Two-Step Fowler-Stephens orchiopexy for intra-abdominal testes: a 28-year single institution experience.

PURPOSE: Two-Step Fowler-Stephens orchiopexy for high undescended testes allows for mobilization of the testicle to the scrotal position while preserving perfusion by collateral circulation after gonadal vessel ligation. Although used for decades, the long-term efficacy of this procedure has not been reported. We present our 28-year clinical experience with this technique. MATERIALS AND METHODS: We retrospectively studied a cohort of patients who underwent 2-step Fowler-Stephens orchiopexy at our institution between 1982 and 2009. Patients were excluded if either step was performed elsewhere or if followup was less than 6 months. Bivariate and multivariate analyses were performed to determine associations between clinical, surgical and anatomical factors and testicular viability at last followup. RESULTS: A total of 62 patients (79 testes) met inclusion criteria. Median followup was 3.1 years (range 0.6 to 20). Based on the most recent examination/ultrasound, 70.9% of testicles were considered to be normal, with the remainder exhibiting relative (15.2%) or complete (14.9%) atrophy. Of the 10 testes assessed at or after puberty 6 were normal and 4 showed relative atrophy. On bivariate and multivariate analyses only an open second stage approach was associated with normal testicular viability, with 69.9% of normal vs 18.9% of completely atrophic testes being managed by an open approach (p = 0.0084). CONCLUSIONS: Thought to be highly effective in short-term followup, our data suggest that 2-step Fowler-Stephens orchiopexy leads to complete testicular viability in 70.9% of cases. This viability is strongly associated with an open second step.

William T. Bovie and electrosurgery.

For thousands of years human beings have used heat in the form of cautery to treat trauma and disease. By the late nineteenth century, as technology advanced, heat could be produced by electric current. In 1920 William T. Bovie, an eccentric inventor with a doctorate in plant physiology, developed an innovative electrosurgical unit that Harvey Cushing, the founder of modern neurosurgery, introduced to clinical practice. The Bovine unit passes high frequency alternating current into the body allowing the current to cut or coagulate. After 75 years this basic device remains a fundamental tool in the practice of surgery.

Beyond the Trendelenburg position: Friedrich Trendelenburg's life and surgical contributions.

Friedrich Trendelenburg (1844-1924) was a giant figure in the formative years of modern surgical practice. His name lives on in the Trendelenburg position, a pelvis-up, head-down position that is of great use in surgical practice. That position, however, was certainly well known before Trendelenburg and the linkage of his name was by no means the greatest of Trendelenburg's achievements. Trendelenburg was a world class surgeon, innovator, and educator who made novel advances that spanned the entire range of surgical practice.

Hippocrates and urology: the first surgical subspecialty.

Hippocrates, who is generally considered a focal point for the start of western medical tradition, left behind a corpus of medical writings that constituted the first recorded comprehensive health system. The pivotal point of the Hippocratic corpus was the Hippocratic Oath, which outlined the duties of healers of his school, but demarcated lithotomy as a practice that was off limits to his fellow physicians. Surgery for bladder stone, urology in essence, was thus the first specifically identified surgical subspecialty.

Modified dartos pouch orchiopexy.

Experimental evidence suggests that transparenchymal suture fixation may risk testicular damage. Even very small sutures can result in inflammation and tubular damage. An alternative to transparenchymal suture fixation of the testis is presented.

Genitourinary surgery and Arthur Jacobs: father of urology in Glasgow.

Arthur Jacobs (1899-1974) was the father of urology in Glasgow. His extensive experience with genitourinary tuberculosis, ureterosigmoidostomy, and bladder augmentation were far ahead of his time. He became an expert in retropubic prostatectomy and was a pioneer in early imaging techniques.

Distal intussusception of processus vaginalis: a cause of acute hydrocele.

