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A cohort of 100 patients underwent laparoscopy for 128 impalpable testes. They ranged in age from 2.7 to 19.3 years (median 10.8 years). There were no complications associated with laparoscopy. In 50% of the cases either blindending cord structures above the internal inguinal ring or intra-abdominal testes were identified; in the remainder, cord structures could be seen passing through the ring, indicating an intracanalicular testis. The impalpable testis was absent in 77% of patients with a contralateral scrotal testis. A seminoma was found in one 18.6-year-old patient with bilateral cryptorchidism. No intratubular germ cell neoplasia (carcinoma in situ) was proved. Germ cell hypoplasia or aplasia was demonstrated in 95% of cases with testicular parenchyma. We recommend laparoscopy as a safe procedure which leads to a diagnosis in patients with impalpable testes; the advent of laparoscopic procedure makes definitive treatment possible in about 50% of such cases.

In a retrospective study of the case reports of 136 boys who were operated on for an imperforate anus and who survived at least 18 months, cryptorchidism was the most common associated anomaly, involving 26 cases (19%). The higher the level of the anorectal malformations, the higher was the incidence of cryptorchidism. The incidence of renal and ureteric malformations and dysplasias showed a parallel tendency. The incidence of vertebral malformations and dysplasias in the T10-S5 area was low among patients with a covered anus or a perineal fistula. Cryptorchidism was found to be associated with urological and with T10-S5 vertebral malformations and dysplasias. Recognition of this association is probably new. The histopathological findings of testicular biopsy specimens and the location of the undescended testes in patients with an imperforate anus showed the same pattern as seen in undescended testes from patients with cryptorchidism only. These findings, together with the existing literature on the subject, indicate that further studies on the association of cryptorchidism, urological, and T10-S5 vertebral malformations and dysplasias may be important for a better understanding of cryptorchidism in general.

Purpose: We investigated the prognostic value of the number of spermatogonia per tubular cross section in a testicular biopsy specimen obtained at orchiopexy for unilateral cryptorchidism., Materials and Methods: A total of 87 consecutive 10 to 12-year-old cryptorchid boys underwent testicular biopsy simultaneously with unilateral orchiopexy. In adulthood 56 of the 87 patients agreed to measurement of serum follicle-stimulating hormone, luteinizing hormone, testosterone and testicular volume, and 54 provided specimens for semen analysis., Results: The number of spermatogonia per tubular cross section correlated to the volume of the operated testis and total testicular volume in adulthood. Serum follicle-stimulating hormone negatively correlated to these volumes, sperm concentration and total sperm count. Contralateral testicular volume correlated to sperm concentration, total sperm count, and percent of living and mobile sperm. When biopsy revealed Sertoli cells only or 1 spermatogonium per 100 tubular cross sections, the age matched number of spermatogonia per tubular cross section was 1% or less. Of these patients 33% later presented with 5 million spermatozoa per ml. or less, no normal motility and generally lower sperm concentrations that those with more than 1 spermatogonium per 100 tubular cross sections (greater than 1%) in the biopsy specimen. When the value was greater than 1%, later sperm quality was not significantly reduced in comparison to that of the general population., Conclusions: The age matched number of spermatogonia per tubular cross section is significant in regard to fertility potential, and a value of 1% or less (approximately Sertoli cells only) may predict low fertility potential. To our knowledge Sertoli cells only have not been observed before 15 months of life, which makes it logical to treat cryptorchidism before this age even in unilateral cases.

Objective: To obtain new information about the pathogenesis of cryptorchidism., Materials and Methods: Published reports of 111 males with splenogonadal fusion were examined and the presence and type of cryptorchidism and the degree of continuity between the spleen and gonads determined., Results: Of the 111 cases, 31% had cryptorchidism and of these 59% were bilaterally cryptorchid; 26% and 65% had right and left intra-abdominal testes, respectively. Of those with continuous splenogonadal fusion, 44% had cryptorchidism. Solely cryptorchid cases with splenogonadal fusion had reported bilateral absence of both legs, imperforate anus, spina bifida, diaphragmatic hernia and hypospadias., Conclusion: An hypothesis is proposed that the abnormal development of the diaphragmatic ligaments of the testes may lead to lack of their involution, with consequent cryptorchidism. In the case of splenogonadal fusion, the abnormal ligaments are colonized by splenic cells, possibly because of an abnormal proximity to the splenic anlage, with the resulting abnormal ligament persisting as the splenic cord and thus resulting in cryptorchidism. The basic abnormality may be in the connections of the diaphragmatic ligaments, caused by abnormal midline development in the third to fourth week of gestation.

