William A. Brock

Laparoscopy for Localization of Nonpalpable Testes

Laparoscopy was performed on 33 consecutive boys with 36 nonpalpable testes whenever 1 or both testes were not palpable, a patient with bilateral nonpalpable testes was known to have responded to human chorionic gonadotropin stimulation and orchiopexy or orchiectomy was planned. Anatomic localization of nonpalpable testes facilitated accurate planning of operative repair, thereby potentially improving the ultimate result. Additionally, the technique rendered exploration unnecessary in patients with the intra-abdominal vanishing testis syndrome. No complications were noted as a result of laparoscopy in these patients.

Location and Fate of The Nonpalpable Testis in Children

The records of 261 children who were treated surgically for cryptorchidism between 1975 and 1980 were reviewed to determine the incidence, exact location and results of treatment of nonpalpable testes. Of these 261 patients 71 had 80 nonpalpable testes (27 per cent). Of these 80 nonpalpable testes 17 (21 per cent) were determined to be absent at the time of thorough intra-abdominal and retroperitoneal exploration. Of the 63 testes found at surgical exploration 34 (56 per cent) were intra-abdominal (intraperitoneal), 10 (16 per cent) were in a preperitoneal position behind the internal inguinal ring, 15 (24 per cent) were canalicular and 4 (5 per cent) were located in the superficial inguinal area. Seventeen (27 per cent) testes were removed because of postpubertal age, testicular atrophy or anatomic deformity inconsistent with an attempt at orchiopexy. In the remaining testes the success rate of orchiopexy was compared on the basis of the original anatomic location of the testis and the type of surgical procedure performed. Of those testes deemed suitable for orchiopexy 89 per cent in a preperitoneal or more distal location and 74 per cent of intraperitoneal testes were placed successfully in the scrotum.

Ectopic Ureteroceles: Surgical Management with Preservation of Continence—Review of 60 Cases

During the last 19 years we treated 60 children with ectopic ureteroceles. There was a 4 to 1 female-to-male predominance. Of the patients 47 per cent presented before age 6 months, 66 per cent were diagnosed after a urinary tract infection and 6 were identified antenatally. Based upon a review of the literature and our data, we believe that total correction (a single operation designed to correct abnormalities of the upper and lower urinary tract) is superior in most instances to an approach in which just the upper urinary tract pathological condition is treated. Only 4 (14 per cent) of 28 patients in whom total correction was used required a second operation (all because of persistent reflux) while 14 of 19 patients (74 per cent) treated with an upper urinary tract procedure intended as definitive therapy have either undergone further surgery or have a residual abnormality that may require further surgery. Marsupialization rather than enucleation of the ectopic ureterocele is effective and safe, risking neither injury to the bladder neck or sphincteric mechanism nor resulting in a vesicovaginal fistula.

Ipsilateral Ureteroureterostomy and Pyeloureterostomy: A Review of 15 Years of Experience With 25 Patients

We reviewed our 15-year experience with pyeloureterostomy and ureteroureterostomy in 25 children with ureteral duplication. Pyeloureterostomy was performed in 5 patients, including 4 with reflux and 1 with upper pole obstruction. The results were good in 4 and in 1 patient postoperative anastomotic obstruction developed. Ipsilateral ureteroureterostomy was performed in 20 patients, including 8 with reflux into 1 or both ipsilateral ureters, 7 with obstructed ectopic upper pole ureters without ureterocele, 4 with ectopic ureteroceles and 1 with incomplete ureteral duplication and obstruction of the common distal ureteral segment. At followup, which ranged from 3 months to 6 years, 17 patients had good postoperative results as demonstrated by improved upper tract drainage and absence of reflux. Of 6 patients who underwent simultaneous ipsilateral ureteral reimplantation at the time of ureteroureterostomy postoperative reflux was noted in 1, necessitating a second procedure. Ureteral stumps were left in 13 patients. Postoperative urinary infection occurred in only 3 of these patients, all as single episodes and 2 associated with persistent contralateral reflux. Significant luminal disparity at the time of ureteroureterostomy was noted in 18 patients and did not adversely affect results.

Urethral Strictures in Children

During a 12-year period 57 children presented for treatment of urethral strictures. The patients ranged in age from 2 months to 18 years and there was 1 girl. Of the strictures 8 were congenital, 34 were iatrogenic, 4 were inflammatory and 11 were traumatic. Diagnosis can be suspected from the history and physical examination (observation of the voided stream), and confirmed radiographically and endoscopically. Urethral dilation was definitive treatment in only 28.6 per cent of the patients in whom it was used. Of 4 inflammatory strictures 2 responded to dilation as the only treatment, while only 1 of 5 congenital strictures and 1 of 5 iatrogenic strictures responded to dilation. Direct vision urethrotomy was successful in 1 of 2 congenital and in 5 of 5 iatrogenic bulbar strictures. A 1-stage urethroplasty seems preferable to multistaged procedures, since only 2 of 7 patients managed with staged procedures were treated successfully in 2 operations, while 5 of 9 treated with a 1-stage procedure have required no further intervention.

