Faculty Bibliography

PURPOSE/OBJECTIVE:Buccal mucosa is the favored graft material for patients with long urethral defects and a paucity of skin. Since 2007, we have used the novel tunneled buccal mucosa tube graft urethroplasty technique in these patients. We describe this operative technique and report our surgical and functional outcomes. MATERIALS AND METHODS/METHODS:Between 2007 and 2013, 37 males with proximal hypospadias underwent tunneled buccal mucosa tube graft urethroplasty. After the penile shaft was optimized at a prior stage a free buccal graft was tubularized and tunneled under the intact ventral shaft skin and into the glans. We retrospectively reviewed all charts to report our results. We assessed uroflowmetry and bladder ultrasound for post-void residual urine. RESULTS:The overall complications rate in 34 patients with more than 1-year followup was 32% (11), including fistula in 5, proximal stricture in 4 and meatal stenosis in 2. In the first 10 patients a total of 7 complications (70%) developed but there were only 4 complications in the next 24 (16%). Surgeon experience was the only significant predictor of complications (p = 0.003). We obtained uroflow and post-void residual urine data on 13 of 37 patients, of whom 9 achieved a normal flow pattern and post-void residual urine, and 4 had a blunted flow pattern. CONCLUSIONS:The novel technique of the tunneled buccal mucosa tube graft in patients with proximal hypospadias represents a good alternative for a long urethroplasty in patients with a paucity of skin. After the learning curve plateaus the rate and degree of complications decrease. Furthermore, voiding function is adequate, as assessed by uroflow studies and post-void residual urine measurement.

PURPOSE/OBJECTIVE:Isolated reported cases of familial torsion yield modest information on incidence, genetics or clinical features. We present what is to our knowledge the largest series of familial torsion, including the first 3 generation case and a review of the literature. MATERIALS AND METHODS/METHODS:Since 2006, we have questioned the presence of a positive family history in all patients with torsion at the initial consultation. We compiled data on familial relationship, laterality, age and outcomes of the proband and affected relatives. We collected previously published cases to better understand clinical features and genetics. RESULTS:Eight of 70 boys (11.4%) with torsion had affected family members. Another 2 families were included from a historical perspective. One relative was affected in 7 families, 2 were affected in 2 and 3 were affected in 1. First degree relatives were most commonly affected. In 1 family torsion occurred in 3 consecutive generations. Despite a family history 50% of patients experienced testicular loss. Brothers were affected in each of the 10 previously reported cases. In 3 families fathers were also affected. There were 3 sets of monozygotic twins. We noted laterality concordance 5 times and discordance 6 times. Age at torsion in probands was adolescence except in 2 with neonatal torsion. No clear inheritance mode was found. CONCLUSIONS:Familial torsion occurs in about 10% of probands and can affect multiple relatives and generations. A positive family history may be useful for torsion diagnosis and management. Relatives of affected patients need education on the signs and symptoms of torsion, and the importance of early presentation to improve outcome.

We report the first and largest family with testicular torsion in three consecutive generations affecting four first-degree relatives. The incidence of familial testicular torsion is under reported in the literature. We recommend eliciting family history in evaluation of acute scrotum, as a useful adjunct for clinical decision making. In families with a strong predisposition to testicular torsion, management should include family counseling about the significant risk of occurrence of this condition.

PURPOSE/OBJECTIVE:In the setting of signs and symptoms of testicular torsion the absence of diastolic flow and/or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates largely from the difficulty on ultrasound of distinguishing salvageable torsed testes from those that are not salvageable. We identified ultrasound findings predictive of testicular viability or the lack thereof. MATERIALS AND METHODS/METHODS:We retrospectively reviewed the charts of all boys who underwent scrotal exploration for signs and symptoms of torsion during a 4-year period. In those who underwent preoperative Doppler ultrasound of the scrotum ultrasound findings were reviewed, as were the operative dictations. In patients who underwent orchiectomy the pathology reports were also reviewed. In patients in whom the torsed testis appeared viable and who underwent orchiopexy followup data were reviewed when available. Emergency room charts were also reviewed to ascertain, when documented, the duration of pain before presentation to the emergency room and the interval between ultrasound and operating room. RESULTS:During this period 55 boys underwent exploration after preoperative scrotal Doppler ultrasound revealed absent diastolic flow and/or color flow Doppler in the symptomatic testis. Assessment of parenchymal echogenicity revealed heterogeneity in 37 testes (67%), of which none were deemed viable at exploration. Orchiectomy was performed in 34 of 37 cases. Pathological examination revealed necrosis in all 34 cases, a finding consistent with late torsion. The remaining 3 testes underwent orchiopexy by parental directive despite nonviability, as confirmed by biopsy and subsequent atrophy. Thus, heterogeneity on preoperative ultrasound was universally predictive of organ loss (chi-square p <0.001). Of the 18 symptomatic testes (33%) demonstrating homogeneity and isoechogenicity on ultrasound 16 (89%) were deemed viable at exploration. Boys in whom the torsed testicle was nonviable on exploration experienced an average of 27.5 hours of pain preoperatively (range 5 to 72), whereas boys in whom the torsed testis was salvaged experienced an average of 20.5 hours of pain (range 2 to 96) (p = 0.073). The nonviable group underwent surgery an average of 49 minutes after ultrasound, whereas the viable group underwent surgery 52 minutes after ultrasound (p = 0.92). None of the 55 patients experienced any surgical or anesthetic complications and no pathological condition was noted intraoperatively in the contralateral asymptomatic testis. CONCLUSIONS:In the setting of Doppler proven testicular torsion heterogeneous parenchymal echo texture indicates late torsion and testicular nonviability. Therefore, the case may not require emergent scrotal exploration. On the other hand, homogeneous echo texture portends extremely well for testicular viability. Thus, such testes should be explored emergently.

PURPOSE/OBJECTIVE:The risk factors for acute testicular torsion are poorly understood. Environmental factors have been implicated by some authors and discredited by others. The only previous known study in the United States did not demonstrate any seasonal correlation, although the study was done in a warmer climate. We sought to determine if environmental factors impact the incidence of testicular torsion in our temperate climate conditions with a large differential between the warmest and coldest temperatures. MATERIALS AND METHODS/METHODS:We retrospectively studied patients who were diagnosed with testicular torsion between January 1997 and December 2006. Data regarding weather conditions were collected, including season, temperature, humidity and atmospheric pressure at the time of onset of symptoms. Spearman's rank correlation was performed to assess the relationship between atmospheric temperature and frequency of testicular torsion. Multivariate analysis was performed to analyze the effect of covariables. RESULTS:A total of 58 children presented with testicular torsion. Mean temperature at onset of symptoms was 6.9C (range -12C to 23C). Of the patients 81% had symptom onset when the atmospheric temperature was less than 15C. Seasonal incidence of testicular torsion was 36.2%, 31%, 19% and 13.8% for spring, winter, summer and fall, respectively. Spearman's rank correlation test revealed a significant negative correlation between the incidence of testicular torsion and increasing temperature (r = -0.94, p <0.0001) and decreasing humidity (r = -0.44, p <0.001). After controlling for effects by patient age, atmospheric pressure and humidity by multivariate analysis a significant correlation was observed between testicular torsion and decreasing atmospheric temperature. None of the other atmospheric factors examined correlated with the incidence of testicular torsion. CONCLUSIONS:An increased incidence of testicular torsion is seen with decreasing atmospheric temperature and humidity, suggesting a possible etiological role.