Jordan Gitlin

NEONATAL TORSION: A 14-YEAR EXPERIENCE AND PROPOSED ALGORITHM FOR MANAGEMENT

PURPOSEnManagement of neonatal torsion is controversial, since the likelihood of testicular salvage and metachronous contralateral torsion must be weighed against the risk of neonatal anesthesia. We reviewed a large series of such cases and stratified neonatal torsion based on time of presentation to determine the potential for testicular salvage. To our knowledge this is the largest series of its kind in the literature.nnnMATERIALS AND METHODSnAll cases of neonatal torsion were classified as either prenatal (noted at the time of delivery) or postnatal (noted after birth and before age 1 month). The charts of all patients were reviewed and data were collected on demographic information, pregnancy and birth history, laterality, physical examination findings, radiological imaging, intraoperative findings, anesthetic morbidities, perioperative complications and pathological diagnoses. Followup data were also collected for patients who underwent detorsion and orchiopexy.nnnRESULTSnA total of 16 neonatal torsions (right side 8, left side 6, bilateral 1) were diagnosed in 15 patients at our institution between 1993 and 2007. A total of 13 torsions (81%) were prenatal and 3 (19%) were postnatal. All 13 prenatal torsions (100%) resulted in infarction (right 7, left 4, bilateral 2) confirmed by pathological examination. All patients underwent testicular exploration via an inguinal approach. A total of 11 cases were managed by orchiectomy at an average of 7.6 days (range 0 to 37) following birth. One of the bilaterally torsed testes showed infarction and necrosis on biopsy, and was detorsed and fixed in place. A second prenatally torsed testis was detorsed and pexed but atrophied on followup. Among the 3 postnatal torsions 1 (33%) was deemed viable on exploration and, therefore, salvaged. Of the 10 prenatal torsions with known prenatal history 5 (50%) were associated with at least 1 significant prenatal complication. Nine of the 10 patients with prenatal torsion (90%) were delivered vaginally, and 1 by cesarean section after prolonged failure of descent.nnnCONCLUSIONSnComplicated pregnancies and vaginal deliveries seem to predispose patients to testicular torsion. Contrary to previous series, neonatal torsions do not appear to favor one side or the other. Prenatal torsions are never salvageable, and, therefore, do not warrant emergent intervention. Postnatal torsions are sometimes salvaged, and a judicious approach to surgical exploration should be taken.

Parenchymal Echo Texture Predicts Testicular Salvage After Torsion: Potential Impact on the Need for Emergent Exploration

PURPOSEnIn the setting of signs and symptoms of testicular torsion the absence of diastolic flow and/or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates largely from the difficulty on ultrasound of distinguishing salvageable torsed testes from those that are not salvageable. We identified ultrasound findings predictive of testicular viability or the lack thereof.nnnMATERIALS AND METHODSnWe retrospectively reviewed the charts of all boys who underwent scrotal exploration for signs and symptoms of torsion during a 4-year period. In those who underwent preoperative Doppler ultrasound of the scrotum ultrasound findings were reviewed, as were the operative dictations. In patients who underwent orchiectomy the pathology reports were also reviewed. In patients in whom the torsed testis appeared viable and who underwent orchiopexy followup data were reviewed when available. Emergency room charts were also reviewed to ascertain, when documented, the duration of pain before presentation to the emergency room and the interval between ultrasound and operating room.nnnRESULTSnDuring this period 55 boys underwent exploration after preoperative scrotal Doppler ultrasound revealed absent diastolic flow and/or color flow Doppler in the symptomatic testis. Assessment of parenchymal echogenicity revealed heterogeneity in 37 testes (67%), of which none were deemed viable at exploration. Orchiectomy was performed in 34 of 37 cases. Pathological examination revealed necrosis in all 34 cases, a finding consistent with late torsion. The remaining 3 testes underwent orchiopexy by parental directive despite nonviability, as confirmed by biopsy and subsequent atrophy. Thus, heterogeneity on preoperative ultrasound was universally predictive of organ loss (chi-square p <0.001). Of the 18 symptomatic testes (33%) demonstrating homogeneity and isoechogenicity on ultrasound 16 (89%) were deemed viable at exploration. Boys in whom the torsed testicle was nonviable on exploration experienced an average of 27.5 hours of pain preoperatively (range 5 to 72), whereas boys in whom the torsed testis was salvaged experienced an average of 20.5 hours of pain (range 2 to 96) (p = 0.073). The nonviable group underwent surgery an average of 49 minutes after ultrasound, whereas the viable group underwent surgery 52 minutes after ultrasound (p = 0.92). None of the 55 patients experienced any surgical or anesthetic complications and no pathological condition was noted intraoperatively in the contralateral asymptomatic testis.nnnCONCLUSIONSnIn the setting of Doppler proven testicular torsion heterogeneous parenchymal echo texture indicates late torsion and testicular nonviability. Therefore, the case may not require emergent scrotal exploration. On the other hand, homogeneous echo texture portends extremely well for testicular viability. Thus, such testes should be explored emergently.

