Split prepuce in situ onlay hypospadias repair: 17 years of experience

PURPOSE

We report our 17-year experience using split prepuce in situ onlay hypospadias repair, including long-term followup of the first 100 patients initially reported on in 1998.

MATERIALS AND METHODS

We identified 421 patients who underwent in situ onlay repair. Charts were retrospectively reviewed to determine preoperative management, intraoperative details and complications.

RESULTS

In situ onlay repair was used to repair glanular hypospadias in 22 cases (5.2%), coronal hypospadias in 184 (43.7%), distal shaft hypospadias in 152 (36.1%), mid shaft hypospadias in 51 (12.1%), proximal shaft hypospadias in 7 (1.6%) and hypospadias in the penoscrotal region in 5 (1.2%). Repair was successful with 1 procedure in 376 patients (89.4%), which increased to 99.8% after a second procedure. Complications were defined as any problem that gave the surgeon or family reason for concern. Functional complications requiring reoperation occurred in 45 patients (10.6%). Minor complications requiring simple procedures or early postoperative evaluation occurred in 17 patients (4%). Concerns not requiring intervention occurred in 27 patients (6.4%). There were no urethral strictures. Three patients (0.7%) were lost to followup. Repair is pending in 1 patient.

CONCLUSIONS

In situ onlay repair preserves the urethral plate and allows the formation of a well vascularized flap with adequate tissue to completely cover the neourethra, resulting in a low rate of major complications. With longer followup, inclusion of more mid shaft repairs and expansion to more proximal degrees of hypospadias our complication rates are higher than previously reported but there have been no urethral strictures in 17 years of experience. Since complications present at a median of 158 days (mean 570) after the procedure, long-term followup is indicated.

Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center

PURPOSE

In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution.

MATERIALS AND METHODS

We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V).

RESULTS

We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury.

CONCLUSIONS

Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.

High-intensity, short-term biofeedback in children with Hinman's syndrome (non-neuropathic voiding dyssynergia)

OBJECTIVE

To evaluate the long-term response to high-intensity, short-term biofeedback in children with severe voiding dysfunction.

PATIENTS AND METHODS

We retrospectively reviewed patients who underwent short-term, high-intensity biofeedback therapy from 1996 to 2004. Improvement was classified based on clinical and radiographic findings. Patients were categorized as having Hinman's syndrome when, in addition to urinary incontinence, at least four of the following categories were present: sphincter dyssynergia, bladder trabeculation, large post-void residual (PVR), hydronephrosis, vesicoureteral reflux (VUR) and urinary tract infections. There were 14 patients (eight males and six females), 13 of whom had Hinman's syndrome. Age when biofeedback was initiated varied from 5.6 to 12.9 years (mu=8.9+/-2.2). Before biofeedback, all had large PVRs, bladder trabeculation and sphincter dyssynergia. Nine had hydronephrosis and five had VUR. One patient had renal failure.

RESULTS

Before biofeedback, the mean PVR was 109 ml (25-270 ml); after biofeedback, this decreased to 21 ml (0-150 ml), including two patients who eventually failed treatment. All 14 patients were able to relax their external sphincter and reduce the PVR during biofeedback and on short-term follow up. Long-term follow up (mu=59.4 months) in 12 patients established that seven had a durable response with remission of symptoms, reduced PVR and radiographic improvement. In three, symptoms partially recurred over time and two failed treatment completely.

CONCLUSION

Short-term, high-intensity biofeedback achieves a durable response in the majority of children with Hinman's syndrome. Long-term follow up is needed to assure compliance.

Parental preferences in the management of vesicoureteral reflux

PURPOSE

We determined parental preferences for the treatment of vesicoureteral reflux in their child.

MATERIALS AND METHODS

Parents of children with vesicoureteral reflux were prospectively recruited to evaluate choices in reflux management. In each case a standard questionnaire that described the treatment options for reflux was administered. Parents were asked to choose between long-term antibacterial prophylaxis with annual radiography studies and open or endoscopic treatment at each of 1 to 5 years of followup. They were also given the choice between open or endoscopic treatment. Annual resolution and/or correction rates provided for medical, surgical and endoscopic management were 20%, 95% to 100% and 80% after 1 or 2 injections, respectively.

RESULTS

We queried 91 families of female (81%) and male (19%) patients. Average duration of reflux followup was 2 years and mean patient age was 49.8 months. At diagnosis reflux was grades I to II in 65% of cases, grade III in 26% and grades IV to V in 9%. The majority of parents chose daily antibiotics over surgery if the child was predicted to have vesicoureteral reflux for 1 to 4 years. However, the majority chose ureteral reimplantation over daily antibiotics and yearly x-ray if a 5-year course was predicted. In contrast, parents chose daily antibiotics rather than endoscopic treatment if the anticipated interval was 1 to 3 years. After 3 years the majority preferred the endoscopic approach. Also, 60% of parents stated that they would choose endoscopic treatment over reimplantation, although the child may require repeat endoscopic treatment and there was a 20% chance of persistent vesicoureteral reflux.

CONCLUSIONS

Parents of children with vesicoureteral reflux prefer antibiotic prophylaxis as initial treatment. However, when daily antibiotics and yearly cystography may be required beyond 3 to 4 years, most parents would choose definitive correction. While endoscopic treatment is less effective than surgery, parents prefer endoscopic treatment, most likely because it is less invasive. Also, when compared directly against each other, the majority of parents stated that they would choose endoscopic treatment over surgery, although it has a lower success rate.

