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Abbas TO, Sennert M, Tiryaki S, Fernandez N, Fawzy M, Hadidi A. Hypospadias-associated penile curvature assessment and management: A global survey of current practice. J Pediatr Urol 2024; 20:440.e1-440.e10. [PMID: 38418260 DOI: 10.1016/j.jpurol.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 03/01/2024]
Abstract
INTRODUCTION Our goal was to assess how surgical management of hypospadias-associated penile curvature (HAPC) varies across continents, focusing on factors that influence assessment and decision-making. METHODS Members of the European Society of Pediatric Urology (ESPU), Society of Pediatric Urology (SPU), and Hypospadias International Society (HIS) participated in an anonymous, 34-question online survey addressing pre-, intra-, and postoperative elements of HAPC evaluation and management. A selection of intraoperative photos were included in the survey to investigate the prevailing surgical approaches and identify management patterns. RESULTS Out of the 267 participants, 38.4% of them are located in Europe. Visual estimation was the predominant approach for evaluating HAPC, although being regarded as the least dependable compared to other techniques. Surgeons who performed more than 40 cases per year were more inclined to use goniometers and had varying degrees of HAPC that were considered acceptable without requiring any correction (P < .001). Out of 58% of respondents, a significant number reported regular utilization of artificial erection tests for all categories of hypospadias. Surgeons with fewer than 10 years of expertise commonly utilized erection test as part of their regular practice. A tourniquet was employed to maintain sufficient intra-corporeal pressure, by134 (50%). 116 participants (43%) inject Saline through the corpora cavernosa through the glans, while 150 (56%) administer saline from the lateral aspect. Moreover, the decision-making process differed based on the intraoperative picture scenarios of mild to moderate penile curvature during erection testing. Contrary to temperatures ranging from 25o to 35o, decision-making in cases with less severe degrees of HAPC was uncomplicated. CONCLUSION This survey reveals a wide range of surgical practice patterns in the assessment and management of HAPC. To our knowledge, this global survey of HAPC practice is the largest to date and could aid in developing new guidelines in pediatric urology. These findings may also provide a foundation for future prospective multinational studies.
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Affiliation(s)
- Tariq O Abbas
- Pediatric Urology Section, Sidra Medicine, Doha, Qatar; College of Medicine, Qatar University, Doha, Qatar; Weill Cornell Medicine Qatar, Doha, Qatar.
| | - Michael Sennert
- Department of Pediatric Surgery, University Clinic, Hamburg, Germany
| | - Sibel Tiryaki
- Ege University, Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Izmir, Turkey
| | - Nicolas Fernandez
- Division of Pediatric Urology Seattle Children's Hospital, Department of Urology University of Washington, United States
| | - Mohamed Fawzy
- Hypospadias Clinic, Department of Pediatric Surgery, Emma and Offenbach Hospitals, Offenbach, Germany
| | - Ahmed Hadidi
- Hypospadias Clinic, Department of Pediatric Surgery, Emma and Offenbach Hospitals, Offenbach, Germany
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Yadav P, Bobrowski A, Ahmad I, Kim JK, Chancy M, Alshammari D, Rickard M, Lorenzo AJ, Bagli D, Chua ME. A scoping review on chordee correction in boys with ventral congenital penile curvature and hypospadias. Indian J Urol 2024; 40:17-24. [PMID: 38314084 PMCID: PMC10836453 DOI: 10.4103/iju.iju_277_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/23/2023] [Accepted: 09/13/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Congenital penile curvature (PC), often concomitant with hypospadias, poses challenges in urology. Surgical correction techniques, including plication and corporotomy, lack standardized guidelines. This study aims to address the paucity of high-level evidence by comprehensively reviewing the outcomes of PC correction procedures in patients with and without hypospadias. This will inform clinical decision-making and provide insights for future research and meta-analyses. Methods We conducted this scoping review in accordance with the JBI Manual for Evidence Synthesis and PRISMA-ScR guidelines. An extensive literature search was performed and comparative studies published in English up to June 2023 were included. The studies were divided into three categories: PC without hypospadias, PC with hypospadias, and studies comparing two or more materials for covering the ventral corporotomy. Data extraction comprised author details, patient characteristics, study design, interventions, outcomes, and complications. Methodological quality