William C. Hulbert

Perforation of the Augmented Bladder in Patientsundergoing Clean Intermittent Catheterization

During urological reconstructive surgery small or large bowel is used to increase bladder capacity or to create a urinary reservoir. In most patients clean intermittent catheterization is necessary for urinary drainage. We report on 4 patients with a sigmoid cystoplasty who perform clean intermittent catheterization and who have experienced a serious long-term complication, urinary reservoir perforation, which was fatal in 1. Two were adolescent girls with myelodysplasia and 2 were prepubertal boys with bladder exstrophy. One patient experienced 2 separate reservoir perforations. Rupture occurred 15 to 48 months (mean 30.2 months) after reconstruction. Diagnosis was made by a static cystogram, which demonstrated extravasation in 2 of 4 patients, and ultrasound. In 2 patients the cystogram was normal. Management included intravenous antibiotics and open abscess drainage in all patients. In patients who have undergone augmentation cystoplasty or continent diversion and in whom abdominal pain and distension develop reservoir perforation should be considered in the differential diagnosis.

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.

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.

A Multi-institutional Randomized Controlled Trial of Adjuvant Web-based Teaching to Medical Students

Purpose To investigate the impact of an adjuvant Web-based teaching program on medical students’ learning during clinical rotations. Method From April 2003 to May 2004, 351 students completing clinical rotations in surgery–urology at four U.S. medical schools were invited to volunteer for the study. Web-based teaching cases were developed covering four core urologic topics. Students were block randomized to receive Web-based teaching on two of the four topics. Before and after a designated duration at each institution (ranging one to three weeks), students completed a validated 28-item Web-based test (Cronbach’s alpha = .76) covering all four topics. The test was also administered to a subset of students at one school at the conclusion of their third-year to measure long-term learning. Results Eighty-one percent of all eligible students (286/351) volunteered to participate in the study, 73% of whom (210/286) completed the Web-based program. Compared to controls, Web-based teaching significantly increased test scores in the four topics at each medical school (p < .001, mixed analysis of variance), corresponding to a Cohen’s d effect size of 1.52 (95% confidence interval [CI], 1.23–1.80). Learning efficiency was increased three-fold by Web-based teaching (Cohen’s d effect size 1.16; 95% CI 1.13–1.19). Students who were tested a median of 4.8 months later demonstrated significantly higher scores for Web-based teaching compared to non-Web-based teaching (p = .007, paired t-test). Limited learning was noted in the absence of Web-based teaching. Conclusions This randomized controlled trial provides Class I evidence that Web-based teaching as an adjunct to clinical experiences can significantly and durably improve medical students’ learning.

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 predictive value of ultrasonography in evaluation of infants with posterior urethral valves

Between 1981 and 1989, 28 infants less than 6 months old with posterior urethral valves underwent ultrasound evaluation as part of the initial evaluation at our hospital. The single ultrasound feature that correlated with subsequent renal function was the status of corticomedullary differentiation. The presence of corticomedullary junctions in at least 1 kidney in 17 infants was always associated with a serum creatinine level of 0.8 mg./dl. or less in long-term followup. Of 11 patients with absent corticomedullary differentiation 7 had eventual creatinine levels of greater than 0.8 mg./dl. with 5 of them suffering clinically significant renal insufficiency. An association between vesicoureteral reflux and absent corticomedullary junctions was also found.

DOES URINARY TRACT ULTRASONOGRAPHY AT HOSPITALIZATION FOR ACUTE PYELONEPHRITIS PREDICT VESICOURETERAL REFLUX

PURPOSE We evaluate the correlation between urinary tract ultrasound during hospitalization for acute pyelonephritis with subsequent voiding cystourethrography in children. MATERIALS AND METHODS Medical records were reviewed of 184 children up to 18 years old who were evaluated with ultrasound during hospitalization for acute pyelonephritis between January 1988 and January 1996. Followup voiding cystourethrography results were compared to the initial ultrasound findings. RESULTS Ultrasound was performed at mean hospital day 2.1 and voiding cystourethrography was done 39 days later. Of the ultrasound studies 77 (42%) were abnormal, and two-thirds of these abnormalities were upper tract dilatation. Subsequent voiding cystourethrography was performed in 76% of the study population, including 67% of those with normal and 87% of those with abnormal ultrasound. Voiding cystourethrography revealed reflux in 39% of children with upper tract dilatation compared to 35% of those with normal and 36% with abnormal ultrasound for any reason. In addition, the severity of reflux on voiding cystourethrography could not be predicted by ultrasound findings. CONCLUSIONS Ultrasound findings during acute pyelonephritis do not correlate with and are not predictive of the presence or grade of vesicoureteral reflux on subsequent voiding cystourethrography.

