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Objective: To review a series of children with anterior urethral valves and diverticula, to elucidate the pathophysiology and optimal management of this entity., Patients and Methods: Nine cases (all boys; 1963 to 2003) were reviewed retrospectively., Results: Seven of nine boys had bulbar diverticula. Continuity between Cowper's duct and the diverticulum was noted endoscopically in two and confirmed radiographically in one. Initially, open surgery was curative but more recently endoscopic management has been the procedure of choice., Conclusion: This series indicates that the distal lip of a ruptured syringocele may function as a flap-valve, leading to anterior urethral obstruction. Advances in imaging and endoscopic instruments have altered the mode of presentation and management of this entity.

Objective: The study compared two populations of patients undergoing bladder neck reconstruction using the silastic sheath in two major pediatric centers. The success with this technique was markedly different in the two centers. The purpose of the study was to determine factors that might explain the divergent results., Patients and Methods: Fifteen patients treated in Indianapolis were compared with 94 patients treated in London with the silastic sheath technique of bladder neck reconstruction. Eighty-seven percent of the Indianapolis patients had myelomeningocele whereas 86% of the London group had exstrophy/epispadias. Median age of the Indianapolis patients was 11 years whereas it was 8.4 years in London. Seventy-three percent of patients in Indianapolis were female and 79% in London were male. Patients were followed for a minimum of eight years in Indianapolis and a mean of seven years in London. Similar surgical technique was employed in the two centers but, over time, the London approach included use of a non-reinforced silastic wrapped loosely around the bladder neck with the interposition of omentum., Results: Both groups achieved continence rates exceeding 90%. Of the Indianapolis patients, two-thirds experienced erosion of the silastic at a mean of 48 months. With modifications in the London technique, the erosion rate of silastic was lowered from 100% to 7%., Conclusion: Direct, snug wrap of silastic without omentum around the Young-Dees tube as well as simultaneous bladder augmentation placed patients at increased risk for erosion. The silastic sheath technique may be less applicable to myelomeningocele patients. It seems most applicable to older male patients with exstrophy or epispadias undergoing Young-Dees bladder neck reconstruction who have the ability to void.

Purpose: We describe ultrasonographic and clinical findings in adolescents with intratesticular varicocele., Materials and Methods: Three adolescent boys 12 to 16 years old each had a large intratesticular multicystic lesion on scrotal Doppler ultrasound for a large extratesticular varicocele. The presence of active Doppler flow within the anechoic lesions supported the diagnosis of intratesticular varicocele., Results: All 3 boys underwent spermatic vein ligation for varicocele. In each case scrotal Doppler ultrasound at 3 months postoperatively demonstrated resolution of the intratesticular anechoic lesions and Doppler flow, confirming the diagnoses of intratesticular varicocele., Conclusions: Intratesticular varicocele is a clinically occult lesion that may occur in conjunction with extratesticular varicocele. This entity is apparent on scrotal Doppler ultrasound as an intratesticular anechoic lesion with active Doppler flow, and has been shown to resolve following spermatic vein ligation. Its clinical significance has not yet been defined.

Purpose: We examined the mechanisms responsible for technical failure of the endoscopic technique for correcting vesicoureteral reflux based on endoscopic anatomy., Materials and Methods: The study included 25 patients, 2 to 15 years old (mean age 8) who received 57 ureteral injections on 1 or more occasions which failed to correct reflux. Each endoscopic procedure for every patient was videotaped and endoscopic photographs were taken to document pretreatment and posttreatment anatomy. Based on the comparative endoscopic anatomical findings, failures were categorized as secondary to volume loss, mound displacement, mound extrusion or indeterminate etiology., Results: Of the 57 ureters the cause of failure was believed to be due to mound displacement in 35%, volume loss in 23%, displacement and volume loss in 29%, mound extrusion in 2% and indeterminate in 11%. The direction of mound displacement was toward the bladder neck (medial, distal) in 76% of those cases., Conclusions: Endoscopic anatomical findings can account for failure of the injection technique to correct reflux in the majority of failed cases (90%). Mound displacement and volume loss account comparably for treatment failure. One incidence of mound extrusion, previously hypothesized as a mechanism for treatment failure, was documented in our study.

Objective: To describe the clinical features of neonatal scrotal haematoma and distinguish them from those of neonatal testicular torsion., Patients and Methods: Five neonates presenting with an acute scrotum and initial diagnosis of neonatal testicular torsion were found to have neonatal scrotal haematoma. In one case the diagnosis was surgical and in four subsequent cases the diagnosis was by colour Doppler ultrasonography, and surgery was avoided. Four of the five children had risk factors associated with neonatal scrotal haematoma, including bleeding diathesis, birth trauma and high birth weight., Conclusions: The importance of including haematoma in the differential diagnosis of the acute neonatal scrotum is emphasized, as is the value of contemporary Doppler ultrasonography in making this diagnosis.

Objective: To assess the efficacy and safety of laparoscopically assisted ureterocystoplasty (LAU) in children., Patients and Methods: From 1999 to 2001, five patients (mean age 7 years, range 3.5-13) from four centres underwent LAU with laparoscopic mobilization of the small kidney and upper ureter combined with ureterocystoplasty, with exposure of the bladder through a Pfannenstiel incision. The details and outcomes are reviewed., Results: The LAU was successful in all five patients; there were no complications. A large midline incision was avoided and the LAU carried out through the better tolerated and less painful Pfannenstiel incision., Conclusion: LAU is an appealing technique that is safe with the added benefit of a reduced abdominal incision and acceptable operative duration. This represents the first published report of LAU.

Purpose: We assessed clinical and ultrasound predictors of the spontaneous resolution of prenatally diagnosed, primary nonrefluxing megaureter., Materials and Methods: Primary nonrefluxing megaureter was prenatally diagnosed in 54 neonates from 1993 to 1998, including 15 in whom it was bilateral (69 megaureters). Median followup period from birth to the last radiology examination was 25.8 months (range 2.3 to 72)., Results: Of the patients 10 underwent surgical repair for severe hydroureteronephrosis, including decreasing renal function on diuretic renography in 1, and an episode of bilateral obstruction and acute renal failure in 1. Hydroureteronephrosis resolved in 39 cases (72%) and persisted in 5 at 30 to 72 months of followup. Laterality, gender and retrovesical ureteral diameter had no significant effect on the resolution rate (p >0.05). Mean initial ureteral diameter in patients with resolution was less than in those without resolution and in those who underwent surgery (0.8 versus 1.15 and 1.32 cm., respectively). Presenting hydronephrosis grade was a significant predictor of the resolution rate (p = 0.03). Grades 1 to 3 hydronephrosis resolved at a median age of 12.9, 23.9 and 34.6 months, respectively (range 4.1 to 66). In patients in whom grades 4 and 5 hydronephrosis resolved the median age at resolution was 48.5 months., Conclusions: Most cases of prenatally diagnosed, primary nonrefluxing megaureter resolve spontaneously. Grades 1 to 3 hydronephrosis tend to resolve between ages 12 and 36 months. For these grades followup intervals may be progressively elongated after a pattern of improving hydronephrosis has been established. In children with grade 4 or 5 hydronephrosis, or a retrovesical ureteral diameter of greater than 1 cm. the condition may resolve slowly and require surgery.

