The sexual and reproductive consequences of congenital genitourinary anomalies

Penile lenghthening original technique using a pubo-cavernous spacer. Long term results from a series of over 200 patients

Introduction: We report our long experience in the surgical treatment of patients requesting penile lengthening by suspensory ligament release and placement of a custom-made soft silicone pubo-cavernous spacer. The aim was to show that with this surgical technique the results obtained are maintained over time. It is crucial to achieve postoperative satisfaction of these patients who show fragility and self-esteem problems. Methods: From 1999 to 2020, we treated 245 patients with congenital or acquired penile brevity. We carefully analysed the preoperative and postoperative (at 6, 12, 24 and 48 months) penile size of the patients to evaluate whether this technique could allow the long-term maintenance of aesthetic results. We also assessed preoperative erectile function and we focused on the psychological aspects to avoid surgery in patients with dysmorphophobia. This original technique involves the section of the suspensory ligament and the implantation of a silicone spacer between the pubic symphysis and the corpora cavernosa. This spacer is conformed to the patient anatomy and maintains the relationship between the anatomical structures unchanged over time. Sexual self-esteem and patient satisfaction were assessed with the APPSSI questionnaire. Results: The mean increase in penile length was about 2.5 cm in flaccid state and 1.9 cm in stretched state. There were no injuries of the neurovascular bundle or urethra, and no erectile dysfunction was noted. These results persisted at 6, 12, 24 and 48 months without significant differences. Over 80% of patients stated that they were completely satisfied with the results obtained. This satisfaction remained stable along follow up. Conclusion: The section of the suspensory ligament and the implant of the soft silicone spacer provide real penis elongation with satisfactory results that persist over time. This technique avoids the frequent complication of short-term shortening due to the scar adhesions of the edges of the dissected ligament. The high aesthetic satisfaction of patients is stable at controls at 6, 12, 24 and 48 months.

Co-culture of smooth muscle cells and endothelial cells on three-dimensional bioprinted polycaprolactone scaffolds for cavernosal tissue engineering

PURPOSE

In vitro evaluation of polycaprolactone (PCL) scaffolds fabricated by a three-dimensional (3D) printing technique for tissue engineering applications in the corpus cavernosum.

MATERIALS AND METHODS

PCL scaffolds were fabricated by use of a 3 D bioprinting system. The 3D-printed scaffolds had interconnected structures for cell ingrowth. Human aortic smooth muscle cells (haSMCs) were seeded on the scaffold and cultured for 5 days, and then human umbilical vein endothelial cells (HUVECs) were also added on the scaffolds and co-cultured with haSMCs for up to 7 days. The ability of these scaffolds to support the growth of HUVECs and haSMCs was investigated in vitro. 3 D strand-deposited scaffolds were characterized by scanning electron microscopy (SEM) images and porosity measurement.

RESULTS

SEM images showed the surface of the PCL scaffolds to be well covered by HUVECs and haSMCs. Immunofluorescent staining of α-flk1 and α-smooth muscle actin on the HUVECs and haSMCs seeded scaffolds confirmed that the cells remained viable and proliferated throughout the time course of the culture.

CONCLUSION

3 D bioprinting of a PCL scaffold is feasible for co-culturing of HUVECs and haSMCs. This was a preliminary study to investigate the possibility of fabrication of tissue-engineered corpus cavernosum.

Congenital genital abnormalities detected during routine circumcision at a South African institution: a retrospective record review

BACKGROUND

Due to the reduction in HIV transmission through male medical circumcisions (MMC), numerous clinics throughout South Africa offer a voluntary free service to boys from the age of ten years and above. An examination prior to the procedure may detect congenital abnormalities missed after birth.

OBJECTIVES

The aim of this study was to measure the incidence of these abnormalities, determine the demographic and clinical characteristics of this group and determine what referral systems, interventions, and follow-up is available to them.

METHODS

The study was a descriptive, observational, retrospective analysis of de-identified medical records at a routine MMC service at a Johannesburg clinic in 2015. The participants were male patients between the ages of 10 - 49.

RESULTS

Out of 1548 participants, 91.0% (n=1409) had a normal genital examination while 3.7% (n=57) had an abnormal examination and 5.1% (n=79) had no examination recorded. Thirty five congenital anomalies were detected and only 2 patients (diagnosed with hypospadias) were seen at the urology out-patient's department.

CONCLUSION

The incidence of congenital genital abnormalities of males presenting for routine circumcision is low. Despite the low incidence the effect on fertility, sexuality, ability to urinate and on psychological wellbeing is significant. Referral services to the urology department should be restructured to improve all outcomes.

Long-term Impacts of Concurrent Posterior Urethral Valve Ablation and Bladder Neck Incision on Urinary Continence and Ejaculation

OBJECTIVE

To assess the long-term impacts of bladder neck incision (BNI) on continence and ejaculatory function of adults who underwent concurrent posterior urethral valve (PUV) ablation and BNI during childhood.

MATERIALS AND METHODS

A retrospective chart review was performed to find all adult patients with relevant history. All patients had undergone BNI at 6 o'clock proximal to the verumontanum with caution to leave the adventitia and verumontanum untouched. Charts were reviewed and attempts were made to contact those ≥18 years old for follow-up. Patients were specifically evaluated for lower urinary tract symptoms and ejaculatory condition.

