Richard M. Ehrlich

Laparoscopic vesicoureteroplasty in children: Initial case reports

OBJECTIVE To determine the feasibility of performing laparoscopic vesicoureteroplasty in children. METHODS Two pediatric patients, a two-year-old boy and a five-year-old girl, underwent laparoscopic vesicoureteroplasty for vesicoureteral reflux. Operating time was two hours fifteen minutes and three hours fifteen minutes, respectively. RESULTS The reflux was successfully corrected without morbidity, and they required only short hospitalization (23 hours) and exhibited decreased peri- and post-operative pain as well as improved cosmesis. CONCLUSIONS These cases represent the first implementation of this technique in humans. We stress that this is a preliminary report and suggest that this technique deserves further study.

Hormonal therapy of cryptorchidism. A randomized, double-blind study comparing human chorionic gonadotropin and gonadotropin-releasing hormone

Abstract We conducted a randomized, double-blind study comparing intranasal gonadotropin-releasing hormone (1.2 mg per day for 28 days) with parenteral human chorionic gonadotropin (3300 IU per week for four weeks) in the treatment of cryptorchidism in 33 boys one to five years old (29 with unilateral and 4 with bilateral cryptorchidism). Testicular descent into the scrotum occurred in 3 of the 16 patients (19 percent) treated with gonadotropin-releasing hormone and in 1 of the 17 (6 percent) treated with human chorionic gonadotropin (P = 0.23). The mean luteinizing hormone and testosterone levels were similar in both groups before treatment. During treatment, the testosterone levels were significantly increased in both groups, but higher levels occurred in the group treated with human chorionic gonadotropin (P<0.05). In a parallel (but uncontrolled) study of five boys with retractile testes (defined as a nonscrotal testis that could be manipulated into the bottom of the scrotum) who were originally exclu...

Laparoscopic renal surgery in children.

A total of 17 laparoscopic renal procedures was performed in children, including nephrectomy (10), nephroureterectomy (4), partial nephrectomy (2) and giant renal cyst excision (1). Patient age ranged from 4 months to 11 years (average age 34 months). The average operating time was 2 hours and 15 minutes, ranging from 1 hour 50 minutes to 2 hours 45 minutes. The usual period of hospitalization was 23 hours, with the longest being 36 hours for 2 patients. No complications ensued. Despite the decreased working space in children, laparoscopic renal surgery offers compelling advantages, including short hospitalization, less perioperative and postoperative pain, improved cosmesis, earlier return to normal unrestricted activities and early return to work for the parents. Methods to accomplish renal laparoscopic surgery safely in children are detailed.

Testicular function in prepubertal and pubertal male patients treated with cyclophosphamide for nephrotic syndrome

Gonadal function and histology were studied in seven male patients who received cyclophosphamide for treatment of nephrotic syndrome prior to or during puberty. Treatment ranged from six weeks to 19 months and the total doses of cyclophosphamide varied from 18.0 to 39.0 Gm. One to four years following cessation of therapy, two patients had normal testicular function, four were azoospermic, and one oligospermic. Testicular biopsies confirmed absence of spermatogenesis in the azoospermic patients. Secondary sex characteristics were normal in all patients, although one patient had diminished testicular size. Serum follicle-stimulating hormone (FSH), luteninizing hormone (LH), and testosterone were measured on all patients; FSH elevation appeared to correspond to the degree of testicular damage.

Bilateral Renal Cell Carcinoma and Renal Cell Carcinoma in the Solitary Kidney

We report on 43 patients with renal cell carcinoma in a solitary kidney, 39 of whom underwent a potentially curative resection. Of 36 patients who had a nephron salvaging procedure only 4 required ex vivo surgical resection. The survival curves of patients with solitary or bilateral lesions are similar, and depend more on the adequacy of tumor resection and tumor stage than on the fate of the contralateral kidney. Crude survival in this series was 64 per cent for patients followed for more than 1 year.

