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Unpredictability of Capsulotomy in Testicular Torsion
1384
PEDIATRIC UROLOGY
The Operative Management of Posterior Urethral Valves J. BRUCE, V. STANNARD, P. G. SMALL, M. J. MAYELL AND L. KAPILA, Departments of Pediatric Surgery and Radiology, University Hospital Nottingham and Nottingham City Hospital, Nottingham, United Kingdom and University of Buffalo, State University of New York, Buffalo, New York
J. Ped. Surg., 22: 1081-1086 (Dec.) 1987 The authors treated 33 boys with posterior urethral valves between 1974 and 1986. A total of 30 patients survived to provide followup information. Ten patients presented within 24 hours of life, including 1 whose condition was suspected antenatally. Six more patients presented within 1 month of life, 9 were diagnosed before they were 2 years old and 5 were not seen until they were older than 2 years. Nine patients presented with an abdominal mass while 9 presented with recurrent urinary infections. Eight patients had a poor stream. In patients younger than 3 months the most common presenting symptoms were an abdominal mass and poor stream. All patients had a Young type I lesion except for 1 who had a type III valve. Twelve patients were treated with transurethral fulguration through a 10 or 12F cystoscope, 14 underwent fulguration with an Innes-Williams hook and 4 underwent fulguration through an 8F cystoscope using a stylet as an electrode. The initial postoperative result was excellent in the 30 surviving patients. However, 4 of the 12 patients in whom a 10 or 12F instrument was used suffered symptomatic urethral strictures within 18 months. In 3 of these 4 patients the stricture was at the membranous urethra while in 1 the problem was meatal stenosis. No strictures developed in patients treated with the Innes-Williams hook or in those treated with an 8F instrument. 3 figures, 26 references George W. Kaplan, M.D. San Diego, California
Editorial comment. There seems to be no question that the electrified diathermy hook can be used to engage and disrupt valves successfully with tactile sensation to recognize engagement of the valve in combination with fluoroscopy. However, most of us who have grown up using a cystoscope for transurethral procedures continue to feel more secure with a loop or hook electrode. I believe transurethral resection of valves has become safe and strictures are almost entirely avoided so long as the small instrument that is used fits comfortably in the urethra without snugness and the leaflet of the valve is elevated away from the wall of the urethra before the cautery is activated. Lowell R. King, M.D. Durham, North Carolina
Reconstruction of Penile Agenesis by a Posterior Sagittal Approach
C. J.
H. STOLAR,
E.
s. WIENER, T. w. HENSLE, M. L. SILEN,
K. SUKAROCHANA, W. K. SIEBER, H. R. GOLDSTEIN AND J.
Division of Pediatric Surgery, Babies Hospital, New York, New York and Department of Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania PETTIT,
J. Ped. Surg., 22: 1076-1080 (Dec.) 1987
The authors present 2 patients in whom the Pena-de Vries approach was used to reconstruct penile agenesis. They believe that a staged approach is needed in these infants. Gonadectomy should be performed before the patient is 3 months old and a diverting colostomy should be created at the same time. Posterior sagittal anoplasty is performed when the patient is 1 year old. A plastic reconstruction of the perineum can be done simultaneously or subsequently, following which the colostomy is closed. 9 figures, 6 references George W Kaplan, M.D. San Diego, California
Editorial comment. This is a rational approach to the reconstruction needed in patients with penile agenesis and it seems that good functional and cosmetic results were achieved in each instance. I asked Doctor Pena about the possibility of using the posterior sagittal approach for the correction of hydrocolpos with or without an imperforate anus. He was less than enthusiastic about the idea because he believed that the anal sphincter mechanism might be injured because the rectum would need to be mobilized extensively to visualize the bladder base, vaginal base and perineum. However, it seems that these fears are groundless. Lowell R. King, M.D. Durham, North Carolina
Unpredictability of Capsulotomy in Testicular Torsion
A. KOLBE, C.-C. J. SUN AND J. L. HILL, Department of Surgery, Section of Pediatric Surgery and Department of Pathology, University of Maryland Hospital, Baltimore, Maryland J. Ped. Surg., 22: 1105-1109 (Dec.) 1987 The authors attempted to determine if testicular capsulotomy would influence the histological changes produced in the testis by spermatic cord torsion. To do so 40 prepubertal male Sprague-Dawley rats were assigned to 1 of 4 experimental groups. Unilateral spermatic cord torsion of 720 degrees was produced for 0, 4, 8 or 12 hours. At the end of this period half of the animals in each group underwent detorsion and capsulotomy, while the other half underwent detorsion alone. The animals were sacrificed 35 days later. Torsion resulted in ipsilateral testicular damage when compared to controls. Damage consisted of degeneration, and loss of germ and Sertoli cells with obliteration of tubular architecture. However, the duration of torsion did not correlate with the amount of damage produced. Capsulotomy did not affect the testicular damage favorably or unfavorably. 4 figures, 2 tables, 16 references George W. Kaplan, M.D. San Diego, California
Editorial comment. Even though the results of this experiment are negative it was a worthwhile study. Some of the effect of torsion might well be related to increased pressure within the testis as edema occurs. It is too bad that capsulotomy at the time of intervention does not protect the testis but it still might improve the salvage rate in some borderline circumstances. Lowell R. King, M.D. Durham, North Carolina