Objective: To describe the tolerability and efficacy of clean intermittent catheterization (CIC) in the management of dysfunctional voiding in patients who are neurologically and anatomically normal., Patients and Methods: The medical records were reviewed in 23 patients (16 girls, mean age 9 years, range 6-14.5, and seven males, mean age 8 years, range 5-20.5) with urinary incontinence and/or urinary tract infection (UTI) who were offered CIC because they had a large postvoid residual urine volume (PVR). All had extensive instruction before starting CIC. All patients underwent urodynamic studies, and urinary and fecal elimination habits were recorded. Detrusor hyperactivity, when present, was treated with anticholinergic medication. The follow-up evaluation included tolerance of CIC, continence status and the incidence of UTI. Behavioural modification or biofeedback training was not used in any patient., Results: Of the 23 patients, 13 presented with both UTI and urinary incontinence, five with incontinence only, four with UTI only, one with frequency and no incontinence, and one with haematuria. Associated symptoms included frequency/urgency, constipation or soiling, and straining to void or incomplete emptying (in nine each), and infrequent voiding in six. CIC was performed within 2 days by 15 patients, while four others required up to 2 weeks to master CIC. However, three of the four patients (all older girls) who needed 2 weeks to learn the technique did not tolerate CIC and discontinued it within 3 weeks. Four other adolescents (three girls and one boy) refused to learn CIC. Of the 16 patients remaining on CIC only three had cystitis; no patient had a febrile UTI. Once successfully instituted, all patients became continent while on CIC. Six boys (mean follow-up 4 months) had a marked decrease in their PVR. CIC was discontinued in three girls who voided normally to emptiness within 6 months of starting CIC; they remained dry and infection-free 16 months (two) and 6 years later., Conclusion: CIC is a viable therapeutic option for the treatment of dysfunctional voiding, associated with a large PVR, in the absence of any neurological abnormality. CIC is well tolerated in the sensate patient and provides a means for expeditiously achieving continence and improving bladder emptying cost-effectively.

Purpose: To compare the accuracy and precision of orchidometer and ultrasonographic (US) measurements of testicular volume in a canine model., Materials and Methods: Volume measurements of 18 canine testes were obtained by using Prader and Rochester orchidometers. Testes were scanned with two linear-array US transducers with imaging frequencies of 6-13 MHz and 5-10 MHz. For each transducer, testicular volumes were calculated by using three formulas: length (L) x width (W) x height (H) x 0.52, L x W(2) x 0.52, and L x W x H x 0.71. Testes were weighed following bilateral orchiectomies. True testicular volume was determined by using the formula volume = weight/density. Paired t tests were used to assess whether mean measurement biases differed significantly from zero. The relationship between true and measured volume was evaluated with a linear regression model., Results: US volume measurements demonstrated lower variability and better linear fit compared with orchidometry (R(2) = 0.75-0.90 vs R(2) = 0.14-0.38). The formula L x W x H x 0.71 had the smallest mean bias relative to true volume with use of either transducer over the entire volume range., Conclusion: US methods of testicular volume measurement are more accurate and precise than orchidometry. The formula L x W x H x 0.71 provides a superior estimate of testicular volume and should be used in clinical practice.

Purpose: While a fascial sling for treating children with intractable urinary incontinence is often successful in girls, its effectiveness in boys remains unclear. We determined the long-term efficacy of a rectus fascial sling in boys with neurogenic sphincteric incontinence and defined its urodynamic characteristics for achieving continence., Methods and Methods: We reviewed the charts of all boys who underwent a rectus fascial sling procedure for neurogenic incontinence to determine urinary continence status at the most recent office visit or by telephone interview, the type and dose of anticholinergic and sympathomimetic medications, the frequency of intermittent clean intermittent catheterization, status of the upper urinary tract and comparative urodynamic findings preoperatively and postoperatively., Results: We evaluated 7 boys 7 to 19 years old, of whom 4 were postpubertal, who fulfilled study criteria and had a followup of 1 to 9 years. In 4 patients a continent stoma was created concurrently at surgery. Postoperatively all patients were dry during the first 3 months after surgery. At the last followup 1 patient was completely dry, 3 had occasional nighttime wetting, 2 had occasional stress incontinence, and 1 had frequent daytime and nighttime wetting requiring subsequent bladder neck closure. Prepubertal and postpubertal males performed catheterization without difficulty and all required less frequent clean intermittent catheterization and medication postoperatively compared to preoperative status. None had hydronephrosis. Postoperatively urodynamic evaluation revealed normal bladder compliance, improved urethral resistance that did not decay with bladder filling and no uninhibited contractions., Conclusions: The rectus fascial sling is effective for increasing bladder outlet resistance and decreasing the degree of incontinence in prepubertal and postpubertal males with neurogenic sphincteric incontinence. It has no long-term deleterious effects on bladder function and does not impair the ability to catheterize postoperatively. A fascial sling is an effective alternative to bladder neck closure when creating a continent stoma.

