Josef Oswald

Optimizing the Operative Treatment of Boys with Varicocele: Sequential Comparison of 4 Techniques

PURPOSE We compared 4 techniques of varicocele ligation in boys and young adolescents to determine the optimal operative treatment that avoids varicocele recurrence and postoperative hydrocele formation. MATERIALS AND METHODS In 10 years a total of 128 varicocelectomies were performed sequentially in 121 boys and young adolescents with a mean age of 12 years using the laparoscopic, inguinal testicular artery sparing, standard Palomo (high mass retroperitoneal ligation) and modified Palomo approaches. The modified Palomo approach involved suprainguinal and retroperitoneal ligation of the veins and artery, and microsurgical sparing of the blue stained lymphatic pathway of the testis. Patients were followed a mean of 52 months. RESULTS In the 19 boys in the laparoscopy group varicocele persisted in 10% and hydrocele developed in 5%. In the 21 patients who underwent inguinal surgery with artery preservation recurrent varicoceles were identified in 14% and no hydroceles were observed. In the 32 patients who underwent the standard Palomo procedure there was no palpable varicocele persistence or recurrence, while hydroceles developed in 12%. Of the 56 patients in the modified Palomo group varicocele recurred in 1 (2%) and there were no hydroceles. No testicular atrophy developed in any patient. CONCLUSIONS Comparison of all 4 groups revealed significant differences in varicocele recurrence (p = 0.038) and hydrocele formation (p = 0.023). Pairwise group comparison showed that the modified Palomo technique resulted in a significant decrease in the incidence of postoperative hydrocele formation compared with the standard Palomo method (p = 0.015). This procedure can be recommended as the optimal surgical technique for varicocele treatment in males of this young age.

Prospective comparison and 1-year follow-up of a single endoscopic subureteral polydimethylsiloxane versus dextranomer/hyaluronic acid copolymer injection for treatment of vesicoureteral reflux in children.

OBJECTIVES To compare, in a prospective study, the efficacy of a single injection of polydimethylsiloxane (Macroplastique) or dextranomer/hyaluronic acid copolymer (Deflux), a new biodegradable substance, and to assess the short-term and 1-year clinical effects concerning reflux resolution and the safety of these two bulking agents. Subureteral injection of bulking agents has recently demonstrated good success rates for endoscopic treatment of vesicoureteral reflux. Macroplastique has been one of the most popular bulking agents during the past years. Nevertheless, considering the synthetic property, new biodegradable substances have become more relevant. METHODS From January 2000 to June 2001, 16 boys and 56 girls (total of 114 ureters) with a mean age of 34.5 months were treated endoscopically for vesicoureteral reflux. A single subureteral Macroplastique or Deflux injection was performed in 34 children (58 ureters) and 38 children (56 ureters), respectively. Both groups were comparable in terms of baseline parameters. Vesicoureteral reflux was grade II in 52, grade III in 57, and grade IV in 5 ureterorenal units. The procedure was performed on an outpatient basis, with the children under general anesthesia. In addition to the routine parameters, the follow-up evaluation consisted of renal ultrasonography and voiding cystourethrography at 3 and 12 months postoperatively. RESULTS Endoscopic treatment was performed without any complications in all cases. At the 3-month follow-up visit, reflux was corrected in 50 (86.2%) of 58 refluxing ureters in the Macroplastique group and in 40 (71.4%) of 56 refluxing ureters in the Deflux group. At 1 year of follow-up, reflux correction was maintained in 80.9% of ureters in the Macroplastique group and in 67.6% of ureters in the Deflux group. No postoperative complications were observed in either group. CONCLUSIONS A single subureteral injection of either polydimethylsiloxane (Macroplastique) or dextranomer/hyaluronic acid copolymer (Deflux) is an effective treatment modality for children with vesicoureteral reflux. The procedure was well tolerated, safe, and associated with low morbidity. Deflux, a new biocompatible, biodegradable substance, seems to be an alternative modality to other bulking agents for treating vesicoureteral reflux in children, with acceptable short-term and 1-year results.

Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial

To evaluate, in a randomized prospective trial in children and adolescents, the feasibility of isosulphan blue‐based lymphatic vessel preservation during laparoscopic varicocelectomy and its impact on the complication rate, as the operative management of varicoceles remains controversial.