Purpose: We investigated the number of germ cells per tubular cross section and testicular weight in cryptorchid fetuses, neonates and infants, and characterized additional abnormalities., Materials and Methods: Our series comprised 35 fetuses and 58 boys with cryptorchidism, and 22 normal fetuses and 25 normal boys. Age ranged from 28 weeks of gestation to 3 years., Results: Cryptorchid fetuses had reduced germ cells per tubular cross section values and lower testicular weights. Values were reduced in cryptorchid boys without a symptomatic inguinal hernia. If a hernia was present, values were normal in the first year of life but decreased at age 1 to 3 years. Malformations or dysplasia of the kidneys, ureter or T10 to S5 vertebrae were present in 34% of the cryptorchid fetuses and 18% of the cryptorchid boys without a symptomatic inguinal hernia., Conclusions: Our study suggests a reduced number of germ cells in undescended testes from week 28 of gestation and germ cell hypoplasia as a consequence of continued postnatal undescended testicular position. Cryptorchidism may result from abnormal development of the caudal developmental field.

In a retrospective study of the case reports of 136 boys who were operated on for an imperforate anus and who survived at least 18 months, cryptorchidism was the most common associated anomaly, involving 26 cases (19%). The higher the level of the anorectal malformations, the higher was the incidence of cryptorchidism. The incidence of renal and ureteric malformations and dysplasias showed a parallel tendency. The incidence of vertebral malformations and dysplasias in the T10-S5 area was low among patients with a covered anus or a perineal fistula. Cryptorchidism was found associated with urological and with T10-S5 vertebral malformations and dysplasias. Recognition of this association is probably new. The histopathological findings of testicular biopsy specimens and the location of the undescended testes in patients with an imperforate anus showed the same pattern as seen in undescended testes from patients with cryptorchidism only. These findings, together with the existing literature on the subject, indicate that further studies on the association of cryptorchidism, urological, and T10-S5 vertebral malformations and dysplasias may be very helpful toward a better understanding of cryptorchidism in general.

Objective: To investigate the value of laparoscopy in boys with impalpable testes, to carry out a histological examination of testicular biopsies or orchidectomy specimens, and to present a clinical description of boys with impalpable testes., Patients and Methods: One hundred consecutive patients underwent laparoscopy for 128 impalpable testes. They ranged in age from 2.7 to 19.3 years (median 10.8). Histological examination was performed on 39 testicular biopsies, nine primarily orchidectomized testes and 13 tissue samples from the end of blind-ending vessels and vasa deferentia. Any additional diagnoses to that of impalpable testes were recorded., Results: There were no complications associated with laparoscopy and the procedure clarified the situation in all patients. In 50% of patients either blind-ending cord structures above the internal inguinal ring or intra-abdominal testes were identified; in the remainder, cord structures could be seen passing through the ring, indicating an intracanalicular testis. The impalpable testis was absent in 77% of patients with a contralateral scrotal testis. A seminoma was found in one 18.6-year-old patient with bilateral cryptorchidism. No intratubular germ cell neoplasia (carcinoma in situ) was found. Germ cell hypoplasia or aplasia was demonstrated in 95% of patients with testicular parenchyma. Additional diagnoses were made in 49% of patients with bilaterally undescended testes (one or both of which were impalpable)., Conclusion: We recommend laparoscopy as a safe procedure which leads to a diagnosis in patients with impalpable testes; the advent of laparoscopic procedures makes definitive treatment possible in about 50% of such patients. Open procedures will be indicated only to ascertain the quality and treatment of intracanalicular testes.

