Neuroblastoma in a Newborn Female.

Neuroblastoma is the most common solid tumor in neonates. Although often aggressive in older children, carrying high mortality rates despite multimodal therapies, neuroblastoma appears to behave differently in the neonatal population. When diagnosis is clear, the disease can often be managed with close observation alone. This is a case of neuroblastoma in a 4-day-old female managed with surgical resection. This case highlights the potential challenges of diagnosis of retroperitoneal masses on prenatal ultrasound and in newborns and the importance of utilizing available resources when making difficult decisions in management.

Efficacy and safety of alvimopan use in benign urinary tract reconstruction.

PURPOSE: To analyze the use of alvimopan, a peripheral mu-opioid receptor antagonist, in expediting gastrointestinal recovery after benign abdominal urinary tract reconstruction. Alvimopan use has been well defined in the management of radical cystectomy and urinary diversion for oncologic indications. It has not been studied in benign abdominal genitourinary reconstruction. METHODS: Patients who underwent urinary reconstruction utilizing harvested bowel segments for benign conditions from 12/2014-7/2019 were retrospectively reviewed. From 5/2018-7/2019 our institution approved the use of perioperative alvimopan in the aforementioned patients (N = 11), who were paired 1:2 with patients from a cohort of alvimopan-eligible patients who did not receive the drug (N = 22). Patients were paired by (1) type of reconstruction and (2) presence of neurogenic bowel-bladder (NBB). RESULTS: Of the 70 patients who underwent urinary reconstruction during the study period, 46 patients (66%) were eligible to receive alvimopan. Length of stay was shorter for the alvimopan group compared to the non-alvimopan group (median 5 days [IQR 4-5 days] vs. 8 days [IQR 6-11 days]; P = 0.002). Time to first bowel movement was shorter for the alvimopan group (median 4 days [IQR 3-4 days] vs. 6 days [IQR 4-7], P = 0.001). No patient treated with alvimopan required a nasogastric (NG) tube for post-operative ileus compared to 7 (32%) patients in the non-treatment group (P = 0.035). Post-operative complications and 30-day readmissions were similar between the two groups. CONCLUSION: The use of perioperative alvimopan in benign abdominal urinary tract reconstruction expedited return of bowel function and decreased length of stay compared to a matched cohort of untreated patients.

Surgical management of pediatric renal masses: surgeon subspecialty practice patterns.

INTRODUCTION: Management of pediatric renal masses has lagged behind adult paradigms adopting minimally invasive surgery (MIS) and nephron-sparing surgery (NSS). This study investigated national practice patterns between pediatric urologists (PU) and pediatric surgeons (PS) in pediatric renal malignancy. MATERIALS AND METHODS: The Pediatric National Surgical Quality Improvement Program database was queried for CPT codes for radical/partial nephrectomy from 2012-2017 performed for renal malignancy. Patients were grouped by specialty and operative approach. RESULTS: PU managed 175 (17%) patients while PS managed 811 (77%). PU were more likely to use MIS (14% versus 5%, p < 0.001) and NSS (33% versus 13%, p < 0.001) compared to PS. PS more commonly performed lymph node (LN) sampling/tumor thrombectomy, especially in MIS cases (67% versus 35%, p = 0.008). PS operated on younger patients with higher ASA class compared to PU, but had higher transfusion rates and longer length of stay. Central venous access surgery was more commonly performed on patients operated on by PS, while PU performed more cystoscopy/retrograde pyelography. Patients who underwent NSS compared to radical nephrectomy were less likely to undergo LN sampling, while LN sampling did not differ between open and MIS groups. CONCLUSIONS: PU were likely to perform MIS and NSS than PS for pediatric renal masses in this national database. This likely results from inherent training differences between PS and PU and reflects emerging data on safety and efficacy of these advanced surgical techniques. Further investigation into the impact on oncologic and clinical outcomes by surgical specialty and operative approach is necessary.

