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Urologist
30 years of experience
Accepting new patients
Video profile

Credentials

Education ?

Medical School Score Rankings
Dartmouth College (1982)
  •  
Top 25%

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Urinary Bladder Neck Obstruction
Urinary Tract Infections (UTI)
Top Docs 2010
"Top Doctors," Philadelphia Magazine
Top Docs 2010; Top Docs 2011; Top Docs 2012
"The Best Doctors In America," Woodward/White Publishers
Top Docs 2012
Top Docs 2011
Castle Connolly America's Top Doctors® (2004 - 2008, 2010 - 2015)
Patients' Choice Award (2011 - 2012, 2014 - 2015)
Compassionate Doctor Recognition (2014)
Associations
American Urological Association
American Board of Urology

Affiliations ?

Dr. Canning is affiliated with 5 hospitals.

Hospital Affiliations

Score

Rankings

  • Hospital of the University of PA
    3400 Spruce St, Philadelphia, PA 19104
    •  
    Top 25%
  • Children's Hospital of Philadelphia *
    324 S 34th St, Philadelphia, PA 19104
    •  
  • Abington Memorial Hospital
    1200 Old York Rd, Abington, PA 19001
    •  
  • Warminster Hospital
    225 Newtown Rd, Warminster, PA 18974
    •  
  • Choppa
  • * This information was reported to Vitals by the doctor or doctor's office.

    Publications & Research

    Dr. Canning has contributed to 171 publications.
    Title Association Between Body Mass Index and Urolithiasis in Children.
    Date November 2011
    Journal The Journal of Urology
    Excerpt

    The prevalence of obesity and urolithiasis in children has increased with time. We evaluated the relationship between body mass and urolithiasis in children.

    Title The History of Hypospadias and Hypospadias Repairs.
    Date August 2011
    Journal Urology
    Title Hypospadias.
    Date July 2010
    Journal The Urologic Clinics of North America
    Excerpt

    Hypospadias results from abnormal development of the penis that leaves the urethral meatus proximal to its normal glanular position anywhere along the penile shaft, scrotum, or perineum. A spectrum of abnormalities, including ventral curvature of the penis (chordee), a hooded incomplete prepuce, and an abortive corpora spongiosum, are commonly associated with hypospadias. Advances in understanding of the causes of hypospadias and current approaches to the correction of hypospadias to provide a cosmetically and functionally satisfactory repair are the focus of this article.

    Title Transient Asynchronous Testicular Growth in Adolescent Males with a Varicocele.
    Date September 2008
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We assessed the testicular growth of adolescent males followed nonsurgically for the presence of left varicocele. MATERIALS AND METHODS: We retrospectively reviewed the charts of adolescent males with a diagnosis of unilateral left varicocele and ultrasound testis volume measurements seen during a 10-year period. A total of 161 boys underwent at least 2 testicular ultrasounds as part of the evaluation for left varicocele. Patients were excluded from study for a history of inguinal/scrotal pathology or endocrinopathy that could affect testicular size. Sonographic testicular volume was calculated using the Lambert volume (length x width x height x 0.71). The resulting volumes were compared to previously published criteria for surgical repair (15%, 20% and 2 cc size differentials). RESULTS: Of the 71 boys with 3 followup ultrasounds 38 (54%) initially had a 15% or greater volume differential. After nonsurgical followup with ultrasounds for 2 years 60 boys (85%) had testicular volume differentials in the normal range (less than 15%). Of the patients 71% were spared potential surgery by size criteria and 50% were spared surgery by the same 15% volume differential criteria. CONCLUSIONS: Adolescent males with unilateral left varicocele often demonstrate asynchronous testicular growth that usually equalizes in time. Therefore, sonographic testicular size measurement at a single point during adolescence is insufficient to determine the need for varicocelectomy. When contemplating varicocelectomy we recommend at least 2, and preferably 3, testicular volume measurements 1 year apart to establish accurately decreased left testicular volume compared to a normal right testis.

    Title Is There a Relationship Between Urinary Tract Infection, Vesicoureteral Reflux and Renal Damage in Children?
    Date July 2008
    Journal Nature Clinical Practice. Urology
    Title Deletion of One Serca2 Allele Confers Protection Against Bladder Wall Hypertrophy in a Murine Model of Partial Bladder Outlet Obstruction.
    Date February 2008
    Journal American Journal of Physiology. Regulatory, Integrative and Comparative Physiology
    Excerpt

    The sarco(endo)plasmic reticulum Ca(2+)-ATPase2 (SERCA2) is downregulated in cardiac hypertrophy with decompensation. We sought to determine whether mice heterozygous for the SERCA2 allele would develop greater bladder hypertrophy and decompensation than their wild-type littermates following partial bladder outlet obstruction (pBOO). We found that following 4 wk of surgically created pBOO, SERCA2 heterozygous murine bladders showed significantly less hypertrophy, improved in vitro cystometry performance, diminished expression of the slow myosin isoform A analyzed by RT-PCR, a significant drop in nuclear translocation of nuclear factor of activated T cells by EMSA, and decreased cell proliferation within the smooth muscle layer following 5-bromo-2'-deoxyuridine labeling compared with their wild-type littermates. Thus, in contrast to cardiac muscle, deletion of a SERCA2 allele confers protection against bladder hypertrophy in a murine model of pBOO. Compensatory mechanisms in heterozygous mice seem to be related to the calcineurin pathway. Further studies are underway to better define the molecular basis of this observation, which has potential clinical applications.

    Title Laparoscopic Orchiopexy.
    Date November 2007
    Journal Bju International
    Title Should Renal and Bladder Function Be Our Compass for Management of Vesicoureteral Reflux?
    Date August 2007
    Journal Nature Clinical Practice. Urology
    Title Transperitoneal Laparoscopic Pyeloplasty for Pelvic Kidneys with Ureteropelvic Junction Obstruction in Children: Technique and Preliminary Outcomes.
    Date January 2007
    Journal Jsls : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons
    Excerpt

    BACKGROUND: Laparoscopic pyeloplasty is rapidly becoming an acceptable procedure for ureteropelvic junction obstruction in the pediatric population. We present our experience with transperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction in pelvic kidneys in pediatric patients. METHODS: A transperitoneal laparoscopic approach was used for performing a pyeloplasty in 4 patients, 7 months to 8 years of age (mean age, 3.14), with ureteropelvic junction obstruction in a pelvic kidney. RESULTS: Average operative time was 2.1 hours (range, 1.5 to 2.8). Mean hospital stay was 2.15 days (range, 1 to 7). No intraoperative complications were noted. CONCLUSIONS: Transperitoneal laparoscopic pyeloplasty for pelvic kidneys is feasible in the pediatric population, and preliminary results appear to offer the same outcome as that seen in orthotopic kidneys.

    Title Is Ultrasound a Safe Alternative to Voiding Cystourethrogram for Vesicoureteral Reflux Screening of Siblings?
    Date November 2006
    Journal Nature Clinical Practice. Urology
    Title Urethral Dilation As Treatment for Neurogenic Bladder.
    Date October 2006
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We documented the change in bladder physiology and clinical outcomes after urethral dilation for managing neurogenic bladder. MATERIALS AND METHODS: Female patients with neurogenic bladder were identified who underwent urethral dilation due to failure to empty at low pressure or upper tract changes. Urethral dilation was performed using curved sounds to 36Fr (range 18Fr to 36Fr). Clinical charts were reviewed to document urodynamics, infection rates, symptomatology, vesicoureteral reflux and upper tract dilatation before and after dilation. RESULTS: A total of 19 children underwent urethral dilation a mean of 2 times. Mean age at first dilation was 19.3 months. Mean followup was 34.9 months. The indication for dilation was high detrusor leak point pressure in 16 children. The remaining children had recurrent infections (1), poor compliance (1) and bladder spasms (1). Clinical manifestations of increased detrusor leak point pressure in 16 children were vesicoureteral reflux in 11, upper tract dilatation in 9 and recurrent infections in 3. Long-standing improvement occurred in 12 of 16 patients with increased detrusor leak point pressure, in 0 of 1 with infection, in 0 of 1 with poor compliance and in 1 of 1 with bladder spasms. Overall improvement was noted in 13 of 19 cases (68%). Vesicoureteral reflux was identified in 14 of 19 patients. Improvement was seen in 6 of 14 cases, including complete resolution in 5 and improvement in 1. Hydronephrosis was seen in 11 of 19 patients with improvement in 7, including resolution in 1 and improvement in 6. Only 6 children required further surgical intervention, that is vesicostomy in 2 and reimplantation in 4. CONCLUSIONS: Urethral dilation is effective for lowering detrusor leak point pressure in children with neurogenic bladder and for improving upper tract dilatation and vesicoureteral reflux. This procedure may prevent the need for more complicated surgical intervention. It should be investigated further in well designed, prospective studies.

    Title Activation of the Calcineurin Pathway is Associated with Detrusor Decompensation: a Potential Therapeutic Target.
    Date September 2006
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We hypothesized that the calcineurin pathway mediated some of the complex remodeling process that allows a bladder subjected to partial outlet obstruction to adapt to its new workload. Atrial natriuretic factor mRNA expression served as a marker of calcineurin activation. MATERIALS AND METHODS: A total of 16 New Zealand White rabbits underwent surgical creation of partial outlet obstruction, followed by randomization to receive cyclosporin A (20 mg/kg intramuscularly twice daily) or no additional treatment for 14 days. Three animals underwent 2 weeks of partial bladder outlet obstruction followed by bladder biopsy and the reversal of obstruction. RESULTS: Atrial natriuretic factor expression was seen only in bladders with severe hypertrophy and it disappeared with the reversal of outlet obstruction. Cyclosporin A treatment resulted in a decrease in atrial natriuretic factor mRNA expression (p <0.05) and a marked shift in myosin heavy chain A-to-B ratios toward normal (p <0.01) and an increase in smooth muscle cross sectional area (p <0.05). Bladder mass decreased 40% but did not attain statistical significance (p = 0.08). CONCLUSIONS: The calcineurin pathway has a significant role in bladder wall hypertrophy following partial outlet obstruction. Bladder hypertrophy could not be fully prevented by cyclosporin A, suggesting that multiple signaling pathways are involved in this pathophysiology. The expression of myosin heavy chain AB isoforms is regulated in part by the calcineurin pathway.

    Title Deflux for Vesicoureteral Reflux: Pro--the Case for Endoscopic Correction.
    Date August 2006
    Journal Urology
    Title Lower Pole Pelvi-ureteric Junction Obstruction in Duplicated Collecting Systems.
    Date January 2006
    Journal Bju International
    Excerpt

    OBJECTIVE: To determine the incidence and efficacy of treatment for pelvi-ureteric junction obstruction (PUJO, the most common cause of hydronephrosis in the fetal kidney) in duplicated systems. PATIENTS AND METHODS: We retrospectively assessed patients with PUJO in a duplex collecting system, reviewing each case for age, sex, anatomy, presenting symptoms and type of management. RESULTS: From 1994 to 2004, 1413 patients were identified to have hydronephrosis; 243 of them had pyeloplasty for PUJO, and five (2%) involved the lower pole of a duplicated collecting system. In two of the patients the presentation was prenatal hydronephrosis (mean age at diagnosis 6 weeks) and the remainder presented with flank pain and pyelonephritis (mean age 5 years); all were boys. There was only one incomplete duplication (Y type). Four patients had a dismembered pyeloplasty and one a ureteric calycostomy. Vesico-ureteric reflux was present in three patients and two required common sheath reimplantation. On a radioisotope scan during the follow-up (mean 12 months) the five patients showed an improvement and no evidence of functional obstruction. CONCLUSION: The incidence of PUJO in duplicated systems was 2%; treatment should be individualized and requires a careful preoperative evaluation. This anomaly appears to be more common in boys and in completely duplicated systems.

    Title Testicular Microlithiasis and Antisperm Antibodies Following Testicular Biopsy in Boys with Cryptorchidism.
    Date November 2005
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Testicular biopsy (TBx) performed during orchiopexy in boys with cryptorchidism can help to predict future semen analyses and possibly identify patients at risk for testicular cancer. It has been theorized that TBx can be detrimental to the long-term health of the testis. We examined testicular microlithiasis (TM) and antisperm antibody (ASA) production in cryptorchid TBx. MATERIALS AND METHODS: A total of 112 males underwent fertility evaluation. These patients had previously undergone orchiopexy and bilateral TBx (mean age 8.6 years) for unilateral or bilateral undescended testis. At a mean age of 19.6 years all patients underwent physical examination and scrotal ultrasound for evaluation of testis size, echotexture and abnormalities. Of 112 patients 57 also underwent direct Immunobead(R) assay with positive controls. Moving sperm free and/or bound to IgG bead complex were counted in the preparation. RESULTS: A total of 29 patients had bilateral and 83 had unilateral undescended testis. Of the 112 patients 26 were black and 86 were white. Four black patients (15.4%) and 4 white patients (4.7%) had testicular microlithiasis. Three patients had bilateral and 5 had unilateral diffuse TM. No tunica albuginea scars or testis masses were noted. In the 57 patients who underwent direct Immunobead assay no semen sample demonstrated evidence of forming bead-sperm complex, ie none had direct ASA. CONCLUSIONS: No patient exhibited evidence of direct ASA. Prepubertal open TBx does not increase the rate of TM. We found no evidence of additive testicular damage associated with TBx at the time of orchiopexy.

    Title Gender Assignment in Female Congenital Adrenal Hyperplasia: a Difficult Experience.
    Date November 2005
    Journal The Journal of Urology
    Title Culture Clash Involving Intersex.
    Date November 2005
    Journal The Journal of Urology
    Title Urinary Levels of Interleukin-6 and Interleukin-8 in Children with Urinary Tract Infections to Age 2.
    Date November 2005
    Journal The Journal of Urology
    Title Overnight Catheter Drainage in Children with Poorly Compliant Bladders Improves Post-obstructive Diuresis and Urinary Incontinence.
    Date October 2005
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Overnight catheter drainage (OCD) has been suggested as a treatment for boys with valve bladder syndrome as well as those with polyuric renal failure. We report our experience using overnight catheter drainage in children with poorly compliant bladders. MATERIALS AND METHODS: Between 1999 and 2004 OCD was initiated in 6 boys and 5 girls (median age 7.5 years) with poorly compliant bladders in whom aggressive daytime intermittent catheterization and anticholinergic use had failed. Etiologies of bladder dysfunction included posterior urethral valves in 1 case, The Hinman-Allen syndrome in 4, myelomeningocele in 2, neuroblastoma in 1, prune-belly syndrome in 1, transverse myelitis in 1 and sacral agenesis in 1. The amount of post-obstructive diuresis was calculated during urodynamics as the volume drained minus volume instilled divided by weight per hour. Other parameters evaluated included serum creatinine, degree of upper tract dilatation, and episodes of urinary tract infection (UTI) and incontinence. RESULTS: Median duration of OCD and followup was 28 months, respectively. One patient did not tolerate overnight drainage. Of 9 patients who were incontinent before OCD daytime urinary incontinence resolved in 6 and improved in 3. Recurrent febrile UTIs in 3 children were eliminated. Despite no change in serum creatinine with overnight drainage, 7 of 8 patients (88%) with upper tract dilatation improved on followup ultrasound. CONCLUSIONS: In select children with poorly compliant bladders OCD reduces diuresis, reduces the frequency of UTIs, improves upper tract dilatation and improves continence. Overnight drainage in conjunction with daytime clean intermittent catheterization may prove to be an alternative to bladder augmentation in select children with poorly compliant bladders and early stages of renal compromise.

