Tunica vaginalis flap for salvaging testicular torsion: A matched cohort analysis.

INTRODUCTION: In testicular torsion, ischemia time from pain onset impacts testicular salvage. A tunica albuginea fasciotomy to relieve compartment pressure followed by a tunica vaginalis flap (TVF) may enhance salvage. OBJECTIVE: To define the optimal window of ischemia time during which TVF may be most beneficial to avoid orchiectomy. STUDY DESIGN: A retrospective cohort study of males presenting with testicular torsion at a single tertiary-care institution from January, 2003 to March, 2017. Ischemia time was defined as duration of pain from onset to surgery. Because TVF would be an option to orchiectomy, and it was found that ischemia time was longer in testicles that underwent orchiectomy, matching was performed. Cases of torsion treated with TVF were matched 1:1 with cases treated with orchiectomy on age at surgery, and ischemia time. Outcomes included postoperative viability, defined as palpable testicular tissue with normal consistency, and atrophy, defined as palpable decrease in size relative to contralateral testicle. Sensitivity analyses were performed restricting to the subgroups with postoperative ultrasound, >6 months' follow-up, and additionally matching for degrees of twist. RESULTS: A total of 182 patients met eligibility criteria, of whom 49, 36, and 97 underwent orchiectomy, TVF, and septopexy alone, respectively. Median follow-up was 2.7 months; 26% of patients had postoperative ultrasound (61% of TVF group). In the orchiectomy, TVF, and septopexy groups, respectively, median ischemia times were 51, 11, and 8 h, postoperative viability rates were 0, 86, and 95%, and postoperative atrophy rates were 0, 68, and 24%. After matching, 32 patients with TVF were matched to 32 patients who underwent orchiectomy. In the TVF group, postoperative viability occurred in 95% (19/20) vs 67% (8/12) of patients with ischemia times ≤24 and >24 h, respectively. Atrophy occurred in 67% (12/18) vs 83% (10/12) of these same respective patients. Sensitivity analysis by ultrasound and longer follow-up found similar viability results, although atrophy rates were higher. Additional matching for degrees of twist showed lower viability and higher atrophy rates for increasing ischemia times. DISCUSSION: Patients who presented with testicular torsion with ischemia times ≤24 h and who were being considered for orchiectomy may have benefitted most from TVF, albeit at high risk of atrophy. However, for ischemia times >24 h, TVF may still have preserved testicular viability in two-thirds of cases. A limitation was short follow-up. CONCLUSION: A TVF was a valid alternative to orchiectomy for torsed testicles, albeit with high testicular atrophy rates.

Dermal patch graft correction of severe chordee secondary to penile corporal body disproportion without urethral division in boys without hypospadias.

Historically, significant ventral penile curvature secondary to corporal body disproportion has been corrected either by dorsal plication or division of the urethral plate. In the rare situations where there is severe chordee in the face of an intact urethra with an orthotopic meatus, division of the urethral plate is commonly performed at the time of grafting the ventral defect created by incising the tunica albuginea. Subsequently, a staged procedure is necessary to reconnect the urethra at a later date. Herein the authors present a novel technique that shows it is possible to perform successful dermal patch orthoplasty without division of the urethra in patients with a normal orthotopic meatus and urethra via urethral mobilization. Three patients over the past 3 years with severe ventral chordee, orthotopic meati and normal urethral anatomy presented for correction. Two patients were 18 years old and one was 10 years old. All three boys were circumcised. The two older boys insisted on dorsal plication as a first approach which worked only temporarily for about 6 months while the younger boy had no prior surgery performed. Each boy underwent a circumcising incision, degloving of the shaft skin, extensive urethral mobilization and dermal patch graft orthoplasty to correct chordee. All surgeries were performed in an outpatient setting. No urinary drainage was used in any patient and a simple bio-occlusive dressing was employed in each case. Follow-up ranged from 11 months to 2 years (mean 1.5 years). All three boys have strong straight erections, full well directed urinary streams and no complications noted to date. Our conclusion based on this experience is that extensive urethral mobilization can allow for correction of severe ventral chordee without urethral division in a single operative setting in boys without hypospadias and a normal urethra. The accompanying movie herein describes the surgical technique.

Fate of renal allografts transplanted in patients with urinary diversion.

