Joel Hutcheson - Academia.edu (original) (raw)

Papers by Joel Hutcheson

The Journal of Urology, 1998

Amiodarone is an antiarrythmic agent, which is often successfully used when all other antiarrythm... more Amiodarone is an antiarrythmic agent, which is often successfully used when all other antiarrythmics have failed. Sterile epididymitis is a recognized complication of treatment in adults, occurring in up to 11% of patients. To date there have been no reported cases of amiodarone induced epididymitis in children. We present a previously unrecognized cause of epididymitis in boys. The medical records, including radiographic imaging, pathology and operative reports, of 2 postpubertal boys who had sterile epididymitis after prolonged therapy with amiodarone were reviewed. In both cases the onset of scrotal pain and subsequent evaluation led to diagnosis of epidydimitis. Amiodarone was determined to be the cause, and cessation of the drug resulted in symptom resolution in 1 case. While it remains uncertain, the pathophysiology of amiodarone induced epididymitis is likely related to its high concentration in testicular tissue. Recognition that amiodarone is a rare but significant cause of epididymitis in children is important to prevent unnecessary surgery in high risk patients. Amiodarone induced epididymitis in children tends to be a self-limited process and of secondary importance to the serious cardiac disease. Whereas discontinuing amiodarone risks sudden cardiac death, a reduction in dosage or temporary cessation of the drug may result in rapid resolution of the epididymitis.

Advances in experimental medicine and biology, 2003

The function of the bladder is twofold: 1) to store urine at low pressure, and 2) under control o... more The function of the bladder is twofold: 1) to store urine at low pressure, and 2) under control of the nervous system, to generate a contractile force coordinated with a lowered urethral resistance that allows for emptying.20 Clinically, this system is most commonly affected by bladder outlet obstruction, and the response of the detrusor is remarkable in its variability. Experimentally, most investigators agree that after outlet obstruction, there is an increase in bladder mass seen irrespective of the model used. Within most experimental models of partial obstruction (as with humans), there exists a degree of variability in terms of detrusor response. Some bladders enter a state of compensation and are able to sustain elevated voiding pressures and empty satisfactorily. Others enter a state of decompensation and lose their ability to empty effectively.15 The molecular mechanisms for such decompensations are under current investigation, and may involve alterations in cytosolic calcium handling,19,21 disruptions in mitochondrial function,4 and changes in the expression of contractile filaments.1 In the late stages, as the bladder slides into the decompensated state, major depositions of extracellular matrix are seen in a variety of species.3,9,11

Bladder Disease, Part A, 2003

... 2003;539(Pt B):773-90. The fate of urinary bladder smooth muscle after outlet obstruction--a ... more ... 2003;539(Pt B):773-90. The fate of urinary bladder smooth muscle after outlet obstruction--a role for the sarcoplasmic reticulum. Stein R, Gong C, Hutcheson J, Krasnopolsky L, Canning DA, Carr M, Zderic SA. Division of Urology, Children's Hospital of Philadelphia, USA. ...

Advances in Experimental Medicine and Biology, 1999

Urologia Internationalis, 2000

An enlarged scrotum in the pediatric population constitutes a relatively frequent physical findin... more An enlarged scrotum in the pediatric population constitutes a relatively frequent physical finding requiring evaluation. Most cases of scrotomegaly have a clearly identifiable etiology. We present a patient with an idiopathic congenital dysmorphic megascrotum.

Urology, 2002

Extrarenal collections of urine have long been associated with obstructive uropathy and may prese... more Extrarenal collections of urine have long been associated with obstructive uropathy and may preserve renal function by acting as a "popoff" valve. Although urinary extravasation manifested as urinary ascites carries a favorable prognosis, perinephric urinomas occurring prenatally are associated with poor renal function in most cases. We report the case of a baby girl with a urinoma diagnosed by fetal magnetic resonance imaging and discuss the significance of this radiologic finding. UROLOGY 60: 697vi-697vii, 2002.

