INTRODUCTION AND OBJECTIVE: Hypospadias is a congenital anomaly most often identified and surgica... more INTRODUCTION AND OBJECTIVE: Hypospadias is a congenital anomaly most often identified and surgically addressed in childhood. The management of distant complications following hypospadias repair is not well documented METHODS: The records of 33 patients, from 1992 to 2003 , with a history of hypospadias repair requiring urethral reconstruction as adults were prospectively entered into a database. Variables of interest were pre-operative symptoms, diagnosis (e.g. stricture, urethrocutaneous fistula, distal failure of hypospadias repair), length and number of strictures, and fistula location. The type and technical specifics of each urethroplasty including post operative outcomes and complications were recorded. RESULTS: Mean followup is 73 months. Table I illustrates the results of 33 patients with previous chi ldhood hypospadias repairs treated with urethroplasty iden tified by location of le sion. Legend: End to end anastomosis=E/E, Fasciocutaneous penile flap=FCF , Perineal urethrostomy=PU, Acellu lar matrix = AM, Myocutaneous flap =MCF CONCLUSIONS : Using a variety of urethroplasty techniques individualized for each patient, adults with complications of previous hypospadias surgery can be reconstructed successfully in a majority of cases. When penile skin is avai lable, fasciocutaneous penile flaps appear to be effective with a low failure rate .
OBJECTIVE The objective of this study was to assess the prevalence and spectrum of spinal dysraph... more OBJECTIVE The objective of this study was to assess the prevalence and spectrum of spinal dysraphism in a cohort of children with cloacal exstrophy (CEX) using MRI. METHODS Children with CEX presenting between 1999 and 2019 with baseline spinal MRI were included. The images were reviewed in consensus to assess the type of dysraphism. The dysraphisms were initially reviewed and described based on their descriptive anatomy, and then classified according to anomalies of gastrulation, primary neurulation, or secondary neurulation. RESULTS Thirty-four children were included. Thirty-three of these children had closed spinal dysraphism, and 1 had a normal spine. Of the 33 cases of closed spinal dysraphism, the conus and/or filum terminale were involved in all cases. The most common malformations were spinal lipoma (n = 20) and terminal myelocystocele (n = 11). The lipomas were heterogeneous: 4 dorsal, 9 transitional, 4 chaotic, and 3 terminal. A large subgroup (10/20, 50%) within the lipom...
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 2003
Fetal bladder outflow obstruction, predominantly caused by posterior urethral valves, results in ... more Fetal bladder outflow obstruction, predominantly caused by posterior urethral valves, results in significant urinary tract pathology; these lesions are the commonest cause of end-stage renal failure in children, and up to 50% continue to suffer from persistent postnatal bladder dysfunction. To investigate the physiological development of the fetal bladder and the response to urinary flow impairment, we performed partial urethral obstruction and complete urachal ligation in the midgestation fetal sheep for 30 days. By electrical and pharmacological stimulation of bladder strips, we found that muscarinic, purinergic, and nitrergic mechanisms exist in the developing fetal bladder at this gestation. After bladder outflow obstruction, the fetal bladder became hypocontractile, producing less force after nerve-mediated and muscarinic stimulation with suggested denervation, and also exhibited greater atropine resistance. Furthermore, fetal bladder urothelium exerted a negative inotropic eff...
Isolated bilateral simplex ectopic ureters (BSEUs) are rare but pose a therapeutic challenge: ure... more Isolated bilateral simplex ectopic ureters (BSEUs) are rare but pose a therapeutic challenge: ureteric reimplantation alone does not accomplish continence in all. Identifying the patients needing additional procedures for continence early could prevent multiple operations. Potential preoperative indicators for postoperative continence are explored in eight BSEU girls without cloacal, anorectal, or spinal anomalies. With institutional approval, all patients with BSEU between 1985 and 2012 were retrospectively reviewed. Cystoscopy determined the site of ureteric ectopia (6 of 16 at the bladder neck [BN], 5 of 16 below the BN, and 5 of 16 in the distal urethra). Bladders were assessed by a combination of ultrasound, urodynamics, micturating cystourethrogram, cystoscopic, and intraoperative observations. Expected bladder capacity for age (EBCA) was calculated by 30 ml + (30 ml × age in years) or 38 ml + (2.5 ml × age in months) for children greater or less than 2 years, respectively. Co...