Scrotal Cystic Lymphangioma: The Misdiagnosed Scrotal Mass

PURPOSE We report 7 cases of scrotal cystic lymphangioma and review the literature on this unusual lesion, which is often misdiagnosed as other conditions and treated incorrectly. MATERIALS AND METHODS We retrospectively reviewed the medical records of 7 patients with scrotal cystic lymphangioma treated from 1984 to 1996 at 5 institutions. RESULTS Mean patient age at presentation was 3 years and painless scrotal swelling was the most common symptom. Physical examination demonstrated an unusual cystic scrotal mass with a normal testis and cord in most patients, and ultrasound in 4 showed a complex septated cystic mass. Preoperative misdiagnosis in all 7 patients included hernia, hydrocele, hematocele, varicocele and possible torsion. In 6 children the lesions were more extensive than expected with deep perineal and/or inguinal involvement, including 2 who also had pelvic and retroperitoneal extension. Incomplete excision led to recurrence in 4 patients. CONCLUSIONS Scrotal cystic lymphangioma presents as an unusual cystic scrotal mass. Although misdiagnosis has been common, awareness of the characteristic features of this lesion should lead to the correct preoperative diagnosis. When lymphangioma is suspected, imaging of the adjacent inguinal, perineal and pelvic regions should be performed. Complete excision is mandatory to prevent recurrence.

Penile block timing for postoperative analgesia of hypospadias repair in children

PURPOSE It has been well established that a dorsal penile nerve block immediately after surgery decreases postoperative pain in children undergoing hypospadias repair. However, to our knowledge the efficacy of a penile block immediately before versus immediately after surgery for postoperative pain control has not been previously studied in such children. MATERIALS AND METHODS We evaluated 98 healthy boys 6 months to 12 years old undergoing hypospadias repair. General anesthesia was induced and maintained in a standard fashion. Patients were randomly assigned to receive a penile block with the same total dose of bupivacaine at the completion of surgery, before the incision or before and at the completion of surgery. No other analgesic was administered intraoperatively. Pain was assessed using a modified objective pain-discomfort scale at 15 minutes, and 3, 12 and 24 hours after surgery. The number of doses of acetaminophen required to control postoperative pain was also recorded. RESULTS Pain scores were defined in a range of 0-no pain to 6-greatest pain. During recovery median pain scores in the 30, 36 and 32 boys who received a penile block after, before, and before and after surgery were 3, 1.5 and 0 at 15 minutes; 2.5, 1 and 0 at 3 hours; 3, 2 and 0 at 12 hours; and 1, 0 and 0 at 24 hours, respectively. There was no difference in acetaminophen doses required 15 minutes and 3 hours postoperatively in the 3 groups. By 12 hours after surgery the number of acetaminophen doses required for pain control was significantly lower in the before and after, and before groups than in the after group. By 24 hours boys in the before and after group required significantly fewer doses of analgesics than those in the after and before groups. There was no statistically significant difference between the after and before groups. CONCLUSIONS Two penile blocks performed at the beginning and conclusion of hypospadias repair, respectively, provide better postoperative pain control than 1 penile block done before or after surgery (p < 0.05). These patients require less analgesic than those who receive a penile block only before or only after surgery.

Abdominoscrotal hydrocele in infancy

Abdominoscrotal hydrocele is an uncommon clinical entity. Fewer than 200 cases have been reported in the literature, only two of which described bilateral involvement. We present five cases of abdominoscrotal hydrocele occurring in infancy, three of which revealed bilateral disease. The first case represents the youngest patient ever reported with this condition and the first reported with secondary bilateral upper tract dilatation. The historical background, pathophysiology, diagnosis, and treatment are reviewed.