Optimal Management of Cloacal Exstrophy

615

PEDIATRIC UROLOGY

Testosterone Concentrations in Human Seminal Plasma and Saliva and its Correlation With Non-ProteinBound and Total Testosterone Levels in Serum

E.

SANNIKKA, P. TERHO, J. SUOMINEN AND R. SANTTI, Institute of Biomedicine, Department of Anatomy, University of Turku, Turku, Finland

Int. J. Androl., 6: 319-330 (Aug.) 1983 A sensitive, specific and precise nonchromatographic method for the radioimmunoassay of testosterone in human seminal plasma and saliva from adults and pubertal boys is described. The values are compared to total and nonprotein-bound testosterone levels in serum. The salivary and serum levels of free testosterone showed better correlation with the stage of puberty than did the serum levels of total testosterone. The relationship between salivary and free testosterone in serum was maintained after oral administration of testosterone undecanoate. Circadian rhythmicity and the rapid fluctuations in the concentration of salivary testosterone are decreased with aging and after estrogen treatment, and increased with human chorionic gonadotropin stimulation. These findings are more likely to be the consequence of the change in the levels of free testosterone in serum rather than altered efficiency of the filtration of testosterone from the blood stream. Determination of testosterone in saliva does provide a convenient and accurate index of the nonprotein-bound concentration of testosterone in serum, that is the availability of hormone to tissues. P. R. R. 5 figures, 3 tables, 30 references Development of the Oocyte-Penetrating Capacity of Spermatozoa in the Human Epididymis

H.

D. M. MOORE, T. D. HARTMAN AND J. P. PRYOR, Institute of Zoology, The Zoological Society of London, and The Institute of Urology, London, England

Int. J. Androl., 6: 310-318 (Aug.) 1983 The spermatozoa were recovered from epididymal tissue of men undergoing vasectomy or epididymal vasotomy. The development of the penetrating capacity of human epididymal spermatozoa was assessed in vitro using zona-free hamster oocytes. The results concur with the findings of Hinrichsen and Blaquier that human spermatozoa obtained from the caudal epididymis were capable of fusion with zona-free hamster oocytes, while those from the corpus or caput epididymis were not. A significantly higher proportion of spermatozoa showed sustained forward movement in samples recovered from tissue of the cauda or corpus epididymis compared to those from the proximal duct. However, a small percentage of spermatozoa in the caput epididymis (not the efferent ducts) were highly motile and retained this movement overnight. Such spermatozoa did collide with oocytes during incubation but were not observed to bind. Whether this is owing to the failure of caput spermatozoa to undergo the acrosome reaction, and subsequently to modify plasmalemma moieties over the important equatorial segment and post-acrosomal region, or to a true lack of receptors is not clear. P. R. R. 1 figure, 1 table, 23 references Climacteric Flushing in a Man

J. GINSBURG AND B. O'REILLY, Academic Department of Medicine, Royal Free Hospital Medical School, London, England Brit. Med. J., 287: 262 (July 23) 1983

Hot flashes in men after orchiectomy or the administration of gonadotropin-reducing hormone agonist have been described previously but, in this report, some documentation of the event is offered. A 60-year-old man began having hot flashes shortly after bilateral orchiectomy for cancer of the prostate. Circulatory studies during one such attack showed marked increase in blood flow to the hand coincident with the symptoms of flushing, which were strikingly similar to those seen in menopausal women. Treatment with clonidine and calcium supplements provided some relief. T. D. A. 1 figure, 5 references

PEDIATRIC UROLOGY Early Contact, Social Support, and Mother-Infant Bonding

E.

