Biomedical subjects
Publications and source records attributed to S B Levitt.
Scrotal ectopia or accessory scrotum are both rare conditions. This report describes a neonate with both abnormalities, who also has elements of the VATER association. This constellation of anomalies has not been previously described.
The finding of ductal structures resembling a vas deferens during pathological examination of a hernia sac specimen has significant medical and legal implications. A method of distinguishing these accessory structures from an inadvertently transected vas has been lacking and is needed. Between July 1989 and January 1990 we examined 147 hernia sacs from 105 consecutive prepubertal and adolescent boys to determine the incidence and salient histological features distinguishing these ductal structures from a true vas deferens. Luminal diameters of the ductal structures were compared with published normal age-related established vas deferens diameters and with those measured during hernia repair in 10 of our youngest patients. Among the 147 specimens 6 hernia sacs (4.1%) contained ductal structures. We found that the mean ductal diameter (0.263 mm.) was significantly smaller than that of a normal vas deferens (0.69 to 1.5 mm.). Furthermore, the surrounding mantle of tissue of these ductal structures lacked muscle tissue when studied with Masson trichrome stain. We conclude that duct diameter and trichrome staining are simple ways of differentiating these structures from a true vas deferens.
Intraoperative post-ligation spermatic venography has proved to be a reliable adjunct in pediatric varicocele surgery. In a previous study we described the technique and initial results. In this series of 60 consecutive patients with pediatric varicoceles having intraoperative venography, we specifically studied the collateral venous circulation and crossover veins to characterize the venographic patterns associated with varicocelectomy failure. The relationship of incision site and number of venograms necessary to ensure complete interruption of the internal spermatic system was evaluated to determine if an optimum incision placement exists, minimizing the number of venograms necessary. Our data indicate that the most common etiology of recurrent varicocele in children seems to be residual proximal (central) collateral veins, pelvic collateral veins (that is cremasteric, deferential and crossover veins) rarely seem to contribute to varicocelectomy failure and there is an inherent but low risk of varicocelectomy failure despite radiological evidence of complete internal spermatic vein interruption.
We evaluated 77 male patients with true cryptorchidism ranging from 2 to 46 months old to determine whether orchiopexy could be performed safely and efficiently, and whether treatment was helpful in patients less than 1 year old. Our results indicate that orchiopexy in patients younger than 1 year is safe, effective and beneficial, and optimizes treatment of this condition.
Clinicopathologic characteristics were evaluated in 20 cases of cystosarcoma phyllodes in relation to clinical outcome. Flow cytometric DNA studies were carried out in 15 of these 20 cases. Stromal overgrowth and an infiltrating tumor border emerged as prominent histopathologic features that were associated with an unfavorable clinical outcome. Flow cytometric S fractions greater than 0.05 were associated with poor clinical outcome. There was no correlation between tumor ploidy and clinical outcome. There were no direct correlations between clinicopathologic features and flow cytometric measurements. Our data suggest that flow cytometric S fractions may be a useful predictor of clinical outcome in cystosarcoma phyllodes that can complement the traditional histologic analysis of these rare breast tumors.
A bladder mucosal graft for urethral reconstruction was performed on 79 patients who had complicated conditions in which local penile or preputial skin was not available. The major and minor complication rates for this procedure were 15.2 and 43 per cent, respectively, the latter representing mucosal glanular protrusion obviated by a technical alteration. Given the difficulty of these cases these complication rates are deemed acceptable in such patients.
The technique used to perform 38 orchiopexies of high undescended testes by spermatic vessel transection in 26 patients is reviewed. Careful attention to detail and selection using the Fowler-Stephens test allowed for an 89 per cent success rate, confirming the efficacy of this procedure in cases selected in this manner.
Only 15 cases of fibroepithelial polyp in children have been reported in the world medical literature. Clinical differentiation between this tumor and a malignant ureteral tumor is difficult and often results in unnecessary nephrectomy. We report the sixteenth case of a child with fibroepithelial polyp of the ureter. The lesion was resected, and the kidney was preserved. Optimum treatment of this lesion mandates renal preservation in children. The rationale for this recommendation is explored.
Three cases of reascent of a previously unequivocally documented descended testis have been encountered. Chorionic gonadotropin treatment was initially attempted in each child and was successful in causing descent of the involved testis in one. The testes of the other two boys were successfully brought down surgically. Possible causes for testicular reascent are presented and the pertinent literature is reviewed. These cases illustrate the need for continued diligence and interval examination of the pediatric scrotum throughout childhood.
