Correction: Antonuccio et al. The Nutraceutical N-Palmitoylethanolamide (PEA) Reveals Widespread Molecular Effects Unmasking New Therapeutic Targets in Murine Varicocele. Nutrients 2021, 13, 734.

In the original publication [...].

The Nutraceutical N-Palmitoylethanolamide (PEA) Reveals Widespread Molecular Effects Unmasking New Therapeutic Targets in Murine Varicocele.

Varicocele is an age-related disease with no current medical treatments positively impacting infertility. Toll-like receptor 4 (TLR4) expression is present in normal testis with an involvement in the immunological reactions. The role of peroxisome proliferator-activated receptor-α (PPAR-α), a nuclear receptor, in fertility is still unclear. N-Palmitoylethanolamide (PEA), an emerging nutraceutical compound present in plants and animal foods, is an endogenous PPAR-α agonist with well-demonstrated anti-inflammatory and analgesics characteristics. In this model of mice varicocele, PPAR-α and TLR4 receptors' roles were investigated through the administration of ultra-micronized PEA (PEA-um). Male wild-type (WT), PPAR-α knockout (KO), and TLR4 KO mice were used. A group underwent sham operation and administration of vehicle or PEA-um (10 mg/kg i.p.) for 21 days. Another group (WT, PPAR-α KO, and TLR4 KO) underwent surgical varicocele and was treated with vehicle or PEA-um (10 mg/kg i.p.) for 21 days. At the end of treatments, all animals were euthanized. Both operated and contralateral testes were processed for histological and morphometric assessment, for PPAR-α, TLR4, occludin, and claudin-11 immunohistochemistry and for PPAR-α, TLR4, transforming growth factor-beta3 (TGF-ß3), phospho-extracellular signal-Regulated-Kinase (p-ERK) 1/2, and nucleotide-binding oligomerization domain-like receptor (NLR) family pyrin domain-containing 3 (NLRP3) Western blot analysis. Collectively, our data showed that administration of PEA-um revealed a key role of PPAR-α and TLR4 in varicocele pathophysiology, unmasking new nutraceutical therapeutic targets for future varicocele research and supporting surgical management of male infertility.

Mucosectomy disrupting the enteric nervous system causes contraction and shrinkage of gastrointestinal flaps: potential implications for augmentation cystoplasty.

INTRODUCTION: Augmenting the bladder with a seromuscular gastrointestinal flap is a promising alternative approach aiming for a mucus-free bladder augmentation; however, the contraction (shrinkage) of the flaps remains a major concern. Enteric nervous system (ENS) abnormalities cause a failure of relaxation of the intestinal muscle layers in motility disorders such as Hirschsprung's disease and intestinal neuronal dysplasia. In mammals, the submucosal enteric nervous plexus contains nitrergic inhibitory motor neurons responsible for muscle relaxation. The authors hypothesize that mucosectomy disconnects the submucosal nervous plexus from the myenteric plexus resulting in flap shrinkage. STUDY DESIGN: After ethical approval, mucosectomy was performed on vascularized flaps from the ileum, colon, and stomach in five anesthetized pigs. In Group (I), only the mucosa was scraped off with forceps, creating a sero-musculo-submucosal flap, while in Group (II), the mucosa and submucosa were peeled off as one layer, leaving a seromuscular flap. Isolated and detubularized segments served as control. The width of each flap was measured before and after the mucosectomy. The ENS was assessed by neurofilament immunohistochemistry in conventional sections and by acetylcholinesterase and NADPH-diaphorase enzyme histochemistry in whole-mount preparations. RESULTS: The stomach contracted to a lesser extent of its original width, 92.82 ± 7.86% in Group (I) and 82.24 ± 6.96% in Group (II). The ileum contracted to 81.68 ± 4.25% in Group (I) and to 72.675 ± 5.36% in Group (II). The shrinkage was most noticeable in the colon: 83.89 ± 15.73% in Group (I) and to 57.13 ± 11.51% in Group (II). One-way equal variance test showed significant difference (P < 0,05) between Group (I) and (II), comparing stomach with ileum and ileum with colon. The histochemistry revealed that the submucosal nervous plexus containing nitrergic inhibitory neurons was disconnected from the myenteric plexus in Group (II) of all specimens. CONCLUSION: Mucosectomy resulted in significant immediate shrinkage of the flaps. This was more expressed when also the submucosa was peeled off, thus fully disrupting the ENS. The shrinkage affected the stomach the least and the colon the greatest. This phenomenon should be taken into consideration when planning mucus-free bladder augmentation.

Urinary diversion in early childhood: indications and outcomes in the exstrophy patients.

