Varicocele treatment in paediatric age: relationship between type of vein reflux, surgical technique used and outcomes.

Varicocele is the first andrological disease in adolescent males. The aim of this study was to report our experience with different techniques. We retrospectively analysed patients treated between January 2005 and January 2011. Inclusion criteria for the study were created. Patients were treated with different techniques based on the type of spermatic vein reflux detected on Doppler velocimetry. The following rates were considered as study endpoints: hydrocele rate, rate of relapses, rate of persistence and rate of testicular atrophy. During the study period, 522 surgical varicocelectomies were performed. Patients were treated with videolaparoscopy, open inguinal technique, subinguinal technique and one-trocar transumbilical technique. The laparoscopic and the subinguinal techniques showed a lower rate of hydrocele, and the laparoscopic technique had a lower rate of relapses. Choosing a technique based on the type of spermatic vein reflux can reduce the post-operative complications. The laparoscopic techniques had a lower rate of relapses with respect to other techniques.

A cross-sectional nationwide survey on esophageal atresia and tracheoesophageal fistula.

BACKGROUND: Our study aims at disclosing epidemiology and most relevant clinical features of esophageal atresia (EA) pointing to a model of multicentre collaboration. METHODS: A detailed questionnaire was sent to all Italian Units of pediatric surgery in order to collect data of patients born with EA between January and December 2012. The results were crosschecked by matching date and place of birth of the patients with those of diagnosis-related group provided by the Italian Ministry of Health (MOH). RESULTS: A total of 146 questionnaires were returned plus a further 32 patients reported in the MOH database. Basing on a total of 178 patients with EA born in Italy in 2012, the incidence of EA was calculated in 3.33 per 10,000 live births. Antenatal diagnosis was suspected in 29.5% patients. 55.5% showed associated anomalies. The most common type of EA was Gross type C (89%). Postoperative complications occurred in 37% of type C EA and 100% of type A EA. A 9.5% mortality rate was reported. CONCLUSIONS: This is the first Italian cross-sectional nationwide survey on EA. We can now develop shared guidelines and provide more reliable prognostic expectations for our patients.

Transumbilical laparoscopic treatment of Congenital Infantile Fibrosarcoma of the Ileum.

Congenital-Infantile Fibrosarcoma (CIF) is a malignant mesenchymal tumor representing 10-20% of soft-tissue tumors. Complete surgical resection is generally the treatment of choice. The most recurrent cytogenetic abnormality was identified as the traslocation t(12;15)(p13:q25), which bears the fusion of Tel gene EVT6 with TrkC gene. This study describes a case of infantile fibrosarcoma of the ileum in a female newborn examined for intestinal occlusion and its laparoscopic treatment.

Clinical course of grade I-III megaureters detected on prenatal ultrasound.

AIM: Primary obstructive megaureter has always been considered a developmental defect. The aim of this study was evaluate the clinical course of grade I-III megaureter at a single Institution through a longitudinal observational study. METHODS: Between April 2004 and April 2006 35 cases of megaureter were observed prenatally. Inclusion criteria were created. Conservative treatment was used for all patients and its efficacy was assessed with routine laboratory tests, ultrasounds and renal scintigraphy. Follow-up was at least three years for all patients. RESULTS: Twenty patients were considered for the study. Single or relapsing infections (36% of patients had more than three urinary tract infections during follow-up) did not seem absolute indications for surgical treatment in these patients, although they are currently the first indication for surgery. CONCLUSION: Clinical results of the study showed that conservative treatment is an effective treatment option. Single or relapsing infections are not a clear indication for surgery. Long-term follow-up for these patients is mandatory.

Unilateral hydronephrosis due to ureteropelvic junction obstruction in children: long term follow-up.

AIM: Hydronephrosis is one of the most common urological disease detected on prenatal ultrasound; The aim of this study was evaluate the role of long-term follow-up in patients with unilateral hydronephrosis. METHODS: On January 2009, the medical charts of patients observed at the Department and Institution for unilateral hydronephrosis were reviewed, for a long-term follow-up evaluation (10 years). All diagnosis were done prenatally. Long term follow-up is described. RESULTS: One hundred and seventy-four 174 patients were observed. At diagnosis grading of hydronephrosis was: 3% grade 0, 25% grade I, 41% grade II, 31% grade IV. At the end of the study, 94 patients underwent surgery, while 80 were managed conservatively. CONCLUSIONS: Grade of hydronephrosis and renal function still remain the most important variables to decide the surgical management. Long-term follow-up shows that over the years many patients need surgery.