Recurrent Bladder Cancer in a Teenage Male.

Urothelial cell carcinoma of the bladder is exceedingly rare in pediatric patients. Based on current literature, bladder cancer in this population is thought to be low-grade, noninvasive, and unlikely to recur, suggesting significant biologic differences when compared to the adult population. This is a 15-year-old male diagnosed with low-grade urothelial cell carcinoma with subsequent multifocal recurrence on surveillance cystoscopy managed by induction and maintenance intravesical Bacillus Calmette-Guerin. This case highlights the challenges of management and surveillance of this rare disease.

International Publication Patterns on Operative Management of Wilms Tumor: A Review by Surgeon Specialty and Surgical Modality.

OBJECTIVE: To review the temporal trends in the published literature of the surgical management of Wilms tumor (WT) relative to surgical modality and authorship by surgeon specialty (pediatric urology [PU] vs pediatric surgery [PS]). METHODS: The MEDLINE/PubMed database was queried for manuscripts published by PU or PS including operative management of WT from 1993-2017. After manuscript review, 187 of 2420 studies were included. Studies were compared by author specialty, country of origin, and represented patients. RESULTS: PU published 32% of included publications. The proportion of first author publications by PU increased over time (25% from 1993-2005 to 39% from 2006-2017, P = .029). While PU were first author on 44% of studies in North America, they were relatively underrepresented internationally. PU and PS were equally likely to be first author on cooperative group studies, which accounted for 19% of the overall publications. 14,958 patients underwent extirpative surgery for WT. There was a small increase in publications reporting the use of minimally-invasive surgery (MIS) and nephron-sparing surgery (NSS) over time (<1% and 4% from 1993-2005 to 2% and 7% from 2006-2017, respectively, P <.001). Compared to PS, PU were significantly more likely to publish on patients managed with MIS and NSS (P = .006 and P < 0.001 respectively). CONCLUSION: Publications by PU on the surgical management of WT are increasing over time, but are still fewer than PS. PU appeared to be the drivers of the temporal trend towards the increasing use of MIS and NSS in the published literature.

Influence of BMI in nephrolithiasis in an Appalachian pediatric population: A single-center experience.

INTRODUCTION: The prevalence of pediatric nephrolithiasis has increased significantly in the past 20 years. Metabolic abnormalities predisposing adults to nephrolithiasis in obese patients include increased urinary sodium and uric acid excretion as well as low urine pH; however, limited data are available in the pediatric population. OBJECTIVE: The aim was to investigate whether obese pediatric patients presenting with nephrolithiasis have a unique metabolic profile similar to reported findings in obese adults with nephrolithiasis. STUDY DESIGN: A retrospective chart review was performed in children aged 1-18 years seen at Kentucky Children's Hospital between 2010 and 2016. Inclusion criteria included all patients with documented stones confirmed by ultrasonography or computed tomography. RESULTS: A total of 111 patient charts were reviewed in the study with a mean age of 11.8 ± 4.2 years. Seventy patients (63%) had a normal BMI and 41 patients (37%) were considered overweight/obese. There was no statistically significant relationship between BMI and stone recurrence. Obese patients had significantly decreased levels of urinary citrate, oxalate, magnesium, and potassium with significant elevations of urinary urea nitrogen, ammonia, and low urine pH compared with normal weight patients (Summary Figure). DISCUSSION: Several groups have reported on metabolic findings within obese and non-obese pediatric patients. A Turkish study reported increased oxalate excretion and hypocitraturia in obese patients while a Korean study also reported increased rates of hypocitraturia in recurrent stone formers. Similar to these studies, we did find significant differences in citrate within our study population; however, we found significantly lower levels of urinary oxalate in obese patients. The majority of these studies do not report an association with BMI and urine pH although this has been reported in the adult population and our findings support an inverse relationship between body mass index (BMI) and pH. Our group found a higher level of calcium phosphate stones, supporting of Eisner's findings that high BMI is associated with increased supersaturation of calcium phosphate. Limitations of our study include being a single center and retrospective in nature. CONCLUSION: Our study demonstrates differences in types of stones and urinary metabolites in an obese pediatric population suggestive of different metabolic profiles contributing to stone disease. We report similar association between BMI and urine pH, urinary potassium, and citrate. This study confirmed our primary hypothesis that obese pediatric patients would have a different urinary mineral profile as evidenced by lower levels of citrate and potassium and low urine pH; however, obese patients did not exhibit significantly elevated urinary sodium and uric acid when normalized to weight, as described in the adult population. Our study did not confirm our secondary hypothesis that stone composition would be associated with BMI status or stone recurrence.

