Testicular histology in the adolescent with a varicocele.

A varicocele is a common cause of adult male infertility, and surgical ligation is a generally accepted mode of therapy. However, the guidelines for management of the adolescent with a varicocele are not clearly defined. Herein, we describe histologic abnormalities noted on testis biopsy in nine of 24 boys with moderate to large varicoceles. Surgical ligation of the varicocele is recommended when there is volume loss of the testis ipsilateral to the varicocele. All others should be reexamined periodically, and an attempt should be made to obtain a baseline semen analysis.

Ectopic ureter opening into seminal vesicle cyst associated with ipsilateral renal agenesis.

An unusual case is presented of an ectopic ureter entering into a seminal vesicle cyst associated with ipsilateral renal agenesis. The embryologic explanation of this anomaly is reviewed, and the differential diagnosis and management highlighted.

Transient acute renal failure in the neonate.

We have observed a transient renal insufficiency in newborns associated with ultrasonographic finding of hyperechoic renal pyramids. This condition rapidly resolves, coinciding with both normalization of the renal ultrasound and the occurrence of significant proteinuria. Others have recognized a similar state of oliguria and cylindruria associated with a prolonged nephrogram on intravenous urography in newborns. There is evidence to suggest that hyaline cast deposition within the collecting tubules may account for these imaging abnormalities. The precise events surrounding the protein deposition are unknown, and it may be either the cause or the result from the transient renal dysfunction. Our 2 cases add to the evidence that there is a distinct entity of acute renal dysfunction, with identifying characteristics, in neonates associated with a good prognosis and rapid resolution.

Pituitary gonadal dysfunction in adolescents with varicocele.

Gonadotropin-releasing hormone stimulation testing was performed on 104 adolescent males with a unilateral left varicocele to determine the frequency of testicular dysfunction in this group of patients. An abnormal test result was noted in approximately 30 percent of varicocele patients. We believe that an abnormal test result indicates a higher risk for future fertility problems, and early treatment may reduce this risk.

Contemporary techniques for the radioisotopic evaluation of the dilated urinary tract.

Regardless of one's approach to the evaluation of hydronephrosis, nuclear imaging should be part of every child's evaluation, as it is the only imaging modality capable of providing significant renal function information. The studies can easily be performed on an outpatient basis without sedation. Diuretic renal scintigraphy is deceptively simple to perform, and commitment to detail is exceedingly important if the results are to be valid. Radioisotope transit time may also be helpful, although its calculation is technically difficult. Determination of the function of the kidneys individually is possible by several methods.

Evaluation and management of upper urinary tract obstruction in infancy and childhood.

Our clinical experience over the past 5 years would suggest that both the diuretic renogram and the Whitaker study permit an objective and quantitative assessment of urinary obstruction. The diagnostic accuracy of both studies exceeds 90 per cent, although neither study has proved to be infallible. Both have potential sources of error that must be monitored carefully if their reliability is to be maximized. Potential sources of error in the diuretic renogram include the state of hydration, renal functional status, distensibility and volume of the collecting system, a filled bladder, and ability to respond to the diuretic. Its reliability can be increased if the standard testing protocol is followed, the study closely monitored, and the limitations of the test realized. Interpretation of the diuretic renogram based only upon the appearance of the washout curve without consideration of the calculated half time or the sequential analogue images is unreliable and in our experience would have been responsible for an incorrect interpretation in 40 per cent of patients. The diuretic renal scan is used as the initial testing modality because it is reliable, reproducible, noninvasive, and objective and provides important information concerning individual renal function. Over 80 per cent of children with hydronephrosis can be completely evaluated by the diuretic renogram alone without the need for more invasive testing modalities. Nevertheless, the pressure perfusion study will continue to be necessary for the evaluation of certain individuals. Because of its invasive nature, we prefer to reserve this study for very specific, well-defined circumstances.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent varicocele.

