A history of cryptorchidism: lessons from the eighteenth century.

PURPOSE: John Hunter in 1786 opened the door to more than 200 years of study and discussion of the cryptorchid testis. We review the history that has brought us to our current surgical treatment of this condition. MATERIALS AND METHODS: We performed a review of the medical and historical surgical literature pertaining to cryptorchidism. RESULTS: The study of cryptorchidism began with the anatomical descriptions of Baron Albrecht von Haller and John Hunter. Attempts at surgical correction of the undescended testis began in the early 1800s, culminating in the first successful orchidopexy by Thomas Annandale in 1877. Further contributions to the surgical technique include: (1) Arthur Dean Bevan's division of the processus vaginalis to prevent reascent and his stress on the importance of adequate mobilization of the spermatic cord, (2) the description by Robert Prentiss of surgical triangles which allowed for mobilization of the spermatic cord and placement of the testis into the scrotum without tension, and (3) Lattimer's subdartos pouch. CONCLUSION: Our understanding and the surgical treatment of cryptorchidism have continued to evolve over the last 200 years. A study of the history of surgical management of the undescended testis sheds light on the rationale behind current management.

Is long-term sonographic followup necessary after uncomplicated ureteral reimplantation in children?

PURPOSE: We examined the necessity of postoperative ultrasound following surgical correction of vesicoureteral reflux beyond initial postoperative assessment. The followup among children who have undergone correction of vesicoureteral reflux has varied, and currently there are no standards to document how long postoperative monitoring for hydronephrosis, renal scarring or renal growth should continue. MATERIALS AND METHODS: The study population included 128 children who underwent surgical correction of primary vesicoureteral reflux between 1992 and 2002. Data were collected as part of a retrospective chart review and included age at surgery, preoperative grade of reflux, indications for surgery, type of surgical correction, postoperative voiding cystourethrogram and ultrasound results, and postoperative course relative to urinary tract infections, incontinence and other symptoms. RESULTS: Of 128 patients 4 had postoperative reflux on voiding cystourethrogram. In each of these cases reflux either resolved completely or remained stable during postoperative followup. A total of 17 patients had grade 2 or 3 hydronephrosis on the initial 3-month postoperative ultrasound. In all of these cases hydronephrosis remained stable or improved during followup. In no case was there evidence of development of new hydronephrosis or worsening of previously established hydronephrosis beyond the 1-year postoperative ultrasound. CONCLUSIONS: Our data indicate that followup of uncomplicated ureteral reimplantation in children more than 1 year postoperatively is not warranted. The elimination of studies beyond 1 year following surgery would result in a significant cost savings.

Prescrotal orchiopexy: an alternative surgical approach for the palpable undescended testis.

PURPOSE: Inguinal exploration has been a standard approach for the management of palpable undescended testis. We performed prescrotal orchiopexy in patients with palpable undescended testes at our institution and we report our results. MATERIALS AND METHODS: We reviewed the charts of patients with palpable undescended testes treated with prescrotal orchiopexy from 1999 to 2002. All children were referred to a university children's hospital and 1 of 2 surgeons performed the procedures. Examination using anesthesia was performed prior to any incision. If the testis was palpable and could be drawn close to the scrotum, prescrotal orchiopexy was performed. Retractile testes were excluded. RESULTS: During this period 291 patients underwent orchiopexy. Prescrotal orchiopexy was performed in 78 patients. Followup was 1 to 36 months (median 6). The overall success rate was 98.8% and the overall complication rate was 4.7%. At 7 months postoperatively 1 patient had a palpable retractile testicle. One patient had wound hematoma and another patient had wound cellulitis. At 31 months of followup 1 patient was considered to have a 25% decrease in testis size. All patients were without clinical evidence of hernia or hydrocele. CONCLUSIONS: Prescrotal orchiopexy is a successful procedure in select patients with a low complication rate. It has the advantage of a single, perfectly cosmetic incision. This approach should be considered an option when performing orchiopexy in a patient with a palpable, mobile undescended testis.

The high intra-abdominal testis: technique and long-term success of laparoscopic testicular autotransplantation.

BACKGROUND AND PURPOSE: Treatment of the high intra-abdominal testis is often a challenging problem. We present our technique of and results with laparoscopically assisted testicular autotransplantation (LATA) for treatment of the high intra-abdominal testis. PATIENTS AND METHODS: We reviewed the medical records of 15 patients with a high intra-abdominal testis who underwent procedures between 1993 and 1999 in which intra-abdominal dissection and testicular mobilization was performed laparoscopically. The LATA technique is described. RESULTS: The 15 patients underwent 17 LATA procedures. Age at surgery ranged from 6 months to 13 years (mean 3.6 years; median 2.5 years). Two of these patients had undergone failed contralateral orchidopexy for an intra-abdominal testis, and two patients underwent metachronous bilateral procedures. The laparoscopic dissection and microvascular anastomoses were successful in all patients. There were no postoperative complications. The involved testis remained viable with adequate growth in 15 of 17 procedures (88%) during a median 42-month (range 7-70 months) follow-up. Successful procedures included those in the two patients with contralateral atrophic testes and the two who underwent bilateral procedures. CONCLUSIONS: The LATA demonstrated a good long-term surgical outcome and may be the technique of choice in patients with bilateral intra-abdominal testes or patients who have contralateral testis atrophy following unsuccessful orchidopexy.

Appendiceal versus ileal segment for antegrade continence enema.

PURPOSE: To assess outcomes after the antegrade continence enema procedure, we present our results with an ileal segment or the appendix in children with severe bowel dysfunction. MATERIALS AND METHODS: A retrospective review of 45 children who had undergone the creation of a continent cecostomy for severe chronic constipation and fecal incontinence was performed. RESULTS: The appendix was used to create the continent cecostomy in 28 patients (group 1) and ileum 17 (group 2). Of 16 patients who underwent simultaneous construction of appendiceal Mitrofanoff neourethra, including continent catheterizable stoma, the appendix was split and used for the cecostomy and neourethra in 11. Overall, acceptable continence was achieved in 39 (87%) patients and total continence 31 (69%). No significant difference was noted in the rate of continence between groups 1 and 2. Nonstomal postoperative complications occurred in 5 patients in group 1 and 3 group 2. Complications that required reoperation related to the continent cecostomy occurred in 10 patients, including stomal stenosis in 8, with 6 group 1 and 2 group 2 (p >0.05), and stricture in 2, with 1 group 1 and 1 group 2. There were 2 patients who had previously undergone colostomy for intractable constipation who were undiverted at the time of the creation of continent cecostomy. Both were continent postoperatively. There were 3 patients, including those 2 who presented with chronic severe constipation of unclear etiology, who underwent colostomy for unrecoverable colonic dys-motility, of whom 1 subsequently required total colectomy. CONCLUSIONS: The creation of a continent cecostomy for antegrade continence enema is a successful management option in children with debilitating fecal incontinence, and may enable undiversion of an existing colostomy. The appendix and ileal segment are viable options for the procedure, with no significant difference noted in continence or complication rates.