The modern staged repair of bladder exstrophy in the female: a contemporary series

ObjectiveMany changes have occurred in the treatment of bladder exstrophy over the last few years and several repairs are now offered, but there is a lack of long-term follow-up data. The purpose of this study was to evaluate long-term outcomes in a select group of female patients in whom modern staged repair was undertaken.Patients and methodsFrom an institutionally approved database 41 patients were identified. All had undergone primary bladder exstrophy closure in 1988–2005, at a mean age of 2 months (range 4 h to 3 months), with or without an osteotomy by a single surgeon, and all were followed up for a minimum of 5 years. Twelve patients underwent osteotomy at the time of primary closure. Eight had a classic transverse innominate and vertical iliac osteotomy, and four a transverse innominate only. Mean age at the time of bladder neck repair (BNR) was 4.2 years (39–65 months). Mean measured bladder capacity under gravity cystograms at the time of repair was 109 cc (80–179 cc).ResultsThirty patients (74%) were continent day and night, and voiding per urethra without augmentation or intermittent catheterization. Social continence, defined as dry for more than 3 h during the day but damp at night, was found in a further four cases (10%). Seven patients are completely incontinent with dry intervals of less than 1 h day and night. The mean time to daytime continence was 12 months (4–16 months) and to night-time continence was 19 months (10–28 months). Patients with a mean capacity greater than 100 cc had better outcomes. Six of the 30 patients achieved dryness after primary closure only, and all six had transverse innominate and vertical iliac osteotomy at the time of primary closure.ConclusionsFemale classic exstrophy patients with a good template who develop adequate capacity after a successful primary closure can achieve acceptable continence without bladder augmentation and intermittent catheterization. A select group will develop continence with closure alone without the need for bladder neck repair.     

Single-stage repair of bladder exstrophy in older children and children with failed previous repair

AimEvaluation of cosmetic and functional outcome of single-stage exstrophy–epispadias complex repair in older children and those with previously failed repair.Materials and methodsThis study comprised 15 children (12 boys and 3 girls) with classic bladder exstrophy and a mean age at repair of 8.6 months (range 2–24 months). Eight children had a previously failed repair. All children underwent complete primary repair using the single-stage Mitchell technique. Half of the boys had complete penile disassembly, while in the others a modified Cantwell–Ransley technique for epispadias repair was used. Anterior iliac osteotomy was performed and hip spica used for immobilization in all children.ResultsOne child had urethral stricture treated by endoscopic visual urethrotomy. Three children had penopubic fistulae that closed spontaneously. No bladder dehiscence or prolapse was encountered. Vesicoureteral reflux was present in 20 renal units but ureteral reimplantation was not performed. Average bladder capacity after closure was 134 cm³ (range 110–160 cm³) with only two partially continent and six incontinent children. Mean follow-up period is 2 years (range 1–3 years).ConclusionsSingle-stage repair was performed in children with previously failed repair and those presenting at an older age with satisfactory results. Acceptable bladder and genital anatomy and function were achieved together with preservation of renal function. The impact of this technique on continence is not encouraging, but needs to be determined in a longer follow-up period.     

Impact of epispadias repair on bladder growth in boys with classic bladder exstrophy

ObjectiveGrowth of the bladder in children with bladder exstrophy is primarily responsible for later ability to void continently. Improvement in bladder capacity has been noted in some boys following epispadias repair. Does the timing of epispadias repair influence the ability of the bladder to grow?MethodsData were collected regarding bladder volume measurements, obtained under anesthesia using a standard technique, during yearly follow-up of boys with classic bladder exstrophy. Volume prior to epispadias repair was compared to the next volume measure following repair. Timing of epispadias repair was compared to changes in bladder capacity in 30 boys. Monthly increases in bladder capacity were calculated in boys repaired at <12 (4), 13–24 (12) and 25–48 (14) months.ResultsPatients who had surgery prior to 12 months of age had the highest rate of monthly increase in bladder capacity (2.40 cc/month). Monthly growth rates were 1.91 cc/month for patients repaired at 13–24 months and 1.18 cc/month for those repaired at 25–48 months.ConclusionsEpispadias repair does lead to early increase in bladder capacity in boys with classic bladder exstrophy. The monthly increases in bladder capacity are greater in boys <12 months. Improvement in bladder volume is less likely when epispadias is repaired after age 29 months.     