Fifty-five kidneys were transplanted into 50 patients with supravesical urinary diversion at 16 transplant centers between 1970 and 1991. Of the 32 males and 18 females, 40 were adults (> or = 18 years) and 10 were less than 18 years old at the time of first transplant. Mean follow-up was 7.8 years. At last follow-up, 94% of recipients were alive and 73% of the kidneys were functioning. Fifteen kidneys were lost: 9 to rejection, 3 to noncompliance, and 3 patients died with a functioning kidney. Ten (18%) transplants were followed by surgical complications. Twenty-four (44%) were followed by medical complications of which urinary tract infection was most common. Recipients age 18 or younger had more urinary tract infections than older patients. No patient had urinary stones and no patient required medical treatment for metabolic abnormalities. We conclude that drainage of kidney transplants into a supravesical urinary diversion is an effective treatment for end-stage renal disease patients without adequate urinary bladders.

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.

Giant hydronephrosis in ectopic kidney in a child.

A rare case of giant hydronephrosis in an ectopic kidney is presented, and the literature is reviewed.

Surgical correction of anterior urethral diverticula after hypospadias repair in children.

We present a new surgical technique to correct acquired anterior urethral diverticula after hypospadias repair. The correction involves a degloving circumferential skin incision, excision of the diverticulum, and closure of the urethra incorporating overlapping suture lines.

Insertion of testicular prosthesis: use of vaginal speculum.

We have used a vaginal speculum to insert a testicular prosthesis through the inguinal approach over the past four years. We have found this technique to be easily performed and reproducible in allowing the testicular prosthesis to be placed in the normal dependent position in the scrotum.

Use of distal Thiersch-Duplay urethroplasty for proximal hypospadias repairs in conjunction with short island pedicle flap.

Experience with 8 boys having proximal hypospadias with severe chordee and a foreshortened dorsal hooded foreskin is presented. Use of a distal Thiersch-Duplay tube was incorporated in addition to an island pedicle flap to achieve the correct meatal location on the glans. One boy with perineal hypospadias required both proximal and distal Thiersch tube with an island flap interposition. Follow-up of nine months to 3.5 years demonstrated excellent cosmetic and functional results with no recurrent chordee or urethral stenosis. The only fistula noted developed at the proximal Thiersch tube-island flap anastomosis in the boy with perineal hypospadias. Advantages of the aforementioned procedure include decreasing the risk of chordee on the basis of a foreshortened island pedicle flap, use of vascularized flaps, and completing the procedure in one stage with a satisfactory result.

Ultrasonography and diagnosis of pediatric genitourinary rhabdomyosarcoma.

Rhabdomyosarcoma is the most common tumor of the lower genitourinary tract in children during their first two decades of life. Four patients with genitourinary rhabdomyosarcoma are presented, with ultrasonographic and radiographic findings. The utility of ultrasound in the diagnosis of this pediatric tumor is emphasized.

Silicone foam dressing for penis after reconstructive pediatric surgery.

Although silicone foam has been used abroad as an effective means to dress the penis after hypospadias surgery, its use has not been widespread in the United States. We have modified the method to apply the foam in order to facilitate its use. We used this method to dress the penis with silicone foam in 50 boys after reconstructive surgery. The dressing appeared to be effective in restricting edema and hematoma formation. Also, the dressing stabilized the indwelling urethral catheter thereby preventing disruption of the glansplasty. The urethrocutaneous fistula rate (10%) was not reduced by use of the foam. The dressings uncommonly fell off prematurely. The boys appeared to experience little discomfort while the foam was in place and during its removal.

Use of kidney internal splint/stent (KISS) catheter in urinary diversion after pyeloplasty.

We report on the use of a new catheter, the kidney internal splint/stent (KISS), to facilitate renal urine drainage following pyeloplasty. The catheter combines the desirable qualities of nephrostomy tube diversion, anastomotic stent, and trocar placement in a single tube. The special construction of its lumen diminishes the likelihood of obstructed drainage. Our experience using the KISS catheter with 31 patients undergoing pyeloplasty shows it provides effective internal and external urinary diversion.

Office urologic ultrasound in pediatric patients.

