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327 PATHOLOGICAL ANALYSIS OF TESTICULAR REMANTS IN NONPALPABLE UNDESCENDED TESTIS
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THE JOURNAL OF UROLOGY姞
METHODS: A cohort analysis of patients (1 month to ⬍18 years of age) who underwent surgery for suspected testicular torsion (n⫽2,443) and neonates (n⫽152) in the 2000, 2003, and 2006 Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) was performed. Patient and hospital characteristics predictive of orchiectomy versus testicular salvage were compared by univariate and multivariate analyses. RESULTS: There is a bimodal distribution of testicular torsion with peaks in the first year of life and early adolescence. The overall mean age at presentation is 10.6 ⫾ 5.8 years. The estimated yearly incidence of testicular torsion for males under age 18 is 3.8 cases per 100,000. Orchiectomy is currently performed in 41.9% of patients under age 18 undergoing an operation for a preoperative diagnosis of testis torsion. The adjusted odds ratio for orchiectomy was highest for children ⬍1 year of age (2.89; 95% CI 1.52-5.48) or age 1–5 years (1.67; 95% CI 1.07–2.62) compared to those aged 15–17 years. Additional independent predictors of orchiectomy included medicaid insurance (OR 1.31; 95% CI 1.02–1.68), non-ER admission source (OR 2.09; 95% CI 1.07– 4.09), and operation at a children’s hospital or unit (OR 1.58; 95% CI 1.23–2.04). CONCLUSIONS: For patients presenting with testis torsion, the rate of orchiectomy is over 40 percent. Younger patients, and patients who present outside of the ER setting are more likely to suffer testicular loss. Poorer access to care, as denoted by Medicaid insurance was also predictive for testis loss. Based upon this data we believe public health measures and hospital quality improvement initiatives could be promoted to reduce the rate of orchiectomy. For example, measures could be developed to bypass community hospitals in the initial evaluation of children who experience testis pain in favor of direct routing to a children’s hospital. Source of Funding: None
326 POST CIRCUMCISION MEATAL STENOSIS IN THE NEONATES DUE TO MEATAL DEVASCULARISATION: A COMPARISON OF FRANULAR ARTERY SPARING, PLASTIBELL AND CONVENTIONAL TECHNIQUE Abdol-Mohammad Kajbafzadeh*, Majid Kajbafzadeh, Mona Arbab, Firouzeh Heidari, Hamid Arshadi, Seyed-Mohammad Milani, Tehran, Iran INTRODUCTION AND OBJECTIVES: To evaluate the incidence of post-circumcision meatal stenosis in the neonates and comparing the results of Plastibell circumcision and conventional circumcision. To study, the possible correlation between the revascularization technique and franular artery sparing technique. METHODS: (Group I), 105 neonates who underwent a classical surgical circumcision with ligation of frenular artery (age from 2 days to 4 months), (Group II), 102 neonates underwent circumcision with a Plastibell ring under local anesthesia at nearly the same age, (Group III), 101 infants were operated by conventional technique without ligation of franular artery. RESULTS: The incidence of meatal stenosis was significantly lower in group III. The incidence of meatal stenosis with franular artery ligation (Group I) was 15% comparing to 5% in Plastibell (Group II) and only 2% in the third group. The incidence of decreased meatal caliber was observed in 40 % of children in group I but remained asymptomatic. Mean follow-up period was 9 years (range 10 to 12). All children were examined for meatal stenosis, subcoronal penile skin adhesion and voiding symptoms. CONCLUSIONS: The frenular artery ligation is the first surgical step in conventional circumcision. The incidence of meatal stenosis is significantly higher in frenular artery ligation group comparing to non-devascularization group. In both groups the types of nappy were the same. In conclusion the ischemic meatal stenosis is more likely than the ammoniac inflammation or the depithelialization of the glans penis surface by the nappy. This study recommends that neonatal circumcision is safe when the frenular artery is preserved.
Vol. 185, No. 4S, Supplement, Sunday, May 15, 2011
Groups Group I
Meatal Stenosis 15%
Skin adhesion 3%
Meatal caliber decrease 40%
Group II
5%
16%
9%
Group III 2% 1% 5% Group I, classical surgical circumcision with ligation of frenular artery; Group II,circumcision with a Plastibell ring; Group III, conventional technique without ligation of franular artery.