Cloacal exstrophy is the most complex congenital, ventral, abdominal wall defect. Traditionally s... more Cloacal exstrophy is the most complex congenital, ventral, abdominal wall defect. Traditionally surgery consists of a staged approach to repair which takes place on many separate theatre visits. In this case a primary approach was undertaken resulting in a relatively short inpatient stay and a reduced risk from multiple surgical procedures under general anaesthesia.
Anthony Michael Kent Rickwood (“Tony”) had a seminal role in establishing paediatric urology as a... more Anthony Michael Kent Rickwood (“Tony”) had a seminal role in establishing paediatric urology as a recognised specialty in the UK and was a founder member of the British Association of Paediatric Urologists in 1990. He was an internationally recognised authority on the paediatric neuropathic bladder. Tony was born on 23 February 1940 in London, where his father was a chemical engineer with ICI. After the war, during which Tony was briefly evacuated to Durham, his family moved to Sheffield, where he spent his childhood and attended King Edward VII School. An outstanding pupil, he won an open scholarship to University College, Oxford, qualifying in medicine in 1965. After junior posts at the Radcliffe Infirmary and a demonstratorship in human anatomy, he returned to Sheffield for his general surgical training at the Royal Hospital. The rotation introduced him to urology, renal transplantation, and paediatric surgery, and in 1974 he started his specialist training in paediatric surgery at Sheffield’s Children’s Hospital. In 1979 Tony was appointed to a newly created consultant post in spinal injuries and spina bifida at Sheffield Children’s Hospital and Lodge Moor spinal injuries unit, where he established an innovative …
Hypospadias is one of the most commonly diagnosed male congenital disorders. Many surgical techni... more Hypospadias is one of the most commonly diagnosed male congenital disorders. Many surgical techniques are described and complications often reported include fistula, wound dehiscence, and meatal stenosis. Many surgeons still believe that hypospadias should be surgically corrected before the age of 12 months. However, it is clear that the longer the follow up, the more complications are reported. Correction of a failed hypospadias repair in adult patients can be challenging. While the need for repair of proximal hypospadias during childhood is evident, distal repair during childhood is questionable. Evidence suggests that the psychosexual and functional outcomes of nonoperated distal hypospadias in the adult population are good. Therefore, the benefit of surgery and the burden of complications must be carefully evaluated. This paper highlights the difficulties inherent in decisions related to the assessment of hypospadias, the need for repair, and the paucity of good long-term data.
Purpose: Congenital bladder outflow obstruction caused by posterior urethral valves is a common c... more Purpose: Congenital bladder outflow obstruction caused by posterior urethral valves is a common cause of end stage renal failure in boys. We hypothesized that fetal bladder outflow obstruction perturbs detrusor contractility and innervation and bladder storage volume-pressure relationships. Materials and Methods: Severe bladder outflow obstruction was induced in male fetal sheep by placing a urethral ring and urachal ligation midway through gestation at 75 days. Fetuses were examined 30 days after surgery, when urinary tract dilatation, enlarged bladders and histologically abnormal kidneys were documented. Isolated strips of bladder detrusor from sham operated and obstructed fetuses were subjected to electrical field stimulation, carbachol, KCl and ␣- methyleneadenosine triphosphate. Whole bladder storage characteristics were determined by filling cystometry and bladder innervation was investigated by immunohistochemistry and Western blot. Results: Tension-frequency contractility studies showed that obstructed fetal bladder strips were significantly hypocontractile versus sham operated controls in response to electrical field stimulation and the specific agonists carbachol, KCl and ␣- methylene-adenosine triphosphate. Hypocontractility was greater with nerve mediated stimulation than with carbachol, suggesting relative denervation. Reduced innervation was confirmed by S100 and protein gene product 9.5 immunohistochemistry and by measuring a significant reduction in protein gene product 9.5 protein expression using Western blot. Filling cystometry showed that obstructed fetal bladders appeared more compliant (⌬V/⌬P, where ⌬V is the change in volume and ⌬P is the change in pressure) with larger capacity, more flaccidity and yet retained stress relaxation. Conclusions: In response to severe experimental fetal bladder outflow obstruction the bladder becomes large and hypocontractile, and has aberrant innervation.
