Objective To present the experience of hypospadias repair using the tubularized incised plate urethroplasty (Snodgrass procedure). Methods FromMay 2001 to November 2004, 82 patients with hypospadias underwent the Snodgrassprocedure and the clinical data were analysed retrospectively. The mean age was5 years (1.5 to 16 years). These cases were divided into: the earlier stage group(34 cases) and the later stage group (48 cases); the proximal group (19 cases)and the distal and middle group (63 cases); the primary operational group (49 cases) and the reoperational group (33 cases). Results Fistulas ocurred in 12 patients (14.6%), complete glans dehiscednce in 1 case. Fistula were as follows: 11 cases in the earlier stage group (32.4%) and 1 case in the later stage group（2.1%）;2 cases in the proximal group (10.5%) and 10 cases in the group of distal and middle group (15.9%); 8 cases in the primary operational group (16.1%) and 4 cases in the reoperational group (12.1%). There was statistically significant difference in the incidence of fistula between the earlier stage group and the later stage group (Plt;0.01). There was no statistically significant difference between the proximal group and the distal and middle group, between the primary operational group and the reoperational group (Pgt;0.05). All patients were followed up more than one month. The neo meatus was innormal position. The results of penile cosmetic and urethral function were satisfactory. Of these cases, 15 were followed up 1.5-6.0 months. The average flow rate was 7.8 ml/s(6.8-10.5 ml/s). The mean of maximum flow rate was 10.5 ml/s (8.8-14.5 ml/s).Conclusion Excellent neourethrol functional and superior casmetic resalts with low rate of complication can be gained by using tubularized incised plate urethroplasty for the cases of hypospadias without chordee or with mild chordee. But the preputialflap procedure should be chosen in condition that the hypospadias was association with obvious chordee.
Objective To discuss the severity grading and procedure design of concealed penis. Methods Between June 2004 and April 2008, 196 cases of concealed penis were surgically corrected. The age ranged from 1 year and 4 months to 44 years, with a median of 9 years. They presented with inconspicuous penis and abnormal cavernosa development. Four cases compl icated by glanular hypospadias and 3 cases by penile epispadias. They were classified as mild in 49 cases, moderate in 109, and severe in 38 according to severity. Surgical procedures were selected based on varied anatomical changes in different categories. Results All the patients got satisfactory appearance immediately after surgery. No voiding problem, wound infection, and skin necrosis were found. With 6 months to 48 months (mean 16 months) follow-up, most patients achieved good results and the penile appearance resembled that after circumcision. Mild penile retraction was noted in 1 moderate case and 1 severe case; and recurrence occurred in another one, the result was satisfactory after reoperation. Conclusion Various surgical procedures can be adopted for concealed penis. The key point is to design procedures according to the anatomical abnormalities.
Objective To review and investigate the compl ication and the treatment in Nuss procedure for correction of pectus excavatum. Methods From September 2005 to March 2009, 221 patients with pectus excavatum were treated withNuss procedure, including 189 males and 32 females and aging 2 years old and 10 months to 25 years old (median 8 years and 7 months old). Of 18 patients with recurrent pectus excavatum, 12 patients underwent a Ravitch procedure and the recurrence time of the depression after the first operation was less than 1 year in 2 patients, 1-3 years in 3, 3-5 years in 5, and over 5 years in 2; 6 patients underwent a stemotumover operation and the recurrence time of the depression after the first operation was less than 1 year in 2 patients, 1-3 years in 1 and 3-5 years in 3. The other 203 patients had a primary Nuss procedure, and the course of disease was from 18 months to 24 years. The preoperative CT scan showed the Haller index was 4.36 ± 1.34. Results The operation in all the patients were performed successfully without compl ications of death, massive hemorrhage and intrathoracic organ injury. The time of operation was 25-80 minutes (mean 40 minutes). The bleeding volume during procedure was 5-25 mL, with an average of 10 mL. Local allergy occurred in 3 cases after 7-10 months of operation, wound reject reaction in 2 cases after 3 and 11 months respectively, and effusion in 3 cases after 6-10 months; incision healed after dressing change. Incision healed primarly in the other patients. Pneumothorax occurred in 3 cases when the operation finished and in 7 cases after 2-4 days, pleural effusion in 4 cases after 3-5 days of operation, Nuss plate displacement in 2 cases after 3 days and 9 months, respectively. The patients having compl ication recovered well after treatment. The compl ication rate was about 8.72% (17/195). The followupperiod was 2-37 months for 195 patients. The postoperative Haller index was 2.52 ± 0.32 after 3 months of operation, showing statistically significant difference when compared with that before operation (P lt; 0.05). Conclusion Nuss procedure with non-thoracoscopic assistance for correction of pectus excavatum is safe because of less trauma and compl ication.