Urology, 2009

Cystic dysplasia of the testis (CDT) is a rare entity that typically does not present with orchal... more Cystic dysplasia of the testis (CDT) is a rare entity that typically does not present with orchalgia in affected patients. Most patients with CDT are asymptomatic and have ipsilateral renal malformations. Our patient with CDT was referred because of prolonged unilateral orchalgia. Computed tomography demonstrated an ipsilateral atrophic kidney and hydro-ureter traveling posterior to the bladder. Orchalgia resolved with resection of the dysplastic kidney and ectopic ureter, which drained to an enlarged seminal vesicle. Atypical symptoms associated with CDT, such as chronic orchalgia, should prompt additional investigation to rule out concomitant malformations. This is the first report of an ectopic ureter associated with CDT.

Urologic Clinics of North America, 2004

Circumcision is one of the oldest surgical procedures performed today. The practice of circumcisi... more Circumcision is one of the oldest surgical procedures performed today. The practice of circumcision in males and females arose in many ancient cultures. Conflicting theories have been proposed to account for this ritual, including a sacrifice or sign of submission to a deity, a fertility offering, a mark of tribal identification, a rite of passage to adulthood, and a means of humiliating and marking vanquished enemies [1]. Circumcision was performed in ancient Egypt and as a ritual by Jews and is described in Genesis [2]. Male circumcision became a common medical practice in the 19th century, with improved anesthetic, surgical, and antiseptic techniques. The prevention of masturbation was one of the primary indications for circumcision. With the ''medicalization'' of circumcision, such misconceptions about the role of circumcision persist [3]. Approximately one man in six is circumcised worldwide. Circumcision is the fifth most common procedure performed in the United States today [4]. In 1992, nearly 1.2 million circumcisions were performed, with 62% of newborn males undergoing the procedure [5]. The practice of circumcision the United States increased dramatically following World War II and peaked in the mid-1970s, when the American Association of Pediatrics (AAP) stated it was not a medically necessary procedure [2]. The AAP reversed its stance, however, after evidence documented an increased risk for urinary tract infections (UTIs) in uncircumcised male infants [6]. At present, routine neonatal circumcision is neither recommended nor condemned by the AAP [7]. It is left to the physician to discuss the pros and cons of circumcision, including the controversy, potential medical benefit, and complications involved with this procedure. Controversies Risk for urinary tract infection Uncircumcised infant males are at increased risk for UTI, especially during the first year of life [6,8-14]. The increase in risk is presumably secondary to increased periurethral bacterial colonization. The incidence of UTI in uncircumcised males is low and ranges between 1 in 100 and 1 in 140. UTI risk seems to be reduced in circumcised males by up to 10 fold. Many of the studies examining the role of circumcision in preventing UTI have not assessed and controlled systematically for other factors, including breastfeeding, that may decrease risk. A recent study has suggested that tight covering of the urethral meatus by the prepuce may increase the risk for UTI [15]. The low risk for UTI in uncircumcised males does not warrant mandatory circumcision. See later discussion for the role of circumcision in those at higher risk for UTI. Anesthesia/analgesia Neonatal circumcisions usually are performed within the first several days of life. Before the 1990s, anesthesia was not used routinely. In a recent survey of physicians stratified by specialty and geography, 35% of pediatricians, 60% of family practitioners, and 70% of obstetricians responding to a questionnaire performed at least one circumcision per month. Of these physicians, only 45%

Neurourology and Urodynamics, 2004

Aims: Recent advances in genetic manipulation have allowed for over expression or deletion of sel... more Aims: Recent advances in genetic manipulation have allowed for over expression or deletion of selective genes in mice. This o¡ers urologic investigators new means of understanding bladder function in the context of normal development or the response to outlet obstruction. It is important to correlate any genetic manipulations in mice with speci¢c phenotypic properties such as voiding patterns, or muscle strip physiology. We describe a simple in vivo whole bladder preparation that may be used to study the phenotypic changes in bladder function. Methods: Murine bladders were mounted on a 30 gauge needle and mounted in an organ chamber containing a physiologic bu¡er solution. Passive bladder properties were assessed with cystometry, and active contractile responses were measured in response to electrical ¢eld stimulation and agonists. The e¡ects of hypoxia were also studied. Results: Compliance in the murine bladder is dependent upon actin myosin interactions, and increased in the presence of calcium free bu¡er and EGTA. The sarcoplasmic reticulum plays a smaller role in the contraction of murine bladder than in other species. Murine bladder smooth muscle demonstrated a remarkable ability to withstand hypoxia. Conclusions: This simple model can be adapted to help study the murine bladder smooth muscle phenotype under highly controlled circumstances. Neurourol. Urodynam. 23:349^354, 2004.

