The importance of correcting a persistently patent processus vaginalis and/or of adequate retroperitoneal mobilization of the cord in cases of high recurrent cryptorchidism has been stressed (Redman skin care zahra buy 40 mg flexresan, 2000; Pesce et al skin care education discount flexresan 30 mg on-line, 2001; Ziylan et al acne chart discount flexresan on line, 2004). The results of secondary orchidopexy appear to be similar to the primary procedure, although the risk of vascular and vasal injury is theoretically higher (Pesce et al, 2001). Various scrotal incisions thathavebeenreported;A,Bianchiincision(Bianchi);B,transverse low scrotal approach (Misra); C, midline scrotal approach. Modifiedscrotal[Bianchi]mid raphe single incision orchiopexy for low palpable undescended testis:earlyoutcomes. After induction of anesthesia, the patient is re-examined to confirm the position of the testis. An incision along the superior scrotal border is made as described by Bianchi and Squire for any palpable testicles. Alternatively, a transverse low scrotal approach (Misra et al, 1997) and midline scrotal approach (Cloutier et al, 2011) have been described for those testes that can be drawn into the scrotum. After the testis has been delivered, the distal sac and overlying cremaster are mobilized proximally as far cranially as possible, "high above the inguinal canal" (Iyer et al, 1995). Some cases require conversion to an inguinal approach for ligation of the sac or to gain further length on the spermatic cord (Parsons et al, 2003; Dayanc et al, 2007). Rajimwale and colleagues confirmed in several cases that the hernia sac had been effectively ligated above the internal ring via the scrotal incision when a secondary inguinal incision was required for further mobilization of the testis (Rajimwale et al, 2004). Fixation sutures through the tunica albuginea have been used in many series of scrotal orchidopexy (Jawad, 1997; Russinko et al, 2003; Bassel et al, 2007; Dayanc et al, 2007; Takahashi et al, 2009), followed by placement of the testis in a subdartos pouch. In an extensive review of the literature by Gordon and colleagues, additional inguinal incisions were needed in 4. The single institution longterm results reported by these authors included a reoperative rate of 4. In a literature review of 1558 cases in 20 series reporting 3 months to 5 years of follow-up, a hernia was present in 30% and 3. Scrotal incision orchidopexy is used selectively in many series, but the available evidence suggests that efficacy and complication rates are similar to those of standard inguinal orchidopexy. Chapter148 Etiology,Diagnosis,andManagementoftheUndescendedTestis 3447 SurgicalApproachtotheAbdominalTestis Once an abdominal testis has been identified, the surgeon must decide whether to proceed with an open or laparoscopic, one- or two-stage orchidopexy with possible spermatic vessel transection. Orchiectomy is appropriate for patients with testes that are poorly viable and/or at higher risk for tumor, which may include testes in postpubertal patients or very small or dysgenetic testes in postpubertal patients, and is in our opinion best performed laparoscopically. Open Transabdominal Orchidopexy Extensive dissection of the vas and vessels is facilitated by a longitudinal opening of the internal oblique and peritoneum through an extended inguinal incision (Kirsch et al, 1998) or via a higher incision medial to the pubic tubercle and a preperitoneal approach (Jones and Bagley, 1979; Gheiler et al, 1997). In the procedure described by Jones and Bagley, the internal ring is approached via a muscle-splitting incision, the peritoneum is opened, the testis delivered, and the vas and vessels freed from their peritoneal attachments. A tunnel is created to the scrotum and the testis is secured in place as for an inguinal orchidopexy. The reported success rate for this procedure for abdominal testes was 95% (Gheiler et al, 1997). Laparoscopic Orchidopexy and Fowler-Stephens Orchidopexy Operative laparoscopy emerged over 15 years ago as the procedure of choice for abdominal orchidopexy (Caldamone and Amaral, 1994; Jordan and Winslow, 1994), and the basic surgical approach and high success rates have stood the test of time (Table 148-1). The feasibility of primary versus Fowler-Stephens orchidopexy depends on the length of the vas and vessels, presence or absence of looping ductal structures, and age of the patient. Although laparoscopy allows the surgeon to assess some of these features before choosing a specific surgical procedure, the choice may be difficult (Yucel et al, 2007). Observed testicular position alone may correlate poorly with the ultimate length of the cord after mobilization. After induction of anesthesia, a further attempt to palpate the testis is made, although a laparoscopic approach may be considered for mobilization of high canalicular testes as well.
