Preservation of the thin distal urethra in hypospadias repair

PURPOSE: We report our experience with preserving the thin distal urethra lacking corpus spongiosum for the treatment of hypospadias. MATERIALS AND METHODS: From January 1997 to October 1999 we treated primary hypospadias in 77 boys with a mean age of 4 years 10 months. After degloving the penile skin a segment of thin distal urethra lacking corpus spongiosum was noted in 18 patients (23.4%) with a mean age of 3 years 5 months. The thin distal urethra was preserved and incorporated as part of urethroplasty (group 1). The procedure was primarily completed by tubularized incised plate urethroplasty. We also performed tubularized incised plate urethroplasty in 31 boys (40.3%) with a mean age of 5 years 2 months who had normal coverage of the corpus spongiosum of a hypospadiac urethra (group 2). We compared the results of treatment in these 2 groups. The remaining 28 patients (36.4%) treated with other methods were excluded from study. RESULTS: In group 1 the distance from the original meatus to the urethra covered by healthy corpus spongiosum was 4 to 20 mm. (mean 8.2). If the thin distal urethra had been excised, the urethral meatus would have been relocated more proximal in these boys. Mean followup in groups 1 and 2 was 9.9 and 7.6 months, respectively. Postoperatively there were 2 (11.1%) urethrocutaneous fistulas in group 1 and 4 (12.9%) in group 2. Tubularized incised plate repair was successful in all 10 cases (100%) of distal hypospadias in group 2, and in 15 of 18 (83.3%) and 17 of 21 (81%) of proximal hypospadias cases in groups 1 and 2, respectively. There was no statistically significant difference in the success rate of hypospadias repair in the groups. CONCLUSIONS: We noted a significantly thin distal urethra in 23.4% of our cases of primary hypospadias. Mean length of the thin distal urethra was 8.2 mm. Preserving the thin distal urethra may simplify the operative procedure without compromising the surgical results of tubularized incised plate urethroplasty.     

非编织状聚乙醇酸膜片重建兔尿道的实验研究

目的探讨非编织状聚乙醇酸膜片重建兔全层尿道的效果。方法制备1cm×1cm的非编织状PGA膜片。建立新西兰大白兔尿道腹侧1cm全层尿道缺损动物模型,将PGA膜片植入尿道缺损区域,修补尿道缺损。术后1、2、3个月进行尿道造影、大体观察和组织学观察评价尿道重建情况。结果PGA膜片修复新西兰兔全层尿道缺损,9只动物除1只术后1个月发生尿瘘外．其余动物均排尿通畅。组织学检查发现尿道黏膜再生良好,但尿道海绵体区域主要以纤维瘢痕增生为主,未见明显尿道海绵体再生。结论PGA膜片能够修复新西兰大白兔1cm尿道黏膜的缺损,但缺乏尿道海绵体再生。     

New surgical procedure for management of Peyronie disease

Surgical excision of fibrotic plaques and replacement of the defect by grafts may be necessary in advanced Peyronie disease. Synthetic, absorbable mesh for grafting the defect was used in 6 mongrel dogs. An area of tunica albuginea 1.5 by 2.5 cm was removed from the corpus cavernosum, thus exposing the spongy cavernous tissue. A Dexon mesh of the same dimensions, woven in our laboratory from polyglycolic acid fibers of 308 denier thickness, was sutured to the defect by 3-0 Dexon sutures. The mesh caused hemostasis and the animals' postoperative course was uneventful. Posterection cavernosograms showed no curvature of the penis, bulging of the operative area, or obstruction of the corpora cavernosa. Histologic studies at three weeks, and two, four, and six months after surgery showed complete healing and gradual replacement of the Dexon mesh by fibrous connective tissue.     