Acute obstruction of a patent processus vaginalis occurred in two boys, mimicking incarceration of an inguinal hernia. In fact, obstruction was caused by an intussusception of the processus vaginalis forming an intussuscipiens that occluded the hernia sac. This lesion, described previously in 1896 and in 1974, is one of the mechanisms by which an asymptomatic hernia or hydrocele becomes acutely symptomatic.

Reed Nesbit and pediatric urology.

OBJECTIVES: To ascertain the pediatric urology experience and contributions of Reed Nesbit, a urologist known primarily as an educator, transurethral resectionist, and prostate expert. METHODS: The writings of Nesbit and appropriate background references were analyzed. RESULTS: Nesbit's contributions to pediatric urology, particularly the Cabot-Nesbit orchidopexy, the buttonhole preputial transposition, the dorsal tunical tuck for chordee, and the elliptical anastomosis were significant. CONCLUSIONS: Nesbit's contributions to pediatric urology were innovative and enduring.

Normal and abnormal pelviscopic anatomy at the internal inguinal ring in boys and the vasal triangle.

OBJECTIVES: We sought to explain and define normal and abnormal laparoscopic pelvic anatomy, which has only recently become the target of much attention. METHODS: The embryology, normal anatomic landmarks, and abnormal findings of the male pelvis, as discerned from more than 350 laparoscopic investigations in boys, were analyzed. RESULTS: The medial umbilical ligament, the wishbone at the internal inguinal ring, the transverse vesical fold, and the vasal triangle are principal laparoscopic landmarks of the male pelvis. Deficient spermatic vessels, abnormal gonadal locations, patent processus vaginalis, single medial umbilical ligament, and transverse testicular ectopia were the abnormal findings. CONCLUSIONS: Laparoscopic familiarity with the male pelvis permits safe and efficient diagnostic and therapeutic navigation in this new surgical arena.

Labial fusion causing upper urinary tract obstruction.

An infant with dense and nearly complete labial fusion had marked hydroureteronephrosis which resolved after incision of the adherent labia. Although this is an unusual consequence of labial fusion, it argues for upper urinary tract screening in these children.

Frederick C. McLellan and clinical cystometrics.

Precise analysis of lower urinary tract function was an unfulfilled dream only a century ago. By the late 19th century, water manometers and plethysmographs were utilized to measure bladder pressures. In the early 1900s, Rose developed a cystometer that was later improved by Munro. In 1938 Frederick C. McLellan, active in clinical research under Reed Nesbit at the University of Michigan, was the first to apply the earlier principles and cystometric tools to a large group of patients and created the first modern paradigm of bladder dysfunction. McLellan's work brought clinical relevance to the cystometer and thus precision to the analysis of lower urinary tract function.

Renal malakoplakia: acute onset of renal failure due to bilateral upper tract involvement.

A case of malakoplakia-induced acute renal failure is presented. In the twenty months following diagnosis the patient remains anuric. Malakoplakia involving the upper urinary tract is not self-limiting and should be considered in the differential diagnosis of acute renal failure.

Treatment of pediatric urethral stricture disease with the neodymium:yttrium-aluminum-garnet laser.

OBJECTIVES: The aim of this study was to assess the efficacy and safety of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in the treatment of pediatric urethral stricture disease. METHODS: Twelve boys who had previously undergone unsuccessful cold-knife internal urethrotomy or serial urethral dilation for urethral stricture disease underwent endoscopic laser internal urethrotomy utilizing a contact-tip fiber for recurrent urethral stricture. RESULTS: At a mean follow-up of 12 months, 10 of the 12 boys are free of stricture disease for an overall success rate of 83%. Two boys were considered failures and underwent successful open urethroplasty. There were no treatment complications. CONCLUSIONS: The Nd:YAG laser utilizing the contact-tip fiber was successful in treating recurrent urethral stricture disease. The hemostatic characteristic of the laser allowed bloodless urethrotomy, which was particularly useful when operating with the smaller pediatric endoscopic instruments.

Ureterocele associated with a single collecting system of the involved kidney.

