Bhagwant Gill

Urolithiasis in children following augmentation cystoplasty.

Until recently urolithiasis in children following augmentation cystoplasty was an infrequently noted problem. We examined our 10-year experience and found urinary calculi to form in 52% of children and young adults undergoing augmentation cystoplasty. Calculi formed at a median interval of 24.5 months after surgery, predominantly in the lower tract. Urinary tract infection was a statistically significant risk factor, while the use of absorbable staples, intestinal mucus and hypocitraturia were also implicated. Calculus composition was primarily a mixture of apatite, struvite and ammonium urate. Bladder calculi were effectively managed endoscopically in the majority of cases without complication. Upper tract calculi presented an endourological challenge.

Significance of epididymal and ductal anomalies associated with testicular maldescent.

Epididymal abnormalities have long been found in conjunction with cryptorchid testicles. The aim of this study was to document the different types of epididymal and ductal anomalies in relation to the position of the cryptorchid testis and to determine their clinical significance. Exploration was performed on 187 cryptorchid testes in 174 boys. The position of the testis and the epididymal and ductal anomalies were documented at operation. A biopsy was taken from the testis or atretic spermatic cord structures for light microscopy. Epididymal, ductal and/or testicular anomalies were detected in 43 per cent of the 187 testes, including anomalies of ductal fusion, anomalies of ductal suspension and anomalies associated with absent or vanishing testes. Biopsy of the testes with severe anomalies of ductal fusion showed preservation of germ cells in 69 per cent and diminished germ cells in 31 per cent. The higher the arrest of testicular descent, the more grossly abnormal was the associated ductal system. Early successful orchiopexy alone may not ensure subsequent fertility despite the presence of normal germ cells.

Electrical stimulation and multichannel EMG recording for identification of functional neural tissue during cauda equina surgery

Electrical stimulation of structures within the surgical field was used to identify functional neural elements during 25 cauda equina operations. EMG responses from anterior thigh, posterior thigh, and anal sphincter muscles were recorded simultaneously using a multichannel signal averager. During nine operations, stimulation of a presumed filum terminale or other tissue produced clear EMG responses, prompting modification of surgical procedures. In one patient, this resulted in preservation of a flattened spinal cord which resembled a band of scar tissue. Some EMG responses were restricted to a single muscle group; these neural structures would probably not have been identified if only a single-channel EMG recording was used. Visual examination alone was not adequate for identifying functional neural elements, or for determining whether atretic-appearing nerve roots were functional. Electrical stimulation with multichannel EMG recording facilitates the preservation of functional neural elements and the optimization of surgical results in cauda equina surgery.

Cryptorchidism. Current concepts.

Cryptorchidism is the most common genitourinary disorder of childhood. Even though its incidence has changed only slightly over the years, the number of operations for cryptorchid testes has tripled. Better understanding of the natural history of cryptorchidism, as well as changes that occur in testicular histology both in the cryptorchid and the contralateral descended testis very early in life, are the cause. This experience has led us to advocate early orchiopexy as the optimum means of treatment.

Routine Intraoperative Post-Ligation Venography in the Treatment of the Pediatric Varicocele

Varicocelectomy in the adult is followed by a relatively low recurrence rate but children treated by conventional techniques seem prone to have more frequent recurrences. We believe that the higher recurrence rate observed in children after routine varicocelectomy actually represents residual varicose communications that had been missed at the primary operation. Routine post-ligation intraoperative venography has been used to detect these occult communications in 26 children undergoing varicocelectomy. Our results indicate a low recurrence rate (3.6 per cent), suggesting that routine use of this procedure with childhood varicocelectomy is beneficial.

Significance of intraoperative venographic patterns on the postoperative recurrence and surgical incision placement of pediatric varicoceles.

Intraoperative post-ligation spermatic venography has proved to be a reliable adjunct in pediatric varicocele surgery. In a previous study we described the technique and initial results. In this series of 60 consecutive patients with pediatric varicoceles having intraoperative venography, we specifically studied the collateral venous circulation and crossover veins to characterize the venographic patterns associated with varicocelectomy failure. The relationship of incision site and number of venograms necessary to ensure complete interruption of the internal spermatic system was evaluated to determine if an optimum incision placement exists, minimizing the number of venograms necessary. Our data indicate that the most common etiology of recurrent varicocele in children seems to be residual proximal (central) collateral veins, pelvic collateral veins (that is cremasteric, deferential and crossover veins) rarely seem to contribute to varicocelectomy failure and there is an inherent but low risk of varicocelectomy failure despite radiological evidence of complete internal spermatic vein interruption.