Are urodynamic studies really needed during bladder augmentation follow-up?

ObjectiveWe assessed clinical and urodynamic outcomes, over a minimum 10-year follow-up period, of neuropathic bladder patients treated with a bladder augmentation (BA) to determine if periodic urodynamic studies are needed.Material and methodsThirty-two patients with poorly compliant bladders underwent BA at a mean age of 11 years (2.5–18). Mean follow-up was 12 years (10–14.5) and mean patient age at the end of the study was 22 years (12.2–33). During follow-up all patients were controlled at regular intervals with urinary tract imaging, serum electrolyte and creatinine levels, cystoscopy and urodynamic studies. Preoperative, 1-year post-BA and latest urodynamic studies results were compared.ResultsUrodynamic studies at 1-year post-BA showed a significant increase in bladder capacity and a decrease in end-filling detrusor pressure compared with preoperative values (396 vs 106 ml; 10 vs 50 cm H₂O, P < 0.0001). The increase in bladder capacity was more significant at the end of the study than after 1 year (507.8 vs 396 ml, P < 0.002). Thirteen patients had phasic contractions after 1 year and 11 at the end (not significant, NS), and these contractions were more frequent with colon than with ileum (NS). At the end of follow-up, phasic contraction pressure had decreased while trigger volume had increased (35 vs 28 cm H₂O; 247 vs 353 ml, NS). All patients are dry and have normal renal function, except one who had mild renal insufficiency before BA.ConclusionBA improves bladder capacity and pressure, and these changes are maintained over time (although phasic contractions do not disappear). Repeated urodynamic studies are only necessary when upper urinary tract dilatation or incontinence does not improve.     

Comparison of traditional enterocystoplasty and seromuscular colocystoplasty lined with urothelium

ObjectiveTo evaluate long-term outcomes between various methods of augmentation cystoplasty.MethodsA retrospective analysis was performed of patients undergoing seromuscular colocystoplasty lined with urothelium (SCLU, n = 26), and their outcomes compared to a similar population of patients in the same institution who had received traditional forms of bladder augmentation (colocystoplasty and ileocystoplasty, n = 32). Measurements included efficacy of the procedure in increasing bladder capacity and achieving urinary continence, and the need of subsequent surgery for complications.ResultsThere was no statistically significant difference in achieved bladder capacity, subjective urinary continence and the rates of subsequent surgery for stones, vesicoureteral reflux, augment failure, bladder neck continence and catheterizable channel. None of the patients in the SCLU group had spontaneous perforation or small bowel obstruction.ConclusionPatients with SCLU are at decreased risk for bowel obstruction and spontaneous perforation, but are not devoid of other long-term complications including bladder stones, vesicoureteral reflux and augment failure. Most of the risks and benefits of augmentation cystoplasty performed using ileum, colon, or SCLU appear similar.     

Total endoscopic management (TEM approach) of children with non-compliant neuropathic bladder: a preliminary report