The Journal of Urology, 2002

The Journal of Urology, 2001

The Journal of Urology, 2000

Purpose: We compared pathological findings in ectopic and undescended testis to determine whether... more Purpose: We compared pathological findings in ectopic and undescended testis to determine whether the pathological evidence supports the hypothesis that the 2 conditions are variants of the same congenital anomaly. Materials and Methods: We identified 24 boys with ectopic testis not in the superfical inguinal pouch of Denis Browne. Seven boys were excluded from study due to unavailable clinical records for 3, contralateral undescended testis in 2 and inadequate biopsy specimens in 2. Pathological findings of ectopic testis in the remaining 17 patients were compared with those of age matched patients with unilateral undescended testis. Total germ cell count, testicular volume, patency of the processus vaginalis and epididymal abnormalities were compared. Data were analyzed using the Wilcoxon matched pairs signed rank and Fisher's exact tests. Results: No difference was noted in total germ cell count (p ϭ 0.33), testicular volume (p ϭ 0.1475), processus vaginalis patency (p ϭ 0.0854) or epididymal abnormalities (p ϭ 1.00) in the 2 groups. Of the 24 boys (8%) with ectopic testis 2 also had a contralateral undescended testis. Conclusions: Similar pathological findings in ectopic and undescended testes as well as the association of ectopic testis with a contralateral undescended testis suggest that ectopic and undescended testes are variants of the same congenital anomaly. Thus, boys with ectopic testis may have an increased incidence of subfertility and testicular malignancy. This spectrum of abnormal testicular position, and its range of pathological conditions and complications may appropriately be called the undescended testis sequence.

The Journal of Urology, 2000

Purpose: Endoscopic incision was performed as the initial therapy for ureteroceles in children pr... more Purpose: Endoscopic incision was performed as the initial therapy for ureteroceles in children presenting to our institutions between 1985 and 1990. To assess the long-term efficacy of this treatment modality we reevaluated the outcome of these patients. Materials and Methods: Parameters reviewed included patient age at surgery, position of the ureterocele, a duplex system, preoperative and postoperative reflux, and the need for additional operations. Statistical analysis consisted of chi-square and Wilcoxon's rank sum tests. Results: Of the patients 22 had intravesical and 22 had extravesical ureteroceles. Average age at initial surgery was 1.9 Ϯ 3.7 years with average followup of 7.2 Ϯ 3.1 years. A second operation was required in 18 cases (41%), which was significantly more likely for an extravesical ureterocele (18% versus 64%, p ϭ 0.002), a duplex system (p ϭ 0.026) or preoperative reflux (p ϭ 0.02). Second operations included reimplantation in 13 cases, upper pole partial nephrectomy in 7, total nephroureterectomy in 3, bladder neck reconstruction in 3 and lower pole pyeloplasty in 3. The only secondary operations performed for intravesical ureteroceles were reimplantation in 3 cases and upper pole nephrectomy in 1. New onset reflux developed in 14 of 27 patients (52%) postoperatively, including 7 with intravesical and 7 with extravesical ureteroceles. None required a second open operation. Conclusions: With extended followup the percentage of patients requiring open surgery after endoscopic incision of ureteroceles increased from our original report of 27% to 41% (p ϭ 0.166). Only 18% of cases with an intravesical ureterocele required a subsequent operation compared to 64% with an extravesical ureterocele (p ϭ 0.002). The reduction in size of the obstructed ureter following endoscopic decompression facilitated successful reimplantation. Endoscopic puncture permits definitive treatment in the majority of children by at most a single incision, open operation at the bladder level.

