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INGUINAL HERNIAS IN PREMATURE INFANTS: IS THERE MORBIDITY ASSOCIATED WITH DELAYED REPAIR?
Vol. 179, No. 4, Supplement, Sunday, May 18, 2008
transportation, two patients had successful detorsion and salvage, two required orchiectomy for torsion and one for a shattered testis. The remaining three patients had intermittent torsion which was dealt with via bilateral orchidopexies within twelve hours of arrival. CONCLUSIONS: We are beginning to identify a trend in which patients are told that urologic care is unavailable at outside institutions which then necessitates emergency transportation to the pediatric center. Precious time has been lost while waiting for transportation and an increased risk to both transport team and patient occurs due to the inability of the outside hospital to assume the care of this child. Source of Funding: None
413 SCREENING FOR A GENETIC BASIS FOR TESTICULAR TORSION: THE INSULIN-3 (INSL3) AND LGR8 GENES Yi Wang*, Maggy Fina, Shaohua Zhang, Ronald Taussig, Linda A Baker. Dallas, TX. INTRODUCTION AND OBJECTIVE: The mechanism and molecular basis of testicular torsion is poorly understood. Rare reports of familial torsion possibly suggest a genetic basis. The testis hormone INSL3 and its receptor, LGR8, are key mediators in murine and human testicular descent. Our Insl3 mutant mice have spontaneous testicular torsion and vanished testes. In our human mutation screening, we observed monorchia in 2 of 6 cryptorchids with LGR8 mutations. To date, no one has screened for mutations in INSL3 or LGR8 in patients ZLWKWHVWLFXODUWRUVLRQ ZHVRXJKWWRDVVHVVDJHQHWLFEDVLVRIWHVWLFXODU torsion. METHODS: From acute or intermittent torsion patients (n=36), genomic DNA was screened for mutations in human INSL3 and LGR8. 105 cryptorchid males and the NCBI dbSNP database VHUYHGDVFRQWUROV7KHPXWDQWSURWHLQVFRQWDLQLQJLGHQWL¿HGPLVVHQVH mutations were functionally tested via mutant receptor transfection into HEK293 cells, and subsequent assessment of cAMP production after stimulation with INSL3. RESULTS: Eleven newborn torsion specimens (mean age GD\V ZHUHREWDLQHGIURP XQLODWHUDO 5 / DQGELODWHUDOFDVHV Of the 11, 3 of 7 queried have positive family history (+FHx) of torsion. 25 peripubertal torsion specimens (mean age 8.6 yrs) were obtained IURPXQLODWHUDO 5 / DQGELODWHUDOFDVHV2IWKHVHRI queried have +FHx of torsion. No nonsynonymous mutations were found in INSL3. In addition to 3 known silent polymorphisms (A87A, ( (DQG// DQGWKHIXQFWLRQDOO\LQVLJQL¿FDQWPLVVHQVH,9 PXWDWLRQLQWKH/*5JHQHZHGHWHFWHGDQRYHOKHWHUR]\JRXV65 mutation in a unilateral neonatal torsion patient with +FHx of torsion and cryptorchidism which was absent in controls. Testing showed the mutant T222P, S314R, R532G, and I604V LGR8 receptors stimulate cAMP same as wild type receptor, with equal dose response curves. CONCLUSIONS: A novel missense mutation in the LGR8 JHQHZDVLGHQWL¿HGLQIDPLOLDOQHZERUQWRUVLRQKRZHYHUPXWDQWSURWHLQ testing did not reveal functional disturbance. Thus mutations in Insl3 and LGR8 are not common in testicular torsion patients. Source of Funding: NIH R01 HD48838 (Baker, LA).
414 INGUINAL HERNIAS IN PREMATURE INFANTS: IS THERE MORBIDITY ASSOCIATED WITH DELAYED REPAIR? Dena L Walsh*, John C Pope, Mark C Adams, John W Brock, John C Thomas. Nashville, TN. INTRODUCTION AND OBJECTIVE: Inguinal hernias occur in approximately 25% of premature infants. Surgical correction is the standard of care. Controversy exists concerning immediate versus delayed repair in terms of increased morbidity. We reviewed our experience with premature infant hernias to address this issue. METHODS: A retrospective review of premature infants (gestational age < 36 weeks) who had undergone inguinal hernia repair was performed at our institution between February 2002 and May 2007. We recorded estimated gestational age at birth, age at initial diagnosis at the time of consultation, time from diagnosis to repair, adverse events, and intra-or postoperative complications.
