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Anterior urethral valves: A case report
170
INTERNATIONAL
sively dilated ureters is a contraindication to this procedure as it lengthens the hypotonic segment of the urinary tract. As there is no need to approach the upper urinary tract, the intestinal tract is avoided and the operation is relatively short, it is of particular value to the debilitated patient requiring urinary diversion.-B. M. Henderson. THE NORMAL URETWROGRAM.C. E. Shapfner, and J. A. Hutch. Radiol. Clin N. Amer. 6:165-189 (August) 1968. A correlation of the gross urethral anatomy with the roentgen anatomy and physiology shows tremendous variation in the normal urethrogram. There may be changing positions of the trigonal plates, varying urethral widths, and different urethral configurations during voiding. Sequential voiding spot films are essential in understanding the configuration of the urethra. An understanding of the variations in the normal urethrogram is essential to prevent mistakes in interpretation.1. Eugene Lewis, Jr. VITAL ROLE OF THE &STAL URETHRAL SEGMENT IN CONTROL OF URINARY FLOW RATE. D. M. Gleason, and M. R. Bottaccini. J. Urol. 100: 167-170 (August) 1968. Voiding cystourethrograms were performed on female children through an 8 Fr. Foley catheter. Measurements of urethral diameters and hydrodynamic analyses were performed. From these studies the authors conclude that the distal urethral segment, as seen radiographically, was the narrowest portion of the urethra, a finding which was confirmed by theoretical calculations using actual pressure flow data. Minimal reductions in diameter of the distal urethra drastically reduced flow rates thus giving it a crucial role in governing them. It appears that the configuration of the proximal urethra is relatively unimportant as compared to that of the distal segment. By using a Tambour dynamometer the exit energy can be calculated which is, for practical purposes, equal to bladder pressure. In this way voiding pressures can be calculated without instrumenting the bladder.-B. M. Henderson. THE URETHRA IN THE FEMALE CHILD. S. Cedar. Brit. J. Ural. 40:441 (August) 1968.
S.
It is difficult to find a satisfactory criterion for the diagnosis of bladder neck obstruction in girls and varying opinions have been expressed in the literature as to its frequency. More recent observers have doubted whether the bladder neck
ARSTRACXS
OF PEDIATRIC
SURGERY
is obstructive and have turned their attention to the distal urethra. The author studied the radiological appearance of the urethra in girls with urinary infection, enuresis, dysuria, or vesico-ureteric reflux. Since the outline of the urethra varies at different stages during micturition, only those cases (92) in which a consistent picture was obtained in several films were evaluated. Four groups were delineated: Group A (18 cases)-There is dilatation of the whole length or of at least the proximal three quarters of the urethra, with a slight waist but no true narrowing at the bladder neck. Group B (35 cases)-The dilatation affects only the upper half of the urethra and a relatively narrow segment can be defined below it. Group C (16 cases)The urethra tapers gradually down to the area of the external sphincter. Group D (23 cases)The urethra is tube-like, showing little variation in diameter throughout its length. Twenty-seven of the girls in groups A and B underwent urethral calibration; the results corresponded to the findings in normal children. There was no correlation between the clinical features and the various groups. The author considers that, in groups A and B, there is distal urethral obstruction. This may be either mechanical, due to meatal or lower urethral stenosis, or functional, resulting from spasm or failure of relaxation of the urethral musculature.-J. H. Johnston. PROLAPSE OF THE FEMALE URETHRA IN CHILDREN. S. B. Owens, and W. H. Morse. J, Ural. 100: 171-174 (August) 1968. Circular prolapse of the female urethra is seen uncommonly; it generally occurs in colored children, usually under the age of 10 years. The authors present a group of 54 colored female children who presented with this lesion and whose principal complaints included bleeding (described as spotting, early menstruation, or hematuria ), frequency, dysuria, incontinence, and acute urinary retention. The prolapse was described as being a smooth bluish-red mass which bled easily and which surrounded the urethra completely. The lesion was treated by ligating the base of the prolapsus over a urethral catheter. They had one recurrence among the 42 patients treated in this way.-B. M. Henderson. ANTERIOR URETHRAL VALVES: A CASE REPORT. C. Y. Chang. J. Urol. loo:2931 (July) 1968. The case of a 3%month-old boy who presented with urinary tract infection and a poor stream is