Augmented anastomotic urethroplasty

PURPOSE: During substitution urethroplasty, if the stricture contains a 1 to 2 cm region that is particularly narrow and/or fibrotic, that portion may be excised with subsequent anastomosis of the dorsal or ventral aspect of the urethra to shorten, widen and optimize the urethral wall onto which an onlay graft is to be placed. This procedure is termed augmented anastomotic urethroplasty. To determine the effectiveness of this approach we reviewed our experience with augmented anastomotic urethroplasty in an 8-year period. MATERIALS AND METHODS: We reviewed the records of patients who underwent augmented anastomotic urethroplasty between October 1997 and April 2005. Perioperative characteristics were compared between successes and failures using the Wilcoxon/Kruskal-Wallis and Fisher exact tests. RESULTS: Of 69 patients who underwent augmented anastomotic urethroplasty for recurrent urethral strictures 5 had undergone previous urethroplasty using a genital skin flap or graft. At a median followup of 34 months (range 13 to 103) 62 patients had no evidence of stricture recurrence and required no further intervention for an overall success rate of 90%. Stricture recurrence, defined as the inability to easily pass a standard flexible cystoscope through the area of repair, occurred in 7 patients (10%). Patients with stricture recurrence were significantly older (mean age 52 vs 39 years, p = 0.02) and more likely to experience postoperative urinary tract infection (28% vs 3.2%, p = 0.05) than patients without repeat stricture. CONCLUSIONS: Augmented anastomotic urethroplasty is an effective technique that allows the use of a shorter onlay graft. It may optimize overall results due to improvement in the urethral wall and the associated corpus spongiosum.     

Delayed repair of post-traumatic posterior urethral distraction injuries: long-term results

OBJECTIVES: There is still controversy regarding the treatment of post-traumatic posterior urethral distraction injuries. Initial suprapubic cystostomy and delayed perineal urethral reconstruction has been considered the reference standard. In this report, we review our experience with delayed perineal urethral reconstruction, with a focus on the long-term outcome and complications. METHODS: A total of 77 men with posterior urethral distraction injury due to pelvic trauma underwent reconstruction with delayed perineal approach. In all cases, the area of fibrosis was aggressively excised, the corpus spongiosum was mobilized, and a tension-free, spatulated end-to-end anastomosis was achieved by splitting the corporeal bodies in 66.2% and by an additional perineally performed inferior pubectomy in 49.3% of the patients. The median time from injury to surgical repair was 12 months. The preoperative evaluation consisted of combined antegrade and retrograde cystourethrograms and cystourethrography. A detailed sexual history was obtained in 58 patients (75.3%). RESULTS: After a mean follow-up of 47 months (range 15 months to 14 years), the urethral continuity was adequate in 94. 8%; however, 2 patients required a perineal surgical revision (total of 79 operations). Postoperative incontinence was observed in 7 (9. 1%) of 77 patients. Postoperative erectile dysfunction was noted in 16.2% of patients who were known to be potent by history before surgery. CONCLUSIONS: Our results support the belief that delayed perineal reconstruction with extensive excision of fibrosis and a tension-free, spatulated end-to-end anastomosis is a successful treatment alternative for posterior urethral distraction defects, with acceptable morbidity.     

A case of urethral reconstruction using a superficial circumflex iliac artery

A radial forearm free flap has been conventionally used for urethral reconstruction. However, aesthetic and functional complications occur frequently at the donor site. The use of a superficial circumflex iliac artery perforator (SCIP) flap can resolve these disadvantages. Here, we report our case with a review of literature. A 69-year-old man visited our hospital with multiple contusions of the abdomen and genital amputation. After necrotic tissue debridement, the length of the residual corpus carvernosum was 1.5 cm and that of the corpus spongiosum and urethra was 1 cm. For the reconstruction of the penis, a SCIP flap and anterolateral thigh free flap was performed. The primary closure was performed at the donor site. Three weeks postoperatively, the patient had a urethral foley catheter removed. The neourethra was functioning well without stricture. Four months postoperatively, the patient had no complications such as urethral stricture. A good recovery was also achieved with no aesthetic deficits at the donor site. SCIP flap is appropriate for urethral reconstruction. Because of its proximity to the recipient sites, it makes surgical preparation easier and the primary closure at the donor site available. It is also advantageous in that its location is almost unnoticeable.     

Correction of intrinsic penile chordee with a ventral penile graft of fascia lata

Chordee is an abnormal curvature of the penis detected on erection. Congenital or primary curvature of the penis without hypospadias is, however, rare. There are two kinds of primary curvatures; those associated with a normal corpus spongiosum and those with a hypoplastic spongiosum. Secondary curvatures associated with Peyronie's disease or periurethral fibrosis associated with urethral stricture are more common in adults. Four nonhuman primates had successful correction of artificially induced chordee with a graft of fascia lata.     