    Title Ballooning of the Foreskin and Physiological Phimosis: is There Any Objective Evidence of Obstructed Voiding?
    Date October 2005
    Journal The Journal of Urology
    Title Anterior Urethral Valves and Diverticula in Children: a Result of Ruptured Cowper's Duct Cyst?
    Date October 2005
    Journal The Journal of Urology
    Title Torsion of the Hernia Sac Within a Hydrocele of the Scrotum in a Child.
    Date October 2005
    Journal The Journal of Urology
    Title Laparoscopic Extravesical Reimplantation for Postpubertal Vesicoureteral Reflux.
    Date September 2005
    Journal The Journal of Urology
    Title Endopyelotomy in Childhood: Our Experience with 37 Patients.
    Date September 2005
    Journal The Journal of Urology
    Title Alarm Treatment is Successful in Children with Day- and Night-time Wetting.
    Date September 2005
    Journal The Journal of Urology
    Title Effect of Alarm Treatment on Bladder Storage Capacities in Monosymptomatic Nocturnal Enuresis.
    Date September 2005
    Journal The Journal of Urology
    Title Renal Transit Time with Mr Urography in Children.
    Date September 2005
    Journal The Journal of Urology
    Title Antenatal Diagnostic Aspects of Unilateral Multicystic Kidney Dysplasia--sensitivity, Specificity, Predictive Values, Differential Diagnoses, Associated Malformations and Consequences.
    Date September 2005
    Journal The Journal of Urology
    Title Pregnancy Outcomes After Abdominal Irradiation That Included or Excluded the Pelvis in Childhood Wilms Tumor Survivors: a Report from the National Wilms Tumor Study.
    Date September 2005
    Journal The Journal of Urology
    Title Transcription Factor Gata-6 is Expressed in Malignant Endoderm of Pediatric Yolk Sac Tumors and in Teratomas.
    Date September 2005
    Journal The Journal of Urology
    Title Outcome of Valve Ablation in Late-presenting Posterior Urethral Valves.
    Date June 2005
    Journal The Journal of Urology
    Title Modification of Meatal Advancement and Glanuloplasty for Correction of Distal Hypospadias.
    Date June 2005
    Journal The Journal of Urology
    Title Pelvic Fracture-associated Urethral Injuries in Girls: Experience with Primary Repair.
    Date June 2005
    Journal The Journal of Urology
    Title Oral Complications After Buccal Mucosal Graft Harvest for Urethroplasty.
    Date June 2005
    Journal The Journal of Urology
    Title Modified Tubularized Transverse Preputial Island Flap Repair for Severe Proximal Hypospadias.
    Date May 2005
    Journal Bju International
    Title Split Onlay Skin Flap for the Salvage Hypospadias Repair.
    Date May 2005
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Following failed hypospadias repair absence of the penile foreskin, a shortage of ventral skin and residual chordee may all contribute to poor long-term results. We describe a technique called the split onlay skin (SOS) flap that has improved our surgical outcomes in boys requiring salvage hypospadias repair. MATERIALS AND METHODS: The SOS flap uses a transverse island of penile shaft skin that is mobilized on its vascular pedicle and rotated into position to the ventrum of the penis at the site of the urethral defect. The flap is transected transversely, and half of the flap is used as an onlay to repair the urethra and the other half is used for additional skin coverage where needed on the penile shaft. We treated 11 boys 30 to 124 months old (mean age 60.3 months) who had a mean of 2 previous failed hypospadias repairs. All 11 boys presented with complex combinations of urethrocutaneous fistulas, stricture or urethral diverticula. RESULTS: Of the 11 patients 6 (54.5%) had development of postoperative fistulas. Five of these fistulas were surgically closed with no further complications. One penoscrotal fistula closed spontaneously after 7 months. Mild chordee from contraction of the flap and a urethral diverticulum developed in 1 boy. At a mean followup of 24.5 months all patients, including those who underwent closure of the secondary fistula, were voiding well with excellent appearance. CONCLUSIONS: In cases where little local tissue is present the SOS flap procedure is an excellent way to transfer healthy dorsal tissue to the ventrum for an onlay salvage urethroplasty while providing additional coverage of the urethral defect and a tension-free skin closure. Despite the high fistula rate we encountered following the initial SOS procedure, we endorse this technique because the transferred dartos provides additional tissue, which facilitates subsequent fistula repair. These boys can achieve a successful cosmetic result without incorporation of scrotal tissue or a free graft, which we believe leads to more predictable results.

    Title Prenatally Detected Primary Megaureter: a Role for Extended Followup.
    Date April 2005
    Journal The Journal of Urology
    Excerpt

    PURPOSE: A high rate of spontaneous resolution of or decrease in urinary tract dilatation is expected for most cases of primary megaureter (PM). We analyzed our results with extended long-term nonsurgical treatment in a group of children diagnosed with prenatally detected PM. We also sought to determine the long-term safety of this approach and the clinical significance of residual hydroureteronephrosis (HUN) when complete resolution does not occur. MATERIALS AND METHODS: We reviewed our experience with 40 infants with prenatally detected hydronephrosis diagnosed as PM who were initially treated nonoperatively between 1986 and 1999. Patients were followed with ultrasonography, nuclear renography and, in some instances, excretory urogram until stable improvement or complete resolution of HUN was noted. Records for patients who specifically returned for long-term followup history and radiological imaging were also reviewed. RESULTS: Of 40 patients with 57 megaureters (17 with bilateral PMs) who were followed 4 infants (10%) with severe HUN were diagnosed with diminished renal function by nuclear renography and underwent surgical repair. A total of 27 infants (67.5%, 40 megaureters) with PM who were followed without surgical intervention returned for followup examination and imaging for a minimum of 24 months after initial diagnosis, for a mean of 6.8 years (range 24 to 210 months). Ultrasonography in these patients revealed complete resolution (Society for Fetal Urology grade 1 or less hydronephrosis) in 21 megaureters (52.5%) at a mean of 2.9 years and improved or stable HUN in 19 megaureters (47.5%). Antibiotic prophylaxis was administered to 12 patients beyond the first month of life and discontinued at a mean age of 19.9 months. A subgroup of 10 patients (16 megaureters) from this cohort returned for extended followup imaging at a mean of 13.4 years (range 84 to 210 months) following initial diagnosis. Four patients with documented resolution of HUN had no recurrence during long-term followup. One male with bilateral PMs diagnosed at birth that had been stable but were not resolved at 8-year followup suffered significant worsening in the degree of HUN, diminished renal function on 1 side and a renal stone on the contralateral renal unit at 14-year followup, despite remaining asymptomatic. CONCLUSIONS: Long-term followup of children with prenatally diagnosed PM with mild to moderate hydronephrosis confirms a high incidence of resolution and improvement. As we have documented 1 case of worsening HUN at 14-year followup, we believe that ultrasonography should be periodically continued until the child reaches adulthood, at least in instances where complete resolution of HUN is not documented.

    Title Dmsa Study Performed During Febrile Urinary Tract Infection: A Predictor of Patient Outcome?
    Date April 2005
    Journal The Journal of Urology
    Title Ovarian Torsion: to Pex or Not to Pex? Case Report and Review of the Literature.
    Date April 2005
    Journal The Journal of Urology
    Title The Danger of Intraoperative Antegrade Cannulation of the Ureter in Infancy and Early Childhood.
    Date March 2005
    Journal The Journal of Urology
    Title Genital Sensation After Feminizing Genitoplasty for Congenital Adrenal Hyperplasia: a Pilot Study.
    Date March 2005
    Journal The Journal of Urology
    Title Rhabdomyosarcoma of the Bladder, Prostate or Vagina: the Role of Surgery.
    Date March 2005
    Journal The Journal of Urology
    Title Prenatal Diagnosis of Congenital Mesoblastic Nephroma Associated with Renal Hypertension in a Premature Child.
    Date March 2005
    Journal The Journal of Urology
    Title Encrusted Cystitis and Pyelitis in Children: an Unusual Condition with Potentially Severe Consequences.
    Date January 2005
    Journal The Journal of Urology
    Title High-grade Renal Injuries in Children--is Conservative Management Possible?
    Date January 2005
    Journal The Journal of Urology
    Title Fetal Cystoscopy in the Management of Fetal Obstructive Uropathy: Experience in a Single European Centre.
    Date January 2005
    Journal The Journal of Urology
    Title Giant Bladder Diverticula Causing Bladder Outlet Obstruction in Children.
    Date January 2005
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Congenital giant diverticulum of the bladder is a consequence of deficiency in the detrusor musculature and has been reported in male infants as a rare cause of bladder outlet obstruction. MATERIALS AND METHODS: A 10-year retrospective review revealed 4 patients (3 boys and 1 girl) with bladder outlet obstruction due to a giant bladder diverticulum. Prenatal and postnatal clinical and imaging records were reviewed. RESULTS: Prenatal sonography was unremarkable in all patients. Three males (ages 4 months, 10 months and 3 years) had no medical history of voiding dysfunction, and 1 female (11 years) had the Ehlers-Danlos syndrome. While the girl presented with urinary tract infection, all patients presented with progressively decreasing urinary stream and urinary retention. Each patient underwent voiding cystourethrography (VCUG) and ultrasound. In each patient VCUG showed a giant (greater than 7 cm) bladder diverticulum that descended below the bladder neck and compressed the urethra during voiding. Vesicoureteral reflux was seen in 2 patients. Ultrasonography demonstrated moderate unilateral hydronephrosis in 2 patients. Bladder diverticulectomy was successfully performed in all patients, with ureteral reimplantation in 3. CONCLUSIONS: A giant congenital bladder diverticulum, when noted on VCUG to descend below the bladder neck, may lead to bladder outlet obstruction. To our knowledge we report the first case of a female presenting with bladder outlet obstruction due to a giant bladder diverticulum. Children with connective tissue disorders may be predisposed to this disorder, which must be excluded, regardless of gender, in all patients presenting with voiding abnormalities. Surgical diverticulectomy, often with ureteral reimplantation, is the preferred treatment, with excellent long-term results.

    Title Unilateral Nephrectomy As Palliative Therapy in an Infant with Autosomal Recessive Polycystic Kidney Disease.
    Date January 2005
    Journal The Journal of Urology
    Excerpt

    Prenatal diagnosis of autosomal recessive polycystic kidney disease (ARPKD) implies a dire prognosis. Neonates affected by the more severe variants of ARPKD suffer respiratory failure caused by massive kidneys that restrict diaphragmatic expansion and result in pulmonary hypoplasia. Afflicted infants who survive the neonatal period and gain adequate respiratory function may subsequently suffer from an inability to tolerate enteral nutrition due to abdominal compression from the massive kidney and the systemic effects of renal compromise. Palliative unilateral or bilateral nephrectomy may be considered in rare instances to facilitate pulmonary expansion and gastrointestinal function. We report on an infant with severe ARPKD who was able to tolerate enteral nutrition only after left nephrectomy.

    Title The 2-stage Hypospadias Repair. Is It a Misnomer?
    Date November 2004
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The repair of penoscrotal or perineal hypospadias with severe chordee may require division of the urethral plate to facilitate repair. While a 2-stage approach to these difficult cases has been advocated, we have used a modified tubularized transverse preputial island flap (TPIF) repair as a 1-stage procedure. We compare our results with both procedures. MATERIALS AND METHODS: Between 1997 and 2001, 1 surgeon (DAC) performed 22 penoscrotal or scrotal hypospadias repairs that required transection of the urethral plate. A TPIF or planned 2-stage repair was done in 12 and 10 boys, respectively. The TPIF was modified by suturing the medial edge of the island flap along the length of the corpora recreating a urethral plate and then tubularizing a neourethra. The 2-stage approach consisted first of mobilizing skin to the ventrum of the penis followed 6 to 12 months later by a urethroplasty. At followup cosmetic and functional results were assessed. RESULTS: The TPIF and staged repair groups have been followed for a mean 24.5 and 43.5 months following the first repair, respectively. Of the 12 boys undergoing a TPIF 2 (16.7%) required a fistula repair or meatoplasty while 7 of 10 (70%) required at least 1 additional operation after the stage 2 urethroplasty (p <0.05). A mean of 1.6 additional repairs following the stage 2 urethroplasty was required. At last followup physical examination demonstrated a straight penis with distal meatus in 19 of 22 boys. Persistent complications include a concealed penis and recurrent fistula in 2 boys following a staged repair and glanular separation in 1 boy following TPIF. CONCLUSIONS: In our experience the staged approach to the repair of severe hypospadias requires significantly more cumulative surgical attempts than the modified TPIF. Indeed, in the majority of our cases the so-called "2-stage hypospadias repair" was a misnomer. The TPIF offers a reliable 1-stage repair. We prefer this approach to staged repairs even for severe hypospadias.

    Title A Male Murine Model of Partial Bladder Outlet Obstruction Reveals Changes in Detrusor Morphology, Contractility and Myosin Isoform Expression.
    Date November 2004
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Mice with gene deletion or targeted over expression are important for understanding the remodeling that follows partial bladder outlet obstruction (PBOO). This condition predominates in males. We produced PBOO in male mice and now report the physiological, histological and molecular consequences. MATERIALS AND METHODS: Male C57bl/6 mice were surgically obstructed or subjected to sham surgery and unoperated mice served as controls. Four weeks later the bladders were excised and their function was assessed with in vitro whole bladder cystometry. The optimum volume for pressure generation was determined and isometric pressures were measured for field stimulation and depolarization with KCl. Bladder hypertrophy was classified as severe-bladder mass greater than 50 mg or mild-bladder mass less than 50 mg. The percent muscle fraction was determined by histological analyses. The expression of C-terminal (SM1 and SM2) and N-terminal (SM-B and SM-A) isoforms of myosin heavy chain was analyzed by reverse transcriptase-polymerase chain reaction. RESULTS: Severely hypertrophied bladders had larger optimum volume (p >0.001) and generated less pressure in response to field stimulation (p >0.001) and KCl (p >0.01) with a slower rate of pressure generation than controls or sham operated mice. Increased SM1-to-SM2 and SM-A-to-SM-B ratios were noted in severely obstructed bladders relative to controls or sham operated mice (p <0.05). The muscle fraction decreased slightly in the severely hypertrophied group (p not significant). CONCLUSIONS: Our male mouse model of PBOO demonstrates an increase in bladder mass, larger capacity and significantly decreased pressure generation in the in vitro whole bladder model. Obstruction induced increases in the expression of C-terminal (SM1) and N-terminal (SM-A) myosin heavy chain isoforms.

    Title Blunt Renal Injuries in Children Can Be Managed Nonoperatively: Outcome in a Consecutive Series of Patients.
    Date October 2004
    Journal The Journal of Trauma
    Excerpt

    BACKGROUND: Nonoperative management of radiographically defined solid organ injuries has proven highly successful in children with blunt splenic and hepatic injuries. The role of nonoperative management protocols is less well defined for blunt renal injuries. The purpose of this study was to review the management and outcome of a consecutive series of children with blunt renal injury. METHODS: The trauma registry from a Level I pediatric trauma center was reviewed to identify all children (age < 19 years) who were treated for a blunt renal injury for the period January 1995 through December 2002. Demographic, anatomic, physiologic, management, and outcome data were analyzed. RESULTS: For the 8 years of review, 101 children with a blunt renal injury were identified, including 95 with accessible and complete data. The renal injury population had a mean age of 10.4 years (range, 0.5-18 years) and was 72.6% male. The renal injuries were distributed as follows: grade 1, n = 22; grade 2, n = 40; grade 3, n = 20; grade 4, n = 11; and grade 5, n = 2. Hematuria was present in 88.1% of children (in whom urinalysis results were available). Four children had underlying congenital renal anomalies. The mean hospital length of stay and intensive care unit stay were 6.0 and 2.6 days, respectively. Overall, 5 children (5.3%) required laparotomy, including 1 nephrectomy (isolated grade 4 injury) and 1 renorrhaphy, for an overall renal salvage rate of 98.9%. In children with isolated renal injuries (n = 48), one child (2.1%) required laparotomy. Seven children required adjunctive urologic procedures (ureteral stenting, n = 5; cystoscopy/cystogram, n = 2). There were seven deaths (7.4% overall; five because of head injury and two because of severe abdominal bleeding at presentation). CONCLUSION: A nonoperative management strategy was advantageous and successful in pediatric blunt renal injuries (94.7% successful nonoperative rate, 98.9% renal salvage rate). Adjunctive urologic procedures (e.g., ureteral stenting) were beneficial in selected cases.

    Title Initial Management of Complex Urological Disorders: Bladder Exstrophy.
    Date October 2004
    Journal The Urologic Clinics of North America
    Excerpt

    Bladder exstrophy is a rare condition associated with lifelong issues including infection,renal insufficiency, incontinence, and fertility. Despite its seriousness, many affected children lead normal lives. With new operative techniques, children require fewer surgeries and have more hope for continence.With close follow-up, no child should develop renal insufficiency. Families should be reassured that a normal life and parenthood with normal sexual function are possible.