The Journal of Urology, 2000

Achieving a scrotally positioned testis with no iatrogenic atrophy is the primary goal of the sur... more Achieving a scrotally positioned testis with no iatrogenic atrophy is the primary goal of the surgical treatment of cryptorchidism. The success rate is associated with preoperative testicular position and the technique used. Our success rate with inguinal orchiopexy for abdominal testis is higher than those previously published and may be due to our anatomical approach to retroperitoneal dissection. We review the relevant anatomy and discuss the surgical technique of inguinal orchiopexy. We researched and reviewed the relevant technical and anatomical literature on inguinal orchiopexy, and describe the anatomical approach to orchiopexy in detail. An understanding of the retroperitoneal fascial layers is the key to understanding surgery of the retroperitoneum. Dividing the internal spermatic fascia is required for the surgeon to separate the processus vaginalis from the vas and vessels. The average age of children undergoing cryptorchid surgery has decreased dramatically during the last 40 years. In such young patients extensive mobilization of the vas and vessels may be accomplished through a relatively small incision. We believe that our success rate with inguinal orchiopexy for abdominal testis is associated with our anatomical approach to retroperitoneal dissection.

The Journal of Urology, 1999

The Journal of Urology, 1999

The Journal of Urology, 2000

Purpose: Regulation of calcium ion homeostasis has a significant role in smooth muscle contractil... more Purpose: Regulation of calcium ion homeostasis has a significant role in smooth muscle contractility. The sarcoplasmic endoplasmic reticulum, calcium, magnesium, adenosine triphosphatase (SERCA) is a regulatory ion pump that may have a role in the functional outcome after outlet obstruction. We investigate what correlation if any existed between SERCA protein and gene expression, and the contractile properties in the same bladder. Materials and Methods: Standardized partial bladder outlet obstructions were created in adult New Zealand white rabbits, which were divided into control, sham operated and obstructed groups. Muscle strip studies subcategorized the obstructed group into compensated (force greater than 50% of control) and decompensated (force less than 50% of control). Microsomal membrane and total RNA fractions were prepared from the same bladder tissue. Membrane proteins were used for Western blot analysis using a SERCA specific monoclonal antibody, and total RNA was assessed with Northern blot analysis. Results: The relative intensities of signals for the Western and Northern blots demonstrated a strong correlation between protein and gene expression. Furthermore there was a strong association between the loss of SERCA messenger RNA and protein expression and loss of bladder function. Conclusions: Bladder contractility after outlet obstruction is influenced in part by smooth muscle cell ability to maintain calcium homeostasis via SERCA. The loss of SERCA protein expression is mediated by down-regulation in gene expression in the same bladder. These data suggest that smooth muscle ion pump gene expression is in part mechanically (pressure work) regulated.

The Journal of Urology, 1999

The Journal of Urology, 2000

The Journal of Urology, 2002

The Page kidney phenomenon is usually associated with blunt renal trauma and accompanying perinep... more The Page kidney phenomenon is usually associated with blunt renal trauma and accompanying perinephric or subcapsular hematoma. We describe a case of Page kidney due to a subcapsular urinoma, likely resultant from blunt trauma. CASE REPORT In March 2001 a 16-year-old white male was referred for evaluation of acute right flank pain. The patient’s medical, surgical, social and family histories were remarkable only for a family history of nephrolithiasis and, at the time of evaluation, participation on his high school wrestling team. Physical examination was remarkable for a blood pressure of 140/90 mm. Hg and right flank tenderness. Urinalysis revealed microhematuria. Noncontrast enhanced computerized tomography of the abdomen and pelvis demonstrated bilateral subcapsular fluid collections. Subsequent images, following intravenous administration of contrast agent, showed extravasation of contrast material into the subcapsular fluid collections (fig. 1). For further definition of the nature of the fluid collections the patient underwent magnetic resonance imaging of the kidneys. Characteristics of the fluid collections on T1 and T2-weighted images were consistent with that of urine (fig. 2). In addition, peripheral plasma renin activity was found to be 36 ng./ml. per hour (normal less than 3.3). Hypertension was treated with lisinopril. Initial surgical management included cystoscopy, retrograde pyelography and ureteral stent placement. Retrograde pyelography revealed bilateral pyelotubular backflow, with extravasation of contrast material. A right ureteral stent was placed to optimize drainage of the collecting system as this was the side on which the patient was symptomatic. Following stent placement, the patient refrained from strenuous physical activity. Followup imaging of the kidneys 2 months later showed resolution of the subcapsular fluid collections. In addition, blood pressure normalized, and the patient was weaned off of the antihypertensive medication 4 months after initial presentation.