Purpose: We present a modified technique of pyeloplasty that seems ideally suited for reoperative as well as primary repair of ureteropelvic junction obstruction due to high ureteral insertion., Materials and Methods: This repair combines the dismembered technique with creation of a V-flap of renal pelvis by dividing and incising through the ureteropelvic junction superolateral onto the pelvis to a height above the most dependent portion of the pelvis just exceeding the length of ureteral spatulation. The V-flap is completed by an inferolateral incision directed toward the lateral aspect of the pelvis at its most dependent portion. The tip of the V-flap is then flipped down and approximated to the apex of the posterior ureteral spatulation. Of the 12 cases managed by this procedure 2 were reoperative and 10 involved select primary repair with high ureteral insertion at the ureteropelvic junction. Patient age was 3 months to 17 years (median 11 months). Two procedures were performed via a dorsal lumbar incision in the oldest patients and 10 were done via the standard anterior extraperitoneal approach. Radiological evaluation, including mercaptoacetyltriglycine renal scan and/or excretory urography, was performed in all patients preoperatively and postoperatively., Results: In all patients postoperative mercaptoacetyltriglycine renal scan and/or excretory urography at 3 months and 1 year showed excellent drainage after dismembered V-flap pyeloplasty., Conclusions: Dismembered V-flap pyeloplasty has proved to be successful with a number of advantages over the Anderson-Hynes dismembered technique in select patients. These advantages include the avoidance of tissue tension that make mobilization of the kidney and ureter unnecessary, aggressive ureteral spatulation, creation of a dependent, funneled configuration and automatic tapering of a redundant pelvis in the routine course of closure without excision of tissue. This technique also has the advantage of being simpler than other flap repairs and it combines the physiological virtues of dismembered repair with the anatomical advantages of flap pyeloplasty.

In boys with familial male-limited precocious puberty, an activating mutation of the luteinizing hormone receptor causes Leydig cell hyperplasia, resulting in excess testosterone production. There are no reports of Leydig cell masses in boys with familial male-limited precocious puberty. We describe a 10-year-old boy with familial male-limited precocious puberty who developed Leydig cell nodules.

Purpose: Endoscopic correction of vesicoureteral reflux continues to attract research of many autologous and nonautologous substances. We previously reported on the initial results of a clinical trial using endoscopic injection of autologous chondrocytes to correct vesicoureteral reflux in children and now present our greater than 1-year followup results., Materials and Methods: A total of 29 children (47 ureters) with grades II to IV vesicoureteral reflux were treated at 2 centers. Each child underwent cystoscopy and posterior auricular cartilage harvesting at the initial setting. Chondrocytes were grown in culture during a 6-week period. Patients returned for transurethral injection of autologous chondrocytes into the ureterovesical junction of the refluxing ureters. Ultrasound was performed at 1 month, 1 year, and 2 and 3 years after implantation, and a voiding cystourethrogram or radionuclide cystogram at 3 months and 1 year after injection. If reflux persisted re-treatment with stored chondrocytes was offered., Results: At 3-month followup initial chondrocyte injection corrected reflux in 55% of ureters (27 of 47) while a second or third injection was successful in additional 15 of 29 patients, resulting in an overall success rate of 86% (42 of 49) ureters and 25 of 29 patients. At 1-year followup reflux correction was maintained in 70% of ureters (32 of 46) and 65% of patients (19 of 29). The 1-year followup results after re-treatment of 3 ureters were not available. In those patients in whom implantation failed cystoscopy revealed evidence of volume loss and shifting of subureteral mounds to account for loss of the antireflux effect. Three patients underwent successful open ureteroneocystostomy for failed autologous chondrocyte implantation. There were no significant complications., Conclusions: Transurethral injection of autologous chondrocytes to correct vesicoureteral reflux in children is safe and reasonably effective. There is a relapse rate which must be considered. Changes in the formulation of the material have been made to enhance implant reliability and increase long-term success.

Prenatal hydronephrosis is diagnosed with an incidence of 1:100 to 1:500 maternal-fetal ultrasonographic studies. Although ultrasonography accurately describes dilation of the renal collecting system, it cannot define mechanical obstruction, a functional characteristic. The purpose of prenatal screening has changed from simple detection of hydronephrosis to selection for specific diagnosis-based management. The natural history of prenatal hydronephrosis is difficult to determine, and therefore physicians who take care of the fetus and infant are challenged with the following question: when does dilation of the renal collecting system indicate that serious pathology (ongoing renal deterioration) exists? The diagnosis of prenatal hydronephrosis, indications for and timing of prenatal intervention, and recommendations for treating children with a history of prenatal hydronephrosis are included in this review.

Objective: To combine and analyse the results from centres with a large experience of laparoscopy for the impalpable testis with small series, to determine the expected success rate for laparoscopic orchidopexy., Methods: A questionnaire was distributed to participating paediatric urologists; each contributor retrospectively reviewed the clinical charts for their cases of therapeutic laparoscopy for an impalpable testis, detailing 36 variables for each patient. The data were collated centrally into a computerized database. For inclusion, the testis was intra-abdominal (including 'peeping' at the internal ring) at laparoscopic examination, was not managed through an open approach and did not undergo orchidectomy. Three surgical groups were assessed, with success defined as lack of atrophy and intrascrotal position: group 1, primary laparoscopic orchidopexy; group 2, a one-stage Fowler-Stephens (F-S) orchidopexy; and group 3, a two-stage F-S orchidopexy., Results: Data were gathered from 10 centres in the USA, covering the period 1990-1999; 252 patients representing 310 testes were included and overall, 15.2% were lost to follow-up. There was no significant difference between success rates in the larger and smaller series. Atrophy occurred in 2.2% of 178 testes, 22.2% of 27 testes and 10.3% of 58 testes in groups 1-3, respectively. Testes were not in a satisfactory scrotal position in 0.6%, 7.4% and 1.7% of groups 1-3, respectively. The mean follow-up for each group was 7.7, 8.6 and 20.0 months, respectively. The overall success for all groups was 92.8% (97.2% group 1; 74.1% group 2; 87.9% group 3), with an atrophy rate of 6.1%., Conclusion: Laparoscopic orchidopexy for the intra-abdominal testis, in both large and small series, can be expected to have a success rate higher than that historically ascribed to open orchidopexy. Within this series, single-stage F-S laparoscopic orchidopexy resulted in a significantly higher atrophy rate than the two-stage repair. However, when considering both F-S approaches, the laparoscopic approach gave greater success than previously reported for the same open approaches. Despite the weaknesses inherent in a retrospective unrandomized study, we conclude that laparoscopic orchidopexy is, if not the procedure of choice, an acceptable and successful approach to the impalpable undescended testicle.