    Title Hypospadias.
    Date October 2004
    Journal The Urologic Clinics of North America
    Excerpt

    Hypospadias results from abnormal development of the penis that leaves the urethral meatus proximal to its normal glanular position anywhere along the penile shaft,scrotum, or perineum. Hypospadiology is an evolving and expanding discipline that remains at the forefront of pediatric surgical innovation. Although modern experiments have begun to yield a deeper understanding of the genetic, hormonal, and environmental basis of hypospadias, the quest for a surgical procedure that consistently results in a straight penis with a normally placed glanular meatus has challenged surgeons for over two centuries. This article focuses on the advances in the understanding of the etiology of hypospadias and the current approaches to the correction of hypospadias.

    Title Murine in Vitro Whole Bladder Model: a Method for Assessing Phenotypic Responses to Pharmacologic Stimuli and Hypoxia.
    Date August 2004
    Journal Neurourology and Urodynamics
    Excerpt

    AIMS: Recent advances in genetic manipulation have allowed for over expression or deletion of selective genes in mice. This offers urologic investigators new means of understanding bladder function in the context of normal development or the response to outlet obstruction. It is important to correlate any genetic manipulations in mice with specific phenotypic properties such as voiding patterns, or muscle strip physiology. We describe a simple in vivo whole bladder preparation that may be used to study the phenotypic changes in bladder function. METHODS: Murine bladders were mounted on a 30 gauge needle and mounted in an organ chamber containing a physiologic buffer solution. Passive bladder properties were assessed with cystometry, and active contractile responses were measured in response to electrical field stimulation and agonists. The effects of hypoxia were also studied. RESULTS: Compliance in the murine bladder is dependent upon actin myosin interactions, and increased in the presence of calcium free buffer and EGTA. The sarcoplasmic reticulum plays a smaller role in the contraction of murine bladder than in other species. Murine bladder smooth muscle demonstrated a remarkable ability to withstand hypoxia. CONCLUSIONS: This simple model can be adapted to help study the murine bladder smooth muscle phenotype under highly controlled circumstances.

    Title Successful Treatment of Encrusted Cystitis and Pyelitis with Preservation of Renal Graft.
    Date August 2004
    Journal Transplantation
    Title The Neonatal Vanishing Kidney: Congenital and Vascular Etiologies.
    Date August 2004
    Journal The Journal of Urology
    Title The Fate of Urinary Bladder Smooth Muscle After Outlet Obstruction--a Role for the Sarcoplasmic Reticulum.
    Date June 2004
    Journal Advances in Experimental Medicine and Biology
    Title Murine in Vitro Whole Bladder Physiology.
    Date May 2004
    Journal Advances in Experimental Medicine and Biology
    Title Juvenile Granulosa Cell Tumor of the Testis:: Contemporary Clinical Management and Pathological Diagnosis.
    Date May 2004
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Juvenile granulosa cell tumor (JGCT) of the testis is a rarely diagnosed subset of testicular stromal tumors. Although this variant of testicular stromal tumor is predominantly a benign entity in prepubertal patients, limited experience precludes a complete understanding of its clinical presentation and pathological diagnosis. MATERIALS AND METHODS: We reviewed all cases of testicular tumors at Children's Hospital of Philadelphia between 1976 and 2002 in males younger than 18 years. We specifically reviewed our experience with JGCT in terms of presentation, surgical treatment and long-term outcome. We also reviewed the microscopic findings and histochemical techniques used to confirm the diagnosis. RESULTS: We identified 77 tumors during the defined interval, of which 3 (3.9%) were JGCTs. All 3 patients with JGCT were first noted to have a testis mass soon after birth. All presented with a firm, unilateral testicular mass. Ultrasonographic findings were consistent with a complex, multiseptated, hypoechoic mass. Two of the 3 patients underwent radical orchiectomy. Testis sparing mass excision was performed in 1 patient. Grossly the tumors were partially cystic masses. Histologically positive immunostaining with inhibin-alpha and negative staining for alpha-fetoprotein (AFP) reliably differentiated JGCTs from yolk sac tumors. At a mean followup of 8.5 years (range 5 to 14) no metastases or local tumor recurrences have been diagnosed. CONCLUSIONS: To our knowledge we report the first case of testis sparing enucleation of a JGCT with a 5-year recurrence-free followup. Testis sparing enucleation is now our procedure of choice for tumors in neonates and prepubertal children with serum AFP in the normal range for age. JGCT should be suspected in neonates presenting at birth with a complex, cystic mass of the testis. Positive immunostaining for inhibin-alpha and a lack of AFP staining have consistently corroborated the pathological diagnosis in our experience and they should be applied for pediatric testis tumors that may mimic yolk sac tumor pathology.

    Title Prevalence of and Risk Factors for Hydrocele in Survivors of Wilms Tumor.
    Date April 2004
    Journal Pediatric Blood & Cancer
    Excerpt

    BACKGROUND: The purpose of this study is to evaluate the prevalence of hydrocele as a complication of Wilms tumor (WT) therapy and nephrectomy and to determine whether radiation therapy to the flank increases the risk. We hypothesize that radiation increases the risk of hydrocele formation in patients treated for WT. METHODS: A retrospective, medical review of the chart was completed on 57 male patients with WT diagnosed between 1985 and 2000. RESULTS: There is an increased prevalence of hydrocele in males that had a nephrectomy as part of their WT therapy. CONCLUSIONS: Male survivors of WT are at risk for development of a subsequent hydrocele that appears to be related to their prior surgery.

    Title Experience with Testis Sparing Surgery for Testicular Teratoma.
    Date January 2004
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Testicular teratoma is a rare neoplasm affecting the pediatric population and has classically been reported to be the second most common testis tumor in children behind yolk sac tumors. Testicular teratomas are benign and partial orchiectomy may be considered. We describe our single institution experience with testicular teratoma and definitive treatment with testis preserving surgery. MATERIALS AND METHODS: We reviewed the pathology records at our institution for all testicular and paratesticular tumors diagnosed between 1976 and November 2002 in males younger than 18 years. We specifically examined the prepubertal incidence of teratoma, including epidermoid cysts, and our experience with testis preserving surgery. Preoperative and postoperative ultrasonography images were used to calculate the atrophy index following surgery. Patients were contacted for long-term followup. RESULTS: Of 77 primary testicular and paratesticular tumors 38 were diagnosed in prepubertal boys (age younger than 13 years) including 11 mature teratomas and 5 epidermoid cysts. Mean patient age at treatment was 34.4 months (range 4 months to 10 years). All boys presented with a painless scrotal mass, cystic foci within an intratesticular mass on ultrasound and a normal alpha-fetoprotein level. Of the 16 boys with benign teratomas 13 (81%) were treated with a testis sparing procedure. At a mean 7-year followup no patient has presented with recurrent tumor in the ipsilateral or contralateral testicle. Postoperative physical examination and scrotal ultrasound were obtained in 9 patients at a median followup of 10.2 months, and there was no evidence of testicular atrophy or persistent discomfort. CONCLUSIONS: Unlike previously published series based on tumor registries, benign teratoma was the most common pediatric testicular tumor treated at our institution. Our single institution experience with testis preservation and long-term followup confirms the role and safety of this technique. Testis sparing surgery remains our technique of choice for testicular teratoma.

    Title Functioning Adrenocortical Neoplasms in Children.
    Date November 2003
    Journal The Journal of Urology
    Title Blunt Renal Trauma-blessing in Disguise?
    Date November 2003
    Journal The Journal of Urology
    Title Management of Failed Primary Intervention for Ureteropelvic Junction Obstruction: 12-year, Single-center Experience.
    Date November 2003
    Journal The Journal of Urology
    Title Outcome at 10 Years of Severe Vesicoureteric Reflux Managed Medically: Report of the International Reflux Study in Children.
    Date November 2003
    Journal The Journal of Urology
    Title Medical Versus Surgical Treatment in Children with Severe Bilateral Vesicoureteric Reflux and Bilateral Nephropathy: a Randomised Trial.
    Date November 2003
    Journal The Journal of Urology
    Title Cystometric Evaluation of Reconstructed Classical Bladder Exstrophy.
    Date November 2003
    Journal The Journal of Urology
    Title Efficacy and Optimal Dose of Daily Polyethylene Glycol 3350 for Treatment of Constipation and Encopresis in Children.
    Date November 2003
    Journal The Journal of Urology
    Title Management of Recurrent Urethral Fistulas After Hypospadias Repair.
    Date November 2003
    Journal The Journal of Urology
    Title Percutaneous Embolization of Varicocele in Children: A Canadian Experience.
    Date November 2003
    Journal The Journal of Urology
    Title Management of Urethrocutaneous Fistula After Hypospadias Repair: 10 Years' Experience.
    Date November 2003
    Journal The Journal of Urology
    Title Infant Vesicoureteral Reflux: a Comparison Between Patients Presenting with a Prenatal Diagnosis and Those Presenting with a Urinary Tract Infection.
    Date November 2003
    Journal The Journal of Urology
    Title Ureteral Stenting in the Management of Urinoma After Severe Blunt Renal Trauma in Children.
    Date September 2003
    Journal Journal of Pediatric Surgery
    Excerpt

    Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.

    Title The Chop Experience with Cloacal Exstrophy and Gender Reassignment.
    Date August 2003
    Journal Advances in Experimental Medicine and Biology
    Title The Cost-effectiveness of Endoscopic Injection of Dextranomer/hyaluronic Acid Copolymer for Vesicoureteral Reflux.
    Date April 2003
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Vesicoureteral reflux is a risk factor for progressive renal damage associated with urinary tract infection. Mild to moderate reflux is routinely treated with long-term antibiotic prophylaxis to prevent recurrent infections and open surgical reimplantation for breakthrough infections despite antibiotic therapy. Endoscopic subureteral injection of implant material is a therapeutic alternative to long-term prophylaxis and open surgery but its widespread use in the United States has been prevented by the lack of a stable implant material. Dextranomer/hyaluronic acid copolymer has been shown to be a safe, effective and durable implant material and was recently approved in the United States. We estimate the effect on costs and cure rates of introducing endoscopic injection with dextranomer/hyaluronic acid copolymer as a treatment alternative in the United States. MATERIALS AND METHODS: We constructed a model that mimics current clinical practice of vesicoureteral reflux treatment for 6 years, and incorporates spontaneous resolution and surgical intervention rates obtained from 2 long-term followup studies. The treatment algorithm was established using medical data from the literature, and clinical management practices from a Delphi survey of 27 pediatric urologists and nephrologists across the United States. Endoscopic injection was introduced into the model as replacement to surgery or alternative to long-term antibiotic prophylaxis. The effectiveness of dextranomer/hyaluronic acid copolymer was calculated from 140 patients (208 ureters) with grade III reflux treated in a clinical study of 221 children in Sweden. RESULTS: With current practice, the average cost per patient in 6 years was 6,640 US dollars and 23.5% of patients continued to have reflux. Replacing open surgery with endoscopic injection led to similar cure rates (22.2% failures) but costs were reduced to 5,522 US dollars. When injection was performed after 1 year of antibiotic therapy failure rates were reduced to 8.5% but costs increased to 7,644 US dollars. CONCLUSIONS: Our results show that a persistent approach to endoscopic surgery can be expected to result in overall success that equals or exceeds open surgery at a lower cost. This finding is particularly true if open reimplant is reserved for patients with high grade or persistent vesicoureteral reflux.

    Title Results of Systematic Voiding Cystourethrography in Infants with Antenatally Diagnosed Pelvis Dilation.
    Date April 2003
    Journal The Journal of Urology
    Title Exstrophy of the Cloaca and Exstrophy of the Bladder: Two Different Expressions of a Primary Development Field Defect.
    Date April 2003
    Journal The Journal of Urology
    Title Is an Artificial Sphincter the Best Choice for Incontinent Boys with Spina Bifida? Review of Our Long Term Experience with the As-800 Artificial Sphincter.
    Date April 2003
    Journal The Journal of Urology
    Title High-pressure Bladder: an Underlying Factor Mediating Renal Damage in the Absence of Reflux?
    Date April 2003
    Journal The Journal of Urology
    Title Detrusor Myotomy: a 5-year Review in Unstable and Non-compliant Bladders.
    Date April 2003
    Journal The Journal of Urology
    Title A Long-term Follow-up of Autoaugmentation in Myelodysplastic Children.
    Date April 2003
    Journal The Journal of Urology
    Title The Outcome of Voiding Dysfunction Managed with Clean Intermittent Catheterization in Neurologically and Anatomically Normal Children.
    Date April 2003
    Journal The Journal of Urology
    Title Cremasteric Reflex and Retraction of a Testis.
    Date April 2003
    Journal The Journal of Urology
    Title 46,xy Intersex Individuals: Phenotypic and Etiologic Classification, Knowledge of Condition, and Satisfaction with Knowledge in Adulthood.
    Date April 2003
    Journal The Journal of Urology
    Title Ambiguous Genitalia with Perineoscrotal Hypospadias in 46,xy Individuals: Long-term Medical, Surgical, and Psychosexual Outcome.
    Date April 2003
    Journal The Journal of Urology
    Title Medical Photography: Ethics, Consent and Intersex Patient.
    Date April 2003
    Journal The Journal of Urology
    Title Spontaneous Regression of Cystic Dysplasia of the Testis.
    Date February 2003
    Journal The Journal of Urology
    Title Testis Histopathology in Boys with Cryptorchidism Correlates with Future Fertility Potential.
    Date February 2003
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We studied the ability of testis biopsy to predict eventual fertility potential. MATERIALS AND METHODS: A total of 25 patients with unilateral undescended testis and 11 with bilateral undescended testes who previously underwent orchiopexy at a median age of 9 years were followed until after age 18 years. Semen analysis, testicular volume, follicle-stimulating hormone, luteinizing hormone, testosterone and inhibin B were compared to previously obtained biopsies of each testis. Biopsies were graded as mild, moderate or severe histology based on published data for normal and undescended testis histology. RESULTS: Patients with unilateral undescended testis and moderate histology were more likely to have a sperm density of greater than 20 million per cc than those with severe histology (p = 0.006), although no difference in hormonal parameters was noted. Patients with bilateral undescended testes and moderate histology were more likely to have normal follicle-stimulating hormone and inhibin B than those with severe histology (p = 0.05 and 0.002, respectively), although no difference in semen analysis was observed. Overall 7 of the 9 patients with bilateral undescended testes had less than 20 million sperm per cc. CONCLUSIONS: Testis biopsy provides useful prognostic information about semen analysis in patients with unilateral undescended testis. In the 9 patients with bilateral undescended testes testis biopsy divided them into normal and abnormal groups in terms of hormonal parameters. Testis biopsy was not able to provide additional prognostic information on semen analysis in patients with bilateral undescended testes since they were uniformly poor.

    Title Magnetic Resonance Imaging of Fetal Urinoma.
    Date January 2003
    Journal Urology
    Excerpt

    Extrarenal collections of urine have long been associated with obstructive uropathy and may preserve renal function by acting as a "popoff" valve. Although urinary extravasation manifested as urinary ascites carries a favorable prognosis, perinephric urinomas occurring prenatally are associated with poor renal function in most cases. We report the case of a baby girl with a urinoma diagnosed by fetal magnetic resonance imaging and discuss the significance of this radiologic finding.

    Title Genitourinary Malformations in Chromosome 22q11.2 Deletion.
    Date December 2002
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We reviewed our experience with genitourinary malformations associated with chromosome 22q11.2 deletion. MATERIALS AND METHODS: We retrospectively reviewed patient intake charts at the 22q clinic at our institution. We assessed 73 renal/bladder ultrasounds and 7 autopsies performed between 1998 and 2000 for renal and bladder malformations. A total of 149 male patients were evaluated for possible testicular and urethral malformations. RESULTS: Of 80 patients 25 (31%) had a structural urinary tract anomaly. Another 8 patients had renal agenesis or multicystic dysplastic kidney, 4 had hydronephrosis and 5 had vesicoureteral reflux or an irregular bladder, while 8 of 73 (11%) had dysfunctional voiding, 9 of 149 (6%) had undescended testes and 12 of 149 (8%) had hypospadias. CONCLUSIONS: Screening renal/bladder ultrasound, careful voiding history and medical but not surgical therapy are recommended for renal and bladder anomalies associated with 22q11.2 deletion. The need for surgery for cryptorchidism and hypospadias is slightly higher than in the general population.