Technical refinements to improve outcomes following distal hypospadias repair.

INTRODUCTION: Hypospadias complications, most notably meatal stenosis, are commonly reported to occur after tubularized incised plate (TIP) hypospadias repair. We focus on a point of technique in TIP repair and its effect on outcome of this possible complication, as well as other commonly reported complications. Meatal stenosis after TIP can be avoided if the urethra and overlying glans are dissected and sutured separately with no attempt at cross suturing whether the urethra ends below, behind, or above the glans sutures. This hypothesis was evaluated by a prospective data collection before and after implementation to evaluate the effect of a technical refinement on rates of meatal stenosis in TIP hypospadias repair. MATERIALS AND METHODS: All cases of coronal to midpenile hypospadias repair during two periods were included in our study. Group 1 included 140 consecutive patients over a 30 month period. Group 2 included 122 consecutive patients over a 36 month period during which the above mentioned technical changes were implemented by all participating pediatric urologists. Rates of complications between the two groups were compared with special emphasis on meatal stenosis. RESULTS: Median follow up for both groups was > 1 year. Overall complication rate in Group 1 was 31.5% compared to 9.8% in Group 2. Meatal stenosis was significantly reduced from 13 patients (9.3%) in Group 1 to 2 patients (1.6%) in Group 2, p = 0.008. CONCLUSION: The technical refinements described resulted in reduction of complication rates and a decrease in incidence of meatal stenosis.

Pattern of clinical presentation of congenital anomalies of the kidney and urinary tract among infants and children.

AIM: Congenital anomalies of the kidneys and urinary tract (CAKUT) comprise various entities of structural malformations that result from defects in morphogenesis of the kidney and/or urinary tract. These anomalies are the most commonly diagnosed malformations in the prenatal period and constitute the leading cause of end-+stage renal disease (ESRD) in children, worldwide. This prospective study was performed to report the patterns of clinical presentation and diagnosis of infants and children with such malformations. METHODS: Patients with suggestive features of CAKUT, presenting to Cairo University Children Hospital over one year duration were investigated and categorized based on underlying renal structural/functional malformation and associated extra-renal anomalies. RESULTS: One hundred and seven CAKUT children were enrolled in the study. Familial clustering was identified in 14% of the cohort and syndromic CAKUT accounted for 31.8% of cases. Different anomaly entities have been identified; posterior urethral valves (PUV) being the commonest detected abnormality (36.4%). Of note, 9.3% of cohort patients had ESRD at presentation, of which 60% had PUV as their primary renal disease. Obstructive cases were noted to present significantly earlier and attain advanced CKD stages rather than non-obstructive ones. CONCLUSION: CAKUT is a clinically heterogeneous group of diseases with diverse clinical phenotypes. More efforts should be aimed at improving antenatal detection as well as classification with comprehensive reference to the clinical, genetic and molecular features of the diseases. The high frequency of familial and syndromic CAKUT among studied patients is seemingly a convincing reason to pursue the underlying genetic defect in future studies.

Distal hypospadias repair using only glans wing mobilization and approximation.

