[Seminal vesical abscess and ipsilateral agenesis of the kidney]

So far only about 20 cases were published on abscesses of the seminal vesicles and only two patients suffered also from agenesis of one kidney. The presented case-history pertains to a patient with a history of haemospermia and a cystically dilated formation in the region of the posterior urethra on ascendent urethrocytography. The solution was surgery-revision and extirpation.

Torsion of an indirect hernia sac: an unusual cause of acute scrotal swelling in children

OBJECTIVES

An indirect inguinal hernia is a common cause of inguinoscrotal swelling in young boys. We describe 3 cases of an extremely unusual entity that has a similar clinical presentation to more commonly diagnosed intrascrotal processes.

METHODS

Two patients presented with acute hemiscrotal enlargement and pain, and a third patient presented with scrotal enlargement only. All patients underwent a scrotal ultrasound evaluation and subsequent inguinoscrotal exploration.

RESULTS

All patients had a multiseptated peritesticular fluid-filled mass on ultrasound evaluation. Subsequent inguinoscrotal exploration revealed a torsion of the indirect hernia sac in each case. A high ligation and excision of the sac was curative.

CONCLUSIONS

Torsion of a hernia sac is an extremely rare entity, and current sonographic imaging fails to clearly diagnose this unusual phenomenon. Because pediatric urologists are commonly called to evaluate a child with an acutely swollen scrotum, awareness of this diagnosis is important.

Skin graft reconstruction of chronic genital lymphedema

OBJECTIVES

We present a simple, reliable method of scrotal and penile reconstruction yielding satisfactory cosmetic and functional results for patients with disabling chronic genital lymphedema.

METHODS

Nine patients were treated with wide excision of the affected genital skin and subsequent coverage of exposed areas with split-thickness skin grafts in a single-stage procedure.

RESULTS

All patients have had excellent cosmetic results without recurrence of genital lymphedema or compromise of sexual function postoperatively.

CONCLUSIONS

Single-stage reconstruction for idiopathic genital lymphedema by radical skin excision and split-thickness skin grafting provides gratifying functional and cosmetic results.

[Chronic lymphedema in the genital area. Etiology and therapeutic possibilities]

The chronic lymph edema, the elephantiasis of the male genitals, is a rare in areas without endemic filiriasis. The genesis of the lymph edema in the genital area is manifold. Diagnostic procedures and considerations determine the chain of events leading to the development of lymph edema in the genital area. Only then, an optimal treatment concept may be established. This includes conservative, conservative surgical, and surgical techniques. The principles of a differentiated treatment procedure is demonstrated by using the literature. The individual procedure depends mainly on the etiology, course of the disease, and the local situation.

Comparison of 1997 Medicare relative value units for gender-specific procedures: is Adam still worth more than Eve?

BACKGROUND

On January 1, 1992, Congress implemented a Medicare payment system based on relative value units (RVUs). The total RVU (which is made up of work, practice, and malpractice RVUs) is multiplied by a dollar conversion factor to set the reimbursement for all procedures covered by Medicare. In a previous study, we found that significant gender bias exists in Medicare reimbursement for female-specific services. Recently, HCFA approved increases (beginning January 1997) in the work RVU for many gynecologic procedures. This study was undertaken to compare work and total RVUs for gender-specific procedures effective January 1, 1997.

METHODS

Using the May 1996 Federal Register, we compared work and total RVUs for 24 pairs of gender-specific procedures. The groups were matched so that the amount of work and level of difficulty would be similar, if not identical. We validated our selection of procedures for comparison by also evaluating the average time required to perform these procedures.

RESULTS

Comparison of work RVUs for the 24 paired procedures revealed that in 19 cases (80%), male-specific procedures had a higher RVU; in 3 cases (12%), female-specific procedures were higher; and in 2 cases, there was no difference. On average, work RVUs were 49% higher for urologic procedures than for gynecologic procedures. Comparison of total RVUs revealed that in 20 cases (83%), urologic procedures had a higher total RVU and in 3 cases (12%), gynecologic procedures were higher. On average, male-specific surgeries are reimbursed at an amount which is 37% higher than that for female-specific surgeries.

