International Abstracts 895

chemistry using antibodies against the neuronal markers PGP 9.5, CGRP

and substance P (SP). The number of stained nerves was counted manually.

PGP 9.5- and CGRP-positive nerves were significantly reduced in

hypospadiac prepuce. PGP 9.5-fibers were found only in the reticular dermis

of hypospadiac skin with less localization in epidermis and papillary dermis,

but in normal skin, fine fibers were distributed in all layers. CGRP nerves

could be analyzed around blood vessels only. SP fibers were increased and

were even mainly localized around the blood vessels.

Trauma and ischemia release neuropeptides from sensory nerves into the

surrounding tissue to improve inflammation and wound healing. The

prominent effect of CGRP is vasodilatation and chemotaxis of neutrophils

and T lymphocytes. SP causes vasodilatation and opens endothelial gaps

resulting in edema. Chemotaxis to inflammatory cells and promotion of

fibroplast and keratinocyte proliferation are known together with increase

of EGF expression. Denervation or hypo- innervationmay slow downwound

healing by the reduction of inflammatory response and blood flow to the skin.

Whether the significant difference in the distribution and density of nerve

fibers in hypospadiac prepuce is responsible for healing disturbances and the

development of urethral fistulae remains unclear and needs a long-term

follow-up. Even the effect of preoperative epidural block and tourniquet on

the immunostaining is unknown. Further studies are necessary to elaborate

the physiological role of sensory nerves in the prepuce.—P. Schmittenbecher

Genetic and molecular aspects of hypospadiasUtsch B, Albers N, Ludwig M. Eur J Pediatr Surg 2004 (October);14:

292-304.

Hypospadias, a midline fusion defect of the male ventral urethra, is a

relatively common genital anomaly, occurring in 0.3-7 per 1000 live male

births. The anatomical location of the misplaced urethral meatus

determines the severity of this anomaly, with the severity increasing

from distal to proximal. Glandular and penile hypospadias, the most

common forms, often appear as an isolated anomaly and account for the

majority of hypospadias, whereas about 20% are classified as scrotal and

perineal types. These latter forms frequently occur in association with

other genital anomalies, such as microphallus, bifid scrotum, penoscrotal

transposition and cryptorchidism, and may represent an intersex

phenotype. Besides a higher incidence in consanguineous families and

a suggested recessive inheritance, a dominant transmission is likely in

other families. The recurrence risk in the next generation seems to be

correlated with the severity of hypospadias. Only 30% of severe

hypospadias can be attributed to defects in testosterone or adrenal steroid

hormone synthesis, receptor defects, syndrome-associated hypospadias,

chromosomal anomalies, defects of other genetic factors, or exogenous

forms. To identify the underlying causes of the remaining 70%

bidiopathicQ hypospadias, familial and twin studies should be performed.

Familial studies can help to identify gene loci and, subsequently,

candidate genes by mutational analysis. Either linkage analysis in large

families with many affected individuals suspicious for a monogenic trait

or association studies in cases of a complex inheritance in many families

with a few affected individuals can be performed. Microarrays and

proteomics can help to detect gene expression or protein differences.

Furthermore, genetically modified animal models can be used to detect

phylogenetically homologous genes in man. In addition to an optimal

documentation and acquisition of blood and tissue samples, this requires

a close cooperation between clinicians in the operative and non-operative

specialities as well as geneticists.—T.A. Angerpointner

A prospective audit of hypospadias correction in a regional pediatricsurgery centerHeer R, Dorkin TJ, Byrne RL, et al. Eur J Pediatr Surg 2004 (October);14:

328-332.

The aim of the study was to prospectively review the management and

treatment of hypospadias in a single regional center, and in particular, to

assess the spectrum of cases treated, techniques used and to determine the

nature of complications. One hundred and fifty-eight consecutive boys

underwent hypospadias repair over a 36-month period. Information was

collected prospectively and included the site of the urethral meatus, presence

of chordee, surgical technique employed, use of urinary diversion, and the

prescription of postoperative antibiotics and analgesics. One hundred and

fifty-seven procedures for hypospadias were performed. Single - stage

reconstruction was carried out in 145 boys. GRAP (glandular reconstruction

and preputioplasty) repair was the most common operation employed.

(n = 112). The overall fistula rate was 11.7%, with the majority of patients

having a satisfactory functional and cosmetic outcome. It is concluded that a

variety of techniques can be employed to provide satisfactory correction of

hypospadias with an increasing emphasis on single-stage day case

procedures. GRAP repair is the favored option for distal hypospadias and

incorporates preservation of the prepuce.—Thomas A. Angerpointner

Prolonged stenting does not prevent obstruction after TIP-repair whenthe glans was deeply incisedLorenz C, Schmedding A, Leutner A, et al. Eur J Pediatr Surg 2004

(October);14:322-327.

The aim of this study was to evaluate whether prolonged postoperative

stenting may reduce the risk of obstruction of the neo-urethra after TIP

repair with deep glandular incision. Twenty-seven patients were operated

on for penile hypospadias, using the TIP technique described by Snodgrass.

In contrast to a previous study with 8-10 days of postoperative catheter

drainage, the indwelling transurethral catheter was kept in place for

12-14 days. Deep incision of the urethral plate up to the tin of the glans is

the most remarkable surgical detail, resulting in a meatus on the top of the

glans, but in a defect on the dorsal rim of the neomeatus as well. After 3-6

months, 22 patients were re-investigated using a scheme to describe the

position of the neomeatus. Uroflowmetry was also performed. Information

was gained by phone in 3 children; 2 patients were lost to follow-up. Two

patients returned with a significant obstruction, including a urethro-

cutaneous fistula in one. In contrast to the good assessment by parents

and compared to the early appearance after catheter removal, a change in

meatal position was observed in the majority of patients. Only 6 children

preserved an unchanged meatal position, whereas the meatus lost its oval or

slit-like shape as well as its position on the tip of the glans in 16 patients.

However, despite one obstructive meatus in the coronal position, 15 patients

showed sufficient size and position of the meatus underneath the tip of the

glans. Uroflowmetry revealed reduced peak-flow values (mean: 8.1 ml/s) in

some of the 9 patients evaluated. It is thus concluded that prolonged stenting

does not give better results in those TIP repairs in whom the urethral plate

was incised across the rim of the neomeatus. The early excellent aspect of

the glans after stent oval is often impaired by partial closure of the glans

incision with a short-term change in size and position of the meatus. To

prevent this, the rim of the meatus should be kept completely epithelialized

during reconstruction.—Thomas A. Angerpointner

Clinical predictors for differential diagnosis of acute scrotumCiftci AO, Senocak ME, Cahit-Tanyel F, et al. Eur J Pediatr Surg 2004

(October);14:333-338.

Accurate and early diagnosis of acute scrota is of the utmost importance

to avoid testicular loss and/or needless surgery. The aim of this Study

was to analyse the clinical presentation and physical examination

parameters together with the results of imaging techniques in order to

find predictors for the differential diagnosis of acute scrotum with special

regard to testicular torsion (TT). One hundred and sixty children with a

mean age of 12.2 years were included. The study group was subdivided

into three groups: b testicular torsion (TT)Q, b torsion of testicular

appendage (TTA)Q and bepididymo-orchitis (EO)Q. The mean duration

of symptoms was 15 hours. No significant differences were noted

between the groups with regard to mean age and duration of symptoms.