ObjectiveTo discuss the reoperation methods of urethral stricture after urethroplasty of hypospadias and their effectiveness.MethodsBetween September 2010 and April 2018, 169 patients with urethral stricture after urethroplasty of hypospadias, who underwent ineffective conservative treatments first, were accepted. The age ranged from 1 year and 7 months to 41years with a median age of 5 years and 8 months. The stricture located at the external urethral orifice in 80 cases, internal anastomosis connection in 87 cases, and constructed urethra in 2 cases. The symptoms of urethral stricture occurred at 2 weeks to 52 months after urethroplasty, with a median time of 4.5 months. The patients with external urethral orifice stenosis were treated with urethral meatus augmentation (74 cases) and urethral advancement (6 cases). The patients with internal anastomosis connection stenosis were treated with internal urethrotomy with urethroscopy (10 cases), urethrotomy and one-stage urethroplasty (26 cases), and urethrostomy (51 cases) including 43 cases of two-stage urethroplasty. The patients with constructed urethral stricture were treated with urethrolysis.ResultsOne hundred and fifty-four patients were followed up 6–86 months with an average of 47 months. The stenosis was relieved in 137 cases, and re-stenosis in 12 cases, urethral fistula in 4 cases, all of which were treated successfully. In addition, 1 case with mild urethral diverticulum did not need to be treated.ConclusionIf it is ineffective for the conservative treatment of urethral stricture after urethroplasty of hypospadias, appropriate surgical treatments could be selected according to the location and length of the stricture, local tissue conditions, complications, and so on.
Objective To investigate the local ization and expression characteristics of androgen receptor (AR) in genital tissue of patients with congenital hypospadias and simple chordee. Methods Between August 2005 and Janury 2007, dorsal prepuce, ventral perimeatal skin, and urethral plate were harvested from 25 patients with congenital hypospadias (aged from 1 year and 11 months to 19 years with an average of 3 years and 7 months) and 4 patients with simple chordee (aged from 3 years and 6 months to 16 years with an average of 7 years and 1 month). Prepuce by circumcision from 18 patients was used as control. The expression intensity and distribution of AR were assessed with mmunohistochemistry. Results AR was expressed in prepuce tissues from congentital hypospadias, simple chordee, and control. The AR positive cell rates were 62.94% ± 5.40% and 62.87% ± 5.33% in dorsal and ventral prepuce of control patients respectively, and were 59.00% ± 3.75%, 58.46% ± 4.14%, and 52.30% ± 3.53% in dorsal prepuce, ventral perimeatal skin, and urethral plate of patients with congenital hypospadias respectively. AR positive cell rate was significantly lower in patients with congenital hypospadias than in control patients (P lt; 0.05), and in urethral plate than in dorsal prepuce and ventral perimeatal skin of patients with congenital hypospadias (P lt; 0.05), and no significant difference was detected between dorsal and ventral specimens (P gt; 0.05). Stratified analysis showed a similar expression mode in severe hypospadias group and severe chordee group (P lt; 0.05). In mild to moderate hypospadias group and mild to moderate chordee group, no significant difference was shown when dorsal and ventral skin specimens were compared to that in normal control (P gt; 0.05), with AR expression diminished in urethral plate (P lt; 0.05), and AR decrease was relative to severity of chordee (P lt; 0.05). The AR positive cell rates were 59.69% ± 2.73%, 55.71% ± 1.67%,and 51.92% ± 1.87% in dorsal, ventral skin, and urethral late of patients with chordee respectively. Reducing tendency of AR expression was observed. Conclusion AR expression decreases in penile skin of patients with congenital hypospadias and simple chordee, especially in urethral plate.
ObjectiveTo explore the indication and effectiveness of urogenital sinus surgery in feminizing genitoplasty of disorder of sex development (DSD).MethodsA retrospective analysis was made on clinical data from 22 patients with DSD who underwent one stage feminizing genitoplasty between October 2010 and December 2015. The patients’ age ranged from 1 year and 2 months to 21 years, with the median age of 2 years and 1 month. According to the Prader classification criteria, the appearance of vulvas were rated as grade Ⅰ in 7 cases, grade Ⅱ in 6 cases, grade Ⅲ in 8 cases, and grade Ⅳ in 1 case. Cystoscopy was applied before feminizing genitoplasty in all patients. Low confluence of vagina and urethra was found in 19 patients, while high confluence was found in 3 patients. The mean length of urogenital sinus was 1.6 cm (range, 0.5-3.0 cm). The mean length of water-filled vagina was 4.4 cm (range, 3.5-5.5 cm). Cervix was detected at the end of vagina in 16 patients, meanwhile absence of cervix was detected in 6 patients. The same procedures of clitoroplasty and labioplasty were used in all patients. Three procedures of urogenital sinus surgery were applied, as the " cut-back” vaginoplasty in 6 patients, the " flap” vaginoplasty in 11 patients, and the partial urogenital sinus mobilization (PUM) in 5 patients.ResultsAll procedures were completed successfully and the incisions healed by stage Ⅰ. All patients were followed up 12-74 months, with the average of 30.5 months. The outcome of appearance evaluation was excellent in 13 patients (59.1%), good in 6 patients (27.3%), and poor in 3 patients (13.6%). Urinary incontinence, post-void residual, urinary infection, and urethrovaginal fistula were not found in 17 toilet trained patients.ConclusionUrogenital sinus surgery is the most critical step in feminizing genitoplasty of DSD. It can be finished in one stage procedure with clitoroplasty and labioplasty before puberty. If thoroughly evaluation before surgery is completed and the principle of different procedures is handled, the outcome will be satisfactory.