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The initial lateral extension of the incision exposes the dorsal nerves of the penis and the attachment of the corpora to the pubis skin care 9 year old cheap flexresan. The urethral plate is mobilized from the corporeal bodies and moved to below them to create a penoscrotal hypospadias skin care solutions buy flexresan 30 mg otc. Laterally acne treatment cheap 10mg flexresan visa, the extraperitoneal space behind the rectus is entered and the vas retracted. An incision is made in the superior aspect of the pubis downward, creating a "flake" to which medially is attached the corpora of the penis and remnants of the urogenital diaphragm. The incision is carried through the levator muscles both deeply and anteriorly to where the levators insert on the back of the pubis. When it appears the entire course has been determined, the flake of the pubis is incised totally and the urethral and bladder neck area and muscles are brought together without tension. Mitchell Repair the Mitchell repair, as in all closures, is best performed in the newborn period. The main difference is that the urethra is separated from its attachments to the underlying corporeal bodies and pelvic diaphragm during the first stage of the procedure. Mitchell purports that this allows better posterior positioning of the bladder neck and posterior urethra into the pelvis. This combined bladder closure with penile repair was originally thought to be sufficient for the patient to achieve urinary continence, but this has been found not to be the case in that most of these patients require bladder neck repair (Gearhart et al, 2005; Shoukry et al, 2009; Gargollo et al, 2011). The closure is begun in the standard fashion, but the incision is carried out onto the urethral plate, taking care to preserve its blood supply and avoiding corporeal injury. The penis is then disassembled into three components-the right corpus, left corpus, and urethral wedge. During standard closure of the bladder, the bladder neck is tailored and the urethra is closed in an attempt to move the urethra to the tip of the penis. If it does not reach the tip of the penis, the urethra is taken to the base of the penis in a hypospadiac position in a majority (70%) of patients. The repair is very similar in the female patient, with care taken to mobilize the bladder neck, urethra, and vagina as a single unit. Vas Bladder Ureteric orifice External iliac vein and artery Dorsal nerve of penis Incison along white line Corpus spongiosum exposed Skin flap from penis and scrotum Pubis Corpus cavernosum Obturator nerve and vessels Mucosa excised Verumontanum Fat of ischiorectal fossa Dorsal nerve of penis A B C D Figure139-21. Once the vessels and bone flake are totally free, the tissues of the penis, bladder neck, and urethraarereconstructed. An increase in bladder capacity in patients with extremely small bladder capacities after epispadias repair prompted a change in the management program (Gearhart and Jeffs, 1989a). In a group of patients with a small bladder capacity after initial closure, there was a mean increase of 55 mL in males only 22 months after epispadias repair. Recent data by Kufner and colleagues (2010) clearly demonstrated better eventual overall bladder capacity in patients in whom the epispadias repair was completed before 12 months of life. With this modification, possibly all patients can achieve an appropriate capacity by the time they are physically and mentally ready to undergo bladder neck reconstruction. Because most boys with exstrophy have a somewhat small penis and a shortage of available penile skin, all patients undergo testosterone stimulation before urethroplasty and penile reconstruction (Gearhart and Jeffs, 1987). Regardless of the surgical technique chosen for reconstruction of the penis in bladder exstrophy, four key concerns must be addressed to ensure a functional and cosmetically pleasing penis.
Congenital renal damage associated with primary vesicoureteral reflux detected prenatally in male infants skin care house philippines discount 10mg flexresan otc. Severe vesicoureteral reflux and chronic renal failure: a condition peculiar to male gender Pregnancies in women with and without renal scarring after urinary infections in childhood acne under microscope purchase 40 mg flexresan amex. Postoperative hospitalization of children undergoing cross-trigonal ureteroneocystostomy skin care products for rosacea purchase 20mg flexresan free shipping. Outcome of pregnancy in an Oxford-Cardiff cohort of women with previous bacteriuria. Endoscopic treatment of vesicoureteral reflux with Coaptite: the first 50 patients. Normal and abnormal development of the ureter in the human embryo: a mechanistic consideration. What is the fate of the refluxing contralateral kidney in children with multicystic dysplastic kidney Incidence of contralateral vesicoureteral reflux following unilateral extravesical detrusorrhaphy (ureteroneocystostomy). Expanded polytetrafluoroethylene patch in hernia repair: a review of clinical experience. Is it reasonable to observe patients with persistent vesico-ureteral reflux after failed first endoscopic injection Embryology and genetics of primary vesicoureteric reflux and associated renal dysplasia. Clinical characteristics of primary vesicoureteral reflux in infants: multicenter retrospective study in Japan. A comparison of calcium hydroxyapatite and dextranomer/hyaluronic acid for the endoscopic treatment of vesicoureteral reflux. Color flow Doppler sonography: a reliable alternative to voiding cystourethrogram in the diagnosis of vesicoureteral reflux in children. A comparative study of endoscopic trigonoplasty for vesicoureteral reflux in children and in adults. Features of primary vesicoureteric reflux detected by investigation of foetal hydronephrosis. Constipation: a cause of enuresis, urinary tract infection and vesico-ureteral reflux in children. Extracellular matrix degradation and reduced nerve supply in refluxing ureteral endings. Resistive index in febrile urinary tract infections: predictive value of renal outcome. Enhanced detection of vesicoureteral reflux in infants and children with use of cyclic voiding cystourethrography. Cyclic voiding cystourethrography: is vesicoureteral reflux missed with standard voiding cystourethrography Vesicoureteral reflux associated renal damage: congenital reflux nephropathy and acquired renal scarring. Vesicoureteral reflux in infants with isolated antenatal hydronephrosis [comment]. Renal scarring following reflux and nonreflux pyelonephritis in children: evaluation with 99m technetiumdimercaptosuccinic acid scintigraphy.
