Luis M. Perez

Critical Analysis of the Clinical Presentation of Acute Scrotum: A 9-Year Experience at a Single Institution

PURPOSEnWe assessed the significance of the clinical presentation of boys who underwent surgical exploration for acute scrotum.nnnMATERIALS AND METHODSnWe retrospectively analyzed the records of 115 consecutive boys who underwent surgical exploration for acute scrotum between October 1986 and January 1996. We divided the children into group 1-83 with spermatic cord torsion a mean of 14.4 years old, group 2-27 with torsion of a testicular appendage a mean of 9.4 years old and group 3-5 with epididymo-orchitis a mean of 14.1 years old. Particular attention was given to nausea and vomiting, patient age and duration of pain.nnnRESULTSnNausea and vomiting occurred in 69 and 60% of the boys in group 1, 8 and 4% in group 2 and none in group 3. Nausea and vomiting had positive predictive values of 96 and 98%, respectively, for spermatic cord torsion. Only 6 of the 83 boys (7%) with spermatic cord torsion were younger than 11 years, whereas 15 of the 27 (56%) with torsion of a testicular appendage were younger than 11 years. Of the 83 boys with spermatic cord torsion the testes were salvaged in 51 (61%) and the duration of pain was 40 minutes to 12 hours (mean 4 hours). The testes were not salvaged in any patient with greater than 12 hours of pain.nnnCONCLUSIONSnWe believe that any boy 11 years old or older with scrotal pain less than 12 hours in duration that is associated with nausea or vomiting should be considered to have torsion of the spermatic cord. In this day of cost-effective medical management it is not necessary to perform imaging in this subset of boys before surgical exploration.

Two-Stage Fowler-Stephens Orchiopexy With Laparoscopic Clipping of the Spermatic Vessels

PURPOSEnWe report the outcome of a staged approach to the intra-abdominal testicle and provide baseline data on operative time, postoperative course and testicular survival.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of 441 boys (547 undescended testes). There were 105 boys (24%) with 124 nonpalpable testes (23%). All patients underwent laparoscopy. Ligation of spermatic vessels was performed as stage 1 on 20 abdominal testes (4%) in 18 boys (4%). Stage 2 orchiopexy was done using an open technique.nnnRESULTSnTwo-stage orchiopexy in 18 boys included a bilateral procedure in 2, of which 1 was asynchronous and 1 was synchronous. Average operative time was 55 minutes for stage 1 and 67 minutes for stage 2. Stage 1 and 2 procedures were performed on an outpatient basis in 18 and 17 (94%) boys, respectively. There were no complications after stage 1 and 1 wound infection developed after stage 2. One testis with no vas deferens was determined to be nonviable at stage 2. The remaining 19 testes (95%) were considered viable at a followup of 6 months or greater. Viability was based on testicular size and consistency similar to those of the contralateral testis.nnnCONCLUSIONSnLaparoscopic ligation of spermatic vessels as a stage 1 procedure is a natural extension of laparoscopy. A staged approach provides adequate viability of the intra-abdominal testis.

RENAL TRANSPLANTATION IN CHILDREN WITH POSTERIOR URETHRAL VALVES REVISITED: A 10-YEAR FOLLOWUP

PURPOSEnRenal transplantation is safe and effective for end stage renal disease in children with posterior urethral valves. We previously reported our 5-year post-transplantation results in boys with posterior urethral valves and matched controls. Graft survival was similar. However, we were concerned about elevated serum creatinine and the potential detrimental effects of hostile bladder dynamics in these children. We performed this study to determine whether our concern would be substantiated.nnnMATERIALS AND METHODSnWe retrospectively analyzed the clinical records and computerized transplantation database in 268 boys younger than 19 years who underwent renal transplantation from May 1968 through November 1988. The 18 children with posterior urethral valves were compared to a nonobstructed cohort of 18 boys in regard to age, number of transplants, donor type and immunosuppression. All children had at least 10 years of followup (range 10 to 19).nnnRESULTSnThe 10-year post-transplant patient survival in the posterior urethral valves and control groups was 94 and 100%, while 10-year graft survival was 54 and 41%, respectively. There was no statistically significant difference in graft survival when comparing immunosuppression type, donor source and pre-transplant proximal urinary diversion. The 10-year mean serum creatinine was 2.3 and 2.0 mg./dl. in the posterior urethral valve and control groups, respectively (not statistically significant).nnnCONCLUSIONSnOur renal transplantation results in children with posterior urethral valves are comparable to those in children with nonobstructive end stage renal disease. The 10-year graft survival was better but not statistically significant in the posterior urethral valve group, while serum creatinine was similar. Our concern regarding renal transplantation in children with posterior urethral valves was not substantiated.

