Ronald Rabinowitz

Testicular Torsion: Direction, Degree, Duration and Disinformation

PURPOSE We 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. MATERIALS AND METHODS We 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. RESULTS Of 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. CONCLUSIONS The 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.

Histological changes occurring in the contralateral testes of prepubertal rats subjected to various durations of unilateral spermatic cord torsion.

Prepubertal rats were exposed to unilateral spermatic cord torsion for 0, 1, 3, 5, 9 or 12 hours duration. At the end of this time the damaged testes were either removed or untwisted and pexed into place. The animals were then allowed to mature to 77 days of age at which time the contralateral testes were examined for 12 histological parameters and scored according to the degree of pathology noted in each. Pathological changes in the contralateral testes were found to be dependent on the duration of spermatic cord torsion but were less severe in the orchiectomized group. Thus, removal of the damaged organ minimized the long-term damage to the contralateral testes. We also noted that specific histological parameters of the contralateral testes correlated well with fertility and that specific changes in the ipsilateral testes predicted contralateral pathology.

The Importance of the Cremasteric Reflex in Acute Scrotal Swelling in Children

The correlation between the presence of the ipsilateral cremasteric reflex and the absence of testicular torsion was 100 per cent in a 7-year evaluation of 245 boys with acute scrotal swelling. The presence of the cremasteric reflex was the most valuable clinical finding in ruling out testicular torsion and the absence of this reflex increased the suspicion of testis torsion.

Buccal mucosal grafts for urethral reconstruction

OBJECTIVES Patients requiring urethral reconstruction but who have a paucity of usable genital tissue present a considerable technical challenge. Herein we report the experience of three centers in the use of buccal mucosa for urethral replacement. METHODS From 1991 to 1996, 22 urethral reconstructions were completed using a graft of buccal mucosa. Eighteen of 22 patients had previously failed hypospadias repairs, while three had bulbar urethral stricture and one had penile carcinoma. Grafts were taken from either the inner cheek or the lower lip, and seven were used as a combined graft. Onlay grafts were used in 6 cases and tubularized grafts in 16 cases. RESULTS Two patients developed complications at the donor site. Nine of 22 patients had complications of the urethroplasty-two had meatal stenosis, four developed a urethral fistula, and three developed urethral stricture. All complications have been managed successfully to date. CONCLUSIONS Buccal mucosa is an excellent source of graft material for urethral replacement in complex urethroplasties. It is readily available, in abundant supply, and has physical properties beneficial to free graft survival.

Transitional Cell Carcinoma of the Bladder in the Pediatric Patient

PURPOSE We report on 5 boys with transitional cell carcinoma of the bladder, describe the identifying characteristics, review the literature, and define the issues of diagnosis, treatment and followup in this rare disease in pediatric patients. MATERIALS AND METHODS Five boys 11 to 18 years old were identified with transitional cell carcinoma of the bladder. Preoperative imaging and urinary cytology were correlated with cystoscopic and biopsy findings. RESULTS In all patients evaluation was prompted by gross hematuria. Low grade lesions, definitive cystoscopic management and a low recurrence rate were uniform findings. Preoperative imaging identified the tumor in all cases and bladder ultrasound was the most sensitive scan with 4 of 4 cases identified. CONCLUSIONS While rare, transitional cell carcinoma of the bladder in children presents a challenge in diagnosis and followup since cystoscopy typically requires general anesthesia in this age group. Bladder ultrasound was found to be extremely sensitive in identifying lesions, and it may be a valuable and minimally invasive surveillance tool.

Outcome Analysis of the Modified Mathieu Hypospadias Repair: Comparison of Stented and Unstented Repairs

