Buccal mucosa graft urethroplasty for anterior urethral stricture: A single-centre experience

Background :To evaluate the outcome and complications after using BMG for anterior urethral stricture. Procedure: This is a retrospective evaluation of prospectively maintained database. A total of 78 patients were operated from August 2012 to September 2019. Patients were evaluated by using IPSS score, uroflometry, post void residual urine and radiological studies. All patients were operated by using combined regional and general anaesthesia. Buccal mucosa was used in all except three where lingual mucosa was also harvested. The catheter was removed at 3-4 weeks after surgery and patients were followed up at one, three and six months, and then three monthly thereafter.The procedure was considered successful if no intervention was required after surgery. Conclusion: In 78 patient’s total of 89 procedures have been done over seven years. The procedure was successful in 84.93%, and it failed in 11 patients over a mean follow up of 45 months (7-59 months). In three patients, single DVIU was sufficient whereas in four regular CIC was required after DVIU. In four patients redo surgery was done after six months. Two patients required staged procedure and in three permanent perineal urethrostomy were made due to poor urethral condition, all in older patients. These five patients were excluded from the study. Anastomotic narrowing was most common finding. Redo urethroplasty was successful in all patients.Buccal mucosa as a free graft provides excellent functional outcome in anterior urethral stricture

Results of tubularized urethral plate urethroplasty in Megameatus Intact Prepuce

Objective: The megameatus variant of anterior hypospadias with an intact complete foreskin occurs in approximately 1%–3% of hypospadias. Hence, the objective of the study was to evaluate the results of tubularized urethral plate urethroplasty (TUPU) in megameatus intact prepuce (MIP). Materials and Methods: A retrospective study (June 1996–June 2015) of MIP from our hypospadias registry was conducted. All patients with megameatus, either with an intact prepuce or with one previously removed, were included in the study. Case sheets of clinical records, investigations, clinical photographs, and videos were reviewed. Patients were classified into, glanular, coronal, subcoronal, and distal penile. TUPU were done. Patients were called for follow-up at 1, 3, 6, and 12 months postoperatively, and then yearly for the assessment of the cosmetic appearance and fistula, meatal stenosis, or other complications. Results: Of 1026 patients with hypospadias, we identified 13 cases of megameatus variant of hypospadias; three of the 13 had been circumcized previously. Glanular approximation was done for the one patients of the glanular variant, and another had frenuloplasty. These two patients were excluded from the study. Incision in the inner preputial skin was closed in 10 patients to have an intact prepuce. Follow-up period varied from 6 months to 4 years (median follow-up 2½ years). None of the patients developed complications such as fistula, meatal stenosis, and/or wound dehiscence. Conclusions: Surgical correction of MIP in the era of increased cosmetic awareness is justified. Excellent results are obtained with TUPU and along with spongioplasty and frenuloplasty because of availability of wide urethral plate and well-developed spongiosum in these patients. TUPU should be the preferred procedure in cases of MIP

Double breasting spongioplasty in tubularized/tubularized incise plate urethroplasty: A new technique

Introduction: The main disadvantage of currently described techniques of spongioplasty is superimposition of 3 suture lines (neourethra, spongioplasty, and skin closure) which is likely to increase the chances of a fistula. We describe and evaluate the results of a double breasting spongioplasty in urethroplasty. Methods: A prospective study of 60 primary hypospadias was undertaken by double breasting spongioplasty from August 2012 to March 2014. Mobilization of the urethral plate and the spongiosum is done by creating a plane just proximal to the meatus. Double breasting spongioplasty is done after tubularization of urethral plate. First layer of spongiosum is sutured toward lateral side of the neourethra covering the suture line. A second double breasting layer is sutured over the first layer with its suture line toward the opposite side covering the suture line of the first layer; thus avoiding overlapping of suture lines of all the three layers. Results: Age of the patients varied from 10 months to 16 years with a mean and median of 3.73 and 3.50 years, respectively. Hypospadias was distal, mid, and proximal in 38, 10, and 12 cases, respectively. Chordee was noticed in 35 cases and torque in 28 cases. Overall complication rate was 5% and fistula rate was 1.66%. Conclusions: Double breasting spongioplasty avoids superimposition of suture line and adds two layers of spongiosum over neourethra, thus decreases the chances of urethral fistula and gives cylindrical shape to neourethra

Severe congenital penile torsion with anterior urethral diverticulum: A case report