Bilateral testicular torsion: an extremely tragic rare condition.

Bilateral intrauterine torsion of the testes and neonatal testicular torsion are rare conditions that sometimes result in a catastrophic event. Surgical exploration is mandatory and sometimes a second-look management should be considered. After describing a rare condition, the authors came to the conclusion that bilateral orchidectomy should be performed only in patients with bilateral necrotic testes.

Correlation between high-resolution ultrasound and surgical/pathological findings in patients with suspected appendicitis.

AIM: Clinical diagnosis of appendicitis in children is often difficult. The aim of this study was to evaluate the usefulness of ultrasound with graded compressed technique in cases with suspected appendicitis. METHODS: A radiological classification of appendicitis was formulated associated with the surgical/histological degree. Afterwards, 92 patients with suspected appendicitis enrolled in this study were prospectively evaluated and managed to follow a new protocol based on the clinical and radiological experiences. In this study, the ultrasonography was considered positive when the diameter of the wall of the appendix was larger than 7 mm and vascularization was increased or absent. RESULTS: Of these 92 patients, 54 patients underwent surgery while 38 were treated conservatively. Of the treated group, 12 patients had a perforated appendicitis, 3 had a gangrenous appendicitis, 36 patients demonstrated a phlegmonous appendix while 3 patients had a catarrhal appendix. Blood cell counts and CRP levels were significantly higher in patients with appendicitis (P<0.05) and WBC and CRP levels were higher for patients with perforated appendicitis compared with patients with simple appendicitis (P<0.05). A CRP value higher than 17 mg/dL was a strong predictor for the presence of infection. Three patients of the conservative group underwent surgery later for recurrent abdominal pain (within 2 weeks); two had a catarrhal appendix while one patient had a normal appendix (confirmed by histology) CONCLUSIONS: Patients with suspected appendicitis could be managed with ultrasound, suggesting an early approach. The selection of patients for surgery prevent complication and unnecessary surgery.

The role of lifestyle changing to improve the semen quality in patients with varicocele.

AIM: To evaluate the recovery of semen quality in patients with high grade varicocele without hypotrophy and abnormal semen analysis using a simple lifestyle changing protocol. METHODS: Fifty-two patients were eligible for this study. Two semen sample were collected at baseline and other two after treatment. PROTOCOL: patients had to stop or decrease the number of cigarette per day, reduce the coffee and alcohol consumption, introduce fruits and vegetables in the daily diet and have a normal sexual activity with an abstinence of tree days before semen collection. All the variables and the semen parameters were evaluated and correlated between responders and non-responders. RESULTS: Forty patients (76%) had an improvement of semen quality showing a normal semen analysis following the WHO criteria. The other 12 patients had an improvement of the semen quality but without statistical differences. Smokers and drinkers (for both coffee and alcohol) had lower sperm volume, lower sperm motility and vitality when compared to the others. CONCLUSIONS: The analysis of data collected by the spermiograms showed that semen quality could benefit from lifestyle changing. This finding is important for the management of patients with varicocele, suggesting that lifestyle changing could avoid surgery.

Contralateral exploration for unilateral inguinal hernia in females: risk factors and surgical findings.

BACKGROUND: Controversy continues over the need to explore the asymptomatic contralateral groin in girls with unilateral inguinal hernia. The aim of this study is to identify the incidence and risk factors of developing a contralateral inguinal hernia. MATERIALS AND METHODS: Between July 1997 and July 2006, 364 consecutive girls aged between 1 month and 8 years with unilateral inguinal hernia underwent surgical exploration of the contralateral inguinal side. Inclusion criteria were created. After collection of the surgical findings, the authors analysed the correlation between the patients' medical history and the incidence of contralateral inguinal hernias. The patients were then divided into eight groups following an age range grouping. RESULTS: One hundred and eighteen patients were enrolled in this study, 74 with right-side inguinal hernia and 44 with left-side inguinal hernia. About 47.4% of these patients showed contralateral true inguinal hernias, 38% right-sided and 63% left-sided hernias. There was no correlation between medical history, age at surgery and the presence of contralateral inguinal hernia. CONCLUSIONS: Although the results of this study are in contrast with many other studies in the literature, the authors came to the conclusion that contralateral exploration should be routinely performed in girls with inguinal hernia until they reach 4 years of age.

