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Long term outcomes of lymphatic sparing laparoscopic varicocelectomy

Rizkala, Emad; Fishman, Andrew; Gitlin, Jordan; Zelkovic, Paul; Franco, Israel
OBJECTIVE:To assess the long-term occurrence of hydroceles and varicocele recurrence in patients receiving lymphatic sparing laparoscopic varicocelectomy (LSLV) compared to those receiving plain laparoscopic varicocelectomy (PLV), and also to assess the growth of testicular volume postoperatively. METHODS:We employed a standard three-trocar configuration. The spermatic vessels were identified in the retroperitoneum above the internal inguinal ring. Lymphatics were dissected free from the spermatic artery and veins based on laparoscopic appearance. The spermatic artery and veins were divided between plastic locking clips. We performed a retrospective chart review of all pediatric patients who underwent laparoscopic varicocelectomy between June 2003 and January 2009. RESULTS:Of a total of 97 patients, 67 underwent LSLV with mean follow-up of 45.8 ± 20.7 months and 30 underwent PLV with mean follow-up of 40.8 ± 25.3 months (p = 15). There was a 4.5% hydrocele rate in the LSLV group compared to 43.3% in the PLV group. Of the patients who underwent a PLV and subsequently developed a hydrocele, 31% (n = 4) required a hydrocelectomy, vs none of those who developed a hydrocele after LSLV. Varicocele rate was 6% in the LSLV group vs 3.3% in the PLV group. However, when the artery was not preserved, the probability of recurrence in the LSLV group was 1.3%. Time to hydrocele formation was 16 months in the LSLV group vs 37 months in the PLV group. There was catch-up testicular growth in both groups. CONCLUSIONS:There appears to be increased risk of need for a hydrocelectomy after a PLV as compared to LSLV. Performing a lymphatic sparing, non-artery preserving, laparoscopic varicocelectomy has success and complication rates comparable with those of subinguinal microsurgical varicocelectomy. There appears to be excellent catch-up testicular growth with either laparoscopic varicocelectomy technique.
PMID: 23498876
ISSN: 1873-4898
CID: 5014432

Evaluating compensatory hypertrophy: a growth curve specific for solitary functioning kidneys

Krill, Aaron; Salami, Simpa; Rosen, Lisa; Friedman, Steven C; Gitlin, Jordan; Palmer, Lane S
PURPOSE/OBJECTIVE:While compensatory hypertrophy is expected in solitary kidneys, the definition of appropriate hypertrophy remains unclear. The normal renal growth rate in children age 1 to 18 years with 2 kidneys has been defined as 0.28 × age (years) + 6.1. Solitary kidneys appear to grow faster and larger and, thus, require a separate growth curve. MATERIALS AND METHODS/METHODS:The records of all patients 18 years old or younger with solitary functioning kidneys were reviewed from 2001 to 2011. Exclusion criteria were greater than SFU (Society for Fetal Urology) grade 2 hydronephrosis, posterior urethral valves, vesicoureteral reflux or any ipsilateral obstruction. Ordinary least squares regression modeled the renal length as a function of age by using only the initial sonogram per subject. The distribution of mean kidney length by age was plotted and compared to published normal values. RESULTS:A total of 91 subjects were included in the study. Patients were evenly split by laterality and gender. Multicystic dysplastic kidney comprised 34% and solitary kidneys 66% of subjects. Of these subjects 55% underwent their first sonogram at younger than 1 year old. There were 61 subjects with multiple sonograms but the initial 91 were included in the study. Age was a better predictor of renal length for subjects age 1 year or older (r(2) = 0.7312) than for those younger than 1 year old (r(2) = 0.6138). For children age 1 to 18 years we used the equation, length = 0.38 × age + 7.2. Solitary kidney values were approximately 2 standard deviations greater than normal values. CONCLUSIONS:The equation 0.4 × age (years) + 7 can be used to accurately estimate expected renal length in children (age 1 to 18 years) with solitary kidneys and can be used as a quick reference to evaluate for renal compensatory hypertrophy.
PMID: 22910263
ISSN: 1527-3792
CID: 5015812