Early diuresis renogram findings predict success following pyeloplasty

PURPOSE

We sought to determine whether drainage across the ureteropelvic junction, as indicated by diuretic renography 3 months after pyeloplasty, is an adequate predictor of surgical success.

MATERIALS AND METHODS

The medical records of 150 children who underwent pyeloplasty from 1986 to 1995 were reviewed. After excluding nonevaluable cases a total of 127 renal units remained for investigation. Preoperatively each renal unit was examined with a standardized (well-tempered) furosemide stimulated renal scan. Postoperatively 60 renal units were evaluated with standardized diuretic renal scans at 3 and 12 months, 33 renal units at 3 months only and 34 renal units at 12 months only. Surgical success was defined by half-time less than 20 minutes on a standardized diuretic renogram.

RESULTS

Of the 33 renal units with a single postoperative study at 3 months 32 (97%) had halftime less than 20 minutes on diuretic renography. The remaining patient in this group with half-time greater than 20 minutes showed 60% improvement in half-time and did not require reoperation. Excluding those without delayed followup, surgical success was obtained in 93 of the 94 (99%) renal units. Among the 60 renal units evaluated with 2 postoperative renal scans success was noted in 48 (80%) and 59 (98%) at 3 and 12 months, respectively. Stenosis did not recur in 48 renal units with half-time less than 20 minutes 3 months after repair. In 1 case that had been treated for postoperative urinoma half-time was greater than 40 minutes at 3 months and repeat pyeloplasty was required.

CONCLUSIONS

Half-time less than 20 minutes 3 months after pyeloplasty predicts surgical success. Most renal units that improve but still have half-times greater than 20 minutes on an early diuretic renogram will demonstrate continued improvement in drainage patterns at 12 months. Those renal units that show no improvement at 3 months may require reoperation and those with half-time less than 20 minutes at 3 months do not require further evaluation.

Early diuresis renogram findings predict success following pyeloplasty

PURPOSE

We sought to determine whether drainage across the ureteropelvic junction, as indicated by diuretic renography 3 months after pyeloplasty, is an adequate predictor of surgical success.

MATERIALS AND METHODS

The medical records of 150 children who underwent pyeloplasty from 1986 to 1995 were reviewed. After excluding nonevaluable cases a total of 127 renal units remained for investigation. Preoperatively each renal unit was examined with a standardized (well-tempered) furosemide stimulated renal scan. Postoperatively 60 renal units were evaluated with standardized diuretic renal scans at 3 and 12 months, 33 renal units at 3 months only and 34 renal units at 12 months only. Surgical success was defined by half-time less than 20 minutes on a standardized diuretic renogram.

RESULTS

Of the 33 renal units with a single postoperative study at 3 months 32 (97%) had halftime less than 20 minutes on diuretic renography. The remaining patient in this group with half-time greater than 20 minutes showed 60% improvement in half-time and did not require reoperation. Excluding those without delayed followup, surgical success was obtained in 93 of the 94 (99%) renal units. Among the 60 renal units evaluated with 2 postoperative renal scans success was noted in 48 (80%) and 59 (98%) at 3 and 12 months, respectively. Stenosis did not recur in 48 renal units with half-time less than 20 minutes 3 months after repair. In 1 case that had been treated for postoperative urinoma half-time was greater than 40 minutes at 3 months and repeat pyeloplasty was required.

CONCLUSIONS

Half-time less than 20 minutes 3 months after pyeloplasty predicts surgical success. Most renal units that improve but still have half-times greater than 20 minutes on an early diuretic renogram will demonstrate continued improvement in drainage patterns at 12 months. Those renal units that show no improvement at 3 months may require reoperation and those with half-time less than 20 minutes at 3 months do not require further evaluation.

Is the vanished testis always a scrotal event?

OBJECTIVE

To determine if perinatal testicular torsion resulting in a vanished testis is an event that primarily occurs in the scrotum.

PATIENTS AND METHODS

The records of 54 boys identified as having a solitary testis were reviewed. The side of absence, size of the solitary testis, method of surgical evaluation (scrotal, inguinal or abdominal), surgical findings and histology of the tissue removed were noted.

RESULTS

The testis was absent twice as often on the left side, the solitary testis was hypertrophic in 25 of 42 boys in whom it was evaluated, and tissue grossly or histologically consistent with a testicular 'nubbin' was removed in 52 boys. Scrotal (47) or inguinal (seven) exploration was carried out in all. Laparoscopy (28) or abdominal exploration (two) was undertaken to confirm that no testicular tissue was present in the abdomen in 30 boys, including the two in whom no tissue was found on scrotal or inguinal exploration.

CONCLUSIONS

Perinatal testicular torsion occurs after descent but before fixation of the tunica vaginalis to the scrotal wall. These testes atrophy, leaving a remnant of tissue in the scrotum that can be identified on scrotal exploration in almost all cases. Therefore, it is recommended that the evaluation of the child with a solitary palpable testis start with scrotal exploration. Laparoscopy should be reserved for those in whom no tissue consistent with a testicular nubbin is found in the scrotum.

Abdominoscrotal hydrocele in infancy: a review and presentation of the scrotal approach for correction

PURPOSE

A simple transcrotal approach to the surgical treatment of abdominoscrotal hydrocele is presented.

MATERIALS AND METHODS

Via a scrotal incision the hydrocele sac is drained and the wall is everted and plicated in the manner described by Lord.

