Inhibin B: comparison with indexes of fertility among formerly cryptorchid and control men.

Infertility may be a consequence of cryptorchidism. We previously reported, using a large study cohort, that 38% of formerly bilateral cryptorchid men, 10% of unilateral cryptorchid men, and 5% of the control group were infertile. Men from this cohort donated blood and semen samples for inhibin B, FSH, LH, testosterone, free testosterone, and semen analyses. Results are reported comparing the entire group; some comparisons are based on normal or low sperm density. Data are also presented for men who had fathered children or had unsuccessfully attempted paternity. Mean (+/-SD) inhibin B levels were lower for the cryptorchid men (109 +/- 59 pg/mL) than the control men (153 +/- 60; P < 0.001), and FSH levels were higher (7.4 +/- 6.2 and 4.0 +/- 3.2; P < 0.0001). Inhibin B levels correlated with all other parameters for the cryptorchid group; however, correlations for the control group were only found with gonadotropins. Among the cryptorchid men, levels were significantly greater among men with normal sperm counts than men with low sperm counts (124 +/- 47 vs. 75 +/- 48 pg/mL; P < 0.0001). No difference was present for the control group (155 +/- 61 vs. 149 +/- 63 pg/mL). When the fertile group (based on paternity) vs. the infertile group (based on attempted paternity) were compared, significant differences were found for the cryptorchid group (117 +/- 62 vs. 73 +/- 52 pg/mL; P < 0.03), but not the control group (163 +/- 62 vs. 146 +/- 73 pg/mL). These data reveal relationships not apparent among the control group of men, which includes infertile men. Inhibin B data suggest that a larger portion of formerly cryptorchid men have compromised testicular function than indicated by paternity data. Low levels of inhibin B among individuals are an indication of diminished seminiferous tubule function and thus compromised potential for fertility. Low inhibin B levels together with elevated FSH levels and decreased sperm density are indicative of a high risk of infertility.

Postoperative necrotizing fasciitis in children.

Necrotizing fasciitis is a rapidly progressive soft tissue infection, involving the skin, subcutaneous tissue, and superficial fascia. It is a rare but life-threatening complication in the postoperative patient. In the last 7 years, we have treated four children in whom necrotizing fasciitis developed after appendectomy for ruptured appendix, bilateral inguinal herniorrhaphy, or gastrostomy closure. These four patients and seven well-described children from the literature with necrotizing fasciitis following surgery form the basis of this review. The ages ranged from six days to 15 years (mean 4.5 years). There were eight boys and three girls. There were five clean, five clean-contaminated, and one contaminated surgical procedures. No patient had evidence of malignancy or diabetes. Two of our four patients had evidence of failure to thrive. Only one patient had an intraabdominal abscess. In ten, the infection started in the abdominal wall; in one, the infection started in the chest wall. In our four patients, three had neutropenia and fever, four had tachycardia, and two had wound crepitation and radiographic evidence of subcutaneous gas. Cultures of all ten wounds were positive for bacteria; six were positive for more than one organism. Blood culture results were positive in five of five patients who died and in only two of five patients who survived. All survivors had wide surgical debridement and were treated with broad-spectrum antibiotics. The mortality rate was 45% in the whole series.(ABSTRACT TRUNCATED AT 250 WORDS)

Paternity after unilateral cryptorchidism: a controlled study.

OBJECTIVE: To determine if paternity is decreased among formerly unilateral cryptorchid men compared with a control group of men. SUBJECTS AND METHODS: Formerly unilateral cryptorchid men who had orchiopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh and a group of control men have had their medical records reviewed and have been surveyed by questionnaire. RESULTS: Among the men who had ever married and had attempted paternity, significantly more of the unilateral cryptorchid men had been unable to father children (10.5%) than among the control group (5.4%). No difference was found when the groups were compared for the duration of regular intercourse without contraception to conception of their first child. There was no relationship between the age of orchiopexy or lifestyle factors and paternity or between the age of orchiopexy and months of regular unprotected intercourse to conception. Paternity among both groups was related to female-related infertility factors and to the presence of varicoceles. CONCLUSION: When compared with a control group, paternity was compromised after unilateral cryptorchidism. Infertility is about twice as frequent among the unilateral group. There was no evidence of subfertility requiring a longer exposure of regular intercourse without contraception among the fertile subgroup. No correlation was found between age of orchiopexy and paternity.

Paternity after bilateral cryptorchidism. A controlled study.

