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The surgical treatment of the priapism is complex and requires various techniques for diversion of the corpora cavernosa with significant morbidity. For the last 15 years, the author have been using a simple transglandular cavernosal spongiosum shunt technique, which satisfies the requirements of functional surgery: restoration of anatomy, reduced morbidity, facility to learn. This article is intended to precisely describe the surgical technique and to present the results based on a personal series of 26 cases of priapism operated with this technique in black patients (19 adults and seven children) in the context of sickle-cell anaemia.

Objective: Described here is a simple treatment for female urinary incontinence present and concurrent cystocele repair, if present. The objective of this technique which combines a bladder neck and a suprapubic percutaneous suspension, is to obtain by a sling effect, efficient cure of the urinary incontinence, in avoiding the common retention problem., Patients and Methods: Between 1992 and 1998, 49 black female patients were treated with this procedure. Average age was 18 years old (the youngest 14, eldest 29 years old) 39 were primigravid while 10 were multigravid (2 to 6 childbirths). 12 (24. 4%) have undergone at least 2 operations for fistula cure, 6 of the patients showed previous incontinence surgery; Burch technique (n=1), Martius fat sling (n=3) and anterior colporraphy (n=2). 25 patients (51%) were suffering from a severe incontinence, for 17 cases the urine leak was grade 2 and 8 cases grade 3 at decubitus., Results: No bladder lesion occurred on any of the 49 patients. Except for one general peritonitis which occurred on a patient who was receiving a combined recto-vaginal fistula operation, the post operative complications were minor (n =7). We observed only one direct recurrent urinary incontinence which was treated a second time with the same technique and was cured. For 46 studied cases and an average follow-up of 28.6 months, 29 patients (63%) were declared totally cured, 8 (17.3%) showed functional improvement, 9 (19.5%) remained incontinent. The global success rate (cure and improvement) was obtained in 80% of cases. The results were less satisfactory in multi-operated patients, particularly in those who suffered from extensive cervico urethral damage (Group III). In this group only one out of two patients obtained cure or improvement., Conclusion: Due to its real simplicity the bladder neck and vagina wall sling is easy to redo, and because its reliability we have chosen this procedure as a choice treatment for incontinence following a vesico vaginal fistula. The excellent results confirmed by a longer follow-up has led us to extend its indication to all types of female urinary incontinence. This technique is particularly well suited for use in developing countries.

Since priapism is uncommon, treatment is controversial and difficult. In this article we describe a practical, well-documented approach for management of priapism in countries with a high incidence of sickle cell disease. This approach is based on our experience including a total of 56 black patients (49 adults and 7 children) as well as on the results reported in the literature. The patients in our series were examined and treated by the same physician over an 18 year period in various African countries, i.e., Burkina (n = 8), Chad (n = 12), Gabon (n = 19), and Niger (n = 17). Etiologies and pathophysiology are reviewed. In all cases, surgical treatment involved diversion from corpora cavernosa. In the 51 cases with follow-up periods of 3 months or longer, results were considered as excellent in 17 cases (33 p. 100), partial in 5 (9.8 p. 100), and unsuccessful in 29 (56.8). Since 1984, needle drainage with a unilateral transglandular cavernosal-spongiosum shunt based on the technique described by Al Ghorab's has led to better results with immediate detumescence in 80 p. 100 of cases and a long-term success rate of 52 p. 100 (13/25 cases with sufficient follow-up). Except in cases involving sickle cell anemia in which concomitant medical treatment of priapism can be useful, immediate surgical treatment is the only technique effective in avoiding secondary impotence, which was common in our series (58.6). Our p. 100 needle drainage technique appears to be the method of choice for simplified achievement of a unilateral transglandular cavernosal-spongiosum shunt.

Objectives: To define, based on the author's experience and the data of the literature, a simple and rigorous practical approach to the management of priapism in developing countries, for which the therapeutic approach is controversial and difficult due to the rarity of this condition., Material and Methods: The reported series is based on 56 cases of priapism in black patients (49 adults and 7 children), observed and treated by the same operator over an 18-year period in Burkina (n = 8) and then in Chad (n = 12), Gabon (n = 19) and Niger (n = 17). The pathophysiology and aetiologies are reviewed., Results: All patients treated surgically underwent various surgical techniques for diversion of the corpora cavernosa. In this group of 51 reported cases, there were 17 successes (33.3%), 5 partial results (9.8%) and 29 failures (56.8%). The overall immediate success rate, resulting in detumescence, was 36/51 (70%). These initial successes almost exclusively concerned patients treated by unilateral cavernoglandular shunt within an interval not exceeding 2 days. Although the long-term results, all treatments combined, were disappointing (56.8% of patients with sufficient follow-up are impotent), creation of a unilateral cavernoglandular fistula to the glans, based on Al Ghorab's technique, appeared to provide the best results with a success rate of 52%, i.e. 13/25 cases of priapism correctly followed., Conclusion: Except in the context of sickle-cell anaemia, in which concomitant aetiological treatment can be proposed, only emergency surgery is effective to avoid secondary impotence. The unilateral cavernoglandular shunt is extremely simple and, according to the author, remains the best procedure.