OBJECTIVE: To evaluate indications and applicability of continent and incontinent urinary diversion (CUD and IUD, respectively) in early childhood in patients with classic bladder exstrophy (CBE). METHODS: Using an institutionally approved exstrophy database, patients with CBE born after 1980 who underwent CUD or IUD by 2 surgeons within the first 5 years of life were identified. All aspects of their care and clinical outcomes were studied. RESULTS: In the CUD group (n = 14), only 21% had successful primary closure. Indications were desire to be dry (7), persistent hydronephrosis (4), urinary tract infections (UTIs) (1), repeat CUD (1), and inaccessible proper follow-up (1). Three patients had neobladder creation, 10 had bladder augmentation with continent stomas, and 2 underwent ureterosigmoidostomy. Currently, all patients are dry with clean intermittent catheterization (CIC). In the IUD group (n = 5), only 1 had successful primary closure. In addition to small, noncontractile bladders, the indications for IUD were severe hydronephrosis (2), recurrent UTIs (2), and noncompliance with catheterization (1). Four patients were re-diverted to CUD after a mean of 9.4 years and 1 has colon conduit. All are socially dry via catheterization. There was no case of renal function loss or malignant transformation. CONCLUSION: The need for early diversion in CBE is primarily driven by upper tract changes after secondary closure and social factors. Urinary diversion can be safe in younger children with a favorable continence outcome.

The application of pelvic osteotomy in adult female patients with exstrophy: applications and outcomes.

OBJECTIVE: • To apply the technique of pelvic osteotomy to a select group of adult female patients with exstrophy, in view of the low complication rate and acceptable success rate of the technique. PATIENTS AND METHODS: • We applied this technique as an adjunct to uterovaginal suspension and abdominal wall repair after our prior success in treating patients with extreme pelvic diastasis. • Bilateral innominate (transverse) and vertical iliac osteotomies were done from an anterior approach and an external fixator was placed. The fixator and pelvic bones were gradually cranked together over a period of 2-3 weeks until the diastasis was less than 4 cm. • Then sacrocolpopexy was performed with revision of the abdominal wall and revision genitoplasty along with the placement of an intrasymphyseal titanium plate. RESULTS: • Six patients presented with uterine/vaginal prolapse and concerns about the appearance of their abdominal wall and genitalia. Three patients had undergone uterine suspension before and one patient had had five prior attempts at suspension, which failed. The mean (range) age was 22.3 (18-26) years. • All the patients underwent staged reduction of pubic diastasis and sacrocolpopexy along with revision of the abdominal wall and in four cases revision genitoplasty was also performed. The mean (range) diastasis was 12.8 (8-18) cm and 2.8 (3-4) cm before and after staged reduction respectively. • Complications included transient femoral nerve palsy (two) and foot drop secondary to sciatic nerve stretch (one), which resolved with time. The symphyseal plate needed to be removed in three patients: secondary to persistent pain at the site (one), persistent discharge from the lower abdominal wound (one) and erosion into the anterior wall of the vagina (one). • At a mean (range) follow-up of 60.7 (2-137) months the cosmetic and functional outcome of the abdominal wall reconstruction and genitoplasty was good with all the patients being satisfied. Five patients are currently sexually active and none has had a recurrence of their prolapse. None has become pregnant yet. CONCLUSIONS: • Although the morbidity of this procedure in the adult is not insignificant, it is a valuable adjunct to pelvic floor reconstruction in young women of childbearing age even in those who have had prior suspension procedures. • In addition, it allows the movement of lateral previously unoperated skin into the midline, allowing scar and skin replacement with healthier more vascularized tissue.

Varicocele in adolescents: a 6-year longitudinal and followup observational study.

PURPOSE: Through a school screening program for varicocele we studied the prognostic value of hemodynamic vs clinical grading for predicting the risk of progression, time to worsening and the final outcome in adolescents with varicocele. MATERIALS AND METHODS: A school screening program was set up for boys between ages 10 and 16 years to assess pubertal development, varicocele, testicular vein reflux and testicular volume. Those who eventually had ipsilateral testicular hypotrophy underwent surgery. All patients underwent semen analysis after age 18 years. Varicocele grade was correlated with pubertal development, testicular vein reflux and semen quality in all groups, whether treated or untreated. RESULTS: A total of 2,107 boys were screened, of whom 609 had a varicocele. By the end of the study 92 patients (15.1%) had undergone surgery. Hypotrophy correlated with spontaneous testicular vein reflux (high grade) in all cases. Semen analysis showed abnormal results in 36% treated and 20% untreated patients. CONCLUSIONS: Children with varicocele should be regularly monitored to identify varicocele grade, testicular volume and vein reflux grade, and management should be determined accordingly. Spontaneous venous reflux toward the testis independent of varicocele grade closely correlates with the onset of testicular hypotrophy and abnormal semen analysis.