OBJECTIVE: To compare paternity among men with former bilateral cryptorchidism (referred to as the bilateral group) with a group of men with former unilateral cryptorchidism (referred to as the unilateral group) and a control group. DESIGN: Epidemiologic survey of study cohort. SETTING: Large urban pediatric hospital. SUBJECTS: Men with former bilateral and unilateral cryptorchidism who underwent orchiopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh, Pittsburgh, Pa, and a group of control men have been surveyed by questionnaire concerning paternity and factors related to paternity. MAIN OUTCOME MEASURE: Paternity. RESULTS: Among the married men who had bilateral cryptorchidism, 50% had fathered children, compared with 76% in the control group and 74% in the unilateral group. Data were similar when the men who were cohabitating were included with the married men. When men who had married and had attempted paternity were evaluated, 62% of the men in the bilateral group had been able to father children compared with 94% of the control group and 89% of the men in the unilateral group. No relationship was noted between the age of orchiopexy or lifestyle factors and paternity. Paternity among all groups was related to female-related infertility factors and to the presence of varicoceles. CONCLUSIONS: Paternity was compromised after bilateral cryptorchidism when compared with men with former unilateral cryptorchidism and a control group. Among the bilateral group, infertility is about 3.5 times as frequent than the unilateral group and more than 6 times as frequent among the control group. No correlation was found between age of orchiopexy and paternity for either group.

Optical valvulotomy for urethral valves using a hook-blade cold knife.

Endoscopic disruption of urethral valves remains a mainstay of the pediatric urologic armamentarium. We describe transurethral optical valvulotomy using a hook-blade cold knife as a safer alternative to valve resection using a wire loop electrode. This technique offers precise control of the resection process and freedom from inadvertent injury to the urethra or sphincter due to a "hot" electrode.

Paratesticular liposarcoma.

The fifteenth reported case of paratesticular liposarcoma is presented, together with a review of the literature. The prognostic and therapeutic implications of this particular neoplasm are discussed.

Absence of microdeletions in the Y chromosome in patients with a history of cryptorchidism and azoospermia or oligospermia.

OBJECTIVE: To determine if cryptorchidism is associated with microdeletions of interval 6 of the Y chromosome, we evaluated this locus in men with a history of cryptorchidism with and without azoospermia or oligospermia and in a control group. DESIGN: Clinical study. SETTING: Academic research environment. PATIENT(S): Men in whom surgical treatment of cryptorchidism had been performed in childhood and healthy control male subjects. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Genotyping of interval 6 of the Y chromosome. RESULT(S): Analysis of semen obtained from men treated for cryptorchidism in childhood showed azoospermia or oligospermia in 14 of 38 (37%) men. No microdeletions were identified with polymerase chain reaction amplification of 17 distinct sequence tagged sites located on the long arm of the Y chromosome and the sex determining region on Y (SRY) gene. CONCLUSION(S): Microdeletions of interval 6 of the Y chromosome were not detected in either the formerly cryptorchid or in the healthy subjects. Although we cannot exclude the possibility of point mutations, we conclude that cryptorchidism or cryptorchidism associated with azoospermia or oligospermia is not due to microdeletions involving interval 6 of the Y chromosome.

Time to conception after orchidopexy: evidence for subfertility?

OBJECTIVE: To determine whether time to conception is increased among men who were formerly bilaterally or unilaterally cryptorchid compared with a group of matched control men. DESIGN: Retrospective cohort study. SETTING: Human volunteers in an academic research environment. PATIENT(S): Men who underwent orchidopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh (n = 547) and a group of matched control men (n = 463) were surveyed by questionnaire. RESULT(S): Of the men who attempted paternity, the mean time to conception for the bilateral cases, unilateral cases, and control men was 33.90, 11.11, and 8.78 months, respectively. Kaplan-Meier survival analysis showed a significantly longer time to conception among bilateral cases compared with unilateral cases and controls, but not between unilateral cases and control men. Adjustment for confounders and covariates using a Cox Proportional Hazards model showed that former bilaterally cryptorchid men were 68% (95% CI = 55% to 81%) less likely than former unilaterally cryptorchid men or controls to conceive per month of unprotected intercourse. CONCLUSION(S): Time to conception was increased among former bilaterally cryptorchid men compared with both former unilaterally cryptorchid and control men. However, there were no significant differences in time to conception between the unilateral cryptorchid men and the control men.

The management of vesicoureteric reflux.

An increasingly large volume of data is being accumulated regarding the effects of vesicoureteric reflux on the kidney, data that influence clinical management. Although concrete guidelines cannot be drawn that will apply to all patients, important considerations include the following: All children with documented urinary infections should have a voiding cystourethrogram. The voiding cystourethrogram may correlate with probability of spontaneous resolution of vesicoureteric reflux. Younger patients have a higher chance of spontaneous resolution of vesicoureteric reflux. There is a definite familial tendency to vesicoureteric reflux, and patients with significant vesicoureteric reflux and scarring are more likely to have affected siblings. DMSA renal scanning is highly sensitive in the detection of scarring. Cystoscopy may play a role in the evaluation of the refluxing ureterovesical junction, but does not have as much prognostic significance as the voiding cystourethrogram. Urodynamic investigation may be important in evaluating children with urinary infections, reflux, and symptoms of voiding dysfunction. High-grade vesicoureteric reflux is associated with an increased incidence of renal scarring, and the answer to optimal management is not yet available. Most scarring occurs in infancy or childhood. Nonoperative management, especially in moderate degrees of reflux, can achieve a high rate of success. Nonoperative management requires continuous antibiotic prophylaxis. Breakthrough infections or lack of compliance with nonsurgical management have a high complication rate and must be managed aggressively. Antireflux surgery can be performed with a minimal complication rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Lacuna magna: a hidden cause of dysuria and bloody spotting in boys.

