Evan J. Kass

Results of Varicocele Surgery in Adolescents: A Comparison of Techniques

We report our experience using 3 different operative techniques for varicocele ligation in adolescents. Between August 1985 and April 1991 we performed 102 varicocelectomies on 91 adolescents. Varicocele persistence rate was 16% with a modified Ivanissevich inguinal approach and 11% using a selective high retroperitoneal technique with preservation of the internal spermatic artery. Intraoperative post-ligation spermatic venography did not significantly improve the results with the artery sparing techniques. Palomo mass high retroperitoneal ligation of the internal spermatic vessels produced significantly better results compared to the artery sparing techniques. Testicular atrophy did not occur in any patient regardless of the surgical technique used. These data suggest that the Palomo technique results in a significant decrease in the operative failure rate compared to the artery sparing procedures and it should be the preferred technique for varicocele ligation in the adolescent.

Adolescent Varicocele: Objective Indications for Treatment

We measured the gonadotropin response pattern to the intravenous injection of luteinizing hormone-releasing hormone in 53 male adolescents 11 to 17 years old (average age 14.2 years) with a grade II to III varicocele. Volume loss of the testis ipsilateral to the varicocele of 2 cc or more was noted in 32 patients. Baseline serum levels of follicle-stimulating hormone, luteinizing hormone and testosterone were determined, and measured again at 15, 30 and 60 minutes following intravenous injection of luteinizing hormone-releasing hormone. Of the patients 23 had an exaggerated response pattern following luteinizing hormone-releasing hormone stimulation, including abnormally high post-stimulation levels of luteinizing hormone only in 6, follicle-stimulating hormone only in 4, and follicle-stimulating and luteinizing hormones in 13. No significant difference in mean age, testosterone levels or loss of testicular volume was noted between the abnormal and normal response groups. This study indicates that approximately 45 per cent of adolescents with a varicocele have evidence of testicular injury. The physical examination was of no value in predicting which patient with a varicocele would display evidence of testicular dysfunction. We suggest that the luteinizing hormone-releasing hormone stimulation test become a routine part of the evaluation of an adolescent with a varicocele.

Do all Children with an Acute Scrotum Require Exploration

A total of 77 consecutive children ranging in age from 1 day to 17 years was evaluated for an acute scrotum by a single examiner (E. J. K.). In 10 children a definite diagnosis of acute spermatic cord torsion was made based upon the history and physical examination. No imaging studies were performed and torsion was confirmed at surgery in 9 children. The diagnosis of testis torsion was not as clear-cut in the remaining 67 children and, therefore, a color Doppler ultrasound was performed before any surgical intervention. The study demonstrated normal or increased blood flow in 55 of these children and none proved to have testicular torsion, although other scrotal pathology requiring surgery was noted in 5 children. Twelve children did not demonstrate evidence of testicular blood flow on the color Doppler ultrasound and all had surgical confirmation of testis torsion. We conclude that in our experience the majority (71%) of children with an acute scrotum did not require immediate surgical exploration. Color Doppler ultrasound can reliably identify those children with an acute scrotum who require exploration and spare the majority needless surgery. Routine scrotal exploration is no longer necessary for all children with an acute scrotum.

Testicular growth after successful varicocele correction in adolescents: comparison of artery sparing techniques with the Palomo procedure.

Testicular growth after varicocele surgery was evaluated in 116 boys 9 to 20 years old. A total of 88 boys was available for followup testicular examination 3 to 60 months after successful varicocele repair (mean 25). Left testicular volume loss of 2 cc or greater was present preoperatively in 72 of the 88 patients. The Palomo procedure was performed in 36 cases and repair using artery sparing techniques was done in 36. Mean relative left testicular volume increased 18% in the artery sparing group and 21% in the Palomo group. The increase in relative testicular volume compared to preoperative volumes was statistically significant in both groups (p < 0.05). There was no significant difference in testicular growth between the groups and no postoperative testicular atrophy was observed. A comparison group of 8 boys with uncorrected varicoceles demonstrated a mean relative volume increase of 3% (mean followup 22 months). The increase in testis volume in successfully corrected cases was statistically different (p < 0.05) from that of uncorrected cases. We conclude that reversal of varix induced testicular growth failure occurs only after successful surgical correction. The Palomo procedure resulted in equivalent testicular growth compared to the artery sparing techniques with fewer complications and no testicular atrophy despite intentional ligation of the testicular artery. Based on our data, we believe that the Palomo procedure should be the procedure of choice for adolescent varicocele correction.

The Sensitivity of Renal Scintigraphy and Sonography in Detecting Nonobstructive Acute Pyelonephritis

Recently it has been demonstrated that any child with proved acute pyelonephritis may be at risk for parenchymal scarring, whether or not reflux is present. Since cortical renal scintigraphy has been shown to detect accurately renal inflammation, we compared cortical scintigraphy with renal sonography in 46 children with documented acute pyelonephritis to determine which modality is best to detect patients at risk for renal injury. Cortical scintigraphy was abnormal in 36 children (78%) and renal ultrasonography was abnormal in 5 (11%). Reflux was demonstrated in only 20 cases (43%). We conclude that cortical scintigraphy is the preferred imaging technique for diagnosing renal inflammation, and it should be used routinely in every child with suspected acute pyelonephritis. A new imaging protocol is proposed.

First and second generation lithotripsy in children: results, comparison and followup.