Purpose: We evaluated the impact of tubularized incised plate urethroplasty on primary and repeat hypospadias repair., Materials and Methods: We retrospectively reviewed the medical records of all boys who underwent hypospadias repair at our institution during a recent 3-year period. The level of the hypospadias defect, technique of repair, primary repair versus reoperation, age at surgery and complications were recorded., Results: A total of 520 hypospadias repairs were done from May 1996 through June 1999. We began to perform tubularized incised plate urethroplasty in November 1996. During the ensuing consecutive 32 months 181 primary and 25 repeat hypospadias repairs were done using this technique. Mean patient age at surgery was 22 months (range 3 months to 30 years). During the 6 months immediately before we began to use this method the Mathieu flip-flap procedure was the most commonly performed technique, accounting for 38% of all hypospadias repairs. In contrast, during the last 6 months reviewed tubularized incised plate urethroplasty accounted for 63% of all repairs, including 41 of 65 primary operations (63%) and 4 of 6 reoperations (67%), while no Mathieu procedures were performed. Postoperative followup was 6 to 38 months for tubularized incised plate repair. Overall meatal stenosis and a urethrocutaneous fistula developed in 1 and 14 boys, respectively (7% complication rate)., Conclusions: Tubularized incised plate urethroplasty has become the preferred technique of primary and repeat hypospadias repair at our institution. The technique has few complications as well as proved success and versatility that continues to expand its applicability and popularity.

Purpose: Testicular volume measurements obtained with the Prader and Rochester orchidometers were compared to those obtained using scrotal ultrasound. The ability of each orchidometer versus ultrasound in detecting volume differential between 2 testes and the accuracy of orchidometer measurement by a less experienced examiner to that of a urologist were compared., Materials and Methods: A total of 65 males were examined by the attending urologist and urology nurse using the Prader and Rochester orchidometers, and scrotal ultrasound was subsequently performed by an attending radiologist. Statistical analysis of the results was performed to determine the correlation of orchidometer measurements between examiners, as well as with ultrasound, and sensitivity and specificity of orchidometer and ultrasound in detecting defined volume differentials between testes of 10%, 15%, 20% and 25%., Results: There was a strong linear relationship between testicular volume measurements using either orchidometer and ultrasound. To detect a defined volume differential as determined by ultrasound orchidometer sensitivity was weak, whereas orchidometer specificity was better. There was a strong correlation between orchidometer measurements of the urology nurse and attending urologist., Conclusions: Although the orchidometer remains valuable in assessing size of the individual testis, it is too insensitive to volume differentials relative to ultrasound to be used routinely to determine growth impairment. For this reason observation of an adolescent with varicocele should include an annual ultrasound assessment of testicular volume.

Purpose: A new endoscopic technique to treat urinary incontinence in children using a self-detachable balloon device was studied., Materials and Methods: The study includes 11 patients with a mean age of 14.6 years and all of whom had intrinsic sphincter deficiency due to myelomeningocele in 9, spinal artery bleed in 1 and cloacal exstrophy in 1. All patients were on clean intermittent catheterization preoperatively and postoperatively. Endoscopic balloon treatment was performed on an outpatient basis. A mean of 5 balloons (range 2 to 8) were placed per patient. All patients underwent formal urodynamic study preoperatively and at 6 weeks and 6 months following balloon placement., Results: Of the 9 patients without prior bladder neck surgery 7 had improvement in urodynamic parameters, including urethral pressure profile in all 7 and functional bladder capacity in 6, 4 were markedly improved clinically and 2 were dry. Two patients with prior bladder neck surgery were clinically unchanged following balloon placement, although 1 had urodynamic improvement., Conclusions: Our initial experience with the transurethral self-detachable balloon system as a minimally invasive outpatient procedure to treat urinary incontinence in children has been encouraging. To date this procedure appears most applicable to the patient who has not undergone surgery and has a neurogenic etiology for urinary incontinence.

The spectrum of Sertoli cell tumors in children covers a wide range of testis and ovarian tumors classified as sex cord-stromal tumors. Sertoli cell tumor of the testis is extremely rare in the pediatric population. The American Academy of Pediatrics Section on Urology Prepubertal Testicular Tumor Registry has reported a total of six cases of Sertoli cell tumor of the testis, accounting for 1.3% of the 430 cases reported to the registry as of October 1996. Despite their rarity, Sertoli cell variants of sex cord-stromal tumors have generated keen interest because of their variable histologic appearance and biologic behavior, including endocrine activity. Because sex cord-stromal tumors occur in the ovary and testis, a primitive cellular origin to these tumors is likely in males and females.

Unlabelled: We evaluated the efficacy of ketorolac in suppressing postoperative bladder spasms after ureteroneocystostomy (ureteral reimplantation). Twenty-four pediatric patients undergoing intravesical ureteroneocystostomy were enrolled prospectively to receive either ketorolac or placebo via double-blinded randomization. Twelve patients in each group shared similar preoperative characteristics. All were maintained on an epidural infusion of bupivacaine (0.1%) with fentanyl (2 microg/mL) throughout the study. Patients were given either ketorolac (0.5 mg. kg(-1). dose(-1)) or placebo (equivalent volume saline) IV after surgery and every 6 h thereafter for 48 h. Parents were instructed to record bladder spasm episodes prospectively by using a standardized time-flow diary. Three patients (25%) in the ketorolac group experienced bladder spasms, compared with 10 patients (83%) in the placebo group (two-sided P < 0.05). The median severity score for the ketorolac group was 1.2 (mild = 1.0, severe = 3.0), compared with 2.6 for the placebo group (P = 0.003). We conclude that IV ketorolac reduces the frequency and severity of postoperative bladder spasms after intravesical ureteroneocystostomy., Implications: We studied the efficacy of ketorolac, a prostaglandin synthesis inhibitor, in the treatment of bladder spasm after ureteroneocystostomy (antireflux operation). Patients were randomized in a double-blinded manner to receive either ketorolac or placebo after the surgery. We demonstrate that ketorolac reduces the frequency and severity of postoperative bladder spasm.

We evaluate a rare case of a 5-year-old boy with granular cell tumor of the penis, located on the coronal margin. We discuss the anatomic distribution of granular cell tumors, noting the marked female predominance of genital involvement and reviewing the distribution of granular cell tumors by site in a pediatric series. We also discuss clinical implications, management, and histogenesis.

