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Purpose: We present a new, 2-stage functional and cosmetic reconstruction of concealed penis in adults with short-term subjective outcomes., Materials and Methods: Patients with excess penile skin removal, shaft tissue scarring and penile retraction with poor functional and cosmetic results underwent 2-stage repair. At stage 1 after a coronal incision and penile degloving an intrascrotal tunnel was formed and the penis was transposed through the scrotum. Three or 4 zero or 2-zero nonresorbable sutures were applied ventral to the penis, crossing through the entire scrotum to ensure complete scrotal skin adhesion to the penis (penile scrotalization). At stage 2 after 6 to 12 weeks the scrotal skin at the penile base was incised bilaterally to separate the skin around the penis from the remaining scrotal skin (penile descrotalization). Evaluation was scheduled 3, 6 and 9 months postoperatively, and annually thereafter., Results: Ten men with concealed penis underwent this 2-stage penile repair, including 8 who were circumcised and 2 who underwent conservative surgery for penile cancer. Mean +/- SD operative time was 75 +/- 15 minutes for stage 1 and 45 +/- 10 minutes for stage 2. No major intraoperative or perioperative complications occurred except superficial scrotal hematoma in 1 patient. At a median followup of 20 months (range 6 to 72) all men were in satisfactory clinical condition and the median patient satisfaction visual analog score was 97 (range 85 to 100). All patients recovered normal spontaneous erection with regular sexual intercourse 4 to 8 weeks after operation 2., Conclusions: This simple, new 2-stage technique seems feasible and effective, and it is well accepted by patients. Further studies are mandatory to confirm preliminary results., (2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To our knowledge epidemiological data on the incidence of failed hypospadias repair and the number of patients seeking further surgical treatment remain unknown. We report an observational, descriptive survey of patients who were evaluated and treated for urethral stricture disease and/or penile defects after primary hypospadias repair., Materials and Methods: We performed a retrospective observational chart analysis of patients evaluated and treated for urethral stricture disease and/or penile defects at 2 tertiary European centers from January 1998 to December 2007. In each case we investigated the primary abnormal meatal site, the number of operations needed to repair primary hypospadias and complications of this primary repair. Patients were offered surgical repair for previous failed hypospadias treatment. After surgery evaluation was scheduled at 3, 6 and 9 months. Success was defined as a functional urethra without fistula, stricture or residual chordee and a cosmetically acceptable glanular meatus after the completion of all secondary procedures., Results: A total of 1,176 patients with a mean age of 31 years were evaluated and treated. To treat failed hypospadias repair 760 (64.6%) and 416 patients (35.4%) underwent 1-stage and staged repair, respectively. Mean followup was 60.4 months. Of 1,176 cases 1,036 (88.1%) were classified as successful and 140 (11.9%) were considered failures., Conclusions: Failed hypospadias repair may be corrected by multiple and complex surgeries. Its effects are experienced during the lifetime of the patient and parents.

Purpose: We present 2 techniques of enhancement and sculpturing of a small and/or deformed glans., Materials and Methods: The small glans in primary or re-do hypospadias repair was enhanced by longitudinal double-faced island flaps incorporated onto the ventral side of the glans between the glans wings. The deformed glans, of small or normal size (with normal urethra or well functioning neourethra), was enlarged and sculptured by injection of hydrogel. Between May 1997 and March 2002, 27 patients underwent glans enhancement and sculpturing. Small deformed glans occurred after failed hypospadias repair in 10 patients, penile trauma in 3, hemangioma sclerozation in 2, primary hypospadias in 8 and normally developed penile body in 4. A double-faced island flap was performed in 14 patients, glans was enhanced by hydrogel injection in 9 and both procedures were performed in 4., Results: Mean followup was 34 months for the double-faced flap technique 17 months for hydrogel injection. Satisfactory enlargement and esthetic appearance were achieved in 13 of the 14 patients who underwent the double-faced flap technique and 1 required surgical correction. Of the 9 patients who underwent either single or multistage hydrogel injection 8 had good results and 1 required partial removal of hydrogel after hypercorrection. The combination of these 2 techniques provided satisfactory results in all 4 cases., Conclusions: Enlargement and sculpturing of a small deformed glans are challenging and difficult. A double-faced island flap and/or injection of hydrogel resolves this problem satisfactorily.

