Stanley J. Kogan

Urolithiasis in children following augmentation cystoplasty.

Until recently urolithiasis in children following augmentation cystoplasty was an infrequently noted problem. We examined our 10-year experience and found urinary calculi to form in 52% of children and young adults undergoing augmentation cystoplasty. Calculi formed at a median interval of 24.5 months after surgery, predominantly in the lower tract. Urinary tract infection was a statistically significant risk factor, while the use of absorbable staples, intestinal mucus and hypocitraturia were also implicated. Calculus composition was primarily a mixture of apatite, struvite and ammonium urate. Bladder calculi were effectively managed endoscopically in the majority of cases without complication. Upper tract calculi presented an endourological challenge.

Subtunical Total Reduction Clitoroplasty: A Safe Modification of Existing Techniques

Subtunical resection of hypertrophied cavernous tissue of the enlarged clitoris allows for maintenance of an intact blood supply to the glans and is an alternative safe method of diminishing shaft and glans size.

Significance of epididymal and ductal anomalies associated with testicular maldescent.

Epididymal abnormalities have long been found in conjunction with cryptorchid testicles. The aim of this study was to document the different types of epididymal and ductal anomalies in relation to the position of the cryptorchid testis and to determine their clinical significance. Exploration was performed on 187 cryptorchid testes in 174 boys. The position of the testis and the epididymal and ductal anomalies were documented at operation. A biopsy was taken from the testis or atretic spermatic cord structures for light microscopy. Epididymal, ductal and/or testicular anomalies were detected in 43 per cent of the 187 testes, including anomalies of ductal fusion, anomalies of ductal suspension and anomalies associated with absent or vanishing testes. Biopsy of the testes with severe anomalies of ductal fusion showed preservation of germ cells in 69 per cent and diminished germ cells in 31 per cent. The higher the arrest of testicular descent, the more grossly abnormal was the associated ductal system. Early successful orchiopexy alone may not ensure subsequent fertility despite the presence of normal germ cells.

Orchiopexy of the High Undescended Testis by Division of the Spermatic Vessels: A Critical Review of 38 Selected Transections

The technique used to perform 38 orchiopexies of high undescended testes by spermatic vessel transection in 26 patients is reviewed. Careful attention to detail and selection using the Fowler-Stephens test allowed for an 89 per cent success rate, confirming the efficacy of this procedure in cases selected in this manner.

Routine Intraoperative Post-Ligation Venography in the Treatment of the Pediatric Varicocele

Varicocelectomy in the adult is followed by a relatively low recurrence rate but children treated by conventional techniques seem prone to have more frequent recurrences. We believe that the higher recurrence rate observed in children after routine varicocelectomy actually represents residual varicose communications that had been missed at the primary operation. Routine post-ligation intraoperative venography has been used to detect these occult communications in 26 children undergoing varicocelectomy. Our results indicate a low recurrence rate (3.6 per cent), suggesting that routine use of this procedure with childhood varicocelectomy is beneficial.

Endoscopic management of bladder calculi following augmentation cystoplasty

OBJECTIVESnWe sought to evaluate the effectiveness and utility of an endoscopic approach to calculi that develop in the bladders of children following augmentation cystoplasty. In addition, we aimed to determine the indications for open vesicolithotomy.nnnMETHODSnWe reviewed our experience between 1981 and 1993 with 26 children who formed bladder calculi following augmentation cystoplasty. Data were retrieved retrospectively with respect to management approach and outcome.nnnRESULTSnNineteen cases were managed cystoscopically using simple extraction and/or electrohydraulic lithotripsy; 3 cases required open vesicolithotomy and four calculi passed spontaneously. Complete stone extraction was achieved after a single endoscopic treatment in every case approached in this fashion. Every patient resumed preoperative voiding patterns and there were no infections, strictures, or other complications. Calculi reformed in 4 patients and were successfully managed endoscopically.nnnCONCLUSIONSnAn endoscopic approach to bladder calculi is a safe and effective method of managing this increasingly prevalent problem in children following augmentation cystoplasty even in the presence of a reconstructed bladder neck. Open vesicolithotomy should be reserved for the very large stone burden.

Bladder Evaluation in Pediatric Patients Before Undiversion in Previously Diverted Urinary Tracts

An easily performed test is described for simulating physiologic micturition in the defunctionalized bladder. Accurate clinical observations of continence and emptying capabilities before undiversion or transplantation are therefore possible. The test has predicted accurately adequate functional capabilities of the bladder in a series of children after total reconstruction. Moreover, when abnormal bladder function is identified by this technique a more physiologic state is provided for further investigation by more sophisticated urodynamic techniques. Successful retesting after appropriate corrective measures have been taken will avoid complications in the undiverted patient.

Urodynamics in Children. Part II. The Pseudoneurogenic Bladder

We evaluated 83 children for recurrent urinary infections, day and night urinary incontinence or both for more than 1 year in the urodynamic laboratory. Bladder instability and/or bladder sphincter dyssynergia was encountered in 74 children. Pharmacologic manipulation of detrusor and sphincter function and biofeedback therapy were highly successful. Routine and random urethral dilation, urethrotomy and fulguration, and/or resection of ill-defined urethral obstructions is unwarranted. Rational treatment requires individualization based upon an objective evaluation by thorough and careful urodynamic testing.

Dermal graft correction of extraordinary chordee.

Severe degrees of primary chordee and persistent or recurrent chordee following previous surgical attempts at correction present a challenging problem. Inadequate resection of involved tissues, which may involve all layers of the penile investiture, or recurrent scarring of the ventral skin, Bucks fascia and tunica albuginea is usually the cause. Reoperation to achieve penile straightening often is unsuccessful unless all chordee-bearing tissue is resected extensively. Excision of large segments of tunica albuginea or wide separation of the margins creates a defect that tends to heal by dense scarring unless the defect is bridged by a graft. Various autogenous materials have been used, including blood vessel, fascia, free fat graft, dermis and tunica albuginea, as well as prosthestic materials, such as polytetrafluoroethylene, with varying results. A series of patients with extensive chordee is presented in whom tunical resection was necessary to achieve penile straightening. The results of free dermal graft replacement of the tunica are reported.

Isolated torsion of penis Report of 6 cases

Torsion of the penis as an isolated anomaly has rarely been reported. Six such cases seen in a pediatric urologic practice within a two and one-half-year span suggest that it is not as rare as has been hitherto suggested. The embryologic abnormality appears to be an isolated skin and dartos defect, since the torsion is completely remedied by simply freeing the penile shaft of its investing tissue. The ease of achieving a normal appearance would appear to justify its surgical correction.