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Although male infants and young boys with epididymitis have a high incidence of anatomical pathology, dysfunctional voiding is not a well established cause of epididymitis. In our series 36 boys with epididymitis underwent noninvasive urodynamic studies to determine whether a physiological defect could be assigned as an etiology. The 2 mechanisms proposed are similar to that in children with vesicoureteral reflux associated with dyssynergia or bladder instability and to a cause of recurrent urinary tract infection in children (the infrequent voider syndrome). Urinalysis and urine culture are recommended in all children with epididymitis and urethral swabs are obtained from those who are sexually active. We recommend renal/bladder ultrasound and voiding cystourethrography in all infants and young children with epididymitis. In the older child we advocate detailed questioning regarding voiding symptoms and the performance of noninvasive urodynamic studies.

Purpose: Patients with intra-abdominal testes represent a small but challenging group who require innovative therapy. We report our 17-year experience with testicular autotransplantation., Materials and Methods: Testicular autotransplantation was performed in 23 patients with 27 intra-abdominal testes., Results: The success rate was 96% and average operative time was 4.25 hours with 40 to 90 minutes for vascular anastomoses. A contralateral Fowler-Stephens procedure had previously failed in 3 cases., Conclusions: Since the variability of collateral blood supply in patients with high undescended testes may potentially compromise the Fowler-Stephens procedure, we believe that testicular autotransplantation should be strongly considered in such patients, particularly those with bilateral undescended testicles.

A 2-year retrospective review of 238 cases of acute scrotal pain encountered in a children's hospital emergency department is presented. The incidences of testicular torsion, torsion of a testicular appendage, and epididymitis were 16%, 46%, and 35%, respectively. Testicular salvage was critically dependent on the interval between onset of pain and surgical intervention. No testis likely to have been viable at the time of presentation was "lost." The diagnostic error rate on first encounter was 7%, resulting in 10 negative scrotal explorations. With the exception of cases of far-advanced necrotic testes, both color Doppler ultrasound and radioisotope imaging were highly specific diagnostic modalities. Thirty-nine percent of the children with epididymitis who underwent investigation were found to have either structural or functional urinary tract abnormalities. Noninvasive urodynamic studies appear to be useful screening modalities in older children with epididymitis.

The authors report on 23 patients who underwent complex continent urinary reconstructions, made successful by the selection of gastrocystoplasty as the chosen augmentation modality. The mean patient age was 6.1 years, and the mean weight was 17.9 kg. The minimum follow-up period was 1.5 years. The bladder capacity increased from a preoperative mean of 77.8 +/- 52.2 (SD) mL to a postoperative mean of 303.5 +/- 117.4 mL (P < .000001). No adverse effects on renal function or serum electrolyte composition were encountered, and there were no instances of acidosis or alkalosis. Continence was achieved in 91% of patients. In two patients (0.9%), hematuria-dysuria developed; one case was extremely mild. The other occurred only during a period of severe oliguria and resolved after transplantation. Gastrointestinal complications were minimal. Five patients had end-stage renal disease at the time of reconstruction and have since had successful transplantation. Gastrocystoplasty is particularly applicable to the pediatric population because of its unique anatomic and metabolic characteristics, which bestow tremendous versatility.

Oftentimes patients with intra-abdominal testes require more than the standard procedure to accomplish orchiopexy. Division of the spermatic vessels has been one mainstay of operative approaches for the intra-abdominal testis since Fowler and Stephens (Congenital Malformations of Rectum, Anus, and Genitouriary Tracts, chapter 19, pp 306-320, 1963) provided an anatomically rational basis for this procedure. Silber and Kelly (J Urol, 115:452-454, 1976) first described using a microvascular anastomosis to bring extra blood supply to the testicle after mobilization of a high intra-abdominal testicle into the scrotum; however, this approach has not been adopted by many for a number of reasons. The microvascular skill and instrumentation required for a successful anastomosis are not universally available and there is a misconception that the procedure is a lengthy one (Bianchi, Br J Urol 56:521-524, 1984; Bogaert et al., Urology 42:182-188, 1993). We present our series for testicular autotransplantation used over a 17 year period with a greater than 95% success.

