Nocturnal enuresis.
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Acupuncture Therapy↗
Biomedical subjects
H Gil Rushton
Publications and source records attributed to H Gil Rushton.
Enucleation for prepubertal leydig cell tumor.
PURPOSE: Leydig cell tumors in children are rare, comprising only 4% to 9% of all primary testis tumors in prepubertal males. Almost all of these boys present with isosexual precocious pseudopuberty associated with increased testosterone, low gonadotropin levels and a testis mass. We present our experience with testis sparing enucleation of Leydig cell tumor in prepubertal boys. MATERIALS AND METHODS: Two patients presented with isosexual precocious puberty at ages 6 and 9 years. Each patient had a well circumscribed, painless testicular mass, increased serum testosterone (101 and 444 ng/dl [normal 0 to 25]), normal gonadotropins and negative alpha-fetoprotein levels. Both patients underwent successful enucleation of the testis mass following proper testis oncological surgical principles. RESULTS: Both patients had normalization of the serum testosterone following enucleation of the Leydig cell tumor. At 9 and 44 months of followup they have maintained normal ipsilateral testicular volume compared to the contralateral gonad, and 1 patient entered puberty spontaneously at 1 year postoperatively. Neither patient suffered any morbidity, and both have presumably benefited from preservation of the involved gonad with preserved testicular volume. CONCLUSIONS: Prepubertal boys with isosexual precocious pseudopuberty, an isolated testis mass, increased testosterone and low or normal gonadotropin levels can reliably be diagnosed with Leydig cell tumors. Based on the ability to establish the diagnosis preoperatively and the universal benign behavior of unilateral, prepubertal Leydig cell tumor, we believe these patients are best treated with testis sparing enucleation of the tumor. In view of the high likelihood that this tumor in prepubertal boys is benign, a transscrotal surgical approach should be considered.
Child↗
Sonographic appearance of the epididymis in pediatric testicular torsion.
OBJECTIVE: The purpose of this study was to determine the frequency of an enlarged epididymis in pediatric patients with testicular torsion and to determine whether an altered epididymis might be a helpful ancillary sonographic sign of testicular torsion. MATERIALS AND METHODS: The sonograms of 50 pediatric patients (age range, neonate-17 years) with testicular torsion were retrospectively reviewed for the size, appearance, and blood flow of the epididymis. Medical records were reviewed for surgical and pathologic findings and to determine whether testicular salvage had been possible. RESULTS: The epididymis was enlarged (maximum dimension, 5.5 cm) in 47 of the 50 patients with acute or late phase torsion and after manual or spontaneous detorsion. The average difference in volume between the ipsilateral epididymis and the contralateral epididymis was 30 cm3, highly significant (p < 0.0001). The shape of the epididymis was altered in 92% of the cases (globular, bilobular, or multilobular). Seventy-three percent showed increased echogenicity and 27% appeared isoechoic. Of those with active torsion, 93% of the epididymides were avascular; 2%, hypovascular; and 5%, hypervascular. After detorsion, 100% of the epididymides (10/10) had blood flow. In patients with testicular loss due to infarction, pathology showed engorgement and enlargement of the epididymis with hemorrhagic infarction. In one patient with a hypervascular epididymis, surgery showed inflammation and erythema of the epididymis. Testicular loss occurred in each type of epididymal flow pattern. CONCLUSION: A markedly enlarged, echogenic, and avascular or hypovascular epididymis is an ancillary sonographic sign in pediatric patients with testicular torsion. A hypervascular enlarged epididymis infrequently occurs (5% of cases) and should not be mistaken for epididymitis. In addition, the return of epididymal blood flow is an ancillary sign of successful testicular detorsion.
Adolescent↗
Nocturnal enuresis in children.
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Adolescent↗
The danger of intraoperative antegrade cannulation of the ureter in infancy and early childhood.
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Age Factors↗
Subspecialty certification in pediatric urology.
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Child↗
Indications for nonoperative management of ureteroceles.