PurposeWe prospectively evaluated the efficacy and durability of a combination of intradetrusor botulinum-A toxin (BTX-A) and endoscopic treatment of vesicoureteric reflux (VUR) to manage children with myelomeningocele (MMC) and non-compliant refluxing bladders who were not responding to standard conservative therapy. We also evaluated whether this combined therapy can lower intravesical pressure, increase bladder capacity, gain social continence and protect the upper tract from recurrent urinary tract infection.Material and methodsA total of 10 patients with a mean age of 5.9 ± 3.6 years (range 2–12 years) with MMC (eight females and two males) were prospectively involved in the study. All patients were fully compliant to clean intermittent catheterization, and all were non-responders (failed to gain continence and/or poor compliance) to the maximum tolerable dose of anticholinergics and catheterization. All patients were subjected to cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) of BTX-A in an infection-free bladder. They all had VUR (16 refluxing ureters, six patients with bilateral VUR) and did not show resolution in the pretreatment voiding cystourethrogram; accordingly, submucosal injection of Deflux^® was performed either with the second BTX-A treatment (initial four patients) or with the first BTX-A treatment (the other six patients). The grade of reflux was G III, IV and V in three, seven and six ureters, respectively.ResultsThe maximum bladder capacity increased significantly from 79 ± 49 to 155 ± 57 ml (p < 0.022), and the maximum detrusor pressure decreased significantly from 55 ± 16 to 37 ± 11 cm H₂O (p < 0.001). Fifteen out of 16 (93.75%) refluxing ureters were completely resolved (one of them on second attempt), and one (6.25%) (GV reflux) remained unchanged despite of two attempts. Of six incontinent patients, five reached complete dryness between catheterizations and one showed partial improvement.ConclusionsA combination of BTX-A and endoscopic correction of VUR is a simple and effective way to overcome the increased risk of high intravesical pressure and recurrent UTI. This treatment decreases the incidence of renal damage in children on whom conservative management fails to help, in a minimally invasive way.     

Role of urethral bulking agents in epispadias–exstrophy complex patients

ObjectiveInjection of urethral bulking agents (UBA) has been used to increase bladder capacity prior to bladder neck reconstruction (BNR) or as an adjuvant therapy following BNR to improve continence. The purpose of this study was to determine the effectiveness of urethral injections in the exstrophy population.Materials and methodsA review was performed of patient characteristics, bladder capacity, and continence status of all patients with the exstrophy–epispadias complex who underwent injection of UBA between 1980 and 2008.ResultsAmong 66 patients with a median follow-up of 8 years, 41 underwent injections prior to BNR, and 25 had injections after BNR. Only 24% of patients who underwent injections prior to BNR were continent on last follow-up. Among 25 patients who underwent BNR prior to injection(s), 16 were partially continent and nine were incontinent prior to first injection. Patients who were partially continent attained social continence (dry interval greater than 3 h) at a significantly higher rate than those who were incontinent (63% vs. 13%, p = 0.047). No patient with cloacal exstrophy in either group attained urethral continence.ConclusionUBAs do not appear to have a role prior to BNR. However, they may provide benefit when given adjunctively following BNR in patients who are partially continent.     

Bladder augmentation and artificial sphincter implantation: urodynamic behavior and effects on continence

ObjectiveTo quantify changes in bladder capacity, pressure and compliance after isolated bladder augmentation or augmentation associated with implantation of an artificial sphincter, and to compare the various types of augmentation.Patients and methodsPreoperative and postoperative urodynamic studies were performed in a group of 38 patients (18 males and 20 females; age range 2–19 years), who underwent a type of bladder augmentation.ResultsThe bladder improved in capacity in all patients (mean values: initial 137 ml, final 336 ml, individual increase 229 ml; 434%) except two, in which the augmentation was done with ureter. The mean pressure improved (initial 32 cm of H₂O, final 14, decrease per patient 18 cm of H₂O; 49%). The curve of compliance, progressively increasing typical of hyperreflexia and poor compliance, present in 70% of the cases preoperatively, improved in 78% cases postoperatively, although there were several different patterns. Urodynamic behavior was analyzed with regard to the tissue used for augmentation (ileum, ureter or sigmoid colon). In the sigmoid colon group, there were no significant differences in the urodynamic behavior of the bladder neo-reservoir in relation to the configuration used.ConclusionWith bladder augmentation comes an increase in bladder capacity, a reduction in pressure, and an improvement in compliance and continence. The level of change in capacity, pressure and compliance varies with the tissue used and the length and caliber of the insert. When the procedure is carried out using sigmoid colon tissue, there are no noteworthy differences among the various possible configurations.     

