Abstracts presented in the 8th Biennial meeting of Indian Society for Paediatric Urology, Asian Society for Paediatric Urology in association with Paediatric-Urology chapter of & Delhi chapter of IAPS IAPS

Abstracts presented in the 8th Biennial meeting of Indian Society for Paediatric Urology, Asian Society for Paediatric Urology in association with Paediatric-Urology chapter of & Delhi chapter of IAPS IAPSs presented in the 8th Biennial meeting of Indian Society for Paediatric Urology, Asian Society for Paediatric Urology in association with Paediatric-Urology chapter of & Delhi chapter of IAPS IAPS August 29 to 31 , 2013 th st 41 Modified Cantwell–Ransley epispadias repair in children: our experience SM RB MN AK Abhijith, Nerli, Reddy, Guntaka, Pravin Patne, Hiremath MB Department of Urology, Kidney Foundation, KLES KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India, 590010 Purpose: We retrospectively evaluated our experience with modified Cantwell-Ransley epispadias repair at our center to determine the complications and long term results. Materials and Methods: We retrospectively reviewed the case records of 43 male children with a mean age of 7.19 years who underwent primary epispadias repair at our center. The results of epispadias repair were assessed both by physical and endoscopic examination. All children who were old enough to opine as well as all parents/guardians were interviewed during the follow-up visits. Results: Urethrocutaneous fistulae occurred in 17.85% (5/28) children of the classic bladder exstrophy group and in 13.33% (2/15) children with penopubic epispadias. Postoperative cystoscopy done 12 weeks after repair revealed a smooth urethral tube in 81.39% (35/43) of children. With the patient in a standing position, the penis was dangling downwards or in a horizontal position in 88.37% (38) of children, 85% of the patients 18 years of age were satisfied with both the functional and cosmetic outcome, as assessed by -36 and 93.02% (40/43) of the patients were continent SF during the daytime with voided volumes of <200 ml. Conclusions: In our experience, Cantwell-Ransley repair creates a functionally and cosmetically acceptable penis and produces a reliably tubularized neourethra with acceptable complication rates. 42 Acute spontaneous scrotal ecchymosis and swelling in an infant: Manifestation of common acquired bleeding disorder in India Sunita Singh, Jiledar Rawat Department of surgery, , Raipur, Chhattisgarh, India, AIIMS 492099 Aim: Acutely presenting spontaneous scrtotal echymosis with scrotal swelling indicate testicular torsion ( ). Till TT date, Henoch-Schonlein-purpura is well described medical condition which mimickes to . This case describes another TT medical condition (very common in India) which can also lead to unnecessary scrotal exploration. Methods: A 5-month-old, calm, healthy infant presented with swelling and discoloration of right inguino-scrotal region for 12 hours. The baby was exclusively breast feed and delivered at home (no vitamin K prophylaxis). The swelling was of normal temperature, non tender, transilluminant negative, but associated with devitalization of overlying skin. The right testis couldn't be palpated. Left testis and abdomen were within normal limits. The Doppler ultrasonogrphy was inconclusive, and facility of testicular scintigraphy was unavailable. As 12 hours had elapsed, scrotum was explored which suggested B/L Scrotal wall hematoma (right> left), and normal testis. Hematoma was evacuated and devitalized tissue debrided. Family history, personel history and general/systematic examination were not significant. Partial thromboplastin ( ) and PT activated partial thromboplastin time was (a ) raised, PTT while full laboratory workup for cause of bleeding was normal. The history of exclusive breast feeding, raised a PTT and , no vitamin K prophylaxis with bleeding in an PT 68 Urology, Sept.