We use office ultrasound to supplement the pediatric urologist's office examination and follow the European model (J. Cukier, personal communication). The study can better serve the child and the family in this setting. We have shown that office ultrasound is an excellent primary screening modality, being both practical and accurate. The portable ultrasound machines now available should permit widespread use of office ultrasonography. However, office studies are not intended to replace studies with the more sophisticated and costly ultrasound machines used in radiology departments, only to complement them. We believe the primary uses of in-office examination in children at present are evaluating for detrusor thickness, residual urine volume, bladder capacity, hydronephrosis, and hydroureter; postoperative follow-up of hydronephrosis; screening for sibling uropathology; screening for occult uropathology in cases of gross hematuria; and study of voiding dysfunction or urinary infection. Experience has taught us that the better we become in performing inoffice ultrasound examinations, the better we use ancillary radiologic tests.

Role of in-office ultrasonography in screening infants and children for urinary obstruction.

With the availability of machines suitable for the office, we studied whether in-office ultrasonography could assist in the management of children with known or suspected hydronephrosis. Of 509 children examined, 81 (16 per cent) had hydronephrosis. In 56 (70 per cent) of these children, ultrasonography was helpful in expediting the diagnosis (9 cases), clarifying the etiology (16 cases), evaluating the condition postoperatively (26 cases), and screening (5 cases). Three incorrect ultrasound diagnoses were encountered. The authors believe that ultrasound is the best initial imaging method for the urinary tract and have shown that it is practical and effective in an office setting.

Abnormalities of the external genitalia.

This article discusses the general nuances of hypospadias, exstrophy/epispadias, and ambiguous genitalia. Embryologic considerations, etiologic factors, anatomy, associated anomalies, and timing of referrals and surgery are discussed.

Rat renal allograft tolerance is associated with local TGF-beta and absence of IL-2r expression within chimeric immunocytic foci.

Tolerance was induced in Lewis (LEW) rat renal allograft recipients of Brown Norway kidneys by multiple pretransplant donor-blood transfusions and prior limited cyclosporine A. Rat renal allograft tolerance was associated with the induction of systemic donor T cells (10%), an early phase of nonspecific suppressor-cell generation, followed by maturation of systemic antigen-specific suppressor cells, and renal cellular infiltrates that develop long-term in situ in the kidney graft model. It was hypothesized that these infiltrates represent chimeric immunocytic foci that are locally regulated via a TGF-beta-dependent mechanism. Both immunohistochemical staining and digital image analysis for cellular and extracellular TGF-beta, IL-2 receptor (CD25), and the BN Class I-MHC marker (OX-27) were performed. Control rejecting (REJ) kidneys did not demonstrate any differences with respect to levels of infiltrating immunocyte area vs long-term surviving (TOL) kidneys (3.9% vs 4.5%, P = .303). Immunostaining with the BN Class I MHC marker (OX-27) demonstrated high levels of chimerism within immunocyte foci of the tolerant grafts (OX-27 BN+immunocytes 49.0% +/- 5.1%). In situ cellular IL-2 receptor (CD25) expression was demonstrated in REJ kidney infiltrates but not within TOL immunocytic infiltrating foci, when measured as percent of total lymphocytes (REJ = 5.0% vs TOL = 0.4%, P = .031). Conversely, TGF-beta expression was significantly higher in immunocytes of TOL kidneys when measured as the number of DAB chromogen-staining pixels per total immunocyte area (TOL = .076 vs REJ = .047, P = .003). In conclusion, these results suggested that stable mixed immune chimerism (SMIC) plays an important role in DST-CyA-induced tolerance in situ. SMIC-induced tolerance may involve a local TGF-beta-dependent mechanism that is associated with in situ TGF-beta (+) and IL-2r (-) immunocytes.

The GAP (glans approximation procedure) for glanular/coronal hypospadias.

A modified glanuloplasty is described for the selective repair of glanular and coronal hypospadias with a wide, deep glanular groove and noncompliant urethral meatus. No urinary diversion is required, and cosmetic and functional results are excellent. A total of 24 children underwent the GAP (glans approximation procedure) during 20 months. Followup ranged from 3 months to 1.5 years with no evidence of meatal or urethral stenosis. One distal glanular fistula developed that required division of a 2 mm. skin bridge that separated the fistulous opening from the neomeatus.

Use of venography as an aid in varicocelectomy.

Venography has been proposed as an aid in preventing persistent varicoceles after internal spermatic vein ligation. Since 1984, 10 patients between 4 and 18 years old underwent successful outpatient varicocelectomy with high ligation and intraoperative internal spermatic venography to assure that all appropriate veins and collaterals had been isolated before ligation.