CONCLUSION

Recent increases in work RVUs for many gynecologic procedures have resulted in improved reimbursement. However, even with these improvements, significant gender bias still exists in the Medicare reimbursement of female-specific procedures. This gender bias is further magnified as more private insurance carriers use the system to set reimbursement.

[Plastic surgery as a last resort in lichen sclerosus]

Lichen sclerosus, formerly called lichen sclerosus et atrophicus, is a chronic skin disease manifesting itself mostly in the perineal region and often associated with itching. Characteristic elements are well-defined depigmentation and degeneration of the skin sometimes showing haemorrhagic bullae or teleangiectases. The skin grows thinner and shrinks. Malignant degeneration is rare. The prevalence is 1:300 to 1:1000. The condition occurs more often in females than in males and more often in adults than in children. Drug treatment (symptomatic) comprises local application of corticosteroids, anaesthetics and/or sex hormones. In case of insufficient response, cryotherapy is a good alternative. Chemical and surgical neurotomy are also sometimes applied, with fairly poor results. In refractory symptoms, excision of the affected skin, possibly with transplantation using a pedicled skin flap, may lead to mitigation.

[Vesico-scrotal hernia. Report of a clinical case]

Incidental discovery of vesical hernias during herniorrhaphy is quite common. In such cases, patients are usually asymptomatic since the hernia portion is small and easily repairable. On the other hand, vesical solid protrusion to the scrotum is quite unusual, and is generally found associated to obstructive urinary symptoms. Management involves basically the correction of any associated obstructive conditions, correction of the vesical hernia and herniorrhaphy.

Intrascrotal epidermoid cyst with extension to the rectum wall: a case report

An 8-year-old boy presented with an asymptomatic intrascrotal epidermoid cyst with extension to deeper planes. Ultrasound examination showed no involvement of the testes or spermatic cord. Complete excision of the lesion was performed transcrotally. The histological examination of the lesion showed aspects with the same characteristics of epidermoid cysts found in the external genitalia.

[Systemic sarcoidosis with involvement of the spermatic cord]

A 49-year-old man presented with an enlarging, painful, right inguinal mass and small red nodules around his nose and upper lip. He had undergone an operation for a right inguinal hernia in childhood. Because malignancy was suspected, the right spermatic cord, testis, and epididymis were resected. Histological examination of the lesion in the spermatic cord revealed non-caseating epithelioid-cell granuloma and no acid-fast bacilli, which was compatible with sarcoidosis. A chest X-ray film and computed tomograms showed enlarged hilar lymph nodes and reticular infiltrates. Histological examination of specimens obtained by transbronchial lung biopsy and by skin biopsy also showed non-caseating epithelioid-cell granulomas. After resection of the spermatic cord, the activity of angiotensin-converting enzume was 29.9 IU/L, which was above the reference range. Systemic sarcoidosis with involvement of the spermatic cord was diagnosed. Because he had no respiratory symptoms and his skin lesions resolved without treatment, he is currently under observation and is not receiving corticosteroid therapy.

Sclerosing lipogranuloma of the scrotum following a laparoscopic herniorraphy and varicocelectomy--a case report

"Sclerosing lipogranuloma" was first coined to describe a lesion of adipose tissue thought to be due to trauma. Later, analysis of the fat within these lesions showed the presence of exogenous paraffin hydrocarbons and a link with paraffin injection was postulated. In Japan, lipogranulomas without a history of trauma or paraffin injection have been described more frequently. Our patient, developed such a lesion in his scrotum following a laparoscopic left herniorrhaphy and varicocelectomy (intra-abdominal approach). He had no prior history of trauma or paraffin injection. A possible relationship is postulated.

Extratesticular epidermoid cyst with extension into the pelvis

We report a case of simple epidermoid cyst of the scrotum with extension into the pelvis. Complete excision was performed transcrotally and the presence of epidermoid cyst confirmed by histopathological examination. Simple excision was sufficient for treatment of this very rare lesion. The patient is now in the follow-up period.

