Halil Atayurt

Testis sparing surgery for steroid unresponsive testicular tumors of the congenital adrenal hyperplasia

The association between testicular tumors/nodules and congenital adrenal hyperplasia (CAH) has been recognized for many years. Tumors are considered to be an aberrant adrenal tissue that has descended with the testes and has become hyperplastic due to ACTH stimulation. The recommended treatment consists of increasing the glucocorticoid dose to suppress ACTH secretions. If the testicular size is not reduced after suppression therapy or a side effect of glucocorticoid dose is noted, surgical intervention should be considered. We diagnosed steroid unresponsive testicular tumors of the CAH in two patients who were treated by testicular sparing tumor enucleation. We believe that testis sparing surgery is the procedure of choice for all patients with testicular adrenal rest tumor, since it maximizes future fertility potential.

Hydatid disease of the liver in childhood: the success of medical therapy and surgical alternatives

Abstract Hydatid liver disease in children is a serious problem where the parasite is endemic. Although surgery is considered the treatment of choice, medical therapy is an alternative, but its curative efficacy is controversial. The aims of this study were to evaluate the curative efficacy of medical treatment and compare the results of surgical techniques with respect to postoperative complications in 102 consecutive children (64 male and 38 female, aged 4 to 15 years, mean 8.15 years) treated in two childrens hospitals between 1988 and 1997. In 67, medication with albendazole was used as the initial therapy; 17 had multiple hepatic cysts and 8 had coexisting cysts in the lung. Success was defined as progressive shrinkage and solidification of the cyst. The overall success of medical therapy was approximately 27%: 18 of the 67 patients were cured with albendazole (15 had a single cyst, 3 multiple cysts) and 1 recurrence (6%) was observed. Age, sex, and the size, location, and number of cysts did not show any relationship to the response to medical therapy. After 12 to 14 weeks of medical treatment, a viable cyst on ultrasonography and/or computed tomography was accepted as a sign of treatment failure and these patients were scheduled for surgery. A total of 84 patients (35 primarily, 49 after unsuccessful medical therapy) were treated surgically. Procedures included cystectomy and tube drainage in 11 patients, cystectomy in 17, cystectomy and capitonnage in 24, and cystectomy and omentoplasty in 32. The incidence of early postoperative complications was 55% for tube drainage, 18% for cystectomy, 13% for capitonnage, and 0% for omentoplasty. During the follow-up period, 2 surgical patients (2%) developed recurrent disease. Medical treatment with albendazole resulted in fewer curative successes than expected. A longer period of medical treatment may increase the success rate; this question requires further study. Omentoplasty decreased the rate of early postoperative complications, especially cavity abscess and biliary fistula, after surgical treatment and should be recommended in this setting.

Anal canal duplication in children: a new technique

Anal canal duplication (ACD) is a very rare abnormality. Because of the high rate of malignant changes in anal canal duplications complete removal of the ACD is recommended. In the current study, simple mucosectomy for management of cases of ACD has been discussed. There was no complication and patients had good cosmetic results with a normal sphincter control. This technique is simple, safe, takes less time and achieves good anatomic appearance and functional results.

Clinical Experience in Hypospadias: Results of Tubularized Incised Plate in 496 Patients

OBJECTIVES To review the tubularized incised plate, a recently popularized technique, and provide outcomes. METHODS From January 2000 to December 2006, 496 patients underwent the tubularized incised plate technique for hypospadias at our clinic. The patient age range was 6 months to 14 years. The postoperative follow-up time was 2 years (range 6 months to 3 years). The patients underwent the technique as described by Snodgrass, with some small technical modifications. The patients were hospitalized for 10 days postoperatively, with a urethral stent in place. RESULTS Of the 496 patients, 48 experienced 53 complications. The most frequent complication was meatal stenosis (n = 27, 5%), followed by urethrocutaneous fistula (n = 25, 5%). Dehiscence was noted in 1 patient (0% of 496 patients and 2% of the 48 patients with complications). Initially, the fistula occurrence rate was 11% and 4% for all 496 and the 48 patients with complications, respectively, which had decreased to 3% and 8% in the most recent 3 years. During the study period, some technical modifications have applied, with a resulting decrease in the complication rates. Complications occurred in 48 patients (9%), of whom 25 required surgical repair (5% of 496 patients). CONCLUSIONS The tubularized incised plate technique is a surgical method that can be applied to most hypospadias anomalies. Increasing clinical experience and minor additions to the technique have enhanced our success with this method.

Eventration of the diaphragm.

OBJECTIVE Eventration of the diaphragm (ED) is defined as the abnormal elevation of the diaphragm. Although asymptomatic ED may be amenable to conservative treatment, symptomatic ED in children, either congenital or acquired, may require surgical treatment. This study evaluated the results of diaphragmatic plication in children with unilateral ED. METHODS Fifteen patients who had undergone diaphragmatic plication for ED between 1997 and 2003 were evaluated retrospectively. The diagnosis of ED was established by routine chest radiographs and fluoroscopy. Patients who failed to respond to nonoperative treatment were referred for surgery. Nine patients underwent diaphragmatic fluoroscopy 1-5 years following plication to assess function. RESULTS Indications for diaphragmatic plication were respiratory symptoms such as tachypnoea, dyspnoea, recurrent pneumonia and failure to thrive. In 14 patients, the position of the diaphragm was normal after plication, but the diaphragm was elevated without symptoms in one patient during postoperative follow-up. The motion of the diaphragm was investigated in nine patients. Fluoroscopic studies showed that the operated hemidiaphragm was immobile and there was no paradoxical motion. No return of symptoms was found during follow-up. CONCLUSION ED is the abnormal elevation of the diaphragm as a result of paralysis or aplasia of the muscular fibres. The abnormally elevated diaphragm may compress the ipsilateral lung, and with respiratory effort the mediastinum may shift towards the normal side. Therefore, diaphragmatic plication is performed to restore normal pulmonary parenchymal volume by replacing the diaphragm in its normal location. After plication, there was immediate remission of symptoms in most patients and decreasing symptoms were observed for a year in others. During follow-up, the location of the diaphragm was normal and no paradoxical movement was observed. Relapse of symptoms was not noted in patients with immobile diaphragms.

