Hypospadias outcome in the first 3 years after completing a pediatric urology fellowship

IntroductionThe requirements of hypospadias surgery today not only include the creation of a straight phallus with optimal meatal placement but also call for excellent cosmetic outcomes with minimal complications. Specialty fellowship training as well as advanced surgical materials and techniques allow for consistent, successful results. We report the outcomes of hypospadias surgeries performed by two academic Pediatric Urologists in the first 3 years of practice after completing a 2-year fellowship.Patients and methodsA retrospective chart review of all patients with hypospadias treated by two surgeons (DF and JC) between July 2004 and August 2007 was performed. The two surgeons had completed a 2-year Pediatric Urology fellowship at two different institutions (Johns Hopkins and Texas Children's Hospital). Level of hypospadias, patient age, type of repair and follow up as well as complications were recorded. Midshaft and distal hypospadias were classified as distal.ResultsIn all, 187 patients were operated on. No significant difference in numbers and complications occurred between the two surgeons. Distal hypospadias was found in 149, proximal in 29, and penoscrotal or perineal was found requiring a two-stage repair in nine patients. Distal hypospadias was repaired using either dorsal plate incision with tubularization (TIP) (n = 112) or meatal advancement and glanuloplasty (MAGPI) (n = 37). All proximal lesions were repaired using TIP. All patients were seen after 1–2 weeks, and 6 and 12 months postoperatively. Fistulae occurred in 10 patients (three in distal, four in proximal, and three in two-stage repairs) for an overall fistula rate of 5.3%. Meatal obstruction occurred in three distal repairs and one two-stage repair, diverticulum in one proximal. No complications occurred with MAGPI repairs. All complications, except for one, were successfully repaired in a single operation.ConclusionModern hypospadias surgical techniques pioneered through decades of surgical innovation can now be successfully transferred to the new generation of specialty-trained Pediatric Urologists. Modern pediatric fellowship training allows performing distal hypospadias repair with a minimal fistula rate of 2.8%. Proximal hypospadias remain more challenging with complication rates of 13.8% for one-stage and 33.3% for two-stage repairs.     

Role of negative pressure wound therapy in total hip and knee arthroplasty

Negative-pressure wound therapy(NPWT) has been a successful modality of wound management which is in widespread use in several surgical fields. The main mechanisms of action thought to play a role in enhancing wound healing and preventing surgical site infection are macrodeformation and microdeformation of the wound bed, fluid removal, and stabilization of the wound environment. Due to the devastating consequences of infection in the setting of joint arthroplasty, there has been some interest in the use of NPWT following total hip arthroplasty and total knee arthroplasty. However, there is still a scarcity of data reporting on the use of NPWT within this field and most studies are limited by small sample sizes, high variability of clinical settings and end-points. There is little evidence to support the use of NPWT as an adjunctive treatment for surgical wound drainage, and for this reason surgical intervention should not be delayed when indicated. The prophylactic use of NPWT after arthroplasty in patients that are at high risk for postoperative wound drainage appears to have the strongest clinical evidence. Several clinical trialsincluding single-use NPWT devices for this purpose are currently in progress and this may soon be incorporated in clinical guidelines as a mean to prevent periprosthetic joint infections.     

The current management of the neurogenic bladder in children with spina bifida

The urological care of the neurogenic bladder consists of 2 components: medical management with preservation of renal function and quality-oflife issues with achieving dryness and independence of bladder and bowel management. Both components are equally important for patients to live a healthy and fulfilled life. This report explores the diagnosis of the neurogenic bladder; quality-of-life issues that caregivers and patients should expect; the importance of primary care knowledge of the neurogenic bladder and treatment; surgical options; the transition of pediatric patients to adult care; and the importance of caregiver and patient understanding of their disease, treatment options, and responsibilities.     