—Dec. , , 2 Journal of Progress in Paediatric 2013 Vol 16 Issue otherwise normal healthy baby pointed towards late-onset Vitamin-K-deficient bleeding disorder ( ) (diagnosis of VKBD exclusion). Result: Vitamin K and fresh frozen plasma were administered, but later baby expired due to development of ARDS. Conclusion: Scrotal Wall hematoma is very rare but essential differential diagnosis of acute scrotum. This case raise the question, whether and a should also be a part and PT PTT parcel of preoperative work up of acute scrotum in infants, especially in developing countries where nutrient deficiency and absence of institutional delivery is still prevalent (cause of late-onset )? VKBD 43 Early results of Exstrophy Bladder repair; experience of 36 cases Dungar Singh Rathore, Rakesh S Joshi, Jaishri Ramji, Mitesh Bachani, Samir Vadher Civil Hospital, B J Medical College, Ahemdabad, Gujarat, India, 380016 Purpose: To share early results of Exstrophy bladder repair at a single institute over five years. Material & Methods: The study includes patients operated for bladder exstrophy repair during the period 2009 – 2013 by local and foreign faculty. The primary operative procedures included Modern staged repair of exstrophy ( ), MSRE complete primary repair of exstrophy ( ) with or without CPRE anterior iliac osteotomy and primary ureterosigmoidostomy. Results: 36 patients (25 boys &11 girls) with classic bladder exstrophy were operated upon. was performed in CPRE 22(61%) patients and in 11(30%) patients whereas 3 MSRE patients underwent primary ureterosigmoidostomy. Anterior iliac osteotomy was performed in 22 patients. Out of 25 patients who have completed all stages in and , MSRE CPRE 12 patients ( 48%) have grade I continence ( dry period 3 hrs. with no stress incontinence ), 8 patients ( 32 % ) are socially continent ( dry during day time but occasional wetting at night) and 4 patients ( 16 % ) are incontinent (continuous wet). 10 of the 12 patients (83%) with grade I continence are from the group. 77 % of patients in whom was CPRE CPRE performed were below 3 years of age and have good continence. The bladder capacitiy of continent patients is 60 – 1 0 0 m l . T h r e e p a t i e n t s u n d e r w e n t p r i m a r y ureterosigmoidostomy due to late presentation and unfavorable bladder anatomy. Five patients who were previously operated underwent ureterosigmoidostomy due to poor bladder growth. Except for one death, we have not encountered any major complications. Conclusion: Bladder Exstrophy is one of the most complex paediatric urological anomaly which needs to be managed at tertiary care center by dedicated and skilled expertise with optimal post operative care. Early results show that although both and have favorable results in skilled CPRE MSRE hands, younger patients do better with as far as urinary CPRE continence is concerned. 44 Experience with transpubic approach for bladder neck reconstruction and innervations preserving sphincteroplasty in female epispadias Vijaymahantesh S Kunnur, Kureel, Archika Gupta, SN Intezar Ahmed, Sunita Singh Department of P ediatric Surgery, King George's Medical a University, Lucknow, Uttar Pradesh, India, 226003 Purpose: This paper reports the transpubic approach to bladderneck reconstruction with external urethral sphincter reconstruction in female epispadias, as the methods of reconstruction of female epispadias described in literature lack adequate exposure of bladderneck and are silent about the external urethral sphincter reconstruction. Method: From 2005 to 2011, four patients of female epispadias presented to our centre aged 8 to 17 years. Only 1 patient aged 8 years presented with correct preoperative diagnosis, remaining 3 patients aged 15 to 17 years presented with incontinence, diagnosed on examination to be having incontinent epispadias. The bladder capacity was adequate in 3 but less than 80ml in 1 patient. Through circumclitoral incision, the root of corpora and the contracting external urethral sphincter cephalad to bulbospongiosus muscle was exposed. Through the transpubic approach, intersymphyseal band was released and the bladder cavity with trigone was exposed. Anatomical bladder neck reconstruction, innervations preserving sphincteroplasty and transvaginal sling of anterior rectus sheath strip was performed. Corporoplasty, clitoroplasty, approximation of pubis and reconstruction of mons pubis completed the repair. Aesthetic appearance on scale of 1 to 10 and the continence measured as 3 hours dry interval were the outcome measurement. Journal of Progress in Paediatric 2013 Vol 16 Issue Urology, Sept.—Dec. , , 2 69 Result: On 2 years follow up, 3 patients with adequate bladder capacity had more than 3 hours dry interval without history of night wetting and no upper tract dilatation. One patint with less than 80ml bladder capacity is dry only for 90 minutes on oxybutynin with history of night wetting. Urodynamic study revealed hyperactive bladder in this case. Aesthetic appearance after repair scored 9 in all cases. Conclusion: Transpubic approach provides excellent exposure for precise bladderneck reconstruction with innervations preserving sphincteroplasty and aesthetic reconstruction of external genitalia in female epispadias. 