INTRODUCTION: Since its first description in 1994, tubularized incised plate (TIP) technique has become the most commonly performed hypospadias procedure and involves incision of the urethral plate with subsequent tubularization. Glans wings are then developed to cover the neourethra, thereby creating a cosmetically appealing repair. In some distal hypospadias cases, mobilization and approximation of glans wings is sufficient to create a normal appearing urethral meatus. MATERIALS AND METHODS: A retrospective chart review of all pediatric urology patients who underwent hypospadias repair by a single surgeon at the University of Kentucky between July 1, 2010 and April 1, 2013 was performed. Of the 46 patients who underwent one-stage distal hypospadias repair during that time, we performed the technique described above on 13 patients with amenable anatomy. Patients were evaluated for functional and cosmetic outcomes as well as complications at subsequent office visits and via telephone. RESULTS: Patients who underwent distal hypospadias repair with our technique had excellent functional and cosmetic outcomes analogous to those who underwent standard TIP repair. The only major complication in the study group was wound dehiscence in one patient that was required a second surgery. All other patients had excellent cosmetic and functional results without fistula formation, strictures or diverticuli, and with excellent parent satisfaction. CONCLUSIONS: Perceived benefits of this technique include simplicity and rapidity of technique, applicability to glanular, coronal and subcoronal hypospadias, and avoidance of sutures between urethra and glans with potential decrease in meatal stenosis.

Crossed testicular ectopia with preoperative ultrasound.

Crossed testicular ectopia/transverse testicular ectopia is a rare congenital anomaly. It is most commonly identified intraoperatively in the setting of inguinal hernia repair with contralateral cryptorchidism. We report a case of crossed testicular ectopia identified in a 3-month-old male who presented with right cryptorchidism. Preoperative ultrasound revealed no testicle on the right and two testicles on the left - one within the left hemiscrotum and one within the left inguinal canal. Laparoscopy at 7 months of age revealed a closed right external ring and right ectopic testicle at the left external ring. Bilateral orchiopexy was performed.

Outcomes of hypospadias repair in older children: a prospective study.

PURPOSE: The American Academy of Pediatrics recommendation is to perform hypospadias repair at age 6 to 12 months. However, our patient population included a significant proportion of patients in adolescence and beyond undergoing primary repair. We report a comparison of outcomes in patients in different age groups. MATERIALS AND METHODS: We prospectively report on patients with distal hypospadias who underwent primary repair at our institution during 7 months. Study parameters included age, degree of hypospadias, surgical technique and the complications rate. RESULTS: A total of 61 patients were included in analysis. All cases underwent repair using the tubularized incised plate technique. More proximal hypospadias and different repair techniques were excluded from study. Patients were classified by age, including group 1-25 (40%) 6 months to 2 years old, group 2-17 (28%) 2.2 to 3.7 years old and group 3-19 (32%) 4 years old or older. Only 6 patients (9.8%) had postoperative complications and all were in groups 2 and 3. In group 2 there were 3 complications (17.6%), including loss of repair, meatal stenosis and hematoma in 1 case each. In group 3 there were 3 cases (15.8%) of postoperative fistula. The fistula incidence was higher in group 3 (p = 0.032). CONCLUSIONS: Despite previous reports suggesting a much higher incidence of complications in older children the complication rate is within the acceptable range for infant hypospadias repair in some series. However, these complications were statistically significantly different between the older groups when compared with the recommended age group under American Academy of Pediatrics guidelines.

Assessment of recoverability of kidney function in children with obstructive calcular anuria: multicenter study.

