Brent W. Snow

Bladder Autoaugmentation: Partial Detrusor Excision to Augment the Bladder without Use of Bowel

A surgical technique of partial detrusorectomy (autoaugmentation) for creation of a diverticular bulge of the dog bladder is described. The method is designed to serve as a bladder augmentation without using bowel. We describe the technique, results with dogs and its clinical application. Partial detrusorectomy appears to function as an autoaugmentation that can be performed reliably in dogs, offers potential advantages over bowel segments, and is a potential alternative to enterocystoplasty in selected patients.

COMPARISON OF LAPAROSCOPIC VERSUS OPEN NEPHRECTOMY IN THE PEDIATRIC POPULATION

PURPOSE Laparoscopic renal surgery has become an accepted approach for benign disease in adults. We compare our experience with laparoscopic and open nephrectomy in a pediatric population. MATERIALS AND METHODS A total of 10 pediatric patients underwent laparoscopic nephrectomy or nephroureterectomy and an additional 10 consecutive children underwent similar open procedures. All patients had benign disease and were treated at a single institution. Medical records were reviewed retrospectively for relevant clinical data. RESULTS Planned surgery was completed in all cases. There were no conversions to open surgery in the laparoscopic group. Mean operative time was 175.6 versus 120.2 minutes (p = 0.01) and mean hospital stay was 22.5 versus 41.3 hours (p = 0.03) in the laparoscopic and open nephrectomy groups, respectively. Blood loss was not statistically different. Analgesic use was qualitatively less in the laparoscopic nephrectomy group. CONCLUSIONS Laparoscopic nephrectomy and nephroureterectomy may be performed safely in children. While operative time was somewhat longer in our initial laparoscopic series, postoperative hospital stay was significantly shorter than for open surgery. Further experience with this technique is warranted.

Comparison of Laparoscopic Versus Open Partial Nephrectomy in a Pediatric Series

PURPOSE Recent advances in laparoscopic surgery as well as increasing experience with these techniques have led to the selection of laparoscopic surgery for many urological procedures. A lesser number of pediatric laparoscopic surgical studies have been reported. Few pediatric comparative laparoscopic versus open surgical procedure studies have been published. We compared 2 groups of similar pediatric patients who underwent partial nephrectomy via the laparoscopic or open technique. MATERIALS AND METHODS A total of 22 consecutive partial nephrectomies were performed in pediatric patients 3 months to 15 years old. Of these procedures 11 chosen according to surgeon preference were performed laparoscopically and 11 were done by the open technique. Clinical data were obtained by chart review and compared retrospectively in the 2 groups. Demographic data, operative time and blood loss, the perioperative complication rate, hospital stay and costs, postoperative analgesic use and followup findings were compared. RESULTS Mean operative time in the laparoscopic and open groups was 200.4 and 113.5 minutes, respectively (p <0.0005). Blood loss was less than 50 cc in all patients. In the laparoscopic and open groups mean hospital stay was 25.5 and 32.6 hours (p = 0.068), and mean cost was

Tunica Vaginalis Blanket Wrap to Prevent Urethrocutaneous Fistula: An 8-Year Experience

6,125 and

Use of Tunica Vaginalis to Prevent Fistulas in Hypospadias Surgery

4,244 (p = 0.016), respectively. Patients in the laparoscopic group required fewer doses of analgesics than those who underwent open surgery (mean 10.9 versus 21, p = 0.041). CONCLUSIONS Our findings show that increased operative time and costs are disadvantages of pediatric laparoscopic nephrectomy compared with open techniques. Conversely decreased hospital stay, lower analgesic requirements and cosmesis support the use of laparoscopy for pediatric partial nephrectomy. These differences must be considered when deciding which technique is best for overall patient care.

CYSTIC TESTICULAR LESIONS IN THE PEDIATRIC POPULATION

An 8-year review of hypospadias repair in patients with a meatus proximal to the coronal margin is reported. Fistula rates were compared among 4 groups: 1) loupe magnification, 2) tunica vaginalis blanket wrap tissue interposition with loupe magnification, 3) operating microscope magnification and 4) tunica vaginalis blanket wrap tissue interposition in conjunction with operating microscope magnification. Rate of fistula formation with loupe magnification alone was 20%, microscope magnification alone was 12% and tunica vaginalis blanket wrap interposition with loupes was 9%. When tunica vaginalis blanket wrap tissue interposition was used in conjunction with intraoperative microscopy no fistulas resulted.