Blunt Renal Trauma in Children: 26 Years Clinical Experience in an Alpine Region

OBJECTIVES From 1975 to 2001, 254 children aged younger than 17 were transferred to our department for renal trauma. We performed a retrospective study to assess causality and kind of the trauma, diagnostic procedures and therapeutic consequences, respectively. METHODS The 254 children at a mean age of 10.56 years (+/-3.8) ranging from 2 to 17 years were treated for kidney trauma. Among these, 166 presented with a grade I trauma according to the kidney injury scale of the American Association for the Surgery of Trauma without any other accompanying injuries and 88 had a grade II-V lesion, respectively. Diagnostic evaluation included various standard lab tests such as urinalysis and routine blood parameters, ultrasound, IVP and/or CT. RESULTS Most of the traumatic injuries resulted from skiing accidents. However, 18 children had a severe polytrauma with laceration of other vital organs. Most of the renal injuries could be treated conservatively. Surgical treatment options included immediate exploration, reconstruction, partial resection, or even nephrectomy. No child died. CONCLUSIONS Due to leisure time activities in our region, skiing accidents often result in isolated laceration of the kidney. About one third presented with a severe kidney trauma, and approximately 20% of all affected children required surgical therapy. However, most of the injured kidneys could be preserved and only four nephrectomies had to be performed.

Voiding Cystourethrography Using the Suprapubic Versus Transurethral Route in Infants and Children: Results of a Prospective Pain Scale Oriented Study

PURPOSE We determined the advantages and disadvantages of different types of contrast medium injection into the bladder for imaging children during evaluation for urinary tract infection in regard to child behavior and distress during urethral catheterization or suprapubic puncture. MATERIALS AND METHODS From December 2000 to September 2001 we prospectively compared transurethral catheter and suprapubic voiding cystourethrography in children with a history of urinary tract infection. A total of 65 children with a mean age of 33.8 months were entered into the study, of whom 32 underwent transurethral catheterization and 33 underwent suprapubic puncture with topical anesthesia. Each child was evaluated, particularly in regard to discomfort and pain using an objective pain score that measures stress and pain during a medical procedure. RESULTS Objective pain score recording showed a mean pain score plus or minus SD of 4.25 +/- 1.3 in the transurethral catheterization and 3.03 +/- 1.21 in the suprapubic puncture groups. Correlation studies of age in the 2 groups also showed a significant impact of age on the objective pain score. In the transurethral group the score increased with age (p <0.001), whereas in the suprapubic group it decreased with age (p <0.001). CONCLUSIONS The current study shows that the suprapubic puncture technique with topical anesthesia was well tolerated and associated with a low pain score independent of patient age. Transurethral catheterization was also tolerated but it was associated with a low pain score only in the younger age group. Thus, we recommend that voiding cystourethrography in children older than 24 months should be done via the suprapubic route.

Interim Outcome of the Single Stage Dorsal Inlay Skin Graft for Complex Hypospadias Reoperations

PURPOSE Despite high success rates for primary hypospadias repair, some cases require multiple procedures for ultimate reconstruction. We report our experience with single stage dorsal inlay urethroplasty using skin grafts for complex reoperations. MATERIALS AND METHODS A total of 31 patients (mean age 13.8 years) with failed previous hypospadias surgery were included in the study. Indications included fistulas, strictures, diverticula and repair breakdown. The urethral plate had been removed or was severely scarred in all patients. A free penile or groin skin graft was sutured and quilted to the corpora cavernosa, guaranteeing sufficient blood supply. The neourethra was tubularized and covered with a tunica vaginalis or dartos flap, followed by glanuloplasty. Outcome analysis included urethrograms, urethral ultrasound and flow measurements. RESULTS Foreskin was used in 15 cases, penile skin in 12 and inguinal skin in 4. Average graft length was 3.92 cm. A total of 20 patients required glanuloplasty with a skin graft extended to the tip of the glans. After a mean followup of 30.71 months 5 patients underwent redo surgery, for a complication rate of 16.1%. Urethral stricture of the proximal anastomosis was the most frequent finding. CONCLUSIONS This single stage approach using dorsal skin grafts is a reliable method to create a substitute urethral plate for tubularization. Complication rates are equivalent to those of staged procedures. Foreskin should be used as a graft donor site to optimize the outcome if available. This approach represents a safe option for reoperations even if the urethral plate or midline penile skin is grossly scarred.

Diagnosis and management of pediatric urethral injuries.