Purpose: We describe several modifications of the retroperitoneoscopic approach to nephrectomy for benign renal disease, including the use of 2 mm. instrumentation and prone patient positioning., Materials and Methods: A total of 14 children underwent retroperitoneoscopic nephrectomy in the prone position. An inflatable dissecting device was inserted into the retroperitoneum after a small muscle splitting incision was made at the lateral border of the sacrospinalis muscle approximately 1 cm. below the costovertebral angle. After inflation the dissecting device was replaced with a 5 mm. cannula and pneumoretroperitoneum was maintained with carbon dioxide insufflation. Two 2 mm. trocars were then placed under endoscopic guidance. Dissection was performed using 2 mm. instrumentation and the specimen was retrieved through the largest port site., Results: Nephrectomy was performed in 9 girls and 5 boys 3 months to 9.8 years old. The preoperative diagnosis included chronic pyelonephritis with minimal renal function, reflux with a nonfunctioning kidney, multicystic dysplastic kidney, an upper pole dysplastic moiety with an associated ureterocele and a dysplastic kidney with a vaginal ectopic ureter. Mean operative time for retroperitoneoscopic nephrectomy was 142 minutes with an estimated blood loss of less than 15 ml. Contralateral ureteral reimplantation was performed after retroperitoneoscopic dissection in 5 patients. Overall average hospital stay was 2 days and there were no complications., Conclusions: Several modifications of the retroperitoneal approach, including the use of prone patient positioning and 2 mm. instrumentation for visualization and dissection, may improve the safety and efficacy of this technique in children.

Purpose: Congenital anterior urethrocutaneous fistula is a rare anomaly that may present in an isolated fashion or in association with other penile abnormalities, such as chordee or hypospadias. There have been 18 cases of congenital anterior urethrocutaneous fistula reported in the literature. We present 14 additional cases of congenital anterior urethrocutaneous fistula., Materials and Methods: We treated 14 patients with congenital anterior urethrocutaneous fistula, of whom 9 were uncircumcised at presentation. Two patients had evidence of chordee and 4 had distal hypospadias., Results: The type of repair was determined by the anatomical variations of this anomaly. All cases were corrected electively by various techniques based on the degree of the defect, including primary closure via a Thiersch-Duplay urethroplasty, pedicle flap urethroplasty, hinged flap urethroplasty and interpositioned island pedicle tube or onlay urethroplasty., Conclusions: To our knowledge the embryological events that cause anterior urethrocutaneous fistula are unclear but they likely result from a defective urethral plate or an abnormality of the infolding of the urethral groove. Surgical technique must be individualized to fit the defect. While there has been considerable skepticism regarding the existence of congenital urethrocutaneous fistula, the fact that 9 of our 14 patients were uncircumcised confirms the congenital nature of this lesion.

Purpose: The exstrophy-epispadias complex represents a spectrum of anomalies with variable implications for upper and lower urinary tract function. Successful treatment of incontinence in this population is challenging and often elusive. To date few studies have focused on urodynamic findings specific to primary epispadias., Materials and Methods: We retrospectively reviewed the records of patients presenting with primary epispadias in the absence of bladder exstrophy. We identified 18 boys and 12 girls, of whom 16 underwent formal urodynamic evaluation before (5), after (6) or before and after (5) surgical narrowing of the bladder neck. Bladder capacity was recorded as percent of expected capacity for age. Bladders were considered hypertonic when end filling pressure was greater than 20 cm. water. End filling pressure was defined as the pressure at which urinary leakage was noted or the patient had discomfort. Uninhibited contractions were considered significant when the amplitude was greater than 15 cm water. The ability of the detrusor to generate a voiding contraction at the end of the filling phase was also recorded. Urodynamic studies were performed with a balloon catheter occluding the incompetent bladder neck or with a standard urodynamic catheter after formal bladder neck repair., Results: Before bladder neck repair average bladder capacity was 157 ml (range 55 to 450), corresponding to 52% (range 22 to 100) of expected capacity. Significant uninhibited contractions were noted in 2 patients. In 7 of the 9 evaluable patients (78%) a voiding contraction was generated. In children in whom urodynamic studies were done after surgery mean bladder capacity was 260 ml (range 77 to 660), corresponding to 76% (range 36 to 147) of expected capacity. Hypertonicity and hyperreflexia were noted in 3 and 2 patients, respectively. In 5 of the 11 cases (46%) a voiding bladder contraction was generated. Of the 5 patients who underwent urodynamic evaluation before and after bladder neck repair the percent increase in bladder capacity was significantly greater in the 2 boys (67 and 110%, respectively) than in the 3 girls (-20, 10 and 20, respectively)., Conclusions: The most frequently noted urodynamic pattern before surgical correction of the bladder neck in patients with isolated epispadias is a low capacity, highly compliant bladder with minimal detrusor dysfunction. Postoperatively capacity increases, albeit to a greater extent in boys than in girls, and the incidence of detrusor dysfunction increases as well. In some patients classic bladder neck repair may result in detrimental bladder dynamics due to as yet poorly elucidated mechanisms.

Purpose: Previous approaches to the endoscopic correction of vesicoureteral reflux have used foreign bulking substances, raising concern regarding safety and long-term efficacy. We describe the results of a clinical trial using transurethral injection of autologous chondrocytes to correct vesicoureteral reflux in children., Materials and Methods: A total of 29 children (46 ureters) with grades II to IV vesicoureteral reflux were treated at 2 sites. Each child underwent cystoscopy and ear cartilage biopsy at the initial setting. Chondrocytes were grown in culture for 6 weeks. Patients then returned for transurethral injection of chondrocytes into the bladder trigone to correct reflux. Ultrasound was performed 1 month and radionuclide cystography was done 3 months postoperatively to confirm reflux resolution. When reflux persisted, repeat treatment with stored chondrocytes was offered., Results: Initial chondrocyte injection corrected reflux in 26 of the 46 ureters (57%), while secondary injection was successful in 12 of 19 (63%). Overall reflux was corrected in 38 of the 46 ureters (83%) and in 24 of the 29 patients (83%). There were no significant complications., Conclusions: Transurethral injection of autologous chondrocytes to correct vesicoureteral reflux in children appears to be an effective and safe technique that holds promise for treating this congenital abnormality in a minimally invasive fashion.

Purpose: Urodynamic study was performed in patients with exstrophy to determine the effect of bladder neck reconstruction and the ability to achieve normal urodynamics following surgery., Materials and Methods: A total of 30 exstrophy cases at different stages of reconstruction were retrospectively reviewed in terms of bladder capacity, compliance, stability and presence of detrusor contractions following urodynamic study., Results: Bladder capacity increased from a third predicted volume for age to half after reconstruction. Approximately 80% of patients had compliant and stable bladders before bladder neck reconstruction. Following bladder neck reconstruction approximately half of the patients maintained normal compliance with a smaller number maintaining normal stability. A quarter of patients maintained normal filling dynamics following bladder neck reconstruction, and 19% maintained normal filling and voiding dynamics after reconstruction., Conclusions: The majority of closed exstrophy bladders have normal filling dynamics before bladder neck reconstruction. Compliance and stability are impaired following bladder neck reconstruction. Approximately 25% of patients with exstrophy may maintain normal detrusor function following reconstruction. However, less invasive alternatives to the Young-Dees-Leadbetter bladder neck reconstruction should be sought.

