Dorsal inlay graft urethroplasty for primary hypospadiac repair

OBJECTIVE: Tubularized incised plate urethroplasty has become a popular technique for repairing distal and proximal hypospadias in many institutions. Dorsal inlay graft urethroplasty has been used in our institution since 2003 to reduce the risk of meatal stenosis. In the present study, we evaluated the results of the dorsal inlay graft procedure. METHODS: A total of 28 patients with no deep groove and no severe curvature underwent one-stage urethroplasty using an inner preputial-based dorsal inlay graft. The medical records of all patients were retrospectively reviewed with regard to complication rate and cosmetic appearance. RESULTS: Mean patient age at surgery was 21 months (range, 14 months to 4.6 years). Preoperatively the urethral meatus was coronal in two cases, distal shaft in 17, proximal shaft in six and penoscrotal in three. Nine patients required testosterone therapy before surgery. Mean operative time was 200 min (range, 154-249 min). Mean length of inlay graft was 20.9 mm (range, 12-30 mm). In all patients, a straight penis was achieved without dorsal plication of the corposa cavernosa, and the neomeatus with a slit-like appearance was positioned at the glans tip. At a mean of 22 months of follow up, a urethrocutaneous fistula developed in only one patient (3.6%), requiring repair surgery 6 months after urethroplasty. No patient had meatal stenosis, neourethral stricture or urethral diverticulum along the inlay graft. CONCLUSION: Dorsal inlay graft urethroplasty is an effective method for hypospadiac repair and leads to good cosmetic outcome with low risk of complications.     

Complex urethral disruptions: In pursuit of a successful reconstruction

OBJECTIVES: We analyzed the methods and outcomes of urethroplasty in men with complex urethral disruptions. METHODS: The medical records of 40 men with complex urethral disruptions were analyzed. Surgical methods were individualized according to stricture location, severity and length of the stricture, bladder neck characteristics and presence of complicating factors. Patients were divided into four groups based on the above characteristics. RESULTS: End-to-end urethroplasty performed in six patients with short bulbar strictures (<3 cm) was successful in all. Elaborated perineal repair was performed in 10 patients with intermediate (3-6 cm) strictures with or without complicating factors. Elaborated perineal repair with urethral substitution was performed in nine patients with long segment stricture (>6 cm). Abdominal transpubic repair was successfully applied to patients with rectourethral fistula or lacerated bladder neck. Success rate of anastomotic urethroplasty was 95% while over all success rate was 85%. CONCLUSION: Guidelines for urethral reconstruction of complex urethral disruptions are predicated on stricture length, location, bladder neck characteristics and associated complicating factors. End-to-end urethroplasty with stricture excision is highly reliable for short strictures for which previous operative repair have failed. Elaborated perineal repair is extremely versatile for intermediate and longer strictures with associated complicating factors. Abdominal transpubic urethroplasty is effective for patients with rectourethral fistula or lacerated bladder neck.     

Single-stage repair of severe hypospadias using bladder mucosa graft

Our experience of single-stage repair of severe hypospadias (penoscrotal, scrotal, and perineal) in 30 children using urinary bladder mucosa for urethroplasty is reported. These children had severe chordee, small prepuce, and often ventral transposition of the penis with bifid scrotum where Devine and Horton, Asopa, or Duckett techniques are not so suitable. The graft uptake was uniformly satisfactory. Ten patients had complications; most of the fistulae healed spontaneously. Surgical intervention was required in 2 cases only: 1 for a fistula and another for a stricture with fistula. Meatal stenosis, seen in 4 cases, led to delayed distal fistulae in 2, which healed spontaneously with meatal dilatation. Regular dilatation of the external meatus is recommended to prevent this problem.     

胃管作尿道支撑引流管在尿道下裂中的应用

目的 评价单纯用胃管兼作尿道支撑管和引流管在尿道下裂尿道成形术中的作用。方法 回顾性分析新华医院1997年12月～2004年12月间收治的先天性尿道下裂患者，在做尿道成形手术中单纯应用胃管作尿道支撑引流管1176例，年龄6个月-20岁。未进行膀胱造瘘等尿液改道引流方法。结果 术后因发生尿瘘而需再次尿道成形术的113例（9．6％），尿道狭窄需再次手术成形的8例（0．7％），尿道裂开需尿道再成形的5例（0．4％）。结论 在尿道下裂尿道成形术中单纯用胃管兼作尿道支撑管和引流管引流尿液是充分有效的，无须另行尿流改道。     

阴部外动脉阴茎支皮瓣尿道成形术的应用解剖

目的：为设计阴部外动脉阴茎皮瓣转位尿道成形术提供依据。方法：30侧经动脉内灌注红色乳胶的成人尸体，解剖观测阴部外动脉起始、行程；着重阴部外动脉阴茎支在阴茎的走行、分支分布。结果：阴部外动脉始于股动脉，外径1．8±0．4mm，伴行静脉1-2支，汇入大隐静脉。阴茎支可视为本干的延续，经耻骨结节两侧靠近阴茎，分别经2(10)点、3(9)点和1(11)点进入阴茎，多数分出背侧支、腹侧支分布阴茎皮肤。外径0．8±0．2mm。结论：阴茎皮肤血管恒定，以阴茎支为蒂，可在阴茎外侧或背外侧、腹外侧设计皮瓣，用于尿道成形术。术式已在临床应用，效果满意。     

带蒂睾丸鞘膜瓣矫治尿道下裂的应用解剖及临床应用

通过25例男性成人尸体和30例手术切除的活体标本的解剖学研究,以精索外动脉为蒂,设计了带蒂睾丸鞘膜矫治尿道下裂新术式,鞘膜取材可达11×5cm。经20例临床应用,效果满意。     

Tissue engineering in urethral reconstruction—an update

The field of tissue engineering is rapidly progressing. Much work has gone into developing a tissue engineered urethral graft. Current grafts, when long, can create initial donor site morbidity. In this article, we evaluate the progress made in finding a tissue engineered substitute for the human urethra. Researchers have investigated cell-free and cell-seeded grafts. We discuss different approaches to developing these grafts and review their reported successes in human studies. With further work, tissue engineered grafts may facilitate the management of lengthy urethral strictures requiring oral mucosa substitution urethroplasty.     

Staged urethroplasty in the management of complex anterior urethral stricture disease

Staged buccal mucosa graft urethroplasty has emerged as a reliable procedure for difficult anterior urethral strictures not amenable to one-stage graft or flap reconstruction. It has primarily been used for strictures and/or fistulae occurring after previous surgery for hypospadias or those related to lichen sclerosus (LS). Success rates in these patient populations have improved when compared to earlier techniques. However, prior studies have demonstrated a number of patients requiring more than two procedures to complete the reconstruction, as well as some who have been content with their voiding pattern after the first operation and therefore elected to forego second stage tubularization. In this setting, we have reviewed the surgical technique and summarized previously published work. There may be an opportunity to complete more of these repairs in two operations using additional oral mucosa at the time of tubularization.