A NEW TECHNIQUE FOR CORRECTION OF THE HIDDEN PENIS IN CHILDREN AND ADULTS

PURPOSE A phenomenon known as hidden penis has numerous origins, including congenital buried penis and obesity with descent of the escutcheon. No previous report to our knowledge mentions abnormal hypermobility of ventral skin and dartos fascia, which is a major cause of surgical treatment failures. Because the skin and dartos fascia are inadequately attached to Bucks fascia, the corporeal bodies telescope proximally inside the scrotum and pubis. Therefore, the subdermis of the penoscrotal junction must also be tacked to the tunica albuginea ventrally to stabilize the proximal penile skin and prevent the penis from retracting into the scrotum. The surgical technique for correction of the hidden penis in adult and pediatric patients with adequate penile shaft skin is described. MATERIALS AND METHODS Surgery for hidden penis from multiple causes was performed in 6 adults and 7 children. Tacking sutures were taken from the subdermis of the ventral penoscrotal junction to the tunica albuginea in all cases. A combination procedure with either suprapubic dermatolipectomy, tacking of the penopubic subdermis to the rectus fascia, penoscrotal Z plasty, circumcision revision or lateral penile shaft Z plasty also was performed in some patients. RESULTS Improvement was noted in all cases. One child requires suprapubic lipectomy for optimal improvement and 3 minor wound problems occurred. CONCLUSIONS Surgery for hidden penis achieves marked aesthetic and often functional improvement. Surgical failure can be diminished by placing ventral tacking sutures from the tunica albuginea to the subdermis of the penoscrotal junction.

Complications of bladder mucosal graft.

A bladder mucosal graft for urethral reconstruction was performed on 79 patients who had complicated conditions in which local penile or preputial skin was not available. The major and minor complication rates for this procedure were 15.2 and 43 per cent, respectively, the latter representing mucosal glanular protrusion obviated by a technical alteration. Given the difficulty of these cases these complication rates are deemed acceptable in such patients.

Laparoscopic seromyotomy (auto-augmentation) for non-neurogenic neurogenic bladder in a child: initial case report.

An eight-year-old boy with lifelong urinary incontinence secondary to non-neurogenic neurogenic bladder underwent successful laparoscopic seromyotomy (auto-augmentation) with resultant cure of his incontinence. The ability to perform this laparoscopically with its seventy-minute operating time, decreased hospital stay, and improved cosmesis militates for its consideration before a standard augmentation is performed.

Recovery of Testicular Blood Flow Following Ligation of Testicular Vessels

To determine whether initial ligation of the testicular vessels of the high undescended testis followed by a delayed secondary orchiopexy is a viable alternative to the classical Fowler-Stephens procedure, a series of preliminary experiments were conducted in the rat in which testicular blood flow was measured by the 133xenon washout technique before, and 1 hour and 30 days after ligation of the vessels. In addition, testicular histology, and testis and sex-accessory tissue weights were measured in 6 control, 6 sham operated and 6 testicular vessel ligated rats 54 days after vessel ligation. The data demonstrate that ligation and division of the testicular blood vessels produce an 80 per cent decrease in testicular blood flow 1 hour after ligation of the vessels. However, 30 days later testis blood flow returns to the control and pre-treatment value. There were no significant changes in testis or sex-accessory tissue weights 54 days after vessel ligation. Histologically, 4 of the surgically operated testes demonstrated necrosis of less than 25 per cent of the seminiferous tubules while 1 testis demonstrated more than 75 per cent necrosis. The rest of the tubules in all 6 testes demonstrated normal spermatogenesis. From this study we conclude that initial testicular vessel ligation produces an immediate decrease in testicular blood flow but with time the collateral vessels are able to compensate and return the testis blood flow to its normal pre-treatment value. These preliminary observations lend support for the concept that initial ligation of the testicular vessels followed by a delayed secondary orchiopexy in patients with a high undescended testis may be a possible alternative to the classical Fowler-Stephens approach.

The Use of Sodium 2-Mercaptoethane Sulfonate to Prevent Cyclophosphamide Cystitis

In 2 patients receiving bone marrow transplantation sodium 2-mercaptoethane sulfonate has proved efficacious in preventing the serious problem of cyclophosphamide cystitis by regional detoxification of acrolein. We detail the first use of sodium 2-mercaptoethane sulfonate in the United States. We are cautiously enthusiastic and optimistic that the simultaneous administration of sodium 2-mercaptoethane sulfonate and cyclophosphamide will decrease if not eliminate cyclophosphamide-induced carcinoma.