The early response genes, c-Fos and c-Jun, are induced by environmental stress and are thought to modulate injury processes via the induction of AP-1-dependent target genes. AP-1 activation is thought to be regulated by changes in intracellular oxidation/reduction reactions involving the redox factor-1 (Ref-1) protein. In this study, NIH 3T3 and HeLa cells were used to determine whether heat shock induces the AP-1 transcription factor via signaling pathways involving Ref-1. Reverse transcriptase-polymerase chain reaction analysis and immunoblotting demonstrated that c-Fos and c-Jun were induced 2-10 h following heat shock, and this induction was accompanied by an increase in AP-1 DNA binding. Electrophoretic mobility shift assay extracts immunodepleted of Ref-1 protein demonstrated that the increase in AP-1 DNA-binding activity following heating was dependent upon the presence of Ref-1 and that Ref-1 regulates inducible, but not basal, AP-1 DNA-binding activity. This was confirmed by the restoration of heat-inducible DNA binding upon addition of Ref-1 to immunodepleted extracts. The ability of Ref-1 from heated cells to stimulate AP-1 DNA binding was abolished by chemical oxidation and restored by chemical reduction. These results indicate that heat shock activates c-Fos/c-Jun gene expression and AP-1 DNA binding and suggests that redox-sensitive signal transduction pathways involving Ref-1 may mediate heat-induced alterations in AP-1 activation.

Cryptococcal meningitis causes significant morbidity and mortality in persons with AIDS. Of 236 AIDS patients treated with amphotericin B plus flucytosine, 29 (12%) died within 2 weeks and 62 (26%) died before 10 weeks. Just 129 (55%) of 236 patients were alive with negative cerebrospinal fluid (CSF) cultures at 10 weeks. Multivariate analyses identified that titer of cryptococcal antigen in CSF, serum albumin level, and CD4 cell count, together with dose of amphotericin B, had the strongest joint association with failure to achieve negative CSF cultures by day 14. Among patients with similar CSF cryptococcal antigen titers, CD4 cell counts, and serum albumin levels, the odds of failure at week 10 for those without negative CSF cultures by day 14 was five times that for those with negative CSF cultures by day 14 (odds ratio, 5.0; 95% confidence interval, 2.2-10.9). Prognosis is dismal for patients with AIDS-related cryptococcal meningitis. Multivariate analyses identified three components that, along with initial treatment, have the strongest joint association with early outcome. Clearly, more effective initial therapy and patient management strategies that address immune function and nutritional status are needed to improve outcomes of this disease.

Purpose: We evaluated a new simplified technique for secondary surgical correction of persistent reflux in a reimplanted dilated ureter., Materials and Methods: Four patients a median of 3 years old with recurrent vesicoureteral reflux after initial reimplantation of ureters greater than 9 mm. in diameter underwent in situ excisional ureteral tailoring., Results: Followup ranged from 15 to 27 months (mean 22). Within 3 months postoperatively ultrasound confirmed no ureteral obstruction, and at 3 to 6 months voiding cystourethrography revealed no vesicoureteral reflux in any case., Conclusions: Our study highlights the surgical details and safety of this technique for preserving the vascularity of the reconstructed ureter and avoiding injury to the contralateral ureter.

Purpose: We delineate the current findings and contribution of diagnostic laparoscopic evaluation in the management of nonpalpable testis., Materials and Methods: We reviewed all cases in which laparoscopy was considered the management associated with a nonpalpable testis in a 4-year period. Since our previous series, we have performed a careful examination for the testis after induction of anesthesia but before committing to laparoscopy. We recorded testis position and quality, character of the vas deferens and spermatic vessels, type of management and contribution of laparoscopy. We also reviewed contemporary published series and collated the findings of studies performed elsewhere., Results: We identified 263 nonpalpable testes in 225 patients between September 1992 and 1996. In 40 patients 46 testes (18%) were found during physical examination under anesthesia. Of the remaining cases considered appropriate for laparoscopy 215 with complete records were further analyzed. Only 12.6% could be considered missed on examination due to a viable testis distal to the inguinal ring. Of the testes 45.7% would have been found during inguinal exploration alone. In 9.8% of the patients there were intra-abdominal vanishing testes, while 4.2% had indeterminate cord structures on inguinal exploration that would have prompted abdominal extension without a laparoscopic demonstration that the vas and vessels entered the canal. A conventional inguinal incision would have provided optimal exposure for operative management in 34% of the testes. For testes distal to the internal ring when the vas and vessels were distinctly atretic we never identified a viable testis, while a normal appearing vas and vessel were associated with a 45% chance of a salvageable testis. Laparoscopy was informative regarding testis position in all cases in which it was performed., Conclusions: In 13.2% of the cases laparoscopic findings precluded unnecessary abdominal exploration. The typical surgical incision for inguinal exploration would have left the surgeon compromised in 66% of the cases compared to the approach optimized as a result of laparoscopic testicular localization. Of the patients 34% arguably did not benefit from laparoscopy versus inguinal exploration. A simple examination under anesthesia significantly decreases the number of uninformative laparoscopic evaluations, and it is well worth the cost of a few minutes of operative time.

Large-cell calcifying Sertoli cell tumor (LCCSCT) is a rare sex cord-stromal tumor found predominantly in the pediatric population. This tumor has distinctive histopathologic features and clinical associations. LCCSCT has also been noted in association with the Carney complex, and in patients with Peutz-Jeghers syndrome. The propensity to metastasize is low, and radical orchiectomy has traditionally been the treatment of choice.