Does treatment with human chorionic gonadotropin induce reversible changes in undescended testes in boys

Between May 1993 and November 1995, 71 cryptorchid boys were treated with human chorionic gonadotropin (hCG); 42 were operated upon following unsuccesful hCG treatment. A routine orchiopexy was performed in each case. In 10 cases a testicular biopsy was made during orchipexy within 3 days following hCG treatment; in another 10 biopsies were taken 6 to 9 months after treatment. Testicular biosies were taken at the time of orchiopexy in 5 cryptorchid boys who were not treated with hCG as a control group. A mild, inflammation-like reaction was found in the cryptorchid testes in the period immediately following the last hCG injections, but those studied 6 to 9 months after the last injection there were no apparent such reactions. In contrast to the inflammation-like reaction, the volume density of blood vessels, interstitial bleeding, and diameter of the seminiferous tubules had not regressed. The numbers of spermatogonia per tubular transverse section and the percentage of tubular transverse sections containing spermatogonia (the fertility index) were increased.

One-stage hypospadias repair with stent or suprapubic diversion: Which is better?

PURPOSE The authors report on 105 consecutive patients who underwent one-stage hypospadias repair based on use of suprapubic diversion or transurethral drainage with stenting. METHODS The surgical procedures included 52 metal-based flap urethroplasty (Mathieu) for coronal, subcoronal, and distal shaft hypospadias; 32 transverse island pedicle graft (Duckett) for mid and proximal shaft hypospadias; 21 transverse island pedicle (Duckett) plus rolled midline tube (Thierchs) for penoscrotal and scrotal hypospadias. To accomplish urinary drainage, suprapubic diversion (cystofix) was used in 28 of 52 Mathieu operations, in 17 of 32 Duckett operations, and in 11 of 21 transverse island pedicle graft plus rolled midline tube operations. In the rest of the cases, transurethral drainage with stenting was used. RESULTS All children had excellent cosmetic and functional outcomes. But the rates of complications such as fistula and meatal stenosis were significantly different between the groups in which suprapubic tube or urethral stent was used. In 56 of the 105 patients in whom suprapubic diversion was used, four (7.14%) had fistulas and three (5.35%) had meatal stenosis, in contrast to a fistula rate of 14.28% and meatal stenosis rate of 12.24% in patients that urethral stent is used for urinary drainage. CONCLUSION The authors believe that the use of suprapubic diversion is advantageous for the outcome of one-stage hypospadias repair in relation to fistula occurrence and meatal stenosis.

Transverse Testicular Ectopia Associated with Persistent Müllerian Duct Syndrome

Transverse testicular ectopia (TTE) associated with persistent Müllerian duct syndrome (PMDS) is a rare genitourinary anomaly. The clinical and operative findings and treatment are discussed. It is very important to perform a careful exploration in TTE when the testes are undescended, in order to exclude the presence of PMDS. Transseptal orchidopexy is the surgical treatment of choice.

Anal transposition without colostomy: functional results and complications.

Abstract Rectovestibular fistula (RVF) is the most common form of anorectal anomaly in female infants. In the surgical repair of these malformations, most pediatric surgeons use cutback, fistula transposition with or without colostomy, and lately, posterior anorectoplasty with colostomy. This is a retrospective evaluation of the functional results and complications in 47 patients who underwent fistula transposition without colostomy for the treatment of a RVF. We prefer to perform the operation when the rectovaginal septum is amenable to dissection (width >2 mm). All patients had voluntary bowel movements; 28 (60%) had completely normal bowel habits, 45 (96%) good and only 2 (4%) fair. We did not encounter serious surgical complications such as infection dehiscence, and fistula recurrence. We thus prefer anal transposition without colostomy to other modes of surgical therapy for RVF.

A comparison of polymer clips and endoloop applications for securing the appendiceal stump during laparoscopic surgery in children.

Introduction: In this study, for the first time in children a polymer clip and endoloop (EL) for securing an appendiceal stump have been prospectively correlated and evaluated radiologically. Methods: Forty-nine patients aged 1 to 15 years were operated upon by the same surgeon for acute or perforated appendicitis between May 2008 and May 2009. The appendiceal stump was ligated by an EL or polymer clip. Patients were radiologically evaluated during the postoperative period. Results: In the EL group, the mean operating time for perforated appendicitis was recorded as 57.40 minutes and in nonperforated appendicitis as 39.37 minutes, respectively. In the clips-applied group, these periods were 48.23 and 34.72 minutes, respectively. Clip application is 3 times cheaper than EL. Conclusions: Polymer clip is an instrument that is cheaper, safe, easily applicable, and takes less time for securing appendiceal stumps compared with EL.