RESULTS

Among patients treated for PUV between 1998 and 2015 in our center, 21 were ≥18 years old at the time of assessment. Until February 2016, we were able to contact 18 patients, all of whom agreed to participate. Mean age was 21.1 ± 2.9 years with a mean follow-up of 12.5 ± 4.8 years. None of those contacted had incontinence or dry ejaculations. All considered their ejaculations normal and only one complained of weak ejaculations. Four of 5 patients who consented to perform a semen analysis had normal tests and 1 had low sperm count with abnormal motility.

CONCLUSION

BNI is not associated with additional risk of incontinence and dry ejaculation in early adulthood and preserves antegrade ejaculation. Concomitant valve ablation with BNI may provide additional benefits in care of PUV children, especially those with prominent bladder neck and poor bladder function at presentation.

Regenerative medicine for the treatment of reproductive system disorders: current and potential options

Regenerative medicine has opened new avenues for treating patients with severe reproductive system disorders, such as congenital abnormalities, cancer, trauma, infection, inflammation and iatrogenic injuries. Over the past two decades, scientists have advanced the field of reproductive tissue engineering to restore normal sexual function and preserve fertility in both female and male patients. In this review, we summarize recent advances in the use of cell, tissue, and organ-based regenerative medicine strategies for clinical application in reproductive system disorders.

Changes over time in sex assignment for disorders of sex development

BACKGROUND AND OBJECTIVE

It is unclear whether the proportion of infants with a disorder of sex development who are raised as male or female has changed over time. The temporal trends in sex assignment of affected cases entered in the International Disorder of Sex Development (I-DSD) Registry were studied.

METHODS

Cases of disorders of sex development reported as partial androgen insensitivity syndrome (PAIS; n = 118), disorder of gonadal development (DGD; n = 232), and disorder of androgen synthesis (DAS; n = 104) were divided into those who were born before 1990, 1990-1999, and after 1999. External appearance of the genitalia was described by the external masculinization score.

RESULTS

The median (5th-95th percentile) external masculinization scores of those infants with PAIS, DGD, and DAS who were raised as boys were 6 (2-9), 6 (3-9), and 6 (1-12), respectively, and were significantly higher than in those raised as girls (2 [0-6], 2 [0-7], and 0 [0-5], respectively); this difference was maintained in the 3 temporal birth cohorts (P < .01). Of the 118 cases in the pre-1990 cohort, 41 (35%) were raised as boys; of the 148 cases in the 1990-1999 cohort, 60 (41%) were raised as boys; and of the 188 cases in the post-1999 cohort, 128 (68%) were raised as boys.

CONCLUSIONS

Although there is an association between the external appearance of the genitalia and the choice of sex assignment, there are clear temporal trends in this practice pointing toward an increased likelihood of affected infants being raised as boys. The impact of this change in practice on long-term health outcomes requires additional focus.

Penile subcutaneous fibrolipoma postaugmentative phalloplasty

Fibrolipomas are a rare subtype of lipomas. We describe a case of a man suffering from subcutaneous penile fibrolipoma, who three months earlier has been submitted to an augmentative phalloplasty due to aesthetic dysmorphophobia. After six months from the excision of the mass, the penile elongation and penile enlargement were stable, and the patient was satisfied with his sexual intercourse and sexual life. To our knowledge, this is the first reported penile subcutaneous fibrolipoma case in the literature. The diagnostics and surgical features of this case are discussed.

Genital reconstruction in exstrophy patients

INTRODUCTION

Surgery for bladder exstrophy has been evolving over the last four to five decades. Because survival has become almost universal, the focus has changed in the exstrophy-epispadias complex to improving quality of life. The most prevalent problem in the long-term function of exstrophy patients is the sexual activity of the adolescent and adult males. The penis in exstrophy patients appears short because of marked congenital deficiency of anterior corporal tissue. Many patients approach for genital reconstruction to improve cosmesis as well as to correct chordee. We report our series of male patients seeking genital reconstruction following exstrophy repair in the past.

MATERIALS AND METHODS

Fourteen adolescent/adult male patients attended urology services during the period January 2000-December 2009 seeking genital reconstruction following exstrophy repair in the past.

RESULTS

Three patients underwent epispadias repair, four patients had chordee correction with cosmetic excision of skin tags and seven patients underwent chordee correction with penile lengthening. All patients reported satisfaction in the answered questionnaire. Patients undergoing penile lengthening by partial corporal dissection achieved a mean increase in length of 1.614 ± 0.279 cm dorsally and 1.543 ± 0.230 cm ventrally. The satisfactory rate assessed by the Short Form-36 (SF-36) showed that irrespective of the different genital reconstructive procedures done, the patients were satisfied with cosmetic and functional outcome.

CONCLUSIONS

Surgical procedures have transformed the management in these patients with bladder exstrophy. Bladders can be safely placed within the pelvis, with most patients achieving urinary continence and cosmetically acceptable external genitalia. Genital reconstruction in the form of correction of chordee, excision of ugly skin tags and lengthening of penis can be performed to give the patients a satisfactory cosmetic and functional system.

