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Introduction: The optimal treatment of proximal hypospadias remains controversial. Several techniques have been described, but the best approach remains unsettled., Objective: To evaluate and compare the complication rates of proximal hypospadias with and without ventral curvature (VC), according to three different surgical techniques: tubularized incised plate (TIP) uretroplasty, dorsal inlay graft TIP (DIG), and staged preputial repair (SR). It was hypothesized that SR performs better than TIP and DIG for proximal hypospadias., Methods: Single-center, retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. The DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive urethral plate (UP) mobilization (UPM), dorsal plication (DP) and/or deep transverse incisions of tunica albuginea (DTITA) were selectively performed when attempting to spare transecting the UP. Division of UP and SR was favored in cases with severe VC (>50°), which was often concurrently managed with DTITA if intrinsic curvature was present. For SR, tubularization of the graft was performed 6 months later., Results: A total of 140 patients were included. Tubularized incised plate (TIP), DIG, and SR techniques were performed in 57, 23, and 60 patients, respectively. The TIP and DIG techniques achieved similar success rates, although DIG was performed in cases of narrow and spongiosum-deficient plates. Reoperation rates with TIP and DIG techniques was 52.6% and 52.1% (NS). Urethro-cutaneous fistulas were seen in 31.5% and 13% of TIP and DIG techniques, respectively. Staged repair accomplished better results than both TIP and DIG techniques, despite being performed in the most unfavorable cases (reoperation rate 28%). After technical modifications, the DIG technique achieved similar outcomes of SR., Conclusions: Proximal hypospadias remains challenging, regardless of the technique utilized for its repair. Urethro-cutaneous fistulas were more commonly seen after long TIP repairs. Approximately half of the patients undergoing long TIP and DIG procedures needed re-intervention, although the percentage decreased significantly with late modifications in the DIG group. Recurrence of VC after TIP and DIG techniques seemed to be a significant and under-reported complication. Staged repairs, despite being performed for the most severe cases, resulted in overall better outcomes., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Low urinary flow rates are common after tubularized incised plate urethroplasty but the etiology remains unclear and may be related to low urethral compliance due to abnormal collagen concentrations and/or fewer elastic fibers in the healed urethral plate. We hypothesized that inserting a preputial mucosal graft over the dorsal raw area after the midline incision may avoid scarring and improve urethral compliance., Materials and Methods: Adult rabbits were submitted to tubularized incised plate urethroplasty with or without inlay preputial graft according to a previously described protocol. Tissular concentrations of collagens I, III, IV, VI, VIII and XIII were measured. Histomorphometric analysis was used to quantify elastic fibers in the urethra. Tubularized incised plate urethroplasty with and without inlay preputial graft was compared to normal rabbit urethras (controls)., Results: mRNA concentrations for collagens I, II and XIII were similar between controls and operated rabbits. The proportions between collagens I and III were 1.05, 0.87 and 1.21, respectively, in controls and animals undergoing tubularized incised plate urethroplasty with and without inlay preputial graft. mRNA concentrations for collagen IV and collagens VI/VIII tended to be higher and lower, respectively, in the operated urethras, despite showing statistical significance only for collagen VIII in animals undergoing tubularized incised plate urethroplasty with inlay preputial graft vs controls (p=0.02). The operated animals did not demonstrate a reduced number of elastic fibers in the urethral tissues compared to controls., Conclusions: Elastic fiber number and distribution were similar between tubularized incised plate urethroplasty cases and controls, suggesting that decreased concentrations of elastic fibers do not explain the reduced urethral compliance after tubularized incised plate urethroplasty. The raw area determined by the dorsal urethral incision regenerated after standard tubularized incised plate urethroplasty, while cicatrization with fibrosis occurred in correspondence to the grafted areas after tubularized incised plate urethroplasty with inlay preputial graft., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

