Clanton B. Harrison

Microvascular autotransplantation of the intra-abdominal testis.

The operative management of intra-abdominal testes is controversial, largely because there is no method of orchiopexy that can reliably produce good results. We report our results on the use of microvascular autotransplantation of intra-abdominal testes. We performed 12 autotransplants in 10 boys ranging in age from 10 months to 14 years (median age 30 months). In each instance the testis had been localized previously by laparoscopy or it was known to be intra-abdominal and was believed to be grossly normal in appearance. The vascular anastomoses of the spermatic to the inferior epigastric vessels were performed by an experienced microvascular surgeon using 10-zero nylon suture and 40 times magnification. Biopsies were taken at operation in 9 patients. Followup of 6 to 30 months is available in 7 patients and all 8 testes are palpably normal and in good scrotal position. This approach is feasible even in small children and the results seem to be superior to the expected results reported with division of the spermatic vessels.

Diagnostic Pneumoperitoneum for the Detection of the Clinically Occult Contralateral Hernia in Children

The detection and management of occult contralateral hernia in children who present with a clinically evident unilateral hernia have evoked controversy. Routine use of herniography, intraoperative probing of the contralateral inguinal area and routine or selective exploration of the contralateral groin all have their advocates and detractors. During the last 5 years we have used intraoperative pneumoperitoneum and we report our experience in 64 patients 3 months to 9 years old. A retrospective analysis of the data revealed that pneumoperitoneum was negative in demonstrating a contralateral inguinal hernia in 59 of 64 patients (92%). Contralateral exploration was not performed in patients in whom pneumoperitoneum was negative. All 5 patients who tested positive had an indirect inguinal hernia upon contralateral exploration and all 5 were less than 3 years old. Patients who had a negative pneumoperitoneum were followed for up to 5 years and only 1 (1.8%) false negative examination was discovered. Pneumoperitoneum is a safe, effective means to evaluate the contralateral groin for occult hernia at the time of unilateral hernia repair in children.

Hernia After Pediatric Urological Laparoscopy

PURPOSE The incidence of port site hernia following adult laparoscopy is 0.1% to 3.0%. There are no known published reports concerning hernia incidence or related factors after pediatric urological laparoscopic interventions. We present our experience with port site incisional hernias following pediatric urological laparoscopy. MATERIALS AND METHODS We reviewed all pediatric urological laparoscopic procedures performed at Childrens Medical Center Dallas from 2000 to 2008. A total of 261 cases were identified with followup available in 218 (83.5%). In 187 cases there were sufficient data to evaluate outcomes for each port site separately, and compare the size, location and fascial closure status to hernia development. RESULTS Median patient age was 6.1 years (range 0.4 to 18.8). A total of 218 patients had a median followup of 5.7 months (range 0.2 to 83.4). Seven hernias (3.2%) were diagnosed at a median of 1.2 months (range 0.1 to 15.1) postoperatively. Patients with hernia were younger than those without hernia, at 1.1 years (range 0.5 to 3.9) vs 6.2 years (0.4 to 18.8, p = 0.04). We analyzed 571 port sites in 187 cases. In 385 ports (67.4%) the fascia was closed. Hernia developed in 4 of 385 ports (1.0%) that were closed and in 3 of 186 (1.6%) that were not closed. No significant relationship was observed between hernia development and port size or location. CONCLUSIONS The incidence of port site hernia after pediatric urological laparoscopy was 3.2%, similar to the reported incidence in adults. While development of hernia after pediatric urological laparoscopy is rare, it is more likely to occur in infants. Due to the low incidence of this complication, it is difficult to draw conclusions regarding contributing factors.

Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score

PURPOSE The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain. MATERIALS AND METHODS Children with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST. RESULTS Of 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%). CONCLUSIONS TWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.

Transscrotal Near Infrared Spectroscopy as a Diagnostic Test for Testis Torsion in Pediatric Acute Scrotum: A Prospective Comparison to Gold Standard Diagnostic Test Study