Purpose: Amiodarone is an antiarrythmic agent, which is often successfully used when all other antiarrythmics have failed. Sterile epididymitis is a recognized complication of treatment in adults, occurring in up to 11% of patients. To date there have been no reported cases of amiodarone induced epididymitis in children. We present a previously unrecognized cause of epididymitis in boys., Materials and Methods: The medical records, including radiographic imaging, pathology and operative reports, of 2 postpubertal boys who had sterile epididymitis after prolonged therapy with amiodarone were reviewed., Results: In both cases the onset of scrotal pain and subsequent evaluation led to diagnosis of epidydimitis. Amiodarone was determined to be the cause, and cessation of the drug resulted in symptom resolution in 1 case., Conclusions: While it remains uncertain, the pathophysiology of amiodarone induced epididymitis is likely related to its high concentration in testicular tissue. Recognition that amiodarone is a rare but significant cause of epididymitis in children is important to prevent unnecessary surgery in high risk patients. Amiodarone induced epididymitis in children tends to be a self-limited process and of secondary importance to the serious cardiac disease. Whereas discontinuing amiodarone risks sudden cardiac death, a reduction in dosage or temporary cessation of the drug may result in rapid resolution of the epididymitis.

Purpose: To assess the safety and efficacy of total lymphoid irradiation (TLI) in patients experiencing chronic rejection following bilateral lung transplantation (BLT)., Patients and Materials: Eleven patients received TLI for chronic allograft rejection (bronchiolitis obliterans syndrome) refractory to conventional treatment modalities. Radiation therapy (RT) was prescribed as 8 Gy delivered in 10 0.8-Gy fractions, 2 fractions/week, via mantle, paraaortic, and inverted-Y fields. Serial pre- and post-RT pulmonary function values, complete blood counts, and immunosuppressive augmentation requirements [use of methylprednisolone, murine anti-human mature T-cell monoclonal antibody (OKT3), polyclonal antithymocyte globulin (ATG), and tacrolimus] were monitored., Results: In the 3 months preceding TLI, the average decrease in forced expiratory volume in 1 s (FEV1) was 34% (range 0-75%) and the median number of immunosuppression augmentations was 3 (range 0-5). Only 4 of 11 patients completed all 10 TLI treatment fractions. Reasons for discontinuation included progressive pulmonary decline (four patients), worsening pulmonary infection (two patients), and persistent thrombocytopenia (one patient). Seven of the 11 patients failed within 8 weeks of treatment cessation. One patient had unabated rejection and received bilateral living related-donor transplants; he is alive and well. Six patients died. Two of these deaths were due to pulmonary infection from organisms isolated prior to the start of RT; the other four deaths were from progressive pulmonary decline. The four remaining patients had durable positive responses to TLI (mean follow-up of 47 weeks; range 24-72). Comparing the 3 months preceding RT to the 3 months following treatment, these four patients had improvements in average FEV1 (40% decline vs. 1% improvement) and fewer median number of immunosuppressive augmentations (3.5 vs. 0). None of these patients has developed lymphoproliferative disease or has died. Features suggestive of a positive response to TLI included longer interval from transplant to RT, higher FEV1 at initiation of RT, and absence of preexisting pulmonary infection., Conclusion: Total lymphoid irradiation for chronic allograft rejection refractory to conventional medical management following BLT was tolerable. A subset of patients experienced durable preservation of pulmonary function and decreased immunosuppressive requirements. Patients with rapidly progressive allograft rejection, low FEV1, or preexisting infection were least likely to benefit from irradiation. Early initiation of TLI for patients experiencing chronic allograft rejection following BLT may be warranted.

Objective: To document the array of diagnostic modalities, the variety of errant diagnoses and treatments. and the time from initial presentation to ultimate diagnosis in girls with an ectopic single-system ureter draining an ectopic hypoplastic and/or dysplastic kidney., Patients and Methods: Between 1990 and 1997, seven females were identified who had an ectopic hypoplastic and/or dysplastic kidney with an ectopically draining ureter, and who were treated at our institutions, either initially or upon referral. The nature and number of all diagnostic evaluations, previous diagnoses and treatments, and the time from presentation to definitive diagnosis were recorded., Results: All seven females had a classical history of successful toilet training, a normal voiding pattern and continuous urinary incontinence. Typically, a solitary kidney was noted on the initial diagnostic evaluation by ultrasonography and/or intravenous urography. The mean (range) age at initial presentation was 3.2 (2-6) years. Additionally, voiding cysto-urethrography, urodynamics, radionuclide scintigraphy, computed tomography, magnetic resonance imaging and endoscopy were performed. The age at definitive diagnosis was 3-16.5 years and the mean (range) time from initial presentation to diagnosis was 5.7 (1-10) years. Nephroureterectomy was curative and all kidneys were dysplastic., Conclusion: Continuous urinary incontinence in females with a normal voiding pattern should prompt an evaluation for ureteric ectopia. When the initial evaluation yields the diagnosis of a solitary kidney, clinicians should be aware of the possibility of a hypoplastic and/or dysplastic, often ectopic, contralateral kidney with an ectopically draining ureter. Identification of this entity should allow curative surgical treatment.

Purpose: We report 7 cases of scrotal cystic lymphangioma and review the literature on this unusual lesion, which is often misdiagnosed as other conditions and treated incorrectly., Materials and Methods: We retrospectively reviewed the medical records of 7 patients with scrotal cystic lymphangioma treated from 1984 to 1996 at 5 institutions., Results: Mean patient age at presentation was 3 years and painless scrotal swelling was the most common symptom. Physical examination demonstrated an unusual cystic scrotal mass with a normal testis and cord in most patients, and ultrasound in 4 showed a complex septated cystic mass. Preoperative misdiagnosis in all 7 patients included hernia, hydrocele, hematocele, varicocele and possible torsion. In 6 children the lesions were more extensive than expected with deep perineal and/or inguinal involvement, including 2 who also had pelvic and retroperitoneal extension. Incomplete excision led to recurrence in 4 patients., Conclusions: Scrotal cystic lymphangioma presents as an unusual cystic scrotal mass. Although misdiagnosis has been common, awareness of the characteristic features of this lesion should lead to the correct preoperative diagnosis. When lymphangioma is suspected, imaging of the adjacent inguinal, perineal and pelvic regions should be performed. Complete excision is mandatory to prevent recurrence.

Purpose: Cystic dysplasia of the rete testis is a benign congenital lesion that can mimic testicular cancer. We report 6 cases, review the literature, discuss the embryological etiology and make management recommendations., Materials and Methods: The records and pathology reports of 6 boys presenting with cystic dysplasia of the rete testis at 5 institutions were reviewed, as was the relevant literature., Results: Of the 6 cases 5 presented as scrotal masses in previously healthy boys and 1 as an abdominal mass in a newborn with multiple congenital anomalies. One patient had been followed from birth for a multicystic dysplastic kidney and 4 were found to have an ipsilateral absent kidney during evaluation. Development of the contralateral side was normal in most cases., Conclusions: Cystic dysplasia of the rete testis is an unusual, benign congenital lesion that can mimic testicular cancer in presentation. The presence of ipsilateral renal anomalies, particularly renal agenesis, can suggest cystic dysplasia of the rete testis in the differential diagnosis preoperatively. Even if cystic dysplasia of the rete testis is suspected, we recommend inguinal exploration and early control of the spermatic cord in the event that neoplasia is identified. If possible, the goal of preserving as much normal testicular parenchyma as possible is desirable. Long-term followup for possible recurrence is recommended, particularly after local excision.