Long-term disease-specific quality of life in adult anorectal malformation patients

BACKGROUND

Fecal and urinary incontinence may differently influence various aspects of quality of life (QOL). The main aim of the present study is to determine whether fecal and urinary incontinence measured at time 1 of the study will predict QOL at time 2 (after 4 years), above and beyond the prediction already explained by fecal and urinary incontinence at time 2.

METHODS

Thirty-six adult patients from the Italian Parents' and Patients' Association for Anorectal Malformations answered items about urinary and fecal incontinence at time 1 of the study and completed the Hirschsprung Disease/Anorectal Malformation Quality of Life questionnaire after 4 years from the first questionnaire. Two sets of hierarchical regression analyses were conducted with fecal and urinary incontinence serving as predictors of QOL and the different areas of QOL from the Hirschsprung Disease/Anorectal Malformation Quality of Life serving as outcome variables.

RESULTS

The principal findings indicated that fecal continence is a strong predictor of QOL in the areas of social functioning, emotional functioning, and body image and that urinary incontinence predicted sexual functioning.

CONCLUSIONS

It seems that one's past experience with fecal incontinence is extremely relevant to current QOL, especially for body image. Urinary incontinence contributed less in explaining QOL in our patients, but because it is very relevant for sexual functioning, it should not be disregarded.

Bioengineered corporal tissue for structural and functional restoration of the penis

Various reconstructive procedures have been attempted to restore a cosmetically acceptable phallus that would allow normal reproductive, sexual, and urinary function in patients requiring penile reconstruction. However, these procedures are limited by a shortage of native penile tissue. We previously demonstrated that a short segment of the penile corporal body can be replaced using naturally derived collagen matrices with autologous cells. In the current study, we examined the feasibility of engineering the entire pendular penile corporal bodies in a rabbit model. Neocorpora were engineered from cavernosal collagen matrices seeded with autologous cells using a multistep static/dynamic procedure, and these were implanted to replace the excised corpora. The bioengineered corpora demonstrated structural and functional parameters similar to native tissue and male rabbits receiving the bilateral implants were able to successfully impregnate females. This study demonstrates that neocorpora can be engineered for total pendular penile corporal body replacement. This technology has considerable potential for patients requiring penile reconstruction.

A method to improve cellular content for corporal tissue engineering

We have previously shown that penile corporal structures engineered using autologous cells are able to achieve erection, penetration, and ejaculation. However, fully functional corpora could not be engineered because of the limited cellular content present within the corporal tissue construct. In this study, we investigated whether a dynamic seeding approach would improve cellularity within the corporal tissue construct and thereby restore normal erectile function. Corporal cells were either statically or dynamically seeded on acellular corporal tissue matrices and maintained in a bioreactor system. After 48 h, the cell-matrix complexes were implanted subcutaneously in athymic mice and analyzed for cell attachment, survival, and distribution using histological and molecular techniques. Native tissues and matrices without cells served as controls. The seeded cells attached and proliferated within the sinusoidal walls of the matrices. After completing the seeding, the DNA and cellular content of the dynamically seeded matrices reached 71% of normal corpora, whereas the statically seeded matrices reached 39% of normal corpora. These findings were confirmed histologically, biochemically, and using scanning electron microscopy. This study demonstrates that dynamic cell attachment, using a bioreactor system, leads to the formation of morphologically and biochemically improved corporal tissue, which may be useful for penile reconstruction.

Contemporary outcomes in bladder exstrophy

PURPOSE OF REVIEW

The patient with bladder exstrophy presents complex surgical and clinical management challenges to the pediatric urologist. This review aims to present recent developments in the care of these patients as well as to review contemporary medical outcomes.

RECENT FINDINGS

Most of the early literature pertaining to bladder exstrophy has focused on surgical techniques and management. In the last 10-20 years, however, there has been an increase in the number of publications dealing with long-term outcomes in these patients. Psychosexual development, sexual function and social adaptation have received as much attention as urinary continence status, bladder, and renal function. This review will examine these topics.

SUMMARY

Despite the complex nature of bladder exstrophy, there are no well designed, prospective trials examining clinical outcomes in these patients. Until better trials are planned, executed and published, much of what we know about patients with bladder exstrophy will be based on retrospective observations with significant biases.

Social quality of life for adult patients with anorectal malformations

BACKGROUND/PURPOSE

Pediatric surgeons who performed the initial surgery on anorectal malformations (ARM) lose contact with the patients as they become adults. In the present study, we examined 20- to 40-year-old adult patients with a history of surgery for ARM and analyzed them from the points of social quality of life.

PATIENTS AND METHODS

Twenty-nine patients with ARM, aged 20 to 40, were surveyed by questionnaire or personal interview. Thirteen with high-type and 9 with intermediate-type anomalies underwent abdominoperineal rectoplasty, and 7 with low-type anomalies underwent perineoplasty between 1965 and 1985. Responses were analyzed from the perspectives of bowel, urinary, and sexual functions and social activity.