Purpose: To characterize intracellular Ca 2+ ([Ca 2+ ] i) regulation in fetal bladders following ... more Purpose: To characterize intracellular Ca 2+ ([Ca 2+ ] i) regulation in fetal bladders following outflow obstruction by examining Ca 2+ response to agonists in smooth muscle cells. Materials and Methods: Severe bladder outflow obstruction (BOO) was induced in male fetal sheep by placing a urethral ring and urachal ligation midway through gestation at 75 days. Fetuses were examined 30 days after surgery. [Ca 2+ ] i in single smooth muscle cells isolated from bladder wall was measured with epifluorescence microscopy using Fura-2 AM during exposure to agonists, such as carbachol and ATP, and other activators, such as caffeine and KCl. Results: Detrusor smooth muscle cells from obstructed bladders had similar resting [Ca 2+ ] i to those of sham-operated controls. The maximal response to carbachol was reduced following obstruction (p<0.05), and construction of dose-response curves also demonstrated a higher EC50 values (p<0.05). These changes were however not mirrored by caffeine-evoked Ca 2+ release, which was not significantly different between the obstruction group and sham-operated controls. Kinetic analysis of carbachol transients further revealed an attenuated maximal rate of rise in obstructed bladders (p<0.01). The magnitude of [Ca 2+ ] i to purinergic neurotransmitter ATP was also found to be smaller in cells from obstructed bladders (p<0.05), although trans-membrane influx by high K depolarization was not significantly affected. Conclusions: Muscarinic and purinergic pathways were down-regulated in fetal detrusor muscle following outflow obstruction. These major functional receptors appeared to be more susceptible to obstruction than other Ca 2+ regulators and their impairment may contribute to compromised contractile function seen with in utero BOO.
Following failed primary reconstruction, various single-stage reconstructive techniques have been... more Following failed primary reconstruction, various single-stage reconstructive techniques have been proposed for secondary hypospadias repair. Unfortunately, these frequently fail to achieve a satisfactory cosmetic and functional outcome. We review a single surgeon&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s experience of two-staged reconstruction in this scenario. Of 104 patients with hypospadias treated in two stages, between July 1998 and June 2003, 42 were secondary reconstructions. The site of the meatus after initial failed repair was glanular (5), subcoronal (11), distal shaft (12), mid-shaft (6) or peno-scrotal (8). Factors associated with the choice of two-stage reconstruction included moderate/severe chordee (14), excessive scarring (15), shallow/no groove or poor glans (8), and balanitis xerotica obliterans (4). The grafts used were post-auricular skin (PAWG, 29) buccal mucosa (BMG, 6), inner prepuce (IP, 6) and one composite graft. The mean age of our patients was 131 months and the average follow up after the second stage was 26.3 months. In 40 of the 42 cases the graft took well. In one patient a PAWG developed keloid scarring which was excised and later successfully replaced with a BMG. In another, severe shrinkage of a BMG led to revision with a PAWG. Following the second stage, complications were experienced in five: the repair broke down in two BMG patients and was successfully reconstructed with a PAWG in both, and three developed fistulae that were repaired (1 PAWG, 1 BMG, 1 IP). The two-staged reconstruction is a versatile and technically straightforward secondary procedure for this difficult patient cohort. Excellent cosmetic and functional results can be achieved with only a small risk of a revision operation. Four of our six BMG patients experienced problems and PAWG appears more satisfactory with superior results.
The reviewer's comments are shown in italics and our responses are shown directly following each ... more The reviewer's comments are shown in italics and our responses are shown directly following each of his/her points. We appreciate the thoughtful comments provided by the reviewer and we have tried to answer these to our best ability. Please consider our responses for this paper alongside those for the accompanying paper (JPUROL-D-05-00239: Experimental short term fetal bladder outflow obstruction: I. Effects on morphology and cell biology). Major changes to the text in response to the referee's criticisms are underlined in the main text of the revised version. This study is submitted in conjunction with the report that describes the morphological alterations of short term bladder obstruction in the fetal lamb. This study presents the alterations in compliance and contractility. As noted before, these studies would be better presented together with a summation of data to permit a more consolidated view of the data, rather than fragmenting them, leaving the reader uncertain as to their interaction. The reviewer suggests that the two current reports could have been combined into one paper. While we quite agree that it is not appropriate to 'stretch-out' studies with only a few data sets over multiple papers, we feel that each of the current papers is already quite 'data-rich', with the morphology and physiology having been studied in some detail with a wide variety of methodologies. Thus, a combined paper would have a Results section with a large number of figures (many of which already have multiple frames within them)-this amount of original data is surely beyond the limit of a single article.