    Title The Ascending Testis and the Testis Undescended Since Birth Share the Same Histopathology.
    Date December 2002
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The etiology of the ascending testis is controversial. We propose that ascending testis, defined as a testis previously thought to be descended and later noted to be out of the scrotum, is due to mild hypogonadotropic hypogonadism affecting both testes. The diagnosis of these low types of true undescended testes is difficult to make clinically in children since they are frequently confused with retractile testes. In this study we compared testicular biopsies in a group of boys with ascending testes with those in boys who had an undescended testis since birth (primary undescended testis). MATERIALS AND METHODS: Between 1985 and 1995, 91 patients with ascending testes underwent orchiopexy and bilateral testis biopsy. The total germ cell count, processus vaginalis status, age at surgery and whether followup was done by a pediatrician or pediatric urologist were compared in patients with ascending and unilateral primary undescended testes. RESULTS: The total germ cell count was similar in the undescended and the contralateral descended testis in patients with ascending and primary undescended testes. The processus vaginalis was more likely to be closed in ascending testes (57% versus 36%, p = 0.0001). Age at surgery and the total germ cell count were similar in patients followed by pediatricians and pediatric urologists. CONCLUSIONS: The ascending testis has the same germ cell count as the primary undescended testis. Yearly followup by the primary care physician is recommended for patients with retractile testes.

    Title Spontaneous Resolution of Vesicoureteral Reflux: a 15-year Perspective.
    Date December 2002
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The spontaneous resolution rate of vesicoureteral reflux is helpful for determining the need for surgical intervention and the proper followup schedule in patients on antibiotic prophylaxis. We determined the resolution rate by patient rather than by ureter and analyzed the effects of laterality, gender, age and dysfunctional voiding. MATERIALS AND METHODS: We retrospectively reviewed the records of 179 girls and 35 boys who presented between 1981 and 1984 with urinary tract infection and were diagnosed with primary vesicoureteral reflux. Mean age at presentation was 4.2 years and median followup was 3 years. Of the patients 107 (50%) had bilateral reflux and 60 had dysfunctional voiding. In 146 children (68%) reflux spontaneously resolved during the study. Patients were categorized by the worst grade of reflux, maintained on antibiotic prophylaxis and underwent voiding cystourethrography yearly until reflux resolved. Kaplan-Meier curves were constructed to define the resolution rate. RESULTS: Grades I to III reflux resolved at 13% yearly during the initial 5 years of followup and then at 3.5% yearly during subsequent followup. Grade IV to V reflux resolved at 5% rate yearly. Bilateral reflux resolved more slowly than unilateral reflux and it resolved more rapidly in boys than in girls. Untreated dysfunctional voiding had no effect on overall resolution. CONCLUSIONS: Grades I to III primary vesicoureteral reflux diagnosed after urinary tract infection resolve at identical rates and significantly more rapidly than grades IV to V. Early repair of grade IV to V reflux should be considered after age 18 months.

    Title Is Postoperative Cystography Necessary After Ureteral Reimplantation?
    Date October 2002
    Journal The Journal of Urology
    Title Hose: an Objective Scoring System for Evaluating the Result of Hypospadias Surgery.
    Date October 2002
    Journal The Journal of Urology
    Title Determinants of Continence in the Bladder Exstrophy Population: Predictors of Success?
    Date October 2002
    Journal The Journal of Urology
    Title Evaluation of Bony Pelvis in Classic Bladder Exstrophy by Using 3d-ct: Further Insights.
    Date October 2002
    Journal The Journal of Urology
    Title Modified Young-dees-leadbetter Bladder Neck Reconstruction: New Concepts About Old Ideas.
    Date October 2002
    Journal The Journal of Urology
    Title Is the Vanished Testis Always a Scrotal Event?
    Date October 2002
    Journal The Journal of Urology
    Title Changes in the Toilet Training of Children During the Last 60 Years: the Cause of an Increase in Lower Urinary Tract Dysfunction?
    Date October 2002
    Journal The Journal of Urology
    Title A Prospective Controlled Study of Karotyping for 430 Consecutive Babies Conceived Through Intracytoplasmic Sperm Injection.
    Date October 2002
    Journal The Journal of Urology
    Title Informed Consent for Neonatal Circumcision: an Ethical and Legal Conundrum.
    Date October 2002
    Journal The Journal of Urology
    Title The Use of Vesicostomy As Permanent Urinary Diversion in the Child with Myelomeningocele.
    Date December 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Treatment of the child with myelomeningocele presents the urologist with many challenges. While vesicostomies are usually used for temporary bladder drainage until continent reconstruction is performed, we have a population of postpubertal patients with myelomeningocele in whom vesicostomies have been preserved. We review our experience with these older children. MATERIALS AND METHODS: A search of our database of 350 patients with myelodysplasia identified 23 with urinary diversion accomplished by permanent vesicostomy. Those who had undergone vesicostomy after age 11 years were designated as group 1. Those who received a vesicostomy early in life that was maintained post puberty were designated as group 2. Indications for vesicostomy, upper tract status before and after vesicostomy, recurrent infections and complications were noted. Upper tract status was determined by serial ultrasounds during routine followup. RESULTS: Group 1 was comprised of 5 patients with mean age at vesicostomy of 17 years and a mean followup interval of 5.2 years. Group 2 was comprised of 18 patients with mean age of vesicostomy at 2.6 years and mean followup interval of 13 years. Hydronephrosis resolved in all children from both groups. Vesicostomy revision was required in 1 patient secondary to prolapse. Other complications included mild prolapse that did not require revision, stenosis requiring revision 5 months after the initial procedure and an early bilateral ureterovesical obstruction that resolved. Of the patients 33% had recurrent upper tract calculi. CONCLUSIONS: While the goal of achieving urinary continence is well worth striving for in the child with myelomeningocele, it is not realistic for all patients. We believe that permanent cutaneous vesicostomy is an acceptable alternative that the reconstructive surgeon should consider. This reliable and simple technique ensures safe decompression of the upper urinary tracts, while avoiding the complications of urinary diversion using segments of bowel.

    Title Vesicoamniotic Shunt in a Female Fetus with the Prune Belly Syndrome.
    Date December 2001
    Journal The Journal of Urology
    Title Buccal Mucosal Grafts: Lessons Learned from an 8-year Experience.
    Date December 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We evaluated our 8-year experience with buccal mucosal grafts in complex hypospadias and epispadias repair. MATERIALS AND METHODS: We reviewed the records of 29 patients in whom a total of 30 buccal mucosal grafts were placed as part of urethral reconstruction between 1991 and 1999. At surgery 16 tubes and 14 onlays were constructed and 24 of 30 repairs involved the meatus. All patients were followed at least 6 months postoperatively (median 5.3 years). Beginning in 1995 meatal design was enlarged to a racquet handle shape and patients were asked to perform meatal self-dilation for 6 months postoperatively. RESULTS: Complications developed in 17 of our 30 cases (57%) and reoperation was done in 10 (33%). All complications were evident by 11 months postoperatively except 1 that presented as recurrent stricture disease at 3 years. Complications developed in 5 and 12 of 15 patients who underwent surgery between 1995 and 1999, and before 1995, respectively (p = 0.027). No patient has had meatal stenosis since 1995. Complications included meatal stenosis in 5 cases, stricture in 7, glanuloplasty, meatal and complete graft breakdown in 1 each, and fistula in 2. Onlays were more likely to result in stricture than tube grafts (6 of 14 cases versus 1 of 16, p = 0.034). CONCLUSIONS: The complication and reoperation rates of buccal mucosal grafts are 57% and 33% at 5 years of followup. Changes in meatal design and temporary postoperative meatal dilation have improved the outcome in the last 5 years. Buccal mucosa remains a good choice in patients who require extragenital skin for urethral reconstruction.

    Title Abnormal Germ Cell Development in Cryptorchidism.
    Date September 2001
    Journal Hormone Research
    Excerpt

    BACKGROUND: Previous studies suggest that two fundamental, probably androgen-dependent, steps in maturation of germ cells normally occur in the prepubertal testis: the disappearance of gonocytes (the fetal stem cell pool) and the appearance of adult dark spermatogonia (the adult stem cell pool) at 2-3 months of age and the appearance of primary spermatocytes (the onset of meiosis) at 4-5 years. Previous studies of small series of cryptorchid boys suggest that both steps are defective in undescended testes and to a lesser degree in descended testes contralateral to unilaterally undescended testes. The purpose of this study is to confirm the previous findings of defective germ cell maturation in a large series of boys with unilateral undescended testes. PATIENTS: Seven hundred and sixty-seven boys with unilateral cryptorchidism who had orchidopexy and bilateral testicular biopsies between birth and 9 years of age were studied. MATERIALS AND METHODS: Total and differential germ cell counts were performed on semithin histologic sections of the biopsies. The results from the undescended and contralateral descended testes were compared using the Wilcoxon signed-rank test and the Wilcoxon-Whitney-Mann U test. RESULTS: Gonocytes failed to disappear and adult dark spermatogonia failed to appear in undescended testes under 1 year of age indicating a defect in the first step in maturation at 2-3 months resulting in failure to establish an adequate adult stem cell pool. Primary spermatocytes failed to appear in undescended testes and appeared in only 19% of contralateral descended testes at 4-5 years of age indicating a defect in the onset of meiosis. CONCLUSION: Unilaterally undescended testes fail to establish an adequate adult stem cell pool which normally occurs at 2-3 months of age and fail to establish adequate meiosis which normally occurs at 4-5 years of age. Similar but less severe changes are seen in the contralateral descended testes. Defects in the two pubertal steps in germ cell maturation are associated with reduced total germ cell counts.

    Title Hormonal Therapy for the Subfertility of Cryptorchidism.
    Date September 2001
    Journal Hormone Research
    Excerpt

    BACKGROUND: The subfertility of cryptorchidism correlates with severely reduced total germ cell counts in prepubertal testicular biopsies of undescended testes. Reduced total germ cell counts are associated with defects in the two prepubertal steps in maturation and proliferation in germ cells: first, the transformation of the fetal stem cell pool (gonocytes) into the adult stem cell pool (adult dark spermatogonia) at two to three months of age and, second, the transformation of adult dark spermatogonia into primary spermatocytes (meiosis) at 4-5 years. The defects in maturation are associated with blunting of the normal surges in gonadotropins and testosterone. Prepubertal treatment with gonadotropin-releasing hormones would theoretically trigger normal germ cell maturation and proliferation and thereby improve total germ cell counts and improve fertility. Prepubertal treatment of cryptorchidism with the GnRH analogue Buserelin has resulted in improved total germ cell counts and improved spermiograms. The purpose of this report is to describe the results of treatment of cryptorchidism with the GnRH analogue Naferelin. PATIENTS: Twelve boys with cryptorchidism, 6 unilateral and 6 bilateral, and severely reduced germ cell counts in testicular biopsies were treated with Naferelin following successful orchidopexy and bilateral testicular biopsies. Response of the total germ cell counts was assessed in follow-up bilateral biopsies within 5 months of completing the hormonal therapy. RESULTS: Eight of the 12 boys (5 of the 6 with unilateral and 3 of the 6 with bilateral cryptorchidism) showed improvement in the total germ cell counts in one or both testes. All 8 had a poor prognosis for fertility pretreatment and a good prognosis for fertility posttreatment. Of the 5 with unilateral cryptorchidism who improved, 2 showed improvement in both testes; and 3, only in the contralateral descended testes. All 3 of the boys with bilateral cryptorchidism who improved showed improvement in both testes. Testes with absence of germ cells and older patients tended to show no improvement. Of the 6 contralateral descended, 5 (83%) improved, and of the 18 undescended testes, 8 (44%) improved. CONCLUSIONS: In this preliminary study, Naferelin therapy appears to induce improvement in the total germ cell counts and the prognosis for future fertility in 75% of patients.

    Title Constipation As a Cause of Scrotal Pain in Children.
    Date August 2001
    Journal The American Journal of Emergency Medicine
    Excerpt

    Six boys with scrotal pain and constipation were seen at our hospital within the past 5 years. All boys had no clinical findings of structural or infectious derangements, and experienced relief of testicular symptoms after evacuation of the fecal mass. The association between constipation and scrotal pain has not been previously reported, and may represent direct neural stimulation or chronic inflammation of testicular structures in patients with dysfunctional voiding. Recognition of the association between constipation and subacute or chronic scrotal pain can guide the clinician towards appropriate therapy for these patients.

    Title Gonadal and Sexual Function in Men Treated for Childhood Cancer.
    Date August 2001
    Journal The Journal of Urology
    Title The Decompensated Detrusor V: Molecular Correlates of Bladder Function After Reversal of Experimental Outlet Obstruction.
    Date August 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Calcium ion homeostasis has a significant role in smooth muscle function. Its regulation requires complex storage and release mechanisms via ion pumps and channels located within intracellular storage sites (sarcoplasmic reticulum) and at the plasma membrane. We have previously reported a dramatic loss of the 2 major sarcoplasmic reticulum proteins sarcoplasmic endoplasmic reticulum calcium magnesium adenosine triphosphatase (SERCA2) and the ryanodine sensitive ion channel, also called the ryanodine receptor, after outlet obstruction. In our current study we investigated the correlation of the expression of these 2 major sarcoplasmic reticulum components with bladder function recovery after the reversal of outlet obstruction. METHODS AND METHODS: Standard partial bladder outlet obstruction was created in adult New Zealand White rabbits. Voiding patterns were monitored 2 and 4 weeks postoperatively, and rabbits were selected for outlet obstruction reversal based on a voiding pattern consistent with a decompensated state, as indicated by a frequency of greater than 30 voids daily and an average voided volume of less than 4 cc. Bladder biopsy was done when outlet obstruction was reversed. Voiding performance was monitored postoperatively and the animals were sacrificed 2 weeks later. Voiding patterns and muscle strip studies enabled us to define 2 functional outcome categories after reversal, namely normal versus minimally improved. Microsomal membrane protein fractions were prepared from the same bladder tissues before and after reversal, and probed by Western blot analysis for SERCA2 and ryanodine receptor expression. RESULTS: Western blot analysis revealed a major loss of SERCA2 and ryanodine receptor expression at the time of reversal and biopsy. In 65% of bladders obstruction reversal resulted in a normalized voiding pattern with a recovery of ryanodine receptor expression that was 15% to 65% of control values. In contrast, in the 35% of bladders with persistent voiding symptoms there was minimal recovery of ryanodine receptor expression. SERCA2 expression increased slightly in each group after reversal but did not differ in bladders with normalized versus improved function. CONCLUSIONS: Bladder decompensation is highly associated with a loss of sarcoplasmic reticulum function. Furthermore, the decompensated detrusor recovers function after obstruction reversal, which is associated with the recovery of these sarcoplasmic reticulum components.

    Title The Decompensated Detrusor Iv: Experimental Bladder Outlet Obstruction and Its Functional Correlation to the Expression of the Ryanodine and Voltage Operated Calcium Channels.
    Date June 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Calcium ion homeostasis has a significant role in smooth muscle function. Its regulation requires complex storage and release mechanisms via ion pumps and channels located within intracellular storage sites (sarcoplasmic reticulum) and at the plasma membrane. A prominent component of the sarcoplasmic reticulum is the ryanodine sensitive ion channel which releases calcium from the sarcoplasmic reticulum into the cytosol. At the level of the plasma membrane the voltage operated calcium channel (dihydropyridine sensitive) serves to allow an influx of extracellular calcium. Our prior studies have shown a loss of sarcoplasmic endoplasmic reticulum Ca++Mg++ATPase expression following outlet obstruction. In this study we correlate ryanodine and voltage operated calcium channel protein expression with bladder function following partial outlet obstruction. MATERIALS AND METHODS: Standardized partial bladder outlet obstructions were created in adult New Zealand white rabbits, which were divided into control, sham operated and obstructed groups. Muscle strip studies further subcategorized the obstructed group into compensated (force greater than 50% of control) and decompensated (force less than 50% of control) and were correlated with in vivo determinations of voiding frequency and voided volumes. Microsomal membrane protein fractions were prepared from the same bladder tissue and were used for Western blot analysis using specific monoclonal antibodies. RESULTS: Increased voiding frequency and decreased voided volumes correlated with the definitions of compensated and decompensated. The Western blots revealed a near disappearance of ryanodine expression in the decompensated group with minimal changes in the expression of the voltage operated calcium channel. CONCLUSIONS: Bladder performance as measured in vivo and in vitro after outlet obstruction is influenced in part by smooth muscle cell ability to maintain calcium homeostasis via the sarcoplasmic reticulum. Bladder decompensation is highly associated with a loss of sarcoplasmic reticulum function with lesser changes taking place in those calcium regulatory proteins at the plasma membrane.

