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.     

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.     

RETRACTED ARTICLE: Missed Monteggia fracture in children: is annular ligament reconstruction always required?

Background  

Missed radio-capitellar joint dislocation is one of the feared complications of Monteggia fractures, especially when associated with subtle fractures of the ulna bone. Many treatment strategies have been described to manage the chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. This study is an attempt to address the issue of annular ligament reconstruction in the surgical management of missed Monteggia fracture.     

Is human chorionic gonadotropin useful for identifying and treating nonpalpable testis?

PURPOSE: We evaluated the efficacy of human chorionic gonadotropin (HCG) for identifying and treating nonpalpable testis. We then compared the cost-effectiveness of this approach to that of laparoscopy. MATERIALS AND METHODS: We reviewed patient charts during a 15-month period and identified 51 boys (64 testes) who underwent surgery to correct cryptorchidism. There were nonpalpable testes in 17 cases and bilateral cryptorchidism in 2 for a total of 19 impalpable testes. All patients were offered a full course of HCG. Those electing hormonal treatment received intramuscular injection of 2,000 IU/m.2 HCG (maximum 1,500 IU/injection) 3 times weekly for 3 weeks. RESULTS: A full course of HCG was given in 8 patients (10 testes). Of the 10 testes 8 became palpable after HCG treatment, including 1 atrophic nubbin located in the inguinal canal. Of the 2 testes that remained impalpable 1 discovered at the level of the renal vessels had complete epididymal nonunion and 1 was located closer to the inguinal ring. All 9 untreated patients underwent laparoscopy, which identified 3 intra-abdominal, 3 vanished and 2 peeping testes, and 1 atrophic testis in the inguinal canal. CONCLUSIONS: HCG therapy is valuable for identifying and treating nonpalpable testis. Using this agent enabled the testicle to be detected while avoiding the risks and cost associated with the laparoscopic procedure.     

Pneumoperitoneum: is exploratory laparotomy always indicated?

Pneumoperitoneum usually indicates a surgical emergency because of visceral perforation in 85 to 95% of cases. Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma for the surgeon who is faced with this problem. Some cases of pneumoperitoneum can and should be managed conservatively. We report three cases of pneumoperitoneum and describe their outcomes. Two cases were treated conservatively, and one underwent laparotomy but no perforated viscus was found. We review the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. Furthermore, a compilation of other aetiologies of pneumoperitoneum without peritonitis as reported in the literature is presented. Pneumoperitoneum, preceded by a reasonable clinical history in a patient with an adequate abdominal examination, may warrant continued observation, thus avoiding an unnecessary laparotomy.     

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.     

Informed consent: is it always necessary?

Informed consent plays a pivotal role in human clinical research. It serves as a marker for the subject's comprehension of all the pertinent elements of the study. It is also a pledge by the investigator that during the trial, the rights and safety of the subject will be protected. Informed consent attempts to ensure that ethical behaviour will be upheld throughout the study. However, obtaining informed consent from certain vulnerable populations is a challenge, and thus warrants improvement. While informed consent is mandated for almost all clinical trial involving human subjects, there are situations of emergency research and trials with minimal risk that call for a waiver of the consent.     

Why is urological laparoscopy minimally invasive?

OBJECTIVES: Laparoscopic procedures have been developed and established with the view that a similar operative effect can be achieved with less traumatization, especially as far as systemic stress response is concerned. We report a prospective, controlled, nonrandomized animal and patient study to determine the systemic response to laparoscopic and open surgical procedures. METHODS: In the animal study, 26 female pigs underwent either a laparoscopic bilateral varix ligation followed by bilateral nephrectomy (group I), sole introduction of trocars (group II) or sole establishment of an open surgical approach (group III). In the patient study, 145 patients underwent various laparoscopic procedures (nephrectomy, renal cyst marsupialization, varix ligation), open surgical procedures (nephrectomy, inguinal orchiectomy) or extracorporeal shockwave lithotripsy (ESWL). The serum parameters interleukin (IL)-6, IL-10 and C-reactive protein (CRP) were measured before, during and after the operative procedure. RESULTS: In animals and patients, laparoscopy resulted in significantly lower serum levels of CRP during and after the operative procedure. Animals in group I showed a 5-fold elevation, in group II a 3-fold elevation and in group III a 9-fold elevation of CRP. In patients, the increase of CRP was twice as high after open unilateral nephrectomy than after laparoscopic unilateral or bilateral nephrectomy. IL-6 showed less marked elevation during laparoscopy, ESWL and minor operative procedures like laparoscopic varix ligation or inguinal orchiectomy when compared to an open unilateral nephrectomy. The parameter IL-10 showed no significant differences among the patient groups. CONCLUSIONS: The extent of the acute phase reaction to the operative trauma correlates much more convincingly to the approach than to the extent of the procedure. Only larger operations like nephrectomy trigger a systemic acute phase reaction, which can be limited by the laparoscopic access. For minor operative procedures like varix ligation or exploration of cryptorchidism, laparoscopy offers technical advantages rather than minimal invasiveness.     

Sodium chloride intake: is lower always better?

Current treatment of kidney disease is not completely satisfactory, particularly when initiated in the late stages of renal progression. There is an urgent need for additional interventions, especially reduction of salt intake, which is rather high in the Western world. In this commentary we provide a critical assessment of post hoc analyses of recent interventional and observational studies on the effect of salt intake on renal and cardiovascular outcomes. To evaluate the mechanisms and safety of reduced salt intake, studies specifically designed to assess salt intake as an endpoint are needed. This approach will have implications for health care policies and labeling of the salt content of purchased foods.     

