Common urologic problems in children: guides to evaluation and referral, Part II.

A discussion of common urologic problems in children is presented to provide primary physicians with appropriate guidelines for evaluation and referrals. The problems will be discussed in two parts: Part I covered urinary tract infections, voiding dysfunctions, hematuria, and proteinuria. Part II will cover abnormalities found on antenatal renal ultrasonography, hypospadias and other penile anomalies, phimosis, undescended testes, inguinal hernia and hydroceles, and varicoceles. An adage states: "The questions in medicine never change over time--only the answers." Certainly the busy primary care physician may experience the frustration of changing evaluation guidelines established by narrow subspecialties. Guidelines for the evaluation of children with disorders of the genitourinary tract are no exception. The following presentation will address some of the most common childhood urologic problems with a brief discussion of how to evaluate and when to refer for pediatric urologic consultation or management.

Common urologic problems in children: guides to evaluation and referral, Part I.

A discussion of common urologic problems in children is presented to provide primary physicians with appropriate guidelines for evaluation and referrals. The problems will be discussed in two parts: Part I will cover urinary tract infections, voiding dysfunctions, hematuria and proteinuria. Part II will cover abnormalities found on antenatal renal ultrasonography, hypospadias and other penile anomalies, phimosis, undescended testes, inguinal hernia and hydrocele, and varicoceles. An adage states: "The questions in medicine never change over time--only the answers." Certainly the busy primary care physician may experience the frustration of changing evaluation guidelines established by narrow subspecialties. Guidelines for the evaluation of children with disorders of the genitourinary tract are no exception. The following presentation will address some of the most common childhood urologic problems with a brief discussion of how to evaluate and when to refer for pediatric urologic consultation or management.

Abdominoscrotal hydrocele mimicking a herniation of the bladder.

We describe an 18-month-old boy with an abdominoscrotal hydrocele that extended into the space of Retzius and mimicked a herniation of the bladder. Preoperative ultrasonography of the scrotum and lower abdomen is recommended in boys with suspected large hydroceles.

Portable cushioned operating table siderails: an adjunct to pediatric surgery.

BACKGROUND: In an effort to prevent falls of pediatric surgical patients from the operating table, a set of portable cushioned operating table siderails was developed. METHODS: A set of portable cushioned operating table siderails was used in the operating room over a 5-year period in more than 2,550 cases. RESULTS: The portable cushioned siderails provided an effective, easily placed barrier to falling. No falls were recorded. CONCLUSIONS: Portable cushioned siderails provide an effective barrier to prevent pediatric surgical patients from falling from the operating table.

An anterior extraperitoneal incision for donor nephrectomy that spares the rectus abdominis muscle and anterior abdominal wall nerves.

PURPOSE: To perform open donor nephrectomy with the least amount of body alteration and complication, a short extraperitoneal incision was developed that preserves the ipsilateral rectus abdominis muscle and abdominal branches of the intercostal nerves. MATERIALS AND METHODS: Donor nephrectomy using the new incision was performed in 11 consecutive patients. RESULTS: Morphine was required for pain relief for 1 to 3 days (mean 1.8), patients tolerated diet at 1 to 4 days (mean 2.2) and postoperative stay was 2 to 5 days (mean 3.5). Complications were minimal, consisting of postoperative fever 1 day in duration. A viable kidney was provided for transplantation in each case. CONCLUSIONS: The extraperitoneal, rectus abdominis muscle and nerve sparing incision resulted in a short course of pain medication, early diet toleration and a short hospital stay.

Inguinal reoperation for undescended testis and hernia: approach to the spermatic cord through the cremaster fascia.

PURPOSE: Reoperation of the inguinal canal is difficult with few available lucid descriptions of the technique. We reviewed our experience with a unique surgical approach to the spermatic cord through the cremaster fascia in patients who had undergone previous operations for undescended testis or hernia and report its outcome. MATERIALS AND METHODS: A total of 54 inguinal reoperations were performed in 45 boys with an undescended testis or indirect inguinal hernia using a unique surgical approach through the cremaster fascia. RESULTS: Of the 54 inguinal canal reoperations surgery was successful in all but 1 patient who sustained a transected vas deferens (1.8% complication rate). CONCLUSIONS: The surgical approach to the inguinal canal through the cremaster fascia is an effective technique for reoperation of the inguinal canal after orchiopexy or hernial repair.

An atraumatic anatomic technique for separation of the pediatric hernia sac from the spermatic cord.

A detailed photographically illustrated anatomic technique for the sequential dissection of the pediatric hernia sac from the spermatic cord has not been described. An illustrated technique to atraumatically dissect the hernia sac in a systematic fashion is therefore presented.

Calculus-producing and cytomegalovirus-infected nephrogenic adenoma of the bladder in a prepubertal renal transplant recipient.