OBJECTIVE: This is a study concerning ureteroceles associated with a single collecting system of the involved kidney. METHODS: Over an eight-year period 9 children (5 boys, 4 girls) had a ureterocele subtending a single collecting system, whereas 63 children had duplex ureteroceles. Malformations of other organ systems were present in only 1 patient. RESULTS: Three patients have undergone surgical interventions: a transurethral incision of bilateral obstructive ureteroceles in 1 and nephroureterectomy in 2. In 4 cases cystic/dysplastic kidneys involuted and were reabsorbed with collapse of the ureteroceles. The last 2 patients have received antibiotic treatment for single episodes of a urinary tract infection. CONCLUSIONS: Earlier reports of a high incidence of concomitant anomalies and male predominance in patients with single-system ectopic ureteroceles could not be verified by our experience. Our current policy for a patient is careful evaluation, individualized therapy, and long-term surveillance.

Urologic manifestations of Goldenhar syndrome.

OBJECTIVE: Goldenhar syndrome (oculoauriculovertebral dysplasia) is associated with anomalies in multiple organ systems. Renal abnormalities have also been reported with the complex, but the incidence of associated genitourinary malformations has not been defined. METHOD: We have reviewed our experience with 28 children with Goldenhar syndrome evaluated during the past twelve years. Twenty children underwent imaging evaluation of the urinary tract and 14 (70% of those imaged) children had urinary tract anomalies. RESULTS: The majority of anomalies presented as an incidental finding on a screening ultrasound (8 patients) or during cardiac catheterization (2 patients). Two children presented with urinary tract infection, 1 child presented with renal failure, and another was diagnosed antenatally. The genitourinary anomalies included the following: ectopic and/or fused kidneys (8 patients), renal agenesis (7), vesicoureteral reflux (5), ureteropelvic junction obstruction (2), ureteral duplication (2), and multicystic kidney (1 patient). Four children have undergone surgical intervention. CONCLUSION: Our experience in children with Goldenhar syndrome suggests that the incidence of genitourinary anomalies is higher than previously reported. A screening ultrasound in the neonatal period allows for early intervention in those children with significant urologic abnormalities.

Pubic symphysis repair strength in simulated bladder exstrophy using a sheep model.

OBJECTIVES: To investigate the mechanical strength of various pubic symphysis suture material in a simulated animal model of neonatal bladder exstrophy. METHODS: Neonatal lamb pelves, which are the approximate size of neonatal human pelves, were used. Twenty-four neonatal lamb pelves were divided into four equal groups. A midline symphysotomy was made through the cartilaginous pubic symphysis in three groups and repaired using two figure-of-eight sutures (size 0) placed through the cartilaginous pubis using polypropylene, braided polyester, or polyglactin. The fourth group served as the control. The pelves were then tested to ultimate load in pure tension at a strain rate of 0.25 mm/s until failure. RESULTS: There was a highly significant difference between the intact specimens and the repaired specimens (P = 0.0008). For the repaired specimens, there was a significant difference in the ultimate load normalized by pubic height between those repaired with polypropylene and polyglactin (P = 0.025), but not for those repaired with polypropylene and braided polyester (P = 0.11) or braided polyester and polyglactin (P = 0.11). CONCLUSIONS: Braided resorbable sutures are recommended for pubic symphysis repair, because they have a lower tendency to cut out of the cartilage.

Outcome analysis of bilateral Cohen cross-trigonal ureteroneocystostomy.

