Adolescent varicocele.

The evaluation and management of adolescents with varicoceles continue to evolve. Current recommendations for repair are based on the findings of impaired testicular growth or spermatogenesis; however, with early evaluation and selective treatment, clinicians should be able to reduce the potential for future fertility problems significantly in adolescents with varicoceles.

Varicocele in adolescence induces left and right testicular volume loss.

OBJECTIVE: To determine the effect of a palpable left-sided varicocele (which in adolescent patients can adversely affect left testicular volume) on right testicular volume with progressive Tanner development and increasing varicocele grade. PATIENTS AND METHODS: The right and left testicular volumes were measured with a standard orchidometer in 70 control patients (mean age 14.6 years, SD 2.2) with no palpable testicular abnormality and in 434 (mean age 14.3 years, SD 2.3) with a palpable left-sided varicocele. Patients with bilateral and right-sided varicoceles were excluded from the study. RESULTS: There was no significant difference between the left and right testicular volumes in the control patients. The testicular volumes of patients with a grade I varicocele were similar to those in control patients. Patients with a grade II varicocele had a significantly smaller left testis than the controls at Tanner stages 4 and 5 (P < or = 0.05). Patients with a grade III varicocele had a significantly smaller left testis than controls at each Tanner stage (P < or = 0.05) and significantly smaller right testis than controls at Tanner stages 4 and 5 (P < or = 0.05). CONCLUSION: The presence of a grade I varicocele in adolescence appears to have no effect on normal testicular growth. Some patients with a grade II varicocele are at risk of left testicular volume loss with time and should have their testicular volume measured annually. Patients with grade III varicocele are at risk of bilateral testicular volume loss; a careful evaluation and early surgical intervention are recommended in this group of patients.

Glanuloplasty and in situ tubularization of the urethral plate: long-term followup.

PURPOSE: We update our experience with glanuloplasty and in situ tubularization of the urethral plate for hypospadias repair first described in 1995, and report its indications and long-term results. MATERIALS AND METHODS: We evaluated the surgical results of glanuloplasty and in situ tubularization of the urethral plate for hypospadias repair in 308 patients. RESULTS: Overall cosmetic results were excellent. The overall complication rate for both series was 9.7%, and complications consisted of a urethral fistula in 9.1% and a urethral diverticulum in 0.6%. However, in our recent series the complication rate decreased to 1.7% for distal repairs and 7.7% for mid shaft hypospadias repair. CONCLUSIONS: Glanuloplasty with in situ tubularization of the urethral plate is an excellent technique for the majority of boys with distal and mid shaft hypospadias, producing a pleasing cosmetic appearance with a low complication rate.

Paediatric urinary tract infection and the necessity of complete urological imaging.

OBJECTIVE: To evaluate voiding cysto-urethrography (VCUG) in assessing children with urinary tract infection (UTI) when renal/bladder ultrasonography and renal scintigraphy show no abnormality. PATIENTS AND METHODS: A total of 468 renal scintigrams taken in children for an indication of UTI between January 1996 and December 1998 were reviewed. The renal and bladder ultrasonograms of those children with a normal renal scan were then reviewed. Children with both normal renal scans and normal ultrasonography were then evaluated for the frequency and grade of vesico-ureteric reflux (VUR) on VCUG. RESULTS: Of the 468 patients, 453 (97%) had complete imaging studies; 152 of the children evaluated had normal renal scans, of whom 101 had a normal renal ultrasonogram. Twenty-three (23%) children with both a normal renal scan and renal/bladder ultrasonogram showed VUR on VCUG, of whom 14 had bilateral VUR and 13 grade III or higher VUR. CONCLUSION: This study indicates that about 23% of patients may have significant VUR despite both a normal renal scan and ultrasonogram. Therefore, VCUG remains important in evaluating and managing children with UTI.

Color Doppler ultrasound evaluation of the acute scrotum.