Purpose: A rapid test for testicular torsion in children may obviate the delay for testicular ultrasound. In this study we assessed testicular tissue percent oxygen saturation (%StO2) measured by transscrotal near infrared spectroscopy as a diagnostic test for pediatric testicular torsion. Materials and Methods: This was a prospective comparison to a gold standard diagnostic test study that evaluated near infrared spectroscopy %StO2 readings to diagnose testicular torsion. The gold standard for torsion diagnosis was standard clinical care. From 2013 to 2015 males with acute scrotum for more than 1 month and who were less than 18 years old were recruited. Near infrared spectroscopy %StO2 readings were obtained for affected and unaffected testes. Near infrared spectroscopy &Dgr;%StO2 was calculated as unaffected minus affected reading. The utility of near infrared spectroscopy &Dgr;%StO2 to diagnose testis torsion was described with ROC curves. Results: Of 154 eligible patients 121 had near infrared spectroscopy readings. Median near infrared spectroscopy &Dgr;%StO2 in the 36 patients with torsion was 2.0 (IQR −4.2 to 9.8) vs −1.7 (IQR −8.7 to 2.0) in the 85 without torsion (p=0.004). AUC for near infrared spectroscopy as a diagnostic test was 0.66 (95% CI 0.55–0.78). Near infrared spectroscopy &Dgr;%StO2 of 20 or greater had a positive predictive value of 100% and a sensitivity of 22.2%. Tanner stage 3‐5 cases without scrotal edema or with pain for 12 hours or less had an AUC of 0.91 (95% CI 0.86–1.0) and 0.80 (95% CI 0.62–0.99), respectively. Conclusions: In all children near infrared spectroscopy readings had limited utility in diagnosing torsion. However, in Tanner 3‐5 cases without scrotal edema or with pain 12 hours or less, near infrared spectroscopy discriminated well between torsion and nontorsion.

Prospective Evaluation of Predictors of Testis Atrophy After Surgery for Testis Torsion in Children

OBJECTIVE To prospectively correlate pain duration, red scrotal skin, ultrasound appearance of testis, and intraoperative testis color to future testis atrophy after acute testicular torsion. METHODS Patients 2 months-18 years old with unilateral acute scrotum were consecutively enrolled in a National Institutes of Health transcutaneous near-infrared spectroscopy study, with a subgroup analysis of the true torsion group. Presence or absence of red scrotal skin, pain duration, testicular heterogeneity on preoperative ultrasound, and intraoperative testis color based on a novel visual chart 5 minutes after detorsion were recorded. All testes underwent orchiopexy regardless of appearance. Percent volume difference between normal and torsed testicles on follow-up ultrasound was compared between patients with and without risk factors. RESULTS Thirty of 56 patients who had surgical detorsion underwent scrotal ultrasound at a mean of 117 days after surgery. A color of black or hemorrhagic 5 minutes after detorsion, pain duration >12 hours, and heterogeneous parenchyma on preoperative ultrasound were associated with significant testis volume loss in follow-up compared with normal testis. All patients with a black or hemorrhagic testis had >80% volume loss. Erythematous scrotal skin was not significantly associated with smaller affected testis volume in follow-up. CONCLUSION Based on the high atrophy rate, orchiectomy can be considered for testes that are black or hemorrhagic 5 minutes after detorsion. Pain duration >12 hours and parenchymal heterogeneity on preoperative ultrasound were also associated with testis atrophy. Red scrotal skin was not a reliable predictor of atrophy and should not delay exploration.

Ureteral injury due to external violence: 49 cases over 5 years

SummaryA total of 49 cases of ureteral trauma secondary to external violence occurring over 5 years were reviewed with regard to etiology, diagnosis, associated injury, management, and follow-up. In all, 47 cases (95.9%) of penetrating and 2 (4.1%) of blunt trauma occurred; 45 cases (91.8%) occurred in men and 4 (8.2%), in women. Both blunt ureteral injuries were secondary to auto/pedestrian accidents. Overall, 92% of ureteral injuries were associated with injury to other organ systems. Our management principles for ureteral injuries have previously been reported [2, 3]. These include debridement, a watertight, tension-free anastomosis, isolation of the anastomosis, and Penrose drainage of the area proximal to the anastomosis. Postoperative complications occurred in eight patients; these consisted of three strictures, two urinomas, two cutaneous fistulas, and one perinephric abscess. There were six perioperative deaths, all unrelated to the genitourinary injuries.

Ewing sarcoma of the scrotum.

Nonosseous Ewing sarcoma commonly occurs in the extremities or deep soft tissues. However, cutaneous and subcutaneous locations have been reported. A 3-year-old boy presented with a 2-year history of a painless, slowly growing mid-scrotal mass. Pathology after surgical excision revealed the lesion to be Ewing sarcoma. The patient is free of metastatic disease and is currently undergoing chemotherapy. Soft-tissue malignancies must be kept in the differential diagnosis of any solid paratesticular mass in a child. Although rhabdomyosarcoma is the most common, as this case demonstrates, other rare sarcomas are also possible.