45 Intersymphyseal band in Exstrophy Bladder: A histological study to ascertain its structure of origin Prabudh Goel, Kureel SN Department of P ediatric Surgery, King George's Medical a University, Lucknow, Uttar Pradesh, India, 226003 Purpose: The aim of the study is to analyze the histology of the intersymphyseal band to ascertain its structure of origin and to identify the presence of any elements in the intersymphyseal bands which could be assimilated into sphincteric structures during surgical correction. Methods: The study was a prospective study conducted over a period of 6 months from April 2012 to September 2012 at our centre. Biopsies were taken from the intersymphyseal bands from each side from each patient of classic bladder exstrophy undergoing bladder closure. Biopsy specimens were analyzed in the Department of Pathology by H&E staining and immunohistochemistry with desmin and αsmooth muscle actin. Results: Seven patients were included in the study and 13 specimens were analyzed, right sided biopsy in one patient could not be processed. H&E staining of 12 specimens showed the presence of abundant fibro-collagenous tissue with interspersed smooth muscle fibres. Immunostaining with desmin and α-smooth muscle actin was also consistent with the above findings. One specimen from left side of a 17 year old male patient showed presence of skeletal muscle fibres, which was an exception. Probably, the skeletal muscle fibres were from a well developed pubo-urethralis muscle in that patient. Conclusions: The histology of the intersymphyseal band shows the presence of abundant fibro-collagenous tissue with interspersed smooth muscle fibres. The intersymphyseal band is not consistent with laid open bladder neck or striated urethral sphincter, but may be a condensation of the urogenital diaphragm. Wrapping of the intersymphyseal band over the bladder neck region at the time of exstrophy repair may serve to support the repair but it definitely will not add to the continence mechanism. 46 Reviving the Mathieu's repair with the symbiotic effect of the Snodgrass incision for distal hypospadias Shilpa Sharma Department of P ediatric Surgery, , New Delhi, Delhi, a AIIMS India, 110029 Purpose: The two methods of single stage urethroplasty for distal hypospadias Mathieu-Mullen's procedure and Snodgrass Belman Procedure have often been compared. Here the experience of combining both the techniques is described. Methods: From February 2009 to March 2012, 56 prospective patients of distal hypospadias were repaired with a modified approach incorporating incisions of Mathieu (parameatal U shaped flap) and Snodgrass (Urethral plate incision) urethroplasty A U shaped flap was planned. Native urethra was also lifted with the flap. Penile shaft was degloved after circumcoronal incision. Two limbs of U shaped flap were extended upto proposed site of neo meatus, parallel to urethral plate with a midline epithelial incision at site of shallow groove. Glanular wings were raised sufficient to cover neourethra without tension after a second layer dartos cover. Operative time, early and late postoperative complications were noted. Results: The median age at repair was 5.4 years (1.5-11 years). The urethra was deficient for a length of 1.2 – 2.7 cm. Urethral plate width was 2-8 mm (mean 4.4). Minimal skin chordee in 9 cases was released by degloving. Operating time ranged from 30 to 70 mins. Darkening of skin was seen in 3 cases that resolved spontaneously. At follow up of 13 50 months, there was only one case of delayed infective dehiscence, repaired by same procedure, 11 months later. All cases healed well with good cosmetic outcome with no stenosis or urethral stricture. All patients passed urine in good thick stream. 70 Urology, Sept.