Construction of a natural looking inverted umbilicus for bladder exstrophy.

PURPOSE: Most attempts to create an umbilicus in the exstrophy abdomen eventually leave the end result of a flat scar rather than an inverted structure. We describe a technique that allows the creation of a better looking inverted umbilicus. MATERIALS AND METHODS: A total of 19 patients between 5 days and 7 years old underwent umbilicoplasty. At the apex of the vertical midline wound the skin and superficial fascia are elevated off the anterior rectus sheath well beyond the top of the skin incision. The skin edge at the most superior apex of the wound is sutured to the linea alba, thereby inverting the skin and fixing it to the sheath. Two skin flaps based superiorly are cut from the margin of the inverted skin. The flaps are then rotated medial and sutured to the linea alba to form the base of the new umbilicus. The superficial fascia inferior to the umbilicus is opposed and the skin edges are approximated. RESULTS: A total of 18 patients had bladder exstrophy and 1 had cloacal exstrophy. Of the patients 11 underwent bladder/cloacal exstrophy closure, 3 underwent epispadias repair, 3 underwent bladder neck repair, and 2 underwent bladder augmentation and continent cutaneous diversion. Mean +/- SD followup was 6 +/- 4 months. The technique allowed the creation of an inverted umbilicus in all patients. None experienced infection or dehiscence. The cosmetic result obtained was excellent and durable. CONCLUSIONS: We recommend the creation of an inverted umbilicus in the exstrophy population at bladder closure or later in life if umbilicoplasty is required.

Subclinical varicocele in the pediatric age group.

PURPOSE: This study was designed to assess the natural history of subclinical varicocele in the pediatric age group. MATERIALS AND METHODS: We conducted a school screening for varicocele in 2,107 children 10 to 16 years old, performing clinical examination and venous Doppler study. A total of 354 boys (16.8%) without clinically detectable varicocele had venous testicular reflux during a Valsalva maneuver. Of these children 36 (a 10% sample) were selected randomly and followed annually for 4 years, with assessment of testicular volume (ultrasound values), degree of varicocele according to the Dubin and Amelar classification, and Doppler findings according to the Hirsh testicular Doppler classification. The control group consisted of 20 children selected randomly from the same population, who did not have a varicocele and had a normal Doppler study. Fisher's exact test was used with a significance value at p <0.05. RESULTS: Mean age of the 36 children at the first assessment was 12.8 years (SD 1.7). Two boys (5.5%) had spontaneous resolution of testicular venous reflux within 2 years, and in 24 (67%) the subclinical varicocele did not change. The remaining 10 children (28%) had a clinically detectable varicocele, which was grade I in 1 patient, grade II in 7 and grade III in 2. Of these patients 1 had associated left testicular hypoplasia greater than 20%. During the 4-year period there were no clinically detectable varicoceles in the control group (p = 0.01). CONCLUSIONS: The proportion of children with subclinical varicocele progressing to a clinically detectable form of the condition was 28% (95% CI 14 to 45) during a 4-year period. We suggest that children with subclinical varicocele require long-term followup.

Effect of varicocelectomy on the plasma oxidative stress parameters.

AIM OF STUDY: This study evaluates the long-term effect of varicocelectomy as measured by plasma oxidative stress parameters. METHODS: Eleven children aged 10 to 16 years presented with left-sided varicocele and ipsilateral testicular hypoplasia. Peripheral blood samples for C-reactive protein, basal thiobarbituric acid reactive substances (TBARS), and plasma peroxidation susceptibility (lag time and slope) were obtained preoperatively and at 1 year after the varicocelectomy. All patients underwent inguinal microvascular varicocelectomy with testicular-inferior epigastric (spermatic-epigastric) venous shunt, and a blood sample from the pampinous plexus was taken. Student's t test for unpaired and paired data was used with a level of significance set at P < .05. RESULTS: When compared with controls, the cohort preoperative basal TBARS (mean, 2.07 nmol/mL; SD, 0.56 nmol/mL) were higher (P = .009), and plasma peroxidation susceptibility lag time (mean, 132.92 minutes; SD, 32.8 minutes) was lower (P = .0002). Blood samples from the pampiniform plexus showed similar results. Peroxidative plasma levels were significantly reduced on peripheral venous specimens taken 1 year after varicocelectomy with mean (SD) TBARS of 1.53 (0.41) nmol/mL (P = .0003) and mean (SD) lag time of 183.7 (17.46) minutes (P = .0025). The slope did not show significant changes compared with controls, or before and after surgery. CONCLUSION: Peroxidative plasma levels were significantly reduced 1 year after surgery, indicating that surgical varicocelectomy with construction of venous shunt reduces oxidative stress.