Objective: To assess the efficacy of hypertonic saline for prevention of arterial hypotension in patients undergoing spinal anaesthesia in Niger., Study Design: Prospective, randomized, double-blinded study., Patients: Fifty adults undergoing scheduled surgery under spinal anaesthesia, allocated either to a hypertonic saline group (HSG) or a isotonic saline group (ISG)., Methods: Over the 15 min prior to anaesthesia, 100 mL of 7.5% saline were infused in patients of HSG, and 100 mL of 0.9% saline in those of ISG respectively. Spinal anaesthesia was performed at the L3-L4 or L4-L5 interspace using either lidocaine 5%, or bupivacaine 0.5% or a mixture of both supplemented with fentanyl. Arterial pressure (AP) and heart rate (HR) were measured the day before surgery, prior to and after spinal anaesthesia, thereafter every 5 min over 30 min and every 10 min thereafter until completion of surgery. Hypotension (30% decrease of systolic AP control value was treated with 500 mL of Ringer lactate solution and in case of failure with ephedrine (5-30 mg i.v.). An isolated bradycardia (HR < 60 b.min-1) was treated with atropine (0.5-1 mg i.v.)., Results: Hypotension occurred in two out of 24 patients of the HSG and eight out of 24 of the ISG (P < 0.05). The mean infused volumes of Ringer lactate solution were 387 +/- 218 mL vs 623 +/- 318 mL respectively (P < 0.05). Ephedrine and/or atropine were not required in HSG, however in 7 out of the 24 patients of the ISG. Adverse clinical effects did not occur., Conclusion: Hypertonic saline prevents efficiently the occurrence of hypotension during spinal anaesthesia. Considering its ease of preparation, the lack of adverse effects, in patients not suffering arterial hypertension or congestive heart failure, and low cost, hypertonic saline is well adapted for use in a developing country, if isotonic solutions are not available.

Reported here is our experience with a single or double-face new procedure using a pedicled labial flap for urethral reconstruction in patients treated for extensive urethral damage after obstetrical injury. Between January 1992 to July 1997, 56 cases of urethral damage on African female patients, with an average age of 18 years old, were treated by pedicled labial urethroplasty. This procedure was done by using a single or double-face pedicled flap obtained from the major or minor labia. The flap was then introduced as in a tunnel beneath the vaginal epithelium reaching the damaged urethra. A variety of techniques were proposed: patch for sufficient lengthening (27 cases), tubularized flap allowing complete reconstruction of the urethra (18 cases) and the double-face urethroplasty (11 cases). Good quality urine continence was obtained by using the sub urethral Martius'sling procedure. In 11 cases, we combined the treatment with a colposuspension procedure. The average follow-up was 23 months (ranging from 5 to 47 months). The global success was 82% (52 patients treated). Recovery of normal miction and absence of urinary leak was obtained in 36 cases (69%). While 7 moderate failures occurred (13%), 9 cases were considered complete failures (17%). In view of the high success rate, we consider that the one-stage procedure by the use of a single or double face pedicled labial flap is a choice treatment and highly suitable for the management of extensive urethral cervical damage after obstetrical injury.

Objectives: To present a new technique for urethral reconstruction, the pedicled labial urethroplasty ULP, and describe the results obtained in patients treated for extensive urethral cervical damage after obstetrical injury., Methods: From January 1992 to January 1996, pedicled labial urethroplasty (ULP), was performed on 31 African female patients, with an average age of 18 years old. The ULP was performed by using a pedicled skin flap obtained from the major labia. The pedicled flap is slid beneath the vaginal epithelieum until the damaged urethra is reached. Different techniques are then proposed : partial urethroplasty, by using a patch to lengthen the existing urethra, or complete reconstruction of the urethra by the use of a tubularized flap. Good quality urine continence was obtained by using the sub urethral Martius' sling procedure. In 6 cases, we combined the treatment with a colposuspension procedure. Post operation follow-up were done during a period of 13 months (6 to 32 months)., Results: In 19 out of 27 cases (70%) normal miction was obtained and the urinary leak cured. While 4 results were considered semi-failures, for 4 other cases failure was considered complete., Conclusion: The pedicled labial urethroplasty ULP has shown to be a reliable technique and highly suitable for the management of extensive urethral cervical damage after obstetrical injury.