A conservative approach to testicular rupture in adolescent boys

Cubillos, Jimena; Reda, Edward F; Gitlin, Jordan; Zelkovic, Paul; Palmer, Lane S
PURPOSE/OBJECTIVE:Management for blunt trauma with breach of the renal capsule or bladder (extraperitoneal) has largely become nonsurgical since a conservative approach proved to be effective and safe. Currently the recommendation for managing testicular rupture is surgical exploration and débridement or orchiectomy. We report outcomes in boys diagnosed with testicular rupture and treated without surgical intervention. MATERIALS AND METHODS/METHODS:In the last year we conservatively treated 7 consecutive boys with delayed presentation of testicular rupture after blunt scrotal trauma. Patients were treated with scrotal support, antibiotics to prevent abscess, rest, analgesics and serial ultrasound. We report clinical information and outcomes. RESULTS:The 7 boys were 11 to 14 years old and presented 1 to 5 days after injury. Trauma was to the left testis in 3 cases and to the right testis in 4. Patients presented with mild to moderate pain and similar scrotal swelling. Ultrasound findings consistently revealed hematocele and increased echogenicity. Blood flow was present in the injured portion of the testes in 3 cases and to the remainder of the affected testicle in 6 of the 7 boys. In the remaining boy an adequate waveform was not seen in either testicle, which the radiologist thought was secondary to prepubertal status. Other findings included scrotal edema, irregular contour and seminiferous tubule extrusion. Followup was greater than 6 months in all cases. Five boys were seen at the office and the 2 remaining had telephone followup. In all cases hematocele resolved, testicular size stabilized without atrophy and echogenicity normalized in the 5 patients with followup ultrasound. One patient required surgical repair of hydrocele 4 months after trauma but no other patient needed surgical exploration. No abscess or infection developed. CONCLUSIONS:A conservative approach in a select group of adolescent boys with testicular rupture can result in resolution of the fracture and maintenance of testicular architectural integrity.
PMID: 20728174
ISSN: 1527-3792
CID: 5014422

Parenchymal echo texture predicts testicular salvage after torsion: potential impact on the need for emergent exploration

Kaye, Jonathan D; Shapiro, Edan Y; Levitt, Selwyn B; Friedman, Steven C; Gitlin, Jordan; Freyle, Jaime; Palmer, Lane S
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.
PMID: 18721947
ISSN: 1527-3792
CID: 5015452

Neonatal torsion: a 14-year experience and proposed algorithm for management

Kaye, Jonathan D; Levitt, Selwyn B; Friedman, Steven C; Franco, Israel; Gitlin, Jordan; Palmer, Lane S
PURPOSE/OBJECTIVE:Management of neonatal torsion is controversial, since the likelihood of testicular salvage and metachronous contralateral torsion must be weighed against the risk of neonatal anesthesia. We reviewed a large series of such cases and stratified neonatal torsion based on time of presentation to determine the potential for testicular salvage. To our knowledge this is the largest series of its kind in the literature. MATERIALS AND METHODS/METHODS:All cases of neonatal torsion were classified as either prenatal (noted at the time of delivery) or postnatal (noted after birth and before age 1 month). The charts of all patients were reviewed and data were collected on demographic information, pregnancy and birth history, laterality, physical examination findings, radiological imaging, intraoperative findings, anesthetic morbidities, perioperative complications and pathological diagnoses. Followup data were also collected for patients who underwent detorsion and orchiopexy. RESULTS:A total of 16 neonatal torsions (right side 8, left side 6, bilateral 1) were diagnosed in 15 patients at our institution between 1993 and 2007. A total of 13 torsions (81%) were prenatal and 3 (19%) were postnatal. All 13 prenatal torsions (100%) resulted in infarction (right 7, left 4, bilateral 2) confirmed by pathological examination. All patients underwent testicular exploration via an inguinal approach. A total of 11 cases were managed by orchiectomy at an average of 7.6 days (range 0 to 37) following birth. One of the bilaterally torsed testes showed infarction and necrosis on biopsy, and was detorsed and fixed in place. A second prenatally torsed testis was detorsed and pexed but atrophied on followup. Among the 3 postnatal torsions 1 (33%) was deemed viable on exploration and, therefore, salvaged. Of the 10 prenatal torsions with known prenatal history 5 (50%) were associated with at least 1 significant prenatal complication. Nine of the 10 patients with prenatal torsion (90%) were delivered vaginally, and 1 by cesarean section after prolonged failure of descent. CONCLUSIONS:Complicated pregnancies and vaginal deliveries seem to predispose patients to testicular torsion. Contrary to previous series, neonatal torsions do not appear to favor one side or the other. Prenatal torsions are never salvageable, and, therefore, do not warrant emergent intervention. Postnatal torsions are sometimes salvaged, and a judicious approach to surgical exploration should be taken.
PMID: 18433778
ISSN: 1527-3792
CID: 5015802

