The museum's mummies: an inside view.

We applied medical and scientific methodology in a study of the mummies in the Metropolitan Museum of Art in New York, New York, by computed tomographic scanning and other radiographic methods. These noninvasive procedures allow us to "unwrap" these mummies without unwrapping them. This is, in effect, technology transfer of routine diagnostic techniques used in medicine to Egyptology. After this noninvasive information-gathering procedure, the mummies are preserved intact for possible future investigations that may be more sophisticated and more informative. The data are presented and put into perspective by a review of pertinent literature.

Thoracolumbar accessory penis: etiology, diagnosis, and management.

Human sacral appendages have rarely been reported. We present a neonate with a thoracolumbar appendage resembling a penis, and discuss the nature of the anomaly and its diagnosis and management.

Diagnostic flexible peritoneoscopy: assessment of the contralateral internal inguinal ring during unilateral herniorrhaphy.

BACKGROUND: Inguinal hernia is the most common pediatric surgical condition, with 75% of cases presenting unilaterally. No diagnostic study exists to determine preoperatively which children are at risk for subsequent contralateral hernia. The literature is not clear in advising whether surgeons should explore the contralateral side at the time of initial unilateral herniorrhaphy. METHODS: Twenty-four patients presenting clinically with a unilateral hernia underwent flexible peritoneoscopy by isolation of the ipsilateral hernia sac and placement of a flexible cystoscope into the peritoneal cavity. After establishing a CO2 pneumoperitoneum, the contralateral side is checked for patency of the internal inguinal ring. RESULTS: Our study found an open internal inguinal ring in 4 of 24 patients examined (16.7%). The other 20 patients were spared the usual routine contralateral exploration. An open contralateral internal inguinal ring was appreciated in two of nine (22.2%) left herniorrhaphy and 2 of 15 (13.3%) right herniorrhaphy patients. This technique requires an average of 4.5 minutes to perform. With 18-to 32-month follow-up, no hernias have developed on the contralateral side. CONCLUSION: Diagnostic flexible peritoneoscopy is safe, quick, simple, and could be used to evaluate the contralateral internal inguinal ring in unilateral pediatric herniorrhaphy patients.

Flexible transinguinal laparoscopy to assess the contralateral ring in pediatric inguinal hernias.

The incidence of contralateral patent processus vaginalis (CPPV) is >50% in infants with clinical unilateral inguinal hernia (CUIH) and decreases only slowly with advancing age. Laparoscopy through the hernia sac (transinguinal laparoscopy) to detect suspected CPPV is a safe and efficient way to minimize routine contralateral inguinal exploration, but can be technically difficult. We used flexible urologic instruments and/or angled cystoscopic lenses to make transinguinal laparoscopy easier. Over a 3-year period, 37 patients (34 boys and 3 girls) ranging in age from 4 months to 12 years (mean age 59 months) with CUIH underwent ipsilateral groin exploration and diagnostic transinguinal laparoscopy. Laparoscopy was performed with flexible 17F cystoscopes (26 cases), flexible 9F ureteroscopes (2 cases), and rigid 70 degrees cystoscope lenses (9 cases). We detected eight CPPV (22%) in our series of 20 right and 17 left inguinal hernias, in a mean transinguinal laparoscopy time of 4.5 minutes. At 26-month mean follow-up, no patient whose contralateral inguinal ring was deemed closed had developed a hernia. Flexible fiberoptic urologic scopes and/or angled cystoscope lenses make transinguinal laparoscopy easy and efficacious in the pediatric population. Our series represents the longest longitudinal study of transinguinal laparoscopy for the diagnosis of CPPV.

Laparoscopic surgery in children with ventriculoperitoneal shunts: effect of pneumoperitoneum on intracranial pressure--preliminary experience.

OBJECTIVES: We monitored changes in intracranial pressure (ICP) in 2 children with myelodysplasia undergoing laparoscopic bladder autoaugmentation. Both children had ventriculoperitoneal shunts (VPS) secondary to Arnold-Chiari malformations (type II). METHODS: ICP was monitored through a 23-gauge needle placed into the shunt reservoir and connected to a pressure transducer and drainage system. Intraoperative mean arterial pressure, end-tidal CO2 (ETCO2), ICP, abdominal pressure, and cerebral perfusion pressures were all monitored. RESULTS: Both children demonstrated rapid onset and sustained increases in ICP of greater than 12 mm Hg above baseline to a maximum pressure of 25 mm Hg. The average cerebrospinal fluid removed from each patient was 30 cc, thereby lowering ICP with no adverse neurologic sequela. The pCO2 remained constant throughout the procedures, as measured by ETCO2. CONCLUSIONS: We believe that intracranial hypertension (IH) results from a "Valsalva-like" phenomenon, which causes cerebral vascular engorgement. In addition, the pneumoperitoneum may increase the resistance to outflow through the distal peritoneal catheter, causing a partial or complete shunt obstruction. Untreated IH may result in adverse neurologic sequelae from brain herniation in these children with hindbrain anomalies and potentially altered brain compliance. We believe it is prudent to perform intraoperative ICP monitoring in this subgroup of patients undergoing laparoscopic surgery and that IH should be treated by ventricular drainage.