ANISFELD AND E. LIPPER, Departments of Psychiatry and Pediatrics, Rose F. Kennedy Center, Albert Einstein College of Medicine, Bronx, New York

Pediatrics, 72: 79-83 (July) 1983 A study was designed to explore the hypothesis that an interval of close contact between mother and newborn immediately after birth facilitates the establishment of a close bond. Mothers were assigned randomly to 1 of 2 sets of procedures established for the immediate postpartum period. A total of 29 mothers experienced ·extra contact procedures in which the baby was placed on the mother's abdomen for 1 hour and 30 received routine care procedures in which the baby was shown to the mother and then taken to the nursery. Observations of maternal behavior during a feeding were made 2 days after birth by an observer blind to the randomization status of the mother. Results of the study indicate that mothers who were given their newborns to hold for an extended interval immediately after delivery exhibited more affectionate-contact behaviors to their babies at 2 days than did mothers who had not been given this opportunity. The most significant finding of the study is that the effectiveness of the extra contact treatment differed for women with different levels of social support. Women with a higher level of social support showed the same amount of affectionate behavior whether or not they received the extra contact treatment. By contrast, treatment had a substantial effect on the women with lower social support. Women with lower social support who did not have early extra contact interacted minimally with their newborns but women with lower social support who did have early contact with their babies exhibited markedly increased affectionate behavior. The study suggests that extra postpartum contact may be helpful for women who have difficulty becoming involved with their newborns owing to poor social support systems. For other women early contact may not be as necessary. P. M. H. 4 tables, 15 references Optimal Management of Cloaca} Exstrophy C. HOWELL, A. CALDAMONE, H. SNYDER, M. ZIEGLER AND J. DUCKETT, Children's Hospital of Philadelphia and the Uni-

versity of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

J. Ped. Surg., 18: 365-369 (Aug.) 1983 The authors reviewed their experience with 15 patients with cloaca! exstrophy. Patient age ranged from 2 days to 21 years,

616

PEDIATRIC UROLOGY

with an average of 9½ years. There were 9 genotypic male and 6 genotypic female patients. Six genotypic male patients were assigned a female sex of rearing. All 15 patients had an omphalocele at the time of presentation. The omphalocele was closed primarily in 13 patients, while 2 required a temporary prosthesis. Of the patients 2 had an anteriorly placed anus that required anoplasty, 2 had permanent ileostomies with resection of the colon, 2 had temporary ileostomies that subsequently were converted to colostomies and 9 underwent a colostomy at the time of closure of the bowel exstrophy. A total of 13 patients had a hemibladder on each side of the exstrophic bowel, while 2 had a single exstrophic bladder off to 1 side of the exstrophic bowel. One patient had bilateral renal agenesis, 4 had left renal agenesis, 4 had crossed-fused ectopia and 5 had megaureters. The exstrophic bladders initially were managed by separation from the bowel and reapproximation in the midline (primary closure of the bladder exstrophy was accomplished in 2 patients). Seven patients have ileal conduits and 1 has a vesicostomy. There were 4 temporary cutaneous pyelostomies and 2 cutaneous ureterostomies. Secondary bladder closures with iliac osteotomies were accomplished in 3 patients. All of the genetic male patients with this anomaly had severe anomalies of the genitalia. Of the 6 female patients 5 had a bifid uterus and 1 had a double vagina. Myelomeningocele was noted in 7 of the 15 patients, scoliosis in 6 and bilateral club feet in 4. There was 1 set of Siamese twins. One patient had left facial paralysis, 1 had a factor VIII deficiency and 1 had an atretic right upper lobe bronchus. Of the 15 patients 13 are well, 1 died of renal agenesis in the newborn period and 1 died at the age of 19 years (a probable suicide). The 2 patients with permanent ileostomies have had problems with marginal weight gain and severe diarrhea. The authors believe that the appropriate initial therapy for this anomaly is early closure of the omphalocele, closure of the vesicointestinal fissure with creation of an end colostomy at the distal end of the blind colonic pouch, reapproximation of the hemibladder and a female sex rearing. Bladder closure and procedures to produce continence should be considered later in the course of the patient. G. W. K. 1 figure, 4 tables, 13 references

