Ureteropelvic junction obstruction repair: when, how, what?

PURPOSE OF REVIEW: To review factors that affect the success of ureteropelvic junction obstruction repair and recent developments in minimally invasive procedures for the repair of ureteropelvic junction obstruction. RECENT FINDINGS: Recent reports and studies further confirm earlier findings that the success rate of endopyelotomy is decreased when a crossing vessel is the primary cause of ureteropelvic junction obstruction, poor renal function and significant hydronephrosis. Various minimally invasive procedures have emerged recently for the treatment of ureteropelvic junction obstruction. These include laparoscopic pyeloplasty, robotically assisted laparoscopic procedures, and percutaneous endopyeloplasty. These procedures offer potential advantages over conventional endopyelotomy, including better success rates in the presence of crossing vessels, wider caliber reconstruction of the ureteropelvic junction, and full-thickness healing with primary intent. SUMMARY: With such a large variety of minimally invasive procedures for the treatment of ureteropelvic junction obstruction available, the treatment choice for ureteropelvic junction obstruction must be based on several factors, including the success and morbidity of the procedures, the surgeon's experience, the cost of the procedure, and the patient's choice.     

Upper urinary tract: when is obstruction obstruction?

PURPOSE OF REVIEW: Obstruction can either be defined as a condition that hampers optimal renal development, or, more conservatively, as a restriction to urinary outflow that, when left untreated, will cause progressive renal deterioration. Currently, management is mostly based on the latter definition, but still remains controversial. Relevant work published before 2002 is considered because of a lack of recent literature. RECENT FINDINGS: Almost all reports comparing the primary conservative treatment of suspected obstruction versus early surgical intervention show comparable results, but there are different interpretations. The approach of 'watch and wait' for a unilateral hydronephrotic kidney with normal function is usually quite safe, with a very low risk of the permanent loss of renal function when accompanied by close monitoring, but it is certainly not without risk. At this time, the main underlying problems are that all currently applied diagnostic methods only detect effects secondary to obstruction, and the currently used definition of obstruction is based on a longitudinal observation period. The most relevant publication in the observation period was an in-depth report on a workshop in which the need for valid prospective markers for renal maldevelopment and 'significant' obstruction was expressed. SUMMARY: The optimal management of infants with congenital hydronephrosis and suspected obstruction will remain controversial until new diagnostic methods are able to discriminate between 'harmful' and 'harmless' obstruction. Most experts currently advocate primary conservative management, with close follow-up and surgical intervention only if there are signs of reduced function of the obstructed kidney.     

How well does contralateral testis hypertrophy predict the absence of the nonpalpable testis?

PURPOSE: We assessed the accuracy of contralateral testis hypertrophy for predicting monorchia in patients with a nonpalpable testis. MATERIALS AND METHODS: From May 1993 to September 1998 we evaluated 60 patients 7 months to 11 years old for a unilateral nonpalpable testis. Four patients were excluded from study who had received human chorionic gonadotropin or had signs of puberty. We correlated contralateral testis hypertrophy, defined as testis volume greater than 2 cc or testis length greater than 2 cm., with presence or absence of the nonpalpable testis. We also recorded the degree to which contralateral testis length less than 2.1 cm. correlated with the presence or absence of the nonpalpable testis. Laparoscopy and open exploration were performed in 52 and 4 cases, respectively. RESULTS: Contralateral testis hypertrophy greater than 2 cm. was noted in 16 patients, including 14 (87.5%) with monorchia and 2 (12.5%) with an intra-abdominal testis. Of the 15 patients with a contralateral measurement of 1.8 to 2.0 cm. 14 had monorchia (93%) and 1 had a tiny ovotestis. Of the 25 patients with a contralateral measurement of less than 1.8 cm. 13 (52%) had testes that were intra-abdominal in 11 and canalicular in 2. The optimal cutoff value for contralateral enlargement was 1.8 cm. (p = 0.00061). The most common laparoscopic finding in patients with contralateral testis hypertrophy greater than 2 cm. was blind ending vessels proximal to the internal ring in 56%. CONCLUSIONS: Contralateral testis hypertrophy is common in patients with a nonpalpable testis. Hypertrophy 1.8 cm. or greater predicts monorchia with an accuracy of about 90%. The finding of contralateral testis hypertrophy provides useful information for preoperative counseling, allowing us to inform parents that the nonpalpable testis is most likely absent. Exploration is still required. Laparoscopy is particularly advantageous in contralateral testis hypertrophy since it was the only procedure required in about half of our cases.     