Destruction of the urethra is the most severe complication of pregnancy-related vesicovaginal fistula. Although uncommon in Europe, pregnancy-related urethral destruction is still observed in Africa. In this study we describe our experience with a new reconstruction technique using a pedunculated skin flap raised from the labia majora. Between January 1992 and June 1996 we treated 35 patients in the Urology Department of Niamey Hospital in Niger. All patients were black. Mean age was 18 years and mean follow-up was 19 months. Two plasty techniques were used, i.e. extension (16 cases) and tubulisation (19 cases). Urinary incontinence was treated using a suburethral loop system created using a fatty flap taken from the labia majora (Martius method). Urethrocervico-suspension of the vagina was necessary in 6 cases. Normal micturition with no leakage was obtained in 24 patients (68.6%) and functional improvement in 6 cases (17.1%) Treatment failed in 5 cases (4.2%). In comparison with previously reported techniques, urethral reconstruction using a pedunculated labial flap and suburethral looping system allows successful treatment of pregnancy-related urethral destruction in 70% of cases. This technique is particularly well suited for use in developing countries where occurrence of this complication is most frequent. However even with the greatest skill, creation of a physiologically perfect closure system is currently impossible.

While this benign tumor of female urethra is relatively rare, reported here are 12 cases of complete mucusa ectropion observed in female black girls. The cases were studied from January 1987 to May 1994, first in Gabon (7 cases) then in Niger (5 cases), all the cases concerned girls below 10 yrs old. The revealing symptom was vulvar bleeding (9 cases) or blood in the urine (2 cases). The remaining case was discovered incidentally. Diagnosis was done at the vue of a pinkish orange soft mass, found in the center of the meatic opening, and which frequently bled on contact. Treatment was exclusively surgical, consisting of a tumoral resection followed by success in all of the cases. This experience while insisting on the rareness of this tumoral illness, strongly suggests a possible predisposition in black girls, where the incidence is underestimated. A more certain diagnosis can be done after analysis of the histological aspects. Although the number of cases reported here is quite limited, the good quality of the results obtained by the treatment demonstrate the value of this surgical management, likewise, certain of its technical details are described in the article. Considering the relative simplicity of the technique, its rapid, long lasting efficiency, and the absence of post operative complications, the author concludes that surgical resection is the treatment of choice for the cure of this benign tumor.

Reported here is our experience with a new procedure using a pedicled labial flap for urethral reconstruction in patients treated for extensive urethral damage after obstetrical injury. From January 1992 to January 1996, 31 cases of urethral damage in African female patients, with an average age of 18-years-old were treated by pedicled labial urethroplasty. This procedure was done by using a pedicled flap obtained from the major labia. The flap was then introduced as in a tunnel beneath the vaginal epithelium reaching the damaged urethra. A variety of techniques were used: the patch to lengthen sufficiency (13 cases), or the tubularized flap following complete reconstruction of the urethra (21 cases). Good quality urine continence was obtained by using the suburethral Martius' sling procedure. In 6 cases, we combined the treatment with a colposuspension procedure. The average follow-up is 14 months (ranging from 6 to 37 months). Recovery of normal micturition with absence of urinary leak was obtained in 21/30 cases (70%). While 5 moderate failures occurred, 4 cases were considered complete failures. In view of the high success rate, the authors consider that the one-stage procedure by the use of a pedicled labial flap is a choice treatment and highly suitable procedure for the management of extensive urethral cervical damage after obstetrical injury.

The author describes a new, simple technique for the treatment of idiopathic hydrocele according to a "fenestration" procedure designed to correct the imbalance of intravaginal hydrostatic exchanges. The operation consists of initially hemming separately the deep fibrous layer and the parietal leaflet of the tunica vaginalis to form the margins of the "window", which is then applied by its fibrous layer to the dartos, continuous with the subcutaneous connective tissue, a site of rich lymphatic drainage. In a series of 108 patients treated by this technique since September 1982, with a follow-up of 6 years, the anatomical and functional results were excellent in 98 cases (90.7%), moderate in 6 cases (5.5%) and poor in 4 cases (3.7%). Compared to classical techniques, the fenestrated opening of the tunica vaginalis with preservation of the tunica vaginalis and limited opening of the serosa, preserves the testicular support and the protective role of the serosa on the testis. Lastly, suture of the margins of the window to the dartos, by facilitating deep lymphatic drainage towards the superficial connective tissue, reconstitutes a physiological equilibrium in the constant exchanges of intravaginal serous fluids. Experience has demonstrated the anatomical and functional efficacy and reliability of this extremely simple procedure, which is essentially indicated in adult patients with idiopathic hydrocele and a healthy tunica vaginalis.