Updated Experience With the Monti Catheterizable Channel

OBJECTIVESnThe Monti catheterizable channel is used as an integral part of continent bladder reconstruction in children. We have updated our ongoing experience at Riley Childrens Hospital with 199 patients.nnnMETHODSnWe identified 199 patients for retrospective review, including all patients for whom a Monti ileovesicostomy was created from January 1997 to August 2004. We assessed the complications, surgical procedures, and stomal continence.nnnRESULTSnAt mean follow-up of 28 months, we found that 194 of 199 patients (97.5%) continued to use their Monti catheterizable channel for bladder drainage. Early surgical complications occurred in 7 patients (3.5%), usually in those who had undergone simultaneous bladder augmentation (5 of 7). Revision was required in 16 patients (8%) for stomal stenosis (n = 11), prolapse (n = 2), or superficial stomal problems (n = 3). Of the 199 patients, 17 (8.5%) required 19 bladder or channel revisions. The primary indications were related to elongation and angulation of the channel in 7 and deficient tunnel length in 8. Minor difficulty with catheterization was noted in 16 patients (8%), and endoscopy with minor procedures was required in 4 patients (2%). Leakage from the channel was uncommon, occurring in only 4 of 115 patients (3.5%).nnnCONCLUSIONSnWith increasing demand for simultaneous appendicocecostomy for stool continence at bladder reconstruction, we continue to use the Monti ileovesicostomy for bladder drainage. Our experience with nearly 200 patients has demonstrated the durability and success of this technique.

History and physical examination findings predictive of testicular torsion: An attempt to promote clinical diagnosis by house staff

OBJECTIVEnTo standardize the history and physical examination of boys who present with acute scrotum and identify parameters that best predict testicular torsion.nnnMATERIALS AND METHODSnOver a 5-month period, a standardized history and physical examination form with 22 items was used for all boys presenting with scrotal pain. Management decisions for radiological evaluation and surgical intervention were based on the results. Data were statistically analyzed in correlation with the eventual diagnosis.nnnRESULTSnOf the 79 boys evaluated, 8 (10.1%) had testicular torsion. On univariate analysis, age, worsening pain, nausea/vomiting, severe pain at rest, absence of ipsilateral cremaster reflex, abnormal testicular position and scrotal skin changes were statistically predictive of torsion. After multivariate analysis and adjusting for confounding effect of other co-existing variables, absence of ipsilateral cremaster reflex (P < 0.001), nausea/vomiting (P < 0.05) and scrotal skin changes (P < 0.001) were the only consistent predictive factors of testicular torsion.nnnCONCLUSIONnAn accurate history and physical examination of boys with acute scrotum should be primary in deciding upon further radiographic or surgical evaluation. While several forces have led to less consistent overnight resident staffing, consistent and reliable clinical evaluation of the acute scrotum using a standardized approach should reduce error, improve patient care and potentially reduce health care costs.

Effect of Tamsulosin on Systemic Blood Pressure and Nonneurogenic Dysfunctional Voiding in Children

