. Soil bulk density decreased fifteen months after adoption of organic system. The results showed that the adoption of practices in organic farming plots increases microbial activity and decreases soil bulk density over time

Influence of forensic examination on the accountability of sexual violence authors in teenagers

OBJETIVO: avaliar a influência do exame médico-legal na responsabilização criminal de acusados de violência sexual contra adolescentes do sexo feminino. MÉTODO: foram analisados retrospectivamente 137 processos judiciais de estupro contra adolescentes matriculadas no Centro de Referência da Criança e do Adolescente entre janeiro de 1995 e dezembro de 2004. Os laudos do Instituto Médico Legal foram classificados como negativos ou positivos para a materialidade do crime sexual e confrontados com a sentença judicial, condenatória ou não para o acusado. Os dados foram informatizados em Programa EpiInfo e submetidos ao teste de Qui-quadrado para Tabelas de contingência, fixando-se em p &lt; 0,05 o nível de rejeição da hipótese de nulidade. RESULTADOS: em 30 casos (21,9%) o laudo foi concordante com a queixa de estupro. Em 107 casos (78,1%) o exame médico-legal não encontrou evidência material do crime sexual. Entre os exames positivos, 25 acusados (83,3%) foram condenados, enquanto nas perícias negativas ocorreram 68 condenações (63,5%). CONCLUSÕES: o exame médico-legal positivo se associou com maior probabilidade de condenação do acusado da violência sexual. A ausência de elementos comprobatórios materiais não impediu a responsabilização de parte expressiva dos acusados, indicando que outros meios de convencimento são admitidos pela justiça.OBJECTIVE: to evaluate the influence of forensic examination on the accountability of sexual violence criminal charges in adolescent girls. METHOD: retrospective study, it was analyzed 137 lawsuits rape in teenagers enrolled in the Reference Center for Children and Adolescents between January 1995 and December 2004. The awards of the Forensic Institute were classified as negative or positive for the materiality of sexual crimes and confronted with the judicial sentence, condemnatory or not. Data was computerized in EpiInfo Program and subjected to chi-square test for contingency tables, considering p < 0.05 the level of rejection of the hypothesis of nullity. RESULTS: in 30 cases (21.9%) the award was consistent with the complaint of rape. In 107 cases (78.1%) the forensic examination found no physical evidence of sexual crime. Among the positive cases, 25 accused (83.3 %) were condemned, while in the negative skills it was observed 68 condemnations (63.5 %). CONCLUSIONS: the positive forensic examination was associated with the most part of probability of condemnation of the accused of the sexual violence. The absence of corroborative material elements did not obstruct the accountability of expressive part of the accused subjects, indicating that other means of persuasion are accepted by the courts