Extravesical detrusorrhaphy is a modification of the Lich-Gregoir antireflux procedure that incorporates ureteral advancement into the repair. We report on our use of laparoscopic detrusorrhaphy to correct vesicoureteral reflux in an animal model. Reflux was created by transurethral incision of the roof of each ureteral orifice. In phase 1 of this study, laparoscopic repair was performed 1 week later in 3 pigs and an open technique was done in the remainder. In phase 2 laparoscopic repair was done in 3 pigs 3 weeks after inducing vesicoureteral reflux. All phase 1 repairs successfully corrected reflux but 1 ureter in the laparoscopic group developed obstruction. All phase 2 repairs were successful, which was determined by preoperative and postoperative cystography, and a postoperative excretory urogram. Average time was 2 hours 21 minutes for laparoscopic repair and 1 hour 10 minutes for the open procedure. Complications included bladder perforation and ureteral obstruction in 1 case each with no postoperative deaths. These preliminary results indicate that laparoscopic detrusorrhaphy is a feasible procedure in a porcine model.

We report on a neonate with a history of failure to thrive who had a large right abdominal mass. Renal ultrasound showed a large cystic mass that arose from the upper pole of the hydronephrotic right kidney. Preoperative antegrade pyelography confirmed that the mass communicated with 1 kidney. Further evaluation revealed no communication of the ureter with the bladder or vagina. Exploratory surgery identified the mass and intraoperative pyelography revealed no communication with the bladder. After resection of the mass and nephrostomy placement, reimplantation of the right ureter demonstrated complete atresia of the distal right ureter. Preservation of the remaining renal parenchyma was possible, because the functioning lower pole collecting system communicated with the cystic mass that arose from the upper pole.

Multicystic kidney was first described in a 7-month-old child. Some physicians advocate nephrectomy in such cases, while others have questioned this procedure. In 1986 the American Academy of Pediatrics, Section on Urology established the Multicystic Kidney Registry to identify and follow patients with multicystic kidney disease. To date 441 patients have been registered, of whom 260 were managed nonoperatively. Based on followup of these patients no kidneys were removed for hypertension, infection, pain or tumor development. Long-term findings show that multicystic kidney disease may take as long as 20 years to resolve, and followup testing will be necessary.

We present our experience with the pyramid hypospadias repair in 37 patients with distal or subcoronal hypospadias. We also describe a significant modification (in the 7 most recent patients) of Duckett's original procedure that minimizes the risk of ventral fistula formation. This modification involves the creation of a vascularized second-layer tissue flap. We incorporated the modified pyramid hypospadias repair into the general surgical approach to subcoronal hypospadias. Our operative approach permits the delayed selection of either a perimeatal-based flap, preputial flap or a modified pyramid type repair after release of the shaft skin. In 35 patients the repair achieved excellent results, while only 2 had urethrocutaneous fistulas. No patient who underwent the modified repair suffered fistula formation. Our surgical technique is applicable to a number of variants of subcoronal hypospadias and maximizes repair options.

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.

In 1987 Firlit et al described their results using Hodgson's technique of the modified extravesical Gregoir-Lich procedure. They coined the term detrusorrhaphy or extravesical ureteral advancement to describe this technique. During the last 4 years we performed this reimplantation on 211 ureters in 132 patients. Of the patients 79 had unilateral and 53 had bilateral procedures. Included were 6 megaureters requiring ureteral tailoring and 9 uncomplicated duplications. All but 1 patient were cured of reflux. No postoperative obstruction was encountered. Our results indicate that this is an excellent procedure to repair vesicoureteral reflux with minimal morbidity and short hospital stay.

