Familial testicular torsion.

PURPOSE: Isolated reported cases of familial torsion yield modest information on incidence, genetics or clinical features. We present what is to our knowledge the largest series of familial torsion, including the first 3 generation case and a review of the literature. MATERIALS AND METHODS: Since 2006, we have questioned the presence of a positive family history in all patients with torsion at the initial consultation. We compiled data on familial relationship, laterality, age and outcomes of the proband and affected relatives. We collected previously published cases to better understand clinical features and genetics. RESULTS: Eight of 70 boys (11.4%) with torsion had affected family members. Another 2 families were included from a historical perspective. One relative was affected in 7 families, 2 were affected in 2 and 3 were affected in 1. First degree relatives were most commonly affected. In 1 family torsion occurred in 3 consecutive generations. Despite a family history 50% of patients experienced testicular loss. Brothers were affected in each of the 10 previously reported cases. In 3 families fathers were also affected. There were 3 sets of monozygotic twins. We noted laterality concordance 5 times and discordance 6 times. Age at torsion in probands was adolescence except in 2 with neonatal torsion. No clear inheritance mode was found. CONCLUSIONS: Familial torsion occurs in about 10% of probands and can affect multiple relatives and generations. A positive family history may be useful for torsion diagnosis and management. Relatives of affected patients need education on the signs and symptoms of torsion, and the importance of early presentation to improve outcome.

Complications of circumcision.

In the United States, circumcision is a commonly performed procedure. It is a relatively safe procedure with a low overall complication rate. Most complications are minor and can be managed easily. Though uncommon, complications of circumcision do represent a significant percentage of cases seen by pediatric urologists. Often they require surgical correction that results in a significant cost to the health care system. Severe complications are quite rare, but death has been reported as a result in some cases. A thorough and complete preoperative evaluation, focusing on bleeding history and birth history, is imperative. Proper selection of patients based on age and anatomic considerations as well as proper sterile surgical technique are critical to prevent future circumcision-related adverse events.

Inconspicuous penis.

Inconspicous penis refers to a constellation of conditions that make the penis look diminutive and small. This could be secondary to short penile shaft often termed as micropenis. But more commonly, this inconspicuous appearance is secondary to other causes ranging from congenital conditions such as penoscrotal webbing or megaprepuce, developmental conditions like prepubic adiposity that overhang the penis, and iatrogenic causes like trapped penis after adhesions secondary to circumcision. In this paper, we propose to define these entities and provide their descriptions and then to describe their management including surgical correction.

A Framework for Biomarkers of COVID-19 Based on Coordination of Speech-Production Subsystems.

Goal: We propose a speech modeling and signal-processing framework to detect and track COVID-19 through asymptomatic and symptomatic stages. Methods: The approach is based on complexity of neuromotor coordination across speech subsystems involved in respiration, phonation and articulation, motivated by the distinct nature of COVID-19 involving lower (i.e., bronchial, diaphragm, lower tracheal) versus upper (i.e., laryngeal, pharyngeal, oral and nasal) respiratory tract inflammation, as well as by the growing evidence of the virus' neurological manifestations. Preliminary results: An exploratory study with audio interviews of five subjects provides Cohen's d effect sizes between pre-COVID-19 (pre-exposure) and post-COVID-19 (after positive diagnosis but presumed asymptomatic) using: coordination of respiration (as measured through acoustic waveform amplitude) and laryngeal motion (fundamental frequency and cepstral peak prominence), and coordination of laryngeal and articulatory (formant center frequencies) motion. Conclusions: While there is a strong subject-dependence, the group-level morphology of effect sizes indicates a reduced complexity of subsystem coordination. Validation is needed with larger more controlled datasets and to address confounding influences such as different recording conditions, unbalanced data quantities, and changes in underlying vocal status from pre-to-post time recordings.

The use of Alloderm® for correction of severe chordee in children: An initial experience.

INTRODUCTION: Correction of chordee remains a prerequisite prior to urethroplasty in children with severe hypospadias. The use of an interposition graft is indicated when significant chordee (>300) persists after division of the urethral plate. The use of free dermis or tunica vaginalis are most often used, but the use of a pre-packaged graft material is attractive with regards to efficiency. The success with small intestine submucosa (SIS) has been variable and experience with Alloderm® has not been published. OBJECTIVE: To determine if Alloderm®, an acellular dermal matrix with regenerative properties, can effectively, safely, and efficiently be used for corporal grafting in cases of severe chordee in children associated with hypospadias or intersex STUDY DESIGN: All boys underwent planned staged repair of severe hypospadias (penoscrotal or more proximal). If artificial erection (AE) demonstrated chordee >450 after penile degloving and removal of fibrotic tissue, and again after urethral plate division, the ventral tunica albuginea was incised 1800 transversely and the oval defect measured in both axes. Alloderm® was trimmed to size and sewn into the defect. AE confirmed chordee correction. At the second stage repair (>6 months later), AE was performed to confirm continued absence of chordee. CONCLUSION: Alloderm®is safe, effective and simple to use graft material for correcting severe chordee. The benefits include performance efficiency without need for separate harvesting and donor site closure, and redundancy of material, if needed. Additional series and longer follow up must confirm these results and better assess durability.

