Surgery to the external genitalia
Transcrição
Surgery to the external genitalia
Surgery to the external genitalia Antonio Macedo Jr and Miguel Srougi Surgery to the external genitalia is one of the most challenging chapters of reconstructive urology, due to the need to correct complex problems such as hypospadias or epispadias (isolated or associated to exstrophies). Although this specialty has shown a continuous technical advancement there is no consensus as to the most efficient surgical procedure or to the best strategy to treat these pathologies. The papers reviewed here reflect these statements and reinforce the idea that surgeons' good sense, allied with their experience in the area, are the factors that define the choice of the ideal surgical option for each case. Curr Opin Urol 11:585±590. # 2001 Lippincott Williams & Wilkins. Department of Urology, Federal University of SaÄo Paulo, SaÄo Paulo, Brazil Correspondence to Antonio Macedo Jr MD, Federal University of SaÄo Paulo, Rua Maestro Cardim, 560/cj 215, 01323-000 SaÄo Paulo, Brazil E-mail: [email protected] Current Opinion in Urology 2001, 11:585±590 Abbreviation ICSI intracytoplasmic sperm injection # 2001 Lippincott Williams & Wilkins 0963-0643 Introduction External genitalia surgery is used for reconstructive treatment of a group of problems, encompassing hypospadias, epispadias with or without exstrophy, and intersex anomalies, and also for a group of day-today problems such as circumcision and testicular pathologies. While in the second group there are few technical divergences concerning the surgery itself, in the ®rst group there is a great disparity in the management, depending on the occasion and the most appropriate technique for the correction. For example, there are at least 300 different techniques to treat hypospadias and exstrophy; epispadias can be treated in several stages or, as suggested recently, in a single stage. The objective of this paper is to focus on recent publications in this area in order to obtain a better understanding of the more accepted tendencies in external genitalia pathologies, but without the claim of de®ning the best management. Circumcision Neonatal circumcision is a routine procedure in the USA, as opposed to the situation in Europe. In a series of 129 boys forwarded consecutively for circumcision during a period of 3 years [1], the authors found 30 (23%) with inconspicuous penis, a designation that includes situations such as buried penis, trapped penis, concealed penis and micropenis. According to the authors, just as in hypospadias and epispadias, the inconspicuous penis must be considered a contraindication for neonatal circumcision. The treatment of penile adhesions after circumcision is unde®ned due to the possibility of spontaneous resolution. The authors evaluated 254 circumcised boys, classifying the degree of adherence and the age of presentation into four groups: less than 12 months, between 13 and 60 months, between 61 and 108 months and more than 109 months. The authors found adherence rates of 71, 28, 8 and 2%, respectively. They concluded that there is no need for manual lysis of these adherences [2]. Anesthetic blockades with or without vasoconstrictors are used commonly in genital surgery. A case of accidental injection of epinephrine leading to intense vasoconstriction of the penile skin was treated successfully with a series of subcutaneous injections of phentolamine, in doses of 0.1±0.2 mg/kg [3]. The authors recommend this treatment in cases of signi®cant ischemia after an accidental injection of epinephrine. 585 586 Paediatric urology Circumcision is the classical treatment of phimosis. When foreskin preservation is desired, an incision only in the ventral face of the prepuce and not in the dorsal face allows the release of the obstruction and the maintenance of genital esthetics indistinguishable from the non-circumcised penis [4]. Neonatal circumcision, lysis of labial adhesions and meatotomy are procedures performed with local anesthesia. The parent perception of discomfort was evaluated in the parents of 99 children submitted for these procedures, and was classi®ed as light, moderate or severe [5]. The authors concluded that parent perception of discomfort was greater when the parents followed the procedures of meatotomy and lysis of labial adhesions than in circumcision. However, 96% of the parents were satis®ed with not having chosen general anesthesia [5]. Undescended testes The non-palpable testis is ideally diagnosed by laparoscopy due to the high accuracy of this method, reported at between 95 and 100%. The trocar access is the critical point of laparoscopy and complications are calculated to occur in 7.8% with the use of the Veress needle and in 3.8% with an open incision. In obese patients this procedure can be even more dif®cult. de Filippo et al. [6] described two cases of non-palpable testis in obese children, identi®ed in