Laparoscopic laser assisted auto-augmentation of the pediatric neurogenic bladder: early experience with urodynamic followup.

PURPOSE: We report our initial experience with laparoscopic laser assisted bladder auto-augmentation for treatment of the symptomatic pediatric neurogenic bladder. MATERIALS AND METHODS: Laparoscopic auto-augmentation of the bladder was performed in 2 children with myelodysplasia and high pressure neurogenic bladders unresponsive to medical management. Detrusorotomy was done using the KTP-532 laser. Laser energy was directed to the tissue to evaluate long-term effects of the procedure. RESULTS: Laparoscopic bladder auto-augmentation can be performed easily and with less morbidity compared to open auto-augmentation. Although results at 6 weeks showed improvement, enterocystoplasty was ultimately performed in both cases due to symptomatic recurrence of incontinence associated with increasing peak detrusor pressure and decreasing compliance. CONCLUSIONS: While this technique has the potential to offer minimally invasive correction in patients with low capacity, high pressure bladders, further modifications will be required to achieve long-term success.

Laparoscopic orchiopexy: clinical experience and description of technique.

PURPOSE: We reviewed the experience, early followup and technique of laparoscopic treatment of the nonpalpable undescended testis at our institution. MATERIALS AND METHODS: Charts of patients who underwent laparoscopic treatment of an intra-abdominal testis from September 1992 to October 1994 were reviewed. RESULTS: A total of 13 laparoscopic orchiopexies was performed on 11 children with nonpalpable undescended testes. In 10 cases sufficient length was gained on the spermatic vessels using laparoscopic dissection to perform tension-free orchiopexy without the need for division of the spermatic vessels. CONCLUSIONS: When localization of an intra-abdominal testis is confirmed, orchiopexy can be performed safely with minimal morbidity using a laparoscopic approach. Length of hospital stay and postoperative morbidity may be improved in comparison to traditional techniques.

Laparoscopic laser-assisted bladder autoaugmentation.

OBJECTIVES: The purpose of this study is to examine the feasibility of performing a laparoscopic bladder autoaugmentation and to assess the urodynamic characteristics of an autoaugmented bladder. METHODS: Laparoscopic bladder autoaugmentation was performed in 9 female canines (20 to 30 kg). Following laparoscopic access to the peritoneal cavity, a midline bladder seromyotomy was performed using the potassium titanyl phosphate 532 nm laser. This produced a large bladder diverticulum. Changes in bladder volume and compliance were quantified over a 3-month period of follow-up. RESULTS: Urodynamic evaluation demonstrated an increase in bladder capacity 6 weeks postoperatively in 8 of 9 dogs, with an average volume increase of 45%. Bladder compliance improved in 7 of 9 dogs with an average increase in compliance of 67%. Three months postoperatively, bladder capacity remained increased in 5 of 9 dogs, with an average increase in volume of only 5.3%. An improvement in compliance was sustained in 5 of 9 animals with an average increase of 13.9%. Laparoscopic exploration revealed grossly normal bladders with adhesions of omentum to the seromyotomy site in all canines and the anterior abdominal wall in 2 of 9 canines. Histologically, the seromyotomy site was devoid of muscle with an intact urothelium and a proliferation of loose connective tissue. CONCLUSIONS: The technique of laparoscopic bladder autoaugmentation can be performed easily in the canine model. Although results at 6 weeks show significant improvement, the longer term, 3-month results were not statistically significant. This technique has the potential to offer a minimally invasive correction for patients with low-capacity, high-pressure bladders that have failed pharmacologic treatment.

Chromophore enhanced laser welding of canine ureters in vitro using a human protein solder: a preliminary step for laparoscopic tissue welding.

Laser welding of the genitourinary tract has the potential advantage of forming an immediate watertight seal. It may obviate the need for sutures, eliminate the inherent lithogenic reaction to suture, and potentially improve healing. In the current study we employed a KTP-532 laser in vitro to weld canine ureters. Ureters were transected over a stent and immediately repaired using the KTP-532 laser (power density 7.14 W/cm.2, spot size = 0.5 cm.) alone or in combination with different tissue solders. Solders consisted of 40% human albumin alone or with the addition of iron oxide or fluorescein as light absorbing dyes (chromophores). Following the repairs, intraluminal bursting strength and the total energy required to complete the repairs were measured. The KTP laser alone was not able to achieve a satisfactory repair. Successful ureteral repairs were achieved in all solder groups while maintaining ureteral continuity at supraphysiologic pressures.

Patch graft urethroplasty using dye enhanced laser tissue welding with a human protein solder: a preclinical canine model.