The author describes a new, simple technique for the treatment of idiopathic hydrocele according to a "fenestration" procedure designed to correct the imbalance of intravaginal hydrostatic exchanges. The operation consists of initially hemming separately the deep fibrous layer and the parietal leaflet of the tunica vaginalis to form the margins of the "window", which is then applied by its fibrous layer to the dartos, continuous with the subcutaneous connective tissue, a site of rich lymphatic drainage. In a series of 108 patients treated by this technique since September 1982, with a follow-up of 6 years, the anatomical and functional results were excellent in 98 cases (90.7%), moderate in 6 cases (5.5%) and poor in 4 cases (3.7%). Compared to classical techniques, the fenestrated opening of the tunica vaginalis with preservation of the tunica vaginalis and limited opening of the serosa, preserves the testicular support and the protective role of the serosa on the testis. Lastly, suture of the margins of the window to the dartos, by facilitating deep lymphatic drainage towards the superficial connective tissue, reconstitutes a physiological equilibrium in the constant exchanges of intravaginal serous fluids. Experience has demonstrated the anatomical and functional efficacy and reliability of this extremely simple procedure, which is essentially indicated in adult patients with idiopathic hydrocele and a healthy tunica vaginalis.

The following report describes a personal experience of an extremely rare case of sharp metal foreign bodies discovered in the stomach of a 22 year old adult African in good health. The authors underline the strange character of the case observed, not only because of the patient's perfect tolerance towards the foreign bodies, mainly sharp metal objects, but also considering the very large amount of objects found and it's corresponding weight (1 kg 400 g). Extraction of the foreign bodies was done by gastrotomy. Basing on our experience and following a review of the literature, the authors discuss the different problems which may occur due to the presence of foreign bodies in the gastrointestinal tract.

The author describes 11 cases of prolapse of the urethral meatus observed in black girls between January 1987 and July 1993 first in Gabon (n = 7) and subsequently in Niger (n = 4). All patients were under the age of 10 years. The revealing symptom was vulvar bleeding (n = 8) or blood in urine (n = 2). In the remaining case prolapse was discovered incidentally. In all cases diagnosis was achieved by physical examination revealing a soft mass that bled on contact. Treatment consisted in surgical resection which was always followed by an uneventful recovery. This experience confirms a predisposition to this uncommon disorder in black children in whom the incidence is probably underestimated. The clinical presentation is consistently the same and the mass can be mistaken for a malignant tumor or for injuries related to sexual abuse. The results of this study demonstrate that the treatment of choice for prolapse of the urethra is surgical resection which is simple, safe, and immediately and lastingly effective.

A simple technique is presented for the management of male urethral strictures through one-stage urethroplasty using a mobile pedicled skin flap, be it scrotal or penial skin. The distinctive feature of this technique is the use of a very versatile pedicle, with good blood supply carved out from the subcutaneous cell tissue and the dartos. Depending on the case encountered, our management technique offers a choice of two kinds of plasty: the widening patch, meant to widen the urethral canal, and the tubular graft, which consist in forming a tubular shaped graft in order to replace part or the entire urethra. Since 1984, we have performed this technique 237 times. All of the patients underwent regular check-up, and results, on the anatomical and functional aspect, were very satisfactory. Our experience in the use of this management technique has convinced us of its efficiency and reliability, particularly for infected, fistulated, recurrent and extensive urethral strictures.

A series of 269 patients treated for male urethral stenoses by the same operator using the same management technique from september 1984 to november 1992, inspired the author to describe an original one-stage canal reconstructive technique, using a mobile, nourished pedicled skin graft. The particularity of the technique resides on the large versatility of the pedicle, well vascularised, carved out from the subcutaneous cell tissue and the dartos. The scrotal or penile skin flap remains attached to the mobile pedicle, giving a much wider facility for use, both for penile urethra or perineal urethra repair. The technique allows a choice of two methods of plasty repair: the widening patch which aims at widening the urethral canal, and the tubularized graft, which aims at replacing part or an entire segment of the urethra. Analysis is made on 245 urethroplasties done for the cure of difficult urethral strictures which made up 80% of the total number of cases observed (fistulated in 56 cases, multi-operated in 47 cases), affecting the penile urethra for 47 cases, the pelvian urethra for 159 cases, and the membraneous bulb for 39 cases, associated lesions where found in 15.9% of the patients. 187 patients where treated by the widening patch process whereas 58 underwent neourethral reconstruction by the tubularized graft process. Post operative follow-up for over half of the total number of cases was 4 years. While 224 of the cases treated obtained good results (91.4%), for 15 patients, the results were considered intermediary (6.1%). Immediate cure was obtained for 87.2% of the cases. Lastly, 5 patients presented bad results (2.3%). Discussion and analysis are made on the execution of the technique as well as the post operative complications encountered: infection (8.9%), urine leakage (6.9-0), urethrocele (2%). Experience acquired from the use of this management technique, showed that it is particularly valuable for the cure of wide, recurrent, infected and fistulated stenoses. Its efficiency and reliability underline the value of this technique, whose particularity lies on the wide manageability of the graft, attached to the pedicle. Its particularity also lies on the eclectic choice offered as to the site where the graft is carved off (scrotal or penile) and the appropriate plasty to be used (widening patch or tubular graft), increasing considerably the favorable chances for surgical repair. Finally, the technique's particularity is in its wide indication, independently of the characteristics and the cause of the stenoses.(ABSTRACT TRUNCATED AT 400 WORDS)