INTERNATIONAL
ABSTRACL9
171
OF PEDIATRIC SURGERY
described. A voiding cystourethrogram demonstrated the presence of anterior urethral valves; the operation performed to excise these is described.-B. M. Henderson. CONGENITAL ANTWOR URETHRAL VALVE-DLKNOSIS AND TREATMENT. J. Daniel, A. M. Stewart, and D. W. Blair. Brit. J. Urol. 40, 589-591 (October) 1968. A case of a 6-year-old boy with an anterior urethral valve is recorded. The upper urinary tract was normal on intravenous urography. The valve was excised by open operation. Y-V plasty at the bladder outlet was performed in addition since the authors were of the opinion that there was coincident bladder neck obstruction.-,I. H. Johnston. COMPLETE AWLSION OF THE ANTERIOR URETHRA IN A BOY: REPORT OF A CASE WITH SUCCESSFUL RECONSTRUCTION.M. N. Al-Ghorab, and A. P. EZ-Badawi. J. Urol. 100:32-25 (July) 1968. The case of a IO-year-old boy who sustained perineal trauma is presented. The perineal urethra had been divided and in attempting to pass a catheter distally the anterior urethra was avulsed. This was reconstructed using scrotal skin and later Dennis-Browne hypospadias repair. The authors suggest that repair of the urethra following trauma should be delayed until the effects of trauma have subsided and that catheterization of the distal urethra in the presence of extravasation may be attended by further damage as occurred in this case.-B. 21f. Henderson. REPEATED TORSION CAUSING CYSTIC DEGENERATION OF INTRA-ABWMINAL TESTIS. E. S. Glen. Brit. J. Surg. 55:651-652 (September) 1968. A case of repeated torsion of an intra-abdominal testis in a g-year-old boy, ending in cystic degeneration of the testis is reported. Following excision of the cystic (benign) mass he made an uneventful recovery. The relationship of malignant change in an intra-abdominal testis to torsion is discussed briefly.-.I. .I. Corkery. MALIGNANT SERTOLI CELL OF THE TESTIS. R. V. Rosvoll, and J. R. Woodward. Cancer 22:8-13 (July) 1968. Although common in dogs, this tumor is unusual in man. It arises in testicles, ovaries, and occasionally in other sites and has a mixed histologic pattern. They are feminizing lesions and on the few occasions when urinary androgens, estro-
gens, and pregnanetriol have been measured they were elevated. The case of an 8-year-old boy with a sertoli cell tumor of the testis which had been present for 3 years is presented. There were associated retroperitoneal metastases-B. Ar. Henderson. TRUE HEHMAPHRODITE WITH BILATERALLY DESCENDEDOVOTESTES.E. C. McDaniel, M. Nadel, and W. C. Woolverton. J. Urol. 100:77-81 (July)
1968.
The case of a I4-year-old Negro is described who was seen because of progressive breast enlargement and was found to have “abnormal testes” palpable in the scrotum. The child was brought up as a boy but stopped taking part in sports because of the enlargement of his breasts. There was biphid ventral raphe of the penis which was elevated into ridges which joined in the frenullar area. The superior half of the gonads was round and firm while the lower half had the consistency of normal testes. No vas could be felt on either side and there was a prostate of normal size. At laparotomy no female structures were found apart from a pink nodule on the dome of the bladder which was made up of endometrical epithelium and stroma. As it was decided to continue raising him as a male, the ovarian portion of the ovotestes was excised. The authors note that only 5 of the reported cases in the literature have normal male external genitalia ,\1. Henwith both gonads in the scrotum.-B. derson. CONGENITAL ADHENAL HYPERPLASIA. Maria I. New. Pediat. Clin. N. Amer. 15:395408 (May) 1968. Cliteroplasty or clitorectomy must he considered before one year of age, if the phallus is markedly enlarged or if the more modestly enlarged clitoris is disturbing to the parents. With slight clitoral enlargement, without offense to parent or patient, operation may be delayed until puberty, at which time the normal growth of pubic hair and labia majora provide a good camouflage for the slightly enlarged clitoris. Repair of the urogenital sinus should be reserved until just before marriage, since early repair will not persist, and repeated procedures then become neccssary.-A. M. Salzberg.