Ectopic Ureteroceles in Children

An ectopic ureterocele may be defined as a cystic dilatation of the distal submucosal or intravesical portion of a ureter that is associated with the ectopic moiety of a completely duplicated system or, in the absence of duplication, associated with a ureter draining into an ectopic position. Using this definition, we reviewed our experience with 22 children treated during a 7-year period. More than 50 per cent were less than 3 years old at the time of presentation. The female preponderance was 3 to 1. Urinary infection was the most frequent mode of presentation. The diagnosis is made most easily when there is a high index of suspicion. Although treatment must be tailored to the situation, in general total heminephroureterectomy and excision of the ureterocele are the preferred choice. Eighty-seven per cent of the patients so treated has a satisfactory result.

Use of the Transpubic Approach for Urethroplasty in Children

The management of traumatic strictures of the posterior urethra in children poses several problems owing to the limitations of perineal exposure, and the small size and delicacy of the structures involved. We have used a transpubic approach in the repair of strictures of the posterior urethra in 5 children, 4 of whom had previously undergone unsuccessful attempts at repair by other routes. In 2 of the transpubic repairs a patch graft technique was used, and 3 consisted of excision and primary reanastomosis. Two repairs were accompanied by concomitant closure of a failed first-stage Turner-Warwick scrotal inlay. The transpubic approach offered excellent exposure and visualization of the involved anatomy, and facilitated accurate suture placement and tissue realignment in all 5 patients. Final results have been satisfactory in 4 patients. There have been no clinically detectable effects on gait and there have been no significant complications or morbidity associated with this approach.

Xanthine Calculi in the Lesch-Nyhan Syndrome

Urinary tract calculi composed primarily of xanthine are rare in adults and children. However, there is risk of xanthine calculi formation in children with hereditary xanthinuria and children on xanthine oxidase inhibitor therapy for hyperuricemia. We describe the clinical presentation and management of 2 children with the Lesch-Nyhan syndrome (a congenital disorder of purine metabolism) and xanthine calculi. Little information has been available to direct the urologic management of such patients. We have based a plan for management upon our clinical experience with these children, as well as upon in vitro dissolution studies of the calculi. We have had some clinical success using an alternating acid/base dissolution therapy developed in the laboratory.

Radical removal of lipomas of the conus and cauda equina with laser microneurosurgery.

Ten patients with ages ranging from 4 weeks to 21 years presented with a subcutaneous lumbosacral mass noted at birth. After spinal high resolution ultrasonography or computed tomography to determine the extent of neural involvement and the length of the tumor mass in the spinal canal, the patients underwent operation. Rectal electromyographic continuous monitoring was used in all for assessment of the S-2 and S-3 function during dissection. Carbon dioxide laser microneurosurgery was used in all operations. Radiating energy was used for the subcutaneous mass removal (40 to 60 W), the intracanalicular dissection (1 to 5 W), and the intraconus dissection (1 to 3 W). A radical removal was obtained in all. Postoperative cerebrospinal fluid fistula occurred in 1 patient and was successfully treated. Wound dehiscence that healed with secondary closure occurred in 2 patients. Would infection that required treatment with systemic antibiotics and topical therapy occurred in 1 patient. Paraplegia occurred in 1 patient. This was the single very significant complication of this series. It was thought to have occurred because of the polymer used to seal the tenuous dura mater at the time of closure. We conclude that, with carbon dioxide laser microneurosurgery, the lipomatous tumors can be removed safely from the neural structures of the conus and cauda.

Post-Hypospadias Repair Urethral Strictures: A Review of 30 Cases

During a 16-year period we treated 30 patients with urethral stricture after hypospadias repair. Of the patients 16 were treated successfully with 1 procedure, while 13 required 2 or more procedures and 1 was lost to followup. A good result was achieved in 83 per cent of the patients. Fourteen patients who presented with symptoms attributable to the stricture within 3 months of the original operation for hypospadias were designated as having early strictures. Those with strictures presenting later than 3 months were considered to have late strictures. Manipulative therapy (dilation and direct vision internal urethrotomy) was successful in 55 per cent of the early strictures but in only 16 per cent of the late strictures. An open operation was performed primarily in some cases or after failed manipulation in others and it was successful in 79 per cent. All 4 failures of open procedures were salvaged with manipulative therapy. We conclude that treatment of post-hypospadias repair urethral strictures initially should be manipulative. Open repair usually will be successful but should be reserved for difficult strictures, late strictures or failures of manipulation.