Significance of accessory ductal structures in hernia sacs.

The finding of ductal structures resembling a vas deferens during pathological examination of a hernia sac specimen has significant medical and legal implications. A method of distinguishing these accessory structures from an inadvertently transected vas has been lacking and is needed. Between July 1989 and January 1990 we examined 147 hernia sacs from 105 consecutive prepubertal and adolescent boys to determine the incidence and salient histological features distinguishing these ductal structures from a true vas deferens. Luminal diameters of the ductal structures were compared with published normal age-related established vas deferens diameters and with those measured during hernia repair in 10 of our youngest patients. Among the 147 specimens 6 hernia sacs (4.1%) contained ductal structures. We found that the mean ductal diameter (0.263 mm.) was significantly smaller than that of a normal vas deferens (0.69 to 1.5 mm.). Furthermore, the surrounding mantle of tissue of these ductal structures lacked muscle tissue when studied with Masson trichrome stain. We conclude that duct diameter and trichrome staining are simple ways of differentiating these structures from a true vas deferens.

EPIDIDYMITIS IN CHILDREN: THE CIRCUMCISION FACTOR?

PURPOSE Recommendations for circumcision have significantly altered in the last several years. Studies have objectively established an increased risk of urinary tract infection in uncircumcised boys. We evaluated the relationship between epididymitis and circumcision status. MATERIALS AND METHODS We studied the relationships among the circumcision status of 36 consecutive boys with epididymitis in a review of 128 with acute scrotal inflammation (group 1), circumcision status of 43 in whom the diagnosis of epididymitis at discharge home had been made elsewhere (group 2), New York State hospital discharge figures for circumcision in newborns (group 3) and the regional prevalence of circumcision in 200 consecutive pediatric emergency department patients at the same institution with nonurological diagnoses (group 4). RESULTS New York State Department figures indicate that 70% of male newborns are discharged home with a hospital code for circumcision. Similarly an evaluation of 200 consecutive male patients without urological diagnoses younger than 18 years in the emergency department revealed that 131 (65%) were circumcised. Comparatively in groups 1 and 2 only 25 and 26% of patients, respectively, were circumcised. The statistical difference in circumcision status among the 4 groups was significant (p >0.0004). CONCLUSIONS These data demonstrate with highly statistical significance that a relationship exists between epididymitis and the presence of a foreskin. We found that an intact foreskin is an important etiological factor in boys with epididymitis.

Can fetal renal artery Doppler studies predict postnatal renal function in morphologically abnormal kidneys ? A preliminary report

PURPOSE The diagnosis of multicystic kidney in utero can be made with reasonable reliability with real-time sonography. However, a cystic hydronephrotic kidney may be difficult to distinguish from a multicystic kidney, necessitating postnatal renography. We report our preliminary observations of Doppler waveform variation in normal and cystic fetal kidneys. MATERIALS AND METHODS Five consecutive fetuses with a unilateral cystic kidney, and one with a unilateral hydronephrotic duplex kidney and cystic upper moiety were evaluated in utero with color Doppler renal sonography. RESULTS Doppler signal on serial ultrasound was consistently absent in the ipsilateral cystic kidney, while normal renal artery Doppler waveforms with a systolic and diastolic component were obtained from the contralateral and unaffected moieties. Postnatal renography confirmed nonfunction in all cystic moieties. The hydronephrotic noncystic moiety of the duplex kidney showed a normal Doppler waveform and good function. CONCLUSIONS Absence of renal artery Doppler waveforms in fetal cystic kidneys correlates with renal nonfunction. If this observation can be further confirmed by additional cases, fetal Doppler sonography would become an additional tool to diagnose confidently a multicystic kidney in utero, which may allow us to dispense with postnatal renography.

Intraoperative spermatic venography reconsidered.

We review our most recent experience with varicocelectomy and post-ligation venography in 58 adolescents as followup to our previously reported series. A single injection venogram confirmed the completeness of varicocele ligation in 82% of cases while 2 or more injections were required in the remainder. Venography was not performed in 8 cases because of technical difficulties in 5 or surgeon choice in 3. The recurrence rate was 8.6% and was not statistically significant whether or not venography was performed (p = 0.86). Although intraoperative spermatic venography is technically simple and safe, in our series its efficacy in diminishing the recurrence rate after varicocelectomy was unproved.