PEDIATRIC INFLAMMATORY BLADDER TUMORS: MYOFIBROBLASTIC AND EOSINOPHILIC SUBTYPES

PURPOSEnBenign bladder tumors are rare in children. A number of descriptive terms have previously been used to describe inflammatory tumors with myofibroblastic proliferation or eosinophilic infiltration. We present our experience with these tumors and review the literature.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of all children presenting with a benign focal bladder mass during the last 5 years, including 2 girls and 3 boys 2 to 12 years old (mean age 7).nnnRESULTSnPresenting symptomatology included irritative voiding symptoms, suprapubic pain and hematuria. All bladder masses were diagnosed by ultrasonography and all patients underwent transurethral resection. Three children who had an inflammatory bladder tumor with myofibroblastic features required open tumor excision with preservation of the bladder. In the 2 remaining children urine culture was positive preoperatively and the diagnosis was an inflammatory bladder tumor with eosinophilic infiltration. Transurethral resection of the mass was performed without partial cystectomy.nnnCONCLUSIONSnInflammatory myofibroblastic and eosinophilic tumors represent forms of focal cystitis with a tumefactive component. Differentiation from the malignant bladder neoplasms of childhood has important consequences for therapy. Management of these benign but aggressive inflammatory lesions involves local control by endoscopic or open surgery with bladder preservation. We encourage refined use of the terminology for inflammatory myofibroblastic and eosinophilic tumors.

ACCURACY OF RENAL-BLADDER ULTRASONOGRAPHY AS A SCREENING METHOD TO SUGGEST POSTERIOR URETHRAL VALVES

PURPOSEnWe determine the usefulness of ultrasonography as a screening modality to support the diagnosis of posterior urethral valves.nnnMATERIALS AND METHODSnA retrospective chart analysis was performed of 93 consecutive boys with newly diagnosed posterior urethral valves from August 1985 through February 1999. Of the 93 boys 65, including 62 who underwent renal and bladder ultrasonography, had preoperative renal sonography available and constitute our study population. Patient age range at presentation was newborn to 13 years, with 33 of the 65 boys presenting as infants (age 1 year or younger). Presentation included fetal hydronephrosis in 13 cases, urinary tract infection in 18, voiding dysfunction in 9, abdominal mass in 6, renal insufficiency in 5, failure to thrive in 4, hematuria in 1 and other in 9.nnnRESULTSnPreoperative sonography identified bilateral hydronephrosis in 48 boys (74%), unilateral hydronephrosis in 9 (14%) and no hydronephrosis in 8 (12%). Bladder sonography revealed an abnormal bladder (thickened, trabeculated and/or significantly distended) in 54 boys (87%). An abnormal bladder was seen in 43 of the 46 boys with bilateral hydronephrosis, 6 of 8 boys with unilateral hydronephrosis and 5 of 8 with normal upper tracts. Only 3 of the 62 boys (5%) had a normal upper tract and bladder. The sensitivity of renal ultrasonography in suspecting posterior urethral valves was 88%, while sensitivity of renal-bladder ultrasonography was 95%. When stratifying for age younger than 4 years and 4 or older, the sensitivity of predicting posterior urethral valves with renal-bladder ultrasonography was 87% and 98%, respectively.nnnCONCLUSIONSnWhile voiding cystourethrography remains the imaging gold standard for the diagnosis of posterior urethral valves, renal-bladder ultrasonography is an appropriate screening study for a boy suspected to have the condition. Renal-bladder ultrasonography may prove particularly useful in the evaluation of the boy with significant voiding dysfunction before deciding on a more invasive study, such as voiding cystourethrography.

TUNICA VAGINALIS ONLAY URETHROPLASTY AS A SALVAGE REPAIR

PURPOSEnWe review our experience with tunica vaginalis onlay urethroplasty for urethral repair after multiple previous hypospadias repairs.nnnMATERIALS AND METHODSnFrom January 1992 through December 1997 we repaired the urethra in 10 boys and 1 man using a tunica vaginalis onlay flap. The tunica vaginalis was placed as a patch on the urethra that was proximal to the glans or brought out to the urethral meatus.nnnRESULTSnNo intraoperative complications or difficulties were associated with harvesting the tunica vaginalis. Of the 4 children and 1 adult in whom the onlay flap was brought out to the urethral meatus meatal stenosis developed in 3 (60%), while 2 void without problems. In 6 children the onlay flap was placed proximal to the glans and in 1 who was lost to followup 2 discontinuous patches were placed. In 3 of the 5 remaining boys (60%) stricture developed, while 2 void without problems.nnnCONCLUSIONSnTunica vaginalis onlay urethroplasty results in a substantial complication rate. We did not confirm any advantage of its use.