A fifteen-year-old male presented with delayed puberty and cryptorchidism. Previous exploratory surgery for bilateral cryptorchidism resulted in left orchiectomy. The right testis was very high and intimately adherent to the mesentery of the appendix, and was left in situ. Subsequently progressive testicular failure was demonstrated by falling plasma testosterone and rising plasma gonadotropin levels. On elective surgical exploration, an atrophic testis with an independent blood supply was found adherent to the mesentery of the appendix. No spermatic duct was present, and orchiectomy was performed. The reasons for orchiectomy and the role of serial hormonal evaluations in the management of this unusual mesoappendicular testis case are reviewed.
Intravascular nephroblastoma involving the renal veins or inferior vena cava, occurring in 6 to 10 per cent of the cases, dramatically complicates the treatment course for those individuals. Heroic surgical procedures, including sternal splitting and cardiopulmonary bypass, have been used to treat these tumors, often with an added morbidity and increased mortality. We have detailed the dramatic responses to preoperative chemotherapy in 3 patients with intravascular nephroblastoma, which resulted in either complete eradication or marked shrinkage of the intravascular tumor, greatly simplifying the ensuing surgical procedure. These observations strongly indicate that preoperative chemotherapy should be used as the primary treatment in patients with this condition.
Recurrent pyelonephritic episodes in children with normal contrast cystograms pose a difficult management problem, since the lack of demonstrable reflux adversely affects the treatment. A total of 10 children with clinical symptoms of pyelonephritis in whom normal contrast cystograms had been performed properly subsequently had significant degrees of reflux detected by isotope cystography. These findings indicate that isotope cystography should be included in the evaluation of patients with pyelonephritis in whom reflux is not confirmed by conventional contrast medium techniques.
Nonintrusive measurement of the hydrodynamic properties of the urinary stream (uroflowmetry) has been included in many adult urological evaluations as an objective diagnostic tool. Measurement and behavioral problems interfere with practical applications in children. We describe a standard procedure for obtaining "impromptu" micturitional flow parameters in clinical pediatric practice. Statistical correlations of these flow parameters in an unselected group of 142 normal boys between 2 and 12 years old are presented. Useful linear regression equations were derived from the sample to assist the clinician in predicting deviations from normal values. Limitations of the methodology are noted.
Successful renal transplantation was accomplished in a patient with spina bifida and a neurogenic bladder, who previously had been continent after bladder neck reconstruction and institution of chronic intermittent bladder catheterization. Satisfactory bladder emptying and renal functional preservation have been maintained during a 4-year followup.
We reviewed the medical records of 65 boys with surgically and pathologically proved monorchism. A striking laterality to the left side was identified. In 83 per cent of the patients wolffian structures were present and in 20 per cent microscopic evidence of a terminal nubbin of hyalinized, calcified or hemosiderin-containing tissue was noted. These findings strongly suggest that in most instances of monorchism a testis had been present and had undergone subsequent in utero degeneration. Characterization of the hormonal changes associated with unilateral absent testes was done by determining fasting morning levels of luteinizing hormone and follicle-stimulating hormone. In a subgroup of monorchid boys and age-matched prepubertal unilateral cryptorchid boys luteinizing hormone release factor stimulation also was performed to determine if endocrine analysis could predict the absence of 1 testis.
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Severe degrees of primary chordee and persistent or recurrent chordee following previous surgical attempts at correction present a challenging problem. Inadequate resection of involved tissues, which may involve all layers of the penile investiture, or recurrent scarring of the ventral skin, Buck's fascia and tunica albuginea is usually the cause. Reoperation to achieve penile straightening often is unsuccessful unless all chordee-bearing tissue is resected extensively. Excision of large segments of tunica albuginea or wide separation of the margins creates a defect that tends to heal by dense scarring unless the defect is bridged by a graft. Various autogenous materials have been used, including blood vessel, fascia, free fat graft, dermis and tunica albuginea, as well as prosthestic materials, such as polytetrafluoroethylene, with varying results. A series of patients with extensive chordee is presented in whom tunical resection was necessary to achieve penile straightening. The results of free dermal graft replacement of the tunica are reported.