Introduction: We present a rare case of severe penile torsion of 180° along with giant congenital anterior urethral diverticula. Presentation of these two rare anomalies together is extremely rare and has not been reported yet. The extreme rarity of the case and its management warrants this presentation. Observation: A 5 years old boy presented to us as a case of epispadias with post-void dribbling and wetting of the underwears. On examination, he was found to be a case of severe congenital penile torsion with diversion and rotation of median raphae in a counterclockwise fashion upto the midline dorsally confirming 180° torsion. During voiding, there was appearance of a swelling in distal penile region with passage of urinary drops while compressing it. Micturating cystourethrogram showed diverticula in penile and bulbar urethra. Torsion was completely corrected by penile de-gloving in a plane between two layers of buck fascia and mobilization of the urethra along with spongiosum proximally upto the penoscrotal junction and distally upto the glans. Diverticula was laid open and underwent urethroplasty along with double breasting of thickened diverticular tissue. Torsion was completely corrected after surgery. Post-operative recovery was uneventful. Urine culture was sterile and uroflowmetry showed maximal urinary flow of 12 ml/s at 3 months postoperatively. Conclusions: Penile de-gloving and adequate urethral mobilization corrects the severe penile torsion of 180°. Correction of severe torsion and urethroplasty is feasible in a single stage with good results. Keywords: Penile torsion, Urethral diverticula, Congenital anomalies, Mobilization of urethra, Urethroplasty, Double Breasting, Correction of penile torsio

Comparison of antegrade percutaneous versus retrograde ureteroscopic lithotripsy for upper ureteric calculus for stone clearance, morbidity, and complications

Introduction: The optimal management of upper ureteric calculus remains controversial. We compare the outcomes of antegrade percutaneous ureterolithotripsy (APCUL) with retrograde ureteroscopic lithotripsy (URSL) for upper ureteric calculus with respect to stone clearance, morbidity, and complication rates. Materials and Methods: This prospective study was carried out from December 2014 to June 2016. A total of 117 patients with upper ureteric calculus sized (10–20) mm who underwent APCUL or URSL were included in the study. Results: APCUL and URSL were performed in 64 and 53 patients, respectively. The mean age and stone size were comparable between the two groups. The stone clearance rate at 1-month follow-up was 93.75% in the antegrade group and 81.13% in the retrograde group (P = 0.036). Mean anaesthesia time was significantly longer for the APCUL group while the actual mean operative time was significantly longer for the URSL group (P < 0.001). The overall complication rate was higher in antegrade group (P = 0.804), whereas most of the major complications (Clavien Grade III or more) occurred only in the URSL group (P = 0.007). Blood transfusion was required only in the APCUL group (7.8% versus 0%; P = 0.50). In the URSL group, stone retropulsion occurred in four patients, of which three subsequently required shock wave lithotripsy and one required percutaneous nephrolithotomy in a second sitting. Conclusion: APCUL has better stone-free rates as compared to URSL for an upper ureteric calculus of size 10–20 mm. Although the postoperative minor complications are higher in the antegrade group, severe complications occurred only in the retrograde group. Hence, antegrade approach can be considered as the preferred option to achieve better stone clearance in a single sitting with acceptable morbidity and complication rates

Spectrum of urinary stone composition in Northwestern Rajasthan using Fourier transform infrared spectroscopy

Introduction: The aim of this study was to evaluate the chemical composition of urinary stones and pattern of changes according to the patient's age in Northwestern Rajasthan using Fourier transform infrared (FTIR) spectroscopy. Materials and Methods: A prospective study of 1005 urolithiasis patients was carried out in two tertiary care centers from September 2012 to September 2016. Chemical composition of urinary stones was analyzed using FTIR spectroscopy, and a subgroup study based on the patient's age was done (8–12 years – Group A, 13–18 years – Group B, and >18 years – Group C). Results: Out of 1005 patients, 59 were in Group A, 104 in Group B, and 842 in Group C. Male predominance was found in all age groups. Mixed composition stones were much more common than pure one (74.83% vs. 25.17%). Overall, combination of calcium oxalate monohydrate with dihydrate was the most common composition (58.0%). Calcium oxalate was the predominant chemical composition in 91.54% of stones, followed by uric acid in 4.28%, struvite in 2.29%, calcium phosphate in 1.49%, and cystine in 0.4%. The proportion of calcium oxalate stone was increasing while that of struvite, uric acid, and cystine stone was decreasing with age. Most of the vesical calculi in pediatric age group (Group A; 8–12 years) patients were made up of combination of struvite, calcium phosphate, and uric acid. A total of 85.11% of staghorn calculi were of oxalates. Conclusion: In Northwestern Rajasthan, calcium oxalate is the most common composition of urinary stones in all age groups. Mixed stones are more common than pure ones. The incidence of calcium oxalate stone increases while that of struvite, uric acid, and cystine stone decreases with age

