Richards P. Lyon

Varicocele in childhood and adolescence: implication in adulthood infertility?

Thirty boys eight to eighteen years of age had a clearly palpable left varicocele. The presenting complaint usually was either an asymptomatic scrotal mass or a scrotal ache after physical exercise. In 77 per cent of the patients the left testis was smaller than its male. All but one of the 17 boys between ages eight and fifteen had a smaller left testis. When the varicocele is symptomatic, presents as a prominent mass, or where growth of the left testicle lags behind that of its mate, surgical correction of the varicocele is recommended.

Intermittent Catheterization Rather than Urinary Diversion in Children with Meningomyelocele

Fifteen girls more than 4 years old and with neuromuscular defects of meningomyelocele are maintaining adequate urinary continence through the use of intraurethral catheterization done by themselves or their parents. Urinary diversion has been necessary in only 1 child. The indwelling catheter has allowed heavily trabeculated bladders to become smooth enough for an antirflux operation to be successful, although the period of followup is only 2 years. Upper tract deterioration has not been observed and urine has been maintained sterile without the help of medication 50 per cent of the time when catheterizations have been done on a routine 3-hour schedule. For this method to be sucessful and replace conduit deversion, parents, child, nurse and physician must be a well-knit team. With the hope that a reliable artificial urinary sphincter will eventually provide contience for some children, one is further justified in pursuing urinary continence by use of the catheter, instead of resorting early to permanent conduit conversion.

Anomalies of the external urethral meatus in girls with non‐neurogenic bladder sphincter dysfunction

 To investigate in a prospective study the clinical and urodynamic characteristics associated with the correlation previously reported between non‐neuropathic bladder sphincter dysfunction and minimal meatal deformities in girls.

A Conservative Approach to Testicular Tumors in Children: 12 Cases and Their Management

During a 34-year period 12 children were seen with testicular tumors. Of 8 benign tumors 7 were treated by orchiectomy and 1 by local excision only. The 4 malignant tumors were managed by orchiectomy and 1 boy also received adjunctive chemotherapy. All patients are alive and have had no recurrent tumors after 1 1/2 to 34 years of followup. Because testicular tumors usually are less aggressive in prepubertal children, the chance of cure by orchiectomy alone in this age group is good. However, the potential of these tumors for metastases makes it imperative that they be observed closely.

Normal growth with renal insufficiency owing to posterior urethral valves : value of long-term diversion : a twenty-year follow-up

Twenty-five patients with posterior urethral valves have been monitored for 10-29 years (mean 18 years). Eight underwent diversion because of impaired renal function (creatinine greater than 0.8 mg/dl) accompanied by unimproved upper tract form and function after valve ablation. In the nondiverted group, 6 patients (35%) progressed to renal failure; in the diverted group 5 patients (63%) did so (p = 0.30). Of 13 patients whose lowest serum creatinine in the first year after valve ablation was greater than 0.8 mg/dl, 9 (69%) went on to renal failure (p = 0.02); in the remaining 12 patients, only 2 (17%) did so (p = 0.008). The mean age for renal failure was 13 years for both groups. The Tanner scale rating (mean percent height) for all patients at 10 years was 61% for the diverted group and 35% for those without diversion (p = 0.004). When the patients treated after the age of 1 year (n = 7) were excluded from the calculation, the rating remained different (54% diversion, 26% no diversion; p = 0.012). We conclude that the boy born with urethral valves and serious upper tract damage is at risk for renal failure, especially during the teen years. An undefined relationship appears to exist between urinary obstruction and growth. In our study, the boys who underwent diversion continued to grow along a normal Tanner height curve.

Ureterovesicoplasty: selection of patients, incidence and avoidance of complications. A review of 3,527 cases.

The procedure of ureteral reimplantation has certainly come of age. The incidence of complications can be kept low by careful selection of patients for operation along clear and definite guide lines, by close attention to detail in the surgical procedures and by rigorous followup care. When surgical intervention is deemed advisable the expected cure rate should be more than 94%. While complications do occur resultant damage to the upper urinary tracts should be minimized by its prompt recognition and by institution of appropriate therapy.

Treatment of vesicoureteral reflux point system based on twenty years of experience

Five hundred girls with recurrent urinary tract infections and documented reflux were seen in our private practice during the last twenty years. All patients received medical treatment for three to forty-eight months (an average of fifteen months) after which the 250 who were not cured were submitted to corrective surgery. The primary reason for antireflux surgery is to protect the kidney from the damaging effect of a combination of high pressure and infection. Thus our criteria for operation included persistent infection, renal changes typical of past pyelonephritis, major reflux, and abdominal or flank pain. Our surgical cure rate after careful long-term follow-up is 96%. Our medical-surgical cure rate at the end of two years reached 88%. This experience has enabled us to evolve a rigorous point system providing common denominators regardind indications for operation. It emphasizes the desirability of attempting a medical cure for at least one year after urethral dilatation, except where major orifice defects and major reflux exist. This system should help to increase communication and coordination of efforts between pediatrician, radiologist, and urologist.

Prostatic acid phosphatase levels: Significance in serum and bone marrow

Abstract In benign prostates, prostatic acid phosphatase levels were higher in peripheral blood than in bone marrow in simultaneously collected specimens. In metastatic disease these levels were reversed. The increase in prostatic acid phosphatase levels after surgery was much greater in benign than in malignant cases. Clinical implications are discussed.

RE: FLOATING KIDNEYS: A CENTURY OF NEPHROPTOSIS AND NEPHROPEXY

To the Editor. This article was most timely and an accurate assessment of the state of the art. We congratulate the author for the comprehensive review and analysis of the published literature. Most urologists who were trained after World War I1 learned to incorporate nephropexy at the conclusion of many surgical procedures on the kidneys, particularly for ureteropelvic junction obstruction, when it is imperative to obtain good gravity flow, accommodating peristalsis, usually with a personal modification of the Deming procedure. Suturing the renal capsule to the fascia and quadratus lumborum strap muscles affer removing the posterior surrounding fat prevents the liver from causing the kidney to prolapse without compromising the adrenal, and renal arterial and venous blood supplies or the accompanying sympathetic and parasympathetic nerve supplies. The various operations for the painful nonobstructed ptotic kidney remain largely abandoned. Nonabsorbable sutures and contact adhesions will fix the kidney, ensuring excellent drainage. Additionally, urological surgeons have incorporated the art of suturing in other procedures, such as undescended testis repair and for torsion of the testicle with simultaneous suturing of the contralateral testis. We believe that program directors at academic centers should alert residents, teaching them the importance of using nonabsorbable sutures in the various noninfected urological surgeries requiring a suturing procedure to prevent recurrence.

Pitfalls of Colony Count Of Urine Cultures

To the Editor:— In the collection of a urine specimen for culture, great emphasis is placed on plating out the specimen immediately, lest there be gross error in the colony count from bacterial multiplication while the urine sits on the shelf. Yet the physician rarely questions either the length of time the urine remains in the bladder (ie, the time of previous voiding) or the specific gravity of the urine. A person with a urinary tract infection may have urinary frequency both from the irritability of the inflamed bladder as well as from a high fluid intake, thereby decreasing the time of previous voiding as well as the specific gravity of the urine. Both of these would decrease the colony count. A series of patients with cystitis were subjected to sequential urine cultures in an attempt to compare the effect on colony count of incubation in the bladder with that