A 37-day-old boy presented with a duplicated penis. Examination revealed presence of two penises, one dorsally located and one ventrally, a large left inguinal hernia and absent right thumb. Abdominal ultrasound and micturating cystourethrogram showed normal kidneys, a single urinary bladder, and partial urethral duplication with no vesicoureteric reflux. The patient was subjected to a new technique, reconstructing the penis without removal of corporal tissue, and therefore not compromising its size. A satisfactory result was achieved. The case is being reported due to its rarity and different surgical approach, in contrast to previous reports of management of diphallia involving excision of one of the penises., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: We analyzed the histological and functional characteristics of the tubularized incised plate vs dorsal inlay graft urethroplasty in an experimental rabbit model., Materials and Methods: A total of 24 New Zealand male rabbits were randomly allocated into 4 groups, including sham operation, urethroplasty, tubularized incised plate urethroplasty and dorsal inlay graft urethroplasty. In the urethroplasty group the anterior urethral wall was half excised and the dorsal aspect was tubularized. In the tubularized incised plate group the same steps were followed but tubularization followed a longitudinal midline incision in the dorsal wall. In the dorsal inlay graft group the defect created by the dorsal incision was covered with an inner preputial graft. The animals were sacrificed at 4 and 8 weeks, respectively. The penis was immediately harvested for standardized passive flowmetry and subsequently fixed for histological staining., Results: The grafts took in all animals. The tubularized incised plate defect was bridged by urothelium while in the dorsal inlay graft group the preputial graft kept its original histological characteristics. There was a significant decrease in average flow in the urethroplasty group (1.6 ml per second) compared to that in the sham operated group (3.4 ml per second) and to the other groups (p <0.05). However, no significant difference in average flow was found for the tubularized incised plate and dorsal inlay graft groups (2.4 and 2.2 ml per second, respectively, p = 0.7)., Conclusions: In this short-term rabbit model dorsal inlay graft urethroplasty was feasible with good graft take and integration. Simple tubularization of a reduced urethral plate led to significantly decreased flow. Incision of the reduced plate with or without grafting improved the average flow. Findings in this experimental model do not support the superiority of dorsal inlay graft urethroplasty over tubularized incised plate urethroplasty in terms of urethral flow dynamics., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Persistent cloaca is a rare urogenital anomaly that can pose significant challenges for adequate diagnosis and management. We describe the case of an infant girl with a cloacal malformation, having a single perineal orifice and an accessory phallic urethra, who presented with ambiguous genitalia at birth. The distal part of the accessory phallic urethra was used to create a mucosa-lined vestibule as a part of the total urogenital sinus mobilization. This technical maneuver allowed a more natural looking, and possibly functioning, vaginal introitus, improving the final cosmetic result., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: Management for clitoral enlargement remains controversial. New understanding of clitoral function stimulated a search for more conservative surgical approaches, such as recession or partial resection. However, these techniques risk decreasing clitoral sensation or causing painful erections. Moreover, irreversibility continues to be the principal problem that fuels patient, surgeon and societal anxiety in the management of this challenging developmental issue. We describe a new technique, corporeal sparing dismembered clitoroplasty, that dismembers the corporeal bodies and preserves all clitoral structures., Materials and Methods: After obtaining full informed consent and institutional review board approval 8 consecutive patients with clitoral enlargement underwent corporeal sparing dismembered clitoroplasty. Five girls had congenital adrenal hyperplasia (Prader IV and V in 4 and 1, respectively), 1 had ovotesticular disorder of sexual differentiation and 2 had partial androgen insensitivity syndrome. One pubertal girl was tested with warm, cold and pain clitoral stimulation before and after surgery. For the clitoroplasty technique the glans and its neurovascular bundles are dissected from the corpora. The isolated corpus is then completely divided starting at the bifurcation. Each separated hemicorpus is rotated inferior and lateral, to be placed inside the labial scrotal folds. The glans is reduced by superficial excision of its epithelium and fixed to the pubic attachments. Labia minora are constructed with preputial Byars flaps. Labioplasty and vaginoplasty are then routinely performed., Results: Eight patients 6 months to 13 years old underwent this procedure. Followup was 6 to 12 months. All patients recovered well from surgery without early complications. The initial cosmetic result was good in all girls. The hemicorpora were easily palpated inside their labia majora pouches, which retained the desired cosmetic appearance following feminizing genitoplasty. All glans clitoris were preserved. The teenaged patient does not report painful erections. She has maintained clitoral sensation and is satisfied with the cosmetic result., Conclusions: Conservative reconfiguration of the female genitalia without removing genital structures is feasible in girls with clitoral enlargement. The cosmetic appearance of the genitalia is acceptable, at least to the surgeon and parents, in that the enlarged clitoris is hidden. The physiological consequences of the current operation and any surgery in the future to reverse it are unknown. With these aspects in mind we believe that corporeal sparing dismembered clitoroplasty should be incorporated into the armamentarium of surgeons involved in the treatment of clitoral enlargement and presented as an option for feminizing genitoplasty.