PURPOSEnA number of therapies for dysfunctional voiding in children have been proposed after conservative measures have failed. Prior studies have shown significant improvement in lower urinary tract symptoms with alpha1-adrenergic antagonists. Nonselective alpha1-adrenergic antagonists can result in systemic vasodilatation and hypotension. We examined the effects of tamsulosin, a uroselective alpha1A-adrenergic antagonist, on blood pressure, as well as its safety and efficacy in the treatment of dysfunctional voiding in a pediatric population.nnnMATERIALS AND METHODSnA total of 23 children without anatomical or neurogenic abnormalities presented with lower urinary tract symptoms refractory to conservative measures. All children had increased post-void residual urine or abnormal uroflowmetry in the absence of pelvic floor activity suggestive of bladder neck dysfunction. All patients were administered tamsulosin daily. Voiding diaries, blood pressure, uroflowmetry studies and patterns along with assessment of post-void residual urine were obtained before and after beginning tamsulosin in all children.nnnRESULTSnMedian duration of tamsulosin therapy was 7 months, and patient followup was 20 months. The number of voiding and incontinent episodes significantly decreased during treatment compared to baseline (p <0.05). Mean blood pressures before and during tamsulosin treatment were 98/55 mm Hg and 110/61 mm Hg, respectively. Significant increases in average and maximum urinary flow rates along with reduction in post-void residual urine were observed during tamsulosin therapy compared to baseline values (p <0.01). A 50% reduction in the number of abnormal uroflow patterns was observed with tamsulosin therapy.nnnCONCLUSIONSnTamsulosin demonstrated no clinically significant effect on blood pressure, while proving to be a safe and effective treatment option for lower urinary tract symptoms in a select pediatric population.

A conservative approach to testicular rupture in adolescent boys

PURPOSEnManagement for blunt trauma with breach of the renal capsule or bladder (extraperitoneal) has largely become nonsurgical since a conservative approach proved to be effective and safe. Currently the recommendation for managing testicular rupture is surgical exploration and débridement or orchiectomy. We report outcomes in boys diagnosed with testicular rupture and treated without surgical intervention.nnnMATERIALS AND METHODSnIn the last year we conservatively treated 7 consecutive boys with delayed presentation of testicular rupture after blunt scrotal trauma. Patients were treated with scrotal support, antibiotics to prevent abscess, rest, analgesics and serial ultrasound. We report clinical information and outcomes.nnnRESULTSnThe 7 boys were 11 to 14 years old and presented 1 to 5 days after injury. Trauma was to the left testis in 3 cases and to the right testis in 4. Patients presented with mild to moderate pain and similar scrotal swelling. Ultrasound findings consistently revealed hematocele and increased echogenicity. Blood flow was present in the injured portion of the testes in 3 cases and to the remainder of the affected testicle in 6 of the 7 boys. In the remaining boy an adequate waveform was not seen in either testicle, which the radiologist thought was secondary to prepubertal status. Other findings included scrotal edema, irregular contour and seminiferous tubule extrusion. Followup was greater than 6 months in all cases. Five boys were seen at the office and the 2 remaining had telephone followup. In all cases hematocele resolved, testicular size stabilized without atrophy and echogenicity normalized in the 5 patients with followup ultrasound. One patient required surgical repair of hydrocele 4 months after trauma but no other patient needed surgical exploration. No abscess or infection developed.nnnCONCLUSIONSnA conservative approach in a select group of adolescent boys with testicular rupture can result in resolution of the fracture and maintenance of testicular architectural integrity.

Uroflowmetry Parameters Before and After Meatoplasty for Primary Symptomatic Meatal Stenosis in Children

PURPOSEnOne measure of a successful outcome of meatoplasty for symptomatic urethral meatal stenosis has traditionally been witnessed voiding and subjective assessment of urinary stream. This evaluation is flawed by nonobjective criteria and potential differing interpretations by different clinicians. We sought to assess urinary flow better following meatoplasty using voiding uroflowmetry to measure objectively response to treatment.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of 22 boys who underwent meatoplasty for symptomatic meatal stenosis and who had uroflowmetry (flow rates, voided volumes and voiding times) performed preoperatively and postoperatively. Statistical comparison of voiding parameters was analyzed using Students paired t test.nnnRESULTSnMean patient age was 7 years (range 4 to 13). There were no complications and no recurrences associated with meatoplasty during a mean followup of 12 months. There was a significant increase in maximum urinary flow rates following meatoplasty (9.7 ml per second preoperatively vs 16.4 ml per second postoperatively, p = 0.001). Mean postoperative post-void residual volumes and voiding times were significantly lower than preoperative values, at 13.9 ml vs 19.3 ml (p = 0.01) and 29 seconds vs 19 seconds (p = 0.03), respectively. Voided volumes did not differ between the time intervals (157 ml preoperatively vs 147 ml postoperatively, p = 0.25). Flow patterns were abnormal in 19 of 22 patients preoperatively, and 88% of these patients had bell curve-shaped patterns following meatoplasty.nnnCONCLUSIONSnFlow rates measured by noninvasive uroflowmetry showed significant increases following meatoplasty for meatal stenosis. Uroflowmetry represents an objective method to assess outcomes following meatoplasty compared to subjective visualization of the urinary stream during voiding.