MUSCULOSKELETAL
SYSTEM
WRINGER INJURIES IN CHILDREN. James
E. Allen,
INTERNATIONAL
sively dilated ureters is a contraindication to this procedure as it lengthens the hypotonic segment of the urinary tract. As there is no need to approach the upper urinary tract, the intestinal tract is avoided and the operation is relatively short, it is of particular value to the debilitated patient requiring urinary diversion.-B. M. Henderson. THE NORMAL URETWROGRAM.C. E. Shapfner, and J. A. Hutch. Radiol. Clin N. Amer. 6:165-189 (August) 1968. A correlation of the gross urethral anatomy with the roentgen anatomy and physiology shows tremendous variation in the normal urethrogram. There may be changing positions of the trigonal plates, varying urethral widths, and different urethral configurations during voiding. Sequential voiding spot films are essential in understanding the configuration of the urethra. An understanding of the variations in the normal urethrogram is essential to prevent mistakes in interpretation.1. Eugene Lewis, Jr. VITAL ROLE OF THE &STAL URETHRAL SEGMENT IN CONTROL OF URINARY FLOW RATE. D. M. Gleason, and M. R. Bottaccini. J. Urol. 100: 167-170 (August) 1968. Voiding cystourethrograms were performed on female children through an 8 Fr. Foley catheter. Measurements of urethral diameters and hydrodynamic analyses were performed. From these studies the authors conclude that the distal urethral segment, as seen radiographically, was the narrowest portion of the urethra, a finding which was confirmed by theoretical calculations using actual pressure flow data. Minimal reductions in diameter of the distal urethra drastically reduced flow rates thus giving it a crucial role in governing them. It appears that the configuration of the proximal urethra is relatively unimportant as compared to that of the distal segment. By using a Tambour dynamometer the exit energy can be calculated which is, for practical purposes, equal to bladder pressure. In this way voiding pressures can be calculated without instrumenting the bladder.-B. M. Henderson. THE URETHRA IN THE FEMALE CHILD. S. Cedar. Brit. J. Ural. 40:441 (August) 1968.
S.
It is difficult to find a satisfactory criterion for the diagnosis of bladder neck obstruction in girls and varying opinions have been expressed in the literature as to its frequency. More recent observers have doubted whether the bladder neck
ARSTRACXS
OF PEDIATRIC
SURGERY
is obstructive and have turned their attention to the distal urethra. The author studied the radiological appearance of the urethra in girls with urinary infection, enuresis, dysuria, or vesico-ureteric reflux. Since the outline of the urethra varies at different stages during micturition, only those cases (92) in which a consistent picture was obtained in several films were evaluated. Four groups were delineated: Group A (18 cases)-There is dilatation of the whole length or of at least the proximal three quarters of the urethra, with a slight waist but no true narrowing at the bladder neck. Group B (35 cases)-The dilatation affects only the upper half of the urethra and a relatively narrow segment can be defined below it. Group C (16 cases)The urethra tapers gradually down to the area of the external sphincter. Group D (23 cases)The urethra is tube-like, showing little variation in diameter throughout its length. Twenty-seven of the girls in groups A and B underwent urethral calibration; the results corresponded to the findings in normal children. There was no correlation between the clinical features and the various groups. The author considers that, in groups A and B, there is distal urethral obstruction. This may be either mechanical, due to meatal or lower urethral stenosis, or functional, resulting from spasm or failure of relaxation of the urethral musculature.-J. H. Johnston. PROLAPSE OF THE FEMALE URETHRA IN CHILDREN. S. B. Owens, and W. H. Morse. J, Ural. 100: 171-174 (August) 1968. Circular prolapse of the female urethra is seen uncommonly; it generally occurs in colored children, usually under the age of 10 years. The authors present a group of 54 colored female children who presented with this lesion and whose principal complaints included bleeding (described as spotting, early menstruation, or hematuria ), frequency, dysuria, incontinence, and acute urinary retention. The prolapse was described as being a smooth bluish-red mass which bled easily and which surrounded the urethra completely. The lesion was treated by ligating the base of the prolapsus over a urethral catheter. They had one recurrence among the 42 patients treated in this way.-B. M. Henderson. ANTERIOR URETHRAL VALVES: A CASE REPORT. C. Y. Chang. J. Urol. loo:2931 (July) 1968. The case of a 3%month-old boy who presented with urinary tract infection and a poor stream is
