Amr Abdelhamid AbouZeid

Intra-Abdominal Testis: Histological Alterations and Significance of Biopsy

PURPOSE Intra-abdominal testes represent only 5% of undescended testes. Review of the literature reveals that few data exist on the histological analysis of intra-abdominal testes. We studied histological alterations in intra-abdominal testes in relation to patient age at orchiopexy. MATERIALS AND METHODS A total of 57 boys underwent laparoscopy for impalpable undescended testes between October 2002 and June 2005. Testicular biopsies were taken from intra-abdominal testes, fixed in 3% glutaraldehyde, embedded in Epon, sectioned at 1 micron thickness and stained with toluidine blue. Histomorphometric analysis was performed by light microscopy. Effect of age at operation on histological evaluation of abdominal testes was also studied. RESULTS Testicular biopsies from 29 patients with intra-abdominal testes showed the histological alterations of decreased mean diameter of seminiferous tubules, germinal cell depletion (55%) and presence of microliths (6.9%). CONCLUSIONS As age at orchiopexy increases, deviation from the norm is more evident and absence of germ cells on biopsy becomes more pronounced, reaching a rate of 93% after age 3 years. Further studies on orchiopexy with or without biopsy in the first few months of life would likely improve our understanding and treatment of cryptorchidism.

Modified Byars’ flaps for securing skin closure in proximal and mid-penile hypospadias

Objective: The objective of this study was to describe a modification for skin closure combined with tubularized incised plate (TIP) urethroplasty in the repair of proximal and mid-penile hypospadias. Patients and methods: The study included 47 patients with nondistal hypospadias who underwent a primary TIP procedure from September 2007 to May 2010. Meatal position was mid-shaft (n = 20), penoscrotal (n = 20), and scrotal (n = 7). The patients in the study were divided into two groups according to a modification in the technique of skin closure, which involved incising the prepuce vertically into two halves, then harvesting the dartos flap for covering the repair from one half, leaving the other preputial half to reconstruct the ventral skin without compromising its blood supply. Results: In the standard procedure (n = 19 patients), complications included glanular dehiscence (10.5%), glanular fistula (5%), urethrocutaneous fistula (10.5%), and skin complications (21%). In the modified procedure (n = 28 patients), complications included glanular dehiscence (7%) and glanular fistula (3.6%), but no skin complications or urethrocutaneous fistulae occurred. Conclusion: The modified Byars’ flaps is a useful alternative for skin closure during proximal and mid-shaft TIP urethroplasty, with fewer complications and acceptable cosmetic outcome.

Posterior Cologastric Anastomosis: An Effective Antireflux Mechanism in Colonic Replacement of the Esophagus.

BACKGROUND The colon may be used to replace a portion of the esophagus in pediatric patients, but prevention of gastrocolic reflux is a concern. We report our experience with the retrosternal colon bypass, and the effect of combining the procedure with a posterior cologastric anastomosis on prevention of gastrocolic reflux. METHODS The study included 35 consecutive pediatric patients who underwent retrosternal colon bypass during the period of 2010 through 2014. In standard practice, the cologastric anastomosis is performed at the anterior gastric wall. Lately, we modified our technique by shifting the cologastric anastomosis to the back of the stomach away from the anterior adhesions around the gastrostomy. In follow-up, a gastrogram was performed to check for gastrocolic reflux. RESULTS The indication for esophageal replacement was postcorrosive esophageal stricture in 19 patients and long gap esophageal atresia in 16 patients. Their mean ages were 51 and 16 months, respectively. No gastrocolic reflux was detected with the posterior cologastric anastomosis, whereas reflux was always present with the anterior cologastric anastomosis. We had two mortalities and one major morbidity (hematemesis and failure to thrive) that were related to regurgitation of gastric contents into the colonic conduit. The last patient was successfully managed by transferring the cologastric anastomosis from the front to the back of the stomach, with marked symptomatic and radiologic improvement. CONCLUSIONS After colonic replacement of the esophagus, the gastrocolic reflux represents a functional problem that may lead to serious complications. Combining a posterior cologastric anastomosis with retrosternal colon bypass is an effective way to avoid this problem.

MRI of persistent cloaca: Can it substitute conventional imaging?