PURPOSE: Ureteroceles have traditionally been managed surgically. We report our indications and outcomes of nonoperative management of ureteroceles in a select cohort. MATERIALS AND METHODS: We identified prospectively for nonoperative management 11 females and 2 males with ureteroceles associated with hydronephrosis or multicystic dysplasia (MCD). Patients presented with either a febrile urinary tract infection (3) or prenatal hydronephrosis (10). All patients were evaluated with renal and bladder ultrasound, voiding cystourethrography and mercaptoacetyltriglycine-3 furosemide renography. Two subgroups were identified, consisting of 10 duplex system upper pole ureteroceles associated with nonobstructed functional systems and 3 ureteroceles associated with a completely nonfunctional single system (2) or duplex (1) kidneys with or without MCD. Median followup was 41 months (range 13 months to 8 years). RESULTS: Of the 13 patients 9 required no surgical intervention. Of these 9 patients 3 had either a nonfunctional upper pole moiety (1) or MCD (2) that involuted, and 6 had good function of the upper pole segments relative to the lower pole without high grade obstruction on furosemide renography. Mean upper pole relative to lower pole differential function as determined by isotope renogram in these 6 patients was 40.8% (range 28% to 65%) and median drainage half-time was 5.3 minutes (4.5 to 19.3). On sonography, hydronephrosis improved in all 6 cases, with 5 (83%) decreasing to grade 0 (3) or I (2). Of these 6 cases of duplex system ureteroceles 5 had associated ipsilateral lower pole reflux of grade III (2) or IV (3). Reflux resolved in all cases. Surgery was necessary for progressive obstruction 1 patient and for breakthrough urinary tract infection in 3. The mean upper pole differential function in the operative group of 24.3% was lower than that of the nonoperative group. The initial median drainage half-time was 12.5 minutes (range 6.9 to 20). There was no significant difference between the nonoperative and operative groups in regard to hydronephrosis grade, reflux grade or ureterocele size. CONCLUSIONS: Furosemide renography can identify a select subgroup of patients with ureteroceles who are candidates for nonoperative management. Ureteroceles with nonobstructed duplex systems have better preservation of renal function and a high rate of natural resolution of hydronephrosis and reflux. Ureteroceles associated with MCD or completely nonfunctioning upper pole moieties may never require surgical management.
Female↗
Stuttering priapism associated with withdrawal from sustained-release methylphenidate.
Stuttering priapism is intermittent, prolonged, painful, pathologic erections with intervening periods of detumescence. An adolescent had stuttering priapism associated with withdrawal from sustained-release methylphenidate. To our knowledge, this is the first such report of stuttering priapism associated with stimulant drugs for treatment of attention deficit hyperactivity disorder.
Adolescent↗
Prepubertal testis tumors: actual prevalence rate of histological types.
PURPOSE: Tumor registries, urological textbooks and literature surveys all assert that yolk sac tumors are the most common primary testicular tumors in boys 12 years and younger. In contrast, several individual institutions have reported that benign tumors are more common than malignant tumors. To clarify these discordant findings, we surveyed the primary pathology records from 4 major pediatric centers. MATERIALS AND METHODS: The pathology records of the contributing centers were culled for primary testicular masses in boys 12 years and younger. Older boys and those with either paratesticular tumors or leukemia were excluded. The prevalence of each histological subtype was calculated from the pooled cases. RESULTS: A total of 98 patients met our criteria. Only 15% had yolk sac tumors. Teratomas comprised 48% of the tumors (mature 44%, immature 4%). Epidermoid cysts were found in another 14% of patients. Gonadal stromal cell tumors represented 13% of the total, divided among granulosa cell (5%), Leydig cell (4%), Sertoli cell (3%) and mixed gonadal stromal cell (1%). Other pathology, including cystic dysplasia (2), lymphoma (4), inflammatory pseudotumor (1) and gonadoblastoma (2), made up 9% of the total number of cases. CONCLUSIONS: We found that benign lesions represent the majority of primary testis tumors (74%), with the most common histological type being teratoma (48%). The reported high prevalence rates of prepubertal yolk sac tumors probably results from a reporting bias, since benign tumors are less likely to be submitted to tumor registries. Therefore, the primary operative approach to the majority of testis tumors in boys 12 years and younger should entail testis sparing surgery. Orchiectomy should be reserved for histologically confirmed malignancy based on increased preoperative alpha-fetoprotein and/or frozen section analysis of the tumor.
Age Factors↗
Is an empty left hemiscrotum and hypertrophied right descended testis predictive of perinatal torsion?
PURPOSE: We determine whether the finding of a nonpalpable left testis and hypertrophied(2 cc or greater) right testis is predictive of an atrophic (perinatal torsion) left testis. MATERIALS AND METHODS: Prospectively, all boys with a nonpalpable left testis and hypertrophied right testis seen between May 2000 and May 2002 were included in the study. Testicular measurement was performed preoperatively with an orchidometer. In 19 of 22 boys size was also confirmed intraoperatively. Surgical exploration was done initially through a scrotal incision. Diagnostic laparoscopy was performed in boys in whom intrascrotal tissue that was consistent with a "nubbin" was not found. All tissue removed was submitted for histological evaluation. RESULTS: In 19 of 22 boys tissue was found in the left hemiscrotum that was clinically consistent with a scrotal nubbin, and histological confirmation was absolute in 18. In 1 patient a hollow oval mass attached to a cord extending to the external inguinal ring was found without the other classic histological features of torsion. In 3 cases scrotal exploration was negative and diagnostic laparoscopy was performed. Of this group the pathognomonic findings of a closed internal ring with hypoplastic vas and vessels were noted in 2 cases, and normal vas and vessels were seen to exit an open internal inguinal ring in 1. Inguinal exploration demonstrated an enlarged intracanalicular testis measuring 3 cc in volume, comparable in size to the descended right testicle. CONCLUSIONS: The combination of a nonpalpable left testis and an enlarged right testis is highly predictive of perinatal testicular torsion. When both criteria were met 20 of 22 (91%) consecutive patients had histological or laparoscopically confirmed perinatal torsion and 1 had only clinical features. This finding supports the concept of scrotal exploration as the initial procedure in the child who has an empty left hemiscrotum and hypertrophied descended right testis. Laparoscopy should be reserved for boys in whom a distinct remnant is not found on scrotal exploration.