RESULTS

One third of patients with high- or intermediate-type anomalies occasionally complained of fecal soiling. However, the other patients gained good bowel function and enjoyed occupational or student life without problems. Fecal soiling was the key factor disturbing occupational life, although the problem remained within a socially manageable level. All of the patients with ARM had normal urinary function. Three of the 18 male patients had sexual problems such as erectile or ejaculatory dysfunction because of associated genitourinary anomalies. Nine of the 11 female patients had regular menstruation and the other 2 had irregular menstrual periods. Five female patients were married and 4 of the 5 had children (1-5 children). Modes of delivery were normal vaginal delivery in 8 and cesarean section in 1. Only one of the 5 had a slight sacral anomaly. However, she had no apparent abnormality of bladder function and got through pregnancy and delivery without difficulty.

CONCLUSION

One third of adult patients with high- or intermediate-type anomalies after abdominoperineal rectoplasty had some problems in bowel function. Fecal soiling was the key factor that disturbed their occupational life. Most of the patients had normal urinary and sexual functions if they did not have associated genitourinary anomalies and enjoyed social activities.

Aesthetic Aspects of Bladder Exstrophy: Results of Puboplasty

PURPOSE

At times children born with bladder exstrophy-epispadias complex must undergo several operations and the resultant scar tissue on the abdomen can be quite disfiguring. Long-term followup in these patients reveals that many have a poor self-image, and the aesthetic aspects of the genitalia and lower abdomen acquire greater significance with age. We present our retrospective case series of the experience of 1 surgeon during 27 years.

MATERIALS AND METHODS

Our database includes 116 patients born with exstrophy-epispadias complex. Primary reconstruction was performed in 62 infants and neonates, while 54 children and young adults underwent initial surgery elsewhere. Secondary puboplasty was performed in 88 of the 116 patients. Various techniques were used, ranging from simple excision and longitudinal closure in 12 cases, Z-plasty and pubic contouring in 23, the use of axial pattern inguinal skin flaps in 50 and tissue expanders in 3, when necessary. Long-term followup data were available on 76 patients. The parent and, when appropriate, the patient determined satisfaction with the cosmetic appearance.

RESULTS

Patient satisfaction with the cosmetic and functional outcomes of surgery was high. Of the 76 patients 73 (96%) were satisfied following puboplasty. Complications included wound infection and keloid formation in 4% and 10% of cases, respectively.

CONCLUSIONS

Achievement of excellent aesthetic results is possible with secondary puboplasty. Simple closure is associated with a higher incidence of keloid formation compared to the Z-plasty closure technique. Axial pattern skin flaps and Z-plasty techniques yield superior cosmetic results for contouring the mons pubis in patients with exstrophy-epispadias complex.

Aesthetic aspects of abdominal wall and external genital reconstructive surgery in bladder exstrophy-epispadias complex

Long-term follow-up of patients born with classical bladder exstrophy-epispadias complex (EEC) reveals that many of them suffer from poor self-image, and the aesthetic aspects of the genitalia and lower abdomen acquire greater significance with age. In this article, we review the aesthetic outcomes in performing puboplasty, umbilicoplasty, and genitoplasty in patients born with EEC. Retrospective review of the cosmetic and functional outcomes in 116 patients born with EEC treated by puboplasty, umbilicoplasty, or genitoplasty was performed. Satisfaction with the cosmetic and functional outcomes of these three reconstructive surgeries was high following initial reconstructive efforts (> 90%). Attention to cosmesis during abdominal wall and genital reconstruction for EEC helps to improve a patient's perception of body image and self-esteem. Our experience with these procedures over the past 25 years demonstrated that the efforts directed toward aesthetics have been well worthwhile.

Quality of life for adult women born with bladder and cloacal exstrophy: a long-term follow up

OBJECTIVE

To assess the quality of life of 23 female patients over 18 years of age treated and followed in the same institution.

METHODS

Fifty questions were sent to this group of patients covering their uro-gynaecological history, education and profession, social life and related psychological issues, sexual life and fertility. All replies were kept anonymous.

RESULTS

Seventeen patients (74%) replied. Urine incontinence at various degrees was found in 65%. Genital prolapse was reported in 29.5%. Students accounted for 41%; 59% were actively working with a satisfactory professional life in 82% of cases. Seventy-six per cent did not consider that exstrophy affected their professional life, and 76% were happy with their social life. Psychological distress was reported by 41%, and the symptoms are detailed. Sixty-four per cent were married or had a stable partner. Seventy-six per cent were active sexually, all declaring heterosexual relations. Eighty-eight per cent had periods. Four pregnancies were reported and morbidity during gestation is described. All children were born by Caesarean section and were normal. These results are discussed and compared with the literature.

CONCLUSION

Despite many hurdles, this group of patients can expect a subnormal social, family and professional life. Urinary incontinence and poor body image were the most important factors altering quality of life.

Myelomeningocele and female sexuality: an issue?

During the last 40 years more and more myelomeningocele (MMC) patients have survived to adulthood and since the 1980s there is growing interest in sexual functioning of these patients. However, most of what is known about the impact of MMC on sexual functioning pertains to males. We have reviewed the literature pertaining to female sexuality and MMC with regard to sexual development, activity, dysfunction, sexual knowledge and education, pregnancy and delivery, as well as future trends.

