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Reconstruction of long posterior urethra defect is technically challenging. Substitution urethroplasty is used in long, complex, recurrent posterior urethral strictures. This article presents a modified technique and the clinical outcome of two-stage substitution urethroplasty with appendix free flap and microvascular anastomosis. A three-year-old boy with a 5 cm iatrogenic posterior urethral defect was managed by urethral substitution using the appendix. An appendix-free flap was used according to anatomic limitations, employing the transposed inferior epigastric artery and saphenous vein to maintain conduit blood supply. The conduit was buried in the scrotum for 3 weeks and its viability monitored until the final reconstructive stage. Two-year follow-up with ultrasound and cystoscopy revealed satisfactory results. A well-vascularised bed and flap are the mainstays of substitution urethroplasty, so we suggest inferior epigastric artery perineal transposition and staged reconstruction as alternatives that may improve the blood supply of the neourethra.

Background: Urodynamic studies (UDS) is a simple non-invasive test to assess lower urinary tract function but it may be affected by several factors includes age, sex, voiding volume and voiding position. These interventional parameters become more highlighted while performing UDS in children whose emotional stress control and coping with unfamiliar situation is more difficult. Methods: Seventy six primary school age healthy children underwent screening uroflowmetry in different voiding positions voluntarily. Cases with urinary symptoms, other coexisting diseases, voiding volume less than 20cc or staccato voiding curve were excluded. Washrooms were designed in both western and eastern styles. UDS indexes were compared regarding voiding habits. Results: Comparison of uroflowmetric indexes between different genders and voiding positions showed differences which were not statistically significant but considering the voiding habits, uroflowmetric indexes were significantly different in familiar compare to unfamiliar voiding position. Q-Max was lower and time to Q-Max and micturition time were longer in unfamiliar voiding position. Conclusions: Urodynamic studies in children should be performed in preferred voiding position for each kid considering the culture and voiding habits. Unfamiliar voiding position may turn the uroflowmetry to a stressful experience for child that make him uncooperative and cause misleading results.

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