Tubularized incised plate urethroplasty for proximal hypospadias

OBJECTIVES: Numerous surgical procedures have been used to correct distal hypospadias. Among them, the tubularized incised plate urethroplasty (Snodgrass procedure) has become a mainstay for the repair of distal hypospadias. We applied the procedure to proximal hypospadias. METHODS: Three patients with proximal hypospadias underwent a tubularized incised urethral plate urethroplasty. The location of the meatus was proximal penis in one, penoscrotal margin in one and scrotum in one. A perimeatal incision was made and the two paramedian incisions were extended to the tip of the glans. The skin of the penile shaft was dissected free to the penoscrotal junction and bands of fibrous tissue were excised until the corpus spongiosum proximal to the meatus was completely exposed inside the scrotum. The urethral plate was then incised in its midline from the tip of the glans to the hypospadiac meatus and was tubularized without tension. The neourethra was covered with a pedicle of subcutaneous tissue dissected from the dorsal skin or the scrotal skin to avoid fistula formation. RESULTS: The tubularized incised urethral plate urethroplasty was carried out successfully in one stage on three patients with proximal hypospadias. CONCLUSIONS: The Snodgrass procedure is suitable for correcting hypospadias in patients with a healthy urethral plate. It is also suitable in patients with proximal hypospadias.     

One-stage repair of moderately severe hypospadias using a transverse preputial tubularized island flap

BACKGROUND: Transverse preputial tubularized island flap (TPTIF) urethroplasty has been used for the repair of moderately severe hypospadias since Duckett described the procedure in 1980. In spite of the excellent results reported by Duckett, subsequent studies showed high complication rates. A TPTIF procedure modified to reduce the complication rate is presented. METHODS: Between 1996 and 1997, 13 boys with moderately severe hypospadias were repaired with the TPTIF procedure. Patient age ranged from 10 months to 3 years with an average age of 23 months. To prevent urethrocutaneous fistula, the neourethra was constructed with a two-layer closure and the portion of anastomosis was wrapped between the native urethra and the neourethra with the tissue of the corpus spongiosum. RESULTS: The moderately severe hypospadias was repaired without complication in 12 of 13 patients. A urethrocutaneous fistula developed at the midshaft of the penis in one patient. No meatal stenosis, urethral stricture or diverticulum developed. CONCLUSION: Transverse preputial tubularized island flap urethroplasty provided excellent cosmetic and functional results for moderately severe hypospadias, and postoperative complications could be decreased by the two-layer closure of the neourethra and application of the wrapping technique of the proximal anastomosed portion with corpus spongiosum tissue.     

Combined Dorsal and Ventral Buccal Mucosal Graft Urethroplasty by Unilateral Mobilisation of Urethra with Single Dorsal Urethrotomy Incision in Long Segment Anterior Urethral Strictures

The aim of this study is to evaluate the outcomes of combined dorsal and ventral buccal mucosal graft urethroplasty by unilateral mobilisation of urethra with single dorsal urethrotomy incision in long and narrow anterior urethral strictures with preserving the narrow urethral plate and blood supply. Between June 2012 and July 2016, 26 men with long anterior urethral strictures underwent urethroplasty by our technique in a tertiary care teaching hospital. The urethra was mobilised only one side. Then, it was opened in the dorsal midline over the stricture. The first graft was secured on the tunica of the corporal bodies. Thereafter, the diseased mucosa on the ventral side of the urethra was excised and the second graft was placed as ventral inlay and fixed to the corpus spongiosum. The cut edges of urethra were closed by suturing to dorsally placed graft. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Mean follow-up was 36 months and mean stricture length was 4.29 cm. Of these 26 cases, 23 (88.4%) were successful and 3 (11.53%) were treatment failures with restricture. The combined dorsal plus ventral buccal mucosal graft urethroplasty by unilateral mobilisation of urethra with single dorsal urethrotomy incision provides adequate urethral augmentation by preserving urethral vascularity and the narrow strip of urethral plate in long and tight anterior urethral strictures.     