Surgical treatment of bilateral large seminal vesicle cysts associated with unilateral renoureteral agenesis

A 26-year-old man presented bilateral cysts of the vesicles, larger on the right side, associated with agenesis of right kidney and ureter. Surgical treatment consisted of removal of the right cyst and volume reduction of the left one. The embryological aspects are discussed, together with the clinical findings and the treatment options.

[Dirofilaria (Nochtiella) repens in the spermatic cord: a new human case in Italy]

A case of human dirofilariasis associated with Dirofilaria (Nochtiella) repens, localised in the spermatic duct, is reported in a 52-year-old man from Lugo di Romagna (Ravenna province, Northern Italy). It represents the 22nd case of human dirofilariasis occurring until now in the same region. According to the relevant world literature this appears to be the 2nd case with this rare localisation the first one occurring in Italy as well.

Erysipelas and elephantiasis of the scrotum--surgery and drug therapy

Elephantiasis of the scrotum is the terminal stage of persistent refractory lymphedema. Its debilitating functional and cosmetic effects have significant psychological, emotional and social consequences for the affected patient. The causal relationship between etiology and recurrent disease is illustrated here by 2 cases. Therapy options are also discussed. Primary therapeutic success is determined by radical surgery, since chronic inflammation and chronic oedema mutually foster one another. Metabolic stability, sanitization of infected cutaneous areas and the prophylactic administration of antibiotics are essential to ensure that the treatment of recurrent erysipelas is successful in the long term.

The Charles procedure: misquoted and misunderstood since 1950

The Charles procedure, named for Sir Richard Henry Havelock Charles, is an eponym for a surgical treatment of leg lymphedema. Sir Havelock led a fascinating life, with his travels taking him to India, the Afghan territories, and the Court of King George V of England. At the turn of this century, Sir Havelock published material describing a series of 140 consecutive patients treated successfully for scrotal lymphedema. In a book chapter published a decade later, entitled "Elephantiasis Scroti," Sir Havelock briefly described the treatment of leg lymphedema but did not document a single successful case report. The name of Sir Havelock Charles was absent from the literature until 1950, when Sir Archibald McIndoe attributed the treatment of leg lymphedema with radical excision and skin grafting to Sir Havelock. References to Charles for the treatment of leg lymphedema have proliferated since that time.

[Nonsurgical and endoscopic therapy in obstructive azoospermia]

The endoscopic therapy has an elective role in the distal obstructive azoospermia for urogenital carrefour pathologies both organics and functional and differently in the resection and/or aspiration with sperm recovery forms. Resolutely attends to the symptomatology and positively to the fertility re-establishment, in front of a short sickness-rate. The Authors describe the different techniques with relative indications, results and complications. Instead medical therapy has a role in the obstructive above all post infection and post inflammatory lesions prevention. Furthermore propose to oneself the goal to improve the seminal quality by the improvement of the semen fertilization capacity and to reduce the affections symptomatology. Finally concurs with the sperm selection techniques to fertility potential wealth.

[A case of Sparganosis mansoni with a painless mass in the inguinal region and the scrotum]

Sparganosis mansoni rarely occurs in the inguinal and perineal regions in Japan. A case of Sparganosis mansoni with a painless mass in the left inguinal region is presented. A 67-year-old male visited our hospital with a complaint of a painless mass in the left inguinal region in May, 1995, and another mass appeared in the scrotum two days after the first visit. Ultrasonography revealed a solid subcutaneous mass 2 cm in diameter. These masses were surgically excised by an inguinal approach and a parasite, 10 cm in length, was found in the mass. The parasite was diagnosed histologically as Sparganosis mansoni, which is a larva of the genus Diphyllobothrium.

[Indication for surgery of pediatric testicular and funicular hydroceles in view of natural course]

PURPOSE

The purpose of this study is to confirm the definite indication for surgery of pediatric testicular and funicular hydroceles in view of natural course.

METHODS

During the period from 1978 to 1994, we encountered 160 hydroceles in 149 pediatric patients. Patients ages ranged from 5 days after birth to 13 years and the mean follow-up periods was 4.7 years. We investigated the indication for surgery of pediatric hydroceles in six points of view: value of an aspiration of hydroceles, of what testicular or funicular or both, communication, size, age and testicular development.