the inguinal region with magnetic resonance imaging, dismissing the use of laparoscopy. The conclusion of their study was that, in the obese patients, magnetic resonance imaging should be performed as routine before laparoscopy [6]. In a Dutch study [7], the authors reported on a case where a small abdominal testis was found by laparoscopy, but it was noticed that the vas deferens, with small caliber vessels, was entering the internal ring. At inguinal exploration, the vessels and the vas deferens were found to end in a tiny round nubbin ®rmly attached to the upper scrotum by the gubernaculum. The authors concluded that, if only an inguinal exploration was performed, the intra-abdominal testis would have been left in the peritoneal cavity, with the known risks of malignancy, thus reinforcing the systematic indication of laparoscopy in non-palpable testes. The classical open exploration of the inguinal testis mandates a second incision to ®x the testis in the scrotum. Forty-eight consecutive patients (60 orchiopexies) with testis below the external ring were treated by the Bianchi single high scrotal incision technique in both primary and secondary surgeries. The conversion into inguinal incision was needed in only four cases and all the others were treated adequately by a high scrotal incision. One of the authors observed that the initial identi®cation of the testis, in cases undergoing an operation, can be even easier due to access without previous inguinal incision ®brosis [8]. Undescended testis and ectopic testis are situations caused by a different physiopathologic mechanism, although the testis has an anomalous position in both cases; in the ectopic testis the abnormality of terminal testicular descent happens after the passage of the external inguinal ring. The ectopic testis can be found in the Denis Browne super®cial inguinal pouch, the perineum or the penis, or lateral to the scrotum, the pubic region, the thigh or the contralateral scrotum. If this ®nal incidence of ectopic testis occurs due to a mechanical obstruction and not due to endocrinopathy, it would be expected that the total germ cell count and testicular volume would be greater than in the undescended testis. Furthermore, a lower rate of patent processus vaginalis and malformed epididymides would be present in patients with an ectopic testis rather than with an undescended testis. Hutcheson et al. [9] compared the pathological ®ndings in 17 cases of ectopic testis, which were not in the Denis Browne super®cial inguinal pouch, with those of age-matched patients with unilateral undescended testis. The authors found no difference in total germ cell count, testicular volume, processus vaginalis patency or epididymal abnormalities. The conclusion of this study was that boys with an ectopic testis also showed an increased incidence of subfertility and testicular malignancy. The initial hormonal treatment of cryptorchidism with human chorionic gonadotropin or gonadotropin releasing hormone has a success rate of around 20% and allows the distinction of truly undescended from retractile testes. The knowledge that the subfertility, translated by a decrease in the number of spermatogonia and gonocytes found in distopic testes, might be reduced by an early surgical intervention has anticipated the age recommendation for orchiopexy. The unphysiological exposure to follicle-stimulating hormone, luteinizing hormone and testosterone, due to human chorionic gonadotropin or gonadotropin releasing hormone therapy, may harm 1- to 3-year-old boys with cryptorchidism. Cortes et al. [10] measured the number of spermatogonia per tubule at orchiopexy in 72 consecutive boys with cryptorchidism who underwent simultaneous testicular biopsy. Among these patients, 27 had received previous hormone treatment. In these patients, the authors found a lower number of spermatogonia per tubule than in those treated only by surgery and suggested that in 1- to 3year-old boys with chryptorchidism the gonadotropic releasing hormone or human chorionic gonadotropin, given for testicular descent, may suppress the number of germ cells. Surgery to the external genitalia Macedo and Srougi 587 Hypospadias The etiology of hypospadias is still the object of discussion. The implied factors include testosterone biosynthesis defects, 5 alpha-reductase type 2 mutations, androgen receptor mutations, in-vitro fertilization (progesterone administration or endocrine abnormalities associated with infertility), and environmental agents that can disrupt the male sex hormone axis. Two papers have been published reviewing the etiology of hypospadias [11,12 . .]