Simultaneous second-stage Fowler-Stephens Orchiopexy and microvascular testicular autotransplantation in a patient with prune belly syndrome with cryptorchidism.

We present a case of simultaneous second-stage Fowler-Stephens Orchiopexy (FSO) with microvascular testicular autotransplantation for cryptorchidism and in a patient with prune belly syndrome. At 5 months old, the patient underwent laparoscopic bilateral first-stage FSO with the right testicle located 1 cm from the liver and the left slightly more caudal. An ultrasound on postoperative Day 72 following second-stage FSO and microvascular autotransplantation showed patent testicular vasculature. Our experience shows that this combination technique is safe and effective to supercharge the testicle and augment collateral vessels if clinical suspicion for monotherapy failure is high.

Technique for preservation of penile skin in genital reconstruction: free graft to the scrotum.

OBJECTIVE: To describe a new technique to preserve the penile epithelium with good cosmetic results when additional surgery is a significant possibility. Complex genital reconstruction can require multiple procedures. METHODS: Seven patients underwent grafting of the penile epithelium to the scrotum during genital reconstruction to bank the tissue for potential future use. The graft size was 8-40 mm in the maximal length. RESULTS: The median age at surgery was 8.1 months. The median interval to the last follow-up examination after surgery was 13.5 months. All 7 patients demonstrated excellent wound healing with good cosmetic results. CONCLUSION: In patients with complex genital anomalies, nonhair-bearing epithelium is a valuable asset. At times, the paucity of available local tissue necessitates autografting with nongenital epithelium. The need for nongenital tissue can be reduced if excess penile skin is banked for potential use at a later date. We describe a technique in which the penile skin is preserved for potential future reconstruction using free grafting to the scrotum.

Pediatric urolithiasis: clinical predictors in the emergency department.

OBJECTIVE: The objective of this study was to identify factors that predict the presence of urolithiasis detected with unenhanced computed tomography (UCT) in children. METHODS: A retrospective study of all subjects <21 years of age who presented to the emergency department at Akron Children's Hospital and underwent UCT of the abdomen between January 2002 and December 2005 was performed. Demographic, clinical, diagnostic, treatment, and disposition data were abstracted by using a standardized form. Univariate and logistic regression analyses of factors associated with urolithiasis were performed. RESULTS: A total of 339 eligible patients were identified, with 110 cases of urolithiasis detected with UCT for 95 individual patients. The mean age of the study patients was 14.4 years; 72 patients (66%) were female. In 17 cases (15%) of urolithiasis, initial urinalysis results were negative for blood. Fifty-seven stones (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children who did not have a stone identified through UCT, 23 cases (10%) of potentially significant, alternative diagnoses were identified. A history of urolithiasis, a history of nausea and vomiting, the presence of flank pain on examination, and >2 red blood cells per high-power field in urine microscopy were positively associated with urolithiasis. A history of fever or dysuria and costovertebral angle tenderness on physical examination were inversely associated with urolithiasis on UCT scans. CONCLUSIONS: UCT plays an important role in the diagnostic evaluation of children with flank pain. Approximately 15% of children with urolithiasis do not have hematuria.

Role of positional instillation of contrast cystography in the algorithm for evaluating children with confirmed pyelonephritis.

OBJECTIVES: To assess the utility of positional instillation of contrast (PIC) cystography in detecting vesicoureteral reflux (VUR) in patients with renal scarring from recurrent febrile urinary tract infections that standard voiding cystourethrography and nuclear cystogram imaging failed to reveal. METHODS: Between June 2004 and November 2004, a total of 5 pediatric patients with recurrent febrile urinary tract infections and radiologic evidence of upper tract involvement were examined with PIC cystography. All patients had at least one previous negative standard reflux study (voiding cystourethrography or nuclear cystography). RESULTS: All 5 patients showed VUR on PIC cystography. Unilateral reflux was detected in 3 patients, and 2 patients had bilateral VUR. CONCLUSIONS: The PIC cystogram should be integrated into the algorithm for diagnosing patients with recurrent febrile urinary tract infection, who do not exhibit VUR on standard imaging modalities. The morbidity associated with undiagnosed VUR, as demonstrated by this group of patients, suggests that permanent renal damage may be prevented by early diagnosis and treatment.

Automated bladder scan urine volumes are not reliable in complex neonatal cases.

PURPOSE: We investigate the accuracy of urine volumes obtained by an automated bladder scan in complex neonatal cases. MATERIALS AND METHODS: Automated bladder scan determinations of urine volumes were obtained by neonatal intensive care unit nursing staff in 10 patients with myelodysplasia and cloacal exstrophy. Urine volumes were then immediately obtained by straight catheterization. Correlation between the scan and catheter volumes was then evaluated across and within cases. RESULTS: There was low correlation between automated bladder scan volume and catheter volume across and within cases (0.037 +/- 0.37) and (0.188 +/- 0.12), respectively. Using a cutoff of 20 cc 25% of significant volumes were missed. The 95% confidence interval from these data indicates that a significant volume is missed 7% to 25% of the time. CONCLUSIONS: We urge clinicians to exercise caution in the use of automated bladder scanners for determination of urine volumes in complex neonatal intensive care unit cases.

Spermatic cord torsion with preserved testis perfusion: initial anatomical observations.

PURPOSE: Despite the high sensitivity and specificity of scrotal ultrasonography, there continue to be reports of missed torsion. These "false-negative" scans are attributed to technical factors and intermittent torsions. We hypothesize that patients with specific anatomical configurations maintain testicular blood flow for prolonged periods, and, therefore, will have flow on ultrasound despite concurrent torsion. MATERIALS AND METHODS: Patient charts and scrotal ultrasounds were reviewed to identify patients younger than 18 years who underwent scrotal exploration between January 1998 and January 2003 for acute scrotum. Patients who underwent radiological evaluation before scrotal exploration were the main focus of this study. Operative reports were reviewed for specific anatomical details. RESULTS: A total of 61 patients underwent scrotal exploration for acute scrotum during the study period. Of these patients 14 had torsion confirmed intraoperatively and a preoperative scrotal ultrasound available. Four of these 14 patients had normal testicular blood flow on ultrasound but had testicular torsion confirmed intraoperatively. Operative findings suggest that these patients have specific anatomical characteristics. CONCLUSIONS: Testis perfusion can be maintained for a prolonged period in the presence of testicular torsion. Anatomical variability may account for differences in the duration of viability of the torsed testis. A high index of suspicion must be maintained to avoid missing the diagnosis of testicular torsion in these challenging cases.