David A. Diamond

A multi-institutional analysis of laparoscopic orchidopexy

Objective To combine and analyse the results from centres with a large experience of laparoscopy for the impalpable testis with small series, to determine the expected success rate for laparoscopic orchidopexy.

Comparative assessment of pediatric testicular volume: orchidometer versus ultrasound.

PURPOSE Testicular volume measurements obtained with the Prader and Rochester orchidometers were compared to those obtained using scrotal ultrasound. The ability of each orchidometer versus ultrasound in detecting volume differential between 2 testes and the accuracy of orchidometer measurement by a less experienced examiner to that of a urologist were compared. MATERIALS AND METHODS A total of 65 males were examined by the attending urologist and urology nurse using the Prader and Rochester orchidometers, and scrotal ultrasound was subsequently performed by an attending radiologist. Statistical analysis of the results was performed to determine the correlation of orchidometer measurements between examiners, as well as with ultrasound, and sensitivity and specificity of orchidometer and ultrasound in detecting defined volume differentials between testes of 10%, 15%, 20% and 25%. RESULTS There was a strong linear relationship between testicular volume measurements using either orchidometer and ultrasound. To detect a defined volume differential as determined by ultrasound orchidometer sensitivity was weak, whereas orchidometer specificity was better. There was a strong correlation between orchidometer measurements of the urology nurse and attending urologist. CONCLUSIONS Although the orchidometer remains valuable in assessing size of the individual testis, it is too insensitive to volume differentials relative to ultrasound to be used routinely to determine growth impairment. For this reason observation of an adolescent with varicocele should include an annual ultrasound assessment of testicular volume.

Children and Adolescents With Gender Identity Disorder Referred to a Pediatric Medical Center

OBJECTIVES: To describe the patients with gender identity disorder referred to a pediatric medical center. We identify changes in patients after creation of the multidisciplinary Gender Management Service by expanding the Disorders of Sex Development clinic to include transgender patients. METHODS: Data gathered on 97 consecutive patients <21 years, with initial visits between January 1998 and February 2010, who fulfilled the following criteria: long-standing cross-gender behaviors, provided letters from current mental health professional, and parental support. Main descriptive measures included gender, age, Tanner stage, history of gender identity development, and psychiatric comorbidity. RESULTS: Genotypic male:female ratio was 43:54 (0.8:1); there was a slight preponderance of female patients but not significant from 1:1. Age of presentation was 14.8 ± 3.4 years (mean ± SD) without sex difference (P = .11). Tanner stage at presentation was 4.1 ± 1.4 for genotypic female patients and 3.6 ± 1.5 for genotypic male patients (P = .02). Age at start of medical treatment was 15.6 ± 2.8 years. Forty-three patients (44.3%) presented with significant psychiatric history, including 20 reporting self-mutilation (20.6%) and suicide attempts (9.3%). CONCLUSIONS: After establishment of a multidisciplinary gender clinic, the gender identity disorder population increased fourfold. Complex clinical presentations required additional mental health support as the patient population grew. Mean age and Tanner Stage were too advanced for pubertal suppressive therapy to be an affordable option for most patients. Two-thirds of patients were started on cross-sex hormone therapy. Greater awareness of the benefit of early medical intervention is needed. Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation.

TUBULARIZED INCISED PLATE URETHROPLASTY:: EXPANDED USE IN PRIMARY AND REPEAT SURGERY FOR HYPOSPADIAS

PURPOSE We evaluated the impact of tubularized incised plate urethroplasty on primary and repeat hypospadias repair. MATERIALS AND METHODS We retrospectively reviewed the medical records of all boys who underwent hypospadias repair at our institution during a recent 3-year period. The level of the hypospadias defect, technique of repair, primary repair versus reoperation, age at surgery and complications were recorded. RESULTS A total of 520 hypospadias repairs were done from May 1996 through June 1999. We began to perform tubularized incised plate urethroplasty in November 1996. During the ensuing consecutive 32 months 181 primary and 25 repeat hypospadias repairs were done using this technique. Mean patient age at surgery was 22 months (range 3 months to 30 years). During the 6 months immediately before we began to use this method the Mathieu flip-flap procedure was the most commonly performed technique, accounting for 38% of all hypospadias repairs. In contrast, during the last 6 months reviewed tubularized incised plate urethroplasty accounted for 63% of all repairs, including 41 of 65 primary operations (63%) and 4 of 6 reoperations (67%), while no Mathieu procedures were performed. Postoperative followup was 6 to 38 months for tubularized incised plate repair. Overall meatal stenosis and a urethrocutaneous fistula developed in 1 and 14 boys, respectively (7% complication rate). CONCLUSIONS Tubularized incised plate urethroplasty has become the preferred technique of primary and repeat hypospadias repair at our institution. The technique has few complications as well as proved success and versatility that continues to expand its applicability and popularity.