RESULTS

The hydrocele is eliminated with a decreased risk of damage to the spermatic cord and epididymis. There has been no recurrence.

CONCLUSIONS

The scrotal approach to abdominoscrotal hydrocele is a simple, safe and effective method of managing this relatively uncommon problem.

Plexiform neurofibroma of the penis in a child

We report a case of a child with the stigmata of von Recklinghausen's disease and a plexiform neurofibroma arising from the penile shaft.

The split prepuce in situ onlay hypospadias repair

PURPOSE

We describe the surgical technique and report the results of the first 100 patients who underwent a modification of the onlay hypospadias repair, which we refer to as split prepuce in situ onlay repair.

MATERIALS AND METHODS

We treated 100 boys with a mean age of 11 months at surgery who had coronal to mid shaft hypospadias with split prepuce in situ onlay hypospadias repair. The operative technique varies from that of the standard onlay procedure by preserving the whole blood supply of the half of the prepuce used for the island onlay flap, and using its abundant subcutaneous tissue to cover completely the suture lines used to create the neourethra.

RESULTS

Only 5 complications required reoperation, including 1 hematoma evacuation and 4 urethrocutaneous fistulas. No patient had meatal stenosis, urethral stricture, meatal retraction or acquired urethral diverticulum necessitating reoperation. A good cosmetic result was obtained in all cases.

CONCLUSIONS

Split prepuce in situ onlay hypospadias repair is applicable in virtually all cases of coronal to mid shaft hypospadias. It optimizes the blood supply to the island flap and provides well vascularized coverage of the neourethra, resulting in a decreased complication rate.

Vesicoureteral reflux

The management options outlined earlier are based on the available treatment modalities; however, when a simple, successful, durable, minimally invasive method becomes available to treat vesicoureteral reflux, the approach likely will change. Endoscopic outpatient treatment of reflux has been available for about a decade. Treatment entails injection of a material into the submucosa at the refluxing ureteral orifice to bolster it, thus curing the problem. A suspension of microscopic size polytetrafluoroethylene (Teflon) particles has been used; however, its safety has been seriously questioned, as some evidence shows migration of the particles to other organ systems, including the central nervous system. More recently, cross-linked bovine collagen has been similarly used; however, it does not appear to be as durable. The use of other materials that are safe and will lead to long-term success are being studied. Chondrocytes and other nonbiologic materials, such as microspheres of bioglass and detachable balloons, are being evaluated. It is fairly certain that when a safe material is found, patients with mild to moderate reflux will be endoscopically treated upon recognition, thereby avoiding the use of long-term prophylaxis and periodic radiographic reevaluation.

The influence of small functional bladder capacity and other predictors on the response to desmopressin in the management of monosymptomatic nocturnal enuresis

PURPOSE

The relationship of functional bladder capacity as well as other variables to the responsiveness to desmopressin in children with monosymptomatic nocturnal enuresis was investigated.

MATERIALS AND METHODS

A total of 95 children 8 to 14 years old with monosymptomatic nocturnal enuresis (6 or more of 14 nights wet) were evaluated in a double-blind study followed by open label crossover extension using 20 to 40 mcg. desmopressin. Evaluated predictors of response included patient age, gender, race, family history, number of baseline wet nights, urine osmolality parameters and maximum functional bladder capacity (as a percent of predicted bladder capacity based on the formula, patient age + 2 x 30 = cc). Responders to desmopressin were classified as excellent (2 or less of 14 nights wet) or good (50% or greater decrease but more than 2 of 14 nights wet) and nonresponders were defined by a less than 50% decrease in wet nights.

RESULTS

Of the 95 patients 25 (29.5%) achieved an excellent response to desmopressin and 18 (18.9%) had a good response for a cumulative response rate of 45.3%. The remaining 52 patients (54.7%) were nonresponders. There were no significant differences between responders and nonresponders in regard to gender, race, positive family history or baseline urine osmolality parameters. Response to desmopressin was associated with older age, fewer baseline wet nights and larger bladder capacity. Patients with a functional bladder capacity greater than 70% predicted bladder capacity were 2 times more likely to respond to desmopressin.

CONCLUSIONS

The responsiveness of children with nocturnal enuresis to desmopressin is adversely affected by reduced functional bladder capacity. The results of this study have implications regarding the potential use of combination pharmacotherapy with desmopressin and an anticholinergic for enuretic patients who are nonresponsive to single drug therapy.

Outcome analysis of pediatric pyeloplasty as a function of patient age, presentation and differential renal function

PURPOSE

We retrospectively reviewed a consecutive series of patients who underwent pyeloplasty. In all cases preoperative and postoperative isotope renal scans were performed to assess the surgical outcome with particular emphasis on the change in renal function postoperatively.

MATERIALS AND METHODS

The clinical records of 108 consecutive children with ureteropelvic junction obstruction were reviewed. Individual renal function was evaluated and obstruction was confirmed by diuretic assisted 99mtechnetium diethylenetriaminepentaacetic acid or mercaptoacetyltriglycine renography. A total of 100 pyeloplasties in 98 children between 5 days and 16 years old was included. Results were analyzed by groups according to patient age and symptoms at presentation.