The Journal of Urology, 1998

Amiodarone is an antiarrythmic agent, which is often successfully used when all other antiarrythm... more Amiodarone is an antiarrythmic agent, which is often successfully used when all other antiarrythmics have failed. Sterile epididymitis is a recognized complication of treatment in adults, occurring in up to 11% of patients. To date there have been no reported cases of amiodarone induced epididymitis in children. We present a previously unrecognized cause of epididymitis in boys. The medical records, including radiographic imaging, pathology and operative reports, of 2 postpubertal boys who had sterile epididymitis after prolonged therapy with amiodarone were reviewed. In both cases the onset of scrotal pain and subsequent evaluation led to diagnosis of epidydimitis. Amiodarone was determined to be the cause, and cessation of the drug resulted in symptom resolution in 1 case. While it remains uncertain, the pathophysiology of amiodarone induced epididymitis is likely related to its high concentration in testicular tissue. Recognition that amiodarone is a rare but significant cause of epididymitis in children is important to prevent unnecessary surgery in high risk patients. Amiodarone induced epididymitis in children tends to be a self-limited process and of secondary importance to the serious cardiac disease. Whereas discontinuing amiodarone risks sudden cardiac death, a reduction in dosage or temporary cessation of the drug may result in rapid resolution of the epididymitis.

Advances in experimental medicine and biology, 2003

The function of the bladder is twofold: 1) to store urine at low pressure, and 2) under control o... more The function of the bladder is twofold: 1) to store urine at low pressure, and 2) under control of the nervous system, to generate a contractile force coordinated with a lowered urethral resistance that allows for emptying.20 Clinically, this system is most commonly affected by bladder outlet obstruction, and the response of the detrusor is remarkable in its variability. Experimentally, most investigators agree that after outlet obstruction, there is an increase in bladder mass seen irrespective of the model used. Within most experimental models of partial obstruction (as with humans), there exists a degree of variability in terms of detrusor response. Some bladders enter a state of compensation and are able to sustain elevated voiding pressures and empty satisfactorily. Others enter a state of decompensation and lose their ability to empty effectively.15 The molecular mechanisms for such decompensations are under current investigation, and may involve alterations in cytosolic calcium handling,19,21 disruptions in mitochondrial function,4 and changes in the expression of contractile filaments.1 In the late stages, as the bladder slides into the decompensated state, major depositions of extracellular matrix are seen in a variety of species.3,9,11

Bladder Disease, Part A, 2003

... 2003;539(Pt B):773-90. The fate of urinary bladder smooth muscle after outlet obstruction--a ... more ... 2003;539(Pt B):773-90. The fate of urinary bladder smooth muscle after outlet obstruction--a role for the sarcoplasmic reticulum. Stein R, Gong C, Hutcheson J, Krasnopolsky L, Canning DA, Carr M, Zderic SA. Division of Urology, Children's Hospital of Philadelphia, USA. ...

Advances in Experimental Medicine and Biology, 1999

Urologia Internationalis, 2000

An enlarged scrotum in the pediatric population constitutes a relatively frequent physical findin... more An enlarged scrotum in the pediatric population constitutes a relatively frequent physical finding requiring evaluation. Most cases of scrotomegaly have a clearly identifiable etiology. We present a patient with an idiopathic congenital dysmorphic megascrotum.

Urology, 2002

Extrarenal collections of urine have long been associated with obstructive uropathy and may prese... more Extrarenal collections of urine have long been associated with obstructive uropathy and may preserve renal function by acting as a "popoff" valve. Although urinary extravasation manifested as urinary ascites carries a favorable prognosis, perinephric urinomas occurring prenatally are associated with poor renal function in most cases. We report the case of a baby girl with a urinoma diagnosed by fetal magnetic resonance imaging and discuss the significance of this radiologic finding. UROLOGY 60: 697vi-697vii, 2002.