Nine recent cases of prolapse of the urethral meatus mucosa in female children treated from january 1987 to october 1992 are reported. Analysed in the article are the principal clinical, etiopathogenic and therapeutic aspects concerning this tumoral formation rarely found in pediatric pathology, yet exceptionally more frequent in African female children. While underlining certain technical details, the author insists on the interest of surgical exerese as a choice treatment for the cure of this benign tumor, because of its technical simplicity, its immediate and durable efficiency, as well as the absence of complications.

Among the treatments of idiopathic hydrocele cutting a window in the tunica vaginalis testis stands out as the choice treatment, the procedure being simple and the results of good quality. In the first stage, the two layers, visceral and parietal, of the tunica are folded separately to form the edges of the window. In the second stage the parietal layer of the window is attached to the dartos which remains united with the underlying subcutaneous layer, forming an excellent tract for lymph drainage. Thus, the anatomical and physiological objectives of the operation are reached: the testicular "cockpit" and the protective function of the tunica vaginalis are preserved. In a series of 83 patients operated upon and followed up for up to 5 years, 9 out of 10 were cured by this method without unwanted sequelae.

A homogeneous series of 261 post-partum urogenital fistulae treated over the last ten years in Africa by the same operator is analysed. Mostly occurring in young, primiparous women in a rural environment, the predominant cause was neglected dystocic delivery in the bush (65.5%). The fistula was traumatic in 27.9% of cases and secondary to hysterectomy in 6.8%. 247 patients underwent surgical repair. The choice of repair procedure, generally performed via the transvaginal route (92.3%), was based on the anatomical classification of the various lesions into three groups of indications: Group I: simple fistulae (98), in which surgical treatment consisted of closing the fistula orifice by simple separate suture of the bladder and vagina, generally followed by success. Group II: more difficult fistulae (109) with severe tissue damage, raising the dual problem of continence and healing and requiring the use of mattressing with a well vascularised adjacent tissue (55 cases). Group III: complicated fistulae (54) with the presence of associated lesions, often requiring multiple urological, genital and intestinal operations as well as complementary plastic techniques (31 cases): double autoplasty of the labia major (17) and adipocutaneous pedicle skin flap (14). 212 of the 261 patients (81.2%) were cured, 23 obtained partial cure (insufficient continence, amenorrhoea, vaginal sclerosis making sexual activity impossible) and there were 26 failures. Urinary diversion was the only solution in 14 patients (7.8%). The objective in surgical correction of urogenital fistulae is twofold: to obtain good quality cure (81.2%), i.e. controlled micturition and a normal, genital, conjugal and social life. overcome the limitations of palliative operations which are always poorly accepted in Africa, at the cost of repeated, staged surgery designed to simplify the lesions in the most severely damaged cases. Prevention programmes designed to eradicate urogenital fistulae, which constitutes a real public health problem in developing countries, will only be made credible by an improvement in the quality of the results obtained in the treatment of this disease.

Personal experience of the treatment of 19 uretero-vaginal fistulae, observed from september 1987 to june 1991 on 17 patients in Africa is described and analysed. Occurring after gynecological or obstetrical surgery, the main cause is hysterectomy (82.3%). Elements for diagnosis were: the appearance of a urine leak, which in most cases came rapidly, echography, and most important, intravenous urography (IVU). Surgical management in all of the cases was mainly aimed at conservation. One end-to-end anastomosis and 18 cuff reimplantations were performed, combined in 2 cases with a sub-mucus tunnel (Politano), in 14 cases combined with a tubular Boari bladder flap (wherein 1 case was bilateral), 3 combined with a bladder psoas hitch and 2 with an isolated ileal graft (ileo-uretero-cystoplasty). One case of vesicouterine fistula and 4 associated vesicovaginal fistulae benefited from a simultaneous surgical operation. In this study of 17 patients treated, except for one patient deceased 14 months following a neoplastic recurrence, the results were excellent. 16 patients were cured. Follow-up extended to more than a year and have shown the perfect conservation of the excretory ducts in all of the cases studied. The cuffed ureterovesical reimplantation combined with a tubular bladder plasty definitively seem to be a most reliable management technique for all ureter injury encountered. While allowing the preservation of the kidney located just below, it has, in particular, prevented ureter stenosis. If the use of simpler methods (psoas bladder hitch) may be sufficient for some cases, the use of more complex methods (ileo-uretero-cystoplasty) for other cases, may be indispensable.

