Biomedical subjects
Publications and source records attributed to S B Levitt.
The technique used to perform 38 orchiopexies of high undescended testes by spermatic vessel transection in 26 patients is reviewed. Careful attention to detail and selection using the Fowler-Stephens test allowed for an 89 per cent success rate, confirming the efficacy of this procedure in cases selected in this manner.
Only 15 cases of fibroepithelial polyp in children have been reported in the world medical literature. Clinical differentiation between this tumor and a malignant ureteral tumor is difficult and often results in unnecessary nephrectomy. We report the sixteenth case of a child with fibroepithelial polyp of the ureter. The lesion was resected, and the kidney was preserved. Optimum treatment of this lesion mandates renal preservation in children. The rationale for this recommendation is explored.
Three cases of reascent of a previously unequivocally documented descended testis have been encountered. Chorionic gonadotropin treatment was initially attempted in each child and was successful in causing descent of the involved testis in one. The testes of the other two boys were successfully brought down surgically. Possible causes for testicular reascent are presented and the pertinent literature is reviewed. These cases illustrate the need for continued diligence and interval examination of the pediatric scrotum throughout childhood.
A fifteen-year-old male presented with delayed puberty and cryptorchidism. Previous exploratory surgery for bilateral cryptorchidism resulted in left orchiectomy. The right testis was very high and intimately adherent to the mesentery of the appendix, and was left in situ. Subsequently progressive testicular failure was demonstrated by falling plasma testosterone and rising plasma gonadotropin levels. On elective surgical exploration, an atrophic testis with an independent blood supply was found adherent to the mesentery of the appendix. No spermatic duct was present, and orchiectomy was performed. The reasons for orchiectomy and the role of serial hormonal evaluations in the management of this unusual mesoappendicular testis case are reviewed.
Intravascular nephroblastoma involving the renal veins or inferior vena cava, occurring in 6 to 10 per cent of the cases, dramatically complicates the treatment course for those individuals. Heroic surgical procedures, including sternal splitting and cardiopulmonary bypass, have been used to treat these tumors, often with an added morbidity and increased mortality. We have detailed the dramatic responses to preoperative chemotherapy in 3 patients with intravascular nephroblastoma, which resulted in either complete eradication or marked shrinkage of the intravascular tumor, greatly simplifying the ensuing surgical procedure. These observations strongly indicate that preoperative chemotherapy should be used as the primary treatment in patients with this condition.
Recurrent pyelonephritic episodes in children with normal contrast cystograms pose a difficult management problem, since the lack of demonstrable reflux adversely affects the treatment. A total of 10 children with clinical symptoms of pyelonephritis in whom normal contrast cystograms had been performed properly subsequently had significant degrees of reflux detected by isotope cystography. These findings indicate that isotope cystography should be included in the evaluation of patients with pyelonephritis in whom reflux is not confirmed by conventional contrast medium techniques.
Nonintrusive measurement of the hydrodynamic properties of the urinary stream (uroflowmetry) has been included in many adult urological evaluations as an objective diagnostic tool. Measurement and behavioral problems interfere with practical applications in children. We describe a standard procedure for obtaining "impromptu" micturitional flow parameters in clinical pediatric practice. Statistical correlations of these flow parameters in an unselected group of 142 normal boys between 2 and 12 years old are presented. Useful linear regression equations were derived from the sample to assist the clinician in predicting deviations from normal values. Limitations of the methodology are noted.
Successful renal transplantation was accomplished in a patient with spina bifida and a neurogenic bladder, who previously had been continent after bladder neck reconstruction and institution of chronic intermittent bladder catheterization. Satisfactory bladder emptying and renal functional preservation have been maintained during a 4-year followup.
We reviewed the medical records of 65 boys with surgically and pathologically proved monorchism. A striking laterality to the left side was identified. In 83 per cent of the patients wolffian structures were present and in 20 per cent microscopic evidence of a terminal nubbin of hyalinized, calcified or hemosiderin-containing tissue was noted. These findings strongly suggest that in most instances of monorchism a testis had been present and had undergone subsequent in utero degeneration. Characterization of the hormonal changes associated with unilateral absent testes was done by determining fasting morning levels of luteinizing hormone and follicle-stimulating hormone. In a subgroup of monorchid boys and age-matched prepubertal unilateral cryptorchid boys luteinizing hormone release factor stimulation also was performed to determine if endocrine analysis could predict the absence of 1 testis.
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Unilateral partial ureteral obstruction was induced in 32 dogs followed by total ileal replacement of the obstructed ureter. The morphologic and functional effects on the kidney using a freely refluxing versus a nonrefluxing ileovesical anastomosis were compared, as well as the effect of total tapering of the reimplanted ileal segment. The tapered ileovesical anastomosis proved more reliable for prevention of reflux than the nontapered technique. Reflux prevention does not appear necessary for maintaining renal morphology and function when bladder function is normal and the observation period short. Total tapering of the ileal segment did not prove to be advantageous in protecting against hyperchloremic acidosis in this short-term canine study.
The pressure characteristics and cinefluoroscopic appearances of a refluxing, nonrefluxing, and totally tapered ileal " neoureter " were compared in 22 dogs with normal bladder function. The totally tapered ileal segment with a reflux preventing ileovesicostomy simulates normal ureteral peristalsis most closely on cinefluoroscopic evaluation. Pressure gradients across the ileovesical junction though were similar in refluxing and nonrefluxing ileovesicostomies , as well as in totally tapered ureters.
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Subtunical resection of hypertrophied cavernous tissue of the enlarged clitoris allows for maintenance of an intact blood supply to the glans and is an alternative safe method of diminishing shaft and glans size.
Severe degrees of primary chordee and persistent or recurrent chordee following previous surgical attempts at correction present a challenging problem. Inadequate resection of involved tissues, which may involve all layers of the penile investiture, or recurrent scarring of the ventral skin, Buck's fascia and tunica albuginea is usually the cause. Reoperation to achieve penile straightening often is unsuccessful unless all chordee-bearing tissue is resected extensively. Excision of large segments of tunica albuginea or wide separation of the margins creates a defect that tends to heal by dense scarring unless the defect is bridged by a graft. Various autogenous materials have been used, including blood vessel, fascia, free fat graft, dermis and tunica albuginea, as well as prosthestic materials, such as polytetrafluoroethylene, with varying results. A series of patients with extensive chordee is presented in whom tunical resection was necessary to achieve penile straightening. The results of free dermal graft replacement of the tunica are reported.
The posterior approach for bilateral nephrectomies in preparation for renal transplantation has not been previously described in children. Thirteen cases are presented. Ileus was strikingly absent in all cases. Morbidity was minimal. This approach is recommended in preference to subcostal or transperitoneal procedures for bilateral nephrectomies in selected children.