Intermittent hematuria, dysuria, or bloody spotting of underwear are symptoms occasionally seen in young boys. The lacuna magna (valve of Guerin) is a common embryologic remnant often found to be the cause of these symptoms. While retrograde urethrography may occasionally be helpful, voiding films that include the distal penile urethra usually establish the diagnosis. Transmeatal excision or incision of the valve-like leaflet is curative, but often the problem is benign and self-limiting even without treatment.

Testicular suture: a significant risk factor for infertility among formerly cryptorchid men.

BACKGROUND/PURPOSE: Although fertility is decreased after cryptorchidism, the importance of risk factors, including parenchymal testicular suture, is unknown. The aim of this study was to examine the relationship between parenchymal testicular suture and failure to conceive a child for 1 year or longer among formerly cryptorchid men. METHODS: Men who underwent orchidopexy between 1955 and 1972 at the Children's Hospital of Pittsburgh (n = 619) were surveyed by questionnaire and their medical records reviewed. Only the men who attempted to conceive a child (n = 387) are included. RESULTS: Logistic regression analysis determined significant risk factors for infertility. Testicular suture was strongly related to infertility (RR, 7.56; 95% CI, 1.66, 34.39) as were bilateral cryptorchidism (RR, 5.51; 95% CI, 1.58, 19.24), varicocele (RR, 4.72; 95% CI, 1.42, 15.75), hormone treatment before surgery (RR, 3.69; 95% CI, 1.22, 11.11), and partner conception problem (RR, 3.32; 95% CI, 1.11, 9.90). CONCLUSIONS: Testicular suture was a potent independent determinant of infertility among formerly cryptorchid men who have orchidopexy. Bilateral cryptorchidism, hormone treatment, varicocele, and partner conception problems also were associated with increased infertility.

Subtotal de-epithelialization and partial concealment of the glans clitoris: a modification to improve the cosmetic results of feminizing genitoplasty.

An unsatisfactory appearance of the external genitalia after otherwise successful genitoplasty may result from failure to reduce the size of a hypertrophied glans clitoris and change its appearance from a large bulbous structure to a small conical cap. A more pleasing cosmetic result can be achieved by modifying a technique for glansplasty originally described by Lattimer: subtotal glans de-epithelialization and partial glans concealment. Six patients with virilized external genitalia (3 with congenital adrenal hyperplasia, 2 with gonadal dysgenesis and 1 true hermaphrodite) underwent feminizing genitoplasty using this modified technique at ages 3 to 13 months. All patients have achieved pleasing cosmetic results that are vastly superior to our experience with other methods for clitoral reduction.

Ureterocystoplasty update.

Ureterocystoplasty is a unique method for bladder augmentation that lines the bladder with transitional epithelium and avoids the potential complications associated with enterocystoplasty. Seven patients have undergone ureterocystoplasty with excellent long-term results. All have maintained good bladder compliance and the contralateral kidney has been protected in all cases.

The blind-ending vas: the fate of the contralateral testis.

From August 1980 to January 1983, 48 testes were explored for orchiopexy (28 unilateral and 20 bilateral testes). Unilateral anorchism (surgically identified blind-ending vas and vessels) was found in 7 of 48 cases (14.5 per cent). One simultaneous and 5 secondary contralateral scrotal explorations confirmed abnormal testicular fixation (bell-clapper deformity) in 5 of 6 testes (83 per cent). During documentation of unilateral anorchism, simultaneous contralateral scrotal exploration should be performed.

Ureterostomy in situ as an aid to reconstructive urologic surgery.

Ureterostomy in situ is a valuable adjunct to reconstructive urologic surgery. While acting as a ureteral splint and safety valve ureterostomy, it offers access for antegrade radiologic and manometric studies and may be used in conjunction with indwelling splints.

Ureterocystoplasty: a unique method for vesical augmentation in children.

Vesical augmentation may be accomplished by using small bowel, large bowel or stomach, and by detrusor myotomy or the autoaugmentation technique. The use of intestinal segments is associated with variable mucus production, electrolyte absorption and the risk of malignant transformation. Autoaugmentation is free of these potential risks but may be unsuccessful in creating sufficient improvement in vesical compliance and capacity. Ureterocystoplasty with a bladder based native ureteral flap has been used in neurovesical dysfunction in association with a nonfunctional refluxing kidney, in a noncompliant valve bladder associated with posterior urethral valves and a nonfunctional kidney, and in augmentation of a small bladder after closure of cloacal exstrophy. Adequate bladder capacity and compliance have been achieved without the use of extra urinary epithelium. The surgical approach is simple and uncomplicated. Ureterocystoplasty in selected cases will provide for adequate bladder capacity and compliance when augmentation cystoplasty is required.