PURPOSE To define the role of MRI in the preoperative assessment of patients with persistent cloaca and whether it can substitute other imaging modalities. METHODS We prospectively examined eleven patients with persistent cloaca between July 2007 and March 2012. Non contrast MRI examinations were performed on 1.5T magnet using head coil. Multiple pulse sequences (T1WI, T2WI, fat suppression) were obtained in axial, sagittal and coronal planes of the pelvis, abdomen, and spine. The scans were reviewed for the following: the level and type of rectal termination, the developmental state of striated muscle complex (SMC), associated genitourinary and spinal anomalies. MRI findings were compared to conventional fluoroscopic imaging, operative and endoscopic findings. We applied novel MRI parameters (urethral length, relative hiatal distance and vaginal volume). The relation between different parameters was tested statistically using Pearson correlation test. RESULTS MRI could accurately demonstrate the level of bowel termination in patients with persistent cloaca, in addition to its high sensitivity for detection of mullerian anomalies which were present in 73% of patients. Furthermore, MRI could disclose associating renal and spinal anomalies, and assess the developmental state of SMC. The shorter the urethra (higher urogenital confluence), the narrower the pelvic hiatus, and the more was the obstruction (vaginal distension). CONCLUSION MRI is a valuable tool in exploring the different internal anatomical features of the cloacal anomaly; and when combined with endoscopy, MRI can make other preoperative conventional imaging unnecessary.

Y-Type Urethral Duplication: A True Variant of the Anomaly or a Misnomer?

Objectives The objective of this study was to define anatomical and radiological features of the so-called Y-type urethral duplication. Methods The study included four male patients and one female patient with congenital connection between the urogenital tract and the external anal orifice. Investigations included renal sonography, urethrograms, and magnetic resonance imaging pelvis in the last patient. The urethrograms of male patients were carefully reviewed, in addition to available urethrograms of similar cases that could be obtained through searching the literature. Results Unlike cases of urethral duplication, the male patients had always a complete prepuce and a functioning anterior urethra in 25%. The accessory uroanal channel had almost always a constant origin from the posterior urethra. Some tension seems to be exerted by the urethroanal tract pulling on and causing a kink in the posterior urethra. Management was simple in patients without anterior urethral hypoplasia (one male and the female patient). Both were treated by simple excision of the communicating ano-urogenital tract through a perineal approach with an excellent outcome. Histopathological examination of excised tracts revealed stratified squamous cell in the former and transitional cell lining in the latter. In patients with hypoplastic anterior urethra, staged urethral reconstruction was performed in two, and progressive dilatation of hypoplastic anterior urethra was tried in the last patient. Conclusion Several observations would support diagnosing the congenital connection between the urinary tract and the external anal orifice in the male as a congenital fistula rather than an accessory urethra. Confirming and accepting this information may have its impact on changing the current surgical approach.

Securing the mucocutaneous anastomosis in the repair of low-anorectal anomalies

PurposeThe aim of this study was to identify the incidence of wound complications after a limited sagittal anorectoplasty for the repair of rectoperineal fistula. Patients and methodsBetween January 2011 and December 2014, patients with rectoperineal fistula treated primarily by a limited sagittal anorectoplasty were included. The patients in the study were divided into two groups according to the extent of rectal dissection and mobilization during the operation. ResultsThirty-six consecutive patients with rectoperineal fistula were included (28 girls and eight boys). Their mean age was 10 months (range 3–42 months). The overall incidence of postoperative wound dehiscence was 22.2% (eight patients). In the first group (limited rectal mobilization), there was a high incidence of wound complications (6/15 patients). Five patients were considered to have a major dehiscence and four required a rescue colostomy. In the second group (extended rectal mobilization, 21 patients), two had minor dehiscence that were managed conservatively. The overall incidence of wound complications was significantly lower in the second group (Mann–Whitney test, P=0.04). ConclusionAmong the patients with rectoperineal fistula, extension of the dissection and mobilization of the rectum from the anterior structures (vagina in girls, and bulpospongiosum in boys) decreases wound dehiscence following a limited sagittal anorectoplasty procedure.

Low-type anorectal malformations in the male: Extent of deviation from the norm.