THE JOURNAL OF UROLOGY®
147
5(68/76 )LIW\HLJKWFKLOGUHQZHUHLGHQWL¿HGDQGLQFOXGHG in this study. The male to female ratio was 28:1 (56 males/2 females). Mean gestational age (GA) at birth was 30.4 weeks (range 23 weeks - 36 weeks). Mean GA age at initial urologic consult and diagnosis was 42 weeks (range 36 weeks -53 weeks). Mean GA age at surgical correction was 45 weeks (range 38 weeks - 65 weeks). Mean time from urology consult/diagnosis to repair was 26 days (range 0 - 164 days). Unilateral KHUQLDVZHUHLGHQWL¿HGLQIRXUSDWLHQWV DQGELODWHUDOLQ¿IW\IRXU patients (93%). Ten patients had adverse events while waiting for repair, LQFOXGLQJLQFDUFHUDWLRQLQRQH DQGDQ(5RURI¿FHYLVLWWRUHGXFH the hernia in nine (15.5%). There were two (2/58, 3.4%) postoperative pulmonary complications including respiratory distress and prolonged intubation. Recurrence of the hernia was seen in one patient (1.7%) who required further surgical treatment. There was no incidence of bowel perforation or gangrenous bowel. CONCLUSIONS: Delaying repair did not seem to be associated with major morbidity, as true incarceration occurred in one SDWLHQW$OVR DQRWKHU EHQH¿W WR GHOD\LQJ VXUJHU\ PD\ EH PLQLPL]LQJ SRVWRSHUDWLYHUHVSLUDWRU\SUREOHPVDOWKRXJKWKLVLVGLI¿FXOWWRSURYHZLWK a retrospective study. The most common problem encountered during the waiting period was elective reduction of the hernia. Therefore, daily inspection of the hernia by nursing staff or parents along with education on reduction and potential signs of incarceration are necessary to make delaying the repair safe and feasible. Source of Funding: None
415 SURGICAL TREATMENT OF VARICOCELE IN CHILDREN BY THE OPEN AND LAPAROSCOPIC PALOMO TECHNIQUE. A METANALYSIS Ubirajara Barroso*, Dennysson M Andrade, Hugo Novaes, Jose M Netto, Juarez Andrade. Salvador, Brazil, and Juiz de Fora, Brazil. INTRODUCTION AND OBJECTIVE: The aim of this study is to evaluate the surgical results of the treatment of varicocele in children E\RSHQDQGODSDURVFRSLFDVZHOODVWKHFODVVLFDQGPRGL¿HG3DORPR technique by means of a systematic review of the literature. METHODS: A systematic review of the literature was performed based on an English literature search using the MEDLINE® database between 1970 and 2006. The key words used were varicocele and children. All articles that were related to treatment of varicocele in children and adolescents with Palomo technique were selected. The exclusion criteria was age higher than 18 years and articles in which the type of treatment and the outcome were not clear. Palomo technique was GH¿QHGDVDKLJKOLJDWLRQRIWKHYHVVHOVSUR[LPDOWRWKHLQWHUQDOLQJXLQDO RUL¿FH:KHQDOOWHVWLFXODUYHLQVDQGDUWHU\ZHUHOLJDWHGWKHVXUJHU\ZDV FDOOHG&ODVVLF3DORPR &3 DQGPRGL¿HG3DORPR 03 ZKHQWKHDUWHU\ was spared. Of 264 papers evaluated 47 were selected. There were only SURVSHFWLYHFDVHVHULHVDQGUDQGRPL]HGFOLQLFDOWULDO RESULTS: 2054 patients were included in the analisis, 1437 and 617 patients were treated by the open and the laparocopic Palomo technique, respectively. When we compared CP with MP the rate of hydrocele and varicocele recurrence was 7.8% vs. 3.2% (P<0.001) DQG YV S UHVSHFWLYHO\ :KHQ ZH DQDO\]HG RQO\ patients who undergone MP, laparoscopic technique had a lower rate of varicocele recurrence 3.8% vs. 10% (P=0.026) than open surgery. The rate of hydrocele in the laparoscopic CP and CP open surgery was 7.1% vs. 11.4% (p=0.146), respectively. The rate of hydrocele in the prospective studies was 23.8% compared to 5.2% in the retrospective VHULHV7KH UDQJH RI WHVWLFXODU FDWFK XS ZDV ]HUR WR PHDQ RI 71.5% and 58% in the CP and MP groups, respectively) CONCLUSIONS: This metanalysis demonstrates that a high rate of hydrocele should be expected in the classic Palomo technique. The rate of testicular catch up after surgery is only reasonable. Source of Funding: None
