Steven J. Skoog

Testicular Volume Assessment in the Adolescent with a Varicocele

Testicular growth arrest is the main criterion for performing varicocele ligation in the adolescent population. Previous assessments concerning significant size discrepancy range from 0.5 to 5 cm.3, a 10-fold difference. We prospectively assessed testicular size in 22 male adolescents (ages 9 to 19 years) with varicoceles, and compared testicular volume as measured by ultrasound and Prader orchidometer in 19 of these patients. The accuracy of ultrasound for this purpose was evaluated by blinded ultrasonic measurements of models of known volume and a standard deviation of +/- 1.6 cm.3 was found. Using a size discrepancy of greater than 2 cm.3 as the criterion for growth arrest, 4 of 17 patients (24%) with growth arrest would have been missed with the Prader orchidometer alone. Testicular volumetric assessment by ultrasound accurately measured volumetric differences of greater than 2 cm.3 and can be used to determine growth arrest in the male adolescent with a varicocele.

Aphallia: Its Classification and Management

Aphallia is an extremely rare disorder with profound urological and psychological consequences. Approximately 60 patients have been reported on in the literature; we report our experience with 3 additional patients. Fifty patients had sufficient information to classify the condition according to the site of the urethral meatus. With the relative relationship of the urethral meatus to the anal sphincter several observations were noted. The more proximal the meatus the higher the incidence of other anomalies and the greater the number of neonatal deaths. Of the patients 30 (60 per cent) had a post-sphincteric meatus located on a peculiar appendage at the anal verge. These patients had the lowest incidence of other anomalies (1.2 per patient) and the highest survival rate (87 per cent). A total of 14 patients (28 per cent) had pre-sphincteric urethral communications (prostato-rectal fistula), of whom 36 per cent died in the neonatal period. Six patients (12 per cent) had urethral atresia. This group had no survivors and the highest incidence of other anomalies (4 per patient). Of our patients 2 had a post-sphincteric meatus and 1 had a pre-sphincteric meatus. In addition to correction of life-threatening anomalies the management of aphallia centers on establishing gender assignment. Bilateral orchiectomy, labial construction and urethral transposition should be done in the newborn period, if possible.

Risk Factors for Perineal Seeding of Prostate Cancer after Needle Biopsy

Between 1975 and 1986, 2,107 perineal prostate biopsies were performed at our institution with 502 (23.8 per cent) positive for prostate cancer. Among this group there were 5 cases (1.0 per cent) of perineal seeding. These 5 cases along with a case referred to our institution represent cases 14 to 19 in the literature. All 19 cases are reviewed to elucidate risk factors for the development of perineal seeding. Biopsy of large volume local tumors appears to be the greatest risk factor associated with 18 of the 19 cases. Technique of biopsy appears to be important in that removal of the Tru-Cut sheath and obturator may expose the perineum to a greater risk of seeding. Other factors discussed include histology, hormonal responsiveness and radiotherapy technique. Distant metastases were discovered simultaneously or within 16 months of the perineal seeding in every case, and all patients died at a median of 36 months after initial diagnosis. Perineal seeding after prostatic needle biopsy is uncommon but its occurrence suggests a poor prognosis.

The posterolateral and the retrorenal colon: implication in percutaneous stone extraction.

Increasing experience with percutaneous nephrolithotomy has fostered an aggressive approach to most renal calculi. We report a case of a stone in a horseshoe kidney. Computerized tomography before anticipated percutaneous stone extraction revealed the colon to be positioned posterior to the left portion of the horseshoe kidney. The posterior position of the colon prevented percutaneous access to the kidney. Computerized tomography should be performed in patients with stones in horseshoe kidneys and other fusion anomalies before elective percutaneous stone extraction is done.