Source of Funding: None
327 PATHOLOGICAL ANALYSIS OF TESTICULAR REMANTS IN NONPALPABLE UNDESCENDED TESTIS Neal Rowe*, Michael Leonard, Joseph de Nanassy, Luis Guerra, Ottawa, Canada INTRODUCTION AND OBJECTIVES: Approximately one fifth of undescended testes (UDT) are impalpable. Surgical exploration often reveals a small testicular remnant distal to the internal inguinal ring. There is controversy in the literature as to whether these remnants contain any viable testicular tissue and whether they should be excised. Furthermore, it is unclear whether inguinal exploration is warranted when the vas deferens and vessels are visualized exiting the internal inguinal ring during laparoscopy. We reviewed the pathology of testicular remnants found distal to the internal inguinal ring on surgical exploration to determine the incidence of viable testicular tissue. METHODS: Institutional review board approved our study. Between January 1st, 2000 and December 31st, 2009, 210 orchiectomy specimens were sent to pathology at our institution. We reviewed the histology and operative reports of 98 consecutive specimens that were excised during exploration for nonpalpable UDT. Nubbins were defined as remnants of tissue identified with a blind ending spermatic cord and consistent with vanishing testis syndrome. If laparoscopy was performed, the status of the vas, vessels, and internal inguinal ring were recorded. RESULTS: 69 nubbins and 29 atrophic testes were identified at the time of surgery for non-palpable undescended testis. All 69 nubbins were identified distal to the internal inguinal ring during inguinal/scrotal exploration. 7.2% (5/69) of nubbins identified contained seminiferous tubules while 2.9% (2/69) contained viable germ cells. In addition to nubbins, 29 atrophic testes were identified and removed. Of these 7 were intra-abdominal with all having seminiferous tubules and 6 having viable germ cells. The remaining 22 atrophic testes were identified distal to the internal inguinal ring. 36.4% (8/22) had seminiferous tubules and 27.3% (6/22) had viable germ cells. A subgroup analysis of all 41 cases with initial laparoscopy found that 8.8% (3/34) of cases with both vas deferens and vessels exiting the internal inguinal ring had viable germ cells and seminiferous tubules. CONCLUSIONS: The incidence of viable testicular tissue in all remnants removed at the time of inguinal/scrotal exploration for nonpalpable UDT is 15.4% in our series. This data supports inguinal/scrotal exploration despite an impalpable testis when the vas deferens and vessels are visualized exiting an internal inguinal ring during laparoscopy. Source of Funding: Non-funded.
328 ONE THIRD OF PATIENTS WITH A UNILATERAL PALPABLE UNDESCENDED TESTES HAVE A CONTRALATERAL PATENT PROCESSUS Himanshu Aggarwal*, Paul Feustel, Barry Kogan, Albany, NY INTRODUCTION AND OBJECTIVES: The incidence of an ipsilateral patent processus vaginalis associated with unilateral palpable undescended testis ranges between 62–90%. However the rate of a contralateral patent processus vaginalis is unknown. The aim of this
THE JOURNAL OF UROLOGY姞
METHODS: A cohort analysis of patients (1 month to ⬍18 years of age) who underwent surgery for suspected testicular torsion (n⫽2,443) and neonates (n⫽152) in the 2000, 2003, and 2006 Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) was performed. Patient and hospital characteristics predictive of orchiectomy versus testicular salvage were compared by univariate and multivariate analyses. RESULTS: There is a bimodal distribution of testicular torsion with peaks in the first year of life and early adolescence. The overall mean age at presentation is 10.6 ⫾ 5.8 years. The estimated yearly incidence of testicular torsion for males under age 18 is 3.8 cases per 100,000. Orchiectomy is currently performed in 41.9% of patients under age 18 undergoing an operation for a preoperative diagnosis of testis torsion. The adjusted odds ratio for orchiectomy was highest for children ⬍1 year of age (2.89; 95% CI 1.52-5.48) or age 1–5 years (1.67; 95% CI 1.07–2.62) compared to those aged 15–17 years. Additional independent predictors of orchiectomy included medicaid insurance (OR 1.31; 95% CI 1.02–1.68), non-ER admission source (OR 2.09; 95% CI 1.07– 4.09), and operation at a children’s hospital or unit (OR 1.58; 95% CI 1.23–2.04). CONCLUSIONS: For patients presenting with testis torsion, the rate of orchiectomy is over 40 percent. Younger patients, and patients who present outside of the ER setting are more likely to suffer testicular loss. Poorer access to care, as denoted by Medicaid insurance was also predictive for testis loss. Based upon this data we believe public health measures and hospital quality improvement initiatives could be promoted to reduce the rate of orchiectomy. For example, measures could be developed to bypass community hospitals in the initial evaluation of children who experience testis pain in favor of direct routing to a children’s hospital. Source of Funding: None
326 POST CIRCUMCISION MEATAL STENOSIS IN THE NEONATES DUE TO MEATAL DEVASCULARISATION: A COMPARISON OF FRANULAR ARTERY SPARING, PLASTIBELL AND CONVENTIONAL TECHNIQUE Abdol-Mohammad Kajbafzadeh*, Majid Kajbafzadeh, Mona Arbab, Firouzeh Heidari, Hamid Arshadi, Seyed-Mohammad Milani, Tehran, Iran INTRODUCTION AND OBJECTIVES: To evaluate the incidence of post-circumcision meatal stenosis in the neonates and comparing the results of Plastibell circumcision and conventional circumcision. To study, the possible correlation between the revascularization technique and franular artery sparing technique. METHODS: (Group I), 105 neonates who underwent a classical surgical circumcision with ligation of frenular artery (age from 2 days to 4 months), (Group II), 102 neonates underwent circumcision with a Plastibell ring under local anesthesia at nearly the same age, (Group III), 101 infants were operated by conventional technique without ligation of franular artery. RESULTS: The incidence of meatal stenosis was significantly lower in group III. The incidence of meatal stenosis with franular artery ligation (Group I) was 15% comparing to 5% in Plastibell (Group II) and only 2% in the third group. The incidence of decreased meatal caliber was observed in 40 % of children in group I but remained asymptomatic. Mean follow-up period was 9 years (range 10 to 12). All children were examined for meatal stenosis, subcoronal penile skin adhesion and voiding symptoms. CONCLUSIONS: The frenular artery ligation is the first surgical step in conventional circumcision. The incidence of meatal stenosis is significantly higher in frenular artery ligation group comparing to non-devascularization group. In both groups the types of nappy were the same. In conclusion the ischemic meatal stenosis is more likely than the ammoniac inflammation or the depithelialization of the glans penis surface by the nappy. This study recommends that neonatal circumcision is safe when the frenular artery is preserved.