. Baskin [12 . .] reviewed the current scienti®c reports on the etiology of hypospadias and presented the embryology and possible mechanisms of urethral and penile formation. The author proposed a new theory of glandular human urethral development via endodermal cellular differentiation to replace the classic explanation of ectodermal intrusion. A Finnish epidemiological study was conducted to de®ne the prevalence of hypospadias in the country. The authors of this study found 28.1 surgically treated patients per 10 000 male live births [13]. With the development of conjugal infertility treatment techniques, the last decade has shown an increase in the number of births after intracytoplasmic sperm injection (ICSI). An interesting Swedish study was conducted to determine the incidence of congenital malformations in children born after ICSI [14 .]. The medical records of 1139 infants were reviewed: 736 singletons, 200 sets of twins and one set of triplets. The total number of infants with an identi®ed anomaly was 87 (7.6%), 40 of which were minor. The incidence of malformations in children born after ICSI was also compared with all births in Sweden using data from the Swedish Medical Birth Registry and the Registry of Congenital Malformations. The only speci®c malformation that was found to occur in excess in children born after ICSI was hypospadias (relative risk 3.0, 95% con®dence interval 1.09±6.50), which may be related to paternal subfertility [14 .]. The use of the urethral plate has become popular in the last 10 years, as has the perception that techniques such as onlay preputial ¯ap, the glans approximation procedure and, more recently, the tubularized incised plate repair are associated with a lower rate of complications. The presence of a marked ventral curvature is one of the factors that can de®ne the surgical correction in one or two stages, as in the less severe cases a Nesbit dorsal plication recti®es the penis and allows use of the urethral plate in urethroplasty. Despite the growing clinical use of the urethral plate, its histological characteristics have not been well described. Two important studies [15,16] have been published emphasizing the urethral plate anatomy. The San Francisco group [15] evaluated the urethral plate of a newborn with hypospadias and of two fetuses with distal hypospadias, with 30 normal fetal penises as controls. The specimens were embedded in paraf®n and serially sectioned (6 mm) after formalin ®xation. Hematoxylin and eosin staining as well as immunohistochemical evaluation of the nerves, smooth muscles, blood vessels and epithelium were performed. According to the authors' ®ndings, the urethral plate is well vascularized, has a rich nerve supply and an extensive muscular and connective tissue backing, supporting its use for hypospadias reconstruction. In a similar study [16], subepithelial biopsies of the urethral plate were carried out in 17 boys, ®ve of them with ventral penile curvature. All the biopsies showed well vascularized connective tissue comprised of smooth muscle and collagen. There was no evidence of ®brous bands or dysplastic tissue. These histological ®ndings support reasonable efforts to preserve the urethral plate, even in cases of mild to moderate penile curvature. The anatomy of the neurovascular bundle is another important feature in the performance of a dorsal plication to correct penile curvature. Historical experience suggests that mobilization of the neurovascular bundle is anatomically possible. The perforating branches into the corporal bodies have been studied in 35 normal human fetal penile specimens, gestational age 8±35 weeks, and three hypospadic specimens, 33±41 weeks of gestation. Baskin et al. [17] concluded that perforating branches from the dorsal lateral neurovascular bundles do not exist, based on serial step sectioning and microscopic examination of male genital specimens. It is possible surgically to elevate the neurovascular bundle, but the dissection needs to remain directly on top of the tunica albuginea to prevent nerve injury. Small perforating branches into the urethral spongiosum may be injured with unknown signi®cance. The authors continued, however, to advocate plication in the nerve-free zone at the 12 o'clock position for correction of penile curvature [17]. The Koyanagi technique for hypospadias repair is based on parameatal ¯aps that extend distally around the distal shaft to incorporate the inner layer of the prepuce. A reoperation rate as high as 50% has limited its use to date. The Columbia group [18] reported their modi®cation of the technique, attempting to preserve the blood supply to the ¯aps and to improve results. The authors treated 20 boys with proximal hypospadias and found four urethrocutaneous ®stulas (20%) with a mean followup of 34 months. The preputial island ¯ap onlay technique continues to be one of the most popular techniques for the treatment of hypospadias due to the excellent cosmetic results and acceptable complication rates. The double onlay preputial ¯ap is an alternative to the conventional techniques because it guarantees neourethra coverage with 588 Paediatric urology well vascularized preputial skin. In a study of 47 children