Sensorimotor conflict tests in an immersive virtual environment reveal subclinical impairments in mild traumatic brain injury.

Current clinical tests lack the sensitivity needed for detecting subtle balance impairments associated with mild traumatic brain injury (mTBI). Patient-reported symptoms can be significant and have a huge impact on daily life, but impairments may remain undetected or poorly quantified using clinical measures. Our central hypothesis was that provocative sensorimotor perturbations, delivered in a highly instrumented, immersive virtual environment, would challenge sensory subsystems recruited for balance through conflicting multi-sensory evidence, and therefore reveal that not all subsystems are performing optimally. The results show that, as compared to standard clinical tests, the provocative perturbations illuminate balance impairments in subjects who have had mild traumatic brain injuries. Perturbations delivered while subjects were walking provided greater discriminability (average accuracy ≈ 0.90) than those delivered during standing (average accuracy ≈ 0.65) between mTBI subjects and healthy controls. Of the categories of features extracted to characterize balance, the lower limb accelerometry-based metrics proved to be most informative. Further, in response to perturbations, subjects with an mTBI utilized hip strategies more than ankle strategies to prevent loss of balance and also showed less variability in gait patterns. We have shown that sensorimotor conflicts illuminate otherwise-hidden balance impairments, which can be used to increase the sensitivity of current clinical procedures. This augmentation is vital in order to robustly detect the presence of balance impairments after mTBI and potentially define a phenotype of balance dysfunction that enhances risk of injury.

Ungated extracorporeal shock wave lithotripsy: safe and effective in the pediatric population.

PURPOSE: Ungated extracorporeal shock wave lithotripsy (SWL) is unsynchronized to the patient's electrocardiogram. Although ungated extracorporeal shock wave lithotripsy (SWL) is associated with cardiac arrhythmias in adults, the incidence of arrhythmias in children has not been established. We report on the safety and efficacy of ungated SWL of renal calculi in children. MATERIALS AND METHODS: We evaluated all children less than 18 years of age undergoing ungated SWL for renal calculi. Lithotripsy with gradual incremental energy increase was used to treat the stones. Patients were monitored for arrhythmias and other standard monitoring intraoperatively and postoperatively. RESULTS: Twenty-four consecutive children (10 boys and 14 girls) between 3.5 and 17 years of age underwent 32 ungated SWL procedures for renal calculi. The stone size ranged from 5 mm to 19 mm. No patient had cardiac arrhythmias or other intraoperative complications, required to have the procedure terminated prematurely, or conversion to gated SWL. The overall stone free rate was 87% based on radiographic imaging. CONCLUSIONS: This series supports our initial series that ungated SWL is safe and efficacious in children less than 18 years of age. The arrhythmias associated with adults do no appear to occur in children undergoing ungated SWL.

Prenatal and postnatal management of hydronephrosis.

The majority of pregnant women in the U.S. undergo prenatal ultrasonography and approximately 0.5% of these examinations will detect fetal malformations. Up to one-half of these abnormalities include the genitourinary system and the most common urological finding is hydronephrosis. Some conditions associated with prenatal hydronephrosis portend a poor prognosis, while others can follow a fairly benign course. This review focuses on the definition and prenatal assessment of hydronephrosis, fetal intervention, and postnatal management.

A critical pathway for successful outpatient ureteral reimplantation: a nursing perspective.

Vesicoureteral reflux is a common pediatric urologic condition. Traditionally, surgical treatment of this condition requires a hospital stay of 1 to 6 days. Our experience has shown that both unilateral and bilateral extravesical ureteral reimplantation can be performed safely in the ambulatory surgery setting. Our perianesthesia care revolves around the concept of family-centered care. We have found that the key to our critical pathway involves both the patient and the family in every part of perianesthesia care. This "team" approach can be adapted for any pediatric procedure.

Extravesical ureteral reimplantation: an outpatient procedure.

PURPOSE: We determined whether implementation of a critical pathway and modification of the extravesical ureteral reimplantation surgical technique to repair unilateral and bilateral vesicoureteral reflux would consistently result in same day patient hospital discharge without increased morbidity. MATERIALS AND METHODS: We evaluated all children undergoing extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distal as possible. No surgical dissection is done in proximity to the obliterated umbilical artery, nor is the artery ligated. Patients follow a strict postoperative critical pathway, and parents receive extensive preoperative and postoperative education. The child is required to fulfill strict criteria to be discharged home. RESULTS: A total of 51 girls and 9 boys 0.9 to 10.5 years old (mean age 5.1) were evaluated. A total of 24 unilateral and 36 bilateral procedures were performed with and without ureteral tapering, and for single systems, duplex systems and an associated Hutch diverticulum. Overall 54 children (90%) were discharged home the same day, while only 6 (10%) went home the next day. All patients who underwent a unilateral procedure and 83% who underwent a bilateral procedure were outpatients. However, when evaluating the last 40 consecutive patients, including 14 with a unilateral and 26 with a bilateral procedure, all (100%) were discharged home the day of surgery without increased morbidity or an additional analgesic requirement. All outpatients were discharged within 5 hours after surgery. All patients tolerated the procedure well without major complications and without any patients requiring an emergency department visit or hospitalization after discharge home. After the urinary catheter was removed all patients were able to spontaneously void postoperatively without any acute or chronic urinary retention. CONCLUSIONS: This study demonstrates that implementation of a strict critical pathway and a unilateral or bilateral extravesical ureteral reimplantation surgical technique with limited dissection can consistently result in same day discharge from the hospital within a few hours postoperatively without increased morbidity or rehospitalization.