Editorial comment. Cloacal exstrophy poses sometimes insurmountable problems in management, although many such children, probably the majority, now survive despite the short intestine using interval hyperalimentation. Colodny has devised a thoughtful and reasonable 4-stage approach to bladder reconstruction that hopefully will result in urinary continence. However, I believe continence will be harder to achieve in patients with cloacal exstrophy than in children with bladder exstrophy alone. In the latter case the best series (Jeffs) reports continence in barely >50 per cent of all patients. Although diversion by cutaneous ureterostomy may be feasible without stealing needed intestine this is a risky procedure in infancy because of the small caliber of the ureter. It probably is best to close the bladder, accept the incontinence and deal with it later. We have turned in the entire cloacal exstrophy (exstrophic bowel as well as bladder), believing that a large reservoir provides a better chance of eventual urinary control. We envision a later incontinence (tightening) procedure or implantation of an artificial sphincter. In either instance obstruction may result in continence when intermittent catheterization is used. L. R. K.

Surgery for Anomalies of the Urachus R. H. RICH, B. E. HARDY AND R. M. FILLER, Department of Surgery, Divisions of General Surgery and Urology, The Hospital for Sick Children, Toronto, Ontario, Canada

J. Ped. Surg., 18: 370-372 (Aug.) 1983 During a 20-year interval the authors identified 60 patients as having anomalies of the urachus, including 35 who form the basis of this report. Of the 35 patients 19 had a patent urachus, 12 had a urachal cyst and 4 had a urachal sinus. The male-to-female ratio was approximately equal. All but 1 of the patients with a patent urachus were <9 months old at presentation. Eleven patients presented with a history of passing urine from the umbilicus and 5 others had umbilical drainage. A patent urachus was found at the time of omphalocele repair in 3 patients. Treatment consisted of complete excision of the urachus in 18 patients and ligation in 1. Both procedures proved curative. Of the 19 patients 10 had other anomalies and 9 major genitourinary anomalies were identified, including vesicoureteral reflux, solitary kidney, ureteropelvic junction obstruction and hydronephrosis. Of the 12 patients with a urachal cyst only 5 were <1 year old at presentation. Sjx patients presented with an anterior abdominal wall abscess and 3 presented with a noninfected abdominal mass. The urachal cyst was found incidentally at laparotomy for other reasons in 3 patients. Of the patients 10 were treated by complete excision and 2 by preliminary incision and drainage (1 presented with an infected cyst and died of overwhelming sepsis). Six patients had other anomalies and there were 5 significant genitourinary anomalies. A urachal sinus was noted in 4 patients who presented at a mean age of 6½ years. All patients presented with umbilical drainage. Excision was curative and no associated anomalies were identified. The authors believe that associated genitourinary anomalies must be considered in patients with umbilical abnormalities and that a screening excretory urogram (IVP) will identify such problems in those patients. Although vesicoureteral reflux was found in 5 of 20 patients in whom cystography was performed, the presence of reflux could have been suspected from the presence of urinary infections or from an abnormal IVP. For this reason the authors do not believe routine cystography is necessary in patients with urachal anomalies. G. W. K. 1 figure, 2 tables, 16 references

Editorial comment. Since reflux was the most common second anomaly in these children it seems best to do a cystogram as well as an IVP. In fact, a cystogram probably helps more than an IVP to delineate the type of urachal abnormality. Perhaps ultrasound of the kidneys is adequate to screen the upper tracts in most situations. L. R. K. Renal Tubular Acidosis in a Patient With Recurrent Metabolic Alkalosis

L. C. HYMES AND B. L. WARSHAW, Department of Pediatrics, Division of Nephrology, Emory University School of Medicine, Atlanta, Georgia Pediatrics, 72: 207-210 (Aug.) 1983 Renal tubular acidosis in childhood is characterized by impaired urinary acidification, hyperchloremic acidosis and failure to thrive. Additionally, other metabolic disturbances and their sequelae may be associated with renal tubular acidosis, including Fanconi's syndrome, osteomalacia, nephrocalcinosis,