Biliary obstruction during cholecystectomy: endoscopic retrograde cholangiopancreatography, evade, or explore?

Biliary obstruction discovered during cholecystectomy remains a challenging problem. To determine the best management, this retrospective study compared intervention during the same admission (SA) versus delayed/no intervention (DN). Furthermore, this study demonstrates the power of a deidentified research database derived from electronic medical records. Patients undergoing cholecystectomy and intraoperative cholangiogram (IOC) were identified in the Vanderbilt Synthetic Derivative database. Patients with biliary obstruction discovered during IOC were included and a cohort study was performed. Interventions for biliary obstruction included endoscopic retrograde cholangiopancreatography or common bile duct exploration. A composite measure of any biliary complication served as the primary outcome. A total of 1899 patients who underwent cholecystectomy were evaluated; 151 met inclusion criteria. Mean age was 44 years with 69 per cent women. Sixty-three per cent of patients had intervention during the SA for cholecystectomy compared with 37 per cent for DN. Nineteen per cent of patients in the SA group had biliary complications versus 16 per cent for DN (P = 0.656). Patients in the SA group had a significantly increased length of stay (4.7 vs 2.1 days, P < 0.05). These data suggest an aggressive approach to biliary obstruction seen on IOC does not reduce postoperative biliary complications and may incur unnecessary resource use.     

Normal and varicocele testis in adolescents

The authors reviewed the results of their research on the structure and composition of normal and varicocele seminiferous tubules in adolescents. They give new evidences of normal structure of adolescent testis and demonstrate, for the first time, the ultrastructural and immunohistochemical modifications of the lamina propria and basal lamina in the adolescent varicocele patients, which are similar to those observed in adults, but less severe, and of the adherence junctions in seminiferous tubules. They also report the presence of oxidative stress in adolescents limited to testis and not generalised as in the adults. These data are well correlated to different clinical studies that support the hypothesis of a progressive course of varicocele and the need for surgical treatment in adolescent varicocele patients.     

Bladder-outlet obstruction — assessment of symptoms

Summary Assessment of symptoms plays a central role in the evaluation of men with suspected bladder-outflow obstruction (BOO) secondary to benign prostatic hyperplasia (BPH). It is on the basis of symptoms that treatment designed to relieve outflow obstruction is recommended. However, a variety of studies have suggested that a considerable proportion of men presenting with suspected outflow obstruction are not obstructed as determined by pressure-flow criteria. The relationship between many so-called obstructive symptoms and BOO has not yet been defined. Furthermore, all previous studies have defined BOO on the basis of urethral resistance factors, which are now regarded as outdated. Using current concepts of urethral pressure-flow relationships, we studied in detail the relationship between the obstructive symptoms of BPH, objective evidence of abormal voiding and BOO. Only the symptoms of hesitancy and poor flow were found to be significantly related to BOO. The symptoms of straining to void, intermittency, terminal dribbling and feeling of incomplete bladder emptying were not specific for BOO. Objective evidence of an intermittent flow pattern and of terminal dribbling do, however, have a high specificity and positive predictive value for BOO. The assessment of men with lower-urinary-tract symptoms must include objective tests of voiding function. A better understanding of the pathophysiology of lower-urinary-tract symptoms should lead to an improved symptomatic outcome of prostatectomy.     

5α-reductase type 2 gene expression in human testis, epididymis and vas deferens

To study the expression pattern of 5α-reductase type 2 gene in human male reproductive organs. Methods: The expression level of 5ct-reductase type 2 gene in human testis, epididymis and vas deferens tissues was determined by in situ hybridization using a digoxin-labeled 5α-reductase type 2 cRNA probe. Results: The brown granules of hybridizing signals distributed in the cytoplasm of the Sertoli and Leydig cells of the testis, the principle cells of epididymis and the epithelial cells of vas deferens, but there was no positive signal in the nuclei of these cells. No positive signal was observed in the germ cells, basement of the testis, interstium of the epididymis and basement and the smooth muscle cells of vas deferens. Conclusion: This study confirmed that the 5a-reductase type 2 gene expressed in the Sertoli and Leydig cells of the testis and the principle cells of the epididymis. The expression pattem of the gene in these cells in the human was similar to that in the rat and monkey. The presence o     

Impalpable testis: laparoscopy or inguinal canal exploration?