RESULTS

Drainage half-times improved in 98% of patients and only 1 required reoperation. Improved renal function greater than 5% was noted in about a third of each age group. Function remained stable in 68% of the kidneys and decreased in only 1. Of the improved kidneys 77% had impaired function preoperatively (40% or less of the total contribution). Those presenting with a renal mass had the greatest improvement in function. There was no statistically significant difference in improvement in renal function by age group or patient presentation. Regression analysis revealed that preoperative differential renal function was the only statistically significant predictor of improvement in renal function after pyeloplasty.

CONCLUSIONS

Pyeloplasty in children is safe and renal functional improvement can be expected in the majority of kidneys with impaired function at presentation. However, there was no indication that early pyeloplasty in infants is more likely to result in improved function than in older children.

Response to desmopressin as a function of urine osmolality in the treatment of monosymptomatic nocturnal enuresis: a double-blind prospective study

To determine if urine osmolality parameters can predict whether children with primary monosymptomatic nocturnal enuresis will respond to desmopressin, we conducted a prospective, double-blind, placebo-controlled study in 96 children 8 to 14 years old. Following a 2-week baseline screening interval patients with at least 6 of 14 net nights were randomized to double-blind regimens of desmopressin or placebo. Urine specimens for osmolality were collected at 6 p.m. and 6 a.m. on 3 consecutive days during the baseline and the 2, 14-day treatment periods. A significantly greater proportion of desmopressin treated children had an excellent (2 or fewer wet nights in 14 days) or good (greater than 50% reduction in wet nights) response compared with placebo treated children (p = 0.004 and p = 0.002 for treatment periods 1 and 2, respectively). Children treated with desmopressin reported a significantly lower number of wet nights than placebo treated children during both treatment periods (p = 0.0258 and p = 0.0136, respectively). Children treated with desmopressin had a significantly higher 6 a.m. urine osmolality during both treatment periods and a higher 6 a.m.-to-6 p.m. osmolality ratio (p = 0.004) in the first treatment period compared with the placebo group. Within the desmopressin treatment group clinical responders had a higher 6 a.m. urine osmolality and 6 a.m.-to-6 p.m. urine osmolality ratio than nonresponders during both treatment periods but these differences did not achieve statistical significance. In conclusion, treatment with desmopressin is associated with a significant decrease in the number of wet nights, and a significant increase in nocturnal urine osmolality and nocturnal/diurnal urine osmolality ratios. However, clinical response was not predictable based on baseline or treatment osmolality parameters.

A perspective on vesicoureteral reflux

Prevention of UTI appears to be the most important way to avoid the serious complications of vesicoureteral reflux, which then requires early recognition, ideally prior to bacterial invasion. With early evaluation of children noted to have dilated collecting systems in utero and the screening of siblings and offspring of those with reflux, this prevention becomes possible. This screening should be performed in the first weeks to months after birth, before the first UTI. The choice of management appears to be less important than control of infection, because the results of both medical and surgical management are equal; however, because mild-to-moderate (grades I-III) reflux is likely to resolve, it seems appropriate to pursue an aggressive nonsurgical course in these patients, at least until some minimally invasive, safe interventional treatment becomes available. If reflux remains severe (grades IV and V) beyond 24 to 48 months of age, surgical intervention appears appropriate because resolution is unlikely, assuming, of course, that an experienced surgeon performs the procedure. As was evident from the European branch of the IRS, renal scarring occurred most frequently in the few patients who had ureteral obstruction after failed surgical correction. In those who continued to have mild reflux beyond 5 to 7 years of age, a trial of medication is justifiable. If infection occurs during that time and reflux persists, correction should be considered for those with clinical or scan-documented pyelonephritis. Patients who have reflux plus bacteriuria present a special problem because it is unclear whether their risks are increased. Finally, we must forewarn all our female patients with UTI in childhood that they are at risk for bacilluria during pregnancy and may require prophylaxis regardless of the state of their reflux at that time.

The de-epithelialized flap and its influence on hypospadias repair

Since its introduction in the 1970s the addition of a complete covering layer over the newly constructed urethra has positively influenced the outcome of hypospadias repairs. Originally applied by Smith during the second stage of a planned 2-stage repair and then to fistula repairs, the de-epithelialized flap has contributed to a marked reduction in post-hypospadias repair complications. The influence of this contribution as well as its application to a variation of the pedicle onlay hypospadias repair is reviewed.

Pediatric pyeloplasty: is routine retrograde pyelography necessary?

To evaluate the necessity for retrograde pyelography in the preoperative evaluation of children undergoing pyeloplasty, we reviewed the records of 108 consecutive patients (age range 5 days to 18 years, median 1 year) who underwent pyeloplasty at our institution during a 6-year period. The routine preoperative evaluation consisted of a renal/bladder sonogram, furosemide renal scan (99mtechnetium-diethylenetriaminepentaacetic acid or 99mtechnetium-mercaptoacetyltriglycine) and voiding cystogram. No other imaging studies were obtained in 95 patients (88%). Other upper tract studies usually performed before referral included excretory urography in 9 cases and computerized tomography in 5. Preoperative retrograde pyelography was only performed in 1 symptomatic patient before referral to our institution. Surgical findings confirmed obstruction at the ureteropelvic junction in all patients. Undetected ureteral dilatation, which might suggest undiagnosed distal obstruction, was not encountered. After pyeloplasty 2 patients were lost to followup, renal drainage improved in 104 (98%) and drainage failed to improve in 2 of whom 1 (0.9%) required reoperation. All patients who presented with symptomatic uretero-pelvic junction obstruction experienced postoperative resolution of the presenting complaints. Our series demonstrates that routine retrograde pyelography to define the level of obstruction is not necessary for successful primary pyeloplasty. In experienced hands and with careful attention to detail, the combination of renal/bladder sonography and diuretic renography can reliably exclude the possibility of distal obstruction in children with hydronephrosis before pyeloplasty.

