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

The buccal mucosa fenestrated graft for Bracka first stage urethroplasty: experimental study in rabbits

Objective To histologically evaluate, in an experimental study in rabbits, the integration process of the buccal mucosa fenestrated graft applied in the corpora cavernosa for Bracka first stage urethroplasty. Materials and Methods A urethral defect was surgically created in 16 male rabbits of the New Zealand breed through the excision of the penile urethra. The urethral defect was corrected by applying buccal mucosa fenestrated graft through two cruciform incisions in the distal portions of its longitudinal axis. The animals were sacrificed at 2, 4, 8 and 12 weeks post surgery and their genitals were subjected to clinical and histological assessment. Results The buccal mucosa fenestrated graft showed complete uptake in all groups, with keratinization squamous metaplasia and mucosal proliferation of the fenestrated areas. The fenestrated graft area represented an increase in length of 25% in length in relation to the original standard graft. Conclusions The fenestrated buccal mucosa graft presented total integration to the adjacent epithelia with re-epithelization of the incision areas of the graft (fenestrations) and no significant inflammatory or scarring reactions when compared to other mucosa transplanted areas; therefore its application is viable in cases of extensive urethral defect whenever the donating area might be insufficient.Federal University of São Paulo Departament of Urology (PO, HB, AR, UBjr, VO, AMjr) Department of Pathology (RD)UNIFESP, Departament of Urology (PO, HB, AR, UBjr, VO, AMjr) Department of Pathology (RD)SciEL

Keratinized versus non-keratinized preputial flap onlay urethroplasty: does it make any difference in the histological analysis? An experimental study in rabbits

Purpose: To compare the histological characteristics of keratinized versus non-keratinized onlay island flaps in an experimental rabbit model.Materials and Methods: Sixteen male rabbits were randomly allocated into two experimental groups: keratinized and non-keratinized onlay island flaps. A defect was created in the ventral aspect of the penile urethra. in the keratinized group, a longitudinal island flap was harvested from the external prepuce and rotated to cover the urethral defect. in the non-keratinized group a transverse island flap was harvested from the inner prepuce. the animals were sacrificed after 2, 4, 8 and 12 weeks.Results: the flaps were viable in all animals, and no deaths were associated with the procedure. Two urethrocutaneous fistulas were identified, one in each experimental group. A similar pattern of fibrosis was identified in both groups. the keratinized epithelium of the external prepuce kept its histological aspect and keratin production. Both keratinized and non-keratinized groups presented a slight decrease on the epithelial thickness, however without a statistically significant difference between groups.Conclusions: in this short-term rabbit model, we observed that the stratified squamous keratinized epithelium from the external prepuce kept its keratin production. There was no statistical influence of the flap type on the mean epithelial thickness.Universidade Federal de São Paulo UNIFESP, Div Urol, São Paulo, BrazilUniversidade Federal de São Paulo UNIFESP, Div Urol, São Paulo, BrazilWeb of Scienc

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

Anthropometric measurements as an indicator of nutritional status in spina bifida patients undergoing enterocystoplasty