Intraoperative double-J stent insertion in children with scintigraphic impaired renal function and obstructive urinary tract malformation.

AIM: Ureteral double-J (DJ) stents are frequently used in modern urologic practice. At present the role of stents in urological and surgical practice and their efficacy in paediatric age are not yet clear. The aim of this study is to evaluate advantages and efficacy of ureteral stents, correlating clinical and radiological data with the permanence of stent in situ. METHODS: Between July 1999 and July 2004 surgery with ureteral stenting was performed on 24 consecutive patients aged between 2 and 13.5 months with scintigraphic impaired renal function due to an obstructive urinary tract malformation. During the study the performance and the efficacy of indwelling stent have been evaluated through clinical and radiological variables: pre-, intra-, and post stenting blood tests, ultrasonographic and scintigraphic parameters were also evaluated. RESULTS: The stent insertion was useful to improve renal parenchymal thickness and renal growth. No correlation was found between improved blood tests and scintigraphic values. The improvements of clinical and radiological data were strictly correlated with the time of stenting (>3 months). CONCLUSION: The insertion of DJ stents as long-term internal urinary diversion is useful and safe. Late complications related to the use of stents are not frequent.

Two patients with tumours presenting as inguino-scrotal masses.

Inguinal masses in children may indicate different conditions and pathologies, ranging from congenital anomalies to neoplasms. Although inguinal hernias represent the majority 'masses' in the inguinal canal, there are other rare lesions that may occur. For this reason, irreducible masses shall always receive an appropriate preoperative diagnosis. In this report, we describe two interesting cases of inguinal masses in children first diagnosed as irreducible inguinal hernia. Appropriate investigations before surgery and local surgical excision are therefore recommended.

The laparoscopic Vecchietti technique for vaginal agenesis.

OBJECTIVE: To evaluate surgical, long-term anatomic and functional results of the laparoscopic Vecchietti procedure to treat women with vaginal agenesis. METHODS: Retrospective analysis of 86 women treated at the Department of Gynecology and Obstetrics at the University of Verona, Italy. Data were analyzed based on surgical results and postoperative sexual satisfaction. Depth and diameter of the neo-vagina was determined. The characteristics of the neo-vaginal mucosa were investigated by vaginoscopy. Patients reported frequency, satisfaction, and any difficulties found at intercourse. RESULTS: Functional success was obtained in 98.1% and anatomic success in 100%. In all patients, at 1 year, the mucosa was pink, trophic, and moist. Two fingers were introduced easily into the neo-vagina in all cases. All patients, which decided to have sexual intercourse, defined these as satisfying within 6 months. CONCLUSIONS: Laparoscopic procedure used in this study is simple, safe, and effective. Anatomical and functional results obtained suggest this laparoscopic procedure as the treatment of choice for this syndrome.

Intussusception due to a cecal duplication cyst: a rare cause of acute abdomen. Case report.

Duplications of the alimentary tract are rare congenital anomalies. The ileum is the most common site, whereas rectal, duodenal, gastric and cecal duplications are extremely rare. Duplication cysts of the cecum, in a neonate, are even rarer, with only 19 cases reported in medical literature to date. We report a case of intestinal intussusception due to a cecal duplication cyst.

Complete pancreatic ectopia in a gastric duplication cyst: a case report and review of the literature.

Ectopic tissue can be histologically detected in gastric duplication cysts. The authors describe the case of a complete pancreatic ectopia in a prenatally diagnosed symptomatic gastric duplication cyst in a 6-month-old male infant. Surgical removal of the cystic formation was curative. In view of the rarity of the lesion, a full clinical and diagnostic classification of the condition proved possible only after radical surgical resection and histological examination. Immunohistochemical investigation enabled us to detect the complete pancreatic ectopia.

