CHAPTER 10: UROGENITAL 2 Flashcards

Question

What surgical procedures are recommended if urethral plate is inadequate?

Answer 1

3. Urethral Plate Augmentation (Snodgraft) * quilted into dorsal incised defect (instead of re-epithelialisation) * useful if glans more conical, with minimal groove and lacking external rotation of glans wings. TIP in these cases will get meatal stricture therefore graft better 4. Urethral Plate Substitution (Snodgrass) 2 stage * Bracka (1995) - more predictable outcome * Q: does urethral plate need transecting?? * best for significant ventral chordee (because full circumferential substitution urethroplasty is needed) * 1st stage = graft: inner prepuce, buccal mucosa (BXO) - min 15mm diameter, Nesbit procedure if needed or ventral tunica release & TV grafts * 2nd stage 6mths - 10mm = urethra, 5mm de-epithelialised and double-breasted

Answer 2

Immediate * Dorsal penile block / ring block * Urinary diversion - 8-10 Fr children * Ketoconazole 400mg tds to control erections (or cyproterone) * Oxybutynin 1mg tds for bladder spasm * Tegaderm dressing * Double nappy Follow- up * monitor for stenosis, fistulae, cosmetic, urinary stream * f/u 3/12 then 1-4yr, puberty

Answer 3

Amputation distal to meatus! Duplay 1874 - ventral releasing preputial skin flaps & urethral reconstruction * modified by Browne, Cecil Culp, Van der Meulen * Duckett - transverse preputial flap tubed * Harris - split prepuce flap * Elder & Duckett - islanded transposition preputial flap Mattieu 1932 - parameatal (flip) flap * modified by Mustarde, Devine & Horton: v-shaped midline glans flap advanced into meatus Duckett 1981 - MAGPI - meatal advancement and glansplasty (distal & mobile meatus) Snodgrass 1994 - TIP Urethroplasty Bracka 1995 - 2 stage inner prepuce FTSG (other donor sites buccal, bladder mucosa, skin) Turner Warwick 1997 - Urethral dissection and advancement = BEAM Bulbar elongation and anastomotic meatoplasty

Answer 4

EARLY bladder spasm, infection, haematoma, wound dehiscence, oedema, erections LATE * fistulae * stricture * meatal stenosis * UTI, residual urine * infertility / sexual dysfunction * hairy urethra from ventral skin flaps * BXO balanitis xerotic obliterans (lichen sclerosis) → phimosis, stenosis → SCC (chronic)

Answer 5

* Congenital defect * anterior urethra terminates on dorsum of penis * abnormal development of cloacal membrane Epispadias * ♂ - dorsal meatus, short penis, dorsal chordee, divergent corpora * ♀ - short vagina, cleft clitoris and wide labia minora Exstrophy - absent ant wall, eversion of bladder

Answer 6

1. Abnormal fixation of penile skin / Dartos fascia - Nesbit procedure: tunica albuginea plication, excision 2. fibrous remnant of corpus spongiosum causing ventral penile curvature & ventral skin shortage 3. Growth deficiency (not fusion defect), preserved frenulum, dorsal hooding, oblique raphe, terminal meatus, inguinal hernia 4. Upward curvature, thickening & fibrosis dorsal surface of tunica albuginea extending into septum b/t corpora - 4-5th decade, assoc w Dupuytren's

Answer 7

1. Liposuction of fat pad 2. Division of suspensory ligament 3. VY skin advancement from pubic area 4. Dermofat onlay grafts around tunica to increase girth 5. Stretching with weights

Answer 8

* MDT - geneticist, paeds * Counsel parents * Assign sex by 2yrs Causes * Enyzyme deficiencies * Karyotype problems * Congenital adrenocortical hyperplasia * Male pseudohermaphroditism * Mixed gonadal dysgenesis * True hermaphroditism 46XY Androgen insensitivity, 5α reductase def, 17 α hydroxy def 46XX CAH (21 hydroxylase def) 45XO Turners Syndrome 47XXY Klinefelter’s syndrome 45XO/46XY Mixed gonadal dysgenesis 46XY ♀ SRY gene mutation 46XX ♂ SRY gene mutation

Answer 9

1 in 4000 live ♀ births Failure of development of paramesonephric duct Examine = vaginal dimple USS = define kidneys, bladder and uterus, not good for vagina IVP = exclude other UT abnormality EUA - endoscopy and dye Chromosome analysis Treatment * Pedicled Colon → mucous * Dilatation→ Frank 1938, sequential glass or plastic moulds * Local labial flaps Graves 1981 * SSG reconstruction → McIndoe. SSG over a mould, labia minora then oversewn and the mould left in situ for 6 months * FTG over stent * Flaps of labia minora * Regional flaps such as gracilis

Answer 10

 Congenital absence (Rokitansky syndrome)  Segmental (imperforate hymen, long segment atresia)  Congenital malformation → ♀ hypospadias  Surgical ablation → e.g. mid section ex for prolapse  Radionecrosis → hostile tissues  Fistulae → requires flap closure

Answer 11

1. Preferred tissues → vagina, vulva, skin, jejunum 2. Distant flaps o Wei → bilat groin flaps o TRAM→ pedicled through pelvis on IEA o Bowel → but tend to get stenosis at mucocutaneous anastomosis 3. Vulval tissue expansion o Appropriate tissue, no donor defect o 2 stages Radionecrosis o Need to import well vascularised tissue = TRAM, Omentum, Gracilis

Answer 12

Epithelium lined cavity created between prostate/urethra/seminal vesicles and rectum Urethra cut obliquely to prevent stenosis Techniques - Inversion of penis, or penis and scrotum skin flaps, most common, labia from scrotum - SSG (McIndoe) with stents - Perineal / abdo pedicled skin flaps - Intestinal segments Post Op - Regular dilatation , stent, vibrator, intercourse

Answer 13

* Abdo tubes * Local flaps -e.g. - abdominal and pubic * Gracilis * Free radial forearm - various designs, staged urethral recon and glansplasty * Penile implant for erection - need to wrap it in Dacron to allow anchoring to pubis * Testicular implants

Answer 14

1. lining 2. skin 3. dead space 4. herniation 5. anal sphincter 6. stomas

Answer 15

Cordeiro Classification (PRS 2002) IA Ant / lat wall → Singapore FC flap (Wee PRS 1989) IB Post wall → VRAM (vertical skin paddle) IIA Upper 2/3 → rolled VRAM (transverse upper abdo skin paddle) IIB Total → bilateral gracilis

Answer 16

Internal pudendal → perineal → posterior labial (good for perforator flaps)

Answer 17

Singapore flap (Wee PRS 1989) Lotus petal flap (Yii, Niranjan BJPS 1996)