Complications of pregnancy in women after childhood reimplantation for vesicoureteral reflux: an update with 25 years of followup.

Tunica vaginalis was used to wrap around the neourethra at the time of hypospadias repair. This tunica vaginalis wrap prevented urethrocutaneous fistulas in 20 patients who underwent hypospadias repair. It also was successful when used in conjunction with urethrocutaneous fistula repair in 2 patients.

The incidence of antisperm antibodies in infertility patients with a history of cryptorchidism.

PURPOSE We present the etiology, histological evaluation and management of all cystic lesions of the pediatric testis. MATERIALS AND METHODS Illustrative cases from our experience are reported with a literature review of all possible diagnoses. RESULTS Included in the differential diagnosis of cystic testis lesions in children are epidermoid cyst, dermoid cyst, prepubertal teratoma, juvenile granulosa cell tumor, cystic dysplasia of the rete testis, testicular cystic lymphangioma, simple cyst and cystic degeneration after torsion. Testis sparing surgery is feasible in many circumstances. CONCLUSIONS Cystic lesions of the pediatric testis are rare but represent an interesting group of diagnoses. Patient age at presentation, examination features, tumor markers and sonographic appearance may assist in making a presumptive and occasionally definitive diagnosis preoperatively. Based on the likely diagnosis enucleation or partial orchiectomy may be considered when performed with frozen section histological assessment. A thorough understanding of potentially cystic testis lesions in children leads to the best management choices and often to preservation of a substantial portion of the affected testis.

APPARENT UNILATERAL URETEROPELVIC JUNCTION OBSTRUCTION IN THE NEWBORN: EXPECTATIONS FOR RESOLUTION

Surgery for the correction of vesicoureteral reflux has been performed routinely since the early 1960s. In 1986 a large group of women who underwent childhood ureteral reimplantation surgery was contacted and surveyed concerning infections, pregnancies and other complications. A notably high rate of cystitis and pyelonephritis was found during pregnancy. Because 9 years have passed and many more pregnancies have occurred, we contacted this cohort again as well as a new cohort of historical controls to reassess long-term complications of childhood ureteral reimplantation in children. Of 67 women who underwent reimplantation with an average followup of 25 years 62 were contacted of whom 75% had urinary tract infections after becoming sexually active and 65% had urinary tract infections with pregnancies. Of 141 pregnancies 57 (40%) were complicated by urinary tract infections and 21 (15%) terminated in spontaneous abortion. Of 37 women with primary vesicoureteral reflux and no surgery with an average followup of 25.5 years there was a 15% prevalence of urinary tract infections with pregnancy in 21. Of 75 pregnancies in this group 14 (18%) terminated in spontaneous abortion. Women with urinary tract infections and reflux as children have high rates of cystitis with the onset of sexual activity whether or not they underwent reimplantation as children. Those who underwent reimplantation as children are at significant risk of urinary tract infection in pregnancy but not at a higher risk of miscarriage than the general population. Education, screening and antibiotic prophylaxis during pregnancy should be considered.

Variables in Successful Repair of Urethrocutaneous Fistula After Hypospadias Surgery

Infertility in patients with a history of cryptorchidism is usually the result of oligo-asthenospermia. In this study we analyzed the incidence of antisperm antibodies in infertility patients with a history of cryptorchidism, general infertility patients and donors of known fertility. Of the cryptorchid patients 66% tested positive for antisperm antibodies compared to 2.6% of the control group of infertile patients and 2.8% of the donors of known fertility. Sperm progressive motility was significantly (p < 0.05) decreased in the cryptorchid patients testing positive for antisperm antibodies compared to those testing negative for antisperm antibodies, and compared to both control groups. Of the patients treated for cryptorchidism by orchiopexy 52% were positive for antisperm antibodies, and the mean patient age at orchiopexy was significantly (p < 0.01) higher in the positive antibody group (14.2 +/- 1.2 years old) than the negative antibody group (8.6 +/- 0.8 years old). While decreased sperm concentration, motility and morphology are usually the primary causes of infertility in patients with a history of cryptorchidism, it appears that the presence of antisperm antibodies is also increased in these patients, which may contribute to reduced fertility.