—Dec. , , 2 Journal of Progress in Paediatric 2013 Vol 16 Issue Conclusions: This technique for urethroplasty provides a deeper navicular fossa, good caliber of urethral tube and places the urethra deep into the glans resulting in good cosmetic and functional outcome 47 New urinary symptoms post-urethroplastycomplications or pre-existing pathology? Nidhi Sugandhi, Anjan Dhua, Amita Sen Dr. Ram Manohar Lohia Hospital and , New Delhi, PGIMER Delhi, India, 110070 Introduction: Hypospadias is one of the most common congenital anomalies of the urinary system. It is not usually thought to be associated with upper tract anomalies. However, in some cases there may be associated undiscovered upper tract anomalies which can complicate the post-operative period and cause anxiety to both the patient and surgeon unless a high index of suspicion is entertained. Material and Methods: Case report of a child operated for hypospadias subsequently presenting with recurrent s UTI necess i ta t ing mult iple hospi ta l admissions and investigations. Results: A 3 year old boy presented with distal penile hypospadias with no other associated urinary complaints such as poor urinary stream, retention, dribbling or dysuria. He underwent an uncomplicated urethroplasty. After 6m TIP of asymptomatic post-op period, the child started suffering from repeated s, episodes of retention and poor stream. UTI Post-urethroplasty stricture was suspected but a retrograde urethrogram, cystoscopy and urethral calibration ruled out the possibility. Upper tract evaluation was then undertaken. Ultrasonography and micturating cystourethrogram were finally able to show a thick walled trabeculated bladder with bilateral dilated and tortuous ureters and bilateral grade 5 VUR. There was associated spina bifida confirming the pathology to be of neurogenic origin. The child underwent bilateral cross-trigonal ureteric reimplantation for the high grade reflux. Post reimplantation the patient remains well at 4 months follow -up with resolution of recurrent s and UTI obstructive uropathy. Conclusion: Pre-existing undiscovered anomalies may complicate the course of a simple case of hypospadias . Thorough investigations, high index of suspicion and preparedness for dealing with unexpected complications are required. If facilities permit, a screening ultrasound before undertaking even a simple hypospadias surgery can detect associated upper tract anomalies and thus circumvent unnecessary anxiety and investigations post-urethroplasty. 48 A novel technique of posterior urethral lengthening Ms Ansari Department of Urology and Renal transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, , India, 226014 UP Objective: To describe the technique of posterior urethral lengthening, double breast wrap around by detrusor muscle and cross tensor fascia lata sling to achieve continence in cases of incompetent bladder neck and urinary incontinence. Materials and Method: We used the technique of posterior urethral lengthening, double breast wrap around by denuded detrusor muscle and cross tensor fascia lata sling to achieve continence in cases urinary incontinence with incompetent bladder neck. Results: Of the 10 patients operated 6 were males and 4 females with the age range from 4 -18 years [mean 7.8]. Of these 4 were of exstrophy epispadias, 2 epispadias, 1 neurogenic bladder and 3 bilateral ectopic ureters. Six patients underwent simultaneous augmentation cystoplasty, done when maximum bladder capacity was less than 60% for the age of the child. Mean follow up was 1.6 yrs [range 0.6 to 3 years]. Eight [80%] patients are continent. Of these 7 are continent day and night, while 1 has leakage of urine at night. Six are voiding voluntarily and 2 require self intermittent catherization through Mitrofanoff. Two of the failed patients belonged to neurogenic group 1, and bilateral ectopic ureter 1. Conclusions: Posterior urethral lengthening, detrusor double breast wrap and cross tensor fascia lata sling is a safe and effective method to achieve continence in cases of incontinence associated with incompetent bladder neck. 49 Congenital prepubic sinus Flavia D'souza, Pradnya Bendre, R Mukund, Parag Karkera Bai Jerbai Hospital for Children, Mumbai, Maharashtra, India, 400012 Journal of Progress in Paediatric 2013 Vol 16 Issue Urology, Sept.—Dec. , , 2 71 Purpose: to present rare case of congenital prepubic sinus with review of literature Text of Abstract: Congenital prepubic sinus ( ) is an CPS extremely rare congenital anomaly with only 30 cases reported so far. We herein add to literature one more such rare case and discuss our findings and review of literature. 