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Summary Background As children transition to adolescence, penile curvature may recur several years, sometimes, decades later. Herein we review our experience with a group of symptomatic patients, their surgical repairs and outcome. Material & methods Reviews were done on the charts of 59 symptomatic adolescents aged 14–21 years who presented with recurrent penile curvature, causing either sexual dysfunction or significant deformity and had undergone surgical correction between 2000 and 2017. Their initial hypospadias repairs were: TIP & dorsal midline plication (28), Tiersch-Duplay (T-D) urethroplasty and Nesbit dorsal repair [9], prepuce mucosal island onlay and Nesbit repair [6], Two-stage Byar repair and ventral dermal graft (3 patients). 13/59 patients were repaired elsewhere, and their records were unavailable. Surgical correction included one stage dorsal replication and skin detethering (32patients), one-stage urethral mobilization and corporal/dermal grafts (12patients), staged corporal/dermal graft and skin coverage followed by urethroplasty (Grafted TIP) 8–12 months later (15patients), and 11/59 had urethral fistula, which were repaired concomitantly. Results 55 out of 59 patients were followed up for 6–48 months (median 30 months) by periodic office visits, and 2–4 weeks in 4 patients whose subsequent follow up was by email. Of the 55 patients, 53 healed well, and 2patients developed wound breakdown and scarring, which resulted in mild recurrent curvature but to a lesser degree than preoperatively. The other 4 patients who corresponded by email were pleased with the surgical outcome. Of the total 59 patients, 28 reported satisfactory sexual activity. None of the patients who had corporal/dermal grafts reported erectile abnormalities. Conclusions Recurrent curvature in adolescents following hypospadias repair, may be caused by peri-urethral and skin fibrosis and/or disproportionate growth of the relatively hypoplastic ventral corporal wall or the reconstructed urethra. Surgical correction of symptomatic patients by dorsal shortening or ventral lengthening procedures depends on the degree of curvature following skin degloving of the penis. We have been recommending to parents of children born with proximal hypospadias who had what appeared to be a good surgical result to follow up after puberty. Surgical repair of the recurrent chordee. One stage repair dorsal plication 32 Pts 16 Redo Nesbitt + 11 skin detethering 16 Redo Baskin + 8 skin detethering One stage urethral mobilization & corporal/dermal graft 12 Pts Two stage corporal /dermal graf and skin coverage 15 Pts

Summary Introduction Reconstruction of urethral strictures in patients with a history of hypospadias repair is controversial. The authors policy has been that if a residual healthy urethral plate is present, single-stage urethroplasty is recommended. However, if the urethral plate is fibrotic or absent or if lichen sclerosus is present, two-stage repair is utilized. Objectives In this study, the authors report their experience in management of patients with urethral stricture and prior hypospadias surgery. Study design Between 1993 and 2015, 62 patients with urethral stricture and a prior history of hypospadias repair underwent urethroplasty. Patients were divided into two groups; patients in group 1 (n = 39) found to have a healthy residual urethral plate and underwent single-stage urethral stricture repair using either an island skin flap or a buccal mucosa graft. Patients in group 2 (n = 23) had either a scarred urethra or evidence of lichen sclerosus and underwent staged repair using a buccal mucosa graft. Post-operatively, patients were evaluated at 3 months, 6 months, 1 year, and then annually. Results The median age of the patients was 10.5 years (2.5–33 years). The mean stricture length was 6.3 cm in group 1 and 7.1 cm in group 2. Overall success rate was 87.1% in group 1; a urethral fistula occurred in one patient (7.1%) who underwent skin flap onlay repair and one patient (4.5%) with a buccal mucosa graft. Recurrent urethral stricture was also diagnosed in one patient (7.1%) after repair using an island skin flap and in two patients (9%) following buccal mucosa graft. In group 2, three patients (13%) developed graft contracture and were revised before the second stage. Two patients (8.6%) had glans dehiscence following second stage urethroplasty. The final success rate in group 2 was 90.4%. Discussion Both single-stage and 2-stage repair showed successful outcome in management of urethral stricture following hypospadias repair. However, the authors continue to believe that the status of the urethral plate dictates the type of surgery to be utilized. In accordance to the previously published data, the study results also further support promising outcomes of application of buccal mucosa in surgical management of these patients. Conclusion In patients with urethral stricture after hypospadias surgery who have a healthy residual urethral plate, single-stage repair using buccal mucosa graft is a viable option with high success rate. In patients with scarred urethral plate, a 2-stage repair is recommended. Postoperative complications No. Pts Complication (%) Management Group 1. Single-stage repair 39 5 pts (12.8) Island skin flap onlay 14 Fistula: 1 pt (7.1) Urethral stricture:1 pt (7.1) Repair of fistula Corrected by buccal mucosa graft Buccal mucosa onlay 22 Fistula: 1 pt (4.5) Urethral stricture: 2 pts (9) Declined closure Elected to perform self-dilation Buccal mucosa inlay 3 – – Group 2. 2-stage repair with buccal mucosa graft 23 Graft contracture after 1st stage: 3 pts (13) Glans dehiscence after 2nd stage: 2 pts (8.6) Graft revision Repair of dehisced glans