We investigated the use of the KTP-532 laser to perform a patch graft urethroplasty in 24 adult male dogs using the inner preputial skin as the donor site. In group 1 (12 dogs) repairs were completed with conventional microsuturing techniques, while in group 2 (12 dogs) they were completed using the KTP-532 laser. In the laser welding group the addition of a protein solder (40% human albumin) doped with fluorescein was used. Assessment parameters included a preoperative and postoperative retrograde urethrogram, measurement of intraluminal bursting pressure in the first 6 animals in each group, operative time and histology. Operative time was 42% faster and acute intraluminal bursting pressures were significantly higher in the laser-solder group. No fistulas occurred in the laser-solder group compared to a 50% fistula rate in the suture group. Significant radiographic abnormalities were seen in the urethras of the suture repair group.

Use of tissue expanders in final reconstruction of infrapubic midline scar, mons pubis, and vulva after bladder exstrophy repair.

Two patients following bladder exstrophy repair presented for final cosmetic reconstruction with the characteristic lower abdominal midline scar, bisected mons pubis, and laterally displaced labia majora. Tissue expanders were used to obtain additional skin and subcutaneous tissue. After adequate serial expansion, the expanders were removed, scar tissue excised, and primary approximation of healthy tissues performed. A tension-free closure and esthetically pleasing midline incision, mons pubis, and vulva were obtained.

Antisperm antibodies in cryptorchid boys.

To explore whether the development of antisperm antibodies might play a role in inhibiting the future fertility of cryptorchid boys, 32 boys who underwent orchiopexy and 21 boys who underwent other inguinal surgeries were examined for the presence of antibodies to donor sperm. This group was compared to 23 boys who underwent noninguinal surgery or who had unrelated medical conditions. Using the indirect immunobead assay, 28% of the boys in the study group were found to have antisperm antibodies. These were predominantly of the IgG isotype. In the comparison group, only 1 boy (4%) had antisperm antibodies (P < 0.05).

Anti-Müllerian hormone in three intersex conditions.

Anti-Müllerian hormone (AMH), secreted by embryonic testicular Sertoli cells, inhibits the development of Müllerian ducts in the male. An enzyme-linked immunoassay (ELISA) for AMH was used to investigate three intersex infants. The AMH level was correlated with each patient's degree of Müllerian duct development. Complete inhibition of Müllerian structures correlated with the normal levels of AMH in the infant with testicular feminization. Detectable levels of AMH were found in the hermaphroditic infant; however, these low levels reflected Sertoli cell inadequacy of the ovotestis, which was documented by a right rudimentary Fallopian tube and a normal uterus. In the infant with persistent Müllerian duct syndrome, (PMDS), the normal Müllerian derivatives are compatible with 1) an AMH receptor defect; 2) a biologically and immunologically abnormal AMH molecule, or 3) a functional AMH deletion. The lack of detectable AMH in this infant excluded the AMH receptor abnormality and thus directed authors' search for the specific defect to the AMH gene. Thus, this ELISA for AMH is as valuable a tool to the molecular biologist studying a precise genetic error as it is to the physician making a precise clinical diagnosis.

Laser welding of pedicled flap skin tubes.

The efficacy of the carbon dioxide laser used at high power levels for tissue destruction is well established. This laser at lower power levels has been used to incise and anastomose blood vessels, tendons, nerves, dura, bowel, fallopian tube, vasa deferentia, ureters and skin. Laser welding is faster, reduces surgical manipulation and introduces less foreign material into the wound than conventional suturing techniques. We tested the feasibility of laser welding of pedicled flap skin tubes to determine if there is a potential application in reconstruction, particularly for hypospadias repair.

Posterior urethral valves. Role of temporary and permanent urinary diversion.

Between 1960 and 1983, 67 boys were treated for posterior urethral valves. Despite adequate valve ablation, azotemia eventually developed in 19, and they underwent permanent urinary diversion. Normal renal function was not achieved in any of these children. Diversion does not appear to have changed the natural course of their renal insufficiency, which is most likely secondary to damage incurred prior to their initial presentation. Prognostic factors useful to identify this select population are examined.

Extracorporeal shock-wave lithotripsy for children.

We report the cases of 17 children between the ages of 3 and 17 years who underwent 19 treatments using extracorporeal shock-wave lithotripsy. Stone size averaged 14.9 mm, with a range of 3 to 25 mm. The number of shock waves delivered averaged 1720, with a range of 600 to 2000. Treatment time averaged 36 minutes, with a range of 15 to 55 minutes. The average length of hospital stay was 2.2 days. In nine of the 19 treatments the kidneys were rendered free of stones. There were no complications.

Childhood retroperitoneal fibrosis.

Retroperitoneal fibrosis is rarely considered in the differential diagnosis of ureteral obstruction in children even when clinical presentation and radiologic findings are typical. In a 12-year-old boy admitted with a 2-week history of flank pain computed tomography showed an enhancing mass obstructing the left ureter. Pathologic examination of the mass and adjacent segment of ureter revealed retroperitoneal fibrosis.