    Title The Histopathology of Iatrogenic Cryptorchid Testis: an Insight into Etiology.
    Date May 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Iatrogenic undescended testis may develop after inguinal hernia repair, presumably as a result of mechanical tethering of the testis or cord in scar tissue. Because some true cryptorchid testes appear to be completely descended at birth and later ascend during childhood, some iatrogenic undescended testes may be low lying undescended testes. To determine whether iatrogenic undescended testes may be unrecognized cryptorchid testes at herniorrhaphy we examined biopsies of iatrogenic undescended testes and the corresponding contralateral descended testis. MATERIALS AND METHODS: Between 1985 and 1999 bilateral testis biopsies were obtained at orchiopexy in 37 boys 1.5 to 11.8 years old who previously underwent inguinal hernia correction. Histomorphometric analysis of germ cell counts was performed on the undescended and contralateral descended testes, and compared to the count in bilateral biopsies of 37 age and position matched patients with true unilateral cryptorchidism. RESULTS: There were no significant differences in volume or total and differential germ cell counts in the undescended and contralateral descended testes in the study groups and age matched controls with primary unilateral cryptorchidism. The mean number of germ cells per tubule in the undescended testis in patients with a greater than 5-year interval from herniorrhaphy to orchiopexy was significantly decreased compared to those with an operative interval of less than 5 years (0.27 +/- 0.33 versus 0.93 +/- 1.4, p = 0.026). CONCLUSIONS: Some patients with iatrogenic undescended testis may have an unrecognized low cryptorchid testis. Careful physical examination before and after inguinal surgery is recommended. The early repair of iatrogenic undescended testis is warranted to prevent further damage.

    Title Laser Tissue Soldering for Hypospadias Repair: Results of a Controlled Prospective Clinical Trial.
    Date May 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Laser tissue soldering has been shown to provide safe and effective tissue closure by creating an immediate leak-free anastomosis with minimal scar formation. We compared the results of laser tissue soldering and conventional suturing for hypospadias repair. MATERIALS AND METHODS: A consecutive group of 138 boys 4 months to 8 years old (mean age 15 months) was divided into a standard suturing (84) and a sutureless laser (54) hypospadias repair group. Urethral repair was defined as simple (Thiersch-Duplay or Snodgrass) and complex (onlay island flap or tube) in 101 and 37 cases, respectively. Laser tissue soldering was performed with 50% human albumin solder doped with 2.5 mg./ml. indocyanine green dye using an 808 nm. diode laser at 0.5 W. In the laser group sutures were used for tissue alignment only. At surgery neourethral and penile length, operative time for neourethral construction and the number of sutures or throws were measured. Postoperatively patients were examined for complications of wound healing, stricture or fistula. RESULTS: Mean patient age, urethral defect severity, type of repair, neourethral length and stenting time plus or minus standard error of mean were not significantly different in the 2 groups. Mean operative time was a fifth as long for laser tissue soldering in simple and complex hypospadias repair compared to controls (1.5 +/- 0.1 and 5.1 +/- 0.3 versus 8.5 +/- 0.8 and 26.7 +/- 1.7 minutes, respectively, p <0.001). The mean number of sutures used for tissue alignment in the laser group for simple and complex repair was significantly less than in controls (3.0 +/- 0.2 and 8.2 +/- 0.6 versus 8.5 +/- 0.8 and 23.2 +/- 1.5, respectively, p <0.001). All patients were followed a mean of 12 months (minimum 6, maximum 22). The complication rate was 4.7% in the laser group and 10.7% in controls with fistula in 2 of 54 cases, and fistula and meatal stenosis in 7 and 2 of 84, respectively. CONCLUSIONS: These preliminary results indicate that laser tissue soldering for hypospadias repair may be performed in almost sutureless fashion and more rapidly than conventional suturing. The ease of the laser technique and the lower complication rate in the laser group indicate that laser tissue soldering is an acceptable means of tissue closure in hypospadias repair.

    Title Antenatal Minimal Hydronephrosis: is Its Follow-up an Unnecessary Cause of Concern?
    Date January 2001
    Journal The Journal of Urology
    Title Early Orchiopexy: Prepubertal Intratubular Germ Cell Neoplasia and Fertility Outcome.
    Date January 2001
    Journal The Journal of Urology
    Title The Decompensated Detrusor Iii: Impact of Bladder Outlet Obstruction on Sarcoplasmic Endoplasmic Reticulum Protein and Gene Expression.
    Date September 2000
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Regulation of calcium ion homeostasis has a significant role in smooth muscle contractility. The sarcoplasmic endoplasmic reticulum, calcium, magnesium, adenosine triphosphatase (SERCA) is a regulatory ion pump that may have a role in the functional outcome after outlet obstruction. We investigate what correlation if any existed between SERCA protein and gene expression, and the contractile properties in the same bladder. MATERIALS AND METHODS: Standardized partial bladder outlet obstructions were created in adult New Zealand white rabbits, which were divided into control, sham operated and obstructed groups. Muscle strip studies subcategorized the obstructed group into compensated (force greater than 50% of control) and decompensated (force less than 50% of control). Microsomal membrane and total RNA fractions were prepared from the same bladder tissue. Membrane proteins were used for Western blot analysis using a SERCA specific monoclonal antibody, and total RNA was assessed with Northern blot analysis. RESULTS: The relative intensities of signals for the Western and Northern blots demonstrated a strong correlation between protein and gene expression. Furthermore there was a strong association between the loss of SERCA messenger RNA and protein expression and loss of bladder function. CONCLUSIONS: Bladder contractility after outlet obstruction is influenced in part by smooth muscle cell ability to maintain calcium homeostasis via SERCA. The loss of SERCA protein expression is mediated by down-regulation in gene expression in the same bladder. These data suggest that smooth muscle ion pump gene expression is in part mechanically (pressure work) regulated.

    Title Identification and Management of Urinary Tract Infection in the Preschool Child.
    Date August 2000
    Journal Journal of Pediatric Health Care : Official Publication of National Association of Pediatric Nurse Associates & Practitioners
    Excerpt

    Urinary tract infections commonly occur in preschool children and can be associated with significant morbidity if they are not identified quickly and treated appropriately. Vesicoureteral reflux is found in a larger proportion of these patients. Recognizing and treating risk factors such as dysfunctional voiding may aid in the resolution of vesicoureteral reflux and reduce the recurrence of urinary tract infections.

    Title Minimum Incidence and Diagnostic Rate of First Urinary Tract Infection.
    Date July 2000
    Journal The Journal of Urology
    Title 45,x/46,xy Mosaicism: Report of 27 Cases.
    Date July 2000
    Journal The Journal of Urology
    Title Acute Scrotal Pain in Children: Results of 543 Surgical Explorations.
    Date July 2000
    Journal The Journal of Urology
    Title A Suspected Case of Trimethoprim-sulfamethoxazole-induced Loss of Fingernails and Toenails.
    Date April 2000
    Journal The Journal of Urology
    Title False-positive Pregnancy Test Associated with Gonadoblastoma.
    Date April 2000
    Journal Urology
    Excerpt

    Gonadoblastomas are known to be hormonally active tumors that occur in streak or dysgenetic gonads of patients with intersex abnormalities. Several reports document their ability to produce beta-human chorionic gonadotropin (HCG), but none have documented an elevated peripheral serum beta-HCG. We report on the case of a patient with pure gonadal dysgenesis with XY karyotype who was found to have an elevated peripheral serum beta-HCG after a positive pregnancy test. Knowledge of gonadoblastoma's potential to elevate serum beta-HCG levels may prevent unnecessary searches for other causes.

    Title The Modern Endoscopic Approach to Ureterocele.
    Date March 2000
    Journal The Journal of Urology
    Excerpt

    PURPOSE: During the last 20 years the surgical approach to ureterocele has evolved from major open surgery to minimally invasive endoscopic puncture. We believe that the endoscopic approach decreases the need for open surgical procedures. We identified specific factors that predict the need for repeat surgery. MATERIALS AND METHODS: We reviewed the charts of 60 new patients with ureterocele treated with primary endoscopic incision between 1991 and 1995. Followup ranged from 4 to 62 months (mean 20). Mode of presentation, ureterocele location, associated vesicoureteral reflux and association of the ureterocele with a duplex system were evaluated. Ureterocele wall thickness was assessed subjectively via radiographic and cystoscopic methods, and categorized as thin, intermediate and thick. RESULTS: All 9 patients with a single system ureterocele had an intravesical ureterocele. No patient had associated reflux nor did any require a secondary open procedure. In 3 cases new onset ipsilateral reflux into the ureterocele spontaneously resolved. Of the 51 patients with a duplex system and associated ureterocele 19 (37%) required a secondary open procedure. The ureterocele was intravesical and ectopic in 22 (43%) and 29 (57%) cases, respectively. Reflux was associated with the ureterocele in 27 patients (53%), and 12 (44%) required a secondary open procedure. A total of 11 patients underwent ureteral reimplantation of 15 refluxing renal units and only 2 renal units required ureteral tapering. Reflux is no longer present in 14 of the 15 renal units (93%). Patients with a thick walled ureterocele required repeat puncture more frequently than those with a nonthick ureterocele. CONCLUSIONS: With the use of modern endoscopic techniques children with intravesical and single system ureteroceles require secondary open surgery less frequently than those with ectopic and duplex system ureteroceles. The mode of presentation does not predict the need for a repeat open procedure. Thick walled ureteroceles require repeat endoscopic puncture more frequently than thin and intermediate walled ureteroceles.

    Title Ectopic and Undescended Testes: 2 Variants of a Single Congenital Anomaly?
    Date March 2000
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We compared pathological findings in ectopic and undescended testis to determine whether the pathological evidence supports the hypothesis that the 2 conditions are variants of the same congenital anomaly. MATERIALS AND METHODS: We identified 24 boys with ectopic testis not in the superficial inguinal pouch of Denis Browne. Seven boys were excluded from study due to unavailable clinical records for 3, contralateral undescended testis in 2 and inadequate biopsy specimens in 2. Pathological findings of ectopic testis in the remaining 17 patients were compared with those of age matched patients with unilateral undescended testis. Total germ cell count, testicular volume, patency of the processus vaginalis and epididymal abnormalities were compared. Data were analyzed using the Wilcoxon matched pairs signed rank and Fisher's exact tests. RESULTS: No difference was noted in total germ cell count (p = 0.33), testicular volume (p = 0.1475), processus vaginalis patency (p = 0.0854) or epididymal abnormalities (p = 1.00) in the 2 groups. Of the 24 boys (8%) with ectopic testis 2 also had a contralateral undescended testis. CONCLUSIONS: Similar pathological findings in ectopic and undescended testes as well as the association of ectopic testis with a contralateral undescended testis suggest that ectopic and undescended testes are variants of the same congenital anomaly. Thus, boys with ectopic testis may have an increased incidence of subfertility and testicular malignancy. This spectrum of abnormal testicular position, and its range of pathological conditions and complications may appropriately be called the undescended testis sequence.

    Title Testicular Volume Does Not Predict Germ Cell Count in Patients with Cryptorchidism.
    Date February 2000
    Journal The Journal of Urology
    Excerpt

    PURPOSE: A germ cell count of less than 0.2 germ cell per tubule on the prepubertal biopsy of cryptorchid testes predicts abnormal spermiograms and decreased fertility in adulthood, and may be used to select patients for post-orchiopexy hormonal therapy. Testicular volume directly correlates with testicular function and spermiogenesis. We determined whether testicular volume would predict the total germ cell count accurately enough to replace testicular biopsy in the modern management of cryptorchidism. MATERIALS AND METHODS: At our hospital 723 patients younger than 9 years with cryptorchidism (unilateral in 619 and bilateral in 104) underwent orchiopexy and bilateral testicular biopsies. These patients had not undergone groin surgery or hormonal therapy previously and had at least 50 tubules in each testicular biopsy. Testicular volume and position, patient age and germ cell counts were analyzed. The generalized estimating equation was used to determine whether a correlation existed between testicular volume and germ cell count. RESULTS: The generalized estimating equation demonstrated a direct correlation between testicular volume and germ cell count. However, germ cell counts predicted from testicular volume varied widely within the 95% confidence intervals. Testes with less than 0.2 germ cell per tubule cannot be reliably distinguished from those with greater than 0.2 germ cell per tubule. CONCLUSIONS: Testicular volume does not accurately predict the germ cell count in patients with undescended testes, cannot be used to select patients for post-orchiopexy hormonal therapy and cannot replace testicular biopsy in the modern management of cryptorchidism.

    Title The Role of Renal Salvage Procedures for Bilateral Wilms Tumor: a 15-year Review.
    Date January 2000
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We reviewed our experience with renal salvage procedures in patients with bilateral Wilms tumor to determine the clinical outcome. MATERIALS AND METHODS: From 1982 to 1997, 23 children with bilateral Wilms tumor were treated with partial nephrectomy at our institution, including 7 who were also treated with brachytherapy. Medical history, use and response to chemotherapy and brachytherapy, operative records, renal function, pathological results, survival, and techniques for partial and repeat nephrectomy and brachytherapy were reviewed. RESULTS: We treated 8 boys and 15 girls, of whom 21 who presented with synchronous bilateral Wilms tumor underwent primary chemotherapy followed by secondary partial nephrectomy. A total of 44 partial nephrectomies were performed and brachytherapy was done in 7 patients. Ten children have normal renal function and no disease, 10 are dead and 2 have metastatic disease. Anaplasia was the most significant factor associated with an unfavorable outcome (p = 0.003). Of the patients who were cured 60% had a positive response to initial chemotherapy compared with only 25% who had an unfavorable outcome (p = 0.09). No significant differences were noted with respect to gender, age at presentation, highest local tumor stage at presentation or initial nephrectomy. No patient treated with brachytherapy had local recurrence. CONCLUSIONS: Preoperative chemotherapy followed by nephron sparing surgery is indicated in patients with bilateral Wilms tumor, while in those with diffuse anaplasia nephron sparing surgery is contraindicated. Brachytherapy should be considered for treating local disease involving chemoresistant tumors.

    Title The Outcome of Stopping Prophylactic Antibiotics in Older Children with Vesicoureteral Reflux.
    Date January 2000
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Accepted management of vesicoureteral reflux includes surgical correction or prophylactic antibiotics with the hope for resolution as the child grows. The physician must consider surgery when reflux does not resolve despite uneventful years on prophylactic antibiotics. An alternative is cessation of the antibiotics. We report on the outcome of children taken off antibiotics with persistent reflux. MATERIALS AND METHODS: During a 14-year period 51 children with documented reflux were taken off antibiotic prophylaxis. Selection criteria included children who were old enough to verbalize the symptoms of a urinary tract infection, and had normal voiding patterns, a minor history of infections and minimal or no renal scarring. Routine followup included nuclear cystography and renal sonography. RESULTS: A total of 40 girls and 11 boys maintained on antibiotics for a mean of 4.8 years were taken off prophylaxis and followed for an average of 3.7 years. Mean patient age when prophylactic antibiotics were stopped was 8.6 years. Reflux resolved in 10 children (19.6%). A urinary tract infection developed in 5 girls and 1 boy (11.8%) (mean age 11) an average of 2.3 years (range 4 months to 9.4 years) after antibiotic discontinuation. One child had symptoms consistent with cystitis and 5 had febrile urinary tract infections. All were treated with oral antibiotics and 5 had subsequent operations. No new renal scars developed. CONCLUSIONS: The majority of children did well following cessation of antibiotic prophylaxis despite persistent vesicoureteral reflux. Cessation of antibiotic prophylaxis is a reasonable option in a highly select patient population with reflux.