A 14-year-old prepubertal boy, a renal transplant recipient, was treated for a nephrogenic adenoma. His case is unique in that he is the second youngest renal transplant recipient diagnosed with a nephrogenic adenoma. In addition, the lesion was calculus producing, which has not been previously described, and contained cytomegalovirus inclusions, which has been described only once previously in association with a nephrogenic adenoma in a transplant patient.

Neonatal circumcision: anatomic contraindications.

Complications from neonatal circumcision may result from inexperience or poor technique, but may also result from poor patient selection based on penile anatomy. The anatomic contraindications to neonatal circumcision are therefore presented in an effort to prevent complications.

Association of epididymal anomalies with patent processus vaginalis in hernia, hydrocele and cryptorchidism.

PURPOSE: We performed a prospective study to assess the relationship between epididymal anomalies and patency of the processus vaginalis in boys presenting with hernia, hydrocele or cryptorchidism. MATERIALS AND METHODS: The degree of patency of the processus vaginalis (closed, partially closed or open) and morphology of the ipsilateral epididymis were recorded in 159 consecutive inguinal explorations. RESULTS: A closed, partially closed and open processus vaginalis was associated with an abnormal epididymis in 14, 36 and 69% of cases, respectively. Epididymal anomalies were more frequent in association with undescended (72%) than descended (34%) testes. CONCLUSIONS: These data confirm the observation of a higher incidence of epididymal anomalies associated with patency of the processus vaginalis irrespective of testicular position, and they support the theory that androgenic stimulation may be required for closure of the processus vaginalis as well as epididymal development.

Applied anatomy of the cremasteric muscle and fascia.

PURPOSE: Although the cremasteric muscle is a prominent structure of the inguinal canal, specific details of its anatomy are seldom discussed in either anatomical or surgical texts. Therefore, a detailed description of the anatomy of the cremasteric muscle and fascia is provided, followed by descriptions of new applications of this knowledge for operations on the inguinal canal. MATERIALS AND METHODS: Observations are described based on more than 1,000 operations on the inguinal canal conducted during a 15-year period. Magnification of 3.5 x was used in all dissections. RESULTS: Careful dissections of the cremasteric muscle and fascia allowed for development of new approaches to enhance exposure of the inguinal canal and internal ring, and to mobilize the spermatic cord and testes. CONCLUSIONS: Knowledge of the anatomy of the cremasteric muscle and fascia, and techniques for dissection are adjuncts to surgery of the inguinal canal, including inguinal hernia repair and orchiopexy.

Experience with ileal augmentation cystoplasty using a short pfannenstiel incision.

PURPOSE: Our study was done to evaluate the efficacy of performing ileal augmentation cystoplasty through a short Pfannenstiel incision. MATERIALS AND METHODS: From December 1986 to June 1988, 7 patients with neurovesical dysfunction secondary to myelodysplasia underwent ileal augmentation cystoplasty via a lower abdominal incision. From July 1989 to July 1993, 12 similar patients underwent ileal augmentation cystoplasty via a short Pfannenstiel incision. RESULTS: Operative time was slightly shorter and mean recovery time, as measured by the return of gastrointestinal function and hospital stay, was shorter in the Pfannenstiel incision group. CONCLUSIONS: In select patients a short Pfannenstiel incision is the incision of choice for ileal augmentation cystoplasty.

Modified Barcat balanic groove technique for hypospadias repair: experience with 295 cases.

PURPOSE: We reviewed the results of a large series of hypospadias repairs (311) using the modified Barcat balanic groove technique. MATERIALS AND METHODS: All patients who underwent modified Barcat repair with closure of the divergent corpus spongiosum were included in our study and were seen or contacted for postoperative followup. RESULTS: Of 295 patients available for followup 94% had excellent cosmetic results. The fistula rate after primary repair was 5% for a glanular or coronal meatus and 18% for a penile meatus, and meatal stenosis was rare. After secondary repair complications were common in patients with a penile meatus. CONCLUSIONS: The Barcat technique allows anatomically superior glans reconstruction in distal hypospadias repair. Fistula rates can be reduced by tissue coverage of the neourethra.

The secondary internal ring: applications to surgery of the inguinal canal.

PURPOSE: In 1975 the clinical importance of the preperitoneal fascial or secondary internal ring was noted based on procedures performed through the suprainguinal preperitoneal approach. The importance of knowledge of the secondary internal ring in the performance of inguinal hernia repairs, orchiopexies and operations for impalpable testes through the inguinal canal is shown, along with a description of the anatomy of the internal ring and subjacent retroperitoneal connective tissue. MATERIALS AND METHODS: More than 250 consecutive inguinal canal dissections were performed during surgery for inguinal hernia repair, orchiopexy or impalpable testes by a single surgeon using 3.5x magnification. RESULTS: The intraoperative dissections clearly showed the existence of a secondary internal ring, which when opened provided wide access to the retroperitoneal space containing the internal spermatic vessels and vas deferens. CONCLUSIONS: Knowledge of the anatomy of the secondary internal ring is an adjunct to the performance of operations through the inguinal canal.