transportation, two patients had successful detorsion and salvage, two required orchiectomy for torsion and one for a shattered testis. The remaining three patients had intermittent torsion which was dealt with via bilateral orchidopexies within twelve hours of arrival. CONCLUSIONS: We are beginning to identify a trend in which patients are told that urologic care is unavailable at outside institutions which then necessitates emergency transportation to the pediatric center. Precious time has been lost while waiting for transportation and an increased risk to both transport team and patient occurs due to the inability of the outside hospital to assume the care of this child. Source of Funding: None
413 SCREENING FOR A GENETIC BASIS FOR TESTICULAR TORSION: THE INSULIN-3 (INSL3) AND LGR8 GENES Yi Wang*, Maggy Fina, Shaohua Zhang, Ronald Taussig, Linda A Baker. Dallas, TX. INTRODUCTION AND OBJECTIVE: The mechanism and molecular basis of testicular torsion is poorly understood. Rare reports of familial torsion possibly suggest a genetic basis. The testis hormone INSL3 and its receptor, LGR8, are key mediators in murine and human testicular descent. Our Insl3 mutant mice have spontaneous testicular torsion and vanished testes. In our human mutation screening, we observed monorchia in 2 of 6 cryptorchids with LGR8 mutations. To date, no one has screened for mutations in INSL3 or LGR8 in patients ZLWKWHVWLFXODUWRUVLRQ ZHVRXJKWWRDVVHVVDJHQHWLFEDVLVRIWHVWLFXODU torsion. METHODS: From acute or intermittent torsion patients (n=36), genomic DNA was screened for mutations in human INSL3 and LGR8. 105 cryptorchid males and the NCBI dbSNP database VHUYHGDVFRQWUROV7KHPXWDQWSURWHLQVFRQWDLQLQJLGHQWL¿HGPLVVHQVH mutations were functionally tested via mutant receptor transfection into HEK293 cells, and subsequent assessment of cAMP production after stimulation with INSL3. RESULTS: Eleven newborn torsion specimens (mean age GD\V ZHUHREWDLQHGIURP XQLODWHUDO 5 / DQGELODWHUDOFDVHV Of the 11, 3 of 7 queried have positive family history (+FHx) of torsion. 25 peripubertal torsion specimens (mean age 8.6 yrs) were obtained IURPXQLODWHUDO 5 / DQGELODWHUDOFDVHV2IWKHVHRI queried have +FHx of torsion. No nonsynonymous mutations were found in INSL3. In addition to 3 known silent polymorphisms (A87A, ( (DQG// DQGWKHIXQFWLRQDOO\LQVLJQL¿FDQWPLVVHQVH,9 PXWDWLRQLQWKH/*5JHQHZHGHWHFWHGDQRYHOKHWHUR]\JRXV65 mutation in a unilateral neonatal torsion patient with +FHx of torsion and cryptorchidism which was absent in controls. Testing showed the mutant T222P, S314R, R532G, and I604V LGR8 receptors stimulate cAMP same as wild type receptor, with equal dose response curves. CONCLUSIONS: A novel missense mutation in the LGR8 JHQHZDVLGHQWL¿HGLQIDPLOLDOQHZERUQWRUVLRQKRZHYHUPXWDQWSURWHLQ testing did not reveal functional disturbance. Thus mutations in Insl3 and LGR8 are not common in testicular torsion patients. Source of Funding: NIH R01 HD48838 (Baker, LA).
414 INGUINAL HERNIAS IN PREMATURE INFANTS: IS THERE MORBIDITY ASSOCIATED WITH DELAYED REPAIR? Dena L Walsh*, John C Pope, Mark C Adams, John W Brock, John C Thomas. Nashville, TN. INTRODUCTION AND OBJECTIVE: Inguinal hernias occur in approximately 25% of premature infants. Surgical correction is the standard of care. Controversy exists concerning immediate versus delayed repair in terms of increased morbidity. We reviewed our experience with premature infant hernias to address this issue. METHODS: A retrospective review of premature infants (gestational age < 36 weeks) who had undergone inguinal hernia repair was performed at our institution between February 2002 and May 2007. We recorded estimated gestational age at birth, age at initial diagnosis at the time of consultation, time from diagnosis to repair, adverse events, and intra-or postoperative complications.