Diuretic renography in the evaluation of neonatal hydronephrosis: is it reliable?

Arguments against the use of diuretic renography in the assessment of newborn hydronephrosis include immature function of neonatal kidneys, previously reported poor diuretic response and nonreproducible drainage patterns. To address these concerns we reviewed the initial and followup renal scans of 17 neonates with hydronephrosis without ureterectasis diagnosed by perinatal ultrasonography. All patients were evaluated with an initial diuretic renal scan up to the age of 28 days, and all had normal cystograms. A total of 19 dilated kidneys was studied of which 13 ultimately required pyeloplasty and 6 were managed nonsurgically. Patient study parameters included age and weight at the time of each renal scan, side of hydronephrosis, differential function of each kidney, pre-diuretic and post-diuretic urine output, and drainage half-time of each kidney. The diuretic renal scans followed a standardized protocol. There was no statistically significant difference between neonatal and followup differential function (p > 0.05), and the correlation coefficient was highly significant (r = 0.968). Comparison of response to diuretic stimulation (ml./kg. per minute) revealed no statistically significant difference as the patients aged with brisk urine output 3 to 5 times greater than previously reported. The distribution and mean drainage half-times for normal nonhydronephrotic kidneys were similar when comparing those performed as neonates and at followup. Hydronephrotic kidneys managed nonsurgically maintained almost identical patterns. Those repaired surgically demonstrated appropriate improvement in drainage but function remained unchanged. These results refute each of the criticisms against the use of diuretic renography to evaluate neonatal hydronephrosis and demonstrate its reliability in neonates.

Testis-sparing surgery for benign lesions of the prepubertal testis

Testis tumors in children are more likely to be benign that those in adults, and those tumors that are malignant are associated with a much lower incidence of metastases. As a result, a less-aggressive surgical approach to pediatric lesions has evolved. A testis-sparing operation in appropriate cases has potential psychological and cosmetic advantages for the developing child, and there may be functional advantages for fertility when the child matures.

Intraoperative spermatic venography during varicocele surgery in adolescents

Intraoperative internal spermatic venography performed immediately following varicocele ligation in the adolescent has been touted as reducing varicocele persistence rates. Previously published data corroborate this statement with low persistence rates. Other series in which venography was not performed report a failure rate of 9 to 30%. During a 5-year period a total of 64 varicocele ligations was performed in 62 male adolescents at our institution. Followup postoperatively revealed an overall varicocele persistence rate of 9%. All patients had intraoperative internal spermatic venography on the affected side. Of 64 venograms 16% had shown collateral drainage that, if not ligated, may have resulted in varicocele persistence. These cases accounted for only 1 of the persistent varicoceles. Additionally, venograms had demonstrated filling of the ipsilateral external iliac vein in 8% of the cases. Despite the fact that no attempt was made to ligate these collaterals, none of these patients had a persistent varicocele. After varicocele ligation 30 of 62 patients were followed long enough to evaluate for testicular catch up growth. Of these 30 patients 24 demonstrated an average relative increase in left testicular volume of 17%. These data support routine intraoperative internal spermatic venography while performing varicocele ligation in the adolescent.

Laparoscopy for Nonpalpable Testes in Childhood: Is Inguinal Exploration also Necessary When Vas and Vessels Exit the Inguinal Ring?

Laparoscopy has proved to be a safe method for determining the status for nonpalpable testes. In a combined series 52 boys with 57 nonpalpable testes were evaluated laparoscopically. Of the 57 nonpalpable testes 26 were located above the internal inguinal ring (abdominal), 4 were found more distally, and blind-ending vas and vessels terminated in the abdomen in 3, and beyond the internal ring (vanished testes) in 24. Of 29 abdominal testes primary orchiopexy was performed in 15, 4 were removed, the vessels were transected (Fowler-Stephens) in 5, stage 1 of staged repairs was done in 2, distinct laparoscopic evidence of blind-ending vessels and vas obviated further surgery in 2, and testis was not identified either laparoscopically or by abdominal exploration. Finally, inguinal exploration in 28 children in whom vas and vessels were found to exit the internal ring resulted in localization of 4 testes that were brought into the scrotum. Removal of 23 testicular nubbins and their evaluation histologically resulted in identification of viable tubular structures in 3. We recommend inguinal exploration in all children who on laparoscopy are found to have vas and vessels exit the internal ring, and removal of testicular nubbins.

Renal scarring following reflux and nonreflux pyelonephritis in children: evaluation with 99mtechnetium-dimercaptosuccinic acid scintigraphy