Objective To investigate the application of cavernosum reduction technology in glanuloplasty during the repair of moderate-severe hypospadias and evaluate the effectiveness. Methods The clinical data of 192 patients with moderate-severe hypospadias between November 2015 and May 2017 were retrospectively analyzed. Among them, 103 patients were treated with the cavernosum reduction technology in glanuloplasty during the repair (observation group), 88 patients were treated with repair and glanuloplasty without the cavernosum reduction technology (control group). There was no significant difference in maximum transverse diameter of glans and the height of glans between 2 groups (t=1.652, P=0.152; t=1.653, P=0.077). The length of reconstructed urethra, complications (e.g. glans dehiscence and fistula), and the maximum flow rate at 3 months after operation in 2 groups were recorded. Results The length of reconstructed urethra were (35.51±7.79) mm in observation group and (32.17±6.37) mm in control group. In observation group, the meatus location after the correction of chordee was proximal in 24 cases and scrotum-perineum in 79 cases. In control group, the meatus location after the correction of chordee was proximal in 21 cases and scrotum-perineum in 67 cases. There was no significant difference in the meatus location between 2 groups (χ2=0.008, P=0.920). All patients were followed up 6-12 months after operation (mean, 9 months). There were 3 cases of urethral fistula, 2 cases of glans dehiscence, and 3 cases of urethral orifice stricture in observation group, with the incidence of complications of 7.8%. There were 7 cases of urethral fistula, 3 cases of glans dehiscence, and 4 cases of urethral orifice stricture in control group, with the incidence of complications of 15.9%. There was a significant difference in the incidence of complications between 2 groups (χ2=4.027, P=0.040). The appearance of the penis was satisfactory, and the urethral orifice was fissured, which was close to the appearance of the normal urethral orifice. At 3 months after operation, the maximal flow rates were (6.23 ± 0.54) mL/s in observation group and (5.44±0.92) mL/s in control group. There was significant difference in the maximum flow rate between 2 groups (t=1.653, P=0.000). Conclusion Cavernosum reduction technology being applied in the repair of moderate-severe hypospadias can reduce the probability of glans dehiscence, urethral fistula, urethrostenosis, and other postoperative complications, and improve the success and satisfaction of surgery.
Objective To provide an ideal seed cell for tissue engineered urinary bladder and urethra by serially culturing canine smooth muscle cells from urinary bladder in vitro and compare biological characteristics of different passagesof cells. Methods Bladder smooth muscle cells of 12-month-old male dogs weighing 10-12 kg were isolated from adult dogs’ urinary bladders by collagenase and trypsin digestion and serially cultured in DMEM medium supplemented with 10% serum of newborn bovines. Morphology and prol iferation of the cells were observed and the serially-cultured cells were identified with the transmission electron microscope and immunohistochemistry. Results The cells appeared spindle in parallel rows when they grew to the degree of subconfluence, and showed the “peak-valley” structure under the inverted phase contrast microscope. The cells could be prol iferated serially to the 12th passage in vitro. The growth curve showed the cells before the 7th passage had the similar prol iferation characteristics and the growth cycle was about 40 hours. The TEM showed myofilament and the dense body in cytoplasm of smooth muscle cells. Smooth muscle actin was positive by immunohistochemical staining. After the 7th passage, the cells’ growth became slow, and myofilament and the dense body in cytoplasm vanished. Conclusion The canine smooth muscle cells from urinary bladder can be serially cultured in vitro and highly purified and largely prol iferated by the appropriate method. The cells before the 7th passage can be used as optimal seed cells for tissue engineered urinary bladder and urethra.