Background: The aim of the study was to evaluate the prognostic significance of DNA ploidy of gastric carcinomas., Methods: The DNA content was analyzed by flow cytometry on archival paraffin-embedded material from tumors of 97 consecutive patients., Results: A multivariate analysis showed that the DNA ploidy pattern and lymph node metastasis were the only independent prognostic markers for survival (p = 0.01 and p = 0.02, respectively). The relative risk of death due to gastric cancer was three times greater for patients with DNA hypertetraploid tumors than for patients with DNA diploid tumors and twice as high for patients with lymph node metastasis as for patients without. Well and moderately differentiated carcinomas were more frequently aneuploid than tumors with poor differentiation (p = 0.047). There was no correlation between tumor ploidy pattern and location. In univariate analysis tumor growth through the serosal wall was predictive of poor survival (p = 0.003)., Conclusions: DNA ploidy is an independent prognostic indicator for cancer-specific survival in gastric cancer.

Background: The aim of this investigation was to evaluate factors influencing the length of convalescence after ambulant inguinal hernia repair., Methods: One hundred and twenty-three patients were followed up to assess when they returned to work, considered that they had regained full working capacity, and resumed leisure time activities. The length of sick leave was recommended on the basis of the load of the occupation., Results: Half of the patients had a longer sick leave than recommended by the surgeon. Active and heavy work showed an independent significant positive correlation to the length of sick leave. Median sick leave among these patients was 42 days, which was the time they considered that they had regained full working capacity and 1 week after they had resumed their leisure time activities. Median sick leave among patients with sedentary or moderately active work was 9 days before regaining full working capacity and 12 days before resuming leisure time activities., Conclusions: Other factors than load of work and surgeon's advice seem to play a role in the patient's decision about when to resume normal activities on the job.

A total of 843 consecutive boys (median age 12.7 years) who had undergone testicular biopsy at operation for undescended testis was followed into adulthood (median age 25.2 years) to examine for testicular germ cell neoplasia. Five cases of testicular germ cell neoplasia were identified, including 1 nonseminoma of the contralateral testis, which had been treated before surgery for an undescended testis, 1 nonseminoma found at followup, 1 seminoma and 2 intratubular germ cell neoplasms. Of the later 3 patients 1 had a 45,X/46,XY karyotype and 2 had abnormal external genitalia. Previous testicular biopsy from the patient in whom nonseminoma was noted at followup showed Sertoli cells only. We recommend that testicular biopsy be performed at operation for undescended testis in boys with abnormal sex chromosomes, particularly 45,X/46,XY karyotype, and in those with abnormal external genitalia. The pattern of Sertoli cells only in biopsies from boys does not preclude the occurrence of testicular cancer in adulthood.

Long-term survival of biliary atresia patients after Kasai hepatoportoenterostomy is being increasingly reported. Favorable prognostic factors are: 1) Young age at operation (max. 60 days). 2) Few incidents of postoperative cholangitis. Jaundice-free long-term survival is achieved in one-fourth to one-third of patients undergoing Kasai hepatoportoenterostomy. Without treatment the average life span is 19 months. Twenty infants with biliary atresia were treated with the Kasai operation between 1976 and 1992. Nine children are alive 11 months to 16 years postoperatively, two after a liver replacement, one at ten months and one at two and a half years old. A tenth child had a well functioning anastomosis but died of heart failure. Eight children with a well functioning anastomosis were all younger than 60 days at the operation. Only one child older than 60 days survived without a liver transplantation. Our results confirm that early diagnosis and treatment of biliary atresia, before 60 days of age, is necessary.

Objective: To assess pulmonary function, pain, and fatigue after elective laparoscopic cholecystectomy., Design: Prospective study., Setting: University hospital., Subjects: The first 53 patients listed to undergo laparoscopic cholecystectomy., Main Outcome Measures: Assessments of pain, peak flow, and the subjective feeling of fatigue before, and 6 hours after, operation, and then daily for the first week., Results: Pain scores at rest and while coughing and fatigue score were less than have been reported after open cholecystectomy. Peak flow was reduced 6 hours after operation (p < 0.01) but less than has been reported after open surgery, and it returned to the preoperative value within the study period., Conclusion: The less disturbance of pulmonary function and the lower pain and fatigue scores may explain the observed early discharge from hospital and the rapid mobilisation, including ability to go to work, in patients who have undergone laparoscopic cholecystectomy.