was assessed using the Newcastle-Ottawa Scale. Results Forty-two studies were included in the review, which collectively comprised 3180 patients. Thirteen comparative studies reported the outcomes of surgery for congenital PC without hypospadias, 22 studies compared different techniques of PC correction in patients with hypospadias and 7 studies compared the type of materials for coverage following ventral corporotomy. In cases of PC without hypospadias, the most commonly reported surgery was the Nesbit's plication. For PC with hypospadias correction, the results of ventral corporotomy were superior to that of dorsal plication in most of the studies. The two-stage repair had better results when compared to the one-stage repair for patients with perineo-scrotal hypospadias. In studies comparing materials for coverage of ventral corporotomy, the tunica vaginalis flap or graft was utilized most commonly. The majority of the studies reported a success rate ranging from 85% to 100%. The methodological quality was high in all but four studies. Conclusion Plication procedures are generally preferred for PC without hypospadias, but they result in penile shortening. For those with hypospadias, corporotomy is associated with superior outcomes than plication, especially for those with severe curvature and redo procedures. For ventral corporotomy coverage, the tunica vaginalis flap or graft is the most commonly reported tissue in the literature.
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Affiliation(s)
- Priyank Yadav
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Adam Bobrowski
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
| | - Ihtisham Ahmad
- Department of Undergraduate Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jin Kyu Kim
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Margarita Chancy
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
| | - Dheidan Alshammari
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
| | - Mandy Rickard
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
| | - Darius Bagli
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
| | - Michael E Chua
- Division of Urology, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
- Department of Urology, Institute of Urology, St. Luke's Medical Center, Quezon City, Philippines
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AbouZeid AA, Medhat Shahin AE, Elsadek M, Dahab MM, Amra HS, Shokry SS. Urethral Plate Substitution in Two-Stage Hypospadias Repair: Grafts Versus Flaps. J Pediatr Surg 2023; 58:2027-2033. [PMID: 37032193 DOI: 10.1016/j.jpedsurg.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Choosing between flaps or grafts to substitute the urethral plate in 2-stage hypospadias repair has been a matter of debate with no consensus in the literature. Flaps have reliable blood supply that maybe theoretically less liable for strictures or contractures. Grafts are more versatile, which can be used in primary and recurrent cases when healthy local skin is deficient.In this report, our aim was to compare outcomes of grafts and flaps when used to substitute the urethral plate in two-stage repair of primary proximal hypospadias with ventral curvature. METHODS This retrospective study included primary cases of hypospadias with significant curvature who underwent two-stage repair using either grafts or flaps to substitute the urethral plate in the first stage. Cases included in the study were divided into two groups according to the technique of substituting the urethral plate at the first stage of repair. During first part of the study period (2015 through 2018), we mostly used grafts to substitute the urethral plate (group A); later, we shifted to skin flaps (Group B) during the period 2019 through 2021. RESULTS The study included 37 boys with primary proximal hypospadias who underwent two-stage hypospadias repair. The meatus position was penoscrotal in 18, scrotal in 16, and perineal in three. Inner preputial graft was used to substitute the urethral plate in 18 cases (group A), while dorsal skin flaps were used in 19 (group B). Out of the 37 cases, 27 were available at follow-up after second stage (group A = 14; group B = 13). Follow up period ranged between 6 and 42 months (mean 19.7; median 18.5). Overall, 14 cases required reoperations for different indications: partial disruptions of distal part of the repair in six, closure of urethro-cutaneous fistula in six, and urethral strictures in two. The rate of complications was higher in group A (10 cases: 71%) compared to group B (4 cases: 31%) (Fisher exact test, p-value = 0.057). CONCLUSION Grafts were associated with higher complication rate than flaps when used to substitute the urethral plate in two-stage repair of proximal hypospadias with chordee. TYPE OF STUDY AND LEVEL OF EVIDENCE This is non-randomized comparative study (level III evidence).