Vol. 185, No. 4S, Supplement, Sunday, May 15, 2011
Groups Group I
Meatal Stenosis 15%
Skin adhesion 3%
Meatal caliber decrease 40%
Group II
5%
16%
9%
Group III 2% 1% 5% Group I, classical surgical circumcision with ligation of frenular artery; Group II,circumcision with a Plastibell ring; Group III, conventional technique without ligation of franular artery.
Source of Funding: None
327 PATHOLOGICAL ANALYSIS OF TESTICULAR REMANTS IN NONPALPABLE UNDESCENDED TESTIS Neal Rowe*, Michael Leonard, Joseph de Nanassy, Luis Guerra, Ottawa, Canada INTRODUCTION AND OBJECTIVES: Approximately one fifth of undescended testes (UDT) are impalpable. Surgical exploration often reveals a small testicular remnant distal to the internal inguinal ring. There is controversy in the literature as to whether these remnants contain any viable testicular tissue and whether they should be excised. Furthermore, it is unclear whether inguinal exploration is warranted when the vas deferens and vessels are visualized exiting the internal inguinal ring during laparoscopy. We reviewed the pathology of testicular remnants found distal to the internal inguinal ring on surgical exploration to determine the incidence of viable testicular tissue. METHODS: Institutional review board approved our study. Between January 1st, 2000 and December 31st, 2009, 210 orchiectomy specimens were sent to pathology at our institution. We reviewed the histology and operative reports of 98 consecutive specimens that were excised during exploration for nonpalpable UDT. Nubbins were defined as remnants of tissue identified with a blind ending spermatic cord and consistent with vanishing testis syndrome. If laparoscopy was performed, the status of the vas, vessels, and internal inguinal ring were recorded. RESULTS: 69 nubbins and 29 atrophic testes were identified at the time of surgery for non-palpable undescended testis. All 69 nubbins were identified distal to the internal inguinal ring during inguinal/scrotal exploration. 7.2% (5/69) of nubbins identified contained seminiferous tubules while 2.9% (2/69) contained viable germ cells. In addition to nubbins, 29 atrophic testes were identified and removed. Of these 7 were intra-abdominal with all having seminiferous tubules and 6 having viable germ cells. The remaining 22 atrophic testes were identified distal to the internal inguinal ring. 36.4% (8/22) had seminiferous tubules and 27.3% (6/22) had viable germ cells. A subgroup analysis of all 41 cases with initial laparoscopy found that 8.8% (3/34) of cases with both vas deferens and vessels exiting the internal inguinal ring had viable germ cells and seminiferous tubules. CONCLUSIONS: The incidence of viable testicular tissue in all remnants removed at the time of inguinal/scrotal exploration for nonpalpable UDT is 15.4% in our series. This data supports inguinal/scrotal exploration despite an impalpable testis when the vas deferens and vessels are visualized exiting an internal inguinal ring during laparoscopy. Source of Funding: Non-funded.
328 ONE THIRD OF PATIENTS WITH A UNILATERAL PALPABLE UNDESCENDED TESTES HAVE A CONTRALATERAL PATENT PROCESSUS Himanshu Aggarwal*, Paul Feustel, Barry Kogan, Albany, NY INTRODUCTION AND OBJECTIVES: The incidence of an ipsilateral patent processus vaginalis associated with unilateral palpable undescended testis ranges between 62–90%. However the rate of a contralateral patent processus vaginalis is unknown. The aim of this