INTRODUCTION AND OBJECTIVE: Hypospadias is a congenital anomaly most often identified and surgica... more INTRODUCTION AND OBJECTIVE: Hypospadias is a congenital anomaly most often identified and surgically addressed in childhood. The management of distant complications following hypospadias repair is not well documented METHODS: The records of 33 patients, from 1992 to 2003 , with a history of hypospadias repair requiring urethral reconstruction as adults were prospectively entered into a database. Variables of interest were pre-operative symptoms, diagnosis (e.g. stricture, urethrocutaneous fistula, distal failure of hypospadias repair), length and number of strictures, and fistula location. The type and technical specifics of each urethroplasty including post operative outcomes and complications were recorded. RESULTS: Mean followup is 73 months. Table I illustrates the results of 33 patients with previous chi ldhood hypospadias repairs treated with urethroplasty iden tified by location of le sion. Legend: End to end anastomosis=E/E, Fasciocutaneous penile flap=FCF , Perineal urethrostomy=PU, Acellu lar matrix = AM, Myocutaneous flap =MCF CONCLUSIONS : Using a variety of urethroplasty techniques individualized for each patient, adults with complications of previous hypospadias surgery can be reconstructed successfully in a majority of cases. When penile skin is avai lable, fasciocutaneous penile flaps appear to be effective with a low failure rate .
OBJECTIVE The objective of this study was to assess the prevalence and spectrum of spinal dysraph... more OBJECTIVE The objective of this study was to assess the prevalence and spectrum of spinal dysraphism in a cohort of children with cloacal exstrophy (CEX) using MRI. METHODS Children with CEX presenting between 1999 and 2019 with baseline spinal MRI were included. The images were reviewed in consensus to assess the type of dysraphism. The dysraphisms were initially reviewed and described based on their descriptive anatomy, and then classified according to anomalies of gastrulation, primary neurulation, or secondary neurulation. RESULTS Thirty-four children were included. Thirty-three of these children had closed spinal dysraphism, and 1 had a normal spine. Of the 33 cases of closed spinal dysraphism, the conus and/or filum terminale were involved in all cases. The most common malformations were spinal lipoma (n = 20) and terminal myelocystocele (n = 11). The lipomas were heterogeneous: 4 dorsal, 9 transitional, 4 chaotic, and 3 terminal. A large subgroup (10/20, 50%) within the lipom...
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 2003
Fetal bladder outflow obstruction, predominantly caused by posterior urethral valves, results in ... more Fetal bladder outflow obstruction, predominantly caused by posterior urethral valves, results in significant urinary tract pathology; these lesions are the commonest cause of end-stage renal failure in children, and up to 50% continue to suffer from persistent postnatal bladder dysfunction. To investigate the physiological development of the fetal bladder and the response to urinary flow impairment, we performed partial urethral obstruction and complete urachal ligation in the midgestation fetal sheep for 30 days. By electrical and pharmacological stimulation of bladder strips, we found that muscarinic, purinergic, and nitrergic mechanisms exist in the developing fetal bladder at this gestation. After bladder outflow obstruction, the fetal bladder became hypocontractile, producing less force after nerve-mediated and muscarinic stimulation with suggested denervation, and also exhibited greater atropine resistance. Furthermore, fetal bladder urothelium exerted a negative inotropic eff...
Isolated bilateral simplex ectopic ureters (BSEUs) are rare but pose a therapeutic challenge: ure... more Isolated bilateral simplex ectopic ureters (BSEUs) are rare but pose a therapeutic challenge: ureteric reimplantation alone does not accomplish continence in all. Identifying the patients needing additional procedures for continence early could prevent multiple operations. Potential preoperative indicators for postoperative continence are explored in eight BSEU girls without cloacal, anorectal, or spinal anomalies. With institutional approval, all patients with BSEU between 1985 and 2012 were retrospectively reviewed. Cystoscopy determined the site of ureteric ectopia (6 of 16 at the bladder neck [BN], 5 of 16 below the BN, and 5 of 16 in the distal urethra). Bladders were assessed by a combination of ultrasound, urodynamics, micturating cystourethrogram, cystoscopic, and intraoperative observations. Expected bladder capacity for age (EBCA) was calculated by 30 ml + (30 ml × age in years) or 38 ml + (2.5 ml × age in months) for children greater or less than 2 years, respectively. Co...