Bladder capacity as a predictor of voided continence after failed exstrophy closure

ObjectiveTo evaluate potential predictors of voided continence among bladder exstrophy patients with a history of a failed closure.Patients and methodsThe authors reviewed all patients who underwent a bladder neck reconstruction (BNR) with a history of one or more failed exstrophy closures between 1979 and 2007. The following data were collected for each patient: number of failures, site of surgery, mode of failure, presence of osteotomy, bladder capacity, need for additional procedures, and continence status.ResultsAmong patients who underwent successful reclosure following one or more failed closures, 52 patients underwent BNR, and 24 (46%) were continent at last follow-up. Bladder capacity was the only variable predictive of voided continence. The median bladder capacity at the time of BNR differed between those who achieved continence (100 mL) and those who did not (65 mL) (p = 0.005). ROC analysis showed an optimal pre-BNR bladder capacity cutoff for predicting future BNR success of between 80 and 100 mL.ConclusionAs previously shown in patients with successful primary closure of exstrophy, these data suggest that bladder capacity also has predictive value in the success of BNR after failed exstrophy closure.     

Influence of type of conduit and site of implantation on the outcome of continent catheterizable channels

ObjectiveContinent catheterizable channels (CCC) using the Mitrofanoff principle are essential for pediatric urinary tract reconstruction. There is controversy over the influence of type of CCC (appendix vs. Yang–Monti) and site of implantation (augmentation vs. native bladder) on outcome.Patients and methodsA retrospective record review was conducted of all patients undergoing CCC since 1999, excluding patients who underwent seromuscular colocystoplasty. We analyzed the type of channel, site of implantation, complications requiring re-operation, and the revision rate according to type of CCC, type of stoma, site of implantation (bladder vs. augmentation) and segment used for augmentation (ileum vs. sigmoid colon).ResultsThere were 41 patients with a mean age of 11.2 years and a mean follow-up of 33.3 months. Of these, 33 CCC were constructed with appendix and eight with a Yang–Monti technique (4 ileal, 4 sigmoid); 31 patients also had an enterocystoplasty (19 sigmoid, 9 ileal and 3 others). Overall revision rate was 27%; revision was required in 8/33 (24%) appendiceal and 3/8 (38%) Yang–Monti CCC (P = 0.7). Revisions were required in 4/21 CCC implanted in the native bladder and 7/20 implanted in augmented bladder (P = 0.3). The majority of revisions were at skin level.ConclusionsAlthough there was no statistical difference in revision rate according to type of CCC, type of stoma or site of implantation, complications appeared to be more common in patients requiring a more complex reconstruction.     

Management of bladder exstrophy in adulthood: Report of 5 cases

ObjectiveTo report our experience in the management of adult classic bladder exstrophy.Patients and methodsDuring 1977‒2006 we treated five adult males presenting with classic exstrophy–epispadias complex. Patient age at presentation ranged from 17 to 30 with a mean age of 23 years. Four patients had received no previous treatment and one underwent previous ureterosigmoidostomy. Work-up included evaluation of upper tract and bladder biopsy. Bladder patch condition was variable. Surgery involved bladder preservation in the three patients who underwent primary repair, including bladder closure, bladder neck reconstruction and epispadias repair; two of them also had augmentation ileocystoplasty. The remaining two patients underwent ureterosigmoidostomy, cystectomy and epispadias repair. Abdominal wall closure was by fasciocutaneous M-plasty. Osteotomy was not done in any case.ResultsIn patients with bladder preservation, one patient was continent (>3 h) and voided normally whereas the other two showed day and night continence (2–3 h) with mild stress incontinence. Patients were satisfied with functional outcome. Ultrasound and intravenous pyelography showed preservation of upper tract. Follow-up period ranged from 1 to 8 years.ConclusionPatients with bladder exstrophy presenting in adulthood should not be denied the opportunity of primary reconstruction with bladder preservation in the absence of significant histological changes in the bladder mucosa.     

