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Spermatic Cord Torsion: Diagnostic Limitations
1345
PEDIATRIC UROLOGY
matozoa in the cc,1c,"u"u,c, while 9 had severe or persistent oligospermia. Of the 23 azoospermic patients 12 had complete obstruction of the vasa, 4 had secondary epididymal blockage and 7 had high antisperm antibody titers (1,024 by the tray agglutination test). Ten of the 12 patients with obstruction had normal sperm counts following repeat vasovasostomy, including 8 who were followed more than 6 months and successfully impregnated their wives. Of the 4 patients with secondary epididymal blockage 3 had normal sperm counts following epididymovasostomy and 2 wives became pregnant. None of the wives of the 7 patients with high antisperm antibody titers became pregnant despite reparative surgery and steroid therapy. Of the 9 oligospermic patients 8 had unilateral obstruction. Five patients had obstruction in the vas and 2 in the epididymis. Two patients had high antisperm antibody titers. In this group 4 patients had normal sperm counts and 1 wife became pregnant after reconstruction. The authors suggest that patients with persistent azoospermia or severe oligospermia after vasectomy reversal should undergo scrotal exploration to establish the cause of the failure so that appropriate treatment may be given. F. T. A. 2 figures, 2 tables, 9 references
but we have torsion of the appendix testis and used that study more to evaluate testicular trauma when ultrasound can demonstrate the integrity of the tunica albuginea of the testis. H. McC. S. L
Editorial comment. This article correctly notes that scrotal ultrasound and testicular scans may be misleading and may be falsely normal in patients with testis torsion. The same is true of the Doppler examination, listening for the pulse in the spermatic artery. The usual problem with scans is that the reactive edema of the scrotal skin, subcutaneous tissue and dartos become so well vascularized in a patient with torsion that it prevents one from seeing the cold central defect of the avascular testis. Several cases have now been documented in which the scan was falsely negative for torsion even though relatively little scrotal edema was present. We believe that patients with this type of scrotal pathological condition are served best by an immediate operation and reserve the diagnosis of epididymitis to patients who have a urinary tract infection and/or the typical adhesion of the inflamed epididymis to the overlying skin. L. R. K.
Urinary Tract In.volveme:nt in EEC Syndrome
PEDIATRIC UROLOGY Spermatic Cord Torsion: Diagnostic Limitations M. L. STOLLER, B. A. KOGAN AND H. HRICAK, Departments of Urology, Pediatrics and Radiology, University of California School of Medicine, San Francisco, California
Pediatrics, 76: 929-933 (Dec.) 1985 The authors review 6 patients 12 to 16 years old in whom ultrasound or nuclear medicine examination was misleading in distinguishing spermatic cord torsion from other intrascrotal pathological conditions. In 2 cases there was misinterpretation of the testicular nuclear scan: torsion was missed in a patient with a large inflammatory hydrocele and epididymitis was diagnosed in a patient with intermittent torsion. Real-time ultrasound was erroneous in 4 cases: epididymitis or a torsed appendix testis was diagnosed in 2 cases of torsion of the testis, epididymitis was diagnosed when torsion of the appendix testis was proved in 1 and epididymitis was diagnosed when spontaneous detorsion was found at operation in L The authors conclude that emergency exploration is imperative if torsion is suspected. 2 figures, 1 table, 12 references Abstracter's comment. It has been our strong belief that ancillary diagnostic studies in boys with an acute scrotum are appropriately used primarily to confirm the diagnosis of a nonoperative condition. Because the nuclear testicular scan can document normal blood flow to the testis and usually can separate epididymitis from torsion of a testicular appendage, it is the usual study performed. If there is suspicion of testicular torsion manual detorsion is attempted if the process is early and there is little scrotal swelling (J. Ped. Surg., 18: 607-610, 1983). Doppler assessment of blood flow confirms successful detorsion but one must remember that if there is a significant inflammatory reaction in the wall of the scrotum then blood flow to this inflamed tissue may give the false impression of blood flow to the testicle. If detorsion is impossible or the diagnosis is uncertain an operation is performed immediately. We have not relied on ultrasound to help sort out testis torsion,