OBJECTIVE: Urolithiasis in children can cause considerable morbidity. Our aim was to evaluate the impact of intervention on the recoverability of kidney functions. MATERIALS AND METHODS: This prospective study included 93 children (66 boys and 27 girls) with median age of 3 years (range 0-14). Inclusion criteria were presence of anuria, oliguria, serum creatinine >2 mg% and/or hyperkalemia ≥ 6 mmol/L. The mean duration of anuria or oliguria was (mean ± SE) 5.3 ± 0.4 days. On presentation, mean plasma creatinine was 6.5 ± 0.29 mg/dl with a mean estimated glomerular filtration rate (eGFR) of 14 ml/min and creatinine clearance (CC) of 8.24 ml/min. Dialysis was performed in 21 (22.6%) patients. When condition allowed, emergency surgery was performed. RESULTS: Mean follow up was 1.5 years with compliance of 82%. At the end of treatment, 83% of patients had complete clearance of calculi. Mean plasma creatinine after treatment was 3.3 ± 0.35 mg/dl with an average GFR of 24.5 ml/min. After treatment renal function returned to normal in 57%, improved in 27% and deteriorated in 16% of children. Renal function recoverability rate was 94.6%. Chronic renal failure developed in 3 (3.2%) patients and 2 (2.2%) patients died. When absolute plasma creatinine concentration [P(cr)] improved 20-50% the eGFR and CC were doubled, and when improved 50-70% eGFR and CC tripled. Beyond 70% improvement in [P(cr)], eGFR and CC improved 7-8 times. Using Spearman's correlation, the mode of presentation and the type of management had a significant correlation with renal function outcome (P = 0.019 and 0.013 respectively). CONCLUSION: Urgent management of calcular anuria both medically and surgically is the cornerstone for favorable outcome. The mode of presentation and the type of management are significant factors affecting final renal function outcome.

Extracorporeal shock wave lithotripsy monotherapy for renal stones >25 mm in children.

OBJECTIVES: To determine the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) as monotherapy for renal stones >25 mm in children. METHODS: Our prospective study included 24 children <14 years old with radiopaque renal stones >25 mm treated by ESWL as first-line treatment using the electromagnetic Dornier DoLi S device. Pretreatment kidney, ureter, and bladder plain films and intravenous urography and post-treatment ultrasonography and kidney, ureter, and bladder plain films were used to monitor the clearance of fragments. Stone clearance was assessed at 1 and 3 months. A stone-free state was defined as no radiologic evidence of stone. Asymptomatic noninfectious and nonobstructive fragments <3 mm were considered insignificant. RESULTS: The 24 children, aged 2-14 years (mean 7) underwent 53 ESWL sessions. Of the 24 children, 10 had stones located in the left kidney and 14 had stones located in the right kidney. The stone size was 25-35 mm (average 31). The average number of shock waves was 3489 per session. All children underwent lithotripsy with a gradual incremental energy increase from 14 to 20 kV. The overall stone-free rate was 83.3%. Four patients had clinically insignificant fragments and were followed up for the possibility of stone regrowth, microscopic hematuria, and urinary tract infection. Complications affected 25% of patients. CONCLUSIONS: ESWL is highly effective for treatment of large renal stones in children as a first-line treatment with minimal morbidity. The placement of a stent is not a prerequisite for success of treatment.

Ureteroureterostomy via inguinal incision for ectopic ureters and ureteroceles without ipsilateral lower pole reflux.

PURPOSE: We report outcomes from ureteroureterostomy performed through an inguinal herniorrhaphy type incision for definitive management of ectopic ureters or ureteroceles in the absence of ipsilateral lower pole reflux. MATERIALS AND METHODS: Records were reviewed for 23 consecutive patients who underwent lower ureteroureterostomy for 26 duplicated systems with ectopic ureter or ureterocele and no ipsilateral lower pole reflux. In 21 patients surgery was performed through an inguinal incision similar to that for herniorrhaphy, while a Pfannenstiel incision was used initially in the series in 2 others with bilateral duplex systems. Median patient age at operation was 10 months (range 2 to 56). RESULTS: At a mean followup of 26 months preoperative upper pole hydronephrosis and distal upper ureteral dilatation had resolved or improved in all cases. Preliminary cutaneous ureterostomy was performed on 4 ureters (3 patients), 2 because the recipient lower pole ureter was thought to be too small for incision and anastomosis, 1 because of purulent drainage and 1 following inadvertent transection of the lower pole ureter. Mean surgical time for inguinal ureteroureterostomy was 101 minutes and mean postoperative hospitalization was 0.6 days. Except for dextranomer/hyaluronic acid injection in 1 patient with symptomatic grade I ipsilateral lower pole reflux, no additional surgical procedures were performed after ureteroureterostomy. CONCLUSIONS: Lower ureteroureterostomy offers potentially definitive treatment for ectopic ureter or ureterocele without ipsilateral lower pole reflux, and can be performed through an inguinal herniorrhaphy type incision.

