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Specialty: Urologic Surgery

Plastibell Circumcision with a Frenulum-Sparing Technique

Plastibell circumcision with frenulum-sparing technique

Ismael Zamilpa MD and Madison Haraway

Introduction: The penile frenulum connects the prepuce to the glans on the underside of the penis. Although the frenulum plays a role in sexual arousal, it can cause painful erections when its length is too short. Conventional neonatal circumcision techniques involve removing the entire foreskin covering the glans, often with division of the frenulum (1). Recently, tissue-sparing approaches have become a matter of interest to reduce the risk of complications, such as bleeding, altered glans sensitivity, and meatal stenosis.

Methods: We describe a frenulum-sparing technique in combination with the Plastibell method. Lysis of preputial adhesions near the frenulum is performed carefully. Selection of an appropriately sized bell is paramount as oversize or undersize can cause bell migration and tissue necrosis (2). The bell should fit snugly over two-thirds of the glans of the penis and fall off spontaneously within 3-7 days.

Results: The patient is a 2-month-old male who presented to Arkansas Children’s Urology with phimosis, which is preputial tightness that prevents foreskin retraction over the glans. He was born at 37 weeks gestation and was not circumcised at birth due to concern for heart murmur. After obtaining cardiac clearance and parental consent, Plastibell circumcision was performed with good preservation of the frenulum, and the patient tolerated the procedure well.

Discussion/conclusions: There is current controversy over the ideal extent of preputial preservation during circumcision. Several publications have highlighted the frenulum’s function in penile erection, owing to its innervation by fine-touch sensory receptors, such as Meissner’s corpuscles (1).

By leaving the frenulum intact, we aim to reduce the risk of complications, particularly meatal stenosis, which is the narrowing of the urethra in circumcised children (3). These children commonly present with symptoms of high-velocity stream (usually upwards), dysuria, and urinary frequency after toilet training.

In conclusion, this tissue-sparing approach potentially reduces complications, improves cosmesis, and retains sensitivity.

References:

Shenoy SP, Marla PK, Sharma P, Bhat N, Rao, AR. Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique. Journal of clinical and diagnostic research. 2015; (9)12: PC01-3. doi:10.7860/JCDR/2015/14972.6860.

Nagdeve NG, Naik H, Bhingare PD,Morey SM. Parental evaluation of postoperative outcome of circumcision with Plastibell or conventional dissection by dorsal slit technique: A randomized controlled trial. Journal of Pediatric Urology. 2013; 9(5): 675-682. doi:10.1016/j.jpurol.2012.08.001.

Abid AF, Hussein NS. Meatal stenosis posttraditional neonatal circumcision-cross-sectional study. Urology annals. 2021; 13(1): 62-66. doi:10.4103/UA.UA_30_20.

Robotic-assisted pyeloplasty for ureteropelvic junction obstruction

Introduction

We present a case of ureteropelvic junction obstruction secondary to aberrant crossing gonadal vessels in a symptomatic 11-year-old female with horseshoe kidney, treated with a robotic-assisted pyeloplasty.

Diagnostic Evaluation

The patient presented with intermittent right-sided flank pain and vomiting. Renal ultrasound showed right-sided hydronephrosis and an abnormal-shaped kidney. MAG-3 renal scan demonstrated decreased function of the right kidney and no drainage. A MR Urogram showed a horseshoe type kidney with malrotation and an anterior dilated renal pelvis.

Surgical Technique

The patient underwent a robotic-assisted dismembered pyeloplasty. Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected from the right ureter and surrounding tissue. The ureter was sharply divided at the level of the ureteropelvic junction and transposed above the crossing vessels. A tension free mucosal to mucosal water-tight anastomosis was performed starting at the apex of the incision. A double-J stent was introduced into the ureter. The remainder of the anastomosis was completed with interrupted sutures. There were no intraoperative or postoperative complications.

Conclusions

Robotic-assisted dismembered pyeloplasty is a safe and effective method for UPJO correction in symptomatic patients with complex renal anatomy.

Laparoscopic Orchiopexy: Use of a Hitch Stitch

Contributors: John Paddack (University of Arkansas for Medical Sciences)

INTRODUCTION AND OBJECTIVES: The percutaneous hitch stitch, a commonly described technique for elevation of the ureteropelvic junction during laparoscopic pyeloplasty, allows for easier dissection and suturing. We have adapted this technique to laparoscopic orchiopexy.

METHODS: The technique described was used for testicular retraction during three consecutive cases of right-sided intraabdominal testicle

RESULTS: There were three cases of non palpable testicle, mean age 31 months (range 22-42). Testicles were all within 3 cm of internal ring on laparoscopy. In all cases, testicle was placed in subdartos pouch in single stage, without division of the spermatic vessels. There were no complications.

CONCLUSIONS: The percutaneous hitch stitch is a simple modification to the traditional laparoscopic orchiopexy. It provides atraumatic retraction of the intraabdominal testicle and facilitates dissection of spermatic vessels from the posterior peritoneum.