Single-port laparoscopic surgery: initial experience in children for varicocelectomy.

OBJECTIVE: To present our initial experience in children undergoing single-port laparoscopic varicocelectomy (SPLV) using a new approach in which the entire procedure is performed through a multichannel single laparoscopic port inserted in the umbilicus rather than the traditional LV performed through three abdominal ports. PATIENTS AND METHODS: We reviewed our experience with all paediatric patients who had undergone transumbilical SPLV [Uni-X Single Port Access Laparoscopic System, Pnavel Systems, NJ, USA]. This novel 20-mm laparoscopic port has three working channels and gas insufflation access. The system also includes a variety of curved laparoscopic instruments that can be introduced through the SP. A Hassan technique through an incision within the inferior aspect of the umbilicus is used to obtain laparoscopic port access to the abdominal cavity. The SP is then fixed into position with pre-placed rectus facial sutures. Using a curved laparoscopic grasper and scissors, an incision is made within the posterior peritoneum on the medial and lateral aspects of the left testicular artery and veins, proximal to the vas deferens. The vessels, both artery and veins, are transected leaving clips both proximally and distally. RESULTS: Transumbilical SPLV was completed in three consecutive adolescents (aged 13, 15 and 16 years) without placing any additional ports or conversion to open surgery. All procedures were performed for left-sided grade III varicoceles. The operative duration was <1 h for each procedure. All patients were discharged on the same day as their surgery and none required re-hospitalization. At a mean (range) follow-up of 8.7 (6-10) weeks there was a good cosmetic result, with no varicocele recurrence, or intraoperative or postoperative complications including wound infection, hydrocele, or incision site herniation. CONCLUSION: We report the first use of a multicannula single laparoscopic port in children and for SPLV. This new laparoscopic approach, similar to any new technique, requires further experience to fully evaluate its benefits and limitations.

Constitutive modeling of the stress-strain behavior of F-actin filament networks.

The central role of the cytoskeleton in both healthy and diseased cellular functions makes it a compelling subject for detailed three-dimensional (3D) micromechanical modeling. Microstructural features of the cytoskeleton govern the cell's mechanical behavior in many of the regulating cellular functions including cell division, adhesion, spreading, migration, contraction, and other mechanotransductive effects which influence biochemical processes. Actin microfilaments (AF) combine to form one of the predominant cytoskeletal networks important to these biological processes. Here, the AF cytoskeletal microstructure and stress-strain behavior is modeled via a microstructurally-informed continuum mechanics approach. The force-extension behavior of the individual filaments is captured using the MacKintosh derivation of the worm-like chain (WLC) constitutive relationship for short chains where a new and direct analytical expression for the filament force as a function of filament extension is developed in this paper. The filament force-extension behavior is then used in conjunction with the Arruda-Boyce eight-chain network model to capture the 3D multiaxial stress-strain behavior of the network. The resulting 3D cytoskeletal network constitutive model provides the ability to track microstructural stretch and orientation states during 3D macroscopic stretching conditions. The non-affine nature of the network model effectively accommodates the imposed macroscopic shear strain through filament rotation and a relatively small amount of filament stretch. These characteristics enable the network model, using physically realistic material properties, to capture the initial stiffness of the AF network as well as the nonlinear strain stiffening observed at large stresses. The network model predictions compare favorably with published microrheological data of in vitro AF networks.

Current diagnosis and management of fetal genitourinary abnormalities.

Prenatal assessment with ultrasonography provides excellent imaging of fluid-filled structures (eg, hydronephrosis, renal cysts, and dilated bladder) and renal parenchyma. This information allows for the generation of a differential diagnosis, identification of associated anomalies, and assessment of the prenatal and postnatal risks of a given anomaly. This enhances parental education and prenatal and postnatal planning. This article discusses the current methods of diagnosis and management of fetal genitourinary anomalies, and also the postnatal evaluation and treatment of these conditions.

Case report: Cowper's syringocele treated with Holmium:YAG laser.

A syringocele is a cystic dilation of Cowper's duct. We report on a 15-year-old boy with persistent dysuria attributable to a syringocele, which was treated by endoscopic unroofing with the holmium:YAG laser. The classification, pathophysiology, and management options of Cowper's syringocele are briefly reviewed.