Urodynamic investigation of valve bladder syndrome in children

ObjectiveTo investigate urodynamic manifestations and their relationship with the postoperative experience of children with valve bladder syndrome (VBS).MethodsIncluded were 16 children (mean age 3.2 ± 1.8 years) with VBS, who were divided into two groups. The urodynamic study was performed less than 1 year in group 1 (seven boys, aged 1–1.9 years) and more than 1 year in group 2 (nine boys, aged 2.9–6.5 years) after urethral valve fulguration; at the time of operation patients were less than 2 years old. Standards of the International Children's Continence Society were respected, and results were compared between the two groups.ResultsCompared to group 1, group 2 showed a significant decrease in maximum detrusor voiding pressure (Pdet.void.max) and bladder compliance (BC), and an increase in post-voiding residual (PVR) and maximum bladder capacity (MBC) (p < 0.05), but the difference in detrusor instability was not significant (p > 0.05), Pdet.void.max and PVR were 56.2 ± 14.1 cmH₂O and 96.6 ± 52.4 ml, respectively, in group 2, and there were more intermittent detrusor contractions during voiding in this group.ConclusionPatients with VBS frequently present with multiple bladder dysfunctions that can be diagnosed accurately using urodynamics. Even after urethral valve fulguration Pdet.void.max and BC were inclined to decrease, while PVR and MBC increased with the growth of the children.     

Pneumovesicoscopic diverticulectomy in children and adolescents: Is open surgery still indicated?

ObjectivesSurgical treatment of a congenital bladder diverticulum is indicated in symptomatic children. Diverticulectomy can be performed by an open or a laparoscopic approach. We report our recent experience in using the pneumovesicoscopic approach for accomplishing vesical diverticulectomy.MethodsWe operated on three boys with a mean age of 11.6 years (10–14 years) during August 2006 to February 2007. In all children, a ureteric catheter was introduced first by cystoscopy followed by intravesical CO₂ insufflation at a pressure of 12–15 mmHg. Three trocars were inserted under visual control in the bladder. Diverticulectomy was performed. The defect was closed by interrupted sutures. Bladder drainage was achieved using a urethral catheter for 2 days.ResultsThe mean operative time was 133.3 min (100–180 min). Oral intake began after a mean of 5.3 h (4–6 h). Minimal blood loss was encountered. Non-steroidal analgesics were used only during the 1st day postoperatively with no need for morphia. All patients were discharged on the 2nd day postoperatively after removal of the urethral catheter and tube drain. The mean follow-up period was 5 months (3–6 months).ConclusionPneumovesicoscopic diverticulectomy is a feasible procedure. It does not require a long learning curve, and is associated with shorter hospital stay and rapid recovery with good cosmetic aspect. Pneumovesicoscopy has the potential to be used in the treatment of other conditions such as vesicoureteral reflux, and may replace open surgery.     

Prentiss orchiopexy applied in younger age group

PurposeTo evaluate the efficacy and safety of the operative technique for the correction of cryptorchidism described by Prentiss in the 1950s, who conducted measurements on patients over 6 years of age, and on cadaveric specimens. We applied the technique in a younger age group.Material and methodsWe prospectively studied the results of 50 orchiopexies in children 8–59 months of age (mean 32.3 months), separated into three age groups: 8–18 (N = 14), 19–36 (N = 18), and 36–59 (N = 18) months. The patients were selected for having their undescended testis in the inguinal canal and not reaching the scrotum after adequate inguinal and retroperitoneal dissection. We eliminated the anatomic angulation of the vas deferens and testicular vessels around the internal inguinal ring and inferior epigastric vessels, in order to improve distal scrotal positioning (Prentiss maneuver). We compared the position of the testis before and after the maneuver. We re-examined the children 1 year postoperatively for testicular position and quality.ResultsThe average gain in scrotal positioning was 6–20 mm (mean 13 mm). At follow-up, 36 testes (78%) had retained a low scrotal position, 10 (20%) a middle scrotal position, and 4 (8%) presented in an upper scrotal position.ConclusionsThe Prentiss maneuver is both safe and efficient when applied to the younger age group, in order to gain adequate intrascrotal cord length and to place the testis in a more distal scrotal position.     