Metabolic stone composition in Egyptian children.

OBJECTIVE: The composition of urinary stones in children depends on socioeconomic conditions, geography and dietary habits. Pediatric urolithiasis remains endemic in developing countries. The aim of this study was to analyze stone composition in an Egyptian patient population. PATIENTS AND METHODS: We analyzed prospectively urinary stones from 100 consecutive children (73 males, 27 females), aged 14 months to 12 years. The stones were located in the upper urinary tract in 78%, lower urinary tract in 19% and both in 3%. Male patients had more lower urinary tract stones. On presentation 67% had flank pain and 37% had hematuria. Stones were treated by open surgery in 69% of patients, shockwave lithotripsy in 20% and endoscopic extraction in 13%. RESULTS: The components of the upper urinary tract calculi were calcium oxalate (47%), ammonium acid urate (26%) and calcium carbonate (21%), whereas the main components of the lower urinary tract calculi were ammonium acid urate (27.2%), struvite (27.2%) and calcium carbonate (22.7%). Urinary tract infection was involved in the development of one third of the stones. Endemic stones were present in 17% of patients, and stones of metabolic origin in 15%. The etiology of stone formation remained unknown in one third of patients. CONCLUSION: The epidemiological profile of urinary stones in Egyptian children can now be considered intermediate between developing countries where dietary deficiencies are the main causes and developed countries where infectious and metabolic calculi are observed.

Safety of ungated shockwave lithotripsy in pediatric patients.

OBJECTIVE: Ungated extracorporeal shockwave lithotripsy (ESWL) in adults is associated with cardiac arrhythmias. We report on the safety and efficacy of this method for treatment of renal calculi in children. PATIENTS AND METHODS: Children under 14 years with radio-opaque renal stones were treated by ungated ESWL. Pre-treatment plain radiographs and intravenous urography and post-treatment ultrasonography and plain films were used to follow up clearance of fragments. All children were monitored for arrhythmias. RESULTS: Thirty-seven children (28 males, nine females) with a median age of 5 years (range 2-14 years) underwent 69 ungated ESWL sessions for renal calculi. Nineteen children had stones located in the left kidney, 17 had stones located in the right kidney and one child had bilateral renal stones. The stone size ranged from 6 to 25 mm (mean 9.9 mm). Shockwave number ranged from 800 to 3650 (mean of 2500 shockwaves per session). All children underwent lithotripsy with a gradual incremental energy increase from 14 to 20 kV. No patient had cardiac arrhythmias or other intra-procedural complications. No patient required conversion to gated ESWL. The overall stone-free rate was 86%. CONCLUSION: The results suggest that ungated ESWL is safe in children under 14 years. The efficacy was comparable to that of gated ESWL from previously published series.

Comparison of outcomes of tubularized incised plate hypospadias repair and circumcision: a questionnaire-based survey of parents and surgeon.