Color Doppler ultrasound has been reported to be useful in ruling out testicular torsion in children. Some investigators, however, have continued to report false-positive and false-negative studies. Herein we review our institution's experience over the past 6 years. From January 1990 to December 1996, over 300 boys 21 years of age or less underwent color Doppler ultrasound for testicular pain and/or swelling. Presentation, ultrasound diagnosis, operative findings (where applicable), and subsequent course were assessed. Complete data was available for 243 boys (average age 10.36 years, range 1 day to 21 years). Fourteen boys were explored without imaging based on strong clinical findings and short duration of pain. Of these, 13 had torsion and 1 had epididymitis. Torsion was ruled out by ultrasound in 182 with 100% specificity verified on follow-up. Forty-five diagnoses of torsion by ultrasound were confirmed operatively. Two patients with equivocal scans also were explored: one had torsion, whereas the other had a torsed appendix. Ultrasonic findings are characterized. Additionally, two cases of false-negative ultrasound from outside institutions are discussed. In conclusion, color Doppler ultrasound can identify reliably those children with an acute scrotum who require exploration and exclude those children without testis torsion who would otherwise undergo needless surgery.

The acute scrotum.

Every boy with acute onset scrotal pain and swelling requires an immediate evaluation. Our protocol (Fig. 6) for the evaluation of these children is based on the history and physical examination combined with the selective use of imaging studies. When used appropriately, this protocol facilitates the rapid identification of children with torsion and minimizes the number of unnecessary scrotal explorations. When the duration of the pain is brief, and history and physical examination suggest that torsion is the most likely diagnosis, urgent surgical exploration without additional imaging studies is recommended. When it is not possible to definitely diagnose or exclude the diagnosis of testicular torsion, or when the duration of pain is greater than 12 hours, then diagnostic imaging can provide significant information. Color Doppler sonography is, in the authors' opinion, preferable to nuclear imaging for the evaluation of children with acute scrotums. When normal or increased blood flow is present, scrotal exploration is not required. When the study demonstrates decreased blood flow or does not provide a definite diagnosis, scrotal exploration is recommended. The authors recommend this approach because less than one third of these children have testicular torsion, and if routine scrotal exploration is performed for all boys with acute scrotums, a significant number of unnecessary surgical procedures will result.

Electrosurgery for routine pediatric penile procedures.

PURPOSE: Traditional teaching in urology has been to avoid electrosurgical devices in penile surgical procedures. In the last several years cutting current has been routinely used on the penis for making skin incisions, degloving, creating Byars flaps and destroying skin bridges. The purpose of this study was to determine the complications and final outcomes of electro-surgery. MATERIALS AND METHODS: A 5-year retrospective chart review was done to determine the complications and final outcomes of exclusively using electrical current to perform pediatric penile procedures. RESULTS: Electrosurgery was used to perform the entire surgical dissection in 346 patients, including circumcision in 124, repeat circumcision in 68, penoscrotal fusion/chordee repair in 127 and skin bridge procedures in 27. All patients had a satisfactory cosmetic result. After correction of penoscrotal fusion, separation at the scrotal suture line in 2 patients healed secondarily without sequelae. There was no hematoma, tissue necrosis or skin sloughing and all surgery was performed on an outpatient basis. CONCLUSIONS: Electrosurgery can be used safely and effectively for routine penile procedures, providing a bloodless operative field and excellent cosmetic results.

Glanuloplasty and in situ tubularization of the urethral plate: a simple reliable technique for the majority of boys with hypospadias.

PURPOSE: We describe glanuloplasty and in situ tubularization of the urethral plate, and report indications, results and complications. MATERIALS AND METHODS: We evaluated our surgical results using glanuloplasty and in situ tubularization of the urethral plate in 166 boys 5 months to 13.5 years old (mean age 20 months). RESULTS: Overall cosmetic results were excellent. No evidence of meatal stenosis, urethral stricture, residual chordee or ballooning of the neourethra was noted at followup. A small urethrocutaneous fistula that formed in 10% of the patients was successfully closed in a brief outpatient procedure. CONCLUSIONS: Glanuloplasty and in situ tubularization of the urethral plate is an excellent technique for the majority of boys with distal shaft and subcoronal hypospadias, producing a superior cosmetic result compared to the Mathieu procedure or meatal advancement and glanuloplasty.

First and second generation lithotripsy in children: results, comparison and followup.