with hypospadias, 30 penoscrotal and ®ve perineal [19], the authors found 17% ®stula, 9% diverticula, 4% meatal recession and 4% persistent penile curvature requiring a repeated dorsal plication. The tubularized incised-plate repair urethroplasty (Snodgrass procedure) was the subject of several papers that examined different features of the technique. A prospective Austrian study [20] comparing the Snodgrass technique with the Mathieu technique in 60 children showed superiority of the ®rst technique, both in terms of less complications and reduced surgery time. The Australian experience with this technique in 60 cases showed urethral ®stulas in six patients (10%) and meatal stenosis in three (5%). A good or satisfactory ®nal cosmetic and functional result was achieved in 58 patients (98%) [21]. Tubularized incised plate urethroplasty has also been used as a procedure to correct complications after hypospadias repair. A Chinese report on six secondary Snodgrass procedures showed good functional results in all patients. A small ®stula in one patient and a mild meatal retraction in another were observed [22]. As surgeons became more experienced with the Snodgrass technique, meatal stenosis became the most frequent complication of this method. There is doubt about the need to dilate the urethra postoperatively to decrease this complication. An Egyptian study [23] reviewing 27 patients with hypospadias, including ®ve glanular, 16 coronal, two recurrent cases of hypospadias after a failed Mathieu repair, and four patients who required a second-stage repair, tried to answer this question. Of the ®rst seven patients, four had a small ®stula associated with meatal stenosis. By regular dilatation of the glanular urethra, all ®stulas resolved spontaneously. Dilatation was instituted in all the remaining patients and no ®stula or meatal stenosis occurred. The author of this study suggests that a routine urethral dilatation is important to prevent adhesions between both sides of the incised plate, which can result in meatal stenosis and ®stula. The group's experience with this technique con®rms the observation seen by several other authors. There is a concept that ¯aps are superior to grafts in proximal hypospadias surgery. The San Diego group reviewed their experience using preputial skin ¯aps or free grafts [24 .]. The records of 142 patients were reviewed and repairs were subdivided into tubularized and onlay reconstructions within the groups. Two-thirds of the repairs were performed with free grafts. A proximal stricture developed in eight patients who underwent free tubularized graft and in none of the free onlay repair patients. Otherwise there was no signi®cant difference in the complication rate of the various types of repairs. Of the 43 patients who had stricture, ®stula or meatal stenosis, 29 (67%) presented with the problem more than 1 year after surgery. The authors concluded that there is a signi®cantly higher proximal stricture rate when a tube and not an onlay free graft is used and that a longer follow-up (more than 1 year after surgery) may be necessary to assess completely the outcome of proximal hypospadias surgery. Hypospadias cripples can be de®ned as patients with remaining functional complications after previous hypospadias repair. A retrospective review of a group of 94 patients showed that 82 had major meatal dystopia (87%), 43 (46%) had residual curvature of the penile body, 19 (20%) showed meatal stenosis and only ®ve had one or more ®stulas [25]. In the absence of genital skin for the urethroplasty, the oral mucosa is the best option for urethral replacement. This tissue is easily obtained and has excellent immunohistochemical properties, similar to those of the urethral epithelium [26]. As shown in the free graft tendency, it should be used as an onlay reconstruction and not tubularized and covered by a Scarpa ¯ap in the dorsal region. The meatus should not be brought to the glans tip, but must be placed in the coronal or proximal region in order to achieve functional success in patients who have already been operated on several times. The dressing must be kept occluded for at least 5±7 days, minimizing local manipulation. A suprapubic cystostomy tube should be left indwelling routinely as the best urinary diversion and a ®ne silicone catheter used as a drain for just the urethral secretions [27,28]. The success rate of severe hypospadias treatment with the use of oral mucosa is between 70 and 80%. The favorable results obtained with oral mucosa for treatment of hypospadias cripples has encouraged some investigators also to use the tissue as a primary repair for one-stage or two-stage treatment. The results have been excellent and are supported by the major histological similarities between oral mucosa and normal urethral tissue, compared with penile skin of the dorsal region. However, there is still a lot of debate about the technique, and some