Atrophy↗
Outcome analysis of simple and complex urethrocutaneous fistula closure using a de-epithelialized or full thickness skin advancement flap for coverage.
PURPOSE: We review our experience repairing simple and complex urethrocutaneous fistulas using a de-epithelialized or full thickness skin advancement flap for 2-layer coverage over the fistula. MATERIALS AND METHODS: We reviewed the records of 1,092 hypospadias repairs performed at our institution. Urethrocutaneous fistula developed in 66 of those patients and 33 additional patients with fistula were referred from elsewhere. These 99 patients underwent a total of 94 fistula repairs. For simple repairs a de-epithelialized flap or a skin advancement flap was used. For complex repairs a variety of techniques were performed, all with a de-epithelialized skin flap for coverage. Stents were not left postoperatively in simple cases and repairs were routinely performed as outpatient procedures. RESULTS: Overall there were 6 (6.4%) failures. In 69 cases (73%) simple fistula closure was covered by a de-epithelialized flap or skin advancement flap, which failed in 3 (4.3%). Of 25 patients who required more complex repairs 18 underwent a tubularized or onlay urethroplasty incorporating the fistula, which failed in 2 (11.1%). Two patients underwent meatoplasty in conjunction with the distal fistula repair, which failed in 1. Two patients underwent urethroplasty in conjunction with separate repair of a urethrocutaneous fistula, and there were no failures. No fistula developed in 3 cases of re-do hypospadias repairs. CONCLUSIONS: Excellent results can be achieved for simple and complex urethrocutaneous fistula closure using a de-epithelialized or full thickness advancement flap. Moreover, almost all repairs can be performed in an outpatient setting. Simple closures do not require stenting postoperatively.
Adolescent↗
Incidence of new renal parenchymal inflammatory changes following breakthrough urinary tract infection in patients with vesicoureteral reflux treated with antibiotic prophylaxis: evaluation by 99MTechnetium dimercapto-succinic acid renal scan.
PURPOSE: Breakthrough urinary tract infections (UTI) are considered an indication for surgical intervention in children with vesicoureteral reflux (VUR) with the goal of preventing new or progressive renal scarring. We assessed the incidence of new renal parenchymal inflammatory changes following breakthrough UTI in patients on antibiotic prophylaxis for VUR. MATERIALS AND METHODS: We prospectively analyzed 38 patients (62 refluxing renal units) with VUR. All patients experienced a culture documented breakthrough UTI (greater than 100,000 cfu/ml) while taking antibiotic prophylaxis. Dimercapto-succinic acid (DMSA) scans were obtained 4 to 6 weeks after UTI to detect new renal inflammatory changes and all scans were reviewed by the same pediatric nuclear medicine specialist (MM). To avoid misinterpretation of preexistent renal scarring for acute inflammation, new pyelonephritis was confirmed by comparison to prior DMSA scan. RESULTS: Of 38 patients 14 (38%) had preexistent renal scarring but only 1 (7%) manifested new changes on DMSA scan. Of the remaining 24 patients with normal baseline studies 3 (12.5%) had changes after UTI. Overall, only 4 patients (10.5%) manifested new changes on DMSA scan. Three additional patients who did not have a baseline scan for comparison demonstrated unequivocal changes of acute pyelonephritis on DMSA scan, increasing the incidence to 17% (7 of 41). Of the patients 7 (17%) underwent surgical correction of reflux and 34 (83%) were maintained on antibiotic prophylaxis. CONCLUSIONS: Of patients with VUR who experienced a single breakthrough UTI while on antibiotic prophylaxis, at most only 17% had renal inflammatory changes on acute DMSA scan. Our findings endorse the usefulness of DMSA scan in tailoring management of VUR and breakthrough UTI cases, and lend support to continued nonoperative management for the majority.
Antibiotic Prophylaxis↗
Sonography for the detection and follow-up of primary nonsarcomatous bladder tumors in children.
OBJECTIVES: To report the use of a dedicated renal-bladder sonogram for the detection and follow-up of primary nonsarcomatous bladder tumors in children. METHODS: Three children (aged 6 to 12 years) recently presented with nontraumatic gross painless hematuria. All were evaluated initially with renal-bladder sonography. RESULTS: Two transitional cell papillomas and one inflammatory myofibroblastic tumor were easily detected initially by sonography in the 3 children. Two were treated with transurethral resection at the time of the confirmatory cystoscopy and one, with an endoscopically unresectable tumor, was treated with excisional biopsy. The use of sonography as the diagnostic tool obviated more invasive and expensive studies, as well as exposure to ionizing radiation. CONCLUSIONS: Renal-bladder sonography is the initial imaging modality of choice in the workup for nontraumatic gross painless hematuria in children. Not only is it an excellent screening tool for congenital malformations and renal calculi, it is also very sensitive for identifying primary bladder tumors in children.
Child↗