R. LONDON, R. M. HEREDIA AND J. ISRAEL, Departments of Pediatrics and Pathology, Mount Sinai Hospital Medical Center, Chicago, Illinois
Amer. J. Dis. Child., 139: 1191-1193 (Dec.) 1985 Little is known about the genetics of the rare syndrome of ectrodactyly (lobster claw deformity), ectodermal dysplasia, and cleft lip and/or palate (EEC syndrome), which was described first in 1970. The authors describe case 4 involving associated urological abnormalities. A 2,570 gm. male neonate was born to a 15-year-old primigravida girl who smoked in the first trimester. The child had slight glandular hypospadias and a cystic abdominal mass with a nonfunctioning left kidney. Diagnostic studies revealed an obstructing left ureterocele that necessitated left nephroureterectomy and excision of the ureterocele when he was 4 months old. Additionally, the kidney showed dysplastic changes and 2 large upper pole cysts. Mild hydronephrotic changes were seen in the contralateral kidney. The authors state the case for urological evaluation of all patients with the EEC syndrome. J. H. N. 4 figures, 1 table, 14 references
Von Hippel-Lin.dau Disease iIDJ. a Newfmu:1.dland Kind:red J.
s. GREEN, M. I. BOWMER AND G. J. JOHNSON, Departments of Community Medicine, Internal Medicine and Surgery, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
Canad. Med. Ass. J., 134: 133-138 (Jan. 15) 1986 Because the von Hippel-Lindau syndrome has been recognized in a large Newfoundland family, a collaborative investigation was begun in 1982 to document the number of affected members and the extent of the disease, and to improve management of the disease. A total of 38 members of the family had the disease. The most common manifestations in order of frequency are retinal angioma, pheochromocytoma, cerebellar hemangioblastoma and hypernephroma. Over-all, the average patient age at the time of onset was 23 years. The authors suggest a screening program that includes annual ophthalmo-
PEDIATRIC UROLOGY
matozoa in the cc,1c,"u"u,c, while 9 had severe or persistent oligospermia. Of the 23 azoospermic patients 12 had complete obstruction of the vasa, 4 had secondary epididymal blockage and 7 had high antisperm antibody titers (1,024 by the tray agglutination test). Ten of the 12 patients with obstruction had normal sperm counts following repeat vasovasostomy, including 8 who were followed more than 6 months and successfully impregnated their wives. Of the 4 patients with secondary epididymal blockage 3 had normal sperm counts following epididymovasostomy and 2 wives became pregnant. None of the wives of the 7 patients with high antisperm antibody titers became pregnant despite reparative surgery and steroid therapy. Of the 9 oligospermic patients 8 had unilateral obstruction. Five patients had obstruction in the vas and 2 in the epididymis. Two patients had high antisperm antibody titers. In this group 4 patients had normal sperm counts and 1 wife became pregnant after reconstruction. The authors suggest that patients with persistent azoospermia or severe oligospermia after vasectomy reversal should undergo scrotal exploration to establish the cause of the failure so that appropriate treatment may be given. F. T. A. 2 figures, 2 tables, 9 references
but we have torsion of the appendix testis and used that study more to evaluate testicular trauma when ultrasound can demonstrate the integrity of the tunica albuginea of the testis. H. McC. S. L
Editorial comment. This article correctly notes that scrotal ultrasound and testicular scans may be misleading and may be falsely normal in patients with testis torsion. The same is true of the Doppler examination, listening for the pulse in the spermatic artery. The usual problem with scans is that the reactive edema of the scrotal skin, subcutaneous tissue and dartos become so well vascularized in a patient with torsion that it prevents one from seeing the cold central defect of the avascular testis. Several cases have now been documented in which the scan was falsely negative for torsion even though relatively little scrotal edema was present. We believe that patients with this type of scrotal pathological condition are served best by an immediate operation and reserve the diagnosis of epididymitis to patients who have a urinary tract infection and/or the typical adhesion of the inflamed epididymis to the overlying skin. L. R. K.