Cloacal exstrophy is the most complex congenital, ventral, abdominal wall defect. Traditionally s... more Cloacal exstrophy is the most complex congenital, ventral, abdominal wall defect. Traditionally surgery consists of a staged approach to repair which takes place on many separate theatre visits. In this case a primary approach was undertaken resulting in a relatively short inpatient stay and a reduced risk from multiple surgical procedures under general anaesthesia.
Anthony Michael Kent Rickwood (“Tony”) had a seminal role in establishing paediatric urology as a... more Anthony Michael Kent Rickwood (“Tony”) had a seminal role in establishing paediatric urology as a recognised specialty in the UK and was a founder member of the British Association of Paediatric Urologists in 1990. He was an internationally recognised authority on the paediatric neuropathic bladder. Tony was born on 23 February 1940 in London, where his father was a chemical engineer with ICI. After the war, during which Tony was briefly evacuated to Durham, his family moved to Sheffield, where he spent his childhood and attended King Edward VII School. An outstanding pupil, he won an open scholarship to University College, Oxford, qualifying in medicine in 1965. After junior posts at the Radcliffe Infirmary and a demonstratorship in human anatomy, he returned to Sheffield for his general surgical training at the Royal Hospital. The rotation introduced him to urology, renal transplantation, and paediatric surgery, and in 1974 he started his specialist training in paediatric surgery at Sheffield’s Children’s Hospital. In 1979 Tony was appointed to a newly created consultant post in spinal injuries and spina bifida at Sheffield Children’s Hospital and Lodge Moor spinal injuries unit, where he established an innovative …
Hypospadias is one of the most commonly diagnosed male congenital disorders. Many surgical techni... more Hypospadias is one of the most commonly diagnosed male congenital disorders. Many surgical techniques are described and complications often reported include fistula, wound dehiscence, and meatal stenosis. Many surgeons still believe that hypospadias should be surgically corrected before the age of 12 months. However, it is clear that the longer the follow up, the more complications are reported. Correction of a failed hypospadias repair in adult patients can be challenging. While the need for repair of proximal hypospadias during childhood is evident, distal repair during childhood is questionable. Evidence suggests that the psychosexual and functional outcomes of nonoperated distal hypospadias in the adult population are good. Therefore, the benefit of surgery and the burden of complications must be carefully evaluated. This paper highlights the difficulties inherent in decisions related to the assessment of hypospadias, the need for repair, and the paucity of good long-term data.
Purpose: Congenital bladder outflow obstruction caused by posterior urethral valves is a common c... more Purpose: Congenital bladder outflow obstruction caused by posterior urethral valves is a common cause of end stage renal failure in boys. We hypothesized that fetal bladder outflow obstruction perturbs detrusor contractility and innervation and bladder storage volume-pressure relationships. Materials and Methods: Severe bladder outflow obstruction was induced in male fetal sheep by placing a urethral ring and urachal ligation midway through gestation at 75 days. Fetuses were examined 30 days after surgery, when urinary tract dilatation, enlarged bladders and histologically abnormal kidneys were documented. Isolated strips of bladder detrusor from sham operated and obstructed fetuses were subjected to electrical field stimulation, carbachol, KCl and ␣- methyleneadenosine triphosphate. Whole bladder storage characteristics were determined by filling cystometry and bladder innervation was investigated by immunohistochemistry and Western blot. Results: Tension-frequency contractility studies showed that obstructed fetal bladder strips were significantly hypocontractile versus sham operated controls in response to electrical field stimulation and the specific agonists carbachol, KCl and ␣- methylene-adenosine triphosphate. Hypocontractility was greater with nerve mediated stimulation than with carbachol, suggesting relative denervation. Reduced innervation was confirmed by S100 and protein gene product 9.5 immunohistochemistry and by measuring a significant reduction in protein gene product 9.5 protein expression using Western blot. Filling cystometry showed that obstructed fetal bladders appeared more compliant (⌬V/⌬P, where ⌬V is the change in volume and ⌬P is the change in pressure) with larger capacity, more flaccidity and yet retained stress relaxation. Conclusions: In response to severe experimental fetal bladder outflow obstruction the bladder becomes large and hypocontractile, and has aberrant innervation.