The natural progression of nephropathic cystinosis to end stage renal disease can be delayed, sometimes by many years, by the reducing agent, cysteamine, which lowers intracellular cystine content to near normal. We report on two patients with nephropathic cystinosis who were treated with cysteamine and developed structural genitourinary abnormalities which may have contributed to an increase in the rate of decline of renal function. One patient, aged 11 years, was found to have massive megacystis and hydroureteronephrosis but no anatomic bladder outlet obstruction. His abnormality was presumed to be related to chronic high urine volumes leading to megacystis and physiologic ureteral obstruction. Vesicostomy stabilized renal function. The second patient, aged 11 1/2 years, was found to have bilateral renal cystic disease which presumably was acquired and may have been related to long-standing hypokalemia. Minor renal abnormalities were found by ultrasound in five additional cystinotic children. We concluded that older children with nephropathic cystinosis may be prone to acquire structural abnormalities of their kidneys or urinary tract.

Since 1988 there have been 15 reported cases of late, spontaneously ruptured intestinal cystoplasties at bowel sites remote from the anastomosis. Ischemic necrosis has been suggested as a possible etiology. We examined this hypothesis by quantifying the uptake of intravascular fluorescein in the augmented bowel of adult mongrel canines. There was a statistically significant decrease in fluorescein uptake at high intravesical pressures, which appeared to be most pronounced at the antimesenteric border. This laboratory study supports a recent clinical report of histological changes pathognomonic for chronic ischemia in the augmented bowel of patients with spontaneous rupture.

Neurovesical dysfunction (NVD) is frequently encountered in children with imperforate anus and its variants. Such functional urologic problems are often compounded by associated anatomic urologic abnormalities that in combination may profoundly alter the course and prognosis of children with imperforate anus. Herein, we report 16 such cases. Management of NVD in children with imperforate anus offers several unique challenges that require important alterations in management. Specific recommendation are presented.

A comparison of polydioxanone, polyglactin, and chromic catgut suture was performed in 120 rat bladders studying propensity for infection, degree of inflammation, calculogenic potential, changes in urine pH, and suture absorption. None of the sutures predisposed to infection and there was wide variability but no correlation in urine pH. Although initially the polydioxanone incited a greater inflammatory response, by six months all three sutures were similar. The absorption of polydioxanone was slower than chromic catgut suture, but similar to the absorption of polyglactin. There was no significant difference in calculogenic potential between the suture materials tested over a six-month period. Based on this study in rats, polydioxanone suture would appear to be equal to catgut and polyglactin suture in bladder surgery.

Hypospadias and cryptorchidism constitute common problems in urology for which the use of routine screening urography has been challenged recently. To assess better current thinking 233 urologists who devote a significant part of their practice to children were surveyed as to the number of procedures performed as well as to the instances when excretory urography was obtained. Of 163 physicians who responded 70 per cent do not favor routine screening urography in cryptorchid patients, while approximately 50 per cent believe that it is worthwhile in hypospadias. In the cryptorchid responses there was a definite decrease in the percentage of physicians obtaining x-rays as the yearly volume of cases increased (50 per cent with less than 10 cases per year and 18 per cent with greater than 20 cases per year), while this relationship was not maintained for hypospadias. A review of the literature correlates well with this survey in that excretory urography is not necessary in cases of cryptorchidism but its value is still debated in cases of hypospadias.

Multilocular cyst of the kidney is a rare pathologic entity occurring in both children and adults. Although diagnosis cannot be firmly established preoperatively, the use of intravenous pyelography, angiography, ultrasonography, and delta scan may aid in its diagnosis. Because of the difficulty in accurate diagnosis and the documented association with renal neoplasia, we recommend exploration and possible nephrectomy as the treatments of choice.