Long-term outcomes of anorectal malformations

Anorectal malformations (ARMs) and cloacal anomalies are rare and complex malformations of the lower gastrointestinal and genitourinary tracts. They affect approximately 1 in 3,500 live births. The treatment of these patients has traditionally focused on achieving urinary and faecal continence, with preservation of renal function. With improved surgical techniques and paediatric intensive care facilities, these patients now live relatively normal lives, with a near-normal life expectancy. Comparing results reported by different surgeons is difficult because a wide range of terminology is employed to describe the anomalies encountered. This paper attempts to simplify some of the reported outcomes of bowel function to allow a more direct comparison between groups. Urinary outcomes were not so easily comparable due to the disparity in assessing patient outcomes. Therefore, before a global analysis of all groups can take place, a standardised terminology will be necessary. At present there is a gap in the published literature of comprehensive follow-up in this group of patients, particularly regarding reproductive and sexual functioning. More detailed information on long-term outcomes is needed in these patients to facilitate informed decision-making by the primary physician (usually the paediatric surgeon) and the parents on behalf of their child.

Formation of corporal tissue architecture in vivo using human cavernosal muscle and endothelial cells seeded on collagen matrices

We explored the feasibility of developing corporal tissue, consisting of human cavernosal smooth muscle and endothelial cells in vivo, using three-dimensional acellular collagen matrices, which are similar in architecture to native corpora. Acellular collagen matrices were derived from processed donor rabbit corpora, using cell lysis techniques. Human corpus cavernosal muscle and endothelial cells were seeded on the acellular matrices. A total of 80 matrices, 20 without cells and 60 with cells, were implanted subcutaneously in athymic mice. An additional 36 matrices seeded with cells were maintained in culture for up to 4 weeks. Hydroxyproline quantification, Western blot analysis, RT-PCR, and scanning electron microscopy of the matrices, with and without cells, were performed at various time points. Animals were killed 3 days and 1, 2, 3, 4, 6, and 8 weeks after implantation. Immunocytochemical and histological analyses were performed to confirm the muscle and endothelial phenotype. Organ bath studies were performed in order to determine the degree of tissue contraction. Western blot analysis detected alpha-actin, myosin, and tropomyosin proteins from human corporal smooth muscle cells. Expression of muscarinic acetylcholine receptor (mAChR) subtype m4 mRNA was demonstrated by RT-PCR from corporal muscle cells before and 8 weeks after seeding. The implanted matrices showed neovascularity into the sinusoidal spaces by 1 week after implantation. Increasing organization of smooth muscle and endothelial cells lining the sinusoidal walls was observed at 2 weeks and continued with time. The matrices were covered with the appropriate cell architecture 4 weeks after implantation. The matrices showed a stable collagen concentration over 8 weeks, as determined by hydroxyproline quantification. Immunocytochemical studies using alpha-actin and factor VIII antibodies confirmed the presence of corporal smooth muscle and endothelial cells, both in vitro and in vivo, at all time points. There was no evidence of cellular organization in the control matrices. Organ bath studies showed that the cell-seeded corporal tissue matrices responded to electrical field stimulation, whereas the unseeded implants failed to respond. This study demonstrates that human cavernosal smooth muscle and endothelial cells seeded on three-dimensional acellular collagen matrices derived from donor corpora are able to form well-vascularized corporal tissues in vivo.

Coping with bladder exstrophy: diverse results from early attempts at functional urinary tract surgery

OBJECTIVES

To report the long-term surgical outcome in a group of patients with bladder exstrophy treated from 1960 to 1982, and to assess physical health, social integration and sexual function, as attempts at functional closure during the development of this surgery resulted in patients with differing surgical status of the genitourinary organs.

PATIENTS AND METHODS

A review of medical record archives revealed 36 patients; of these, seven had died, six were untraceable and six declined to participate, leaving 15 evaluable subjects (seven men and eight women, mean age at follow-up, 35 years). Data were collected from medical records and direct interviews were conducted using a semi-structured questionnaire, after obtaining informed consent. The Short Form-36 (SF-36) v2 Health Survey instrument was used to assess health and well-being.

RESULTS

Three patients have retained the use of their bladder, and 11 had initial bladder closure but required (at a mean age of 3.1 years) various urinary diversions. Eight patients had a pelvic osteotomy. Of 27 functioning renal units, 25 are in reasonable to good condition. Six men and six women had genital reconstruction. Four men are capable of penetrative intercourse and ejaculate; six women manage penetrative intercourse and five have orgasms. All patients attended mainstream school and 13 achieved examination success. Nine patients took vocational training and 11 work full-time. Five patients are married and five are in long-term relationships. Two men have achieved three pregnancies and one women has had a child. The mean total SF-36 score (maximum 3600) was 2763 in men and 2235 in women.

CONCLUSIONS

Surgery for bladder exstrophy has been developing for more than 40 years and the legacy of early attempts at functional closure is a population of adults who have a diversity of lower urinary tracts, good preservation of renal function overall and acceptable sexual function. They are usually robust, healthy and well-adjusted individuals functioning well in society, often in full-time employment and long-term relationships. Adolescent follow-up must be clearly focused, incorporating a multidisciplinary team approach to facilitate a seamless transition into adulthood.