99mTechnetium dimercaptosuccinic acid (DMSA) scintigraphy is the imaging modality of choice for the detection of acute pyelonephritis and chronic renal scarring in children. Using the DMSA scan we prospectively evaluated renal scarring after reflux and nonreflux pyelonephritis in children. The study population consisted of 33 patients with acute pyelonephritis documented by a DMSA renal scan at infection. The children were evaluated for renal scarring with a followup DMSA scan 4 to 42 months (mean 10.7 months) after the acute infection. All new scarring on followup DMSA scans occurred at sites corresponding exactly to areas of acute inflammation on the initial DMSA scan. Therefore, only those kidneys with acute changes on the initial scan were subsequently analyzed. Of 38 kidneys new or progressive scarring developed in 16 (42%), including 6 of 15 (40%) with associated vesicoureteral reflux and 10 of 23 (43%) without demonstrable reflux. New renal scarring developed in 6 of the 7 kidneys (86%) associated with a neuropathic bladder or posterior urethral valves. In contrast, new scarring developed in only 10 of 31 kidneys (32%) associated with a normal bladder (p = 0.028). Excluding the kidneys associated with a neuropathic bladder or posterior urethral valves, new renal scarring developed in 3 of 12 (25%) with primary reflux, compared with 7 of 19 (37%) without vesicoureteral reflux. Except for the white blood count and the species of infecting bacteria, no other statistically significant differences could be found between those cases in which scars did or did not develop. We conclude that acquired renal scarring only occurs at sites corresponding to previous areas of acute pyelonephritis, the acute parenchymal inflammatory changes of acute pyelonephritis are reversible and do not lead to new renal scarring in the majority of cases, and once acute pyelonephritis has occurred ultimate renal scarring is independent of the presence or absence of vesicoureteral reflux.

Nonsurgical management of primary vesicoureteral reflux in complete ureteral duplication: is it justified?

We reviewed the treatment of 56 children with vesicoureteral reflux and complete duplication of the collecting system, including 14 who had complete bilateral duplication. A total of 70 refluxing duplicated systems was analyzed. Of the patients 18% demonstrated spontaneous resolution of reflux within 42 months, 23% are currently stable on prophylactic antibiotics and 57.1% underwent surgical correction. Spontaneous resolution of reflux occurred in 58% of the children with grades I to III/V reflux. In comparing the group with reflux and duplication to a group with reflux into single systems, we conclude that the patients with duplication and lower grades of reflux can be managed nonoperatively, while infection is prevented with antibiotic prophylaxis.

Primary vesicoureteral reflux in the black child

Primary vesicoureteral reflux is a polygenic abnormality due to a deficiency of the ureterovesical junction which allows urine in the bladder to ascend into the ureter and kidney. Fifty-one black children with primary vesicoureteral reflux were evaluated and treated at Children's Hospital from 1976 to 1986. The results of the evaluation and treatment were compared with those of 493 white patients with primary vesicoureteral reflux seen during the same time interval. The general approach to management was nonsurgical. There were no radical differences in the mode of presentation, age at presentation, and age at resolution. The distribution of reflux by maximum grade was not affected by race. Overall, 19 (37%) black children experienced spontaneous resolution of reflux. The mean duration of reflux in black children who had spontaneous resolution was 14.6 months. This duration was statistically significantly shorter than that in white patients with spontaneous resolution of vesicoureteral reflux (P less than .005). Surgical correction was believed to be required in 8 (16%) patients and 8 (16%) were lost to follow-up. Renal scarring demonstrated by intravenous pyelogram or renal scan was initially present in 12 (23%) black patients compared with 65 (13%) white patients. This was due to a higher percentage of renal scarring in black girls which was not explained by distribution of grades of reflux. There was no progression of scarring in our black patients, whereas 3 (0.6%) white patients had progression of scarring. Although vesicoureteral reflex is rarely seen in black patients (9% of series), it has similar demographic features.(ABSTRACT TRUNCATED AT 250 WORDS)

Testicular sparing surgery for prepubertal teratoma of the testis: a clinical and pathological study

We report on 5 patients 14 months to 6 1/2 years old with prepubertal teratoma of the testis treated by testicular sparing tumor enucleation. All 5 patients had no evidence of recurrence at a mean followup of 96 months. Recognizing that this is not accepted therapy for testis tumors, 17 orchiectomy specimens containing teratoma from children were histologically analyzed in cooperation with the Armed Forces Institute of Pathology Tumor Registry. All patients were prepubertal at orchiectomy (3 months to 8 years old) and all are well with a mean followup of 174 months. Histological examination revealed no foci of teratoma separate from the main tumor in any specimens. Immunohistochemical studies with placental alkaline phosphatase, a marker for malignant germ cells, were done to detect carcinoma in situ in the seminiferous tubules of these testes. This test did not reveal any intratubular malignant germ cells (carcinoma in situ). Based on our clinical experience with testicular sparing tumor enucleation, the histological findings on Armed Forces Institute of Pathology review demonstrating no associated carcinoma in situ and the universally benign behavior of prepubertal testicular teratomas, we recommend a testicular sparing operation rather than orchiectomy for testicular teratoma in prepubertal patients.

Renal scarring and vesicoureteral reflux in children with myelodysplasia

The records of 180 myelodysplasia patients followed from 3 to 18 years were reviewed. Studies included cystography to evaluate vesicoureteral reflux and dimercapto-succinic acid renal scintigraphy to identify acute inflammation and renal scarring. Scarring was noted in 28 of 180 patients (15.5%), of whom 68% were girls. Of the patients with renal scarring 75% had associated reflux and 40% over-all were identified as having reflux. Management of patients with vesicoureteral reflux included clean intermittent catheterization, antibiotic prophylaxis and anticholinergics when indicated. Only 17 of 72 patients (24%) had ureteral reimplantation. Surgical indications included persistent high grade reflux and/or progressive upper tract damage. Reflux resolved in 62% of those on medical management. Resolution was not dependent on grade of reflux (as compared to primary reflux). Twenty-one patients are stable and being followed with persistent reflux. In 7 patients new renal scars developed during aggressive medical management, 5 of whom underwent subsequent surgical correction.