A total of 91 boys underwent bilateral orchiopexy with testicular biopsy. The percentage of tubular transverse sections containing spermatogonia, the fertility index (FI) and the number of spermatogonia per tubular transverse section (S/T) were measured and expressed as a percentage of the minimum normal value (FI% and S/T%, respectively). The maximum and mean of the 2 FI% and S/T% values were noted for each patient. At follow-up, testicular volume was measured in 73 men; 71 of these gave a blood sample for FSH and 67 provided specimens of semen for analysis. The maximum and the mean FI% and S/T% values of the patients were positively correlated to maximal sperm density and to volume of pair of testes and negatively correlated to serum FSH. It seems reasonable to use these histological parameters as prognostic indices of fertility potential. In adulthood only 11 patients had sperm density greater than or equal to 20 million/ml, 37 had normal serum FSH and 29 had bilateral testicular volume greater than or equal to 15 ml. Patients with both testes originally placed in the superficial inguinal pouch at surgical exploration had a higher maximal sperm density than the rest of the study group.

In vitro tetraploidy (IVT) in skin fibroblasts cultures measured by flow cytometry was compared with histological type and degree of dysplasia in 22 patients with adenomas of the colon and rectum. Furthermore, IVT was compared with stage and differentiation in 36 patients with carcinoma of the colon and rectum. In vitro tetraploidy in skin fibroblasts was correlated to type as well as dysplasia in adenomas and differentiation in carcinomas but was not correlated to Dukes' stage in carcinomas. Skin fibroblast genetic instability, expressed as increased IVT (IVT+), has been reported to reflect a genetic predisposition to colorectal cancer in the hereditary nonpolyposis colorectal cancer syndrome. Because IVT+, which appears to be associated with the progression of adenomas to carcinomas, also is found in many of the non-syndrome colorectal cancers, we suggest that development of colorectal cancer is considerably influenced by the constitutive genetic instability of the autosomal dominant colorectal cancer syndromes.

The efficiency of subcutaneous dihydroergotamine in preventing infusion thrombophlebitis was assessed in a randomized trial. One hundred and fourteen postoperative patients were studied. They furnished a total of 160 infusion sites. The difference between treatment and control group with regard to incidence of infusion thrombophlebitis was not significant (p greater than 0.05). Accordingly dihydroergotamine has no substantial effect.

181 patients who received low-dose heparin prophylaxis in connection with major abdominal surgery were screened for postoperative thromboembolism by means of the 125 I-fibrinogen uptake test, venography and ventilation/perfusion lung scans. Among a number of potential risk factors analyzed only colonic surgery and preoperative anaemia were associated with significantly increased risk of postoperative thromboembolism.

Prospectively, 125 patients were examined with 99mTc-perfusion scintigraphy, 89mKr- or 127Xe-ventilation scintigraphy and chest radiogram prior to major surgery. Postoperative therapy-demanding pulmonary complications occurred in 18% of the patients. A statistical association could be demonstrated between all the preoperative tests except ventilation scintigraphy and the frequency of complications. However, the predictive values of each of the tests, or even the combined results, were not significantly different from the frequency of complications among all the patients. It is concluded that the predictive values of perfusion- and ventilation scintigraphy, spirometry and radiogram of the chest are too low to be of any practical use.

A case of late presentation of a left posterolateral diaphragmatic hernia in a four-year-old boy is reported. Shortly after incidental diagnosis of the diaphragmatic hernia, he was admitted with acute abdominal symptoms and laparotomy was performed. The stomach, small intestine, part of the colon, and the spleen were intrathoracic. There was a 720 degree torsion of the splenic pedicle. After reduction, the spleen was placed in the abdomen. At scintiscans 12 days and 14 weeks after operation, no certain splenic function was demonstrated, but at follow-up up 21/2 years later the splenic scan was normal.