Currently, we recommend varicocele repair in adolescents when (1) the results of semen analysis are abnormal, (2) the volume of the left testis is at least 3 mL less than that of the right, (3) the response of either luteinizing hormone or FSH to Gn-RH stimulation is supranormal, (4) bilaterally palpable varicoceles are detected, or (5) a large symptomatic varicocele is present. When surgery is necessary, the Palomo approach significantly decreases the risk of operative failure and has facilitated "catch-up" growth of the left testis that is comparable to that after artery-sparing procedures. It is important to note that there is potential for impaired fertility whenever a palpable varicocele is present. Unfortunately, no test or group of tests can predict with absolute certainty whether an adolescent with a varicocele will be fertile or infertile. Therefore, it is important to observe untreated patients until they complete their families. Patients who are unwilling or unable to adhere to the follow-up protocol may be candidates for surgical intervention.

Primary hydronephrosis. Assessment of diuretic renography, pelvis perfusion pressure, operative findings, and renal and ureteral histology.

Hydronephrosis generally implies ureteropelvic junction obstruction, but may be mimicked by a variety of other disorders. The authors have attempted to determine the relative diagnostic value of diuretic renography and the pelvis perfusion test in children with hydronephrosis by correlating the results with operative findings, renal and ureteral histology, and postoperative results.

Adolescent varicocele.

The evaluation and management of adolescents with varicoceles continue to evolve. Current recommendations for repair are based on the findings of impaired testicular growth or spermatogenesis; however, with early evaluation and selective treatment, clinicians should be able to reduce the potential for future fertility problems significantly in adolescents with varicoceles.

The acute scrotum.

Every boy with acute onset scrotal pain and swelling requires an immediate evaluation. Our protocol (Fig. 6) for the evaluation of these children is based on the history and physical examination combined with the selective use of imaging studies. When used appropriately, this protocol facilitates the rapid identification of children with torsion and minimizes the number of unnecessary scrotal explorations. When the duration of the pain is brief, and history and physical examination suggest that torsion is the most likely diagnosis, urgent surgical exploration without additional imaging studies is recommended. When it is not possible to definitely diagnose or exclude the diagnosis of testicular torsion, or when the duration of pain is greater than 12 hours, then diagnostic imaging can provide significant information. Color Doppler sonography is, in the authors' opinion, preferable to nuclear imaging for the evaluation of children with acute scrotums. When normal or increased blood flow is present, scrotal exploration is not required. When the study demonstrates decreased blood flow or does not provide a definite diagnosis, scrotal exploration is recommended. The authors recommend this approach because less than one third of these children have testicular torsion, and if routine scrotal exploration is performed for all boys with acute scrotums, a significant number of unnecessary surgical procedures will result.

The significance of elevated scrotal temperature in an adolescent with a varicocele.

Simultaneous measurements of left and right scrotal, and axillary skin temperatures were recorded in 58 consecutive adolescents (mean age 14.4 years) with a grade II-III left sided varicocele, and nine control adolescents without genital pathology (mean age 15.7 years). Left and right testicular volumes were determined in both groups. The adolescents with a varicocele had a significant bilateral elevation of the scrotal temperatures compared to the control subjects. This relative hyperthermia was present in both supine and standing positions. The mean left scrotal temperature of varicocele patients was significantly higher in the standing position than in the supine position, which may reflect the dependent venous filling of the varicocele. Those varicocele patients who maintained a left scrotal temperature at least 1.4 degrees C cooler than axillary did not have significant left testicular volume loss, whereas those whose left temperature was approximately equal to axillary did have significant growth retardation of the left testis. Following successful varicocele surgery, left scrotal temperatures were significantly cooler, and statistically indistinguishable from controls. The left testicular volumes were also significantly improved with respect to corresponding right testicular volumes. These observations suggest that adolescents with a moderate to large left varicocele have a significant bilateral loss of testicular thermoregulation. In those individuals with a significantly warmer left hemiscrotum, there is a definite increased potential for left testicular volume loss. Varicocele surgery can reverse this process.

Acute and recurrent urinary tract infections in children.