During a 5-year period 32 children and adolescents 4 to 18 years old underwent 35 extracorporeal shock wave lithotripsy (ESWL*) treatments for 37 calculi. The unmodified Dornier HM3 lithotriptor was used in 21 cases (60%) while the remaining cases were treated with the Siemen Lithostar lithotriptor. The HM3 necessitated general anesthesia in 67% of patients and the Lithostar necessitated intravenous sedation in 86%. The majority of pediatric lithotripsy treatments were performed on an outpatient basis (24) or during an overnight hospital stay (3) while 8 were done on an inpatient basis. Of the 37 stones treated with 1 ESWL session 68% resolved, 19% had residual fragments less than 4 mm., 8% had residual fragments greater than 4 mm. and 5% required an endoscopic procedure for resolution. When success rates by lithotriptor were examined no significant difference between the 2 machines was identified although the HM3 treated larger stones (p = 0.0499). There were no statistical differences in regard to success and the use of stents, patient age or stone location between the 2 lithotriptors. Three patients required adjuvant procedures, and complications and morbidity developed in 2 and 5, respectively. All children or parents were contacted for followup (range 7 to 67 months). One child required ESWL for a new stone while another passed a stone without intervention. Only 1 child with a residual fragment less than 4 mm. became symptomatic but needed no intervention while 1 of 3 with fragments greater than 4 mm. needed intervention. No patients required open or percutaneous intervention.

Varicocelectomy in adolescent boys: long-term experience with the Palomo procedure.

PURPOSEnWe report our long-term experience with the Palomo technique for varicocele ligation in the pediatric population.nnnMATERIALS AND METHODSnBetween August 1986 and December 2006, 312 patients 7 to 21 years old (median age 14.6) underwent varicocele ligation using the Palomo technique for complete retroperitoneal ligation of the internal spermatic veins and artery. In 234 patients the varicocele was grade III, in 75 it was grade II and in 3 it was grade I. Indications for surgery were relative left testicular volume loss compared to the right testicle in 248 patients, bilateral palpable varicoceles in 8 and pain or parental preference in the remainder. Postoperative followup was 2 weeks to 10.6 years (mean 17.4 months). A total of 233 patients had at least a 6-month followup.nnnRESULTSnPersistent varicocele was noted in 9 of 233 patients (3.9%). Of the 233 patients 68 (29%) presented with a secondary hydrocele an average of 14 months (range 18 to 1,964 days) following surgery, of whom 12 (17.6%) underwent hydrocele correction. The 12 patients who underwent hydrocelectomy represented 5% of the patients with varicocelectomy. Postoperative testicular atrophy was not documented in any patient and no other surgical complications were noted.nnnCONCLUSIONSnThe Palomo procedure for adolescent varicocele repair is safe and effective with a high success rate and low complication rate. Postoperative hydrocele formation developed in 29% of our patients. However, most secondary hydroceles were small, asymptomatic and did not require surgical correction.

Pediatric Urology: Management of Suspected Antenatal Torsion: What Is the Best Strategy?

Currently, management of the newborn with suspected antenatal torsion is somewhat controversial. Many surgeons recommend early surgical exploration within the first few days of life, primarily to avoid errors in diagnosis. However, since the surgical and general anesthetic risks at this age are increased, it might be preferable to defer an operation until risks to the patient are minimized. The optimal solution to this dilemma would be the ability to diagnose torsion and exclude other conditions noninvasively. We present a series of 12 patients 1 to 14 days old who presented with a scrotal mass secondary to suspected antenatal testis torsion. Color Doppler ultrasound in each case demonstrated abnormal testicular blood flow and architecture consistent with testis torsion. Eventual exploration of all 12 patients confirmed prenatal torsion. We conclude that scrotal ultrasound with color Doppler enhancement can accurately identify neonates with antenatal testis torsion and exclude other scrotal pathological conditions. If elected, surgery for torsion can then be deferred until the risks of anesthesia and surgery are improved.

Pituitary gonadal dysfunction in adolescents with varicocele

Gonadotropin-releasing hormone stimulation testing was performed on 104 adolescent males with a unilateral left varicocele to determine the frequency of testicular dysfunction in this group of patients. An abnormal test result was noted in approximately 30 percent of varicocele patients. We believe that an abnormal test result indicates a higher risk for future fertility problems, and early treatment may reduce this risk.

Outcomes of Lumbar to Sacral Nerve Rerouting for Spina Bifida

PURPOSEnRestoring bladder and bowel function in spina bifida by creation of a skin-central nervous system-bladder reflex arc via lumbar to sacral nerve rerouting has a reported success rate of 87% in China. We report 1-year results of the first North American trial on nerve rerouting.nnnMATERIALS AND METHODSnNine subjects were enrolled in the study. Intradural lumbar to sacral nerve rerouting was performed. Subjects underwent urodynamic testing with stimulation of the cutaneous dermatome and careful neurological followup. Adverse events were closely monitored along with changes in bowel and bladder function.nnnRESULTSnAt 1 year 7 patients (78%) had a reproducible increase in bladder pressure with stimulation of the dermatome. Two patients were able to stop catheterization and all safely stopped antimuscarinics. No patient achieved complete urinary continence. The majority of subjects reported improved bowel function. One patient was continent of stool at baseline and 4 were continent at 1 year. Of the patients 89% had variable weakness of lower extremity muscle groups at 1 month. One child had persistent foot drop and the remainder returned to baseline by 12 months.nnnCONCLUSIONSnAt 1 year a novel reflex arc with stimulation of the appropriate dermatome was seen in the majority of subjects. Improvements in voiding and bowel function were noted. Lower extremity weakness was mostly self-limited, except in 1 subject with a persistent foot drop. More patients and longer followup are needed to assess the risk/benefit ratio of this novel procedure.