Intracranial metastases in prostate cancer

In a clinicopathologic review of 126 autopsied cases with prostate cancer, 14 demonstrated intracranial metastases. Only two of nine symptomatic patients were evaluated for suspected central nervous system metastases prior to death, and five asymptomatic patients were incidentally found to have metastases at autopsy. Intracranial metastases in prostate cancer occur in the setting of widespread disease, and tissue pathology may reveal moderately to poorly differentiated tumor (11 of 14 cases).

Cellular Congenital Mesoblastic Nephroma: What are the Options

Cellular congenital mesoblastic nephroma is a potentially aggressive variant of the usually benign congenital mesoblastic nephroma. Our recent experience with 3 patients with cellular congenital mesoblastic nephroma prompted a critical review of the literature to evaluate risk factors for recurrence and present treatment programs. A total of 38 patients, including our 3 patients, with cellular congenital mesoblastic nephroma were divided into 2 groups: those with recurrent (7) and those with nonrecurrent (31) tumors. A statistical comparison of clinical and pathological data was performed. Of the 7 patients with local recurrence and/or pulmonary metastasis, 3 died. The average time to first recurrence was 5.4 months. Histological differences were not predictive of recurrent disease. Pathologically positive surgical margins (p less than or equal to 0.02) were the only statistically significant variable suggesting recurrent disease. While the presenting age was not predictive of recurrence (p equals 0.27), the relative risk of recurrence doubles in the first 3 months of life and quadruples after 6 months of life. Treatment programs also were evaluated. An infant with cellular congenital mesoblastic nephroma, regardless of age, is cured with surgery alone given clear pathological margins. In 4 of 5 children with recurrent tumors Wilms tumor treatment agents (vincristine and actinomycin D) failed to control local or distant disease. Of these cases 2 subsequently were treated with sarcomatous chemotherapy (vincristine, cyclophosphamide and doxorubicin) and both are in remission. These agents may prove to be more efficacious in the treatment of local or metastatic disease.

Extragonadal germ cell tumors. Clinicopathologic findings and treatment experience in 12 patients

In patients with primary germ cell tumors, treatment with combination chemotherapy followed by surgical debulking of residual tissue usually produces favorable results. The best treatment for patients with extragonadal germ cell tumors (EGCT) remains a problem. In our series of 12 patients, important clinical features were related to the site of bulky tumor, and all patients exhibited sharply elevated levels of lactate dehydrogenase (LDH), beta subunit human chorionic genadotropin (beta‐HCG), and/or alpha‐fetoprotein (AFP). Each patient was treated with systemic chemotherapy, and ten were treated with the same combination chemotherapy—cyclophosphamide, actinomycin, vinblastine, bleomycin, and cisplatin (VAB) alternating with VP‐16 and vincristine (VV). Of these ten patients, five died of progressive disease, three of whom had brain metastases. The other five are alive and clinically free of disease. The addition of VP‐16 and vincristine did not improve responses. Advanced disease at presentation contributes to the poorer prognosis for these patients. Earlier diagnosis and surgical debulking may improve the long‐term survival of patients with this disease.

The Posterior Sagittal Pararectal Approach to Posterior Urethral Anomalies

We report a case of enlarged symptomatic utricle that was excised using a posterior sagittal pararectal approach. This surgical approach provides direct access to the posterior urethra to permit complete resection of the utricle and optimal exposure for accurate urethral repair.

Testicular masses associated with congenital adrenal hyperplasia: MRI findings

T he development of bilateral testicular masses is an unusual complication of congenital adrenal hyperplasia (CAH) , occurring in patients with poorly controlled adrenal insufficiency (21hydroxylase deficiency and less commonly llbeta-hydroxylase deficiency). The cell of origin of the testis mass and the management of these patients has been a source of controversy.1

EDITORIAL: PRIMARY NOCTURNAL ENURESIS-AN ANALYSIS OF FACTORS RELATED TO ITS ETIOLOGY

2 The images presented are from a 17-year-old male with a history of salt-wasting adrenal insufficiency