8 month old boy presented with history of watery discharge from the prepubic region since birth. He was investigated. Sinogram revealed a tract from the skin till the pubic symphysis. After total resection of the sinus, histological examination revealed that the tract was lined with transitional epithelium proximally and squamous epithelium distally. These findings strengthen the theory that is a variant CPS form of dorsal urethral duplication. Conclusion: congenital prepubic sinus though rare can be successfully managed by simple surgical excision 50 Penile growth in response to hormone treatment in children with micropenis Prabhnoor Sing, Nerli, Reddy, Guntaka, Pravin RB MN AK Patne, Hiremath MB Department of Urology, Kidney Foundation, KLES KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India, 590010 Purpose: Micropenis is defined as a stretched penile length 2.5 standard deviations less than the mean for age without the presence of any other penile anomalies, such as hypospadias. The term refers to a specific disorder that has a known set of causative factors and defined treatment modalities. The purpose of this study was to determine the effect of hormonal therapy on the gonadal response and penile growth in children who presented with micropenis. Materials and Methods: Children (<18 years) who met the criteria for micropenis were included in this study. Children more than 11 years old were treated using a standard protocol of 1,500 to 2,000 human chorionic gonadotrophin IU administrated intramuscularly, once per week, for 6 weeks. Children less than 11 years old were treated with parenteral testosterone enanthate 25 mg once a month for 3 months. Response was evaluated in terms of change in testosterone levels and size of penis. Results: Serum testosterone levels at baseline and after 8 weeks of hormonal treatment were <20 and 449.4 ng/mL, respectively (P < 0.0001) in all children more than 11 years old. Stretched penile length after hormonal treatment increased from 15.54 to 37.18 mm in children less than 11 years old and from 26.42 to 64.28 mm in children more than 11 years old (P < 0.001). Conclusions: Management of isolated micropenis revolves around testosterone (direct administration or encouraging the patient's body to make its own), and results with respect to increase in penile length are promising. 51 Study of anatomy of arrangement of fascial planes and course of superficial vessels in epispadiac penis Archika Gupta , Kureel , Chandra Shekhar Singh , Manoj 1 1 1 SN Kumar Department of Surgery, Medical College, Agra Uttar SN Pradesh, India, 282002 Department of Radiodiagnosis, Medical University, KG Lucknow, India, 226003 Purpose: To study anatomic arrangement of the fascial planes and superficial vessels in epispadiac penis to enhance the precision in the surgical technique of epispadias repair. Materials & Methods: Total six exstrophy-epispadias patients (4 classic exstrophy and 2 incontinent epispadias), who presented beyond adolescence without previous intervention, were selected for the study over the duration of 4-years. Magnetic resonance imaging ( ) of the MRI epispadiac penises were done with 1.5-T scanner and MRI compatible 3-inch surface coil, using fast spin echo and contrast-enhanced T1and T2-weighted sequences. The imaging findings were also verified during the subsequent reconstructive surgery. Results: A clear demarcation of the skin, dartos fascia, Buck's fascia, corpora cavernosa, corpus spongiosum,and the intraglanular planes were seen with the course of the blood vessels. The penile dartos received axial pattern vessels from the external pudendal vessels, with collateral branches from the dorsal penile artery as transverse branches at the shaft of the penis and preputial branches at the coronal sulcus. Buck's fascia sleeved the corpora cavernosa, enveloped the neurovascular bundle, and fused with the corpus spongiosum without crossing the dorsal midline. Intraglanular extension of Buck's fascia separated the intraglanular vascular arcade 72 Urology, Sept.—Dec. , , 2 Journal of Progress in Paediatric 2013 Vol 16 Issue from the tip of the corpora. Conclusion: Parallel to the ventral midline, axial pattern vessels to the dartos course in the skin-dartos complex, with relative avascularity at the midline. The preputial dartos receives an additional blood supply from the terminal penile arteries. The fact can be used for designing the skin coverage during epispadias repair. The subfascial plane between the tip of the corpora and the intraglanular vascular arcade and the plane of cleavage between the cavernosa-spongiosum interface can be used for efficient corporo-urethral separation. 