Understanding new genetics of male infertility

PURPOSE

Greater than 10% of couples are unable to achieve pregnancy. In at least 30% to 50% of these infertility cases a male factor abnormality is involved. Genetic defects are believed to be the cause of a significant percent of these abnormalities. In fact, defects causing infertility, such as chromosomal disorders and congenital hypothalamic-pituitary-gonadal axis syndromes, have long been recognized. With the development of gene targeting technologies in animal models many genes required for male fertility in animals are known, contributing to our understanding of the etiology of this important health problem. We present not only recognized genetic disorders associated with male infertility, but also its emerging and previously unrecognized genetic etiologies.

MATERIALS AND METHODS

This review is organized to enable the reader to recognize promptly the major types of genetic defects associated with male infertility, their clinical characteristics and appropriate therapeutic approaches. Due to the explosion of current knowledge in this field and to length restrictions the discussion of genetic defects is concise, referencing predominantly review articles relevant to the topic.

RESULTS

Assisted reproductive technologies for overcoming sterility resulting from unrecognized etiologies may have important potential consequences for infertile couples and their offspring.

CONCLUSIONS

Familiarity with the genes associated with male infertility is essential for the urologist to better understand, diagnose and treat the male factor couple.

Reconstitution of human corpus cavernosum smooth muscle in vitro and in vivo

A large number of congenital and acquired abnormalities of the genitalia would benefit from the availability of transplantable, autologous corpus cavernosum tissue for use in reconstructive procedures. We describe the results of preliminary experiments designed to determine the feasibility of using cultured human corporal smooth muscle cells seeded onto biodegradable polymer scaffolds for the formation of corpus cavernosum smooth muscle in vitro and in vivo. Primary cultures of human corpus cavernosum smooth muscle cells were derived from operative biopsies obtained during penile prosthesis implantation. Cells were characterized in vitro and seeded as a contiguous multilayered sheet onto polymers of non-woven polyglycolic acid. The seeded polymer constructs were then implanted subcutaneously in athymic mice. Animals were killed 7, 14, and 24 days after surgery and implants were examined via histology, immunocytochemistry, and Western blot analyses. Cultured cell multilayers were identified as smooth muscle before implantation via phase-contrast microscopy, immunocytochemistry and Western blot analyses. Retrieved implants from all time points demonstrated corporal smooth muscle tissue grossly, and histologically, at the time of sacrifice. Intact smooth muscle cell multilayers were observed growing along the surface of the polymers. There was evidence of early vascular ingrowth at the periphery of the implants by 7 days. By 24 days, there was evidence of polymer degradation. Maintenance of the smooth muscle phenotype in vivo was confirmed immunocytochemically and by Western blot analyses with antibodies to alpha-smooth muscle actin. This study provides evidence that cultured human corporal smooth muscle cells may be used in conjunction with biodegradable polymer scaffolds to create corpus cavernosum smooth muscle tissue in vitro and in vivo.

Magnetic resonance imaging in the assessment of complex Müllerian anomalies

OBJECTIVE

To evaluate the accuracy of magnetic resonance imaging in assessment of adolescent patients with complex Müllerian anomalies and its contribution towards operative management.

DESIGN

A retrospective review of magnetic resonance imaging and operative findings.

SETTING

A London teaching hospital that is a tertiary referral centre for complex reproductive tract disorders.

SAMPLE

All adolescents referred for assessment of complex Müllerian anomalies, from 1996 to 1999, and undergoing both magnetic resonance imaging and surgical assessment.

METHOD

In the nine suitable patients magnetic resonance imaging and surgical findings were compared and the role of magnetic resonance imaging in determining the route and type of surgery was evaluated.

MAIN OUTCOME MEASURES

Magnetic resonance imaging data on reproductive tract anatomy and surgical findings detailing reproductive tract anatomy.

RESULTS

There was good correlation of magnetic resonance imaging and operative findings in all cases. The best correlation was with uterine structure. In four cases the magnetic resonance imaging findings were essential for the appropriate choice of the surgical approach and type of procedure.

CONCLUSIONS

Magnetic resonance imaging is a valuable tool in the management of this particular complex group of patients.

Total urogenital complex mobilization in female patients with exstrophy

PURPOSE

Female bladder exstrophy/epispadias has traditionally been approached in a staged fashion. This approach results in a vagina that remains in an abnormal position on the anterior abdominal wall. We present a surgical correction of the female exstrophy/epispadias urogenital complex with total mobilization that returns the vagina to its proper anatomical position.

MATERIALS AND METHODS

Since 1997, 7 female patients presenting with variants of the exstrophy/epispadias complex have undergone surgical repair using total urogenital complex mobilization. Of the patients 1 newborn and 2 school-age children had classic bladder exstrophy, 2 school-age children had cloacal exstrophy and 2 school-age children had primary epispadias. Total urogenital complex mobilization involved treatment of the urethra and vagina as a single unit. Complete disassembly of the pelvic diaphragm or floor anterior to the rectum was required to reposition the urethra and vagina to their proper anatomical positions in the perineum. The pelvic diaphragm was then reconstructed anterior to the urogenital complex to recapitulate the normal female pelvic floor anatomy.