OBJECTIVE: There is great controversy regarding the best approach to impalpable testis. In this retrospective study we evaluated the accuracy of intraperitoneal laparoscopy, inguinal canal exploration and ultrasound in the diagnosis of impalpable testis. MATERIAL AND METHODS: Over a 2-year period (2004-06), 76 patients with a diagnosis of uni- or bilateral clinically impalpable testis were referred to our center. A preoperative ultrasound evaluation was done and all patients underwent intraperitoneal laparoscopy. An inguinal canal incision and exploration was done in all cases except for patients with high intra-abdominal testes (> 2 cm above the internal ring), for whom laparoscopic dissection, mobilization and orchidopexy were necessary. RESULTS: The mean age of the patients was 15.36 years (range 1-39 years). The undescended testis (UDT) was right-sided in 25% of patients, left-sided in 41% and bilateral in 34%. Intraperitoneal laparoscopy, inguinal canal exploration and ultrasound detected 70.6%, 78.4% and 15.6% of testes, respectively. CONCLUSIONS: Laparoscopy changed the management protocol of impalpable UDT in only 21% of cases. Inguinal canal exploration alone was sufficient in the majority of our cases. We recommend laparoscopy for those patients with impalpable UDT in whom an initial inguinal canal exploration proves negative.     

Adult nonpalpable testis: is laparoscopy always required?

Laparoscopy is widely used in the diagnosis and treatment of nonpalpable testes. Some nonpalpable testes are vanishing testes. In such cases, unnecessary laparoscopic interventions can be avoided by a careful selection of cases. Between 1996 and 2001, laparoscopic intervention was applied to 107 patients with nonpalpable testes. Of the cases, 23 were bilateral and 84 were unilateral. Patients were between 19 and 27 years of age (average age, 23 years). Diagnostic ultrasonography was performed in 44 of the 84 patients with nonpalpable testes. Dimensions of the scrotal testis were determined by the Prader orchiometer method. The dimensions of the opposite scrotal testis (of the scrotal nubbin) and the abdominal testis were compared with the dimensions of 20 normal, healthy individuals' scrotal testis (control group). Results were evaluated by the Mann-Whitney U test. During laparoscopy, 24 (28.5%) of the patients were found to have a vanishing testis. The vas deferens and the testicular blood vessels ended bluntly at the anterior edge of the interior inguinal ring in one patient, inside the inguinal canal in five patients, and in the scrotum in 18 patients. Among the 84 patients with nonpalpable testes, no testis was found in any of the 18 patients with palpable scrotal nubbins. The opposite scrotal testes were hypertrophic in 17 (70.8%) of 24 patients who had vanishing testis (P < .05), and they were hypertrophic in 22 (36%) of the 60 patients (P > .05) who had laparoscopically identified intraabdominal testes. We conclude that clinical and radiologic diagnosis is sufficient for adult patients with nonpalpable testicles and palpable scrotal nubbins and hypertrophic contralateral scrotal testes. Laparoscopic intervention should be applied to patients who do not have palpable scrotal nubbins.     

Limited Wegener's granulomatosis of the epididymis and testis

A case is presented of Wegener's granulomatosis limited to the testis and epididymis,simultaneously,in a 69-year-old man.Orchiectomy was carried out through an inguinal incision under the presumptive diagnosis of a righttesticular tumor.A hard,irregular mass occupied the upper testicle and a portion of the epididymal head was visualized.Histopathologic examination of the specimen showed granulomatous inflammation of the testis and epididymis withprominent angiocentric granulomata in the walls of arteries,veins and foci of fibrinoid necrosis,surrounded bypalisading inflammatory cells with a few giant cells.The diagnosis of limited Wegener's granulomatosis was considered,although antineutrophil cytoplasmic antibody(c-ANCA)test was negative 2 weeks after orchiectomy.The patientshowed an excellent response after local complete excision.He remains free of disease 18 months after orchiectomy.(Asian J Androl 2006 Nov,8:737-739)     