Urology, 2009

Cystic dysplasia of the testis (CDT) is a rare entity that typically does not present with orchal... more Cystic dysplasia of the testis (CDT) is a rare entity that typically does not present with orchalgia in affected patients. Most patients with CDT are asymptomatic and have ipsilateral renal malformations. Our patient with CDT was referred because of prolonged unilateral orchalgia. Computed tomography demonstrated an ipsilateral atrophic kidney and hydro-ureter traveling posterior to the bladder. Orchalgia resolved with resection of the dysplastic kidney and ectopic ureter, which drained to an enlarged seminal vesicle. Atypical symptoms associated with CDT, such as chronic orchalgia, should prompt additional investigation to rule out concomitant malformations. This is the first report of an ectopic ureter associated with CDT.

Urologic Clinics of North America, 2004

Circumcision is one of the oldest surgical procedures performed today. The practice of circumcisi... more Circumcision is one of the oldest surgical procedures performed today. The practice of circumcision in males and females arose in many ancient cultures. Conflicting theories have been proposed to account for this ritual, including a sacrifice or sign of submission to a deity, a fertility offering, a mark of tribal identification, a rite of passage to adulthood, and a means of humiliating and marking vanquished enemies [1]. Circumcision was performed in ancient Egypt and as a ritual by Jews and is described in Genesis [2]. Male circumcision became a common medical practice in the 19th century, with improved anesthetic, surgical, and antiseptic techniques. The prevention of masturbation was one of the primary indications for circumcision. With the ''medicalization'' of circumcision, such misconceptions about the role of circumcision persist [3]. Approximately one man in six is circumcised worldwide. Circumcision is the fifth most common procedure performed in the United States today [4]. In 1992, nearly 1.2 million circumcisions were performed, with 62% of newborn males undergoing the procedure [5]. The practice of circumcision the United States increased dramatically following World War II and peaked in the mid-1970s, when the American Association of Pediatrics (AAP) stated it was not a medically necessary procedure [2]. The AAP reversed its stance, however, after evidence documented an increased risk for urinary tract infections (UTIs) in uncircumcised male infants [6]. At present, routine neonatal circumcision is neither recommended nor condemned by the AAP [7]. It is left to the physician to discuss the pros and cons of circumcision, including the controversy, potential medical benefit, and complications involved with this procedure. Controversies Risk for urinary tract infection Uncircumcised infant males are at increased risk for UTI, especially during the first year of life [6,8-14]. The increase in risk is presumably secondary to increased periurethral bacterial colonization. The incidence of UTI in uncircumcised males is low and ranges between 1 in 100 and 1 in 140. UTI risk seems to be reduced in circumcised males by up to 10 fold. Many of the studies examining the role of circumcision in preventing UTI have not assessed and controlled systematically for other factors, including breastfeeding, that may decrease risk. A recent study has suggested that tight covering of the urethral meatus by the prepuce may increase the risk for UTI [15]. The low risk for UTI in uncircumcised males does not warrant mandatory circumcision. See later discussion for the role of circumcision in those at higher risk for UTI. Anesthesia/analgesia Neonatal circumcisions usually are performed within the first several days of life. Before the 1990s, anesthesia was not used routinely. In a recent survey of physicians stratified by specialty and geography, 35% of pediatricians, 60% of family practitioners, and 70% of obstetricians responding to a questionnaire performed at least one circumcision per month. Of these physicians, only 45%

Neurourology and Urodynamics, 2004

Aims: Recent advances in genetic manipulation have allowed for over expression or deletion of sel... more Aims: Recent advances in genetic manipulation have allowed for over expression or deletion of selective genes in mice. This o¡ers urologic investigators new means of understanding bladder function in the context of normal development or the response to outlet obstruction. It is important to correlate any genetic manipulations in mice with speci¢c phenotypic properties such as voiding patterns, or muscle strip physiology. We describe a simple in vivo whole bladder preparation that may be used to study the phenotypic changes in bladder function. Methods: Murine bladders were mounted on a 30 gauge needle and mounted in an organ chamber containing a physiologic bu¡er solution. Passive bladder properties were assessed with cystometry, and active contractile responses were measured in response to electrical ¢eld stimulation and agonists. The e¡ects of hypoxia were also studied. Results: Compliance in the murine bladder is dependent upon actin myosin interactions, and increased in the presence of calcium free bu¡er and EGTA. The sarcoplasmic reticulum plays a smaller role in the contraction of murine bladder than in other species. Murine bladder smooth muscle demonstrated a remarkable ability to withstand hypoxia. Conclusions: This simple model can be adapted to help study the murine bladder smooth muscle phenotype under highly controlled circumstances. Neurourol. Urodynam. 23:349^354, 2004.

