Robert A. Mevorach

Testicular Torsion: Direction, Degree, Duration and Disinformation

PURPOSEnWe reviewed and contrast with the literature the cumulative clinical experience at our pediatric urological division in the last 20 years with managing testicular torsion, focusing specifically on the direction and degree of testicular torsion and the duration of symptoms before presentation. We also addressed the incidence of gastrointestinal symptoms, role of manual detorsion, residual torsion and incidence of atrophy.nnnMATERIALS AND METHODSnWe reviewed the medical records of 200 consecutive males 18 months to 20 years old who underwent surgical exploration by a pediatric urologist for a diagnosis of testicular torsion between 1980 and 2000.nnnRESULTSnOf 186 nonelective explorations symptoms were localized to the left side in 52% and to the right side in 48%. Information on the direction and degree of testicular rotation was available in 162 of 186 cases (87%) and anticipated medial rotation occurred in only 108 (67%). Lateral rotation in 54 of 162 cases (33%) occurred in 28 of 84 (33%) with left torsion and in 26 of 78 (33%) with right torsion. A median of 540 degrees of torsion (range 180 to 1,080) was noted in the 70 orchiectomy cases (38%) and a median of 360 degrees (range 180 to 1,080) was noted in the 116 salvaged testes (62%). Manual detorsion was attempted in 53 orchiopexy cases with residual torsion in 17 (32%). Testicular atrophy developed in 27% of the patients.nnnCONCLUSIONSnThe traditional teaching that testicular torsion occurs primarily in the medial direction is misleading since in a third of cases it occurs in the lateral direction. While manual detorsion should be guided by response and return of normal anatomy, surgical exploration remains necessary since residual torsion still poses a risk to testicular viability. Long-term followup is warranted to assess the true incidence of subsequent atrophy after the management of acute testicular torsion.

Perinatal extravaginal torsion of the testis in the first month of life is a salvageable event.

OBJECTIVESnTo determine the effectiveness of immediate surgical exploration in salvaging perinatal testicular torsion.nnnMETHODSnA retrospective analysis from 1995 to 2000 of boys younger than 30 days of age with surgically documented extravaginal testicular torsion was conducted. All cases were diagnosed after a normal testicular examination by a neonatologist, and all patients underwent urgent exploration to confirm the exact diagnosis and attempt testicular salvage by detorsion with bilateral orchiopexy. If a nonviable testis was determined intraoperatively, it was removed and contralateral orchiopexy was performed. Success was determined by physical examination at 6 months of follow-up.nnnRESULTSnTen patients with 10 affected testes were identified and a total of 4 (40%) were salvaged. All the studied testes were right-sided, and of the 4 salvaged testes, all were palpably normal and equal in size to their mate at the 6-month follow-up examination. Of the 6 removed testes, 1 was potentially viable by permanent pathologic section analysis despite preoperative ultrasonography demonstrating no flow and a negative intraoperative bleed test.nnnCONCLUSIONSnBoys younger than 30 days old presenting with clinical findings suggestive of extravaginal testicular torsion who are expeditiously explored surgically may have a salvageable event in at least 40% to 50%. These statistics are similar to the salvage rates found with the similar management approach of intravaginal torsion.

Human Papillomavirus Type 6 in Grade I Transitional Cell Carcinoma of the Urethra

Of 4 patients who underwent cystourethroscopy, biopsy and laser excision of suspected urethral condylomata acuminata 3 had coexistent grade I papillary transitional cell carcinoma of the urethra. Human papillomavirus type 6 messenger ribonucleic acid was demonstrated within biopsy specimens using tritium-labeled single-stranded antisense ribonucleic acid probes. Compared to condylomata the papillary transitional epithelium expressed less viral message, which might be expected in an epithelium that does not show full squamous epithelial or koilocytotic differentiation. Among these patients there was 1 papillary transitional lesion in the bladder that, although histologically similar, did not express human papillomavirus message, suggesting differential susceptibility of epithelium between the bladder and urethra. The finding of active human papillomavirus transcription within the urethral papillary transitional lesions raises the possibility of an active role for the virus in the pathogenesis of these lesions. These findings broaden the spectrum of epithelial types reported to support human papillomaviruses and provides impetus for a wider search for these viruses in other transitional cell neoplasms.

Effects of Endothelium-Derived Nitric Oxide on Renal Hemodynamics and Function in the Sheep Fetus

ABSTRACT: We investigated the effects of the endothelium-derived nitric oxide system on renal hemodynamics and function during the 3rd trimester in a chronically catheterized fetal sheep preparation. Acetylcholine caused a significant decrease in renal vascular resistance (60% of the baseline value) as compared with aortic constriction (142% of the baseline value). The effects of acetylcholine could be blocked by prior administration of Nω-nitro-L-arginine (renal vascular resistance = 102% of baseline). Sodium nitroprusside also caused a significant drop in renal vascular resistance (63% of baseline), but this could not be blocked by Nω-nitro-L-arginine (77% of baseline). Infusion of Nω-nitro-L-arginine with blood pressure maintained at a constant level resulted in a significant increase in renal vascular resistance (148% of the baseline value) as compared with saline alone (94% of baseline). Glomerular filtration rate increased after saline infusion (156% of the baseline value), but this increase was blocked by Nω-nitro-L-arginine (87% of baseline). Sodium excretion also increased (340%), and this increase was blunted by Nω-nitro-L-arginine (235%). We conclude that basal production of endothelium-derived nitric oxide results in ongoing renal vasodilation in 3rd-trimester fetal sheep, maintaining baseline renal blood flow. The endothelium-derived nitric oxide system can also be stimulated to an increased level of activity, and its blockade partially prevents the homeostatic response of the fetus to volume and salt overload.