The prune belly syndrome: a comprehensive approach to management

Our approach to management of the prune belly syndrome entails a program of comprehensive early reconstruction, including abdominoplasty, bilateral orchiopexy, reduction cystoplasty, and selective ureteral tailoring and reimplantation. Of 20 patients with the prune belly syndrome treated at our institution during the last 18 years 15 underwent comprehensive reconstruction. Abdominoplasty was performed in 16 patients. Results were evaluated as to cosmetic appearance, functional performance, and preoperative and postoperative electromyography. Immediate good results were obtained in 9 patients. Of 16 patients 6 required more than 1 abdominal wall tailoring and 3 had minor complications that did not compromise the ultimate result. Transabdominal orchiopexy was performed on 32 testes; 28 (88 per cent) are in the scrotum and growing. Of the 4 failures 3 occurred in patients greater than 2 years old at repair. Selective urinary tract reconstruction has been performed; 13 patients underwent tapering and reimplantation of 1 or both ureters. Reduction cystoplasty was done in all 15 patients. Functional assessment of the upper urinary tract by improved radiological techniques and the necessity for long-term antibiotic prophylaxis have led to a more conservative approach in 5 recent patients. Renal function as measured by serum creatinine and/or glomerular filtration rate has remained stable in 12 of 15 patients (92 per cent) undergoing comprehensive reconstruction. Aggressive surgical management of patients with the prune belly syndrome provides improved abdominal wall function and appearance, and offers excellent testicular salvage. Surgical reconstruction of deformed ureters should be selective and decided on longitudinal studies of renal function.

Experience with the Kropp anti-incontinence procedure

The experience of 2 surgeons working independently at separate institutions is reported to demonstrate the use of the Kropp urethral lengthening and implantation procedure. This experience includes 18 patients between 6 and 19 years old (median age 11.6 years) with neurogenic bladder dysfunction. The etiology of the neuropathic bladder was myelodysplasia in 16 patients and sacral agenesis in 2. There were 10 boys and 8 girls. All patients had failed trials of clean intermittent catheterization with adjunctive pharmacological manipulation. Incontinence was a significant social problem. Of the 18 patients 2 had undergone prior urinary diversion and the Kropp procedure was used as part of undiversion. One patient had had 2 previous failed attempts at continence using an artificial urinary sphincter. Augmentation cystoplasty was an adjunctive maneuver in 14 patients; ileum was used in 8, sigmoid in 4 and the ileocecum in 2 (both of whom had been diverted previously). The bladder capacity in the 4 patients in whom augmentation was not performed ranged from 200 to 450 ml. Of the 18 patients 17 achieved a good result and 14 were considered to have achieved an excellent result. The 1 failure is the patient who previously had failed to gain control with an artificial sphincter. Of the 4 patients who did not undergo bladder augmentation 3 required adjunctive anticholinergics to achieve continence.

Aphallia: its classification and management

Aphallia is an extremely rare disorder with profound urological and psychological consequences. Approximately 60 patients have been reported on in the literature; we report our experience with 3 additional patients. Fifty patients had sufficient information to classify the condition according to the site of the urethral meatus. With the relative relationship of the urethral meatus to the anal sphincter several observations were noted. The more proximal the meatus the higher the incidence of other anomalies and the greater the number of neonatal deaths. Of the patients 30 (60 per cent) had a post-sphincteric meatus located on a peculiar appendage at the anal verge. These patients had the lowest incidence of other anomalies (1.2 per patient) and the highest survival rate (87 per cent). A total of 14 patients (28 per cent) had pre-sphincteric urethral communications (prostato-rectal fistula), of whom 36 per cent died in the neonatal period. Six patients (12 per cent) had urethral atresia. This group had no survivors and the highest incidence of other anomalies (4 per patient). Of our patients 2 had a post-sphincteric meatus and 1 had a pre-sphincteric meatus. In addition to correction of life-threatening anomalies the management of aphallia centers on establishing gender assignment. Bilateral orchiectomy, labial construction and urethral transposition should be done in the newborn period, if possible.

Acquired undescended (ascended) testis: effects of human chorionic gonadotropin

A total of 7 boys 4 to 10 years old was evaluated for undescended testes. All patients had been seen previously by a pediatric urologist and diagnosed as having a retractile testis. In fact 4 boys had undergone surgical correction of a contralateral undescended testis at an earlier date at which time the testis in question could be manipulated into the scrotum. Another boy was examined under anesthesia and the operation was canceled because the testis could be brought into the scrotum. Subsequently, on followup evaluation 2 to 8 years later the ipsilateral testis could not be manipulated into the scrotum. Of the boys 6 then were treated with a short course of human chorionic gonadotropin. Four patients had a positive response but in 3 the testis was undescended again at examination 6 months later. Of the boys 6 ultimately underwent orchiopexy. Boys with highly retractile testes require periodic examination until puberty to ensure that those testes do not ascend secondarily.

De-epithelialized skin flap coverage in hypospadias repair

The results in 84 hypospadias repairs using a de-epithelialized skin flap are reported. A variety of 1-stage repairs were applied including those of King, Mathieu, Mustardé and Duckett, and a combined midline and transverse island flap for perineal hypospadias. In each repair a flap of transposed prepuce was swung ventral, de-epithelialized and applied over the urethroplasty. In all but 2 repairs complete coverage of the urethra was achieved by this technique. Reoperation was required in 7 patients (8 per cent) but in only 3 (3.5 per cent) ws this to close a urethrocutaneous fistula. The addition of a de-epithelialized flap to create a layer completely covering the neourethra appears to reduce the incidence of fistulas significantly.