Purpose Open dismembered pyeloplasty is usually performed through flank, anterior subcostal or posterior lumbotomy incisions. These incisions are cosmetically less acceptable and may produce significant postoperative pain. We present the smallest incision for open pyeloplasty, called a ‘miniature pyeloplasty’. The aim of this study was to reduce hospital stay and postoperative pain, along with enhanced cosmetic results. Patients and method 373 infants (mean age 4 months) with hugely dilated pelvises underwent the miniature pyeloplasty. The exact site of incision was determined by intraoperative renal ultrasonography and palpation. A muscle-splitting incision was made in the most dependent part of the lower quadrant. After meticulous dissection of the ureteropelvic junction component, the affected section was pulled out and underwent classic dismembered pyeloplasty without renal pelvis reduction. All children had long-duration stented anastomoses. Surgical incision size, operative time, hospital stay, postoperative analgesic use and complication rate were recorded. Results The operation was successful in all patients. The mean operative time was 53 min (range 43–75) and patients were discharged after 18 ± 3 (mean ± SD) h. Incision size ranged from 11 to 15 mm (mean 13). No narcotic analgesic was required postoperatively and there were no major complications during follow up. Conclusions Miniature pyeloplasty is a safe and successful technique for ureteropelvic junction obstruction that avoids long operative time with negligible postoperative pain compared to the classic open pyeloplasty in infants. The exact incision site must be reconfirmed intraoperatively by physical examination or renal ultrasonography.

Purpose Tissue-engineered pericardium (TEP) is a collagen-rich matrix that has previously been shown to promote in vivo and in vitro tissue regeneration. We evaluated the potential of TEP as a source for the in-vivo creation of bladder muscular wall grafts. We used bladder wall as a bioreactor to create a natural environment for cellular growth and differentiation. Materials and methods Sixteen rabbits were divided into four groups. A control group underwent classical bladder autoaugmentation. Other groups underwent insertion of TEP between bladder mucosa and muscular layer: group 2 with insertion of TEP, group 3 with TEP over autologous bladder muscular wall fragments, and group 4 with autologous bladder smooth muscle cells (SMCs) seeded on TEP. After 4 and 8 weeks, grafts were biopsied for histopathological evaluations. Results Frames from groups 3 and 4 demonstrated more organized muscular wall generation with a significantly higher number of CD34 + endothelial progenitor cells and CD31 + microvessels, and maintenance of α-smooth muscle actin expression through immunohistochemistry. Group 4 showed significant enhancement of SMC penetration to TEP. Although the fragment-seeded group required a simpler procedure, the cell-seeded group showed superior organization of the muscular layer on histopathology. We found a semi-organized muscular layer and new vessels in the margins of TEP in group 3, while there was a homogeneous pattern of SMCs and new vessels in both the margins and center of TEP in group 4. Conclusions This preliminary work has important functional and clinical implications, as it indicates that use of the autologous SMC seeding method may enhance the properties of TEP in terms of bladder wall regeneration.