In vitro tetraploidy (IVT) in cultures of skin fibroblasts was compared with tumor DNA ploidy, as determined by flow cytometry on paraffin-embedded material, in 99 patients with colorectal neoplasm. In 63 patients with non-heritable carcinoma we found a significant correlation between the number of aneuploid stemlines in the tumor and IVT in the fibroblast culture. Furthermore, tumor aneuploidy was significantly correlated to the size of the tetraploid subpopulation in the fibroblasts. There was no correlation between aneuploidy and Dukes's stage or the degree of differentiation. In 36 patients with adenoma no correlation between tumor aneuploidy and fibroblast IVT was demonstrated, whereas the number of tumor stemlines was significantly correlated to histopathologic stage and grade of dysplasia. IVT in cultured skin fibroblasts, which has been reported to reflect a genetic predisposition to colorectal cancer in heritable colon cancer syndromes, thus seems to be relevant also for the understanding of tumor formation and progression in the 'non-heritable' type of colorectal cancer.

Renal handling of acid and base was studied in patients with persistent metabolic acidosis 3-9 years after jejunoileal bypass for morbid obesity. Excretion of acid was studied before and after intravenous infusion of NH4Cl and excretion of bicarbonate after infusion of NaHCO3. Bypass patients showed impaired capacity for acidification of urine. The lowest urinary pH was 5.53 +/- 0.10 in 10 bypass patients and 4.76 +/- 0.06 in 6 controls. The corresponding values for standard bicarbonate in plasma were 15.0 +/- 0.3 mM and 15.8 +/- 0.3 mM. Glomerular filtration rate was identical in the two groups. Fractional loss of bicarbonate in urine was higher in controls than in bypass patients. The renal impairment is classified as distal renal tubular acidosis.

A 10-year-old boy with bilateral carcinoma in situ in maldescended testes and concomitant ambiguous genitalia is presented.

We compared the results of dihydroergotamine mesylate administered with low-dose heparin sodium with those of low-dose heparin given alone in a randomized trial based on 181 patients who underwent major abdominal surgery. We found no significant difference in the incidence of thromboembolism between the two groups but a higher incidence of abnormal fibrinogen uptake test results in patients given heparin alone. There was no difference in hemoglobin levels and the number of blood transfusions. We concluded that there is little, if any, clinical advantage in adding dihydroergotamine to low-dose heparin to prevent thromboembolic complications in patients who have undergone major abdominal surgery.

The object of the present investigation was to identify those who, among high-risk patients, would "break through" low-dose heparin prophylaxis and develop thromboembolism after major abdominal surgery. Twenty-nine variables (clinical characteristics, pre- and postoperative coagulation and fibrinolytic factors) from 19 patients with and 26 patients without thromboembolism were analyzed by means of a multivariate supervised pattern recognition technique (SIMCA). We found no statistically significant difference between patients with and without thromboembolism. Thus, in the studied group of high-risk patients it was not possible to identify a predictive index for selection of individual patients liable to develop postoperative thromboembolism despite low-dose heparin prophylaxis in major abdominal surgery.

The effects of dihydroergotamine (DHE) on postoperative ileus after major abdominal surgery were studied. Forty-one patients received 0.5 mg DHE subcutaneously twice a day from the day of surgery to the seventh postoperative day. Thirty-three patients served as controls. There were no significant differences in the time to the first postoperative passage of flatus or delivery of stools nor in the quantity of laxatives given. It is concluded that DHE does not reduce the duration of postoperative ileus.

Leakage of tight junctions as observed with electron microscopy and demonstration of solute transport across bladder epithelium was investigated in 13 patients with different bladder diseases: urinary retention and infection, bladder tumours and interstitial cystitis. The latter group showed consistent leakage of solutes through the urothelium. Electron microscopy revealed leaky tight junctions. This finding might be helpful in establishing the histological criteria and explain the pathogenesis of interstitial cystitis.

The effect of intranasal LH-RH on cryptorchidism was investigated in 45 prepubertal boys with 68 undescended testes. A daily dose of 1.2 mg LH-RH was given for 4 weeks. A total of 16 testes (24%) descended. Follow-up examination 5 years later showed that relapse had occurred in two cases. Fifty-two testes did not descend during the LH-RH treatment. However, seven of these testes descended spontaneously during puberty. So far surgical treatment has been carried out in 39 of the remaining 45 testes. Anatomical anomalies (ectopic position of the testis, open processus vaginalis, abnormal epididymis) explained the failure of LH-RH to cause descent in the majority of the surgically treated cases.