The author reports 230 cases of vesico-vaginal fistula taken from a series of 271 obstetrical fistulae treated by the same operator. The fistula was obstetrical in most cases (93 percent), occurring in young women and primiparas. Associated lesions (urethro-vaginal, recto-vaginal and perineal) were observed in 23.4 percent of the patients. Also studied were 7 pure urethro-vaginal fistulae and 2 urethro-vesical fistulae. Surgical treatment, usually (85.6 percent) through the lower route, consisted of closing the orifice of the fistula by simple separate sutures performed on the bladder and the vagina (Chassar Moir) in 95 cases. A filler tissue, a muscular and fatty pedicle flap (Martius technique), was used in 55 cases. Complementary techniques were considered indispensable in 49 cases. Eighteen patients underwent palliative surgery. Among 230 fistula patients whose postoperative follow-up ranged from 6 months to 1 year, 180 (80 percent) were considered cured (no incontinence and recovery of mictional function), and 17 were considered partially cured (sphincteral leakage during efforts); there were 29 failures. Far from being eradicated in Africa, vesico-vaginal fistulae continue to be one of the major public health problems, with an average annual prevalence of 2 percent. This critical situation is due to different social, economic, traditional and cultural factors which stay firmly inalterable. There is a need for a fistula management strategy based on a classification of the lesions encountered to increase the chances of success. The author describes the main prognostic and therapeutic groups: simple fistulae where success was obtained as a rule (group I, 33 percent of the cases in this series); difficult fistulae (group II, 43 percent), with the dual problem of attaining watertightness and healing, where the support of a well-vascularized filler tissue has proved necessary (Martius); complex fistulae (group III, 23.9 percent), where the associated lesions call for several urological, genital and gastrointestinal operations. Complete anatomical destruction of the urethra, accompanied by sclerous atresia of the genital tract, marks the limit of surgical possibilities of repair, beyond which palliative surgery has to be accepted.

From 1984 through 1990, 41 children with malignant diseases were admitted to the department of general pediatrics of 6,700 patients. The department had 40 beds including ten for neonates. Patients often sought medical advice only late in the disease. In many cases, solutions can be found to the problems raised by the treatment of these patients in a tropical area with no specialized facilities. However, this treatment is a significant burden for both the physicians and the families and new, adapted solutions are needed.

Personal experience of the treatment of 19 ureterovaginal fistulae, observed from september 1987 to june 1991 on 17 patients in Africa is described and analysed. Occurring after gynecological or obstetrical surgery, the main cause is hysterectomy (82.3%). Elements for diagnosis were: the appearance of a urine leak, which in most cases came rapidly, echography, and most important, intravenous urography (IVU). Surgical management in all of the cases was mainly aimed at conservation. One end-to-end anastomosis and 18 cuff reimplantations were performed, combined in 2 cases with a sub-mucus tunnel (Politano), in 14 cases combined with a tubular Boari bladder flap (wherein 1 case was bilateral), 3 combined with a bladder psoas hitch and 2 with an isolated ileal graft (ileo-ureterocystoplasty). One case of vesicouterine fistula and 4 associated vesicovaginal fistulae benefited from a simultaneous surgical operation. In this study of 17 patients treated, except for one patient deceased 14 months following a neoplastic recurrence, the results were excellent. 16 patients were cured. Follow-up extended to more than a year and have shown the perfect conservation of the excretory ducts in all of the cases studied. The cuffed ureterovesical reimplantation combined with a tubular bladder plasty definitively seem to be a most reliable management technique for all ureter injury encountered. While allowing the preservation of the kidney located just below, it has, in particular, prevented ureter stenosis. If the use of simpler methods (psoas bladder hitch) may be sufficient for some cases, the use of more complex method (ileoureterocystoplasty) for other cases, may be indispensable.

The author presents a well experimented technique for male urethral strictures. This plasty uses a mobile skin flap, taken from the scrotum or the penis, and vascularized from the dartos. The technique performed under locoregional anesthesia, offers a choice of two methods of repair: the widening patch and the substitution plasty, a tubularized graft for urethral substitution. Our technique is applicable to all types of stenoses, allowing one stage repair of all urethral strictures, whatever the cause, the site or the length of the stricture. Attention is called for on two technical points: the size of the flap which must be shorter than the urethral tissue loss; careful dissection of the pedicle, whose excellent blood supply, flexibility and mobility will provide a wide maneuverability to the graft. We have performed 237 cases using this technique and have obtained excellent results (96.7) success rate, which have proven long lasting, as follow-up exceeded 7 years for the oldest cases. Although our technique requires meticulous execution, calling for certain precautionary items that the author attempts to emphasize in this article, this widely used technique, because of its reliability and efficiency, may certainly be considered at first, particularly for the repair of difficult, infected, fistulated, and recurrent urethral strictures.