52 Cloacal malformation: our experience Sudipta Sen Department of Paediatric Surgery, Vellore, Tamilnadu, CMC India, 632004 Purpose: To analyse retrospectively the experience with cloacal malformations with focus on their presentations and approach to management. Materials and methods: This study is a retrospective analysis of available medical and surgical records of children who underwent treatment for cloacal malformations during the period from 2004 to 2013 at our centre. Results: 27 patients were analysed with age ranging from at birth to 18 years. 10 patients were presented primarily with cloaca while remaining 17 referred from elsewhere with diversion procedures and/or attempted repairs. While anomalies at ano-genito-urinary-sacral regions were common and are the main subject matter in this presentation, anomalies distant to the region were not common except for one case of esophageal atresia with tracheoesophageal fistula. Anomalies in the region of interest included pouch colon(8), hindgut duplication (1), unfused mullerian system with /without hematometra in one or both mullerian system(6), solitary kidney(1), ectopic (1), Fused kidney(1), absent or redimentary bladder (2), sacral agenesis+/caudal regression (4) and spinal dysraphism (1). Fecal diverting stoma had been performed in all but 5 patients. Bowel pull through had been performed either by us or elsewhere in all patients by variety of methods including anterior sagittal, posterior sagittal, abdominoperineal, laparoscopic assisted and total urogenital mobilization. Additional surgery related to the bowel management included Malone's procedure, resection of pouch colon, tapering of pouch colon and colocolic anastomosis for duplicated colon. 9 children presented with urinary tract problems of incontinence and/ or retention with hydroureteronephrosis, they were managed by a variety of methods including via mitrafanoff, bladder neck CIC division and bladder augmentation/ substitution. 2 patients presented with symptomatic hematometra and underwent excision of atretic hemiuterus with abdominoperineal vaginal pull through (1) and colovaginoplasty (1). Another patient had undergone vaginostomy for urocolpos in infancy which continued to leak urine in pubertal life along with menstrual flow through the stoma, she underwent ileovaginoplasty. Prepubertal patients are awaiting vaginoplasty to be done at puberty (except 2 patients). Conclusion: Management of cloaca needs complex reconstructions and we have adopted a need based approach to the alimentary, genital and urinary tracts in these patients rather than a one stage total correction. 53 Penile length in hypospadias Narinder Teckchandani, Minu Bajpai, Shasanka S Panda Department of Paediatric Surgery, , New Delhi, Delhi, AIIMS India, 110029 Background: Cosmesis is as important in hypospadias surgery as the functional outcomes. A prime cosmetic factor affecting long-term patient satisfaction after hypospadias repair is penile length. This study was aimed to compare the penile length in hypospadias with the penile length-for-age nomogram in prepubertal Indian boys. Patients and methods: After approval of the institute ethics committee, 20 consecutive boys, with genitalia-unrelated surgical problems, in following ten age slots: 0-1yr, 1-2yrs, 23yrs, 3-4yrs, 4-5yrs, 5-6yrs, 6-7yrs, 7-8yrs, 8-9yrs, 9-10yrs, underwent penile length measurement to establish the penile length–for age nomogram. 100 preop hypospadias patients upto 10 years age were categorized as distal, mid or proximal , hypospadias. 30 hypospadias patients upto 10 years age, who were more than two years post-chordee-correction were included.15 patients in the age group of 8-10 years, who were more than two years post-chordee-correction were categorized according to their age at chordee correction (< 2 years, 2-5 years and > 5 years). Their stretched penile lengths were recorded. Journal of Progress in Paediatric 2013 Vol 16 Issue Urology, Sept.—Dec. , , 2 73 Results and Conclusions: Penile length in hypospadias is within the normal range for age. Until 2 years of age, the severity of hypospadias and presence of chordee do not seem to affect the . Chordee in proximal hypospadias seems to SPL affect the penile growth beyond 2 years of age. There exists a possibility of catch-up penile growth after chordee correction in proximal hypospadias. Age at chordee correction affects the potential for penile growth in proximal hypospadias. Thus, chordee correction should be done before 2 years of