Our initial experience with the technique of complete primary repair for bladder exstrophy

ObjectiveWe reviewed our initial results with complete primary repair of exstrophy in regard to continence status and the need for subsequent continence procedures.Patients and methodsWe performed a retrospective review of our surgical records from 1996 to 2008 to identify all patients with bladder exstrophy managed at our center.ResultsSixteen children were closed successfully. Six patients (37.5%) experienced complications: umbilical hernias in two, transient penopubic fistula in three, and subcoronal fistula due to meatal stenosis in one. Of the 12 males, seven (58.3%) were left with a hypospadias at the time of primary closure. Two (22.2%) children required a formal bladder neck reconstruction to achieve continence. Bladder augmentation and continent catheterizable stoma was performed in four cases (44.4%), and bladder neck injection in one case (11.1%). Bladder neck closure was also performed in another child following primary closure. Three of these children are continent and void spontaneously (33.3%). The remaining six require clean intermittent catheterization four to six times a day, resulting in four (44.4%) being continent. The number of continence procedures and mean number per patient were 15 and 1.66, respectively.ConclusionOur early experience with this technique has been encouraging, with few major complications, a highly successful closure rate and a cosmetically normal result.     

Inhalation of [123I]alpha1-protease inhibitor: toward a new therapeutic concept of alpha1-protease inhibitor deficiency?

The alpha1-protease inhibitor (alpha1-Pi) is separated from human serum and is therefore extremely expensive. Because only 2%-3% concentrates in the lung after intravenous administration, inhalational therapy for alpha1-Pi deficiency would seem likely to be better. The aims of this study were therefore to determine the pattern of deposition of inhaled alpha1-Pi labeled with 123I and measure the amount deposited in the lungs. METHODS: Eighteen patients with congenital severe alpha1-Pi deficiency were enrolled in the study. The low-specific-activity 123I-labeled alpha1-Pi aerosol (median particle size +/- SD, 3.9 +/- 2.5 microm) was generated by an air pressure-driven nebulizer. The patients inhaled for an average of 23.6 +/- 8.9 min. Static scintigrams in two projections were acquired immediately after (T1) and 1 (T2), 4 (T3), and 24 h (T4) after inhalation. The patients were divided into the following three groups according to their forced expiratory volume in 1 s (FEV1): group I, < or =40% of predicted normal (n = 8); group II, 40% < FEV1 < or = 60% of predicted normal (n = 4); group III, >60% of predicted normal (n = 6). RESULTS: The absolute percentage uptake values of alpha1-Pi in group I were 12.4 for T1, 7.3 for T2, 4.6 for T3, and 1.2 for T4; in group II the values were 13.0, 9.6, 6.2, and 2.0, respectively; and in group III, 14.6, 11.4, 6.5, and 3.6, respectively. Differences between the groups were generally statistically significant. Between T1 and T2, the probability value was <0.05 for group I versus group II, <0.006 for group I versus group III, and <0.39 for group II versus group III. Between T1 and T3, the probability value was <0.29 for group I versus group II, <0.22 for group I versus group III, and <0.94 for group II versus group III. Retention (between T1 and T4) was also dependent on the grade of the disease: P < 0.2 for group I versus group II, P < 0.001 for group I versus group III, and P < 0.02 for group II versus group III. Grading of the uptake pattern by three independent experienced investigators (87% agreement) revealed a peripheral deposition that was group dependent. We found that greater peripheral deposition corresponded with lower lung functional impairment: P < 0.5 for group I versus group II, P < 0.01 for group I versus group III, and P < 0.08 for group II versus group III. Degradation also corresponded with functional impairment: P < 0.05 for group I versus group II, P < 0.006 for group I versus group III, and P < 0.3 for group II versus group III. CONCLUSION: The results of this study show that sufficient amounts of alpha1-Pi can be deposited in the periphery of the lung by inhalation at least in patients with low-grade disease. Inhalation of alpha1-Pi may thus represent a new and more convenient route of drug administration.