    Title Five-year Study of Medical or Surgical Treatment in Children with Severe Vesico-ureteral Reflux. Dimercaptosuccinic Acid Findings.
    Date January 2000
    Journal The Journal of Urology
    Title Prognostic Factors for Long-term Renal Function in Boys with the Prune-belly Syndrome.
    Date October 1999
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Renal failure develops in 25 to 30% of patients with the prune-belly syndrome. The clinical parameters associated with renal failure in this condition are not well understood. We determined which factors predict renal failure in children with the prune-belly syndrome. MATERIALS AND METHODS: We reviewed the records of 35 patients with the prune-belly syndrome who were treated at our hospital during a 37-year period. Nadir serum creatinine, time to nadir creatinine, presence or absence of a patent urachus, presence and severity of urinary tract infection, and renal failure were analyzed. RESULTS: Mean followup was 14 years 2 months. In 2 of the 17 patients with a nadir serum creatinine of less than 0.7 mg./dl. renal failure developed. Each of these 2 children also had clinical pyelonephritis and urosepsis. In 12 of the 13 patients nadir serum creatinine greater than 0.7 mg./dl. strongly predicted renal failure. Nonfebrile urinary tract infection within the first year of life was not predictive of outcome (p = 0.8) but a history of clinical pyelonephritis correlated with eventual renal failure (p<0.001). Urosepsis also correlated with renal failure (p = 0.008). Children with at least 1 normal kidney on renal ultrasound or renal scan had a significantly lower chance of renal failure (p<0.001). CONCLUSIONS: Bilaterally abnormal kidneys on ultrasound or renal scan, a nadir serum creatinine of greater than 0.7 mg./dl. and clinical pyelonephritis are prognostic for renal failure.

    Title Newer Concepts in the Management of Hypospadias and Its Complications.
    Date October 1999
    Journal The Journal of Urology
    Title Cohort Study on Circumcision of Newborn Boys and Subsequent Risk of Urinary-tract Infection.
    Date October 1999
    Journal The Journal of Urology
    Title Rectovestibular Fistula with Absent Vagina: a Unique Anorectal Malformation.
    Date July 1999
    Journal The Journal of Urology
    Title Plastibell Complications Revisited.
    Date May 1999
    Journal Clinical Pediatrics
    Title Histological and Histochemical Study of the Vesicoureteric Junction in Infancy and Childhood.
    Date March 1999
    Journal British Journal of Urology
    Excerpt

    The morphology of the vesicoureteric junction was compared using 19 post mortem specimens obtained from male and female Afro-American and Caucasian children with an age range of 1 to 72 months (mean 4). All specimens were serially sectioned and the tissues processed using standard histological and histochemical techniques (acetylcholinesterase ¿AChE¿ and pseudocholinesterase ¿PChE¿). The results failed to reveal any differences in the structure of the vesicoureteric junction with respect to age, sex and ethnic origins. The vesicoureteric junction comprised 3 histologically and histochemically distinct smooth muscle components. Ureteric muscle formed a complete inner layer rich in PChE which continued beyond the ureteric orifices to merge distally with the superficial trigone. An intermediate layer of muscle was also demonstrated whose constituent muscle cells possessed specific histological features and which was rich in both AChE and PChE, which is distinct from that derived from the ureter and detrusor. The presence of detrusor muscle on the outer aspect of the juxtavesical segment of ureter rich in AChE was also confirmed. While this study, using histochemical studies in infants and children, did not reveal any differences in the structure of the vesicoureteric junction with respect to age, sex or ethnic origin, an intermediate layer of muscle was identified with histochemical characteristics more like that of the male genital tract than that derived from the ureter or detrusor muscle.

    Title Hypospadias Trends in Two Us Surveillance Systems. Rise in Prevalence of Hypospadias.
    Date March 1999
    Journal The Journal of Urology
    Title Is Partial Nephrectomy Appropriate Treatment for Unilateral Wilms' Tumor?
    Date March 1999
    Journal The Journal of Urology
    Title High Incidence of Bacteriuria Following Renal Transplantation in Children.
    Date March 1999
    Journal The Journal of Urology
    Title Acute Epididymitis and Urinary Tract Anomalies in Children.
    Date January 1999
    Journal Scandinavian Journal of Urology and Nephrology
    Excerpt

    OBJECTIVES: To evaluate the incidence of urinary tract infection (UTI) and genitourinary malformations in children presenting with acute epididymitis. PATIENTS AND METHODS: Twenty-five children between 2 months and 14 years of age presenting with acute epididymitis underwent urine culture, abdominal ultrasound, voiding cystourethrography and, in selected cases, intravenous pyelography. Eleven patients were infants and 14 were older than 1 year. UTIs and genitourinary malformations were recorded. Fisher's exact test was used to compare the incidence in two age groups. A p value of less than 0.05 was considered significant. RESULTS: Seven UTIs and eight genitourinary malformations were diagnosed in infants, while in older children three UTIs and three malformations were discovered. Infants had a higher rate of associated UTI (p 0.049) and genitourinary malformations (p 0.017) than did older children. CONCLUSIONS: Our data show a close relationship between acute epididymitis in infants for both UTIs and genitourinary malformations. Every infant presenting with epididymitis would undergo a complete evaluation including abdominal ultrasound and voiding cystourethrography. In older children the need for imaging should be dictated by clinical history and physical findings.

    Title Comparison of Dermal and Epithelial Approaches to Laser Tissue Soldering for Skin Flap Closure.
    Date September 1998
    Journal Lasers in Surgery and Medicine
    Excerpt

    BACKGROUND AND OBJECTIVE: Prior studies of laser tissue soldering (LTS) of epithelial skin have shown poor wound strength in the short-term; however, we hypothesize that greater tensile strength and healing properties will result from directing laser energy to the dermal aspect of the skin. The current study compares wound strength and histology in a rat skin flap model of epithelial and dermally applied LTS. STUDY DESIGN/MATERIALS AND METHODS: Skin flaps (2.5 x 4 cm) were raised and bisected on the dorsum of Sprague-Dawley rats. The center line of bisection was closed from a dermal approach by LTS (LTS-D, diode laser 15.9 W/cm2 + Columbia solder), the upper incision by epithelial LTS (LTS-E), and the lower incision by suturing (7-0 Vicryl). Wound skin strips (1-2 mm x 10 mm) were studied immediately (N = 14) and at 3 (N = 57), 7 (N = 31), and 10 (N = 28) days postoperatively and were subjected to tensiometric analysis. Histologic staining with hematoxylin and eosin and Mallory's trichrome methods were used to define wound architecture. RESULTS: No wound dehiscences were noted in any group. Greater immediate tensile strength was noted in wounds closed by LTS-D (521 +/- 61 g/cm2) versus LTS-E (342 +/- 65 g/cm2); however, this difference was not statistically significant (P = .08). By 3 days, both LTS-D (476 +/- 55 g/cm2) and LTS-E (205 +/- 37 g/cm2) maintained their initial strength; however, LTS-D and sutured (436 +/- 49 g/cm2) wounds were stronger (P < .05) than LTS-E. At 7 and 10 days, LTS-D (2,433 +/- 346 g/cm2 and 3,100 +/- 390 g/cm2) showed superior tensile strength (P < .05) compared to both LTS-E (1,542 +/- 128 g/cm2 and 2,081 +/- 219 g/cm2) and suturing (1,342 +/- 119 g/cm2 and 1,661 +/- 115 g/cm2). Histologic analysis of LTS-D wounds at 3 days showed full-thickness tissue apposition, complete epithelialization, and minimal inflammation or thermal injury. At 7 days, solder was present in the wounds. In contrast, LTS-E wounds at 3 days displayed lack of epithelialization secondary to thermal injury and partial-thickness tissue apposition. However by 7 days, epithelialization was complete with moderate scarring, and no solder was seen. Sutured samples appeared similar to LTS-D, except for poorer tissue apposition at the hypodermis. CONCLUSION: Our results show that skin flap wound healing after dermal LTS is superior to epithelial LTS and emphasizes the importance of site specificity in the utilization of this operative technique in reconstructive surgery.

    Title Surgical Management of the Nonpalpable Testis: the Children's Hospital of Philadelphia Experience.
    Date April 1998
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The management of the nonpalpable testis permits an individualized operative approach. We analyze the results of surgical management of a large series of patients with a nonpalpable testis. MATERIALS AND METHODS: Between January 1986 and June 1994 we treated 1,866 boys with undescended testes. There were 447 testes (24%) that were not palpable at presentation. Intra-operative data on these patients were collected for age at presentation, bilateral testes position, testicular size, associated inguinal anomalies (vas, epididymis and processus vaginalis) and surgical approach. For intra-abdominal testes postoperative results of 2 surgical techniques, the Fowler-Stephens procedure and Koop orchiopexy (retroperitoneal mobilization of spermatic vessels and vas) were compared in 76 patients with at least 18 months of followup. RESULTS: Average patient age at presentation was 34 months with 63% presenting before age 48 months. Of the impalpable testes 58% were on the left side, 35% were on the right side and 7% were bilateral. At operation 181 testes (41%) were atrophic or absent, 91 (20%) were intra-abdominal with 14 (3.1%) bilateral, 136 (30%) were in the inguinal canal and 39 (9%) were in other locations, including 22 at the pubic tubercle, 2 in the upper scrotum, 13 in the superficial inguinal pouch and 2 in the perineum. Of the intra-abdominal group associated extratesticular malformations were identified in 36 cases (39%). Attachment of the vas deferens to the testis was abnormal in 23 of 64 cases (36%), including 10 that were completely detached and 13 with head or tail attachment only. Of the 91 evaluable cases in the intra-abdominal group 38 (42%) had been treated with the Fowler-Stephens repair (5 in 2 stages), 33 (36%) with inguinal orchiopexy and intraperitoneal dissection without dividing the spermatic vessels, 5 with 2-stage procedures and vessel preservation and 14 (15%) with orchiectomy. One testis was left in situ. The inguinal approach with intraperitoneal extension was successful in defining the testis location or blind-ending vas and vessels in 100% of the cases. A single operation to perform orchiopexy was successful in 92% of the cases. Overall, results were considered excellent or acceptable in 32 of 33 cases (97%) after Koop orchiopexy and 28 of 38 (74%) after the Fowler-Stephens orchiopexy. CONCLUSIONS: Nonpalpable testes accounted for 24% of the patients presenting with undescended testes. At surgical exploration 39% of impalpable testes were distal to the external inguinal ring, 41% were atrophic or absent and 20% were intra-abdominal. All cases were treated through a standard inguinal incision. These data provide evidence that the inguinal approach to orchiopexy with transperitoneal mobilization of the vas and vessels without transection is highly successful for the intra-abdominal cryptorchid testis and, to date, is the preferred technique for the management of the intra-abdominal undescended testis.

    Title Surgical Repair of Urethral Circumcision Injuries.
    Date December 1997
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The 2 types of urethral injury that can occur during circumcision are urethrocutaneous fistula and urethral distortion secondary to partial glans amputation. We report the surgical repair of these rare injuries. MATERIALS AND METHODS: In 8 patients urethrocutaneous fistulas located on the distal penile shaft or at the coronal margin were managed by splitting the glans and using a Mathieu style skin flap in 4 or vascularized penile skin flap in 4 to bridge the urethral defect. Three patients underwent repair of a hypospadiac deviated urethra secondary to partial glans amputation by 1 cm. of urethral mobilization and repositioning the meatus into a terminal position within the remaining glans tissue. RESULTS: The 8 patients with urethrocutaneous fistulas voided via a terminal meatus without fistula recurrence at a mean followup of 3.2 years (range 1 to 6). The 3 patients with partial glans amputation and urethral deviation repaired by short urethral advancement had functionally acceptable results, defined as a normal urinary stream, although 1 required meatal dilation postoperatively. CONCLUSIONS: The 2 types of urethral injuries that can occur during circumcision are a subcoronal urethrocutaneous fistula and scarred abnormal urethra from partial glans amputation. The urethrocutaneous fistula can be successfully repaired by splitting the glans and forming a neourethra from a vascularized pedicle flap of penile skin. The abnormal urethra after partial glans amputation is more difficult to repair but repositioning the urethra in a more cosmetic location has restored function.

    Title Laser Soldering Technique for Sutureless Urethral Surgery.
    Date October 1997
    Journal Techniques in Urology
    Excerpt

    Investigators have attempted sutureless surgery to decrease operative time, lessen the inflammatory response, maintain luminal continuity, and increase the ease of performing technically difficult surgery. Only recently has laser-tissue welding (LTW) been used for urologic reconstruction in humans. Herein, we present our technique of laser soldering with the half-watt diode laser and wavelength matched albumin-based solder. Our methodology of LTW relies on bonding between the outer surface of the wound edges and the solder. The 808-nm diode wavelength does not penetrate deep tissue, and thus relies on indocyanine green dye to localize photon absorption. Since 1994, we have performed LTW, as an adjunct to suturing (N = 25) and as a primary means of tissue closure (N = 11). Preoperative diagnoses included hypospadias, urethral stricture, urethral diverticulum, and urethral fistulae. Follow-up ranged between 3 months and 3 years to identify complications of wound healing, stricture, and fistula formation. In the 37 patients undergoing urethral surgery, no strictures or diverticula have resulted. None of the patients have had wound infections or poor wound healing. Overall, five patients have developed fistulas between 2 weeks and 6 months postoperatively. The location of the hypospadiac meatus was scrotal or penoscrotal in four of these patients. Two fistulas developed following sutureless urethroplasty (reoperative) after traumatic catheterization for urinary retention (one case for inadvertent catheter removal). In our initial experience, the overall complication rate using laser soldering was 19% compared to 24% in an historical control group. Half of the complications occurred in a reoperative situation. More recently, the overall fistula rate was 14%; however, for primary cases, the current fistula rate is only 6%. LTW is safe and easy to perform. The application of protein solders (+/-chromophores) have permitted far greater tensile strengths to be achieved than laser alone. Temperature-control and chromophore-control have permitted safety and efficacy to be achieved. Solder application site and technique are equally important in the success of the LTW process. A randomized, prospective study comparing LTW to suturing is ongoing.

    Title The Operative Management of Recurrent Ureteropelvic Junction Obstruction.
    Date September 1997
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Surgical repair of ureteropelvic junction obstruction is successful in 98% of cases. We evaluated children undergoing repeat pyeloplasty and discuss the etiology of recurrent ureteropelvic junction obstruction, surgical approach and outcome. MATERIALS AND METHODS: Between 1982 and 1996, 366 children with ureteropelvic junction obstruction were surgically treated at our institution, including 16 who presented with recurrent ureteropelvic junction obstruction and required surgery. RESULTS: Repeat repair was successful in all 16 patients, including ureterocalicostomy in 3 and dismembered pyeloplasty in the remainder. No nephrectomy was necessary. Anteriorly elongated flank incisions were made in all cases. Dense scar tissue around and obstructing the ureteropelvic junction was noted in the majority of cases. In 7 patients a redundant pelvis resulted in a kink at the ureteropelvic junction. A nephrostomy tube was placed in all cases and an additional transanastomotic stent was used in all but 2. Obstruction was relieved with 1 operation. CONCLUSIONS: A redundant pelvis resulting in a kink at the ureteropelvic junction may contribute to a higher change of urinary leakage and subsequent obstructive scar formation in cases of failed pyeloplasty. Before repeat surgery anatomy should be precisely identified by antegrade and retrograde studies. The surgical approach usually involves identifying the ureter below the area of the previous surgery and then ensuring a tension-free anastomosis. If inadequate ureteral length or an intrarenal pelvis precludes direct anastomosis, ureterocalicostomy is an alternative. A nephrostomy tube and transanastomotic stent are advisable. Nephrectomy is rarely necessary and a good functional result can be anticipated.