Outcome of tubularized incised plate urethroplasty with spongioplasty alone as additional tissue cover: A prospective study

Introduction: Additional cover after neourethra formation to decrease the fistula rate, has been described using the dartos, tunica, denuded skin and corpus spongiosum. The use of corpus spongiosum alone to cover the neourethra is infrequent. The objective of this study was to evaluate the efficacy of spongioplasty alone as an intervening layer in the prevention of urethral fistula following tubularized incised plate urethroplasty (TIPU). Materials and Methods: A prospective study was performed including 113 primary hypospadias cases undergoing TIPU with spongioplasty from June 2010 to March 2012. Correction of chordee was carried out by penile degloving alone in 5, mobilization of urethral plate with spongiosum in 22 and combination of both in 45 cases. Intra-operatively, spongiosum was taken to be poorly developed if it was thin and fibrous, moderate if good spongiosal tissue with good vascularization and well-developed if healthy robust spongiosum, which became bulkier than native spongiosum after tubularisation. Spongioplasty was done in a single layer after mobilization of spongiosum, starting just proximal to the native meatus and into the glans distally. Results: The mean age of the patients was 11.53 years. The type of hypospadias was distal, mid and proximal in 81, 12 and 20 cases respectively. Spongiosum was poorly developed in 13, moderate in 53 and well-developed in 47 cases. The mean hospital stay was 8-10 days and follow-up ranged from 6 months to 2 years. Urethral fistula was seen in six patients (11.3%) with moderate spongiosum (distal 1, mid 1 and proximal 4), and three (23.03%) with poorly developed spongiosum (one each in distal, mid and proximal) with an overall 7.96% fistula rate. None of the patients with well-developed spongiosum developed a fistula. Poorer spongiosum correlated with a greater number of complications (P = 0.011). Five out of thirteen cases with poor spongiosum (38.46%) had proximal hypospadias, i.e. more proximal was the hypospadias, poorer was the development of the spongiosum (P = 0.05). Meatal stenosis was seen in two patients (1.76%) with proximal hypospadias, one with moderate and the other with poorly developed spongiosum. More proximal was the hypospadias, greater were the number of complications (P = 0.0019). Conclusion: TIPU with spongioplasty reconstructs a near normal urethra with low complications. Better developed and thicker spongiosum results in lower incidence of fistula and meatal stenosis. More proximal hypospadias is associated with poorer spongiosum. We recommend spongioplasty to be incorporated as an essential step in all patients undergoing tubularized incised-plate repair for hypospadias

Auto-Digestion of Penis after Ring Block with Xylocaine & Adrenaline: A Lethal Iatrogenic Trauma

A 10 years old insulin dependent diabetic male child presented with gradual blackening of penis and ketoacidosis after incision and drainage of abscess at penile shaft under penile ring block with xylocaine with adrenaline. Patient was managed for diabetes, debridement and SPC was done but process of gangrene continued; finally whole penis slough out. Perineal urethrostomy was done and patient was advised for penile reconstruction later on

Penile anthropometry in North Indian children

Introduction: Physicians frequently encounter questions by parents regarding the normal size of a child′s penis. We evaluated normal variations of penile dimensions, correlation of penile length with height, weight, and body mass index (BMI) of boys and analyzed the differences in penile dimensions from those reported from other countries. Materials and Methods: A cross-sectional study was conducted at our institution during October 2012-December 2012. A total of 250 subjects (birth to 10 years) were evaluated and divided into 10 groups with 1-year interval taking 25 children in each. Penile dimensions measured twice by a single observer with Vernier calipers included the length of flaccid penis fully stretched and diameters at mid-shaft and corona. Diameters were multiplied by pi (π = 3.14) to calculate circumferences. Mean, standard deviation, and range were calculated. Height, weight, and BMI were noted and statistically correlated with the penile length using the Pearson correlation coefficient. Data were compared with similar studies reported on other populations in the past and individually evaluated with every study using Student′s t-test. Results: The mean values for the penile length, mid-shaft circumference, and coronal circumference were 3.34, 3.05, 3.29 cm during infancy, 4.28, 3.86, 4.11 cm during 4-5 years, and 5.25, 4.78, 5.05 cm during 9-10 years, respectively. The penile length increased with advancing age in successive age groups, but it did not have a direct correlation with either height, weight, or BMI. Penile dimensions in North Indian children were found to be statistically smaller in comparison with most studies from other countries. Conclusion: We provide the normal range and variations of penile dimensions in North Indian children