Erectile dysfunction following direct vision internal urethrotomy

A total of 104 evaluable patients 20-90 years old treated by direct vision internal urethrotomy a.m. Sachse for urethral strictures reported retrospectively via a questionnaire their sexual potency before and after internal urethrotomy. Eleven patients (10.6%) experienced partial or total erectile dysfunction following the operation, most of whom had distal and long strictures. Eight were evaluated for impotence and on grounds of a comprehensive history, physical examination, penile Doppler investigations, and papaverine tests it was concluded that 3 patients might have achieved an abnormal communication between the corpus cavernosum and corpus spongiosum. In two of the patients cavernosographies were carried out and in one total opacification of the corpus spongiosum was demonstrated, but the exact location of the leak could not be pinpointed, and surgical treatment therefore not rendered feasible. Possible factors in the development of erectile dysfunction following internal urethrotomy are analyzed.     

Non-transecting anastomotic bulbar urethroplasty: a preliminary report

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Excision of a stricture and end‐to‐end anastomosis of the two ends is thought to be the best form of treatment for short strictures of the proximal bulbar urethra but involves transecting the main blood supply of the corpus spongiosum and the urethra. This is a preliminary report of achieving the same goal but without transecting the blood supply of the corpus spongiosum of the urethra.

OBJECTIVE

• ? To report our early experience with a novel approach to the excision and end‐to‐end anastomotic repair of bulbar urethral strictures.

PATIENTS AND METHODS

• ? A total of 22 patients underwent excision and end‐to‐end anastomosis of a proximal bulbar urethral stricture using a technique in which the corpus spongiosum is not transected, so as to maintain its blood supply intact.
• ? The range of follow‐up was 6–21 months and for 16 patients the follow up was ≥1year.

RESULTS

• ? At 1 year of follow‐up there was no evidence of a recurrent stricture on symptomatic assessment or uroflowmetry in the 16 patients.
• ? On urethrography one patient has a urethral calibre 80% of normal. In the other 15 the calibre is normal or greater than normal.

CONCLUSION

• ? The non‐transecting anastomotic bulbar urethroplasty technique used appears to give results that are as good as those of traditional anastomotic urethroplasty with less surgical trauma.

     

Acquired ventral penile curvature: spongiofibrosis caused by urethral manipulation

Fibrosis of the corpus spongiosum, caused by urethral manipulation, and the resulting ventral penile curvatures are known as the urethral manipulation syndrome. This acquired, largely iatrogenic deformity is noticed only be sexually active patients. Partial, gradual disappearance of glans engorgement and irregularities palpable along the penile urethra associated with ventral curvature are constant findings. The post-manipulative ventral curvature can be transient, disappearing when the inflammatory process subsides or the repeated urethral manipulation ceases. Since fibrosis of the corpus spongiosum begins with urethral inflammation, patients in whom irregularities of the penile urethra are observed during urethrography should be questioned about any erectile deformity. Surgical treatment is indicated when the deformity interferes with sexual intercourse or is accompanied by severe urethral strictures.     

Congenital Megalourethra: A Case Report

We describe a case of a male infant with a scaphoid megalourethra. A physical examination showed a large, flabby phallus with bilateral undescended testes. The corpus spongiosum was absent with normal corpora cavernosa. Urethrography showed a crescent-shaped dilatation of the anterior urethra. Further examination revealed an association with concomitant urogenital anomalies, right renal hypoplasiadysplasia, bilateral vesicoureteral reflux and the prune-belly syndrome. A urethroplasty with resection of the excess urethral tissue and reconstruction of the urethra was performed. There was a satisfactory surgical result and the patient now voids without difficulty.     

A case report: an urethral tumor with cavernous structure developed after optical urethrotomy

A 70-year-old man underwent transurethral resection of the prostate (TURP) in February 1999 and he received optical urethrotomy because of urethral stricture in May. In May 2000, a distal urethral tumor was found by urethroscopy. Endoscopic resection of the urethral tumor was performed. The tumor consisted of normal urethral epithelial tissue and had a cavernous structure. We conclude that the tumor was vegetation of the corpus spongiosum penis.     

Cavernospongious shunts: anatomical study of intrapenile vascular pathways.