Intravesical phallus in cloacal exstrophy

We report a case of a fused phallus located within the urinary bladder in a child with cloacal exstrophy. Surgical exploration revealed a phallus formed by fusion of the left and right corpus cavernosum and completely covered by bladder urothelium. The phallus was surgically separated from the bladder and mobilized to a more normal position and a neourethra created from tubularized bladder urothelium. Skin coverage was done using perineal skin flaps to cover the penile shaft, with the bladder urothelium covering the tip of the phallus being left intact to provide the appearance of a glans penis.

Standardized education and parental awareness are lacking for testicular torsion

INTRODUCTIONnTesticular torsion leads to orchiectomy in 30-50% of cases, which may cause psychological upset and parental guilt over a potentially avertable outcome. Presentation delay is an important modifiable cause of orchiectomy; yet, families are not routinely educated about torsion or its urgency. The present study assessed parental knowledge regarding acute scrotal pain.nnnMATERIALS AND METHODSnAn anonymous survey was distributed to parents in Urology and ENT offices, asking about their childrens gender and scrotal pain history, urgency of response to a childs acute scrotal pain, and familiarity with testicular torsion.nnnRESULTSnSurveys of 479 urology and 59 ENT parents were analyzed. The results between the two were not statistically different. Among the urology parents, 34% had heard of testicular twisting/torsion, most commonly through friends, relatives or knowing someone with torsion (35%); only 17% were informed by pediatricians (Summary Figure). Parents presenting for a childs scrotal pain were significantly more likely to have heard of torsion (69%) than those presenting for other reasons (30%, OR 5.24, Pxa0<xa00.0001). Only 13% of parents of boys had spoken with their children about torsion. Roughly three quarters of them would seek emergent medical attention - by day (75%) or night (82%) - for acute scrotal pain. However, urgency was no more likely among those who knew about torsion.nnnDISCUSSIONnThis was the first study to assess parental knowledge of the emergent nature of acute scrotal pain in a non-urgent setting, and most closely approximating their level of knowledge at the time of pain onset. It also assessed parents hypothetical responses to the scenario, which was markedly different than documented presentation times, highlighting a potential area for improvement in presentation times. Potential limitations included lack of respondent demographic data, potential sampling bias of a population with greater healthcare knowledge or involvement, and assessment of parents only.nnnCONCLUSIONSnParental knowledge of testicular torsion was lacking, suggesting both ineffective education in the well-child setting and inappropriately timed education during or after pain occurrence. Awareness was most commonly anecdotal or taught unreliably, as even familiar parents were no more likely to seek emergent attention. Therefore, standardized, effective parental education on testicular torsion and the need for prompt presentation is needed, as is improvement in the quality of information taught in the healthcare setting. Further assessment of knowledge among preadolescent and adolescent boys regarding testicular torsion is warranted. It is hopeful that pre-hospital delay may be minimized and greater rates of testicular salvageability may be achieved through these efforts.

Tailored sutureless meatoplasty: A new technique for correcting meatal stenosis

OBJECTIVEnStandard practice for meatoplasty includes the use of sutures to evert the mucosa. We present a novel technique that is equivalent to standard meatoplasty without the need for suturing.nnnMATERIALS AND METHODSnA retrospective chart review was performed of patients who presented with primary meatal stenosis in 2007-2009. One group underwent a tailored, sutureless meatoplasty performed by one surgeon. The second group underwent a standard meatoplasty with mucosal advancement and suturing of the mucosal edges by another surgeon. Data were collected regarding demographics, presenting symptoms, symptom resolution, and postoperative complications. These were then compared between the two groups. Preoperative and postoperative uroflowmetry data were collected for the sutureless group to demonstrate objective improvement.nnnRESULTSnOf 85 patients, aged 2-17 years, 60 underwent the tailored, sutureless procedure while 25 had a standard meatoplasty. The majority of patients presented with a deviated and/or narrowed stream of urine. There was no statistical difference between the two groups in regard to symptom resolution. Uroflowmetry data analyzed for 20 patients in the sutureless group demonstrated a significant improvement in Q(max) and flow pattern; there was no significant change in % post-void residual. No patient had a complication in either group, or presented with recurrence.nnnCONCLUSIONSnTailored sutureless meatoplasty is comparable to meatoplasty with mucosal advancement in resolving symptoms, improving uroflowmetry parameters, and complication rate, but is more efficient and cost effective.