Perioperative anesthetic and analgesic management of newborn bladder exstrophy repair

ObjectiveReconstruction of bladder exstrophy in newborn infants requires immobilization, sedation and pain management to prevent distracting forces from compromising the repair. We present a 6-year review of our experience.Subjects and methodsWe reviewed the perioperative management of newborn infants undergoing reconstruction between November 1999 and October 2006. Data are presented as means ± SD.ResultsTwenty-three newborn infants underwent surgery under a combined epidural and general anesthetic technique. Tunneled caudal epidural catheters were inserted in all patients and intermittently injected with 0.25% bupivacaine with 1:200,000 epinephrine. Postoperatively, a continuous infusion of 0.1% lidocaine, 0.8–1 mg/kg/h was administered for 15 ± 8 (range 4–30) days. Children were sedated with diazepam for 20 ± 13 (range 2–40) days. Central venous catheters were maintained for 20 ± 9 (range 1–34) days for fluids, drug administration and blood sampling. No patient experienced bladder prolapse or wound dehiscence.ConclusionPerioperative management with tunneled epidural and central venous catheters in newborn infants with bladder exstrophy facilitates immobilization, analgesia and sedation, resulting in an excellent cosmetic repair with no case of bladder prolapse or wound dehiscence.     

Laparoscopic heminephrectomy in infants and children: first 54 cases

ObjectiveHeminephrectomy in the pediatric population remains a popular open surgical procedure. We describe our experience with laparoscopic heminephrectomy using a retroperitoneoscopic approach.Materials and methodsData were collected retrospectively and prospectively on all patients undergoing laparoscopic heminephrectomy by a single surgeon using a prone retroperitoneoscopic approach. Information relating to the age, sex, laterality, duration of surgery, analgesic requirements, duration of hospital stay, postoperative complications and outcome was recorded.ResultsBetween March 2001 and August 2005 54 laparoscopic heminephrectomies were performed in 48 children (34 girls and 14 boys). The median age at surgery was 14 months (range 2–112 months). Forty-four upper and 10 lower moieties were removed. The median operative time was 105 min (range 50–150 min). There were no intraoperative complications and no conversions. There were four minor complications, comprising haematuria (n = 1) and postoperative pyrexia (n = 3). The median length of follow up was 22 months (range 3–57 months). All patients remained asymptomatic at last follow up. Ultrasound findings included presence of a visible ureteric stump (n = 7) and cysts at the resection margin of the remaining remnant (n = 17); none of these patients manifested clinical symptoms (e.g. infection, pain).ConclusionsWith advanced laparoscopic skills, laparoscopic heminephrectomy is a feasible operation for the treatment of non-functioning duplex renal units in children and infants.     

Urodynamic changes in patients with anterior urethral valves: before and after endoscopic valve ablation

PurposeTo retrospectively review a series of children with anterior urethral valves (AUV), with emphasis on patterns of urodynamic change and long-term outcome of endoscopic treatment.Patients and methodsWe reviewed the medical records of eight patients who had undergone thorough radiological and urodynamic exams before and after treatment. The diagnosis of AUV was based on radiological imaging and confirmed by urethrocystoscopy. The valves were ablated through either transurethral fulguration or resection. The upper urinary tracts were studied by renal scan and ultrasonography before and after the procedure. Bladder function was assessed urodynamically 3 months after surgery. Uroflowmetry was performed as soon as the children were toilet trained.ResultsEndoscopic ablation of AUV was successful in all cases and no surgical complications occurred. The initial symptoms resolved in all boys. VUR disappeared in two out of three patients, and five children had bladder trabeculation that was resolved after surgery. The final outcome was successful in seven patients (88%). The major urodynamic dysfunction was bladder hypercontractility that resolved following valve ablation. The mean maximum voiding detrusor pressure (P_detmax) decreased from 213.2 ± 17.9 cmH₂O to 80.7 ± 9.9 cmH₂O, 6 months after treatment (P < 0.001). None of the patients had low-compliant bladder, detrusor instability or myogenic failure. The voiding pattern in all toilet-trained patients was staccato and of an interrupted shape prior to surgery, but changed to a normal bell-shaped voiding pattern following valve ablation.ConclusionAUV should be considered in the differential diagnosis of patients presenting with infravesical obstruction. We recommend endoscopic valve ablation as the treatment of choice.     