Purpose: To characterize intracellular Ca 2+ ([Ca 2+ ] i) regulation in fetal bladders following ... more Purpose: To characterize intracellular Ca 2+ ([Ca 2+ ] i) regulation in fetal bladders following outflow obstruction by examining Ca 2+ response to agonists in smooth muscle cells. Materials and Methods: Severe bladder outflow obstruction (BOO) was induced in male fetal sheep by placing a urethral ring and urachal ligation midway through gestation at 75 days. Fetuses were examined 30 days after surgery. [Ca 2+ ] i in single smooth muscle cells isolated from bladder wall was measured with epifluorescence microscopy using Fura-2 AM during exposure to agonists, such as carbachol and ATP, and other activators, such as caffeine and KCl. Results: Detrusor smooth muscle cells from obstructed bladders had similar resting [Ca 2+ ] i to those of sham-operated controls. The maximal response to carbachol was reduced following obstruction (p<0.05), and construction of dose-response curves also demonstrated a higher EC50 values (p<0.05). These changes were however not mirrored by caffeine-evoked Ca 2+ release, which was not significantly different between the obstruction group and sham-operated controls. Kinetic analysis of carbachol transients further revealed an attenuated maximal rate of rise in obstructed bladders (p<0.01). The magnitude of [Ca 2+ ] i to purinergic neurotransmitter ATP was also found to be smaller in cells from obstructed bladders (p<0.05), although trans-membrane influx by high K depolarization was not significantly affected. Conclusions: Muscarinic and purinergic pathways were down-regulated in fetal detrusor muscle following outflow obstruction. These major functional receptors appeared to be more susceptible to obstruction than other Ca 2+ regulators and their impairment may contribute to compromised contractile function seen with in utero BOO.
Following failed primary reconstruction, various single-stage reconstructive techniques have been... more Following failed primary reconstruction, various single-stage reconstructive techniques have been proposed for secondary hypospadias repair. Unfortunately, these frequently fail to achieve a satisfactory cosmetic and functional outcome. We review a single surgeon&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s experience of two-staged reconstruction in this scenario. Of 104 patients with hypospadias treated in two stages, between July 1998 and June 2003, 42 were secondary reconstructions. The site of the meatus after initial failed repair was glanular (5), subcoronal (11), distal shaft (12), mid-shaft (6) or peno-scrotal (8). Factors associated with the choice of two-stage reconstruction included moderate/severe chordee (14), excessive scarring (15), shallow/no groove or poor glans (8), and balanitis xerotica obliterans (4). The grafts used were post-auricular skin (PAWG, 29) buccal mucosa (BMG, 6), inner prepuce (IP, 6) and one composite graft. The mean age of our patients was 131 months and the average follow up after the second stage was 26.3 months. In 40 of the 42 cases the graft took well. In one patient a PAWG developed keloid scarring which was excised and later successfully replaced with a BMG. In another, severe shrinkage of a BMG led to revision with a PAWG. Following the second stage, complications were experienced in five: the repair broke down in two BMG patients and was successfully reconstructed with a PAWG in both, and three developed fistulae that were repaired (1 PAWG, 1 BMG, 1 IP). The two-staged reconstruction is a versatile and technically straightforward secondary procedure for this difficult patient cohort. Excellent cosmetic and functional results can be achieved with only a small risk of a revision operation. Four of our six BMG patients experienced problems and PAWG appears more satisfactory with superior results.
The reviewer's comments are shown in italics and our responses are shown directly following each ... more The reviewer's comments are shown in italics and our responses are shown directly following each of his/her points. We appreciate the thoughtful comments provided by the reviewer and we have tried to answer these to our best ability. Please consider our responses for this paper alongside those for the accompanying paper (JPUROL-D-05-00239: Experimental short term fetal bladder outflow obstruction: I. Effects on morphology and cell biology). Major changes to the text in response to the referee's criticisms are underlined in the main text of the revised version. This study is submitted in conjunction with the report that describes the morphological alterations of short term bladder obstruction in the fetal lamb. This study presents the alterations in compliance and contractility. As noted before, these studies would be better presented together with a summation of data to permit a more consolidated view of the data, rather than fragmenting them, leaving the reader uncertain as to their interaction. The reviewer suggests that the two current reports could have been combined into one paper. While we quite agree that it is not appropriate to 'stretch-out' studies with only a few data sets over multiple papers, we feel that each of the current papers is already quite 'data-rich', with the morphology and physiology having been studied in some detail with a wide variety of methodologies. Thus, a combined paper would have a Results section with a large number of figures (many of which already have multiple frames within them)-this amount of original data is surely beyond the limit of a single article.
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