The vesicovaginal fistulae encountered in Africa are a real plague. Their origin is obstetrical as a rule, and they occur in young women, often in primiparas. They are seldom simple as they have been operated repeatedly and involve associated lesions and a large loss of substance, so that they raise complex problems of repair. The experience with the treatment of 230 obstetrical fistulae by the same surgeon in Africa leads the author to describe a repair technique fit for complex fistulae, especially those involving an extensive loss of substance and associated lesions (rectovaginal fistula, perineal destruction). With a low approach, the procedure consists in using a filler tissue, namely a skin flap removed from a greater lip, for which the vasculature is maintained by the preservation of a thick musculous and fatty pedicle, cut from the fibers of the bulbocavernosus muscle. Once sutured around the orifice of the fistula, this graft closes it while fostering its healing. Out of the 14 patients treated with this technique, the results achieved were regarded as good for 10 (72%), including 7 after a first operation and 3 after second surgery. In 9 cases, there were associated lesions, including 5 rectovaginal fistulae and 4 cases of complete tearing of the perineum. We have had 4 failures, including 3 definitive ones, and a partial failure with the persistence of urine incontinence in station due to be destruction of the ureter. When the simpler Martius' procedure (on which ours is patterned) is no longer sufficient, the use of a pedicled skin-fat graft taken from the greater lip allows considerably restricting the indications of palliative surgery. Our technique increases the percentage of success for fistulae regarded as irreparable or after the usual repair procedures have failed.

The author reports his experience and the results of a series of 104 patients suffering from urethral strictures, operated by the same operator from September 1984 to March 1990 and treated by the same surgical method: one stage urethroplasty using a pedicled skin graft. The principles which guided his technique are: complete exposure of the pathological tissue, appropriate size and cut of the graft from a healthy skin zone, careful dissection of the pedicle, elliptical anastomosis at each end and sparing of the corpora cavernosa. Eighty percent of the urethral strictures encountered in the series were complex and situated in various locations: 19 were penile, 55 were bulbar perineal, 30 were bulbar membranous. The urethral strictures were fistulated for 31 cases, multi-operated in 32 case, half of the cases had upstream repercussions from the stenosed zone, and 17 cases had an accompanying pathology. Ninety-one percent of the patients benefited from a patch graft designed to widen the stenosed zone, while a tubular graft was performed for 13 patients to reconstitute a neo-urethra. For a large number of the cases studied, postoperative follow-up was done for two years and for some cases exceeded two years. The operative results were quickly obtained. Good results observed after 3 months generally did not deteriorate thereafter, whereas bad results observed immediately after operation are not definitive since they can be reoperated by the same technique. For 82.7% of the patients, definitive cure was obtained, while 96% of the total number of patients showed considerable improvement. The intermediate results, average (13.6%) and the bad results (3.6%) both show the same inducing factors: past history of localized dilatory manipulations, infected areas but mostly defective application of management techniques. The superiority of this type of surgical technique and its reliability are stressed in the discussion. Also analysed are the following: the difficulty encountered in the management of stenoses of penile sites, the images which appear on the urethrographic controls and the cases where the choice of the tubular graft is appropriate, the problem of draining and the appropriate type and method of draining. Six years of experience in the utilisation of our technique, one-stage urethroplasty using a pedicled skin graft, leads the author to consider the technique as reliable and useful for the management of urethral strictures, especially for difficult multi-operated, infected, fistulated strictures. For these cases, our technique constitutes the best indication.

118 cases of urethral stenosis treated by the same surgeon from September, 1984, to December, 1989, have led the author to describing a one-stage technique for the surgical treatment of urethral stenosis using a widening implant or a pedicled penoscrotal tube. This technique is patterned on ORANDI's and BLANDY's procedures and utilizes a pedicled skin graft taken from a remote, therefore unaffected, site. 87 patients were treated with this procedure for urethral stenosis, often complicated by infection and fistulae, 34 after the failure of previous treatment. With a distance in time exceeding 2 years for most operated cases, the percentage of satisfied patients is of about 95%. The results were estimated according to the quality of urination, to the strength of the urine flow, to micturating and retrograde pyelography and to a fiberendoscopic checkup. In 71 cases (81.6%), the result was rated as good, immediately in 66 cases, after a second operation in 4 and after 3 operations in 1 case. The results were regarded as average in 12 cases (13.5%) and poor in 4 cases (4.6%). Cutaneous urethroplasty using a pedicled skin flap is relatively easy and represents an excellent procedure for the treatment of urethral stenosis owing to the low rate of failure and to the quality of the results obtained. The author stresses the advantages of grafting a well-vascularized skin flap, which is particularly indicated, whatever the site and extent, in cases of urethral stenosis with infection, fistulae or following several operations, the pedicled skin graft being a procedure of choice for all these aggravating factors.