RESULTS

Nevertheless, of 160 hydroceles, 66 (41%) were performed an aspiration of hydroceles, the aspiration of hydrocele was ineffective in the majority of patients. Common hydroceles in neonates and infants required no specific treatment, as the majority of hydrocele resolve spontaneously, however surgical treatment was required for a communicating large hydrocele that had been often attacked by aspiration and appeared at older age. Funicular hydroceles were more difficult to spontaneous healing. Ipsilateral testis manifests a well-developed comparing control material.

CONCLUSION

The indication for surgery of pediatric hydroceles were as follows: 1) hydroceles complicated by a inguinal hernia or cryptorchidism, 2) hydroceles appeared at older age and not resolved during 2-3 years over, 3) giant communicating funicular and testicular hydroceles present with an/hindrance for daily life.

[Clinical studies on acute scrotum--focusing on torsion of the spermatic cord]

Surgical exploration was done on 50 patients with acute scrotum between June 1982 and October 1995. Of them, 24 (48%) had torsion of the spermatic cord, 9 (18%) had torsion of the appendage testis, 11 (22%) had intrascrotal hematoma, 4 (8%) had acute epididymitis, and 2 (4%) had bleeding of testicular tumor. The patients who had torsion of the spermatic cord were between 0 and 26 years of age (the mean: 14.6); 9 had torsion on the right side, and 15 on the left side. Infectious manifestations occurred in about 30%, and Prehn's sign developed in 37.5%. Of all cases, orchiopexy was performed in 10 cases and orchiectomy in 14. The testis was saved in 8 (88.9%) of the 9 patients who underwent surgery within 12 hours after onset. On the contrary, the testis was saved in only 2 (13.3%) of the 15 patients who underwent surgery more than 12 hours after onset. We concluded that early consultation, and exploration by a urologist are obligatory in the treatment of torsion of the spermatic cord.

Is the conservative management of the acute scrotum justified on clinical grounds?

OBJECTIVE

To determine whether there is justification for a policy of conservative management of acute scrotal emergencies, based on the ability to exclude a twisted testicle or the assumption that there is a "missed torsion' when the duration of symptoms is prolonged.

PATIENTS AND METHODS

The case notes of 209 consecutive emergency scrotal explorations, carried out in one district general hospital over a 7-year period, were reviewed. The decision to operate was based solely on a clinical diagnosis, with no information from additional radiological investigations.

RESULTS

The commonest finding was testicular torsion (39.5%) with an orchidectomy rate of 22%. Only 5% of scrotal torsions occurred in patients < 12 years of age, whereas 26% occurred in those > 20 years of age. In five of 82 cases (6%) of confirmed testicular torsion, the surgeon did not consider this the most likely diagnosis. With a pain duration of < 16 h, 89% of testes were salvaged, but with pain for > 16 h this decreased to 25%. In three cases the testis was viable after pain had been present for > 24 h.

CONCLUSION

In the absence of supportive radiological investigations, a small but significant number of twisted testes will be missed if conservative management is adopted.

[Symptomatic efficacy of clotrimazole combined with surgery in the treatment of recurring anal and genital condylomatosis in seropositive and AIDS patients]

During their daily surgical activity in Hiv-positive and AIDS patients the authors have seen in surgical treatment of anogenital recurring acuminate condylomata (treated with diatermocoagulation) in 1995 that prescribing elotrimazole ointment in Candida albicans infection of the same regions there was and amelioration or the healing of the mycotic infection but also a net lowering of the condylomata and persistent latency (disease-free time) till to the next local recurrence. So they have hypothesized and antiviral and antiblastic effect of elotrimazole. Under this heading they have done a literature research discovering that in 1995, only some months ago, two fundamental works have been published on this intriguing topic. They demonstrate at an experimental level in mice a strong antiviral and antiblastic activity of clotrimazole. This new fascinating field is completely open to future research and the consequences at a therapeutic level will be of utmost importance.