OBJECTIVES: The reality of cavernospongious shunts has never been confirmed and their role in penile erection remains undetermined. We aim to describe the intrapenile vascular anatomy as the precise nature of the connections between the corpus spongiosum, the glans and the corpora cavernosa remains unknown. METHODS: Ten human penises were removed from adult male cadavers 8 days after arterial casting with latex. In four specimens coloured latex was injected into the corpus spongiosum. Ex situ microdissection was performed to analyse the origin and distribution of the penile arteries. The anastomotic arterial pathways were dissected. RESULTS: In all the specimens, 6-10 anastomoses were found between the cavernous arteries (a. profundae penis) and the spongious arterial network. These arteries arose at regular intervals from the cavernous arteries and perforated the tunica albuginea vertically to anastomose with urethral arteries (a. urethralis). No arteriovenous shunts were found between the corpus spongiosum and the corpora cavernosa, nor was there any venous drainage from the corpus spongiosum entering the corpora cavernosa. CONCLUSION: These shunts are arteries connecting the urethral and cavernous arteries. Cavernospongious arterial anastomoses were found in all the cadavers dissected. Further studies are needed to determine their role in penile erection.     

腹膜前间隙腹股沟疝修补术65例临床治疗体会

目的探讨善愈补片经腹膜前间隙腹股沟疝修补术的技术操作要点,并评价其疗效。方法回顾分析我院2006年8月至2009年8月用国产善愈补片行开放性前入路腹膜前间隙腹股沟疝修补术共65例的临床资料。结果手术时间45—55min,平均50min。全组患者伤口一期愈合,无浆液肿及感染发生。术后随访2—24个月,无复发。结论应用国产善愈补片治疗腹股沟疝安全有效,术后恢复快,近期疗效满意。     

Assessing the potential regeneration ability of corpus spongiosum in rabbit models

Most congenital or acquired urethral diseases are usually accompanied by corpus spongiosum (CS) defects. However, Substitution urethroplasty can only reconstruct urethral lumen, not the CS. Many long-term complications occur due to the lack of protection from CS. Is CS a kind of tissue that cannot be repaired by regeneration and self-healing? In this study, the CS defect with urethral mucosa intact model was established in rabbits by removing the ventral CS tissue. Based on this model, three groups of different CS defect sizes, with lengths of 0.5 cm (Group A), 1.0 cm (Group B) and 1.5 cm (Group C), were then constructed, respectively, to assess the potential regeneration ability of CS. Three months later, the entire urethra, including the CS defect, was assessed by histological staining. Results showed that the vascular sinusoids were completely removed from urethral mucosa. The rabbit model of CS defect was established successfully. Three months post-operatively, the CS defects in all the 3 groups were replaced by disordered collagen instead of regenerating typical sinusoid-like vascular structure, which is significantly different from the normal CS rich in vascular sinusoids. The CS defects could not be repaired through self-healing. The potential regeneration ability of CS is extremely poor.     

A case of acute spongiositis with diabetes mellitus

We report a case of acute spongiositis with diabetes mellitus. A 63-year-old man with a 7-year history of diabetes mellitus was admitted to our hospital complaining of perineal pain and pyrexia. Physical examinations revealed induration and tenderness of the corpus spongiosum, but no signs of rubor or erosion. A laboratory investigation showed leukocytosis (12,000/microliter), an elevated level of C-reactive protein (3.38 mg/dl) and hyperglycemia (532 mg/dl). Pyuria and bacteriuria were absent. Magnetic resonance imaging (MRI) yielded abscess-like lesion of the corpus spongiosum. Culture of the aspirated specimen demonstrated B-hemolytic streptococci. Treatment with antibiotics and insulin resolved leukocytosis and tenderness of corpus spongiosum. He left the hospital on the 23rd day after admission and no evidence of recurrence of the spongiositis was found for 1 year after discharge.     

Aphallia in an adult male with 46,XY karyotype

Aphallia is a rare urogenital anomaly with an estimated incidence of 1 in 10–30 million. We report a case of aphallia in a male, who had two well‐developed testicles, but lacked a penis. Digital rectal examination revealed the urethral meatus was opening to the anterior wall of the rectum posterior to the sphincter. Magnetic resonance imaging showed complete absence of penile development with normal testis and scrotum, as well as the urethra running posterior to the prostatic apex and corpus spongiosum in sagittal and coronal T2‐weighted images. Chromosome karyotype confirmed 46,XY, and the polymerase chain reaction method tested no azoospermic factor (AZF) or sex‐determining region Y (SRY) gene deletion. Taking into account the physical and psychosocial conditions, seeking a female without sexual desire as his wife was recommended.