authors believe that free grafts should be limited to circumstances where there is total absence of genital skin suitable for urethral construction [29]. We believe that oral mucosa is a good tissue option; it is also very easy to harvest. The lower lip is the donor site of choice, but tissue should be removed very super®cially. We do not believe that this technique is too aggressive for obtaining tissue, especially when there is concern about the quality of the tissues in the genital area. The great number of hypospadias repairs is also combined with different types of hypospadias dressings. As repairs become more complicated, dressings often become more complicated as well. A randomized study performed in 100 consecutive patients evaluated the Surgery to the external genitalia Macedo and Srougi 589 success and complications of hypospadias with and without dressings [30]. All but one repair preserved the integrity of the urethral plate. The authors found similar results in both groups and concluded that the success rate for hypospadias repairs that preserve the urethral plate is independent of dressing usage and that dressing may not be indicated for all hypospadias repairs. The authors, however, reinforce that these ®ndings do not apply to hypospadias repairs that produce a potential space between the urethral plate and the corpora, and to graft urethroplasty. Epispadias±exstrophy Interest has increased in combining procedures during reconstruction of bladder exstrophy in an effort to reduce the number of procedures and to improve results. Genitalia reconstruction, which in the past was delayed until after bladder closure, is now often performed together with the initial surgery. Gearhart and Mathews [31] reported on 24 boys with classic bladder exstrophy who underwent combined bladder closure and epispadias repair. The mean patient age was 20 months. Eighteen boys had undergone a prior failed closure. Osteotomies were performed in all patients. Urethrocutaneous ®stulas developed in seven patients but no instances of bladder prolapse or dehiscence were noted. The authors reinforce that boys presenting after failed initial closure or who are older than 5 months of age may be candidates for a combination of epispadias repair with bladder closure [31]. The technique of complete reconstruction in exstrophy and its results were reviewed in a paper published by the Seattle group [32 . .]. From 1989 to 1997, the authors performed a complete primary repair approach in 18 patients with bladder exstrophy and six patients with cloacal exstrophy. Eighteen patients underwent this procedure in the ®rst day of life. No patients experienced dehiscence of the primary closure. The staged approach for female bladder exstrophy± epispadias results in a vagina that remains in an abnormal position on the anterior abdominal wall. The Oklahoma group reported on seven female patients who underwent total urogenital complex mobilization, with complete disassembly of the pelvic diaphragm or ¯oor anterior to the rectum, to reposition the urethra and vagina to their proper anatomical positions in the perineum [33]. No complications were noticed, all patients having adequate vaginal caliber without evidence of stenosis. The authors suggest that this procedure should be considered in the initial approach, because the majority of female patients with exstrophy will require surgical reconstruction of the vagina and external genitalia later in life. The Johns Hopkins 10-year experience with the modi®ed Cantwell±Ransley procedure for exstrophy and epispadias has now been reported [34]. The authors reported on 93 males with a mean follow-up of 68 months. The incidence of ®stulas was 23% in the immediate postoperative period and 19% at 3 months. Urethral stricture at the proximal anastomotic area developed in seven patients. Continence after exstrophy and bladder neck reconstruction can be achieved without intermittent catheterization. The Indiana group reviewed 53 patients and found an alarming frequency of clinical and urodynamic problems related to voiding [35 . .]. The authors of this report questioned the normalcy of the voiding pattern and risks to achieve continence among patients with exstrophy. We agree with these observations and, since June 1998, we have been treating failed primary exstrophy repairs with a continent catheterizable ileumbased reservoir, anastomosed to the bladder plate [36 . .]. Conclusion The advances in surgery on the external genitalia are related to a better understanding of embryology and physiopathology of the urogenital tract congenital anomalies. The techniques employed in the treatment continue to evolve and change the treatment strategies. Specialists in this area must pay attention to these developments in order to be able to apply these new concepts in clinical practice. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: . of special interest .. of outstanding interest 1 Williams CP, Richardson BC, Bukowski TP. Importance of identifying the inconspicuous penis: prevention of circumcision complications. Urology 2000; 56:140±143. 2 Ponsky LE, Ross JH, Knipper N, Kay R. Penile adhesions after neonatal circumcision. J Urol 2000; 164:495±496. 3 Adams MC, McLaughlin KP, Rink RC. Inadvertent concentrated epinephrine injection at newborn circumcision: effect and treatment. J Urol 2000; 163:592. 4 Dean GE, Ritchie ML, Zaontz MR. La Vega slit procedure for the treatment of phimosis. Urology 2000; 55:419±421. 5 Smith C, Smith DP. Office pediatric urologic procedures from a parental perspective. Urology 2000; 55:272±275. 6 de Filippo RE, Barthold JS, GonzaÂlez R. The application of magnetic resonance imaging for the preoperative localization of nonpalpable testis in obese children: an alternative to laparoscopy. J Urol 2000; 164:154±155. 7 Wolffenbuttel KP, Kok DJ, den Hollander JC, Nijman JM. Vanished testis: be aware of an abdominal testis. J Urol 2000; 163:957±958. 8 Caruso AP, Walsh RA, Wolach JW, Koyle MA. Single scrotal incision orchiopexy for the palpable undescended testicle. 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An interesting observation of the increased incidence of hypospadias and other congenital malformations in children born after ICSI. 15 Erol A, Baskin LS, Li YW, Liu WH. Anatomical studies of the urethral plate: why preservation of the urethral plate is important in hypospadias repair. BJU Int 2000; 85:728±734. 16 Snodgrass W, Patterson K, Plaire JC, et al. Histology of the urethral plate: implications for hypospadias repair. J Urol 2000; 164:988±990. 17 Baskin LS, Erol A, Li YW, Liu WH. Anatomy of the neurovascular bundle: is safe mobilization possible? J Urol 2000; 164:977±980. 18 Emir H, Jayanthi VR, Nitahara K, et al. Modification of the Koyanagi technique for the single stage repair of proximal hypospadias. J Urol 2000; 164:973± 976. 19 Barroso Jr U, Jednak R, Barthold JS, GonzaÂlez R. Further experience with the double onlay preputial flap for hypospadias repair. J Urol 2000; 164:998± 1001. 20 Oswald J, Korner I, Riccabona M. Comparison of the perimeatal-based flap (Mathieu) and the tubularized incised-plate urethroplasty (Snodgrass) in primary distal hypospadias. BJU Int 2000; 85:725±727. 21 Holland AJ, Smith GH, Cass DT. Clinical review of the `Snodgrass' hypospadias repair. Aust N Z J Surg 2000; 70:597±600. 25 Van der Werff JF, van der Meulen JC. Treatment modalities for hypospadias cripples. Plast Reconstr Surg 2000; 105:600±608. 26 Macedo Jr A. The use of buccal mucosa in reconstruction of the lower urinary tract. Doctoral thesis, University of Mainz, Mainz, Germany; 1996. 27 Andrich DE, Mundy AR. Substitution urethroplasty with buccal mucosal-free grafts. J Urol 2001; 165:1131±1133. 28 Fichtner J, Fisch M, Filipas D, et al. Refinements in buccal mucosal grafts urethroplasty for hypospadias repair. World J Urol 1998; 16:192±194. 29 Baskin L. Hypospadias: a critical analysis of cosmetic outcomes using photography. BJU Int 2001; 87:534±539. 30 Van Savage JG, Palanca LG, Slaughenhoupt BL. A prospective randomized trial of dressings versus no dressings for hypospadias repair. J Urol 2000; 164:981±983. 31 Gearhart JP, Mathews R. Penile reconstruction combined with bladder closure in the management of classic bladder exstrophy: illustration of technique. Urology 2000; 55:764±770. 32 Grady RW, Mitchell ME. Complete primary repair of exstrophy. Surgical .. technique. Urol Clin N Amer 2000; 27:569±579. The authors present details of the operative steps of complete primary exstrophy repair. 33 Kropp BP, Cheng EY. Total urogenital complex mobilization in female patients with exstrophy. J Urol 2000; 164:1035±1039. 34 Surer I, Baker LA, Jeffs RD, Gearhart JP. The modified Cantwell±Ransley repair for exstrophy and epispadias: 10-year experience. J Urol 2000; 164:1040±1043. 23 Elbakry A. Tubularized-incised urethral plate urethroplasty: is regular dilatation necessary for success? BJU Int 1999; 84:683±688. 35 Yerkes EB, Adams MC, Rink RC, et al. How well do patients with exstrophy .. actually void? J Urol 2000; 164:1044±1047. An elegant discussion of the quality of micturition of patients with exstrophy, who have been treated attempting to preserve a physiological urinary flow by the urethra. 24 Powell CR, McAleer I, Alagiri M, Kaplan GW. Comparison of flaps versus grafts . in proximal hypospadias surgery. J Urol 2000; 163:1286±1289. An elegant discussion of the advantages and disadvantages of both techniques in hypospadias repair. 36 Macedo Jr A, Srougi M. A continent catheterizable ileum based reservoir. BJU .. Int 2000; 85:160±162. The authors present a new technique to obtain a continent reservoir with Mitrofanoff outlet from only one ileal segment. 22 Luo CC, Lin JN. Repair of hypospadias complications using the tubularized, incised plate urethroplasty. J Pediatr Surg 1999; 34:1665±1667.