RESULTS

All patients have an anatomically correct position of the urogenital complex. All the vaginas reached the perineum without the need for skin flaps. All patients have adequate vaginal caliber without evidence of stenosis.

CONCLUSIONS

The female with exstrophy/epispadias has unique anatomical defects in the urogenital complex that require special attention. Anterior displacement of the bladder, urethra and vagina with concomitant lack of development of the anterior pelvic floor musculature make a single stage, total urogenital complex mobilization repair ideal for this population. The results of this technique have been functionally and cosmetically pleasing. Whether repositioning the urogenital complex into the normal anatomical position will improve bladder dysfunction and urinary continence rates, and decrease or eliminate the need for future surgery will only be known after further long-term followup has been completed.

The child with micropenis

Micropenis refers to an extremely small penis with a stretched penile length of less than 2.5 SD below the mean for age or stage of sexual development. It should be differentiated from a buried or hidden penis and aphallia. It is important to use a standard technique of stretched penile measurement and nomograms for age to identify children with micropenis. All children above 1 year of age with a stretched penile length of less than 1.9 cm need evaluation. Based on etiology they can be classified as hypogonadotropic hypogonadism (hypothalamic or pituitary failure), hypergonadotropic hypogonadism (testicular failure), partial androgen insensitivity syndrome and idiopathic groups. The help of a pediatric endocrinologist, geneticist, pediatric surgeon and/or urologist is often necessary. Growth velocity is an important determinant of associated hypothalamic or pituitary pathology. GnRH and/or hCG stimulation tests are often helpful in evaluating the etiology. Similarly chromosomal studies are indicated in a few. Often the diagnosis is inferred by the presence of clinical features suggestive of a syndrome usually associated with hypogonadotropic hypogonadism. Irrespective of the underlying cause a short course of testosterone should be tried in patients with micropenis and an assessment of the penis to respond should be made. Transdermal DHT has also been reported to be effective in prepubertal children. Children with hypopituitarism and GH deficiency respond to appropriate hormonal therapy. Surgical correction is not indicated in the common endocrine types of micropenis. Many studies have shown that most testosterone treated children have satisfactory gain in length of penis and sexual function. Thus sexual reassignment is done very infrequently now.

Sexual activity and other high-risk behaviors in adolescents with chronic illness: a review

This article is a literature review of high-risk behaviors, including sexual activity, in adolescents with chronic illness. Three different models describing biopsychosocial constructs for risky behaviors are discussed. Regarding specific behaviors, findings from the literature include a substantial prevalence of sexual activity, but low level of knowledge and low prevalence of contraceptive use, in youth with chronic illness. Regarding substance use, alcohol was the most commonly used substance regardless of medical condition. Overall, substance use, as well as delinquent behavior, was lower among youth with chronic illness when compared to that in comparison groups. Results were mixed regarding the prevalence and determinants of unhealthy eating habits in these populations. Although high-risk behaviors in teenagers with chronic illness may be a normal part of development, awareness of their prevalence, along with early identification and counseling are important in order to anticipate adverse effects on their medical conditions.

Reconstitution of human corporal smooth muscle and endothelial cells in vivo

PURPOSE

The availability of autologous erectile tissue composed of corporal smooth muscle and endothelial cells would be beneficial in patients undergoing penile reconstruction. We previously showed that cultured cavernous cells seeded on polymer scaffolds form corporal muscle when implanted in vivo. However, to reconstruct corporal tissue endothelial and corporal muscle cells are necessary. In this study we investigated the possibility of developing tissue composed of corporal cells in vivo by combining smooth muscle and endothelial cells.

MATERIALS AND METHODS

Human corporal smooth muscle and endothelial cells were seeded on biodegradable polyglycolic acid polymer scaffolds at concentrations of 20 x 10(6) and 10 x 10(6) cells per cm3, respectively. A total of 60 polymer scaffolds seeded with cells and 20 control polymers without cells were implanted in the subcutaneous space of 20 athymic mice. Mice were sacrificed 1, 3, 5, 7, 14, 21, 28 and 42 days, respectively, after implantation. Immunocytochemical and histochemical analyses were performed with antifactor VIII, antipancytokeratins and anti-alpha actin antibodies.

RESULTS

Histologically the retrieved polymers seeded with corporal smooth muscle and endothelial cells showed the formation of multilayered smooth muscle strips adjacent to endothelial cells 7 days after implantation. Increased organization of the smooth muscle tissue and accumulation of endothelium lining the luminal structures were evident by 14 days. A well organized tissue construct was noted 28 and 42 days after implantation. There was no evidence of tissue formation in controls. Immunocytochemical analysis using antifactor VIII to identify native vasculature only and antipancytokeratins to identify ECV 304 endothelial cells only distinguished the origin of the vascular structures in each construct. Anti-alpha-actin confirmed the smooth muscle phenotype.