A review of surgical treatment of undescended testes with emphasis on anatomical position

We reviewed our 5-year surgical experience with undescended testes in 295 patients. Surgery had been performed in a standardized fashion to identify accurately testicular position. Before opening the fascia of the external oblique muscle, the superficial inguinal pouch and area beyond the external ring were explored carefully. Testes beyond the external ring were defined as ectopic. Other positions identified included intracanalicular and intra-abdominal. Of 336 testes 66 per cent were ectopic, 16 per cent intracanalicular, 10 per cent abdominal and 3 per cent absent. Maldescent was unilateral in 254 patients and bilateral in 41. In the unilateral cases of 178 testes were ectopic (70 per cent) and the testis was palpable preoperatively in 158 (89 per cent). Bilateral undescended testes were palpable on both sides preoperatively in 25 of 41 cases (61 per cent), including 16 (64 per cent) ectopic testes. There were 10 cases of bilateral nonpalpable testes and in 8 (80 per cent) both testes were intra-abdominal. Based on the high incidence of ectopic testes and their associated abnormal attachments, it is our prediction that nonsurgical treatment (hormonal) of undescended testes would not be expected to achieve optimal results.

A nonsurgical approach to the management of primary vesicoureteral reflux

We performed a retrospective review to evaluate the results of a nonsurgical approach to the management of primary vesicoureteral reflux during a 10-year period (1976 to 1986). During that interval patients with reflux were studied initially with a standard voiding cystourethrogram and either an excretory urogram or a renal scan with glomerular filtration rate and/or differential renal function determination. Height, weight, blood pressure, urine cultures and serum creatinine measurements also were obtained. Isotope cystography was used for followup examinations. A single, negative isotope cystogram was the radiological criterion for cessation of reflux. The charts of 545 children (55 per cent had bilateral reflux) with 844 refluxing ureters were reviewed. Based upon the international classification vesicoureteral reflux was grade I in 6.6 per cent of the cases, grade II in 54.2 per cent, grade III in 31.6 per cent, grade IV in 5.7 per cent and grade V in 1.9 per cent. All children were kept on long-term continuous prophylactic antibiotics and they were re-evaluated annually with isotope cystography. The followup rate for the entire group was 88 per cent. During the observation period spontaneous resolution of reflux was noted in 36 per cent of the patients and 39 per cent of the total refluxing ureters. Only 13 per cent of the entire group underwent surgical correction of reflux. Presently, 39 per cent (215) of the patients continue to be followed with reflux. Of the total group 66 patients (12 per cent) were lost to followup. In the 194 patients with spontaneous resolution of reflux the mean duration of reflux was 1.69 years, with 30 to 35 per cent resolving each year. Based on Student's t test there was a significant difference in duration of reflux in patients with grade II compared to grade III reflux (1.56 versus 1.97 years, p less than 0.04). When age at presentation was compared with duration of reflux there was a significantly shorter duration of reflux only in those patients presenting from age 0 to 12 months, compared to those 13 months and older (1.44 versus 1.85 years, p less than 0.02). Renal function was evaluated by serum creatinine, calculated glomerular filtration rate or differential diethylenetriaminepentaacetic acid scan results.(ABSTRACT TRUNCATED AT 400 WORDS)

Testicular histology in the adolescent with a varicocele

A varicocele is a common cause of adult male infertility, and surgical ligation is a generally accepted mode of therapy. However, the guidelines for management of the adolescent with a varicocele are not clearly defined. Herein, we describe histologic abnormalities noted on testis biopsy in nine of 24 boys with moderate to large varicoceles. Surgical ligation of the varicocele is recommended when there is volume loss of the testis ipsilateral to the varicocele. All others should be reexamined periodically, and an attempt should be made to obtain a baseline semen analysis.

Acquired megalourethra: an uncommon complication of the transverse preputial island flap urethroplasty

We describe 4 patients with significant dilatation of the entire neourethra following transverse preputial island flap urethroplasty. Two patients presented after repair of chordee without hypospadias, which was corrected by interposition with a pedicle graft. The problem arises about 6 months after the repair and is manifested by ballooning of the urethra during urination and postvoid dribbling. We have labeled this entity acquired megalourethra and the repair is similar to that for congenital megalourethra.

Reversal of testicular growth failure by varicocele ligation

A total of 20 male patients 11 to 19 years old had a grade 2 or 3 varicocele and volume loss of the testis ipsilateral to the varicocele. None of these patients presented because of subfertility. Following varicocele ligation a significant increase in volume of the testis ipsilateral to the varicocele was observed in 16 of 20 patients. All 20 patients have been followed for 1 to 6 years. Our results suggest that a moderate to large varicocele can be responsible for testicular growth retardation and that early ligation of the varicocele may reverse this process.

The communicating hematocele: an unusual presentation for blunt splenic trauma

The communicating hematocele is an unusual scrotal disorder that is rarely anticipated. Surgical exploration for an enlarging hydrocele and an abnormal scrotal sonogram in a 19-month-old boy revealed a communicating hematocele. Further evaluation demonstrated a fractured spleen. The association between a patent processus vaginalis and blunt abdominal trauma in the pathogenesis of the communicating hematocele is discussed.