PEDIATRIC UROLOGY
The Operative Management of Posterior Urethral Valves J. BRUCE, V. STANNARD, P. G. SMALL, M. J. MAYELL AND L. KAPILA, Departments of Pediatric Surgery and Radiology, University Hospital Nottingham and Nottingham City Hospital, Nottingham, United Kingdom and University of Buffalo, State University of New York, Buffalo, New York
J. Ped. Surg., 22: 1081-1086 (Dec.) 1987 The authors treated 33 boys with posterior urethral valves between 1974 and 1986. A total of 30 patients survived to provide followup information. Ten patients presented within 24 hours of life, including 1 whose condition was suspected antenatally. Six more patients presented within 1 month of life, 9 were diagnosed before they were 2 years old and 5 were not seen until they were older than 2 years. Nine patients presented with an abdominal mass while 9 presented with recurrent urinary infections. Eight patients had a poor stream. In patients younger than 3 months the most common presenting symptoms were an abdominal mass and poor stream. All patients had a Young type I lesion except for 1 who had a type III valve. Twelve patients were treated with transurethral fulguration through a 10 or 12F cystoscope, 14 underwent fulguration with an Innes-Williams hook and 4 underwent fulguration through an 8F cystoscope using a stylet as an electrode. The initial postoperative result was excellent in the 30 surviving patients. However, 4 of the 12 patients in whom a 10 or 12F instrument was used suffered symptomatic urethral strictures within 18 months. In 3 of these 4 patients the stricture was at the membranous urethra while in 1 the problem was meatal stenosis. No strictures developed in patients treated with the Innes-Williams hook or in those treated with an 8F instrument. 3 figures, 26 references George W. Kaplan, M.D. San Diego, California
Editorial comment. There seems to be no question that the electrified diathermy hook can be used to engage and disrupt valves successfully with tactile sensation to recognize engagement of the valve in combination with fluoroscopy. However, most of us who have grown up using a cystoscope for transurethral procedures continue to feel more secure with a loop or hook electrode. I believe transurethral resection of valves has become safe and strictures are almost entirely avoided so long as the small instrument that is used fits comfortably in the urethra without snugness and the leaflet of the valve is elevated away from the wall of the urethra before the cautery is activated. Lowell R. King, M.D. Durham, North Carolina
Reconstruction of Penile Agenesis by a Posterior Sagittal Approach
C. J.
H. STOLAR,
E.
s. WIENER, T. w. HENSLE, M. L. SILEN,
K. SUKAROCHANA, W. K. SIEBER, H. R. GOLDSTEIN AND J.
Division of Pediatric Surgery, Babies Hospital, New York, New York and Department of Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania PETTIT,
J. Ped. Surg., 22: 1076-1080 (Dec.) 1987
The authors present 2 patients in whom the Pena-de Vries approach was used to reconstruct penile agenesis. They believe that a staged approach is needed in these infants. Gonadectomy should be performed before the patient is 3 months old and a diverting colostomy should be created at the same time. Posterior sagittal anoplasty is performed when the patient is 1 year old. A plastic reconstruction of the perineum can be done simultaneously or subsequently, following which the colostomy is closed. 9 figures, 6 references George W Kaplan, M.D. San Diego, California
Editorial comment. This is a rational approach to the reconstruction needed in patients with penile agenesis and it seems that good functional and cosmetic results were achieved in each instance. I asked Doctor Pena about the possibility of using the posterior sagittal approach for the correction of hydrocolpos with or without an imperforate anus. He was less than enthusiastic about the idea because he believed that the anal sphincter mechanism might be injured because the rectum would need to be mobilized extensively to visualize the bladder base, vaginal base and perineum. However, it seems that these fears are groundless. Lowell R. King, M.D. Durham, North Carolina
Unpredictability of Capsulotomy in Testicular Torsion
A. KOLBE, C.-C. J. SUN AND J. L. HILL, Department of Surgery, Section of Pediatric Surgery and Department of Pathology, University of Maryland Hospital, Baltimore, Maryland J. Ped. Surg., 22: 1105-1109 (Dec.) 1987 The authors attempted to determine if testicular capsulotomy would influence the histological changes produced in the testis by spermatic cord torsion. To do so 40 prepubertal male Sprague-Dawley rats were assigned to 1 of 4 experimental groups. Unilateral spermatic cord torsion of 720 degrees was produced for 0, 4, 8 or 12 hours. At the end of this period half of the animals in each group underwent detorsion and capsulotomy, while the other half underwent detorsion alone. The animals were sacrificed 35 days later. Torsion resulted in ipsilateral testicular damage when compared to controls. Damage consisted of degeneration, and loss of germ and Sertoli cells with obliteration of tubular architecture. However, the duration of torsion did not correlate with the amount of damage produced. Capsulotomy did not affect the testicular damage favorably or unfavorably. 4 figures, 2 tables, 16 references George W. Kaplan, M.D. San Diego, California
Editorial comment. Even though the results of this experiment are negative it was a worthwhile study. Some of the effect of torsion might well be related to increased pressure within the testis as edema occurs. It is too bad that capsulotomy at the time of intervention does not protect the testis but it still might improve the salvage rate in some borderline circumstances. Lowell R. King, M.D. Durham, North Carolina