    Title Skin Flap Closure by Dermal Laser Soldering: a Wound Healing Model for Sutureless Hypospadias Repair.
    Date September 1997
    Journal Urology
    Excerpt

    OBJECTIVES: Laser tissue soldering (LTS) with the diode laser and human albumin-hyaluronate-indocyanine green solder is a safe and effective method of providing an immediate leak-free closure during hypospadias repair. In this report, we compare the physiology, histology, and immunohistochemistry of wound healing following LTS and suturing in a rat skin flap model. METHODS: A 4 x 5-cm skin flap was raised and bisected (4 cm) on the dorsum of 48 Sprague-Dawley rats. The central wound was either closed from a dermal approach by suturing or LTS or left open, and studied at 0, 3, 5, 7, 10, 14, and 21 days postoperatively. An intraoperative comparison was made between suturing and LTS with respect to operative time. Postoperatively, flaps were excised for tensiometric analysis, and sections were stained with hematoxylin-eosin to define wound architecture. Resting skin temperature, laser exposed temperature without solder, and maximum temperature with solder (one drop) were measured at the level of the deep dermis, superficial striated muscle layer, and within the solder. Mean peak temperatures were recorded during a 1-minute laser activation time. RESULTS: Mean continuous suturing time (4.9 +/- 1.1 minutes) was significantly (P < 0.001) faster than either LTS (7.7 +/- 0.77 minutes) or discontinuous suturing (8.2 +/- 0.62 minutes). Two seromas (sutured) and two instances of partial wound dehiscence (1 sutured, 1 LTS) were noted. Tensile strength was increased significantly (P < 0.001) for up to 5 days in the LTS group, but was equal to suturing at 7 and 10 days. Immediate tensile strength after LTS was equivalent to a 7-day healed wound. At 14 days, wounds initially left open and those closed by LTS were stronger than sutured wounds (P < 0.05). There was no evidence of thermal injury or foreign body reaction in the LTS group. Solder was incorporated within the dermis in all wounds at 21 days. Laser activation of solder resulted in significant increases in temperature at all three tissue levels: 65.0 +/- 5.2 and 69.9 +/- 6.8 degrees C in the deep and superficial skin (no significant difference between the two), and 101 +/- 15.6 degrees C within the solder (P < 0.001 versus superficial and deep skin). CONCLUSIONS: Our results indicate that sutureless dermal LTS of skin flaps provides increased tensile strength for up to 7 days, with relatively greater tensile strength provided within the first 3 days. Our laser technique does not appear to alter the normal wound healing process. Rather, solder-tissue interaction initially, and extracellular matrix infiltration of solder later, provide the basis for improved wound strength. For hypospadias repair using skin flaps, these wound attributes may permit sutureless surgery.

    Title Testis Sparing Surgery for Steroid Unresponsive Testicular Tumors of the Adrenogenital Syndrome.
    Date April 1997
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Surgical management of steroid unresponsive testicular tumors of the adrenogenital syndrome has been orchiectomy. Magnetic resonance imaging (MRI) of these tumors accurately delineates the extent of disease. Testis sparing surgery is an important consideration, since male individuals with congenital adrenal hyperplasia are potentially fertile. We present our results of surgical management of this tumor based on MRI findings. MATERIALS AND METHODS: Four boys with steroid unresponsive testicular tumors of the adrenogenital syndrome were evaluated with MRI, testicular ultrasound and color flow Doppler examinations preoperatively and postoperatively. Three patients had 21-hydroxylase deficiency and 1 had 3-beta-hydroxysteroid dehydrogenase deficiency. Contralateral testicular abnormalities included a vanished testis, testicular atrophy due to trauma and bilateral tumors in 1 boy each. Bilateral orchiectomy and surgical enucleation were performed in 1 and 3 patients, respectively. Followup ranged from 8 to 18 months. RESULTS: Postoperative MRI of the testis in 2 of 3 patients showed no evidence of recurrent tumor. Postoperative testicular sonography revealed no tumor and vascular flow in 2 of 3 patients. All 3 patients who underwent testis sparing surgery have a viable testis in the scrotum without evidence of recurrent disease. CONCLUSIONS: MRI of the testis in patients with testicular tumors of the adrenogenital syndrome accurately defines the extent of disease. Surgical enucleation of this tumor has been performed successfully without recurrent disease. This surgical approach should be considered for any patient with a steroid unresponsive tumor and contralateral abnormalities. We believe that surgical enucleation is the procedure of choice for all patients with this tumor, since it maximizes future fertility potential.

    Title Bladder Exstrophy: the Case for Primary Bladder Reconstruction.
    Date January 1997
    Journal Urology
    Title 10-year Experience with Prenatal Intervention for Hydronephrosis.
    Date September 1996
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We evaluated clinical outcomes after attempted prenatal intervention in fetuses with hydronephrosis. MATERIALS AND METHODS: We retrospectively reviewed the histories of 10 fetuses considered for prenatal intervention between 1984 and 1993. One female and 8 male fetuses had bilateral hydroureteronephrosis and profound or progressive oligohydramnios, and 1 male fetus had massive progressive unilateral hydronephrosis. RESULTS: Shunt placement was not recommended and it was refused by the parents in 1 case each. Amniotic shunting was attempted in 8 fetuses between 22 and 28 weeks of gestation. Shunts were successfully placed with decreased hydronephrosis and increased amniotic fluid volume in 4 cases, while shunt placement was not technically possible in the remainder. Two shunts that retracted intra-abdominally at birth required laparotomy for retrieval. Postnatally all patients with shunts had compromised renal function. Of the 4 patients in whom attempts were unsuccessful 3 had mildly diminished renal function and 1 died of nonrenal causes (intraabdominal sepsis) on day 16 of life. No patient with a functioning shunt had postnatal pulmonary problems, whereas 3 without successful intervention had mild respiratory compromise. CONCLUSIONS: No definite advantage was noted in the small number of fetuses that underwent successful shunting. Successful shunt placement did not prevent renal insufficiency. The relief of oligohydraminos may benefit pulmonary function in some patients. The high technical failure and complication rates of in utero intervention should be considered before proceeding.

    Title The Long-term Outcome in Men with Exstrophy/epispadias: Sexual Function and Social Integration.
    Date August 1996
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We evaluated the long-term outcome of social integration and sexual function in 29 men with bladder exstrophy and epispadias. MATERIALS AND METHODS: Four men with epispadias and 25 with bladder exstrophy were available for long-term followup. Patients were interviewed by telephone regarding sexual history and social integration. Semen analyses were obtained in 8 cases. RESULTS: Patient assessment of genital appearance was good or fair in 71%. Potency was present in all patients, and erections were straight in 66% and curved in 34% with no curvature so severe as to prevent sexual intercourse. Semen analysis showed a normal sperm count in 63% of the men and no azoospermia. Social integration was satisfactory: 100% of the men attended high school, 55% have a college education and all who are not attending school have full-time jobs. CONCLUSIONS: Our long-term review demonstrates that despite what appears to be a significant sexual handicap, patients with exstrophy/epispadias can have adequate sexual function and overall successful social integration.

    Title Treating Complications of Circumcision.
    Date August 1996
    Journal Pediatric Emergency Care
    Title The Long-term Outcome of Posterior Urethral Valves Treated with Primary Valve Ablation and Observation.
    Date June 1996
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We believe that primary valve ablation with observation is the preferred management for posterior urethral valves. However, debate continues as to the role of high diversion. We examined the long-term outcome of a large series of patients treated with primary valve ablation, and compared it to the outcome of high diversion and vesicostomy. MATERIALS AND METHODS: We reviewed the records of 100 patients treated with primary valve ablation (74%), vesicostomy (13%) or high diversion (9%) before 1985. Median followup was 11.2 years. RESULTS: Overall 13% of our patients had end stage renal disease by age 15 years. Three patients initially treated with valve ablation and 3 initially treated with vesicostomy later underwent high diversion but none benefited from the secondary procedure. Four patients initially treated with valve ablation subsequently underwent vesicostomy but only 1 benefited. Bladder storage capacity was well preserved. Diurnal urinary continence developed in 46% of patients at age 10 years and only 1 remained incontinent after age 20 years. One patient with diversion who awaits transplantation had a small contracted bladder. Recent urodynamic studies in 10 cases of delayed urinary continence have not shown decreased bladder compliance or capacity. Kaplan-Meier analysis of outcomes of the different treatments indicated no statistical difference in patient age at end stage renal disease development. However, comparing the number of surgical procedures in the different treatment groups revealed a significant increase in the amount of surgery in infants with diversion. Our results were equivalent to those of the best published series, many of which strongly advocate high diversion. CONCLUSIONS: By avoiding diversion in most cases bladder function is preserved and the need for bladder augmentation is decreased.

    Title Autologous Periurethral Fat Injections for the Creation of Bladder Outlet Obstruction.
    Date March 1996
    Journal Advances in Experimental Medicine and Biology
    Title Use of Injectable Fat to Obstruct the Urethra in Rabbits.
    Date September 1995
    Journal Neurourology and Urodynamics
    Excerpt

    Bulking agents have been injected to correct urinary incontinence for at least 15 years. The injection seeks to increase bladder outlet resistance by partially obstructing the urethra and thereby reduce urinary leakage in patients with stress urinary incontinence. Although the implant is effective and requires a shorter in-hospital stay than more traditional procedures, no ideal implant substance has been discovered. To assess the effectiveness of injected fat as a bulking agent, we injected small volumes of perivesical fat into the bladder neck in New Zealand White (NZW) rabbits and tested the effect on the bladder. In eight rabbits, we harvested perivesical fat and partially closed the urethral lumen with an initial injection. A second injection 1 month later completely closed the urethral lumen. We injected six other rabbits with similar volumes of saline as controls. Two weeks after the second injection, we measured micturition frequency, bladder weight, response to electrical field stimulation, and response to bethanecol in each group. Fat implants were present at the injection site in each case 4 weeks after the first injection. Rabbits receiving fat implants had increased micturition frequency, increased bladder weight, and increased response to bethanecol and field stimulation. Previous studies have demonstrated that these changes are characteristic of mild outlet obstruction in rabbits. Injected fat can be made to close the urethra and create bladder outlet obstruction in rabbits. The short-term success of fat as a bulking agent in this experiment is encouraging and suggests the need for longer term studies.

    Title Ureterocele Eversion with Vesicoureteral Reflux in Duplex Kidneys: Findings at Voiding Cystourethrography.
    Date August 1995
    Journal Ajr. American Journal of Roentgenology
    Excerpt

    OBJECTIVE. Ureterocele eversion refers to the sudden appearance of a bladder diverticulum at the site of ureterocele compression during voiding cystourethrography (VCUG). The radiologic appearance closely resembles a congenital bladder (paraureteral) diverticulum. Distinguishing ureterocele eversion with vesicoureteral reflux in duplex kidneys from congenital bladder diverticula with reflux is important for preoperative planning. This study describes the findings of ureterocele eversion and lower pole vesicoureteral reflux in duplex kidneys on VCUG and demonstrates how its appearance can be misleading. MATERIALS AND METHODS. Medical records, sonograms, and cystograms were reviewed retrospectively for 12 children who had VCUGs demonstrating bladder diverticula with vesicoureteral reflux and who, at surgery, had ureteroceles associated with duplex systems. Each case was assessed as to whether the finding of a diverticulum with reflux on VCUG had been correctly interpreted as ureterocele eversion with lower pole vesicoureteral reflux. RESULTS. Diagnosis of ureterocele eversion with lower pole reflux was uncertain or misinterpreted as congenital bladder diverticula with reflux in five patients in whom ureteroceles were not identifiable or in whom reflux occurred into what resembled single systems rather than lower poles of duplex systems. In two patients in whom ureteroceles were not initially identified, fluoroscopy recognized ureterocele eversion with lower pole reflux. Sonography confirmed ureterocele in one of these patients, and cystoscopy in the other. CONCLUSION. Ureterocele eversion with lower pole vesicoureteral reflux is readily diagnosed by VCUG when a ureterocele is initially identified or if the fluoroscopic appearance is typical. Ureterocele eversion with lower pole reflux can be mistaken for a congenital paraureteral diverticulum with reflux into a single collecting system if the ureterocele is small or not initially detected or if the refluxed system is not recognized as a lower pole moiety.

    Title Ultrasound Diagnosis of Bladder Outlet Obstruction in Rabbits.
    Date February 1995
    Journal Neurourology and Urodynamics
    Excerpt

    One of the primary characteristics of partial outlet obstruction secondary to BPH is an increase in bladder mass commonly referred to as bladder hypertrophy. This condition has been simulated in rabbits by the partial ligation of the catheterized urethra. Ultrasonography has been utilized in both adult and pediatric urology to visualize the bladder and diagnose specific bladder disorders. The aim of the present study is to determine if ultrasonography can visualize bladder wall hypertrophy induced by obstruction. Partial outlet obstructions were created in NZW rabbits using standard methodologies, and then 5 to 7 days later, sonography was performed. The films were read by both the principal investigator and blinded investigators instructed to determine bladder wall thickness and from this predict the bladder weight. Then results were correlated with cystometrograms (CMGs) and whole bladder weights. Both the principal investigator and the blinded investigators were consistently able to distinguish obstructed from control bladders based solely on sonographic depictions of relative bladder wall thickness. In addition, the investigators were able to distinguish between low (control), medium, and high bladder weights based on sonography. The accuracy of predicting the bladder weights increased when cystosonograms were correlated with CMG studies. Thus, the degree of bladder hypertrophy can be accurately estimated by the combination of cmg and ultrasonography.

    Title Meconium Hydrocele in a Female Newborn: an Unusual Cause of a Labial Mass.
    Date December 1994
    Journal The Journal of Urology
    Excerpt

    Meconium peritonitis results from in utero perforation of the bowel and subsequent spillage of meconium into the peritoneal cavity. Free communication of the peritoneal space with the processus vaginalis during gestation permits formation of a meconium hydrocele. Meconium hydrocele has been reported in the newborn scrotum but to our knowledge there has been no previous report of meconium hydrocele in the labium of a female neonate. The predominance of meconium hydrocele in the male infant may be due to the obliteration of the processus vaginalis occurring later in the male than in the female fetus.

    Title Persistence of Autologous Free Fat Transplant in Bladder Submucosa of Rats.
    Date July 1994
    Journal The Journal of Urology
    Excerpt

    The endoscopic correction of vesicoureteral reflux is a well accepted procedure. However, the search for the ideal injectable substance continues. We compared the persistence of autologous free fat transplants from the perivesical fat pad and the abdominal wall to the bladder submucosa in an animal model. Perivesical fat consistently showed greater persistence than abdominal wall fat over time. Perivesical fat may be an ideal substance for endoscopic injection when treating vesicoureteral reflux.

    Title An Immunohistochemical Study of the Innervation of the Ureterovesical Junction in Infancy and Childhood.
    Date May 1994
    Journal British Journal of Urology
    Excerpt

    OBJECTIVE: To use histological and immunohistochemical methods to study the structure and innervation of the human ureterovesical junction (UVJ). MATERIALS AND METHODS: A series of 24 post-natal specimens taken from patients ranging in age from 1 month to 6 years were examined. Routine histological slides were stained with Masson's trichrome. In addition, an indirect immunohistochemical method was used to study the occurrence and distribution of nerves immunoreactive for the neuropeptides vasoactive intestinal polypeptide (VIP), neuropeptide Y (NPY), substance P (SP) and calcitonin gene-related peptide (CGRP). Immunoreactivity to tyrosine hydroxylase (TH), dopamine-B-hydroxylase (DBH) and to protein gene product (PGP) 9.5, a general nerve marker, were also studied. RESULTS: The UVJ comprised a ureteric muscle component (the intramural ureter) and a detrusor component (the immediately adjacent region of the urinary bladder). In the majority of specimens a third or intermediate layer was also present. This additional component consisted of tightly-packed smooth muscle cells which formed an incomplete layer that partially surrounded the juxta-vesical and intramural parts of the ureter. Numerous PGP-, VIP-, NPY, DBH- and TH- like immunoreactive (-LIR) nerves were associated with the smooth muscle bundles which comprised the intramural ureter. Such nerves ran in the connective tissue separating ureteric smooth muscle bundles and rarely coursed amongst individual smooth muscle cell comprising each bundle. SP- and CGRP- containing nerves were rarely observed in association with the intramural ureter and none were detected in the ureteric submucosa. The intermediate muscle layer was richly innervated by PGP-, TH-, DBH- and NPY- containing nerves which ran amongst the smooth muscle cells comprising this layer. VIP-, SP- and CGRP-LIR nerves were not observed within the intermediate layer. The detrusor component of the UVJ was innervated by PGP-, NPY- and VIP-LIR nerves which frequently extended between the smooth muscle cells forming the detrusor muscle bundles. TH-, DBH-, SP- and CGRP-LIR nerve fibres were rarely encountered. CONCLUSION: These findings indicate that noradrenergic nerves play a major role in the control of the ureteric component of the UVJ. In addition, the present results form baseline morphological data with which to compare the results of future studies on the structure of the UVJ in cases of vesicoureteric reflux.