Color doppler ultrasound compared to a radionuclide scanning of spermatic cord torsion in a canine model

High resolution color doppler ultrasound can simultaneously display blood flow superimposed on detailed gray scale anatomic images. Using a single-blind study design, nine adult male dogs underwent intravaginal spermatic cord torsion and subsequent evaluation with technetium 99M-pertechnetate radionuclide, and color doppler ultrasound imaging techniques. Torsions of 90 to 720 degrees were created surgically, followed by examination with each modality at one hour (four animals), and four hours (five animals) following the procedure. Testicular torsion was diagnosed if perfusion was absent or markedly diminished on color doppler imaging or radionuclide scan. In all cases of 360 degrees or greater, torsion was diagnosed by either modality at both one and four hour time delays. If observers did not diagnose torsion, they were asked to assess the relative testicular perfusion. Color doppler ultrasound and radionuclide scanning were without error in correctly detecting a relative decrease in perfusion in each of these instances. Furthermore, color doppler imaging with spectral analysis was able to detect an enhancement of the diastolic component of the arterial signal at 180 degrees of torsion. This spectral pattern coupled with a relative decrease in blood flow allowed presumptive diagnosis at one hour of partial torsion that was subsequently apparent as absent perfusion only after 4 hours on radionuclide and repeat color doppler ultrasound. Color doppler ultrasound proved to be superior to radionuclide scanning in detecting diminished perfusion in this experiment. The detailed information provided by spectral and anatomic display with color doppler ultrasound recommends it for the evaluation of acute scrotal pathology of uncertain etiology.

Results of a 2-Year Multicenter Trial of Endoscopic Treatment of Vesicoureteral Reflux With Synthetic Calcium Hydroxyapatite

PURPOSEnWith no FDA approved material available for endoscopic treatment of vesicoureteral reflux, in 2001 we began a prospective multicenter trial of synthetic calcium hydroxyapatite as a subureteral bulking agent in children with traditional indications for surgical repair.nnnMATERIALS AND METHODSnA total of 98 patients (155 ureters) with grades II to IV reflux were enrolled at 10 sites in the United States to obtain 86 patients with completed protocol end points at 3 months. Of the 86 patients 74 underwent renal and bladder ultrasonography, blood count and serum chemistry analysis, and VCUG at 1 year. A total of 46 patients (47%) completed 2-year study end points, including VCUG.nnnRESULTSnAt 1 and 2 years 24 of the 74 patients (32%) were cured. Ureteral cure rates were 46% and 40% at 1 and 2 years, respectively. With 35 patients treated and 85% compliance with the required 2-year VCUG the primary center achieved 2-year cure rates of 66% of patients and 72% of ureters.nnnCONCLUSIONSnSynthetic calcium hydroxyapatite is a safe, durable and effective material for endoscopic treatment of VUR. Increased experience with the injection of synthetic calcium hydroxyapatite yields improved results.

Testicular Abscess: Diagnosis by Ultrasonography

We reviewed 8 cases of surgically proved testicular abscess with emphasis upon the ultrasonographic findings. The images were correlated with testicular anatomy and the pathological findings of abscess formation. In 3 of 8 patients undergoing serial high resolution ultrasound examinations a consistent pattern of testicular abscess was present 1 to 7 weeks preoperatively. In the remaining 5 patients preoperative ultrasound documented the presence of abscess. Recognition of the ultrasonographic appearance of testicular abscess should permit expedient surgical intervention.

Bladder calculus formation and urinary retention secondary to perforation of a normal bladder by a ventriculoperitoneal shunt.

Urinary retention due to bladder calculus formation is unusual in the pediatric population. This case report describes a rare sequence of events in which a bladder stone formed secondary to the erosion of a ventriculoperitoneal shunt through a normal bladder wall. A review of the literature is included.

Third trimester ultrasound of fetal pyelectasis: Predictor for postnatal surgery ☆

OBJECTIVEnThe ability to predict surgically relevant fetal renal pyelectasis is limited. We sought to determine whether the intrauterine timing of prenatal pyelectasis can predict the need for postnatal surgery.nnnMETHODSnWe retrospectively reviewed all patients with ultrasound measurements of the fetal renal pelvis during the 2nd and 3rd trimesters and postnatally. Pyelectasis was defined as >7mm for renal pelvis antero-posterior diameter in the 2nd trimester and >10mm in the 3rd trimester.nnnRESULTSnFifty-nine patients out of 2397 candidates met the criteria for inclusion. A total of 116 kidneys were analyzed independently. Second trimester pyelectasis was associated with grade of postnatal hydronephrosis but not the need for surgery. Third trimester pyelectasis was associated with both postnatal hydronephrosis and surgery. The positive and negative predictive values for postnatal surgery were respectively 18% and 95% in the second trimester, and 27% and 100% in the third trimester.nnnCONCLUSIONSnThird trimester ultrasound for fetal pyelectasis was better able to predict surgically relevant hydronephrosis than second trimester ultrasound.

Ultrasound diagnosis of tunica albuginea cyst: Clinical perspective

Two case reports of tunica albuginea cysts are presented. Imaging of this lesion by high resolution ultrasonography and the impact of this technique on management are considered.