Purpose To introduce a new biomarker [(carbohydrate antigen 19-9 (CA 19-9)] as a prognostic value for fetal renal function. The possible clinical application of fetal urinary CA 19-9 as a diagnostic and predictive biomarker in fetus with (PUV) is presented. Material and Methods Urinary and amniotic fluid CA 19-9 in 7 pregnancy with fetal PUV, and 7 healthy fetus (first voided urine immediate postpartum) were evaluated. Additionally, fetal urinary sodium, chloride, urine osmolarity; β2-microglobulin and NAG were measurement of in both groups. Results CA 19-9 level in the aspirated amniotic fluid and fetal bladder urine puncture (ranged from 476.45 to 2525 IU/ml) were significantly greater than the control. Ca19-9 was 45 IU/ml (45 in PUV group) . The higher fetal urine CA 19-9 the poorer renal function an immediate post-partum respiratory insufficiency or bilateral pnuemothroax. The serum Cr increased from 2 days of life up to a week and gradually decreases or remained stable in 3 infants with urinary level of CA 19-9 below 1000 IU/ml. Two neonates had died at the age of 2-6 days in NICU under high standard respiratory care. The prenatal urinary CA19-9 in these 2 infants was 2525 ad 2318 IU/ml respectively. The serum Cr remains normal and stable in 2 infant with Antenatal urinary CA19-9 less than 500 IU/ml, and decreases dramatically following bladder drainage and deceased hydronephrosis 2 weeks time. Conclusions CA 19-9 in fetal urine and amitotic fluid is a clinically applicable marker in congenital obstructive nephropathy (PUV). Our findings may propose that the proper decline in urinary Ca19-9 levels in fetus is a predictive of excellent surgical and renal function outcomes.

Purpose To investigate the potential of tissue-engineered pericardial (TEP) matrixes to form effective sources for in-vivo creation of urinary bladder wall grafts. Material and Methods Sixteen rabbits were divided into 4 groups. The control Group underwent classical autoaugmentation (Group 1). Other groups underwent insertion of 2x1cm2 frame acellular pericardium as a natural tissue expander between bladder mucosa and seromuscular layer. Group 2 underwent insertion of acellular pericardium. In group 3, inserted scaffold was implanted with autologous tissue fragments; biopsy of 10x5mm2 smooth muscle cell (SMC) layer of bladder was dissected and minced into 20 fragments. The fragments were coated on bladder mucosal layer. In group 4 the SMCs were isolated and cultured from dissected SMC layer and seeded on acellular pericardium. After 6 weeks, the in-vivo constructed muscular layer was grafted to remaining bladder host muscular layer. Before grafting and at 30d intervals after grafting, bladder biopsies were obtained for determination of CD31/34, SMC α-actin, and cytokeratin AE1/AE3 following cystometric evaluations. Results The frames containing fragment-seeded and cell-seeded tissue expanders, demonstrated more organized muscular wall generation with mature muscular layers, while number of CD34+ endothelial progenitor cells and CD31+ microvessels were significantly higher(P Conclusions The results demonstrate the bladder wall acted as an in-situ bioreactor; preserved autologous bladder tissue culture with seeded fragments and cells on a tissue expander provided a histologically organized muscular wall. Application of decellularized pericardium was an effective method for in-vivo constructed grafts in augmentation cystoplasty.