During a 5-year period 32 children and adolescents 4 to 18 years old underwent 35 extracorporeal shock wave lithotripsy (ESWL*) treatments for 37 calculi. The unmodified Dornier HM3 lithotriptor was used in 21 cases (60%) while the remaining cases were treated with the Siemen Lithostar lithotriptor. The HM3 necessitated general anesthesia in 67% of patients and the Lithostar necessitated intravenous sedation in 86%. The majority of pediatric lithotripsy treatments were performed on an outpatient basis (24) or during an overnight hospital stay (3) while 8 were done on an inpatient basis. Of the 37 stones treated with 1 ESWL session 68% resolved, 19% had residual fragments less than 4 mm., 8% had residual fragments greater than 4 mm. and 5% required an endoscopic procedure for resolution. When success rates by lithotriptor were examined no significant difference between the 2 machines was identified although the HM3 treated larger stones (p = 0.0499). There were no statistical differences in regard to success and the use of stents, patient age or stone location between the 2 lithotriptors. Three patients required adjuvant procedures, and complications and morbidity developed in 2 and 5, respectively. All children or parents were contacted for followup (range 7 to 67 months). One child required ESWL for a new stone while another passed a stone without intervention. Only 1 child with a residual fragment less than 4 mm. became symptomatic but needed no intervention while 1 of 3 with fragments greater than 4 mm. needed intervention. No patients required open or percutaneous intervention.

Management of suspected antenatal torsion: what is the best strategy?

Currently, management of the newborn with suspected antenatal torsion is somewhat controversial. Many surgeons recommend early surgical exploration within the first few days of life, primarily to avoid errors in diagnosis. However, since the surgical and general anesthetic risks at this age are increased, it might be preferable to defer an operation until risks to the patient are minimized. The optimal solution to this dilemma would be the ability to diagnose torsion and exclude other conditions noninvasively. We present a series of 12 patients 1 to 14 days old who presented with a scrotal mass secondary to suspected antenatal testis torsion. Color Doppler ultrasound in each case demonstrated abnormal testicular blood flow and architecture consistent with testis torsion. Eventual exploration of all 12 patients confirmed prenatal torsion. We conclude that scrotal ultrasound with color Doppler enhancement can accurately identify neonates with antenatal testis torsion and exclude other scrotal pathological conditions. If elected, surgery for torsion can then be deferred until the risks of anesthesia and surgery are improved.

Adolescent varicocele.

Currently, we recommend varicocele repair in adolescents when (1) the results of semen analysis are abnormal, (2) the volume of the left testis is at least 3 mL less than that of the right, (3) the response of either luteinizing hormone or FSH to Gn-RH stimulation is supranormal, (4) bilaterally palpable varicoceles are detected, or (5) a large symptomatic varicocele is present. When surgery is necessary, the Palomo approach significantly decreases the risk of operative failure and has facilitated "catch-up" growth of the left testis that is comparable to that after artery-sparing procedures. It is important to note that there is potential for impaired fertility whenever a palpable varicocele is present. Unfortunately, no test or group of tests can predict with absolute certainty whether an adolescent with a varicocele will be fertile or infertile. Therefore, it is important to observe untreated patients until they complete their families. Patients who are unwilling or unable to adhere to the follow-up protocol may be candidates for surgical intervention.

Testicular growth after successful varicocele correction in adolescents: comparison of artery sparing techniques with the Palomo procedure.

Testicular growth after varicocele surgery was evaluated in 116 boys 9 to 20 years old. A total of 88 boys was available for followup testicular examination 3 to 60 months after successful varicocele repair (mean 25). Left testicular volume loss of 2 cc or greater was present preoperatively in 72 of the 88 patients. The Palomo procedure was performed in 36 cases and repair using artery sparing techniques was done in 36. Mean relative left testicular volume increased 18% in the artery sparing group and 21% in the Palomo group. The increase in relative testicular volume compared to preoperative volumes was statistically significant in both groups (p < 0.05). There was no significant difference in testicular growth between the groups and no postoperative testicular atrophy was observed. A comparison group of 8 boys with uncorrected varicoceles demonstrated a mean relative volume increase of 3% (mean followup 22 months). The increase in testis volume in successfully corrected cases was statistically different (p < 0.05) from that of uncorrected cases. We conclude that reversal of varix induced testicular growth failure occurs only after successful surgical correction. The Palomo procedure resulted in equivalent testicular growth compared to the artery sparing techniques with fewer complications and no testicular atrophy despite intentional ligation of the testicular artery. Based on our data, we believe that the Palomo procedure should be the procedure of choice for adolescent varicocele correction.