A New Method to Assess Metastatic Potential of Human Prostate Cancer: Relative Nuclear Roundness

A new technique has been developed that helped in an accurate prediction of the prognosis of 27 patients with stages B1 and B2 prostatic cancer following radical prostatectomy. This method involves computer-assisted image analysis of histological specimens of the primary lesion removed at the time of radical perineal prostatectomy. On the basis of a nuclear shape factor, known as nuclear roundness, we have been able to distinguish those tumors with a high metastatic potential from tumors that are less aggressive. This technique provides pathologists with quantitative information about the metastatic potential of a tumor, which may aid in the management of the individual patient.

Current findings in diagnostic laparoscopic evaluation of the nonpalpable testis

AbstractPurpose: We delineate the current findings and contribution of diagnostic laparoscopic evaluation in the management of nonpalpable testis.Materials and Methods: We reviewed all cases in which laparoscopy was considered the management associated with a nonpalpable testis in a 4-year period. Since our previous series, we have performed a careful examination for the testis after induction of anesthesia but before committing to laparoscopy. We recorded testis position and quality, character of the vas deferens and spermatic vessels, type of management and contribution of laparoscopy. We also reviewed contemporary published series and collated the findings of studies performed elsewhere.Results: We identified 263 nonpalpable testes in 225 patients between September 1992 and 1996. In 40 patients 46 testes (18%) were found during physical examination under anesthesia. Of the remaining cases considered appropriate for laparoscopy 215 with complete records were further analyzed. Only 12.6% could be conside...

THE EFFECT OF STREPTOZOTOCIN-INDUCED DIABETES ON THE NEUROENDOCRINE-MALE REPRODUCTIVE TRACT AXIS OF THE ADULT RAT

Studies in the streptozotocin rat model for diabetes mellitus suggest that sexual dysfunction in these animals may result from diabetes-induced alterations of the neuroendocrine-reproductive tract axis. Our investigation was performed to better define the effects of diabetes on the neuroendocrine sex accessory organ axis in the male rat. Rats were rendered diabetic, and were either left untreated or treated with insulin, testosterone or both. Diabetes resulted in decreased body and reproductive organ weights, as well as diminished sperm counts and motility and prostatic acid phosphatase. Seminal fructose was increased. A significant decrease in serum LH, FSH and testosterone was noted. Insulin treatment of the diabetic rats restored serum gonadotropins, reproductive organ weight, sperm counts and motility, and seminal fructose to control levels. Prostatic weight and prostatic acid phosphatase levels remained abnormal. Testosterone restored the above mentioned parameters to control levels, with the exception of LH. Treatment with insulin and testosterone had a synergistic effect on spermatogenesis. A GnRH stimulation test demonstrated that pituitaries of diabetic animals had a blunted response, with diminished LH and FSH secretion. In the diabetic animal, there are both pituitary and testicular abnormalities which may be responsible for reproductive dysfunction.