Urinary tract infection is a common problem in children. Significant renal damage can result from the first episode of urinary tract infection. Early diagnosis, treatment, and evaluation can significantly reduce the potential for renal injury. All children with a potential urinary tract infection should have a reliable urine specimen sent for culture, and if infection is documented, a radiographic evaluation of their urinary system is required.

Dorsal corporeal rotation: an alternative technique for the management of severe chordee.

Chordee with or without hypospadias is usually managed successfully in a fairly straightforward manner. However, on occasion there are patients with severe chordee that cannot be corrected with the standard techniques. In this setting tunica vaginalis grafts, dermal grafts and Nesbit plication techniques have been used but all of these procedures have major drawbacks. During the last 5 years we have used an alternative technique for the correction of severe ventral curvature that persists despite complete resection of fibrous chordee. This technique combines a deep vertical incision between the corporeal bodies ventrally with a series of transverse dorsal plicating sutures to correct chordee. There is no incision into the corporeal bodies and no shortening of the penis as with the Nesbit technique, and potential injury to the neurovascular bundles is minimized. Followup 1 to 5 years later in 6 patients confirms satisfactory chordee correction in all cases.

Reversal of testicular growth failure by varicocele ligation.

A total of 20 male patients 11 to 19 years old had a grade 2 or 3 varicocele and volume loss of the testis ipsilateral to the varicocele. None of these patients presented because of subfertility. Following varicocele ligation a significant increase in volume of the testis ipsilateral to the varicocele was observed in 16 of 20 patients. All 20 patients have been followed for 1 to 6 years. Our results suggest that a moderate to large varicocele can be responsible for testicular growth retardation and that early ligation of the varicocele may reverse this process.

Electrosurgery for routine pediatric penile procedures.

PURPOSE: Traditional teaching in urology has been to avoid electrosurgical devices in penile surgical procedures. In the last several years cutting current has been routinely used on the penis for making skin incisions, degloving, creating Byars flaps and destroying skin bridges. The purpose of this study was to determine the complications and final outcomes of electro-surgery. MATERIALS AND METHODS: A 5-year retrospective chart review was done to determine the complications and final outcomes of exclusively using electrical current to perform pediatric penile procedures. RESULTS: Electrosurgery was used to perform the entire surgical dissection in 346 patients, including circumcision in 124, repeat circumcision in 68, penoscrotal fusion/chordee repair in 127 and skin bridge procedures in 27. All patients had a satisfactory cosmetic result. After correction of penoscrotal fusion, separation at the scrotal suture line in 2 patients healed secondarily without sequelae. There was no hematoma, tissue necrosis or skin sloughing and all surgery was performed on an outpatient basis. CONCLUSIONS: Electrosurgery can be used safely and effectively for routine penile procedures, providing a bloodless operative field and excellent cosmetic results.

Anorexia nervosa and nephrolithiasis.

A patient with primary anorexia nervosa developed acute abdominal pain and hematuria. Cytoscopy and retrograde pyelography confirmed nephrolithiasis. A calcium oxalate stone was passed. The association between anorexia nervosa and nephrolithiasis has not been previously reported. Dietary factors and chronic dehydration are known to contribute to the development of renal stones; therefore, the association may not be coincidental.

Results of varicocele surgery in adolescents: a comparison of techniques.

We report our experience using 3 different operative techniques for varicocele ligation in adolescents. Between August 1985 and April 1991 we performed 102 varicocelectomies on 91 adolescents. Varicocele persistence rate was 16% with a modified Ivanissevich inguinal approach and 11% using a selective high retroperitoneal technique with preservation of the internal spermatic artery. Intraoperative post-ligation spermatic venography did not significantly improve the results with the artery sparing techniques. Palomo mass high retroperitoneal ligation of the internal spermatic vessels produced significantly better results compared to the artery sparing techniques. Testicular atrophy did not occur in any patient regardless of the surgical technique used. These data suggest that the Palomo technique results in a significant decrease in the operative failure rate compared to the artery sparing procedures and it should be the preferred technique for varicocele ligation in the adolescent.