Purpose: Megaureter represents the ideal tissue for bladder augmentation but to date ureterocystoplasty has been used only in select cases. We demonstrate that ureterocystoplasty can be used more frequently by dividing the megaureter and using its distal part for bladder augmentation and proximal part for reimplantation into the bladder. This technique can be performed as a 1 or 2-stage procedure., Materials and Methods: From November 1995 to October 1998 ureterocystoplasty was performed in 16 patients 3 to 12 years old (mean age 6.6). In 9 cases with impaired renal function loop cutaneous ureterostomy had been previously done to preserve and improve renal function. In the remaining 7 cases bladder augmentation and simultaneous ureteroneocystostomy were performed without cutaneous ureterostomy. Ureterocystoplasty was done extraperitoneally. This distal part of megaureter was used for bladder augmentation and the proximal part was implanted into the bladder using extravesical detrusor tunneling ureteroneocystostomy in a majority of cases., Results: Followup ranged from 12 months to 4 years (mean 2.8). The new increased bladder capacity ranged 296 to 442 ml. (mean 371) in both groups. Compliance was improved in all cases with a decrease in the number of clean intermittent catheterizations daily, and there was no further worsening of renal function. Vesicoureteral reflux was noted in 3 patients without clinical symptoms., Conclusions: Megaureter presents the ideal tissue for bladder augmentation. Division of the ureter and use of its distal part for augmentation is always possible. Augmentation ureterocystoplasty performed this way can be done more frequently.

Purpose: We present 2 variants of the penile disassembly technique for epispadias repair that refine some details of the Mitchell technique. In some cases the urethral plate retracts and shortens, and there may be poor vascularization at the most distal portion. In addition, when the neurovascular bundles of the separated hemicorporeal glanular bodies are intact, it is difficult to achieve excellent correction of dorsal chordee., Materials and Methods: Between 1995 and 1998 we performed the modified Mitchell technique in 11 boys 2 to 14 years old using 1 of 2 variants. For variant 1 the hemiglans and urethral plate remain connected by a small tissue bridge to avoid shortening the urethral plate and ensure a better blood supply. For variant 2 each corporeal body is dissected from the glans cap and neurovascular bundle to achieve complete mobility. This procedure enables ideal mobility of the corporeal bodies as well as curvature repair. When corporeal rotation was unsuccessful, we corrected persistent dorsal chordee using the Ransley corporotomy with corporostomy in 2 patients and with dermal grafting in 1., Results: Mean followup was 17 months (range 6 to 30). Dorsal curvature was corrected in all cases. Cosmetic appearance was good. Complications included meatal stenosis and urethral fistula in 1 case each., Conclusions: Our variants of epispadias repair may be good alternatives to the Ransley and Mitchell complete penile disassembly techniques.

Purpose: Techniques for penile straightening generate the serious dilemma of which is most appropriate. We created and describe our penile disassembly technique to avoid penile shortening in curvature repair., Materials and Methods: From November 1995 to March 1997 we performed our penile disassembly technique in 87 patients 12 months to 47 years old (mean age 4.5 years). Indications for surgery were isolated penile curvature and chordee with or without hypospadias, curvature of the distal third of the corpora cavernosa and a small penis with curvature. Our method consists of separation of the penis into its entities, a glans cap with its neurovascular bundle dorsally, a nondivided or divided urethra, or urethral plate ventrally and corpora cavernosa that may be partially separated in the septal region. This maneuver achieves excellent correction of penile curvature. In addition, during this procedure a space is created between the glans cap and the tips of the corpora cavernosa into which various tissues may be inserted to avoid penile shortening due to corporoplasty or even to lengthen the penis., Results: Mean followup was 16 months (range 6 months to 2 years). There were no injuries to the neurovascular bundle or urethra. Complications developed only in relation to onlay or tubularized urethroplasty in 4 patients., Conclusions: Our penile disassembly technique seems to be the most effective procedure in select cases of severe curvature of the distal penile shaft, marked glans tilt and a small penis with curvature. In addition, the procedure provides the possibility of penile lengthening.

Purpose: We report our efforts to create an ideal continent urinary catheterizable stoma., Materials and Methods: Our approach includes the creation of a continent stoma using a preputial penile island skin flap in male patients and a preputial clitoral island skin flap in female patients. The flaps are transposed suprapubically, tubularized and implanted in a nonrefluxing manner into the bladder or other urinary reservoir., Results: From 1994 to April 1995 the technique was performed in 14 male patients 4 months to 42 years old and 7 female patients 4 to 14 years old. Early results were satisfactory at 2 to 12 months of follow up (mean 6)., Conclusions: This technique could be an alternative to other methods of urinary continent diversion.

From 1987 to 1992, 128 predominantly male patients 15 days to 19 years old (mean age 22 months) with a total of 167 megaureters underwent surgery for obstruction and/or reflux and symptomatic recurrent urinary infections. The technique consists of creating 2 holes through a muscle up to the mucosa by the detrusor splitting maneuver on the lateral bladder wall. Between the 2 holes a submucosal tunnel is created without detrusor resection. The megaureters are inserted into the tunnel and an anastomosis is made between the ureter and bladder mucosa. In cases of double megaureters 2 separate tunnels may be created. Regardless of the size, the megaureters can be inserted into the tunnel without any modeling. There are no problems with a wide megaureter since it spontaneously folds within the tunnel. However, the ureter must be maximally shortened and straightened to enable better urine flow, despite poor propulsive capacity of megaureters. Followup ranges from 3 months to 5 years (mean 2.5 years). Complications include 2 cases of stenosis and 3 of reflux recurrence. The method is safe with minimal surgical trauma. It is particularly applicable in newborns, infants and patients with neurogenic bladder.