If there are medical concerns or the bladder segments are too small for closure acne rosacea order generic flexresan online, delayed closure after initial intestinal diversion is appropriate (Mathews et al acne inflammation flexresan 5mg lowest price, 1998) skin care clinique order flexresan amex. To this end, bilateral orchiectomy was combined with phallic reconstruction as a functional clitoris and early or delayed vaginoplasty. Reiner and Gearhart (2004) have reported on 29 males with cloacal exstrophy who had gender reassignment to female. Psychosexual evaluation indicated that all of these patients had a marked male shift in psychosexual development despite having no pubertal hormonal surges. A comparison of patients with cloacal exstrophy and other cloacal anomalies at the Great Ormond Street Hospital for Sick Children, however, indicated no difference in social or behavioral competence or psychological problems. Gender assignment was not associated with childhood psychological, emotional, or behavioral problems (Baker Towell and Towell, 2003). Schober and coauthors (2002), reporting on 14 children who had undergone early gender reassignment, indicated that although patients had masculine childhood behavior, they had a feminine gender identity. Currently, however, most authors recommend assigning gender that is consistent with karyotypic makeup of the individual if at all possible. A recent survey of pediatric urologists indicated that two thirds of respondents favored gender-congruent assignment (Diamond et al, 2006). This policy can be supported by a report indicating that the histology of the testis at birth is normal (Mathews et al, 1999a). Furthermore, with evolution of techniques for phallic reconstruction, a functional and cosmetically acceptable phallus can now be constructed (Husmann et al, 1989b; Massanyi et al, 2012). UrinaryReconstruction Modern Staged Reconstruction the staged management of the urinary tract follows that used for the management of bladder exstrophy (Gearhart and Jeffs, 1991b). Once the bladder halves have been approximated posteriorly, the lateral edges are separated from the abdominal wall and brought together in the midline. As in the patient with classic exstrophy, placement of the bladder and posterior urethra deep into the pelvis remains a key factor in the successful surgical reconstruction of the urinary tract. Use of an AlloDerm patch to reduce the incidence of erosion of the interpubic stitch and prevent penopubic fistulization has been shown to be beneficial (Henderson et al, 2010). In ImmediateSurgicalReconstruction Cloacal exstrophy patients should undergo carefully planned and individualized reconstructions (Ricketts et al, 1991; Lund and Hendren, 1993; Mathews et al, 1998). After closure of the myelocystocele, long-term genetic females and in genotypic male subjects undergoing gender reassignment, reconstruction should be performed to improve the appearance of the genitalia. Recent reports by Thomas and colleagues (2007) in a series using a staged approach found successful results in a series of seven patients, all with tethered cords. The psychiatric studies of children who have had gender assignment have fueled interest in male gender assignment if adequate unilateral or bilateral corporeal tissue is present (Reiner, 2004). Histologic studies indicate normal histology in the testes of male subjects who have had gender reassignment despite the presence of cryptorchidism (Mathews et al, 1999a). Past results of phallic reconstruction in male patients with limited penile tissue have been disappointing. Penile replacement with phalloplasty has now permitted successful reconstruction to be performed and allows most if not all genotypic males to be raised with a congruent sex (Lumen et al, 2008). Multiple flaps have been used successfully for phallic reconstruction (Bluebond-Langner and Redett, 2012; Massanyi et al, 2012).
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