The Journal of Urology, 2002

The Journal of Urology, 2001

The Journal of Urology, 2000

Purpose: We compared pathological findings in ectopic and undescended testis to determine whether... more Purpose: We compared pathological findings in ectopic and undescended testis to determine whether the pathological evidence supports the hypothesis that the 2 conditions are variants of the same congenital anomaly. Materials and Methods: We identified 24 boys with ectopic testis not in the superfical inguinal pouch of Denis Browne. Seven boys were excluded from study due to unavailable clinical records for 3, contralateral undescended testis in 2 and inadequate biopsy specimens in 2. Pathological findings of ectopic testis in the remaining 17 patients were compared with those of age matched patients with unilateral undescended testis. Total germ cell count, testicular volume, patency of the processus vaginalis and epididymal abnormalities were compared. Data were analyzed using the Wilcoxon matched pairs signed rank and Fisher's exact tests. Results: No difference was noted in total germ cell count (p ϭ 0.33), testicular volume (p ϭ 0.1475), processus vaginalis patency (p ϭ 0.0854) or epididymal abnormalities (p ϭ 1.00) in the 2 groups. Of the 24 boys (8%) with ectopic testis 2 also had a contralateral undescended testis. Conclusions: Similar pathological findings in ectopic and undescended testes as well as the association of ectopic testis with a contralateral undescended testis suggest that ectopic and undescended testes are variants of the same congenital anomaly. Thus, boys with ectopic testis may have an increased incidence of subfertility and testicular malignancy. This spectrum of abnormal testicular position, and its range of pathological conditions and complications may appropriately be called the undescended testis sequence.

The Journal of Urology, 2000

Purpose: Endoscopic incision was performed as the initial therapy for ureteroceles in children pr... more Purpose: Endoscopic incision was performed as the initial therapy for ureteroceles in children presenting to our institutions between 1985 and 1990. To assess the long-term efficacy of this treatment modality we reevaluated the outcome of these patients. Materials and Methods: Parameters reviewed included patient age at surgery, position of the ureterocele, a duplex system, preoperative and postoperative reflux, and the need for additional operations. Statistical analysis consisted of chi-square and Wilcoxon's rank sum tests. Results: Of the patients 22 had intravesical and 22 had extravesical ureteroceles. Average age at initial surgery was 1.9 Ϯ 3.7 years with average followup of 7.2 Ϯ 3.1 years. A second operation was required in 18 cases (41%), which was significantly more likely for an extravesical ureterocele (18% versus 64%, p ϭ 0.002), a duplex system (p ϭ 0.026) or preoperative reflux (p ϭ 0.02). Second operations included reimplantation in 13 cases, upper pole partial nephrectomy in 7, total nephroureterectomy in 3, bladder neck reconstruction in 3 and lower pole pyeloplasty in 3. The only secondary operations performed for intravesical ureteroceles were reimplantation in 3 cases and upper pole nephrectomy in 1. New onset reflux developed in 14 of 27 patients (52%) postoperatively, including 7 with intravesical and 7 with extravesical ureteroceles. None required a second open operation. Conclusions: With extended followup the percentage of patients requiring open surgery after endoscopic incision of ureteroceles increased from our original report of 27% to 41% (p ϭ 0.166). Only 18% of cases with an intravesical ureterocele required a subsequent operation compared to 64% with an extravesical ureterocele (p ϭ 0.002). The reduction in size of the obstructed ureter following endoscopic decompression facilitated successful reimplantation. Endoscopic puncture permits definitive treatment in the majority of children by at most a single incision, open operation at the bladder level.