Ten-year experience in Africa with post-delivery fistula therapy, including 39 cases of combined recto-vaginal lesions and 13 cases of laceration of perineum, prompted the author to describe a technique for surgical repair of vesico-rectovaginal fistulas. Inspired from Martius' graft of already proven efficacy in the treatment of complicated vesico-vaginal fistulas, the author used the same procedure on all complex cases of combined recto-vaginal fistulas, i.e., autoplasty of the labium majus. This operation carried out intravaginally consists in utilizing a flap of fatty tissue--either a split graft or one taken separately from each labium majus, placed in contact with the suture lines of the vesical and rectal walls. This dual autoplasty performed optimally in a single step, may however also be carried out separately whenever necessary. Over a period of 4 years (1985-1989), 17 female patients were operated on using this procedure. Treatment of both fistulas, vesico- and recto-vaginal, could be achieved in 11 cases during the same operation, and in 9 cases this involved using a single split graft. 14 women recovered, including 3 who had repeated surgery (2 bladder-derived Martius grafts and one dual autoplasty). The 3 failure cases all had repeated surgery and presented quite important lesions and tissue damage. Failure was considered final in two cases and partial in one case (residual orthostatic urinary incontinence). Dual autoplasty of the labium majus has provided cure to 14 out of 17 surgical patients in one or two operations, that is, 82% of cases, which is an excellent score considering the special difficulty of treatment encountered.

The technique of one stage operations using pedicled skin grafts represent an undeniable progress in the treatment of urethral strictures. The same operator in 1984-1990 performed 104 urethroplasties by using this technique. The proposed technique, originally inspired by Orandi and Blandy was performed as surgical treatment to all of the urethral strictures encountered most often, to broaden a stenosed urethra by the use of the pedicled skin graft as a patch, for other cases, by making a tubular graft meant to replace a segment of the urethra and for 2 extreme cases to replace pratically the entire damaged urethra. The urethral strictures were of different localisations: 19 were penien, 55 were bulbar perineal, 30 were bulbar membranous. The majority of the cases were qualified as "difficult and complex urethral strictures" due to: accompanying infections and iatrogenic diseases, 31 of them were fistular stenosis, 37 were multi-operated, half of the total number of the cases suffered upstream repercussions of the stenosis, and 17 cases had an associated pathology. The author used the pedicled skin graft as a patch to broaden the stenosed urethra on 91 patients, made a tubular graft to replace a segment of the urethra for 11 patients and for 2 extreme cases, to replace practically the entire urethra. Follow-up for half of the cases operated extended up to 2 years, the longest being up to 5 years, showed that 96% of the patients were satisfied. The criteria used for judging the quality of the results were clinical, radiographic and endoscopic.(ABSTRACT TRUNCATED AT 250 WORDS)

Experience in fistula repair of over 190 obstetrical fistulae in Africa, all done by the same operator, have led the authors to describe a technique adequate to repair complex fistulae with a large loss of material, associated with other damages (recto-vaginal fistula, and perineal damage). This operation conducted thru the vaginal route consiste in using a replacement tissue, the pedicle musclefat flap, thick, well vascularized together with a skin graft obtained from the major labia, this is then sutured around the fistuleus gap thus permitting its closure and activating the healing process. This technique was employed on 11 patients, 8 were successfully repaired, 5 of them, after the 1st operation while for 3 of them, the fistula was repaired after the 2nd operation. For 6 cases, other damages were present: 4 recto-vaginal fistulae, 2 cases with the perinea completely damaged. We have met 3 failures, 2 are definitive, where a palliative treatment was administered (uretero-ileo-sigmoidostomie, Bricker) and 1 is considered a partial failure due to the persisting urinary incontinence from urethra damage. Our operational technique, derived from the Martius is useful for such cases wherein the Martius would be insufficient. It increases the chances of successful repair for such fistulae normally considered incurable or after failure met by the use of usual methods of fistula repair. This technique is likewise valuable because it retards the necessity of going to the extremity, which is the palliative operation.

The authors report their surgical experience of complicated stenosis of urethra in the Department of Urology of the Central Hospital of N'Djaména (Tchad) from 1984 to 1987 (July). The surgical treatment was indicated for the complicated cases of stenosis of the urethra, which were obstructed (less than a quarter of the patients who were admitted for urethra stenosis). Before 1984 the only surgical procedure was called "Chemin de fer: a blind pull-through method with a lot of complications. After 1984 the one stage urethroplasties were used in forty four cases: either with a free full thickness skin graft (DEVINE), or with a vascularized flap (BLANDY'S or ORANDI'S technique). The results are studied with a follow up of 18 months. The urethroplasties with a vascularized flap have had less failures (16%) than with a free full thickness skin graft (33%).