The prognostic value of relative renal function greater than 51% in the pelvi-ureteric junction-obstructed kidney on 99mtechnetium mercaptoacetyltriglycine study

ObjectiveObstructed kidneys with relative function (RRF) estimates >50% are occasionally noted in ^99mtechnetium mercaptoacetyltriglycine renal studies. It is thought that increased RRF might confer some benefit and/or permit delayed intervention. We compared the RRF and absolute renal function, as defined by effective renal plasma flow (ERPF), of obstructed kidneys in the ranges >51%, 40%–50% and <40% RRF before and after pyeloplasty.MethodsTwenty children, median age 13.5 months (range 3 weeks–126 months), satisfied criteria for the diagnosis of PUJ obstruction and estimated function >51% (group 1). Their pre- and post-intervention data were compared with 21 children, median age 2 months (range 1 week–126 months), with PUJ obstruction and 40%–50% RRF (group 2); and 21, median age 6 months (range two days–110 months), with RRF below 40% (group 3). Kidneys showing signs of continuing obstruction after surgery were excluded.ResultsFinal ERPF was negatively related to age: younger children, and those with a higher preoperative ERPF, recovered better than older children and those with a lower ERPF (p < 0.05). Pre- and postoperative mean ERPF in group 1 was 76 (range 21–203) and 102 (6–240) ml/min/1.73 msq respectively. In group 2, these values were 75.2 (30–187) and 130.9 (44–306) ml/min/1.73 msq, and they were 42.6 (5–179) and 80.2 (17–205) ml/min/1.73 msq in group 3. When adjustment was made for preoperative ERPF, there was no evidence that RRF grouping was related to ERPF outcome. The postoperative ERPF of seven of 20 kidneys from group 1 (>51%) was lower than the ERPF before surgery compared to 2/21 in group 2 and 4/21 in group 3, but these differences were not statistically significant (p = 0.25).ConclusionsMost kidneys in each functional range improved when obstruction was relieved. An RRF >51% in the obstructed kidney was not always prognostically beneficial, and may be a warning of impending decompensation in a minority.     

Factors affecting the outcome of foreskin reconstruction in hypospadias surgery

ObjectiveDespite ongoing refinement of numerous techniques, the incidence of complications following hypospadias repair is still significant. The aim of this study is to evaluate the factors that affect the success in childhood of foreskin reconstruction with hypospadias repair.Materials and methodsA retrospective study was carried out of all primary hypospadias repairs with foreskin reconstruction (n = 408) over the last 23 years. The hypospadias was coronal in 160 (39%), glanular in 114 (28%), subcoronal in 78 (19%) and distal penile in 56 (14%) cases. Foreskin reconstruction was included in 362 cases suitable for a meatal advancement (191) or distal urethral tubularization (171), and 46 cases for a flip-flap procedure (37 Mathieu, nine Barcat). Outcome analysis was of foreskin-related complications post surgery.ResultsForeskin repair was successful in 333 cases (92%) that underwent meatal advancement/distal urethral tubularization, and 33 (72%) that underwent a flip-flap operation. Complications related to the foreskin occurred in 10% of the whole group with a urethral fistula rate of 8%. The median age at surgery was 13 months (2–120 months), and the median follow-up period was 11 months (1–100 months).ConclusionsA good cosmetic and functional outcome can be achieved with foreskin reconstruction combined with a variety of hypospadias repairs. The outcome in this series was better in cases of distal hypospadias using interrupted polyglactin sutures.