The Journal of Urology, 2000

Achieving a scrotally positioned testis with no iatrogenic atrophy is the primary goal of the sur... more Achieving a scrotally positioned testis with no iatrogenic atrophy is the primary goal of the surgical treatment of cryptorchidism. The success rate is associated with preoperative testicular position and the technique used. Our success rate with inguinal orchiopexy for abdominal testis is higher than those previously published and may be due to our anatomical approach to retroperitoneal dissection. We review the relevant anatomy and discuss the surgical technique of inguinal orchiopexy. We researched and reviewed the relevant technical and anatomical literature on inguinal orchiopexy, and describe the anatomical approach to orchiopexy in detail. An understanding of the retroperitoneal fascial layers is the key to understanding surgery of the retroperitoneum. Dividing the internal spermatic fascia is required for the surgeon to separate the processus vaginalis from the vas and vessels. The average age of children undergoing cryptorchid surgery has decreased dramatically during the last 40 years. In such young patients extensive mobilization of the vas and vessels may be accomplished through a relatively small incision. We believe that our success rate with inguinal orchiopexy for abdominal testis is associated with our anatomical approach to retroperitoneal dissection.

The Journal of Urology, 1999

The Journal of Urology, 1999

The Journal of Urology, 2000

Purpose: Regulation of calcium ion homeostasis has a significant role in smooth muscle contractil... more Purpose: Regulation of calcium ion homeostasis has a significant role in smooth muscle contractility. The sarcoplasmic endoplasmic reticulum, calcium, magnesium, adenosine triphosphatase (SERCA) is a regulatory ion pump that may have a role in the functional outcome after outlet obstruction. We investigate what correlation if any existed between SERCA protein and gene expression, and the contractile properties in the same bladder. Materials and Methods: Standardized partial bladder outlet obstructions were created in adult New Zealand white rabbits, which were divided into control, sham operated and obstructed groups. Muscle strip studies subcategorized the obstructed group into compensated (force greater than 50% of control) and decompensated (force less than 50% of control). Microsomal membrane and total RNA fractions were prepared from the same bladder tissue. Membrane proteins were used for Western blot analysis using a SERCA specific monoclonal antibody, and total RNA was assessed with Northern blot analysis. Results: The relative intensities of signals for the Western and Northern blots demonstrated a strong correlation between protein and gene expression. Furthermore there was a strong association between the loss of SERCA messenger RNA and protein expression and loss of bladder function. Conclusions: Bladder contractility after outlet obstruction is influenced in part by smooth muscle cell ability to maintain calcium homeostasis via SERCA. The loss of SERCA protein expression is mediated by down-regulation in gene expression in the same bladder. These data suggest that smooth muscle ion pump gene expression is in part mechanically (pressure work) regulated.

The Journal of Urology, 1999

The Journal of Urology, 2000

The Journal of Urology, 2002

The Page kidney phenomenon is usually associated with blunt renal trauma and accompanying perinep... more The Page kidney phenomenon is usually associated with blunt renal trauma and accompanying perinephric or subcapsular hematoma. We describe a case of Page kidney due to a subcapsular urinoma, likely resultant from blunt trauma. CASE REPORT In March 2001 a 16-year-old white male was referred for evaluation of acute right flank pain. The patient’s medical, surgical, social and family histories were remarkable only for a family history of nephrolithiasis and, at the time of evaluation, participation on his high school wrestling team. Physical examination was remarkable for a blood pressure of 140/90 mm. Hg and right flank tenderness. Urinalysis revealed microhematuria. Noncontrast enhanced computerized tomography of the abdomen and pelvis demonstrated bilateral subcapsular fluid collections. Subsequent images, following intravenous administration of contrast agent, showed extravasation of contrast material into the subcapsular fluid collections (fig. 1). For further definition of the nature of the fluid collections the patient underwent magnetic resonance imaging of the kidneys. Characteristics of the fluid collections on T1 and T2-weighted images were consistent with that of urine (fig. 2). In addition, peripheral plasma renin activity was found to be 36 ng./ml. per hour (normal less than 3.3). Hypertension was treated with lisinopril. Initial surgical management included cystoscopy, retrograde pyelography and ureteral stent placement. Retrograde pyelography revealed bilateral pyelotubular backflow, with extravasation of contrast material. A right ureteral stent was placed to optimize drainage of the collecting system as this was the side on which the patient was symptomatic. Following stent placement, the patient refrained from strenuous physical activity. Followup imaging of the kidneys 2 months later showed resolution of the subcapsular fluid collections. In addition, blood pressure normalized, and the patient was weaned off of the antihypertensive medication 4 months after initial presentation.