Is the Fowler-Stephens procedure still indicated for the treatment of nonpalpable intraabdominal testis?

Purpose

There are no formal guidelines for the management of boys with nonpalpable testis. In this article, we report our experience in treating all nonpalpable intraabdominal testis (NPIT) with standard inguinal orchidopexy without dividing the spermatic vessels stating that the Fowler-Stephens technique is no longer indicated for the treatment of the intraabdominal testis.

Methods

Between June 2003 and April 2008, we treated 23 boys with NPIT confirmed by ultrasound or laparoscopy. All cases were treated through an inguinal orchidopexy without division of the spermatic vessels by fixing the testis to the scrotum by 2 absorbable stitches even if there was an upward retraction of the scrotal skin. Location and size of testis were reported at 1 week, 1 month, 3 months, and 6 months through physical examination.

Results

Average age at presentation was 24 months. Ten patients (43%) had the NPIT on the right side, 8 (35%) on the left side, and 5 (22%) were bilateral. We had no intraoperative complications. All patients were discharged on the same day. In all cases, the testis was normal in size and found in the scrotum after 6 months of follow-up.

Conclusion

On the basis of our experience, we believe that the Fowler-Stephens procedure is not indicated anymore in the management of NPIT. Orchidopexy without division of the spermatic vessels should be the treatment of choice even for the cases of very high intraabdominal testis because it does not affect normal testicular vascularization and is minimally invasive.     

Small bowel intussusception: what is the role of laparoscopy?

Small bowel intussusception in adults is a rare surgical disease which almost always occurs as a complication of either benign or malignant lesion of the bowel that is working as a leading point. In adults, the surgical approach consists of the resection of the bowel involved to ensure the excision of the lesion below. The authors report a case of ileocecal intussusception occurred in a young woman, 35 years old, observed for abdominal pain and signs of small bowel occlusion. She underwent surgical resection of the ileocecal segment with laparoscopic approach. The authors discuss the feasibility of the laparoscopic approach in this rare surgical disease and its benefits in terms of patient's postoperative comfort and outcome.     

Missed Monteggia fracture in children: Is annular ligament reconstruction always required?

Background:

Chronic (neglected) radiocapitellar joint dislocation is one of the feared complications of Monteggia fractures especially when associated with subtle fracture of the ulna bone. Many treatment strategies have been described to manage chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. The purpose of this study is to highlight the management of missed Monteggia fracture with particular emphasis on utility of annular ligament reconstruction by comparing the two groups of patients.

Materials and Methods:

In a prospective study 12 patients with mean age of 7.4 years, who presented with neglected Monteggia fractures, were studied. All children underwent open reduction of the radiocapitellar joint. Five children (Group A) were treated with angulation-distraction osteotomy of ulna and annular ligament reconstruction and six cases (Group B) required only angulation-distraction osteotomy of ulna without ligament reconstruction. In one case an open reduction of the radiocapitellar joint was sufficient to reduce the radial head and this was included in Group B. The gap between injury and presentation was from 3 months to 18 months (mean 9 months). Ten patients were classified as Bado I, and one each as Bado II and III respectively. We used the Kim''s criteria to score our results.

Result:

The mean follow-up period was 22 months. All ulna osteotomies healed uneventfully. The mean loss of pronation was 15 degree in Group A and 10 degree in Group B. Elbow flexion improved from the preoperative range and no child complained of pain, deformity and restriction of activity. The elbow score was excellent in 10 cases, and good in two cases.

Conclusion:

Distraction-angulation osteotomy of the ulna suffices in most cases of missed monteggia fracture and the need for annular ligament reconstruction is based on intraoperative findings of radial head instability.     

Cystourethroscopy following midurethral slings: is it always necessary?

Midurethral slings are the mainstay of treatment for stress urinary incontinence. The role of cystourethroscopy to detect lower urinary tract injury following retropubic midurethral slings is well-established; however, its role following transobturator or single-incision sling placement remains controversial. Some advocate “routine” whereas others advocate for “selective” cystourethroscopy. This paper reviews the arguments for and against cystourethroscopy to detect lower urinary tract injury following transobturator and single-incision slings.     

Ureterovascular hydronephrosis in children: is pyeloplasty always necessary?

OBJECTIVE: To evaluate the efficacy of the vessel transposition technique in ureterovascular hydronephrosis in children. METHODS: Over a 25-year period, we treated 111 patients with 112 instances of ureterovascular hydronephrosis. In order to determine the obstructive effect of the vessels, we performed an intraoperative diuretic test. Using this approach, 61 patients judged to have only vascular pyeloureteral junction obstruction underwent vessel transposition. However, 50 patients in whom the intraoperative diuretic test proved doubtful needed pyeloplasty. RESULTS: Surgical success was achieved in 98% of the patients. Only 1 child treated by vessel transposition had an unsatisfactory outcome which necessitated a subsequent pyeloplasty for persistent hydronephrosis. This was due to a previously unrecognized intrinsic pyeloureteral junction obstruction. CONCLUSION: Based on our clinical experience, the intraoperative diuretic test has proven to be a safe and effective diagnostic tool in children with ureterovascular hydronephrosis. Its use may contribute to treating some cases of ureterovascular hydronephrosis without resorting to pyeloplasty.