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Affiliation(s)
| | | | - Menan Elsadek
- Department of Pediatric Surgery, AlAzhar University, Cairo, Egypt
| | - Mohamed Mousa Dahab
- Department of Pediatric Surgery, Faculty of Medicine-Ain Shams University, Cairo, Egypt
| | - Hazem Samir Amra
- Department of Pediatric Surgery, Faculty of Medicine-Ain Shams University, Cairo, Egypt
| | - Shady Sherin Shokry
- Department of Pediatric Surgery, Faculty of Medicine-Ain Shams University, Cairo, Egypt
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AbouZeid AA, Habak RA, Hamad MM, Shahin AEM. De-epithelialized overlap flap to secure urethroplasty in second stage hypospadias repair: revisiting the Smith technique. BMC Urol 2023; 23:143. [PMID: 37648994 PMCID: PMC10469420 DOI: 10.1186/s12894-023-01312-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 08/23/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND The application of a second layer between the neourethra and skin was a major contribution, which has improved the outcome of hypospadias repair. Here, we report our experience of revisiting the original Smith technique using a de-epithelialized overlap flap to support the urethroplasty in staged hypospadias repair. METHODS The study included primary cases of proximal hypospadias with significant chordee who underwent two-stage repair during the period 2016 through 2021. The ventral curvature was corrected at first stage by excision of the urethral plate, followed by covering the ventral shaft by skin flaps or inner preputial graft. The second stage (Thiersch -Duplay urethroplasty) was performed six months later. The de-epithelialized overlap flap (double breasting) technique was used to cover the neo-urethra in all cases, which was combined with a dartos scrotal flap to cover the proximal neourethra when indicated. RESULTS The study included 17 boys with proximal hypospadias who underwent two-stage repair. Follow up period after the second stage ranged between 6 and 30 months (mean 19.7; median 18.5). Post-operative complications were detected in 7 cases (41%). Most complications were related to distal/glanular disruptions whether partial or complete (5 cases). One case developed a penoscrotal fistula that was closed surgically. Another case (belonging to the group which used preputial graft in the 1st stage) presented 21 months after the second stage with urethral stricture (penoscrotal). CONCLUSION Applying the de-epithelialized double-breasting skin closure can offer alternative second layer coverage for the neourethra along the penile shaft in staged repair of proximal hypospadias.
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Harris TGW, Mudalegundi S, Haney NM, Morrill CC, Khandge P, Yang R, Redett RJ, Gearhart JP. The Role of Tissue Expanders in the Reconstruction of Proximal Hypospadias. Urology 2023; 176:150-155. [PMID: 36944401 DOI: 10.1016/j.urology.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias. METHODS Proximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage. RESULTS A total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%). CONCLUSION Proximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage.
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Affiliation(s)
- Thomas G W Harris
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shwetha Mudalegundi
- Department of Urology, Jeffs Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nora M Haney
- Department of Urology, Jeffs Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD
| | - Christian C Morrill
- Department of Urology, Jeffs Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD
| | - Preeya Khandge
- Department of Urology, Jeffs Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD
| | - Robin Yang
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John P Gearhart
- Department of Urology, Jeffs Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD.
