Use of an inner preputial free graft to extend the indications of Snodgrass hypospadias repair (Snodgraft)

Tubularized incised plate (tip) urethroplasty or Snodgrass repair has become the most commonly used procedure for distal hypospadias repair. However, where the urethral plate is narrow or shallow, the good results may be compromised. We present our experience of using a small inner preputial graft to deepen and widen the urethral plate (Snodgraft). This procedure has certainly reduced the number of two-stage hypospadias repairs in patients who lack a urethral groove or have a small glans. The cosmetic and functional results are excellent.     

Comparison of angiogenic activity after urethral reconstruction using free grafts and pedicle flap: an experimental study.

PURPOSE: An experimental study was undertaken in order to estimate the angiogenic activity in different free grafts and pedicle flap in urethral reconstruction in an animal model. METHODS: Twenty-eight white New Zealand rabbits were randomly divided into five groups (O, A, B, C and D). A ventral urethral defect was created in all groups. In the group O, (n = 4), a simple closure of the defect was performed. Free penile skin graft (group A, n = 6), buccal mucosal graft (group B, n = 6), bladder mucosal graft (group C, n = 6), and pedicle penile skin graft (group D, n = 6) were used to bridge the urethral defect as an onlay patch. The animals were euthanized on the 21st postoperative day. The angiogenic activity was assessed with immunohistochemistry, using the anti-CD31 MoAb and the alkaline phosphatase antialkaline phosphatase procedure. The native vascularity of penile skin as well as buccal and bladder mucosa was assessed in rabbits from group O (n = 3). Statistical analysis was performed using one-way ANOVA. RESULTS: The angiogenesis seen with a magnification of x 200 in groups O, A, B, C, and D was 34.1 +/- 4.1 (mean +/- SD), 61.7 +/- 6.4, 94.3 +/- 6.4, 91.5 +/- 7.2, and 30.8 +/- 5.2 vessels per optical field, respectively. There were statistically significant differences (p < 0.001) between group O and groups A, B, C and between group A and groups B, C, D, but not (p > 0.5) between groups B and C and groups O and D. The native vascularity of penile skin, buccal mucosa and bladder mucosa was 23.3 +/- 3.0, 24.6 +/- 3.7 and 17.0 +/- 2.6 vessels per optical field, respectively. CONCLUSION: Buccal and bladder mucosal grafts exhibit a higher angiogenic activity than free and pedicle penile skin flap when transplanted in urethral defects. As the buccal mucosal graft showed the higher angiogenic activity and its harvesting is easier than bladder mucosa, we propose that in urethral reconstruction surgery the use of this graft might offer more reliable results.     

Congenital scalp and skull defects with terminal transverse limb anomalies (Adams-Oliver syndrome): Report of three additional cases

Aplasia cutis congenita of the scalp combined with terminal transverse limb defects (Adams-Oliver syndrome) is a rare congenital disorder with autosomal dominant inheritance. Thirty-one patients with the complete syndrome have been published. We report three additional patients (one mother and her affected child, one sporadic case) and discuss the probable vascular disruptive pathogenesis, the clinical variability and the treatment of this condition in the light of a comprehensive review of the literature.     

A comparison of free skin graft, fascia lata, alloderm, bovine pericardium and primary repair in urethrocutaneous fistulas without diversion: an experimental study

The purpose of this study is to compare primary repair procedure with those that use bio-concordant materials in the treatment of urethrocutaneous fistula. Twenty-five New Zealand rabbits were randomly placed into five groups (primary repair, free graft, allograft fascia lata, alloderm and bovine pericardium repair groups). A single dose of 20 mg/kg of ceftriaxon was applied intramuscularly as a prophylactic dose. Urethrocutaneous fistula was formed on midpenile level. Later, while primary repair was applied in one group, repair with free grafts and with other bio-concordant materials were performed in other groups. Urinary diversion was not used in any of the rabbits. The macroscopic observation was evaluated with urethrography obtained 21 days after the operation and then the rabbits were sacrificed. A total point was obtained by awarding a point to each good parameter in the histopathological evaluation and all the groups were compared. The urethrographic findings and macroscopic examinations were normal in all groups. In histopathological examinations, ranging from the best to worst results, bovine pericardium group (8 points) had a better total score than primary repair group (7 points), allograft fascia lata group (7 points) and alloderm group (7 points). The free graft group had the worst total point (6 points). Bio-concordant materials can be used in urethrocutaneous fistula repair as an alternative to primary repair or to the grafts obtained from body tissues.     