    Title Techniques to Create Continence in the Failed Bladder Exstrophy Closure Patient.
    Date August 1993
    Journal The Journal of Urology
    Excerpt

    We reviewed retrospectively 315 patients with bladder exstrophy treated at our hospital between July 1976 and April 1992 to assess the outcome of those who failed primary closure of the bladder. Of the patients 47 required reclosure of the bladder, including 28 who have undergone a procedure to restore urinary continence. Methods used to achieve dryness included bladder neck reconstruction in 18 patients, bladder neck reconstruction along with augmentation in 4, augmentation alone in 4, repeat bladder neck reconstruction in 1, and reclosure with creation of a continent stoma and augmentation in 1. Nine of 18 patients who underwent primary bladder neck reconstruction are dry on intermittent catheterization, while 8 of the remaining 9 are dry and voiding without catheterization. Four patients who underwent primary bladder neck reconstruction and augmentation, and 4 who underwent augmentation after bladder neck reconstruction are dry on intermittent catheterization. The patient who underwent reclosure, bladder augmentation and creation of a continent abdominal stoma is dry on intermittent catheterization. Virtually all patients who failed the initial closure and later bladder neck reconstruction for continence require augmentation and intermittent catheterization to remain dry. Of 28 patients who underwent salvage procedures only 1 had upper tract changes. With attention to detail and the use of a variety of reconstructive techniques children who have failed exstrophy closure can achieve continence and have stable renal function.

    Title The Cephalotrigonal Reimplant in Bladder Neck Reconstruction for Patients with Exstrophy or Epispadias.
    Date July 1993
    Journal The Journal of Urology
    Excerpt

    A modified technique of ureteroneocystostomy with bladder neck plasty was used in 36 of 75 patients undergoing staged repair of bladder exstrophy or epispadias between 1986 and 1992. This procedure entails mobilizing the ureter while preserving the trigonal hiatus as with the cross-trigonal technique. The distal ureteral segments are directed superiorly toward the bladder dome rather than across the mid line. Of 75 patients 36 underwent cephalotrigonal reimplantation and 39 had a conventional cross-trigonal reimplant. Continence rate was 77% in the patients who underwent cephalotrigonal reimplantation and 72% in those who had a cross-trigonal reimplant. No patient had ureteral obstruction or vesicoureteral reflux. The ureter in exstrophy patients enters the bladder from an inferior position within the true pelvis. Directing the ureter superiorly rather than across the mid line provides a more gradual course through the hiatus and submucosal tunnel. The cranial course of the distal ureter frees more of the trigone for use in the rolled segment of the bladder neck and provides more muscle area for the tube. This is especially important in the patient in whom the distance between the mid prostate and trigone is particularly short.

    Title An Immunohistochemical Study of Human Postnatal Paraganglia Associated with the Urinary Bladder.
    Date July 1993
    Journal Journal of Anatomy
    Excerpt

    Histological and immunohistochemical methods were used to study pelvic paraganglia in a series of human postnatal specimens ranging in age from 1 month to 6 y. Up to 5 months of age, many of the encapsulated paraganglia contained small pacinian-like sensory corpuscles which occurred either singly or in small clusters, implying an unknown functional interrelationship during this period. In older specimens, this intimate association was not observed since pacinian corpuscles and small nonencapsulated clusters of paraganglion cells were observed only as separate structures. It is suggested that the paraganglion cells may induce the formation of the pacinian corpuscles during fetal development. Immunohistochemistry using the nerve marker protein gene product (PGP 9.5) demonstrated a rich plexus of varicose nerve fibres within the paraganglia which may directly innervate the paraganglion cells and/or be associated with the profuse vascular supply. A similar density of vasoactive intestinal polypeptide-containing nerves was also demonstrated while some of the nerves contained calcitonin gene related peptide or substance P. The paraganglion cells stained positively for tyrosine hydroxylase, dopamine-beta-hydroxylase and neuropeptide Y, but not for phenylethanolamine N-methyltransferase. This combination of immunostaining confirms them as a rich source of noradrenaline.

    Title Nonsurgical Management of Primary Vesicoureteral Reflux in Complete Ureteral Duplication: is It Justified?
    Date December 1991
    Journal The Journal of Urology
    Excerpt

    We reviewed the treatment of 56 children with vesicoureteral reflux and complete duplication of the collecting system, including 14 who had complete bilateral duplication. A total of 70 refluxing duplicated systems was analyzed. Of the patients 18% demonstrated spontaneous resolution of reflux within 42 months, 23% are currently stable on prophylactic antibiotics and 57.1% underwent surgical correction. Spontaneous resolution of reflux occurred in 58% of the children with grades I to III/V reflux. In comparing the group with reflux and duplication to a group with reflux into single systems, we conclude that the patients with duplication and lower grades of reflux can be managed nonoperatively, while infection is prevented with antibiotic prophylaxis.

    Title Failed Bladder Neck Reconstruction: Options for Management.
    Date October 1991
    Journal The Journal of Urology
    Excerpt

    During the last 10 years 17 patients have been seen at this institution for persistent urinary incontinence after Young-Dees-Leadbetter bladder neck reconstruction. Of these patients 16 were born with classical bladder exstrophy and 1 with complete epispadias. Six patients underwent 1, 10 underwent 2 and 1 underwent 3 prior bladder neck procedures. As salvage procedures 8 patients underwent another Young-Dees-Leadbetter procedure, 1 repeat bladder neck reconstruction and augmentation cystoplasty, 3 augmentation alone, 4 bladder augmentation with creation of a continent abdominal stoma and 1 augmentation with implantation of an artificial urinary sphincter. Of the 8 patients who underwent a repeat Young-Dees-Leadbetter procedure 7 are dry for 3 hours or more and 1 is dry for greater than 3 hours on intermittent self-catheterization. All of those who are dry for greater than 3 hours are dry at night and 1 wears pads when engaging in strenuous physical activity. Of the 9 patients who underwent augmentation cystoplasty along with other adjunctive procedures 8 are continent for greater than 3 hours on intermittent catheterization, 6 are dry at night if they perform catheterization at bedtime and 1 remains totally incontinent after removal of the artificial urinary sphincter. Thus, with persistence and creativity a child with a previously failed bladder neck reconstruction or even multiple failed repairs can be made socially continent, providing a satisfactory alternative without resorting to urinary diversion.

    Title Endoscopic Injection of Glutaraldehyde Cross-linked Bovine Dermal Collagen for Correction of Vesicoureteral Reflux.
    Date January 1991
    Journal The Journal of Urology
    Excerpt

    From November 1986 through May 1989, a Food and Drug Administration approved investigational study was done to assess the safety and efficacy of glutaraldehyde cross-linked bovine dermal collagen in the endoscopic treatment of vesicoureteral reflux. Over-all, 57 patients (92 ureters) were treated. The majority of ureters (68.5%) had grade II to III/V vesicoureteral reflux (international classification). One treatment was given in 61.4% of the patients, while 33.3% required 2 and 5.3% required 3 treatments. Nonduplicated/primarily refluxing ureters comprised 68.5% of the total, while 13% were duplex/primarily refluxing and 18.5% were surgical failures. The procedures were performed on an outpatient basis in all but 3 patients. Patients were evaluated by voiding cystourethrogram and renal/bladder sonography before and after treatment at 1 month and 1 year. Cure at 1 month after the last treatment was achieved in 75% of the ureters. Among the ureters cured at 1 month the cure persisted in 79% at 1 year after treatment. Cure at 1 year was achieved in 65% of all ureters evaluated, regardless of the status at 1 month. Procedure-related morbidity was minimal and there were no adverse reactions to the implant substance. Thus, glutaraldehyde cross-linked bovine dermal collagen appears to be safe and effective in the endoscopic treatment of vesicoureteral reflux.

    Title Local Tissue Reaction to the Subureteral Injection of Glutaraldehyde Cross-linked Bovine Collagen in Humans.
    Date June 1990
    Journal The Journal of Urology
    Excerpt

    Although the technique of subureteral injection has been widely accepted as an alternative to reimplantation in the treatment of vesicoureteral reflux, the choice of the material to be used is controversial. We have used glutaraldehyde cross-linked bovine collagen to correct vesicoureteral reflux within the context of a Food and Drug Administration approved investigational study. We report the local tissue reaction to the implanted collagen in 7 patients who underwent reimplantation 3 to 19 months after failed endoscopic therapy. Glutaraldehyde cross-linked bovine collagen engendered a minimal localized inflammatory reaction without causing granuloma formation. Subsequent reimplantation was not hindered by the presence of the implant materials.

    Title Suspected Testicular Torsion and Ischemia: Evaluation with Color Doppler Sonography.
    Date June 1990
    Journal Radiology
    Excerpt

    Color Doppler sonography was performed in 32 patients with a painful scrotum in whom testicular ischemia from torsion or postherniorrhaphy was clinically suspected. Surgical correlation was available in 15 patients, and scintigraphic correlation was available in 17 patients. Seven of the 32 patients were diagnosed as having testicular ischemia from torsion. Color Doppler flow imaging demonstrated a lack of intratesticular flow in six of the seven testes with torsion and relatively normal intratesticular flow in one of the patients with acute torsion. Normal or increased intratesticular flow was demonstrated by color Doppler in all 57 of the nonischemic testes. Using the single criterion of presence or absence of identifiable intratesticular flow, the authors found that color Doppler was 86% sensitive, 100% specific, and 97% accurate in the diagnosis of torsion and ischemia in the painful scrotum. Color Doppler sonography is an accurate, noninvasive means of rapidly assessing perfusion of the testis in the painful scrotum.

    Title Nutritional Consequences of Bowel Segments in the Lower Urinary Tract.
    Date August 1989
    Journal The Journal of Urology
    Excerpt

    To assess for altered fat absorption in a group of 26 patients who underwent bladder replacement or augmentation between 1975 and 1988 serum samples were assayed for levels of B12 and carotene. Reconstruction was done with ileum and/or cecum in 22 patients, and 4 who had undergone sigmoid cystoplasty and were not expected to be at risk for fat malabsorption were included as controls. Followup ranged from 4 months to more than 8 years. No patient demonstrated low values of B12 or carotene regardless of postoperative duration, bowel segment location or length of segment. Use of ileal segments less than 45 cm. long even with associated incorporation of the ileocecal valve and adjacent cecum does not appear to compromise fat absorption or the enterohepatic circulation.

    Title A New Technique of Using the in Situ Appendix As a Catheterizable Stoma in Continent Urinary Reservoirs.
    Date June 1989
    Journal The Journal of Urology
    Excerpt

    A new technique of using the in situ appendix to construct a continent catheterizable stoma is described in a patient who underwent continent urinary diversion, and the technical aspects of this procedure are illustrated in detail. The appendix is remodeled by invaginating its base into the cecum for 1 cm., cecoplicating the middle portion for 2 cm. and bringing the distal end to the skin as a cutaneous stoma. This new technique demonstrates that the in situ appendix can be constructed successfully to provide continence without the need for isolating it from the cecum and implanting the distal end into the urinary reservoir as described in the Mitrofanoff technique.

    Title Testicular Torsion in a 62-year Old Man.
    Date July 1987
    Journal The Journal of Urology
    Excerpt

    A 62-year-old man is described who had surgically confirmed testicular torsion. This is the second oldest reported patient with this condition. Although uncommon in men more than 30 years old, this diagnosis should be considered when evaluating the acute scrotum in all age groups.

    Title Predictors of Recurrent Clinical Stage I Nonseminomatous Testicular Cancer. A Prospective Clinicopathologic Study.
    Date July 1986
    Journal Urology
    Excerpt

    A prospective clinicopathologic study of 60 patients with clinical Stage I nonseminomatous testicular cancer (NSTC) has been reported. Of 60 patients with clinical Stage I NSTC who underwent retroperitoneal lymphadenectomy (RPLA), 6 proved to be Stage II, a staging error of 10 per cent. In 4 patients of the remaining 54, metastases developed in the lungs. In 1 patient metastases developed both in the lung and in retroperitoneal lymph nodes. There was no death in these groups of patients. These 10 patients with staging error and/or recurrence after RPLA have been analyzed for the causes of treatment failure utilizing a set of prognostic criteria (tumor cell type, vascular or lymphatic invasion in the primary tumor, extension to the spermatic cord, and size of the primary tumors). It has been concluded that embryonal carcinoma (P less than 0.001), vascular invasion (P less than 0.001), and extension of the tumor to the spermatic cord (P less than 0.001) are significant predictors of metastases and/or recurrence after RPLA in Stage I NSTC. A plan of management is suggested based on these criteria.

    Title Testicular Compartment Syndrome: a New Approach to Conceptualizing and Managing Testicular Torsion.
    Date
    Journal Urology
    Excerpt

    OBJECTIVES: Decompression of compartment syndrome is known to salvage tissues in numerous organ systems. To demonstrate evidence that testes exposed to prolonged ischemia exhibit compartment syndrome physiology and propose a novel technique in treating this phenomenon. METHODS: Three boys, aged 11, 14, and 16 years, with prolonged testicular torsion lasting 6-7 hours were taken to the operating room. All testes appeared dusky and congested on manual detorsion. Testicular fasciotomy was performed by making a longitudinal incision in the tunica albuginea. The coloration of all testes improved dramatically. When the tunica albuginea was reapproximated, each testis returned to an ischemic appearance. The tunica albuginea was again opened. A harvested tunica vaginalis patch was placed over the exposed seminiferous tubules and secured in place. In the case of the 11-year-old boy, a handheld compartment monitor needle was used to measure the compartment pressure at all stages of the procedure. RESULTS: All testes maintained a well-perfused coloration at completion of the procedure. The compartment pressures in the testis of the 11-year-old boy (diastolic pressure 52 mm Hg) were as follows: 34 mm Hg after detorsion, 5 mm Hg after testicular fasciotomy, 46 mm Hg after reapproximation of the tunica albuginea, 3 mm Hg on repeat fasciotomy, and 5 mm Hg after tunica vaginalis patch application. CONCLUSIONS: Testicular compartment pressures appear elevated after prolonged torsion. Testicular fasciotomy, combined with a tunica vaginalis patch, relieved testicular compartment syndrome. Additional investigation is warranted to determine whether this technique affords improved preservation of testicular tissues.

    Title Cryptorchid Testis Histopathology in Myelomeningocele Patients.
    Date
    Journal Journal of Pediatric Urology
    Excerpt

    PURPOSE: Cryptorchidism occurs in 25% of boys with myelomeningocele (MMC) compared to 3% of the general population. Testicular biopsy histopathology correlates with future sperm counts. We studied testicular histology in boys with cryptorchidism and MMC to investigate if the MMC influences histological findings. MATERIALS AND METHODS: The study group consisted of six patients with MMC and undescended testis (UDT) who underwent orchiopexy and bilateral testis biopsy. Twelve testicular biopsies from six patients were compared to 40 biopsies from 20 UDT-only controls. Total germ cell count per tubule (TGC/T) and the percentage of adult dark spermatogonia (%Ad) in undescended and contralateral descended testes from the patients were compared with controls. RESULTS: In the study group, two had total absence of germ cells (TGC/T=0) and three had severely reduced germ cells (TGC/T<0.2). Four had total absence of Ad spermatogonia and the remaining two had severely reduced Ad spermatogonia (%Ad=5). The mean TGC/T and %Ad in patients with UDT and MMC were conspicuously lower than controls. The differences did not reach statistical significance (P=0.09-0.29). CONCLUSION: These results suggest that patients with both MMC and UDT have a more severe reduction in total number and more severely delayed maturation of germ cells than do patients with UDT alone. With only six patients in this study, there was not the power to detect statistical significance. In addition to the reproductive problems due to erection and ejaculatory dysfunction in patients with MMC, this severe testicular histopathology may increase the risk of subfertility.

    Title Histological Findings in Patients with Cryptorchidism and Testis-epididymis Nonfusion.
    Date
    Journal The Journal of Urology
    Excerpt

    Fusion anomalies of the testis and epididymis are associated with cryptorchidism. The bilateral histology of the cryptorchid testis associated with the nonfused epididymis has not been reported previously.

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