OBJECTIVES: The perioperative and long-term outcomes of children with vesicoureteral reflux (VUR) treated by cross-trigonal ureteroneocystostomy were ascertained. METHODS: One hundred ten consecutive children with VUR who underwent bilateral cross-trigonal ureteroneocystostomy were studied retrospectively. Nineteen children with neurovesical dysfunction or megaureters requiring tapered reimplants were excluded. Outcome parameters of the remaining 91 children consisted of operative time, length of hospitalization, days of Foley catheter drainage perioperative complications, correction of reflux, subsequent morbidity, and parental satisfaction. RESULTS: Of 182 renal units, 11 (6%) had grade 0 VUR, 18 (10%) had grade I, 43 (24%) had grade II, 59 (32%) had grade III, 36 (20%) had grade IV, and 15 (8%) had grade V reflux. The mean operative and hospitalization times were 180 minutes and 5.6 days, respectively. No postoperative complications occurred. Three children were lost to follow-up, and the remaining 88 children had an extended mean follow-up in excess of 3 years. Voiding cystourethrogram documented a 98.3% (173 of 176 renal units) success rate. Sixteen children (18%) experienced nonfebrile clinically symptomatic cystitis episodes and 3 children (3%) experienced one febrile episode each. Telephone parental survey of overall surgical experience revealed a 94% very satisfied, 2% satisfied, and 3% dissatisified rate. CONCLUSIONS: Cross-trigonal ureteroneocystostomy is a safe and effective technique that is virtually complication free and has high parental satisfaction. The results of this study provide a baseline for comparison of non-operative treatment of reflux as well as laparoscopic and endoscopic techniques.

Intravesical instillation of gentamicin sulfate: in vitro, rat, canine, and human studies.

OBJECTIVE: Intravesical instillation of gentamicin sulfate has been used empirically as prophylaxis and to treat bacilluria in spinal-cord-injured patients undergoing clean intermittent catheterization. To assess the risks of absorption and the effects of storage conditions on antimicrobial potency, a series of studies were conducted. METHODS: Four studies were carried out: (1) An infected fulgurated rat bladder model was created to determine the effects of inflammation and infection on absorption. (2) A canine model with bilateral vesicoureteral reflux and elevated bladder pressures (> 40 cmH2O) assessed the effects of reflux and storage pressure. (3) The effects in patients with associated conditions including renal transplantation, myelomeningocele, vesicoureteral reflux, and bladder augmentation, were analyzed. (4) To determine the effects of storage conditions, solutions of gentamicin sulfate (480 mg gentamicin sulfate in 1 L 0.9% NaCl) were made that controlled for pH, storage temperature, and duration. RESULTS: (1) Increased absorption was found in 43 percent of rat serum samples. (2) None of the dogs demonstrated measurable absorption. (3) None of the patients likewise had measurable absorption. (4) All solutions were equally potent when tested against a panel of common urinary pathogens. Storage up to two months at room temperature without alkalinization had no effect on potency. CONCLUSIONS: Instilled intravesical gentamicin sulfate has a low risk of absorption and is highly effective. Severe bladder inflammation can increase transvesical absorption. It has prolonged stability without special storage conditions and should be considered as a route of prophylaxis in patients who perform intermittent catheterization.

The pathophysiology of UPJ obstruction. Current concepts.

It took more than half of a century for urologists to recognize that hydronephrosis is not necessarily equivalent to obstruction. Keeping this important truism in mind, particularly when dealing with antenatal hydronephrosis, one must also remember that hydronephrosis is not a normal condition. It is conceivable that although the initial intrinsic stenosis or ureterovascular obstruction may not be clinically significant in terms of renal functional damage, as compensatory renal pelvic dilatation develops, secondary obstructive elements may be recruited to create an insertional anomaly and peripelvic fibrosis. The individual types of UPJ obstruction that are seen in diagnostic studies or on the operating table may represent isolated "snapshots" of evolving pathophysiologic processes. If this is true, patients with asymptomatic congenital hydronephrosis, although lacking obvious renal function loss, require long-term follow-up.

The undescended testis. Theory and management.

Surgical techniques and research efforts to define the pathophysiology of cryptorchid testes have progressed rapidly in recent decades. Medical and surgical treatment modalities have focused on the young patient with an undescended testis. The potential adult complications of cryptorchidism, infertility, and malignancy should not be forgotten or dismissed.