THE JOURNAL OF UROLOGY®
147
5(68/76 )LIW\HLJKWFKLOGUHQZHUHLGHQWL¿HGDQGLQFOXGHG in this study. The male to female ratio was 28:1 (56 males/2 females). Mean gestational age (GA) at birth was 30.4 weeks (range 23 weeks - 36 weeks). Mean GA age at initial urologic consult and diagnosis was 42 weeks (range 36 weeks -53 weeks). Mean GA age at surgical correction was 45 weeks (range 38 weeks - 65 weeks). Mean time from urology consult/diagnosis to repair was 26 days (range 0 - 164 days). Unilateral KHUQLDVZHUHLGHQWL¿HGLQIRXUSDWLHQWV DQGELODWHUDOLQ¿IW\IRXU patients (93%). Ten patients had adverse events while waiting for repair, LQFOXGLQJLQFDUFHUDWLRQLQRQH DQGDQ(5RURI¿FHYLVLWWRUHGXFH the hernia in nine (15.5%). There were two (2/58, 3.4%) postoperative pulmonary complications including respiratory distress and prolonged intubation. Recurrence of the hernia was seen in one patient (1.7%) who required further surgical treatment. There was no incidence of bowel perforation or gangrenous bowel. CONCLUSIONS: Delaying repair did not seem to be associated with major morbidity, as true incarceration occurred in one SDWLHQW$OVR DQRWKHU EHQH¿W WR GHOD\LQJ VXUJHU\ PD\ EH PLQLPL]LQJ SRVWRSHUDWLYHUHVSLUDWRU\SUREOHPVDOWKRXJKWKLVLVGLI¿FXOWWRSURYHZLWK a retrospective study. The most common problem encountered during the waiting period was elective reduction of the hernia. Therefore, daily inspection of the hernia by nursing staff or parents along with education on reduction and potential signs of incarceration are necessary to make delaying the repair safe and feasible. Source of Funding: None
415 SURGICAL TREATMENT OF VARICOCELE IN CHILDREN BY THE OPEN AND LAPAROSCOPIC PALOMO TECHNIQUE. A METANALYSIS Ubirajara Barroso*, Dennysson M Andrade, Hugo Novaes, Jose M Netto, Juarez Andrade. Salvador, Brazil, and Juiz de Fora, Brazil. INTRODUCTION AND OBJECTIVE: The aim of this study is to evaluate the surgical results of the treatment of varicocele in children E\RSHQDQGODSDURVFRSLFDVZHOODVWKHFODVVLFDQGPRGL¿HG3DORPR technique by means of a systematic review of the literature. METHODS: A systematic review of the literature was performed based on an English literature search using the MEDLINE® database between 1970 and 2006. The key words used were varicocele and children. All articles that were related to treatment of varicocele in children and adolescents with Palomo technique were selected. The exclusion criteria was age higher than 18 years and articles in which the type of treatment and the outcome were not clear. Palomo technique was GH¿QHGDVDKLJKOLJDWLRQRIWKHYHVVHOVSUR[LPDOWRWKHLQWHUQDOLQJXLQDO RUL¿FH:KHQDOOWHVWLFXODUYHLQVDQGDUWHU\ZHUHOLJDWHGWKHVXUJHU\ZDV FDOOHG&ODVVLF3DORPR &3 DQGPRGL¿HG3DORPR 03 ZKHQWKHDUWHU\ was spared. Of 264 papers evaluated 47 were selected. There were only SURVSHFWLYHFDVHVHULHVDQGUDQGRPL]HGFOLQLFDOWULDO RESULTS: 2054 patients were included in the analisis, 1437 and 617 patients were treated by the open and the laparocopic Palomo technique, respectively. When we compared CP with MP the rate of hydrocele and varicocele recurrence was 7.8% vs. 3.2% (P<0.001) DQG YV S UHVSHFWLYHO\ :KHQ ZH DQDO\]HG RQO\ patients who undergone MP, laparoscopic technique had a lower rate of varicocele recurrence 3.8% vs. 10% (P=0.026) than open surgery. The rate of hydrocele in the laparoscopic CP and CP open surgery was 7.1% vs. 11.4% (p=0.146), respectively. The rate of hydrocele in the prospective studies was 23.8% compared to 5.2% in the retrospective VHULHV7KH UDQJH RI WHVWLFXODU FDWFK XS ZDV ]HUR WR PHDQ RI 71.5% and 58% in the CP and MP groups, respectively) CONCLUSIONS: This metanalysis demonstrates that a high rate of hydrocele should be expected in the classic Palomo technique. The rate of testicular catch up after surgery is only reasonable. Source of Funding: None