Psychological concerns for the timing of medical procedures on children result from the longstanding realization that events and behavioral patterns of childhood have wide-ranging effects on the later behavior of the adult. A review of the literature regarding the effects of surgery on psychological development is presented. Particular reference is made to the impact of genitourinary surgery with specific emphasis on the repair of hypospadias, a congenital anomaly affecting 1:250 to 1:400 live male births. Studies of adults who underwent hypospadias repair as children suggest that they are psychologically different from their peers who did not have this surgery. Specifically, as adults they frequently have sexual difficulty despite erectile competence and they generally occupy less responsible, less competitive, and less independent professions than similarly intelligent cohorts. These findings imply that the experience of hypospadias or its surgical repair may in some way affect psychological development. By examining these experiences in light of emotional and cognitive development and the emergence of body image and sexual identity, predictions for psychologically optimal timing of surgery are made. Importance of the role of the family in the psychological outcome and a discussion of surgical considerations are also provided.

Percutaneous needle puncture and aspiration of suspected cystic renal masses may provide accurate diagnosis in selected cases. However, renal cyst puncture is not a totally innocuous procedure and certain complications may be encountered. Report is made of 2 cases of renal cyst puncture followed by abscess formation, necessitating surgical intervention. An improved technique involving surgical preparation of the operative area and utilization of double-needle method of cyst puncture is advocated.

The use of optical magnification (loupes) to repair hypospadiac anomalies in children is well known. A mouth-controlled operating room microscope (Zeiss OPMI 6CH Contraves Stand) became available that has been utilized in 34 cases of hypospadias repair which included 13 flip-flap, 4 MAGPI, 14 Hodgson XX (modified Asopa), and 3 other procedures. Other results show that in 2 patients fistula developed and in 1 meatal stenosis. Based on our experience, we believe this new microscope compares favorably with previous results and allows the surgeon to use small sutures with great accuracy.

During the past eight years, reestablishment of previously diverted urinary tracts has become more frequent. During the past three years, 11 patients have been evaluated and 7 subsequently operated on to reestablish continuity of the urinary tract. Four patients were eliminated from surgical consideration because of the extent of renal disease. The surgical procedures involve the use of ileum as well as the transureteroureterostomy with the psoas hitch procedure to reestablish urinary continuity. Examination of the over-all results illustrates urinary undiversion surgery in children is worthwhile. The initial results with neuropathic bladder disease has been a little discouraging, and more data will be required before a conclusion can be reached.

Between 1977 and 1981, 106 children were operated on for hypospadias anomalies. Of these patients 51 have undergone the modified flip-flap urethroplasty or meatal advancement and glanuloplasty, 30 were repaired using a 1-stage Hodgson or Duckett tube urethroplasty, 10 have completed a 2-stage Belt-Fuqua procedure and 15 were treated for multiple complications. A urethrocutaneous fistula developed in 4 patients (4 per cent), meatal stenosis in 3 (3 per cent) and a transient urethral stricture in 1 (1 per cent). All procedures were performed using optical magnification, 2.5 times during the first 1 1/2 years followed by 4.5 times during the subsequent years. In addition, 58 children completed repair before age 2 years, with a mean age of 16 months, with no difference in complication rate. These results indicate that through the use of optical magnification hypospadias surgery can be accomplished safely using a 1-stage reconstruction repair before the child is 2 years old.

Children with intra-abdominal testes comprise a small group presenting for surgical management of the undescended testicle. During the last 4 years 6 children with 8 intra-abdominal testes have undergone testicular surgery. In 7 testicles the technique involved high intraperitoneal division of the testicular pedicle with reanastomosis of the distal spermatic artery and vein to the inferior epigastric artery and vein using the operating room microscope. Microsurgery on the 7 intra-abdominal testicles led to good results in 6 cases. In 1 testicle venous infarction occurred secondary to venous congestion. Although many children with intra-abdominal testes have been managed using the standard Stephens-Fowler technique, we believe that microsurgical reanastomosis will improve the previously reported results.