Molecular identity, expression and functional analysis of interleukin-lα and its isoforms in rat testis

Interleukin-1α(IL-1α) is a proinflammatory cytokine that has also been found to act as a paracrine mediator involved in the regulation of testicular functions. The present review provides an overview of the role of IL-1α in testicular physiology. Bioactive IL-1α isolated from adult rat testis was found to consist of three distinct immunoreactive protein species with apparent sizes of 45, 24 and 19 kDa. These isoforms showed bioactivity in athymocyte proliferation and steroidogenesis assays with different biopotencies. The background of the molecular heterogeneity and processing, secretion and regulation of the isoforms of testicular IL-1α are discussed. All three isoforms have been found to be secreted into the testis tubular lumen and interstitial space. We have provided evidence that IL- 1α is a paracrine factor that may be of importance in, e.g., the regulation of Leydig cell steroidogenesis.Pathophysiologically, testicular IL-1α may contribute to testicular relapse of acute lymphocytic leukemia in boys.     

Molecular identity, expression and functional analysis of interleukin-1α and its isoforms in rat testis

Interleukin-1α (IL-1α) is a proinflammatory cytokine that has also been found to act as a paracrine mediator involved in the regulation of testicular functions. The present review provides an overview of the role of IL 1α in testicular physiology. Bioactive IL-1α isolated from adult rat testis was found to consist of three distinct immunoreactive protein species with apparent sizes of 45, 24 and 19 kDa. These isoforms showed bioactivity in a thymocyte proliferation and steroidogenesis assays with different biopotencies. The background of the molecular heterogeneity and processing, secretion and regulation of the isoforms of testicular IL-1α are discussed. All three isoforms have been found to be secreted into the testis tubular lumen and interstitial space. We have provided evidence that IL-1α is a paracrine factor that may be of importance in, e.g., the regulation of Leydig cell steroidogenesis. Pathophysiologically, testicular IL-1α may contribute to testicular relapse of acute lymphocytic leuke     

Developmental expression of c-kit protooncogene in the rat testis

IntroductionInmammalianembryos,thegermcelllinebeginswithprimordialgermcelIs,andinmales,primordialgermcellsbecomegono-cytes,thece1lprecursorsofthespermatogoni-a.ThedevelopmentofanormaltestisdependsupontheproliferationofprimordialgermcellsandtheiraggregationwithSertolicellprecur-sorsLl:.Theseeventshavebeenshowntobeassociatedwiththeexpressionofthec-kitProtooncogenemappedtothe"whitespottinglocus(W)~ofthemouse[2,3j.Thec-kitPro-tooncogeneencodesatransmembranetyrosinekinasereceptor(4,5).Thestructu…     

Is the vanished testis always a scrotal event?

OBJECTIVE: To determine if perinatal testicular torsion resulting in a vanished testis is an event that primarily occurs in the scrotum. PATIENTS AND METHODS: The records of 54 boys identified as having a solitary testis were reviewed. The side of absence, size of the solitary testis, method of surgical evaluation (scrotal, inguinal or abdominal), surgical findings and histology of the tissue removed were noted. RESULTS: The testis was absent twice as often on the left side, the solitary testis was hypertrophic in 25 of 42 boys in whom it was evaluated, and tissue grossly or histologically consistent with a testicular 'nubbin' was removed in 52 boys. Scrotal (47) or inguinal (seven) exploration was carried out in all. Laparoscopy (28) or abdominal exploration (two) was undertaken to confirm that no testicular tissue was present in the abdomen in 30 boys, including the two in whom no tissue was found on scrotal or inguinal exploration. CONCLUSIONS: Perinatal testicular torsion occurs after descent but before fixation of the tunica vaginalis to the scrotal wall. These testes atrophy, leaving a remnant of tissue in the scrotum that can be identified on scrotal exploration in almost all cases. Therefore, it is recommended that the evaluation of the child with a solitary palpable testis start with scrotal exploration. Laparoscopy should be reserved for those in whom no tissue consistent with a testicular nubbin is found in the scrotum.