Urinary Tract In.volveme:nt in EEC Syndrome
PEDIATRIC UROLOGY Spermatic Cord Torsion: Diagnostic Limitations M. L. STOLLER, B. A. KOGAN AND H. HRICAK, Departments of Urology, Pediatrics and Radiology, University of California School of Medicine, San Francisco, California
Pediatrics, 76: 929-933 (Dec.) 1985 The authors review 6 patients 12 to 16 years old in whom ultrasound or nuclear medicine examination was misleading in distinguishing spermatic cord torsion from other intrascrotal pathological conditions. In 2 cases there was misinterpretation of the testicular nuclear scan: torsion was missed in a patient with a large inflammatory hydrocele and epididymitis was diagnosed in a patient with intermittent torsion. Real-time ultrasound was erroneous in 4 cases: epididymitis or a torsed appendix testis was diagnosed in 2 cases of torsion of the testis, epididymitis was diagnosed when torsion of the appendix testis was proved in 1 and epididymitis was diagnosed when spontaneous detorsion was found at operation in L The authors conclude that emergency exploration is imperative if torsion is suspected. 2 figures, 1 table, 12 references Abstracter's comment. It has been our strong belief that ancillary diagnostic studies in boys with an acute scrotum are appropriately used primarily to confirm the diagnosis of a nonoperative condition. Because the nuclear testicular scan can document normal blood flow to the testis and usually can separate epididymitis from torsion of a testicular appendage, it is the usual study performed. If there is suspicion of testicular torsion manual detorsion is attempted if the process is early and there is little scrotal swelling (J. Ped. Surg., 18: 607-610, 1983). Doppler assessment of blood flow confirms successful detorsion but one must remember that if there is a significant inflammatory reaction in the wall of the scrotum then blood flow to this inflamed tissue may give the false impression of blood flow to the testicle. If detorsion is impossible or the diagnosis is uncertain an operation is performed immediately. We have not relied on ultrasound to help sort out testis torsion,
R. LONDON, R. M. HEREDIA AND J. ISRAEL, Departments of Pediatrics and Pathology, Mount Sinai Hospital Medical Center, Chicago, Illinois
Amer. J. Dis. Child., 139: 1191-1193 (Dec.) 1985 Little is known about the genetics of the rare syndrome of ectrodactyly (lobster claw deformity), ectodermal dysplasia, and cleft lip and/or palate (EEC syndrome), which was described first in 1970. The authors describe case 4 involving associated urological abnormalities. A 2,570 gm. male neonate was born to a 15-year-old primigravida girl who smoked in the first trimester. The child had slight glandular hypospadias and a cystic abdominal mass with a nonfunctioning left kidney. Diagnostic studies revealed an obstructing left ureterocele that necessitated left nephroureterectomy and excision of the ureterocele when he was 4 months old. Additionally, the kidney showed dysplastic changes and 2 large upper pole cysts. Mild hydronephrotic changes were seen in the contralateral kidney. The authors state the case for urological evaluation of all patients with the EEC syndrome. J. H. N. 4 figures, 1 table, 14 references
Von Hippel-Lin.dau Disease iIDJ. a Newfmu:1.dland Kind:red J.
s. GREEN, M. I. BOWMER AND G. J. JOHNSON, Departments of Community Medicine, Internal Medicine and Surgery, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
Canad. Med. Ass. J., 134: 133-138 (Jan. 15) 1986 Because the von Hippel-Lindau syndrome has been recognized in a large Newfoundland family, a collaborative investigation was begun in 1982 to document the number of affected members and the extent of the disease, and to improve management of the disease. A total of 38 members of the family had the disease. The most common manifestations in order of frequency are retinal angioma, pheochromocytoma, cerebellar hemangioblastoma and hypernephroma. Over-all, the average patient age at the time of onset was 23 years. The authors suggest a screening program that includes annual ophthalmo-