AIM: We administered a standardized questionnaire to parents and operating surgeon to determine their opinions regarding outcomes from tubularized incised plate (TIP) hypospadias repair. METHODS: Likert scale questionnaires were used to assess six outcomes: overall penile appearance, cosmesis of meatus and skin, penile size, straightness during erection, and voided stream. These were answered by consecutive parents of boys 6 weeks following TIP hypospadias repair, as well as by the surgeon. Controls were normal boys 6 weeks after elective circumcision, with their parents and the surgeon answering the same questionnaires. RESULTS: There were no significant differences in responses between parents of boys undergoing TIP repair for distal (n=50) to proximal (n=15) hypospadias compared to parents of normal boys undergoing elective circumcision (n=22). Surgeon impressions of cosmetic results were slightly, but significantly, more favorable than those of parents. Surgeon scores were higher for distal versus proximal hypospadias outcomes. CONCLUSIONS: Our study provides objective evidence that parents consider TIP hypospadias repair to create a normally functioning and appearing penis. Parent and surgeon opinions of cosmetic outcomes were similar, although surgeon impressions were more favorable.

Decision making during laparoscopic orchiopexy for intra-abdominal testes near the internal ring.

PURPOSE: We studied whether testicular proximity to the ipsilateral internal ring or ability to reach the contralateral ring predicted the likelihood that laparoscopic orchiopexy would deliver an intra-abdominal testis to the dependent scrotum. MATERIALS AND METHODS: Records of patients undergoing laparoscopic orchiopexy for testes within 2 cm of the internal ring were reviewed. Factors considered included patient age, mobility of the testis to the contralateral ring, intraoperative positioning in the upper vs lower scrotum, and postoperative findings of testicular viability and location. RESULTS: Of 46 testes treated with laparoscopic orchiopexy 20 reached the low scrotum. The remaining 26 testes only reached the upper scrotum. Of these testes 14 were fixed to the most distal aspect of the scrotum that they would reach, while 12 were managed by vessel transection with 1-stage orchiopexy to the low scrotum in 10 and the upper scrotum in 2. Patient age at surgery, location within 2 cm of the internal ring and mobility to the contralateral ring did not predict ability of laparoscopic orchiopexy to bring the testis to the low scrotum. Followup was available in 42 testes at a mean of 6.8 months (range 1 to 25), with 25 (60%) in the low scrotum, 6 (14%) in the upper scrotum, 6 (14%) showing atrophy and 5 (12%) reoperated on for a position at or above the upper margin of the scrotum. CONCLUSIONS: Factors evaluated did not indicate the likelihood that laparoscopic orchiopexy would result in a testis in the dependent scrotum. It is unclear whether a testis only reaching the upper scrotum should be fixed with vessels intact, or undergo 1-stage Fowler-Stephens orchiopexy to attempt to reach the low scrotum.

Scrotal exploration for unilateral nonpalpable testis.

PURPOSE: We previously reported initial scrotal exploration for unilateral nonpalpable testis, followed by laparoscopy when a viable testis was not found. Although we concluded that scrotal exploration could often make laparoscopy unnecessary, the knowledge that patients with presumed nubbins would undergo laparoscopy meant that the surgeon did not have to decide whether findings were definitive. In a second series of consecutive patients laparoscopy was used only when it appeared indicated. MATERIALS AND METHODS: Boys with unilateral nonpalpable testis underwent initial scrotal exploration. Laparoscopy was only performed when neither a nubbin nor a testis was found, when there was a patent processus vaginalis and/or when gross findings suggesting a nubbin were thought inconclusive. RESULTS: There were 43 patients, including 30 (70%) with monorchism and 13 (30%) with an extra-abdominal (7) or intra-abdominal (6) testis. Of 30 patients found to have monorchism laparoscopy was performed only in 7 (23%), including 2 with scrotal nubbins with a patent processus vaginalis, 1 with a questionable nubbin, 1 with a definitive nubbin but preoperative magnetic resonance imaging suggesting a testis and 3 with an empty scrotum (intra-abdominal vanished testis in 1 and inguinal nubbins in 2). The finding of monorchism was strongly predicted by a contralateral descended testicular length of 1.8 cm or greater. CONCLUSIONS: Scrotal exploration is potentially definitive for the diagnosis and management of extra-abdominal testes and nubbins in patients with unilateral nonpalpable testis. Laparoscopy is only definitive when an intra-abdominal testis is found, which occurs in a minority of cases.