Purpose: We report on 7 patients with splenogonadal fusion and review the literature on this unusual condition., Materials and Methods: The medical records of patients diagnosed with splenogonadal fusion between 1989 and 1994 at 4 institutions were retrospectively reviewed., Results: All 7 patients were properly diagnosed at surgery and the testes were salvaged in 5. In 1 intersex patient gonadectomy was appropriate., Conclusions: Splenogonadal fusion is a rare condition. Familiarity with this lesion allows for intraoperative diagnosis and testicular salvage.

Purpose: We studied a population of patients undergoing unilateral antireflux surgery to determine the mechanism of new onset contralateral reflux postoperatively., Materials and Methods: A total of 141 patients underwent unilateral antireflux surgery via the Cohen, Glenn-Anderson or extravesical technique. The 18% of patients who had new onset contralateral vesicoureteral reflux were analyzed according to grade of initial reflux, presence of a Hutch diverticulum or duplex system and surgical technique., Results: Surgical technique did not influence the development of contralateral reflux. As grade of corrected reflux increased, a significant trend toward development of contralateral reflux was noted. A Hutch diverticulum was not a risk factor for contralateral reflux but reflux into a duplicated system was a distinct risk factor (26 versus 12% in single system reflux)., Conclusions: Our study supports the concept that new onset contralateral reflux may result from elimination of a pop-off mechanism. Surgical distortion of the contralateral hemi-trigone appears not to be responsible. Correction of severe (grade V) reflux and reflux into duplex systems put patients at particular risk for development of contralateral reflux postoperatively.

Purpose: In 1986 we reported the placement of a silicone sheath sandwiched between layers of omentum around a newly reconstructed bladder neck. We now present long-term followup of 94 cases of silicone sheath bladder neck reconstruction., Materials and Methods: A total of 94 silicone sheaths was placed in 84 patients between August 1983 and October 1992. We retrospectively reviewed our results and divided the reconstructions into 3 groups according to modifications in surgical technique. We report the results of each modification and current recommendations for use., Results: Each sequential modification of silicone sheath bladder neck reconstruction significantly reduced the risk of erosion from 100%, 32% and 7%, respectively (p < 0.05). Erosion was independent of patient age, sex, pathological condition or whether bladder neck reconstruction was a repeat procedure. Patients who had silicone sheath erosion did not have different continence or loss of urethral continuity than those with no erosion. In 13 patients (16%) artificial sphincter placement was clearly facilitated by the silicone sheath., Conclusions: Modifications in the surgical technique of silicone sheath placement around a reconstructed bladder neck have resulted in a decrease in the erosion rate to 7%. The primary benefit of silicone sheath placement is ease of subsequent sphincter placement. Currently we reserve silicone sheath placement for a small subset of patients who are most likely to benefit from subsequent artificial sphincter placement.

Purpose: We report on 5 boys with transitional cell carcinoma of the bladder, describe the identifying characteristics, review the literature, and define the issues of diagnosis, treatment and followup in this rare disease in pediatric patients., Materials and Methods: Five boys 11 to 18 years old were identified with transitional cell carcinoma of the bladder. Preoperative imaging and urinary cytology were correlated with cystoscopic and biopsy findings., Results: In all patients evaluation was prompted by gross hematuria. Low grade lesions, definitive cystoscopic management and a low recurrence rate were uniform findings. Preoperative imaging identified the tumor in all cases and bladder ultrasound was the most sensitive scan with 4 of 4 cases identified., Conclusions: While rare, transitional cell carcinoma of the bladder in children presents a challenge in diagnosis and followup since cystoscopy typically requires general anesthesia in this age group. Bladder ultrasound was found to be extremely sensitive in identifying lesions, and it may be a valuable and minimally invasive surveillance tool.

Purpose: We analyzed the incidence and outcome of postoperative contralateral reflux after unilateral ureteral reimplantation by the Cohen and Glenn-Anderson techniques., Materials and Methods: We retrospectively reviewed the records of 120 patients 3 months to 21 years old in whom unilateral vesicoureteral reflux was treated by unilateral reimplantation. The incidence of postoperative contralateral reflux was documented by followup voiding cystourethrography., Results: Overall 19% of patients who underwent unilateral reimplantation had contralateral vesicoureteral reflux postoperatively, including 21% after the Cohen and 17% after the Glenn-Anderson procedure. Of the cases 61% spontaneously resolved, 13% were surgically corrected and 26% continue to be followed., Conclusions: The rates of postoperative contralateral vesicoureteral reflux are not significantly different after Cohen and Glenn-Anderson repair. A majority of cases will resolve spontaneously within 2 years. The likelihood of trigonal distortion as the etiology of contralateral reflux is low given the similar incidence in cross-trigonal and ureteral advancement reimplantation.

Purpose: Radionuclide voiding cystography is generally advocated as a screening study to detect familial reflux. We assessed the efficacy of tailored low dose fluoroscopic voiding cystography for this purpose., Materials and Methods: We evaluated 10 boys and 10 girls 9 months to 10 years old (mean age 5 years) who were siblings of patients known to have reflux. The technique used a low dose fluoroscopic system. A tailored voiding cystographic protocol was designed to minimize gonadal radiation dose., Results: Absence of reflux was confirmed in 10 patients. Mean fluoroscopy time was 19 seconds (range 14 to 22), resulting in mean gonadal radiation exposure of less than 1.5 mrad., which is comparable to the lowest reported doses with the radionuclide technique. After reflux was demonstrated in 10 patients the study was immediately converted to a standard fluoroscopic imaging technique to define lower tract anatomy and quantitate reflux, avoiding a second study., Conclusions: Tailored low dose fluoroscopic voiding cystography appears to be a practical approach for the assessment of familial reflux.

Transverse testicular ectopia (TTE) is a rare genitourinary anomaly. We report a case of TTE in a 14-year-old boy diagnosed and managed laparoscopically. The clinical features and etiology of this rare testicular anomaly are reviewed.