Objetivo: Utilizar as medidas antropométricas para comparar o \ud estado nutricional em crianças com bexiga neurogênica secundária \ud à mielomeningocele submetidas a enterocistoplastia àquelas não \ud submetidas à cirurgia. Métodos: Estudo tipo caso-controle conduzido \ud em 20 crianças, divididas em dois grupos, aquelas que realizaram \ud enterocistoplastia (Grupo A) versus crianças não operadas (Grupo B), \ud pareados por gênero e idade. Os parâmetros utilizados foram peso, \ud altura, circunferência do braço e prega cutânea triciptal. A avaliação \ud nutricional foi determinada calculando-se índices baseados na idade \ud e no gênero. A classificação foi baseada em porcentagens, e os \ud resultados foram comparados com valores de referência. Resultados: \ud A média da idade foi 6,41 anos no Grupo A e de 6,35 no Grupo B. O \ud intervalo entre a cirurgia e a avaliação foi de 11 meses. As seguintes \ud medidas foram encontradas para o Grupo A: 80% das crianças eram \ud eutróficas, 30% maior do que no Grupo B; circunferência braquial \ud foi adequada em 40% dos pacientes, 20% maior do que no Grupo \ud B; a área do músculo do braço foi adequada em 90%, 30% maior \ud do que no Grupo B. Os valores no Grupo B foram os seguintes: \ud 60% apresentaram prega cutânea triciptal acima do valor médio, \ud uma porcentagem 20% acima do que no Grupo A; para índice de \ud gordura braquial, 60% dos pacientes estavam acima da média, \ud 40% maior do que no Grupo A. Conclusão: Pacientes submetidos à \ud enterocistoplastia demonstraram melhor estado nutricional enquanto \ud o grupo controle apresentou índices de gordura mais elevados nas \ud medidas antropométricas. Entretanto, a diferença entre os grupos \ud não foi estatisticamente significativaObjective: To use anthropometric measurements to compare nutritional \ud status in children with neurogenic bladder dysfunction secondary \ud to meningomyelocele who underwent enterocystoplasty and those \ud who did not undergo surgery. Methods: A case-control study \ud was conducted in 20 children, divided into two groups: those who \ud had enterocystoplasty (Group A) and those who did not undergo \ud surgery (Group B), matched for genre and age. Weight, height, arm \ud circumference, and triceps skinfold thickness were the parameters \ud used. Nutritional assessment was determined by calculating the \ud indexes, based on age and genre. Classification was based on the \ud percentile and the results were compared with the reference values. \ud Results: The mean age was 6.41 years in Group A and 6.35 years \ud in Group B. The interval between surgery and evaluation was 11 \ud months. The following measures were found for Group A: 80% of \ud children were eutrophic, a percentage 30% greater than that in Group \ud B; arm muscle circumference was adequate in 40% of patients, a \ud percentage 20% greater than that in Group B; arm muscle area was \ud adequate in 90%, a percentage 30% greater than that in Group B. \ud Values in Group B were as follows: for triceps skinfold thickness, 60% \ud of patients had values above the mean, a percentage 20% greater \ud than that in Group A; for arm fat index, 60% of patients were above \ud the mean value, 40% greater than in Group A. Conclusion: Patients \ud who had undergone enterocystoplasty showed better nutritional \ud status, while the control group presented higher fat indexes in \ud anthropometric measures. However, the differences between groups \ud were not statistically significan

Hypospadias

Purpose of reviewHypospadias is one of the most common congenital anomalies in men. We searched the recent literature (since 1 January 2011) using the following keywords in the title or abstract: hypospadia or hypospadias, in order to provide the reader with an updated view of the subject.Recent findingsEarly repair is recommended; distal forms are mainly treated by the tubularized incised plate technique; however, meatal stricture concerns are still noticed, limiting its use on proximal forms. the debate of proximal primary repair in either one or two stages is still ongoing. Minor modifications for preparing the distal bed for the urethroplasty in two stages are presented. One-stage repairs, either with reconstruction of the urethral plate (three-in-one concept) or simply with the onlay to tunica albuginea (Rigamonti), is a viable option with over 70% success in one surgery. the importance of barriers, such as tunica vaginalis and dartos flap, was reassessed and flow rates may indicate obstructive voiding patterns after 1-year follow-up.SummaryFurther experience and comparative studies for distal and proximal hypospadias are required. Long-term data may indicate the appropriate procedure selected for primary repair.Universidade Federal de São Paulo, Dept Urol, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Urol, São Paulo, BrazilWeb of Scienc

Is it possible to use the rectus abdominis neo-sphincter as a continence mechanism for urinary catheterizable channels? A histologic and histochemical evaluation in an experimental study in rabbits

Objective: To evaluate in a rabbit experimental model a mechanism of continence of catheterizable urinary conduits (CUC), focusing on the behavior of intersected rectal muscle fibers in relation to the channel by histological and histochemical analysis, and secondarily to register conduit continence rates from clinical and urodynamic data.Materials and methods: 12 rabbits were submitted to construction of a CUC from two abdominal skin flaps and divided into two groups: 8 with a urinary neo-sphincter created according to Yachia and 4 controls. We registered clinical outcome, urodynamic studies and microscopic analysis of CUC on the surface of the conduit, which was in direct contact with the mechanism of continence. We took muscle samples from the mechanisms of continence and performed histochemical evaluation by enzymatic reactions.Results: Histological evaluation of the CUC showed no difference between groups. Histology and immunohistochemistry of the muscle fibers showed that areas of necrosis, cell atrophy and motor neuron injury from the first eight weeks recovered by the end of 16th week. Conduit complications occurred in 4 animals (33%). the average detrusor leakage point pressure through the conduit was 90 cm H2O versus 39 cm H2O through the urethra.Conclusion: the mechanism of continence did not promote ischemic stress on the conduit, was able to promote high pressure resistance and showed good recovery of intersected muscle fibers, after an initial slight atrophy, suggesting good durability of the neo-sphincter. (C) 2013 Journal of Pediatric Urology Company. Published by Elsevier B.V. All rights reserved.Universidade Federal de São Paulo, Div Urol, São Paulo, BrazilUniversidade Federal de São Paulo, Div Urol, São Paulo, BrazilWeb of Scienc