Objective: The incidence of urethral injuries in children is rare due to the fact that the urethra is short, mobile and protected by the pubic bone. The management of urethral trauma in childhood remains controversial because of the limited expertise of most urologists. Material and Methods: We performed a literature review by searching the Medline database for articles published between 1975 and 2010 based on clinical relevance. Electronic searches were limited to the keywords ‘pediatric’, ‘urethral injury’, ‘trauma’ and ‘reconstruction’. Results: Retrograde urethrography is considered the gold standard for diagnosis of urethral injuries. The initial management should ensure drainage of the bladder either by suprapubic cystostomy or urethral realignment if possible: in complete anterior urethral disruption as well as in children with life-threatening pelvic and intra-abdominal injuries after posterior urethral injuries, a deferred repair after 3 months is necessary. Immediate primary suturing of disrupted and dislocated urethral ends should be avoided because of high complication rates. Primary repair, however, of the defect is possible in girls avoiding a 2-stage approach. Conclusion: The aim of therapy is minimizing remote damages such as urethrocutaneous fistulae, periurethral diverticulae, strictures, incontinence and impotence with different therapeutic management depending on classification of the injury and the presence of life-threatening injuries.

Optimizing the outcome of microsurgical subinguinal varicocelectomy using isosulfan blue : A prospective randomized trial

PURPOSE Varicoceles are the main cause of correctible male factor infertility. Loss of testicular volume and abnormal seminal parameters are indications for varicocelectomy. We assessed a prospective randomized trial comparing standard microsurgical varicocele repair with the microsurgical approach using isosulfan blue. We determined if the use of isosulfan blue reduces the incidence of postoperative hydroceles following microsurgical varicocele repair. MATERIALS AND METHODS Two groups of 25 consecutive patients each were randomized. Indications for surgery included fertility problems as well as scrotal pain and difference in testicular size. All patients underwent microsurgical repair using the subinguinal approach. Patients in group 1 underwent standard microsurgery. Those in group 2 had additional isosulfan blue administration. All were investigated 3 and 6 months postoperatively regarding varicocele recurrence, hydrocele, atrophy, pain or other complications. RESULTS There were no intraoperative complications. At 3 months postoperatively the incidence of hydrocele in group 1 was 20% decreasing to 16% at 6 months, whereas in group 2 no hydrocele was detectable. There were 2 patients in each group who reported ongoing pain, and 1 in each presented with recurrent varicocele. No atrophy was seen. In 1 patient blue pigmentation of the left hemiscrotum was seen at 3 months but vanished at 6 months. CONCLUSIONS Microsurgical repair of varicoceles using isosulfan blue helps in identifying and preserving the lymphatic drainage. It prevents postoperative hydrocele, the most common postoperative complication, without any supplementary risk to the patient. Additionally, testicular edema causing impaired spermatogenesis can be avoided.

Comprehensive Analysis of Six Years Experience in Tubularised Incised Plate Urethroplasty and its Extended Application in Primary and Secondary Hypospadias Repair

OBJECTIVE We evaluated the potential of tubularised incised plate (TIP) urethroplasty in primary and secondary hypospadias repair focusing on the extended application of this procedure, the utility and handling of the urethral plate and operative results. METHODS In this retrospective study, we analysed the medical records of 228 children with different levels of the hypospadiac meatus who underwent a TIP procedure between February 1997 and December 2002. The children were followed a mean of 42 months. Our medical records provided us with details about the location of the hypospadiac meatus, the width of the urethral plate before and after midline incision, primary versus secondary surgery, complications as well as notes on the extended application of the TIP procedure. RESULTS The overall postoperative complication rate was 7.8%. The overall fistula rate was 5.7%, with 4.1% in primary distal, 9.6% in primary proximal and 7.5% in secondary repair respectively. We had one case of meatal stenosis (0.4%) and one of urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). Due to the encouraging results, the frequency of TIP procedure in hypospadias surgery increased from 33% in 1997 to 82% in 2002. CONCLUSION In our study the TIP procedure has emerged as the first-choice technique in primary hypospadias repair--irrespective of the level of the hypospadiac meatus and the width of the original urethral plate. This procedure has also proved to be favourable for many cases at secondary surgery.

Endoscopic application of dextranomer/hyaluronic acid copolymer in the treatment of vesico-ureteric reflux after renal transplantation

Study Type – Therapy (case series)