DOI: http://dx.doi.org/10.17797/n1nnrufxpt

Laparoscopic Transposition of Lower Pole Crossing Vessels or ‘The Vascular Hitch’

Contributors: John Loomis (Texas A&M Health Science Center)

Purpose: Relief of UPJ obstruction

Instruments: da Vinci Robotic Surgical System

Landmarks: Retropertionem, ureters, kidney, lower pole crossing vessel

Procedure: The laparoscopic transposition of lower pole crossing vessels, or “vascular hitch”, has been successfully used to relieve purely extrinsic ureteropelvic junction obstruction in both adults and children. This case describes the surgical steps for successfully completing this technique. Our patient is a 7 year old female. After induction of general anesthesia, the patient is placed in the right or left lateral decubitus postion (depending on the affected kidney). Access to the abdomen is accomplished with an infraumbilical incision utilizing a Veress needle, with insufflation and saline drop test. A 12mm port is placed in this incision and 2 robotic ports are placed under direct supervision, one in the midline of the suprapubic region and the other in the midline of the epigastric region, with an additional 5mm assistant port. Release of the liver or splenic attachments, with mobilization of the right and left colon, allows for exposure. After doing so, dissection into the retroperitoneum reveals the ureter, which can then be followed to the UPJ and the vessels of interest. Careful dissection of these vessels, the ureter, and lower pole, allows for mobilization of the crossing vessels to a more cranial point on the renal pelvis. “Hitching” of the vessels to this point is accomplished with interrupted 5-0 PDS, and allows for relief of the UPJ obstruction. The lower pole of the kidney is observed throughout to ensure adequate vascularization after hitching of the crossing blood vessels. Closure of the fascia and skin is accomplished in the usual fashion.

Conflict of Interest: None

References: 1. Sakoda A1, Cherian A, Mushtaq I., “Laparoscopic transposition of lower pole crossing vessels (‘vascular hitch’) in pure extrinsic pelvi-ureteric junction (PUJ) obstruction in children.”, BJU Int. 2011 Oct;108(8):1364-1368. http://dx.doi.org/10.1111/j.1464-410X.2011.10657.x

2. Gundeti MS, Reynolds WS, Duffy PG, Mushtaq I. “Further experience with the vascular hitch (laparoscopic transposition of lower pole crossing vessels): an alternate treatment for pediatric ureterovascular ureteropelvic junction obstruction.”, J Urol. 2008 Oct;180:1832-1836. http://dx.doi.org/10.1016/j.juro.2008.05.055

3. Schneider A, Ferreira CG, Delay C, Lacreuse I, Moog R, Becmeur F., “Lower pole vessels in children with pelviureteric junction obstruction: laparoscopic vascular hitch or dismembered pyeloplasty?”, J Pediatric Urol. 2013 Aug;9(4):419-423. http://dx.doi.org/10.1016/j.jpurol.2012.07.005

DOI: http://dx.doi.org/10.17797/maqcmavan0

Robotic Pelvic Lymph Node Dissection

Contributors: Kristina Butler, MD and Javier Magrina, MD

Pelvic lymphadenectomy is part of most gynecologic malignancy staging procedures. Knowledge of the retroperitoneal anatomy is key to safely completing this procedure.

DOI: http://dx.doi.org/10.17797/5xzrp8fuk3

Editor Recruited By: Dennis S. Chi, MD, FACOG, FACS

Robotic Retroperitoneoscopic Partial Nephrectomy: 4-Arm Technique

In this video, we demonstrate the set-up, port configuration, and key steps involved in performing a robotic-assisted retroperitoneoscopic partial nephrectomy.

DOI#: https://doi.org/10.17797/di559dgayo

Open Anterograde Anatomic Radical Retropubic Prostatectomy Technique R2PA2

This video describes step by step a new surgical technique for performing “Open Anterograde Anatomic Radical Retropubic Prostatectomy” (R2PA2) for the treatment of prostate cancer in the same way as performed by the robot, without the need for using the robotic platform, video or any equipment other than those used in the conventional open surgery described by Patrick Walsh in 1983. This prospective and randomized study is registered in the ClinicalTrials.gov identifier number: NCT02687308, and the full description of this technique was published in: Fabricio et al., Surgery Curr Res 2017, 7:5
DOI: 10.4172/2161-1076.1000304.

Authors: Borges Carrerette F. 1, Damião R. 1, Barberan J.P. 1, Mendes Miranda T. 1, Almeida Gazzoli R. 1, Lucio Carrasco C.H. 1, Alves Machado H. 1, Figueiredo Filho R.T. 1, Da Silva E.A.. 1, Costa Lara C. 1, Freire F. 1,

1 Pedro Ernesto University Hospital, Rio de Janeiro State University, Surgery, Urology, Rio de Janeiro, Brazil.

Partial Penectomy due to Penile Calciphylaxis

Partial penectomy is the surgical standard of care for invasive tumors of the mid to distal penis, but is utilized in cases of distal penile calciphylaxis due to pain. Partial Penectomy is advantageous compared to a total penectomy, as the patient is able to urinate in the standing position.

A 51-year-old man on dialysis for end stage renal disease presented to the emergency department with pain that was increasing in severity for over a month at the glans of the penis.  On examination, the glans of the penis was firm with gangrenous necrosis extending distal to the corona, and the urethral meatus was not identified due to the extensive scarring.  A clinical diagnosis of penile calciphylaxis was determined and a Partial Penectomy was subsequently performed.  Calciphylaxis is a rare life-threatening systemic disease in patients with end stage renal disease due to medial calcification and fibrosis of blood vessels leading to infection and gangrene.  The prognosis for penile calciphylaxis tends to be poor with an overall mortality of 64% with a mean time to death of 2.5 months.

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