Horton, Charles E. MD, FACS, FRCS(G) (Hon.); Ruffin, Willcox Jr. MD, FACS; Horton, C E.; Ruffin, W. Jr. Author Information

Duplex kidneys are one of the most common major congenital abnormalities of the urinary tract. The antenatal diagnosis of duplex kidney and its associated ureterocele is infrequent. We report on our experience with the prenatal diagnosis of duplex kidneys in seven fetuses over the past 24 months. In all fetuses, the sagittal length of the duplex kidney was above the 95th centile for gestational age. A 'cyst-like' structure in the upper pole of the duplex kidney and a ureterocele in the urinary bladder were present in all of the seven fetuses. An ipsilateral dilated ureter was seen in six of seven fetuses. Postnatal confirmation of renal duplication anomalies was obtained in all neonates. Increased familiarity of the prenatal sonographer with duplex kidney will allow for its antenatal diagnosis and thus early postnatal treatment.

*Department of Plastic Surgery, Eastern Virginia Medical School, Norfolk, VA †Urology, Eastern Virginia Medical School, Norfolk, VA

Peyronie’s disease is characterized histologically by excessive collagen deposition in the lesion. We examined the collagen types in Peyronie’s disease plaque tissues compared to unaffected tissues from the same patient, other control tissues, and Dupuytren’s contracture. Gel electrophoresis of pepsin-solubilized collagen demonstrated the presence of type I collagen and an increased content of type III collagen in plaque tissue. Increased type III collagen was detected in apparently normal tissue adjacent to the plaque and in Dupuytren’s lesion, confirming previous findings. Although the cause of excessive collagen accumulation of Peyronie’s disease is unknown, the results suggest an imbalance in the regulation of extracellular matrix production leading to pathologic fibrosis.

Patients with ileocecal conduits are at risk for development of late complications. We present 3 patients who had strictures in the ileal portion of the ileocecal conduit, leading to deterioration of the upper urinary tract. The pathogenesis of these strictures appears to result from chronic inflammation. Long-term periodic upper urinary tract screening with ultrasonography is important for early detection of this complication. When new or increasing hydronephrosis is found a loopogram or antegrade pyelogram (if the ileocecal valve is competent) should be performed to evaluate the ileal portion of the ileocecal conduit.

The two inferiorly based rectus abdominis myocutaneous flaps are the most versatile and accessible flaps for high pelvic defects. Their primary contribution is in the obliteration of the pelvic "deadspace." At the present time, these useful flaps are generally considered only for massive defects of the perineum, groin, and pelvis, but improved flap designs will enhance their usefulness for smaller defects.

In 1992 a retrospective review was conducted of 190 patients evaluated and treated for complications of hypospadias surgery during 1979 through 1990 at the Devine Center for Genitourinary Reconstructive Surgery of Sentara Norfolk General Hospital and Children's Hospital of the King's Daughters. We could not contact 13 patients and 8 are awaiting a second stage procedure. Of the 177 patients 167 (94.35%) have had a successful outcome, defined as a controllable urinary stream, functional erection and an acceptable cosmetic appearance, and 2 (1.13%) are considered failures. Details of presenting problems, surgical techniques and recent modifications of these procedures are presented.

Skin grafting remains a primary modality for reconstruction of genitourinary defects. Many of these conditions are discussed and emphasis has been placed on the different indications for full-thickness, split-thickness, and dermal grafts. Complications have been few, and long-term results excellent. This experience has allowed the formulation of a number of surgical principles, which are presented. Refinements in reconstruction are currently being evaluated to obtain the optimal result.

The increasing acceptance of the transsexual patient by society as well as a willingness of insurance companies to compensate for associated surgical procedures will result in an increase in patients presenting for sex reassignment. Data from gender identity centers suggest that the multidisciplinary approach leads to the best therapeutic results. Significant advances in phalloplasty techniques are yielding genitalia with more normal function and appearance.

Inferiorly based rectus abdominis muscle flaps and fascial flaps have been used to construct a firm abdominal wall without hernias and to provide coverage of the bladder, bladder neck, and proximal urethra in the secondary reconstruction of patients with epispadias/exstrophy complex. They have also been used to produce an elevation of the mons area, which is lacking in the typical exstrophy patient. Rectus fascial flaps have been the mainstay of abdominal closure when wide diastasis of the rectal muscles is present and when the lower abdomen lacks fascial support. We are pleased with the results of utilizing either the rectus muscle or rectus fascia in this complex condition. We have been using fascial flaps for over 10 years in our epispadias/exstrophy closures and abdominal wall strengthening procedures. We have been using bone grafts and the rectus muscle for the construction of a mons for the past 5 years. Although the rectus muscle procedure to cover the bladder and the bladder neck has been in use for only 2 years, we have seen patients with incontinence restored to a continent state; these patients have not been plagued with fistula problems when a neourethra has to be constructed to elongate the phallus. Previous attempts at urethral repair in this area have been successful in the main, but an occasional fistula at the junction between the penile skin and the abdominopubic skin has resulted. Since using the rectus muscle to cover the bladder and bladder neck area, we have not had this problem. Patients with epispadias/exstrophy remain such difficult problems that every advance in technique should be used to improve results.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors review four current techniques in hypospadias surgery that yield superior functional and aesthetic results to those obtained in the older, multi-stage repairs. If the repair is performed before the age of memory recall, there will be less psychological trauma to both the patient and his parents.

Full-thickness skin grafts are superior for certain types of vaginal reconstruction. The advantages of this procedure are decreased contraction, reduced time for postoperative stenting, correction at an earlier age, a lower risk of vaginal stenosis, and improved donor site cosmesis. In addition, the patient has the psychological assurance that she is externally normal as she develops through puberty and adulthood.