Climatic conditions and the risk of testicular torsion in adolescent males

Srinivasan, Arun K; Freyle, Jaime; Gitlin, Jordan S; Palmer, Lane S
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.
PMID: 17945301
ISSN: 1527-3792
CID: 3939882

Lack of major involvement of human uroplakin genes in vesicoureteral reflux: Implications for disease heterogeneity

Jiang, Songshan; Gitlin, Jordan; Deng, Fang-Ming; Liang, Feng-Xia; Lee, Andy; Atala, Anthony; Bauer, Stuart B; Ehrlich, Garth D; Feather, Sally A; Goldberg, Judith D; Goodship, Judith A; Goodship, Timothy H J; Hermanns, Monika; Hu, Fen Ze; Jones, Katrin E; Malcolm, Sue; Mendelsohn, Cathy; Preston, Robert A; Retik, Alan B; Schneck, Francis X; Wright, Victoria; Ye, Xiang Y; Woolf, Adrian S; Wu, Xue-Ru; Ostrer, Harry; Shapiro, Ellen; Yu, Jun; Sun, Tung-Tien
Lack of major involvement of human uroplakin genes in vesicoureteral reflux: Implications for disease heterogeneity. Background. Primary vesicoureteral reflux (VUR) is a hereditary disorder characterized by the retrograde flow of urine into the ureters and kidneys. It affects about 1% of the young children and is thus one of the most common hereditary diseases. Its associated nephropathy is an important cause of end-stage renal failure in children and adults. Recent studies indicate that genetic ablation of mouse uroplakin (UP) III gene, which encodes a 47 kD urothelial-specific integral membrane protein forming urothelial plaques, causes VUR and hydronephrosis. Methods. To begin to determine whether mutations in UP genes might play a role in human VUR, we genotyped all four UP genes in 76 patients with radiologically proven primary VUR by polymerase chain reaction (PCR) amplification and sequencing of all their exons plus 50 to 150 bp of flanking intronic sequences. Results. Eighteen single nucleotide polymorphisms (SNPs) were identified, seven of which were missense, with no truncation or frame shift mutations. Since healthy relatives of the VUR probands are not reliable negative controls for VUR, we used a population of 90 race-matched, healthy individuals, unrelated to the VUR patients, as controls to perform an association study. Most of the SNPs were not found to be significantly associated with VUR. However, SNP1 of UP Ia gene affecting a C to T conversion and an Ala7Val change, and SNP7 of UP III affecting a C to G conversion and a Pro154Ala change, were marginally associated with VUR (both P= 0.08). Studies of additional cases yielded a second set of data that, in combination with the first set, confirmed a weak association of UP III SNP7 in VUR (P= 0.036 adjusted for both subsets of cases vs. controls). Conclusion. Such a weak association and the lack of families with simple dominant Mendelian inheritance suggest that missense changes of uroplakin genes cannot play a dominant role in causing VUR in humans, although they may be weak risk factors contributing to a complex polygenic disease. The fact that no truncation or frame shift mutations have been found in any of the VUR patients, coupled with our recent finding that some breeding pairs of UP III knockout mice yield litters that show not only VUR, but also severe hydronephrosis and neonatal death, raises the possibility that major uroplakin mutations could be embryonically or postnatally lethal in humans
PMID: 15200408
ISSN: 0085-2538
CID: 43158

BTG2 protein is abundant in proliferative inflammatory atrophy but not in prostate cancer: Role of proteosomal degradation

Woo, Ken; Fraiman, Mitchell; Ficazzola, Michael; Gitlin, Jordan; Walden, Paul
BIOSIS:200000524611
ISSN: 0302-2838
CID: 15782

Expression of the BTG2 antiproliferative gene in prostate cancer

Walden, P; Ficazzola, M; Fraiman, M; Gitlin, J
BIOSIS:200000083003
ISSN: 0302-2838
CID: 15864

New concepts on the histological changes in experimental augmentation cystoplasty: Insights into the development of neoplastic transformation at the enterovesical anastomosis [Meeting Abstract]

Gitlin, JS; Wu, XR; Ritchey, ML; Shapiro, E
ISI:000075810500392
ISSN: 0031-4005
CID: 53771