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A meta-analysis comparing dorsal plication and ventral lengthening for chordee correction during primary proximal hypospadias repair. Pediatr Surg Int 2022; 38:389-398. [PMID: 35048166 DOI: 10.1007/s00383-022-05065-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Recurrent chordee (RC) is an important complication of proximal hypospadias repair. In this meta-analysis we compared RC incidence following dorsal plication (DP) versus ventral lengthening (VL). METHODS We searched the databases to identify all papers between 2001 and 2021 pertaining to proximal hypospadias and recurrent chordee. Duplicate publications, review articles and incomplete articles were excluded. Meta-analysis of heterogeneity was reported with I2 statistics. The pooled outcomes were compared to Chi square/Fishers exact test. RESULTS A total of 17 articles were included covering 582 patients. The I2 statistics for prevalence of RC among different publications showed no heterogeneity for DP (I2 = 0%) and low heterogeneity for VL (I2 = 26%). RC was noticed in 31/122 (25.4%; 95% CI 18%-33%) among patients who had DP alone while it was significantly lower, 24/460 (5.3%; 95% CI 4%-8%) when VL was used (p = 0.0001). When compared to DP, all VL techniques had significantly lower incidence of RC. Among the VL techniques lowest incidence of RC was found for ventral corporotomies (4%) followed by small-intestinal- submucosa (SIS 4.2%) and tunica vaginalis flap (TVF)/free graft-TVFG (5%). Among the VL subtypes: the proportion of RC with use of TVF (4/70, 5.7%) and TVFG (3/69, 4.3%) for corporoplasty was comparable (p = 1); single-layer SIS was associated with significantly less RC (1/90, 1.1%) than 4-layer SIS (5/51, 9.8%; p = 0.02). CONCLUSION For correction of severe ventral chordee during primary proximal hypospadias repair, dorsal plication carries a higher risk of recurrence compared to ventral lengthening procedures.
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Castagnetti M, El-Ghoneimi A. Surgical management of primary severe hypospadias in children: an update focusing on penile curvature. Nat Rev Urol 2022; 19:147-160. [PMID: 35039660 DOI: 10.1038/s41585-021-00555-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 11/09/2022]
Abstract
Over the past two decades, assessment and treatment of associated curvature has emerged as a major issue in treating patients with proximal hypospadias. However, the cut-off for defining a curvature as clinically significant is still unclear, as not all patients are bothered by the same degree of curvature and, although the need for a method to assess the curvature objectively has been emphasized, no standard method yet exists. Curvature is multifactorial. The same degree of curvature can be due to any possible combination of skin and/or subcutaneous dartos tethering, a short urethral plate and an intrinsic corpora disproportion. Different strategies can be used to treat curvature, depending on the underlying cause, surgeon preferences, and the goals of the repair. In the past 10 years, use of urethral plate transection and ventral lengthening procedures has increased, although the lack of long-term follow-up data on ventral lengthening procedures suggests that the use of such procedures should be selective. Furthermore, straightening manoeuvres are influenced by the technique used for subsequent urethroplasty and, in turn, may influence the success rate of the urethroplasty. This Review provides a comprehensive overview of the major developments from the past 10 years in the management of severe proximal hypospadias in children.
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Affiliation(s)
- Marco Castagnetti
- Paediatric Urology Unit, Department of Surgery, Bambino Gesù Children Hospital and Research Institute, Rome, Italy. .,Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy.
| | - Alaa El-Ghoneimi
- Department of Paediatric Surgery and Urology, Reference Centre for Rare Urinary Tract Malformations (MARVU), Hôpital Robert Debré, APHP, Université de Paris, Paris, France
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Babu R, Chandrasekharam VVS. Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade. J Pediatr Urol 2021; 17:681-689. [PMID: 34099397 DOI: 10.1016/j.jpurol.2021.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/08/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade. METHODS A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes. RESULTS The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load. CONCLUSIONS Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.
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Affiliation(s)
- Ramesh Babu
- Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India.
| | - V V S Chandrasekharam
- Pediatric Surgery, Pediatric Urology and MAS, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India
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Atan A, Sonmez K, Turkyilmaz Z, Karabulut R. Letter to the Editor. J Pediatr Surg 2021; 56:1255. [PMID: 33715842 DOI: 10.1016/j.jpedsurg.2021.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Ali Atan
- Department of Urology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Kaan Sonmez
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Besevler, Cankaya, 06550 Ankara, Turkey
| | - Zafer Turkyilmaz
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Besevler, Cankaya, 06550 Ankara, Turkey
| | - Ramazan Karabulut
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Besevler, Cankaya, 06550 Ankara, Turkey.
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