Coronal hypospadias is a frequent abnormality of the genitalia. It is recommended that patients with coronal hypospadias be assessed with the technique of penile corporeal injection during anesthesia and any patient with coronal hypospadias should be circumcised with the utmost caution and surgical discretion.

The retrospective analysis of 210 patients between 1 month and 17 years old with 314 primary vesicoureteral units with reflux was reviewed. Our results show that there was a direct correlation between the grade of reflux and the per cent of abnormal ureteral orifices. Medical management of low grade reflux produced successful results in 60 per cent of the cases. Operation was highly successful in grade I, II, and III reflux as opposed to grade IV. The distal tunnel (Glenn-Anderson) and Politano-Leadbetter procedures were equally effective in curing reflux. Postoperative urinary infection occurred equally in all grades and usually was confined to the bladder.

There were 35 hypofertile men who underwent assay of serum follicle stimulating and luteinizing hormones, and testosterone, and were placed in a trial program using clomiphene citrate in a 25-day cycle, with 5-day rest periods. Therapy has been maintained for up to 9 months with a projected termination of 12 months. No relationship could be established between serum follicle stimulating hormone and spermatozoal number in this population. The spermatozoal count improved in 31 men while they were on therapy and 8 pregnancies have occurred. Clomiphene citrate seems to be effective in improving the quanttity of spermatozoa and the spermatozoal motility in these hypofertile men.

A 9-month-old female with opsoclonus and ataxia was examined. Computerized axial tomography (CT) of her abdomen identified a retroperitoneal mass of neural crest origin that was not recognized by more conventional roentgenographic methods. The syndrome of cerebellar ataxia, myoclonus, and opsoclonus, and its relationship to neural crest tumors is reviewed along with the usefulness of abdominal CT.

Patients with retroperitoneal or mediastinal neoplasms of gonadal tissue type and clinically normal testes pose interesting therapeutic dilemmas. Three major groups of patients are recognized: (1) tumor is primary extragenital gonadal neoplasm; (2) occult microscopic primary neoplasm in a testicle with metastases; (3) area of fibrosis in a testicle representing local regression of tumor, but with distant metastases. Review of case reports often indicates lack of data sufficient for classification. Every effort should be made to group patients into proper categories, since treatment will vary. Two patients classified as group 2 are presented.

Experience with late escutcheon reconstruction in 4 adult patients, 2 men and 2 women, is presented. All had similar presenting complaints of abnormal external appearance of their pubic region and genitalia, as well as one or more typical related problems. Our surgical approach and correction of these conditions were simple and definitive.

Between January 1976 and December 1980, 109 children with 157 ureters with reflux were seen in consultation. Of these ureters 52 were operated upon using the Cohen cross-trigonal technique, while 105 were followed conservatively. The operative procedure is a complete intravesical ureteral mobilization followed by the creation of a submucosal tunnel across the base of the bladder. Followup studies, including an excretory urogram and voiding cystourethrogram, showed minimal hydronephrosis in 1 ureter and persistent grade I reflux in 1 ureter. Evaluation of these initial results indicates that the Cohen cross-trigonal ureteroneocystotomy is a safe and effective antireflux procedure.

The management of patients with hypospadiac anomalies requires sound surgical judgment to obtain optimal results. From January 1983 to June 1985, 150 patients were operated on for hypospadias. Of these patients 37 underwent the Hodgson XX (modified Asopa) repair. Two patients suffered urethral fistulas, 1 had meatal stenosis and 1 had mild torsion. No strictures were noted. Based on our findings it appears that the Hodgson XX (modified Asopa) procedure provides excellent results for patients with hypospadias and chordee.

The use of the operating room microscope to accomplish microscopic anastomosis is gaining wider application. The technique to accomplish autotransplantation of the intra-abdominal testes involves division of the spermatic artery and vein with reanastomosis to the inferior epigastric vessels under the operating room microscope. The over-all success rate cannot be assessed without long term follow-up study, but this procedure offers more potential success than vascular pedicle division alone and will eliminate staged orchiopexy.