Fifty-nine patients with severe urinary tract infections were treated with either cefotaxime or ampicillin plus netilmicin in a controlled, open randomised study of the clinical and bacteriological effects. The patients responded favourably in both groups. The minimum inhibitory concentrations of cefotaxime against the isolates from blood were low for all bacterial strains except one (Streptococcus faecalis). Time to normalisation of temperature was significantly shorter in the cefotaxime group. The results suggest that cefotaxime is an effective and well-tolerated agent in the treatment of serious infections. However, the difference between the two groups was too small to allow preference of one procedure over the other.

One hundred and seventy-six patients scheduled for elective major abdominal surgery were randomized to two prophylactic regimens to prevent postoperative thromboembolism. All patients were screened with the 125I-labelled fibrinogen uptake test, and thromboembolism was verified by ascending phlebography and/or perfusion/ventilation lung scintigraphy. In the group of patients receiving low-dose heparin treatment (5000 units twice daily subcutaneously) 12 per cent developed thromboembolic complications. In the other group, where low-dose heparin treatment was supplemented with graded compression stockings only 2 per cent developed thromboembolism. It is concluded that the combination of low-dose heparin and the use of graded compression stockings is superior to heparin alone in preventing thromboembolism following major abdominal surgery.

Operative treatment of undescended testes was performed in 556 boys (695 testes). The histopathological changes in the testicular tissue were more severe in older patients. However, post-operative clinical results were found to be significantly better in boys treated immediately before puberty than in boys treated at an earlier age.

Nine patients with a prenatal ultrasonic diagnosis of unilateral ureteropelvic junction obstruction underwent pyeloplasty in early neonatal life. Based on radiological and renographical assessment of the results, immediate postnatal intervention had no demonstrable advantage over those subjects in a control group who underwent an operation after presenting with symptoms. Half of the children in both groups had normal parenchymal function of the hydronephrotic kidney. Because of the operative complications we found it unacceptable to operate on neonates without symptoms and with normal function of the affected kidney. The advantage of prenatal diagnosis lies in the early recognition of the necessity of close surveillance. The primary indications for surgical intervention should be symptoms and impairment of the hydronephrotic kidney function.

The nuclear DNA content in 67 prostatic carcinomas was measured by flow cytometry of nuclear suspensions prepared from paraffin-embedded tissue blocks. A method was developed that provided nuclear suspensions of good quality whether tissue blocks from transurethral resections or transvesical prostatectomies were used. Thirty (43.7%) of the tumors were found to be aneuploid. No significant correlation between clinical stage or histological grade and aneuploidy was demonstrated.

Management of children with severe infravesical or bilateral ureterovesical obstruction with or without reflux is difficult. Our experience over 10 years includes 29 such children, 19 of whom presented in the first 3 months of life. At the time of diagnosis, 13 had severe disturbance of renal function. There were two deaths. Five children have severe and two a moderate reduction of renal function; twenty good renal function. There were ten nephrectomies and four heminephrectomies. Seven patients had a temporary and eight a permanent urinary diversion. However, four of the latter were later undiverted. Removal of an obstruction is not always followed by full restitution of function. It seems probable that renal dysplasia and developmental injury to the ureterovesical musculature set a limit to the therapeutic possibilities. Careful management is important, especially in neonatal cases, where extensive reconstructive procedures are technically demanding and the rate of complications is high.

Within a 10-year period reconstructive urinary tract surgery has been carried out in eight children with solitary kidneys. The children were 0-5 years old. Six had unilateral renal agenesis and two had unilateral multicystic kidney. In five children ureteroneocystostomy was performed, in two of them because of reflux. In two children pyeloureteroplasty was performed, and in one both ureteroneocystostomy and pyeloureteroplasty. The multicystic kidneys were removed. The renal function was poor preoperatively in five children; two of these also had urosepsis. These children were all under 15 months of age. Postoperatively, the renal function was subnormal (although improved) in two children; in six it was normal. The most important prognostic factors in solitary kidneys with urinary tract obstruction are infection and developmental injury.