PURPOSE To define the degree of deviation from the norm among boys with minor forms of anorectal malformations (ARM). PATIENTS AND METHODS Between March 2015 and January 2016, we studied the preoperative MRI of nine boys with low-type ARM. For comparison, we included another nine boys (control group) who underwent MRI pelvis for causes other than ARM (e.g. impalpable testes). RESULTS In boys with low-type ARM, the rectum descends forwards to touch the back of the prostate (as in the norm), but then goes downwards (with little or no backward deflection) keeping intimately attached to the bulb of the corpus spongiosum and displacing it downwards and forwards. The striated sphincter muscles do not follow the anterior displacement of the bowel termination, but remain orthotopically compacted at the normal predestined site of the anal canal. CONCLUSION Among boys with low ARM, the minor abnormalities at the external anal orifice are associated with deeper anatomical aberrations in the form of anterior misplacement of the anorectum. These findings may help in understanding the disturbed act of defecation among these patients, and provide guidance to the best way of surgical correction.

Feasibility and safety of monopolar diathermy as an alternative to clip ligation in laparoscopic Fowler-Stephens orchiopexy

PURPOSE The aims of the study were to study the effect of Fowler-Stephens orchiopexy (FSO) on testicular histology and to assess the feasibility of using monopolar diathermy as an alternative to clip ligation during laparoscopic FSO. PATIENTS AND METHODS The study included 20 patients with 20 intraabdominal testes and short vessels managed by laparoscopic-staged FSO. Biopsies were taken from intraabdominal testes during the first and second stages of the procedure for histologic comparison. The patients in the study were divided into 2 groups according to the method of dividing the testicular vessels in stage 1. The first 13 patients (group A) were managed by clip ligation of the vessels, whereas monopolar diathermy was used in the following 7 patients (group B). RESULTS Biopsy findings at stage 2 revealed an overall reduction in both the total number of germ cells per tubule and mean diameter of seminiferous tubules, whereas there was no statistically significant difference between the results in groups A and B. CONCLUSION The seminiferous cells can withstand (survive) dividing the main blood supply of the testis during FSO. The monopolar diathermy can be used as an alternative to clipping during laparoscopic procedures, having the advantages of lower expenses and using smaller instruments.

Laparoscopic classification of the impalpable testis: an update

PurposeWe present a classification for the nonpalpable testis (NPT) based on laparoscopic findings and suggest guidelines for the interpretation of these findings. Patients and methodsFrom October 2002 to December 2010, 121 patients with NPT underwent laparoscopy at two tertiary centers of Pediatric surgery in Egypt. The lower abdomen and pelvis were inspected to identify the following structures and their inter-relationships: the internal inguinal ring (and its patency), spermatic vessels, vas deferens, and testis. The laparoscopic findings were documented by one of the authors who attended all procedures, and video recordings were available in some cases. Further management was dependent on laparoscopic findings, classification, and plan of treatment. ResultsThe study included 117 patients with 142 nonpalpable testes. Their mean age was 4.9 years. Among patients with unilateral NPT, a contralateral palpable undescended testicle was always associated with a viable NPT (100%), whereas a contralateral scrotal testis had an equal chance (50%) of finding a viable NPT, without a significant difference whether it was right or left sided. ConclusionFailure of normal testicular descent leads to a spectrum of anatomical variations that can be precisely and safely defined by laparoscopy in about two-thirds of patients with nonpalpable testes. In the remaining one-third of patients, including inguinal exploration after laparoscopy can help us to exclude a missed viable inguinal testis.

Anatomical alterations following the ‘PSARP’ procedure: Correlating MRI findings with continence scores

PURPOSE To identify anatomical aberrations following PSARP procedure by using MRI, while correlating MRI findings to clinical outcome. PATIENTS AND METHODS Between January 2014 and December 2017, we conducted our study on male patients with rectourethral fistula who underwent PSARP. Postoperative pelvic MRI studies were performed and correlated to their clinical continence scores (Rintala, and Krickenbeck classification). RESULTS The study included 31 patients. Fourteen patients were retrieved from the hospital records and accepted to participate in the study; while the remaining 17 were collected from the fecal incontinence clinic. Their age ranged from 40 to 156 months (mean 83) We divided patients in the study into two groups according to their Rintala continence scores: (Group A) 15 patients with low scores (10 or less); and (Group B) 16 patients with higher scores (more than 10). We detected wider pelvic hiatus (hiatus/PC ratio) and more obtuse anorectal angle in group A than B. CONCLUSION Several anatomical alterations can be detected by MRI following the PSARP procedure that include abnormalities in the striated muscle sphincter (attenuation/deficiency), deviated neorectum, and presence of excessive perirectal fat. A widened pelvic hiatus and/or obtuse anorectal angle may correlate with poor fecal continence in these patients. LEVEL OF EVIDENCE This is a case control study (level III evidence).