A multi-institutional analysis of laparoscopic orchidopexy

OBJECTIVE

To combine and analyse the results from centres with a large experience of laparoscopy for the impalpable testis with small series, to determine the expected success rate for laparoscopic orchidopexy.

METHODS

A questionnaire was distributed to participating paediatric urologists; each contributor retrospectively reviewed the clinical charts for their cases of therapeutic laparoscopy for an impalpable testis, detailing 36 variables for each patient. The data were collated centrally into a computerized database. For inclusion, the testis was intra-abdominal (including 'peeping' at the internal ring) at laparoscopic examination, was not managed through an open approach and did not undergo orchidectomy. Three surgical groups were assessed, with success defined as lack of atrophy and intrascrotal position: group 1, primary laparoscopic orchidopexy; group 2, a one-stage Fowler-Stephens (F-S) orchidopexy; and group 3, a two-stage F-S orchidopexy.

RESULTS

Data were gathered from 10 centres in the USA, covering the period 1990-1999; 252 patients representing 310 testes were included and overall, 15.2% were lost to follow-up. There was no significant difference between success rates in the larger and smaller series. Atrophy occurred in 2.2% of 178 testes, 22.2% of 27 testes and 10.3% of 58 testes in groups 1-3, respectively. Testes were not in a satisfactory scrotal position in 0.6%, 7.4% and 1.7% of groups 1-3, respectively. The mean follow-up for each group was 7.7, 8.6 and 20.0 months, respectively. The overall success for all groups was 92.8% (97.2% group 1; 74.1% group 2; 87.9% group 3), with an atrophy rate of 6.1%.

CONCLUSION

Laparoscopic orchidopexy for the intra-abdominal testis, in both large and small series, can be expected to have a success rate higher than that historically ascribed to open orchidopexy. Within this series, single-stage F-S laparoscopic orchidopexy resulted in a significantly higher atrophy rate than the two-stage repair. However, when considering both F-S approaches, the laparoscopic approach gave greater success than previously reported for the same open approaches. Despite the weaknesses inherent in a retrospective unrandomized study, we conclude that laparoscopic orchidopexy is, if not the procedure of choice, an acceptable and successful approach to the impalpable undescended testicle.

Refined microscopic urinalysis for red blood cell morphology in the evaluation of asymptomatic microscopic hematuria in a pediatric population

PURPOSE

The use of refined microscopic urinalysis for the presence of dysmorphic red blood cells (RBCs) has been evaluated in children and adults with a known source of hematuria. We examined the clinical usefulness of this study in a pediatric population with an unknown source of hematuria.

MATERIALS AND METHODS

Children 12 years old or younger referred for evaluation of asymptomatic microscopic hematuria exhibiting 4 or more RBCs per high power field were enrolled in this study. Patients provided a first morning urine sample subjected to refined urinalysis for RBC morphology. Standard evaluation of patients was performed until a final diagnosis of the hematuria source was identified.

RESULTS

A total of 44 patients completed the study. Refined urinalysis revealed pure dysmorphic RBCs in 22 patients, pure isomorphic RBCs in 8 and mixed isomorphic/dysmorphic RBCs in 14. The presence of dysmorphic RBCs correctly predicted a glomerulotubular source of hematuria in 29 of 36 patients (sensitivity 83%, specificity 81%), while the presence of isomorphic RBCs predicted a uroepithelial source of hematuria in 2 of 8 patients (sensitivity 25%, specificity 22%). Hematuria and 2+ proteinuria (100 mg./dl.) were more sensitive (100%) and specific (83%) than the presence of dysmorphic RBCs in predicting glomerulotubular hematuria.

CONCLUSIONS

We believe that this is a costly test offering little additional information to the evaluation of microscopic hematuria in children. A thoughtful history and physical examination with microscopic urinalysis and dipstick for proteinuria provide an equal amount of diagnostic information. We do not recommend its routine use in the evaluation of microscopic hematuria in children.

Comparison of glucose tolerance, lipids and blood pressure in young male Ethiopians from two different immigrations, 1989 and 1991

The prevalence of glucose intolerance and hypertension was compared between a group of 87 young Ethiopian males (age 21.6 +/- 2.8 years) from the post Moses immigration of 1989 (group 1) and 89 age-matched Ethiopian males (age 21.4 +/- 3.1) from the Solomon immigration of 1991 (group 2). Both groups demonstrated a relatively high, for age, prevalence of glucose intolerance: 5% and 8% in groups 1 and 2 respectively (not significant). However, group 1 had a higher glucose level 2 h after an oral glucose tolerance test (P < 0.05) and a higher level of HbA1C (P < 0.05) and fructosamine (P = 0.07), concomitant with a lower fasting insulin (P < 0.005), when compared with group 2. Group 2 had a significant increase in both systolic and diastolic blood pressure when compared with group 1 (P < 0.05, P < 0.005 respectively). Group 2 had higher blood pressure levels and higher fasting insulin than group 1, suggesting a relationship between insulin levels and blood pressure in this population.

Induction of insulin resistance in normal adipose tissue by uremic human serum

An incubation of uremic human serum with normal rat adipose tissue will make the subsequently isolated adipocytes less responsive to insulin. To examine the extent of insulin resistance, we obtained sera from nondiabetic, uremic patients, who had not undergone dialysis therapy. The sera were then dialyzed (3500 molecular-weight cutoff) for 18 hr against a defined culture medium to eliminate possible in vitro effects of altered levels of end-product metabolites, electrolytes, and metabolic substrates. After an incubation of epididymal fat tissue from normal rats, for 3 hr with the dialyzed sera (50% vol/vol), cells were isolated and washed. The insulin stimulation of 14C-glucose (0.2 mM) incorporation to 14CO2 and total lipids was significantly reduced in the adipocytes pretreated with sera from 19 of the 29 uremic patients. Although elevated in the uremic patients, the sera levels of insulin, and parathyroid and growth hormones were not correlated to insulin resistant activity. Furthermore, incubation of adipose tissue for 3 hr with insulin, glucagon, or PTH did not produce resistance. The uremic sera reduced glucose utilization equally at 0.2 and 50 mM glucose, suggesting that the insulin resistance was induced additionally at a site distal to the glucose transport system. However, the concentration of insulin (22 microunits/ml) required for half-maximal stimulation of glucose metabolism was not altered by pretreatment with uremic serum. Also, neither the isoproterenol-stimulated lipolysis nor the inhibition of this cellular event was influenced by pretreatment with uremic sera.(ABSTRACT TRUNCATED AT 250 WORDS)