Bilateral asynchronous Sertoli cell tumor in a boy with the Peutz-Jeghers syndrome.

A rare type of Sertoli cell tumor with features of a large cell calcifying Sertoli cell tumor and a sex cord tumor with annular tubules developed in a boy with the Peutz-Jeghers syndrome. A similar tumor had been removed from the contralateral testicle 9 years previously. The clinical and pathological findings in our case are compared to 3 similar cases reported in the literature.

Dorsal corporeal rotation: an alternative technique for the management of severe chordee.

Chordee with or without hypospadias is usually managed successfully in a fairly straightforward manner. However, on occasion there are patients with severe chordee that cannot be corrected with the standard techniques. In this setting tunica vaginalis grafts, dermal grafts and Nesbit plication techniques have been used but all of these procedures have major drawbacks. During the last 5 years we have used an alternative technique for the correction of severe ventral curvature that persists despite complete resection of fibrous chordee. This technique combines a deep vertical incision between the corporeal bodies ventrally with a series of transverse dorsal plicating sutures to correct chordee. There is no incision into the corporeal bodies and no shortening of the penis as with the Nesbit technique, and potential injury to the neurovascular bundles is minimized. Followup 1 to 5 years later in 6 patients confirms satisfactory chordee correction in all cases.

Do all children with an acute scrotum require exploration?

A total of 77 consecutive children ranging in age from 1 day to 17 years was evaluated for an acute scrotum by a single examiner (E. J. K.). In 10 children a definite diagnosis of acute spermatic cord torsion was made based upon the history and physical examination. No imaging studies were performed and torsion was confirmed at surgery in 9 children. The diagnosis of testis torsion was not as clear-cut in the remaining 67 children and, therefore, a color Doppler ultrasound was performed before any surgical intervention. The study demonstrated normal or increased blood flow in 55 of these children and none proved to have testicular torsion, although other scrotal pathology requiring surgery was noted in 5 children. Twelve children did not demonstrate evidence of testicular blood flow on the color Doppler ultrasound and all had surgical confirmation of testis torsion. We conclude that in our experience the majority (71%) of children with an acute scrotum did not require immediate surgical exploration. Color Doppler ultrasound can reliably identify those children with an acute scrotum who require exploration and spare the majority needless surgery. Routine scrotal exploration is no longer necessary for all children with an acute scrotum.

Pituitary gonadal dysfunction in adolescents with varicocele.

Gonadotropin-releasing hormone stimulation testing was performed on 104 adolescent males with a unilateral left varicocele to determine the frequency of testicular dysfunction in this group of patients. An abnormal test result was noted in approximately 30 percent of varicocele patients. We believe that an abnormal test result indicates a higher risk for future fertility problems, and early treatment may reduce this risk.

Transient acute renal failure in the neonate.

We have observed a transient renal insufficiency in newborns associated with ultrasonographic finding of hyperechoic renal pyramids. This condition rapidly resolves, coinciding with both normalization of the renal ultrasound and the occurrence of significant proteinuria. Others have recognized a similar state of oliguria and cylindruria associated with a prolonged nephrogram on intravenous urography in newborns. There is evidence to suggest that hyaline cast deposition within the collecting tubules may account for these imaging abnormalities. The precise events surrounding the protein deposition are unknown, and it may be either the cause or the result from the transient renal dysfunction. Our 2 cases add to the evidence that there is a distinct entity of acute renal dysfunction, with identifying characteristics, in neonates associated with a good prognosis and rapid resolution.

The sensitivity of renal scintigraphy and sonography in detecting nonobstructive acute pyelonephritis.

Recently it has been demonstrated that any child with proved acute pyelonephritis may be at risk for parenchymal scarring, whether or not reflux is present. Since cortical renal scintigraphy has been shown to detect accurately renal inflammation, we compared cortical scintigraphy with renal sonography in 46 children with documented acute pyelonephritis to determine which modality is best to detect patients at risk for renal injury. Cortical scintigraphy was abnormal in 36 children (78%) and renal ultrasonography was abnormal in 5 (11%). Reflux was demonstrated in only 20 cases (43%). We conclude that cortical scintigraphy is the preferred imaging technique for diagnosing renal inflammation, and it should be used routinely in every child with suspected acute pyelonephritis. A new imaging protocol is proposed.