Objective To document the effect of surgical steps, including penile degloving, plate transection, dorsal plication, and fasciocutaneous coverage, in primary hypospadias repair on penile length. Methods A consecutive series of 209 prepubertal boys with primary hypospadias repair was included with the age ranged from 10 to 97 months (mean, 31.7 months). Intraoperative stretched penile length (SPL) was measured before operation (n=209), and after each step, namely penile degloving (n=152), plate transection (n=139), dorsal plication (n=170), and fasciocutaneous coverage (n=209). SPLs before and after each steps or the entire operation were analyzed. The SPL was compared between plate transection group and plate preservation group, dorsal plication group and non-plication group, and plate preservation with plication group and plate preservation without plication group, respectively. Differences of SPL between before and after each steps were analyzed with factors including neourethra length, rest dorsal penile length, rest ventral penile length, preoperative SPL, and the degree of penile curvature after penile degloving, with multivariate linear regression analysis. ResultsAll the four steps resulted in SPL difference. The SPL increased after penile degloving and plate transection (P<0.05), and decreased after dorsal plication and fasciocutaneous coverage (P<0.05). The SPL increased after all steps were completed (P<0.05). In patients with plate transection, postoperative SPL increased when compared with that before operation (P<0.05). No significant difference was noted in patients without plate transection (P>0.05). And there was significant difference in the increased length of SPL between patients with and without plate transection (P<0.05). In patients with dorsal plication, a significant increase of postoperative SPL (P<0.05) was noted. No significant difference was noted in patients without dorsal plication (P>0.05). And there was no significant difference in increased length between patients with and without dorsal plication (P>0.05). When patients with plate transection were excluded, dorsal plication resulted in no significant difference on postoperative SPL (P>0.05). The increased length of SPL after penile degloving, dorsal plication, or cutanofascial coverage was not related to the neourethra length, the rest dorsal penile length, the rest ventral penile length, the preoperative SPL, and the degree of penile curvature (P>0.05). However, the neourethra length and preoperative SPL were the influencing factors for the increased length of SPL after plate transection (P<0.05). ConclusionThe main steps in primary hypospadias repair can change SPL. The lengthening effect of plate transection would not be counteracted by dorsal plication. Dorsal plication makes no significant difference on postoperative SPL.
Objective Anthropometric variants in prepubertal boys with hypospadias were assigned and assessed to illustrate anatomical malformation. Methods A total of 516 prepubertal (Tanner grade Ⅰ) boys with hypospadias who were admitted to three medical centers between March 2021 and December 2021 and met the selection criteria for primary surgery were selected. The age of the boys ranged from 10 to 111 months, with an average of 32.6 months. Hypospadias were classified according to the location of the urethral defect, 47 cases (9.11%) of the distal type (the urethral defect is in the coronal groove or beyond), 208 cases (40.31%) of the middle type (the urethral defect is in the penis body), and 261 cases (50.58%) of the proximal type (the urethral defect is at the junction or proximal side of the penis and scrotum). The following indexes were measured: penis length before and immediately after operation, reconstructed urethral length, and total urethral length. Morphological indicators of the glans area, including preoperative height and width of glans, AB, BC, AE, AD, effective AD, CC, BB, the urethral plate width of the coronal sulcus, and postoperative height and width of glans, AB, BE, and AD. In which point A is the distal endpoint of navicular groove, point B is the protuberance lateral to the navicular groove, point C is the ventrolateral protuberance of the glans corona, point D is the dorsal midline point of the glans corona, and point E is the ventral midline point of the coronal sulcus. The foreskin morphological indicators, including the foreskin width, inner foreskin length, and outer foreskin length. The scrotal morphological indicators, including the left, right, and front penile to scrotum distance. The anogenital distances, including anoscrotal distance 1 (ASD1), ASD2, anogenital distance 1 (AGD1), and AGD2. ResultsThe penis length of the distal, middle, and proximal types decreased successively before operation, the reconstructed urethral length increased successively and the total urethral length decreased successively, these differences were all significant (P<0.05). The height and width of the glans of the distal, middle, and proximal types significantly decreased successively (P<0.05), but the height/width of the glans was generally close; AB value, AD value, and effective AD value significantly decreased successively (P<0.05); there was no significant difference in BB value, urethral plate width of the coronary sulcus, and (AB+BC)/AD value between the groups (P>0.05). There was no significant difference in the width of glans between the groups after operation (P>0.05); AB value and AB/BE value increased successively, and AD value decreased successively, these differences were all significant (P<0.05). The inner foreskin length in the 3 groups significantly decreased successively (P<0.05), while the outer foreskin length had no significant difference (P>0.05). The left penile to scrotum distance of middle, distal, and proximal types significantly increased successively (P<0.05). ASD1, AGD1, and AGD2 significantly decreased from distal type to proximal type successively (P<0.05). The other indicators’ differences were significant only between some groups (P<0.05).Conclusion The anatomic abnormalities of hypospadias can be described by anthropometric indicators, which can be used as the basis for further standardized surgical guidance.