PURPOSE We compared surgical outcomes of stented and unstented Mathieu repairs in boys with primary distal hypospadias, and evaluated the efficacy and safety of caudal analgesia relative to other forms of analgesia (penile block and epidural analgesia). MATERIALS AND METHODS We retrospectively reviewed the records of 336 consecutive boys who underwent the modified Mathieu repair for primary distal hypospadias. A urethral stent was placed in 114 patients and nonstented repair was performed in 222. Adjunct caudal analgesia was given in 136 cases, a penile block in 158 and continuous epidural analgesia in 42. RESULTS None of the unstented cases had urinary retention. Analysis of surgical outcomes revealed no difference in fistula formation between patients with and without stents (2.63 versus 2.70%, respectively, p > 0.999). Overall complication rates in the stented and unstented groups were not significantly different (2.63 versus 3.60%, respectively, p = 0.756). The fistula rate in patients who received adjunct caudal analgesia was no different than in those who received other forms of adjunct analgesia (2.21 versus 3.0%, respectively, p > 0.999). CONCLUSIONS These data suggest that successful Mathieu hypospadias repair is independent of the use of a stent. Caudal analgesia, a penile block and epidural analgesia provided effective postoperative pain control with no difference in complication rates. To our knowledge our report represents the largest observational study reported to date comparing stented and unstented repairs. However, because of the small number of complications in each group, a much larger study is required to determine statistically significant differences among these groups.

LATE PRESENTATION OF CRYPTORCHIDISM: THE ETIOLOGY OF TESTICULAR RE-ASCENT

PURPOSE We reviewed the records of 21 boys who had 23 previously documented descended testes that reascended and who underwent orchiopexy during a 2-year period. MATERIALS AND METHODS We retrospectively reviewed a 2-year experience in 103 boys (115 undescended testes) who underwent orchiopexy in 1988 and 1989. RESULTS In our 2-year experience 21 of the 103 boys with undescended testes had multiple recorded confirmations of testicular descent in the past. Of the boys 40% had previously been examined in the office or with general anesthesia by a pediatric urologist or pediatric surgeon for another reason, and 40% had a nurse or physician parent. Surgery was performed at ages 5 to 14 years, an average of 2 years after the initial presentation with reascent. Human chorionic gonadotropin was unsuccessful in causing testicular descent. There was no correlation with a patent processus vaginalis and no association with adhesions. The testis was located in the superficial inguinal pouch in the majority of patients, and the gubernacular attachment was in an abnormal location in all and ectopic in half of the cases. CONCLUSIONS Our observations confirm that the etiology of this condition is a missed diagnosis at a younger age. The testis is undescended but almost completely descended. With somatic growth the distance between the terminal portion of the gubernaculum of the apparently descended testis and the scrotum increases, making the diagnosis more obvious. The potential for this condition makes it mandatory that intrascrotal testicular location be confirmed by periodic physical examination through puberty.

The Mechanism of New Onset Contralateral Reflux Following Unilateral Ureteroneocystostomy

PURPOSE We studied a population of patients undergoing unilateral antireflux surgery to determine the mechanism of new onset contralateral reflux postoperatively. MATERIALS AND METHODS A total of 141 patients underwent unilateral antireflux surgery via the Cohen, Glenn-Anderson or extravesical technique. The 18% of patients who had new onset contralateral vesicoureteral reflux were analyzed according to grade of initial reflux, presence of a Hutch diverticulum or duplex system and surgical technique. RESULTS Surgical technique did not influence the development of contralateral reflux. As grade of corrected reflux increased, a significant trend toward development of contralateral reflux was noted. A Hutch diverticulum was not a risk factor for contralateral reflux but reflux into a duplicated system was a distinct risk factor (26 versus 12% in single system reflux). CONCLUSIONS Our study supports the concept that new onset contralateral reflux may result from elimination of a pop-off mechanism. Surgical distortion of the contralateral hemi-trigone appears not to be responsible. Correction of severe (grade V) reflux and reflux into duplex systems put patients at particular risk for development of contralateral reflux postoperatively.

Diagnosis of Nonopaque Calculi by Computed Tomography

Computed tomography can aid in the distinction of calculi from both tumors and clots in the urinary tract. Its availability, simplicity of interpretation, and noninvasiveness establish it as an important diagnostic modality in selected cases when calculus is in the differential diagnosis of upper urinary tract filling defects.

Acute scrotal swelling in children

We have found that the blanket philosophy of emergency scrotal exploration in all cases of acute scrotal swelling in boys results in an unacceptably large number of unnecessary explorations. The use of specific aspects of the clinical examination, in conjunction with the radioisotope testicular scan in selected instances, has guided our management of 150 consecutive boys presenting with acute scrotal symptoms.