ENDOSCOPIC CORRECTION OF VESICOURETERAL REFLUX IN CHILDREN USING AUTOLOGOUS CHONDROCYTES: PRELIMINARY RESULTS

PURPOSE Previous approaches to the endoscopic correction of vesicoureteral reflux have used foreign bulking substances, raising concern regarding safety and long-term efficacy. We describe the results of a clinical trial using transurethral injection of autologous chondrocytes to correct vesicoureteral reflux in children. MATERIALS AND METHODS A total of 29 children (46 ureters) with grades II to IV vesicoureteral reflux were treated at 2 sites. Each child underwent cystoscopy and ear cartilage biopsy at the initial setting. Chondrocytes were grown in culture for 6 weeks. Patients then returned for transurethral injection of chondrocytes into the bladder trigone to correct reflux. Ultrasound was performed 1 month and radionuclide cystography was done 3 months postoperatively to confirm reflux resolution. When reflux persisted, repeat treatment with stored chondrocytes was offered. RESULTS Initial chondrocyte injection corrected reflux in 26 of the 46 ureters (57%), while secondary injection was successful in 12 of 19 (63%). Overall reflux was corrected in 38 of the 46 ureters (83%) and in 24 of the 29 patients (83%). There were no significant complications. CONCLUSIONS Transurethral injection of autologous chondrocytes to correct vesicoureteral reflux in children appears to be an effective and safe technique that holds promise for treating this congenital abnormality in a minimally invasive fashion.

Clinical outcome and management of prenatally diagnosed primary megaureters

The objective of this study was to evaluate the clinical outcome of infants diagnosed perinatally with primary obstructive megaureter, and to determine which anatomical and physiological indexes best predict such outcome. A total of 67 megaureters thought to be due to primary vesicoureteral junction obstruction was detected in 53 newborns as a result of prenatally diagnosed hydronephrosis or hydroureteronephrosis. These patients were followed nonoperatively using periodic ultrasound and 99mtechnetium-diethylenetriaminepentaacetic acid (Tc-DTPA) renal scans. After a mean followup period of 3.1 years 23 dilated ureters (34%) spontaneously resolved while 33 (49%) persisted. Repair was performed on 11 megaureters (17%) because of breakthrough urinary infections in 3 and deteriorating renal function in 8. Postoperatively, all renal units showed improved drainage on 99mTc-DTPA renal scan, while half of those with decreased renal function regained the lost function. None had further deterioration in renal function. Of the clinical indexes studied ultrasonographic ureteral diameter (less than 6 mm. good, greater than 10 mm. poor prognosis) and drainage on 99mTc-DTPA renal scan correlated best with outcome. We conclude that the majority of primary megaureters detected in the perinatal period can be followed conservatively using periodic ultrasound and 99mTc-DTPA renal scans. Relatively few cases required surgical intervention and those at risk were identifiable by a diameter greater than 10 mm. and poor drainage on 99mTc-DTPA renal scan.

RATE AND PREDICTORS OF SPONTANEOUS RESOLUTION OF PRENATALLY DIAGNOSED PRIMARY NONREFLUXING MEGAURETER

PURPOSE We assessed clinical and ultrasound predictors of the spontaneous resolution of prenatally diagnosed, primary nonrefluxing megaureter. MATERIALS AND METHODS Primary nonrefluxing megaureter was prenatally diagnosed in 54 neonates from 1993 to 1998, including 15 in whom it was bilateral (69 megaureters). Median followup period from birth to the last radiology examination was 25.8 months (range 2.3 to 72). RESULTS Of the patients 10 underwent surgical repair for severe hydroureteronephrosis, including decreasing renal function on diuretic renography in 1, and an episode of bilateral obstruction and acute renal failure in 1. Hydroureteronephrosis resolved in 39 cases (72%) and persisted in 5 at 30 to 72 months of followup. Laterality, gender and retrovesical ureteral diameter had no significant effect on the resolution rate (p >0.05). Mean initial ureteral diameter in patients with resolution was less than in those without resolution and in those who underwent surgery (0.8 versus 1.15 and 1.32 cm., respectively). Presenting hydronephrosis grade was a significant predictor of the resolution rate (p = 0.03). Grades 1 to 3 hydronephrosis resolved at a median age of 12.9, 23.9 and 34.6 months, respectively (range 4.1 to 66). In patients in whom grades 4 and 5 hydronephrosis resolved the median age at resolution was 48.5 months. CONCLUSIONS Most cases of prenatally diagnosed, primary nonrefluxing megaureter resolve spontaneously. Grades 1 to 3 hydronephrosis tend to resolve between ages 12 and 36 months. For these grades followup intervals may be progressively elongated after a pattern of improving hydronephrosis has been established. In children with grade 4 or 5 hydronephrosis, or a retrovesical ureteral diameter of greater than 1 cm. the condition may resolve slowly and require surgery.