Purpose To investigate the potential of different scaffolds in bladder wall construction, using bladder as a bioreactor. Material and Methods Forty rabbits were divided into 10 groups. The control group underwent classical autoaugmentation (G1). In all other groups, different scaffolds were implanted between bladder mucosa and seromuscular layer. A biopsy of 10x5 mm2 full thickness of bladder was dissected. The smooth muscle cell (SMC) and urothelial cell (UC) layers were separated and minced into 20 fragments. The SMC fragments were seeded on mucosal layer and UC fragments were placed on 2x1cm2 framed scaffold under seromuscular layer.The scaffolds used in each groups were as follow: G2:acellular pericardium, G3:biofilm, G4:Polyglycolic Acid (PGA) as a biodegradable scaffold, G5:biofilm-coated acellular pericardium, G6:PGA-coated pericardium, G7:Pericardium-coated Biofilm, G8:PGA-coated Biofilm, G9:Pericarduim-coated PGA, and G10:Biofilm-coated PGA. After 2 and 6 weeks, biopsies were performed for histologic examinations and then the recombinant bladder tissue layers were grafted to the remaining host bladder. Biopsies at 1month intervals were obtained for determination of CD31/34, SMC α-actin, and cytokeratin AE1/AE3, following cystometry. Results Histopathological examinations revealed granulation in G3, 5, 7, 8, and 10.Bladder wall frames in G2 and 6 demonstrated organized bladder wall generation in two different expanded layers with mature UCs and SMCs and showed a significant bladder capacity increment as compared with other groups(P Conclusions Our results demonstrated effective role of tissue-engineered pericardium as a potential scaffold for SMC and UC seeding in bladder wall acting as a natural bioreactor. The biodegradable scaffolds could be also helpful in association with acellular matrixes in improvement of cell attachment and optimizing the in-vivo bladder wall construction for bladder auto augmentation.

Purpose Previously, we reported elevated level of urine carbohydrate antigen 19-9 (CA 19-9) in childern with ureteropelvic junction obstruction (UPJO). In present study we aimed to investigate the role of urinary CA 19-9 as a predictive biomarker to serve as a surrogate in differentiating between children with UPJO in need of pyeloplasty and those with dilated nonobstructed kidneys suitable for conservative treatment. Material and Methods The study included 36 children with UPJO treated with pyeloplasty (GI) and 24 children with dilated nonobstructed kidneys who were treated conservatively (GII). Voided urine samples were obtained for CA 19-9 measurement before treatment, and every 3 months during follow-up. Additionally, ultrasonography in three-month intervals and annual renography were performed. Follow-up ranged from 12-27 months (average 16.4 months). pyeloplasty was considered for patients with >10% loss of renal function. Results In GI preoperative CA 19-9 was significantly higher than in GII and a cutoff value of 41.06 U/ml yielded a sensitivity of 96.7% and a specificity of 93%. Compared to initial measurements, CA 19-9 decreased significantly at 3 months after pyeloplasty in GI and in the 12th month in GII with significant correlation with changes in renal pelvis diameter. In three patients due to rising CA 19-9 levels during follow-up along with decline in renal function (mean 12.8%) pyeloplasty was considered. Conclusions Urinary CA 19-9 is a non-invasive clinically applicable marker for definition of management protocol in children with UPJO. The practical clinical implications of the biomarker for long-term follow-up of children with UPJO after pyeloplasty and those receiving conservative treatment are significant.

Purpose To compare the results of cystoscopic intradetrusor injection of Botulinum Toxin A (BTX-A) with Electromotive Drug Administration(EMDA) as a minimally less invasive method and evaluate the effects of these two treatment modalities on incontinence and urodynamic parameters. Material and methods This study is a randomized controlled trial that approved by ethical committee. We selected 20 eligible children with overactive bladder (refractory to CIC and anticholinergic medications) divided into two equal groups. Group I, received the BTX-A by EMDA. Following insertion of special catheter containing a spiral silver electrode, the bladder was drained with sterile water. The preferred instillation volume based on estimated cystometeric bladder capacity results in a spherical bladder configuration. Two electrode pads were placed at paraumbilical region using contact electrode gel. The current generator which connected to the electrodes produced a pulsed direct current with a frequency of 2,500 Hz. BTX-A was administered (10U/kg) to the maximum designated current intensity (15 mA) in 15 minutes.Group II, received conventional cystoscopic BTX-A injection under general anesthesia. Clinical and urodynamic assessments were performed before and after the procedure in both groups. Results Detailed results will be reported in our presentation. According to our data it seems that using BTX-A by EMDA, improved the urinary incontinence and urodynamic parameters with higher therapeutic duration, disseminated infusion and deeper layer penetration with no invasive procedures in comparison with intaravesical injection. Conclusions To the best of our knowledge, this is the first report of BTX-A application for the treatment of pediatrics overactive bladder by EMDA as a simple and safe method, and compare its trapeutic effects with intradetrusor injection.