CONCLUSIONS

Human corporal smooth muscle and endothelial cells seeded on biodegradable polymer scaffolds formed vascularized corpus cavernosum muscle when implanted in vivo. To our knowledge this is the first demonstration in tissue engineering in which capillary formation was facilitated by the addition of endothelial cells in composite tissue in vivo.

Reconstitution of human corporal smooth muscle and endothelial cells in vivo

PURPOSE

The availability of autologous erectile tissue composed of corporal smooth muscle and endothelial cells would be beneficial in patients undergoing penile reconstruction. We previously showed that cultured cavernous cells seeded on polymer scaffolds form corporal muscle when implanted in vivo. However, to reconstruct corporal tissue endothelial and corporal muscle cells are necessary. In this study we investigated the possibility of developing tissue composed of corporal cells in vivo by combining smooth muscle and endothelial cells.

MATERIALS AND METHODS

Human corporal smooth muscle and endothelial cells were seeded on biodegradable polyglycolic acid polymer scaffolds at concentrations of 20 x 10(6) and 10 x 10(6) cells per cm3, respectively. A total of 60 polymer scaffolds seeded with cells and 20 control polymers without cells were implanted in the subcutaneous space of 20 athymic mice. Mice were sacrificed 1, 3, 5, 7, 14, 21, 28 and 42 days, respectively, after implantation. Immunocytochemical and histochemical analyses were performed with antifactor VIII, antipancytokeratins and anti-alpha actin antibodies.

RESULTS

Histologically the retrieved polymers seeded with corporal smooth muscle and endothelial cells showed the formation of multilayered smooth muscle strips adjacent to endothelial cells 7 days after implantation. Increased organization of the smooth muscle tissue and accumulation of endothelium lining the luminal structures were evident by 14 days. A well organized tissue construct was noted 28 and 42 days after implantation. There was no evidence of tissue formation in controls. Immunocytochemical analysis using antifactor VIII to identify native vasculature only and antipancytokeratins to identify ECV 304 endothelial cells only distinguished the origin of the vascular structures in each construct. Anti-alpha-actin confirmed the smooth muscle phenotype.

CONCLUSIONS

Human corporal smooth muscle and endothelial cells seeded on biodegradable polymer scaffolds formed vascularized corpus cavernosum muscle when implanted in vivo. To our knowledge this is the first demonstration in tissue engineering in which capillary formation was facilitated by the addition of endothelial cells in composite tissue in vivo.

Disorders of sexual differentiation

An infant born with ambiguous genitalia requires an accurate and prompt diagnosis so that a management plan can be formulated. This article discusses the signaling cascade of genes that controls sexual differentiation. Clinical disorders involving sex reversal or ambiguous genitalia are discussed in relation to the genes regulating sexual development. An approach to the treatment of these disorders is outlined.

Somatic function, mental health and psychosocial functioning in 22 adolescents with bladder exstrophy and epispadias

PURPOSE

We report the long-term somatic outcome, mental health and psychosocial adjustment in adolescents with bladder exstrophy and epispadias.

MATERIALS AND METHODS

A total of 22 adolescents 11 to 20 years old (median age 14.5), including 19 with bladder exstrophy and 3 with epispadias, were assessed for urogenital status, stoma, renal and bowel function, anorectal physiology, mental health and psychosocial functioning by physical examinations, semistructured interviews and standardized questionnaires. The parents of 21 patients were interviewed and completed questionnaires. Information was also obtained on control groups.

RESULTS

Of the 22 patients 9 (41%) had no urinary diversion and were urinary incontinent, 6 (27%) had persistent fecal staining and anal canal pressures that were lower than the controls, 10 (59%) were dissatisfied with the penile appearance and 11 (50%) met the criteria for psychiatric diagnoses. The main predictors of mental health were parental warmth and patient genital appraisal in the 11 to 14-year age group, and parental warmth and urinary continence function in the 15 to 20-year age group. Psychosocial dysfunction was predicted by fecal incontinence in the younger group and worries about future sexual relationships in the older group.

CONCLUSIONS

The present multimodal outcome study revealed that adolescents with bladder exstrophy and epispadias had significant physical and mental problems. Genital malformation, and urinary and fecal incontinence may have a negative impact on mental health and psychosocial functioning. Our findings emphasize the need to include psychosocial experts on health care teams to reveal the amount of distress caused by these anomalies and to offer psychosocial support.

Exstrophic anomalies: recent advances and long-term outlook

Exstrophy-epispadias complex has been a difficult disease to treat. As in the minds of the public and most physicians alike, these children are crippled with life-long ailments and multiple operations. Much of the morbidity of this condition relates to failure to preserve urogenital tract function in these children. In recent years, through better understanding of the exstrophic anatomy and improved surgical techniques, complete repair of the exstrophic anomaly has become possible as soon as the child is born. Results of such closure indicate that such repair is not only feasible but mandatory for a successful outcome. Continence rate and cosmetic appearance are superior to the conventional 3-stage technique. Such repair is also socially acceptable as the parents will bring home a normal-looking baby with much fewer operations expected in the future. It is anticipated that complete one-stage exstrophy closure in the newborn period will revolutionize the outcome of all exstrophy patients.