UROLOGICAL OUTCOME OF PATIENTS WITH CERVICAL AND UPPER THORACIC MYELOMENINGOCELE

PURPOSEnWe determined the incidence of voiding disorders and upper tract deterioration in children with cervical and upper thoracic level myelomeningocele.nnnMATERIALS AND METHODSnWe retrospectively reviewed the neurosurgical and urological presentation, evaluation and treatment of 11 patients of whom 8 had cervical and 3 had upper thoracic myelomeningocele. There were 7 female and 4 male patients 10 months to 39 years old (mean age 12 years). All patients were ambulatory and 5 of 11 (45%) had hydrocephalus. Although a voiding history was obtained by a neurosurgeon in all patients, only 9 had undergone a formal urological evaluation, including video urodynamic assessment in 5.nnnRESULTSnNo patient had an increased post-void residual and none had ever been placed on intermittent catheterization. Tethered spinal cords from caudal fixation (thickened filum terminale and a lipomyelomeningocele) were present in 2 patients with urinary incontinence of whom 1 had recurrent cystitis. Imaging studies of the upper tracts were normal in all 9 patients and video urodynamics were normal in 3 of 5. No patient has required urological operative intervention.nnnCONCLUSIONSnTo our knowledge, this study represents the largest reported series of patients with cervical and upper thoracic myelomeningocele who have undergone urological evaluation. Our experience suggests that patients with cervical and upper thoracic myelomeningocele have a low risk of voiding disorders and upper tract deterioration unless other conditions, such as a congenital tethered cord, are present. Additional reports of children with cervical and upper thoracic myelomeningocele are necessary to confirm these findings.

CONTRALATERAL VESICOURETERAL REFLUX AFTER SIMPLE AND TAPERED UNILATERAL URETERONEOCYSTOSTOMY REVISITED

PURPOSEnWe reviewed our experience with contralateral vesicoureteral reflux following unilateral ureteroneocystostomy.nnnMATERIALS AND METHODSnWe retrospectively identified 88 children who underwent unilateral ureteroneocystostomy from 1986 through 1995, including standard repair in 69 and tapered repair in 19. Cystoscopy was performed in all cases immediately before repair.nnnRESULTSnGrades IV to V vesicoureteral reflux was identified preoperatively in 34% of the patients, including 13 (19%) and 14 (74%) who underwent standard and tapered repair, respectively. Renal duplication was noted in 24% of the cases, including 18 standard (26%) and 3 tapered (16%) repairs. An abnormal contralateral nonrefluxing ureteral orifice was present in 8 of the 53 standard (15%) and 3 of the 14 (21%) tapered cases. Ipsilateral reflux was corrected in all children undergoing standard repair but it persisted in 4 (21%) in the tapered repair group. Postoperatively contralateral vesicoureteral reflux developed in 1 child (1.4%) in the standard and 1 (5.3%) in the tapered repair group.nnnCONCLUSIONSnContralateral vesicoureteral reflux is rare and does not appear to be influenced by preoperative reflux grade, a duplicated system or the endoscopic appearance of the ureteral orifice.

Xanthogranulomatous pyelonephritis in an infant with an obstructed upper pole renal moiety

We report a case of xanthogranulomatous pyelonephritis in an infant involving the upper renal pole moiety of a duplicated system associated with an obstructed ectopic ureter. It was successfully managed by an upper pole heminephroureterectomy. We also review the published reports of xanthogranulomatous pyelonephritis in pediatric patients.

A rare form of crossed-fused renal ectopia: fusion anterior to the left orthotopic kidney

A white girl with a history of spina bifida and severe kyphosis presented with recurrent urinary tract infections. Renal ultrasound revealed a crossed-fused renal ectopia with both kidneys located in the left renal fossa and the larger kidney fused anterior to the smaller kidney (Figure 1). Voiding cystourethrography during videourodynamic evaluation demonstrated an irregularly shaped neurogenic bladder with bilateral vesicoureteral reflux. Grade 4 reflux was noted in the right collecting system, which crossed the midline and was the larger anterior renal unit noted in the left renal fossa by renal ultrasound. Grade 3 reflux was noted in the smaller posterior left collecting system (Figure 2). The patient was treated with clean intermittent cath-