INTERNATIONAL
ABSTRACL9
171
OF PEDIATRIC SURGERY
described. A voiding cystourethrogram demonstrated the presence of anterior urethral valves; the operation performed to excise these is described.-B. M. Henderson. CONGENITAL ANTWOR URETHRAL VALVE-DLKNOSIS AND TREATMENT. J. Daniel, A. M. Stewart, and D. W. Blair. Brit. J. Urol. 40, 589-591 (October) 1968. A case of a 6-year-old boy with an anterior urethral valve is recorded. The upper urinary tract was normal on intravenous urography. The valve was excised by open operation. Y-V plasty at the bladder outlet was performed in addition since the authors were of the opinion that there was coincident bladder neck obstruction.-,I. H. Johnston. COMPLETE AWLSION OF THE ANTERIOR URETHRA IN A BOY: REPORT OF A CASE WITH SUCCESSFUL RECONSTRUCTION.M. N. Al-Ghorab, and A. P. EZ-Badawi. J. Urol. 100:32-25 (July) 1968. The case of a IO-year-old boy who sustained perineal trauma is presented. The perineal urethra had been divided and in attempting to pass a catheter distally the anterior urethra was avulsed. This was reconstructed using scrotal skin and later Dennis-Browne hypospadias repair. The authors suggest that repair of the urethra following trauma should be delayed until the effects of trauma have subsided and that catheterization of the distal urethra in the presence of extravasation may be attended by further damage as occurred in this case.-B. 21f. Henderson. REPEATED TORSION CAUSING CYSTIC DEGENERATION OF INTRA-ABWMINAL TESTIS. E. S. Glen. Brit. J. Surg. 55:651-652 (September) 1968. A case of repeated torsion of an intra-abdominal testis in a g-year-old boy, ending in cystic degeneration of the testis is reported. Following excision of the cystic (benign) mass he made an uneventful recovery. The relationship of malignant change in an intra-abdominal testis to torsion is discussed briefly.-.I. .I. Corkery. MALIGNANT SERTOLI CELL OF THE TESTIS. R. V. Rosvoll, and J. R. Woodward. Cancer 22:8-13 (July) 1968. Although common in dogs, this tumor is unusual in man. It arises in testicles, ovaries, and occasionally in other sites and has a mixed histologic pattern. They are feminizing lesions and on the few occasions when urinary androgens, estro-
gens, and pregnanetriol have been measured they were elevated. The case of an 8-year-old boy with a sertoli cell tumor of the testis which had been present for 3 years is presented. There were associated retroperitoneal metastases-B. Ar. Henderson. TRUE HEHMAPHRODITE WITH BILATERALLY DESCENDEDOVOTESTES.E. C. McDaniel, M. Nadel, and W. C. Woolverton. J. Urol. 100:77-81 (July)
1968.
The case of a I4-year-old Negro is described who was seen because of progressive breast enlargement and was found to have “abnormal testes” palpable in the scrotum. The child was brought up as a boy but stopped taking part in sports because of the enlargement of his breasts. There was biphid ventral raphe of the penis which was elevated into ridges which joined in the frenullar area. The superior half of the gonads was round and firm while the lower half had the consistency of normal testes. No vas could be felt on either side and there was a prostate of normal size. At laparotomy no female structures were found apart from a pink nodule on the dome of the bladder which was made up of endometrical epithelium and stroma. As it was decided to continue raising him as a male, the ovarian portion of the ovotestes was excised. The authors note that only 5 of the reported cases in the literature have normal male external genitalia ,\1. Henwith both gonads in the scrotum.-B. derson. CONGENITAL ADHENAL HYPERPLASIA. Maria I. New. Pediat. Clin. N. Amer. 15:395408 (May) 1968. Cliteroplasty or clitorectomy must he considered before one year of age, if the phallus is markedly enlarged or if the more modestly enlarged clitoris is disturbing to the parents. With slight clitoral enlargement, without offense to parent or patient, operation may be delayed until puberty, at which time the normal growth of pubic hair and labia majora provide a good camouflage for the slightly enlarged clitoris. Repair of the urogenital sinus should be reserved until just before marriage, since early repair will not persist, and repeated procedures then become neccssary.-A. M. Salzberg.
MUSCULOSKELETAL
SYSTEM
WRINGER INJURIES IN CHILDREN. James
E. Allen,