Associated coarctation of the aorta and mitral valve disease: nine cases with surgical correction of both lesions in three.

Nine cases of the combination of coarctation of the aorta and mitral stenosis were evaluated over a seven-year period. Symptoms did not usually cause distress in infancy, but began subtly with pneumonia or cardiac failure at about 2 years of age. Important clues were differences in blood pressure between the arms and legs, paroxysmal dyspnea, congestive heart failure, right ventricular hypertrophy, and left atrial enlargement. Cardiac catheterization studies showed elevated right ventricular and main pulmonary artery wedge pressures. These features in patients with coarctation of the aorta should suggest associated mitral valve disease. The importance of demonstrating associated valvular lesions, particularly mitral stenosis, is emphasized. Two of our children had successful repair of the coarctation of the aorta and mitral stenosis simultaneously. In a third child, resection of the coarctation was followed in six years by mitral valve replacement.     

Comparison of two preterm formulas with or without addition of medium-chain triglycerides (MCTs). II: Effects on mineral balance.

Medium-chain triglycerides (MCTs) are included in the fat blend of several preterm formulas because of their complete absorption and rapid oxidation. The effects of two different fat blend compositions on calcium (Ca), phosphorus (P), and magnesium (Mg) balances and plasma levels and on plasma levels of parathyroid hormone (PTH), alkaline phosphatase (AP), and 1,25-dihydroxyvitamin D [1,25-(OH)2D] were investigated in 28 healthy very-low-birth weight infants at 4 weeks of age. A preterm formula with a traditional corn oil/MCT blend containing 38% MCTs (MCT group) was compared to a new fat blend, designed to resemble human milk more, containing 6% MCTs (LCT group). There was a higher absorption of Ca in the MCT group (73% vs. 60%. p less than 0.005), and an equal absorption of P (both 92%). The excretion of Ca correlated with the excretion of fat (p less than 0.00005). The LCT group showed a higher median PTH level (MCT: 2.1 pmol/L, LCT: 4.7 pmol/L, p less than 0.01) and a higher urinary P excretion (p less than 0.001). Mg absorption was also lower with LCT, but retention of Mg exceeded intrauterine values in both groups. Mineral plasma levels were in the normal range in both groups. AP was not different between groups and in the upper part of the reference range, whereas 1,25-(OH)2D levels were above the normal range and also not different between groups. We conclude that with the LCT formula, Ca absorption is slightly lower than with the MCT formula, whereas P absorption is unaffected.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of two preterm formulas with or without addition of medium-chain triglycerides (MCTs). I: Effects on nitrogen and fat balance and body composition changes.

Medium-chain triglycerides (MCTs) are included in the fat blend of several preterm formulas because of their complete absorption and rapid oxidation. The effects of two different fat blend compositions on nitrogen and fat balances and macronutrient oxidation were investigated in 28 healthy very-low-birth weight infants at 4 weeks of age. A preterm formula with a traditional corn oil/MCT blend containing 38% MCTs (MCT group) was compared to a new fat blend, designed to resemble human milk more, containing 6% MCTs (LCT group). There were no differences in nitrogen absorption or in excretion. Median nitrogen retention was 74% (MCT) vs. 71% (LCT) of intake. Fat absorption was higher (p less than 0.05) in the MCT group (88%) vs. 79% in the LCT group (median values). MCTs did not stimulate fat oxidation as measured by indirect calorimetry, so fat deposition was also higher on the MCT formula. As weight gain was not different between groups, the percentage of weight gain consisting of fat accretion was significantly (p less than 0.005) higher with the MCT formula (24% vs. 21%). On the other hand, there was no increase in percent protein accretion (both 15% of weight gain). We conclude that the existence of a slightly lower fat absorption in the healthy growing neonate fed a LCT formula compared with a MCT formula does not impair growth or nitrogen retention, but merely induces a slight decrease in the high relative fat accretion encountered in the preterm neonate.