Microsurgical spermatico-epigastric venous anastomosis in the treatment of varicocele in children: assessment of long-term patency.

AIM: To demonstrate the long-term patency of microsurgical anastomoses between the internal spermatic vein and the inferior epigastric vein, constructed in the treatment of essential varicocele in paediatric patients to supplement ligation of the spermatic veins. MATERIALS AND METHODS: We submitted 66 patients to inguinopelvic colour-flow Doppler ultrasonography. The patients had been treated 18 - 36 months earlier for essential varicocele by microsurgical inguinal ligation of the testicular venous pedicle and anastomosis between the internal spermatic vein and the inferior epigastric vein. RESULTS: Preoperatively, the 66 patients operated on at ages ranging from 10 to 16 years (13 +/- 1.4) presented with Dubin and Amelar grade II (14 patients) or grade III (52 patients) left varicocele with ipsilateral testicular hypotrophy. The postoperative follow-up showed 2 cases of persistence of disease and 3 cases of persistence of "medium" spermatic vein reflux without clinical evidence of varicocele. Seven patients developed left hydrocele which resolved spontaneously in 5 cases, whereas in 2 cases it proved necessary to perform an eversion of the tunica vaginalis of the testis. The results obtained in patients treated for Coolsaet type I varicocele (64 patients) were as follows: long-term patency of the anastomosis was observed in 58/64 patients (90.6 %); in 4 patients (6.2 %) the left inferior epigastric vein presented a position in relation to the homologous artery that prevented adequate sampling and thus made it impossible to assess the patency of the anastomosis; in 2 patients (3.1 %) the anastomosis was closed. In the two patients who had submitted to anastomosis for Coolsaet type III varicocele, colour-flow Doppler failed to identify the shunt. CONCLUSIONS: The results of this study demonstrate that microsurgical anastomosis between the internal spermatic vein, and the inferior epigastric vein remains competent in the long term, thus confirming the validity of this technique for the treatment of essential varicocele in children.

Congenital true pancreatic cyst in pediatric age: case report.

Congenital pancreatic cysts are rare lesions in pediatric age. We present a case of congenital true pancreatic cyst in otherwise asymptomatic boy aged 4 years. Clinical history, laboratory, imaging, immunohistological findings and surgical treatment are also described.

Secondary omental torsion in children: report of two cases and review of the literature.

Torsion of the greater omentum (TGO) may be due to a congenital abnormal attachment of its free edge. There are no specific symptoms that allow a preoperative differential diagnosis of this condition from common pathologies such as acute appendicitis. Attachment of the omentum to the large bowel and the absence of concomitant diseases make it possible to distinguish TGO secondary to a congenital attachment anomaly from omental infarction, primary TGO, and TGO secondary to an acquired attachment anomaly (attachment to cysts, tumours, hernias, surgical scars, or perforated bowel segments). Resection of the ischaemic portion of the omentum permits complete resolution of the clinical symptoms. The authors report two cases of TGO in children due to abnormal attachment of the greater omentum to the ascending and transverse colon, respectively.

[The role of continent perineal colostomy in surgical emergencies of the distal bowel]. / Il ruolo della colostomia perineale continente nelle emergenze chirurgiche del grosso intestino.

Diverting colostomy is commonly required in surgical emergencies of the distal colon, especially if the patient is in poor condition. This paper shows that the colostomy could be unnecessary in most cases. In the last 10 years, 6 patients (4 with high-risk or postoperative complicated Hirschsprung disease, 1 with intestinal neuronal dysplasia and 1 with iatrogenic rectal stenosis obstruction) have been submitted to primary continent perineal colostomy-modified Duhamel's procedure. The modified technique consists of the exteriorization of the normal colon or ileum by a retrorectal and trans-anal way, while the excision of redundant tissue and rectal spur section are postponed at least for 10 days. In personal experience this peculiar surgical approach allows to avoid not only the complications due to the fashioning of a contraindicated primary anastomosis, but even those due to stomy performance and its closure, promoting good anatomo-functional results in all patients. The advantages of modified Duhamel's operation compared to other procedures (Swenson-Pellerin or Soave pull-through) depend on the rapidity of execution and on the quality of short and long term outcome.

[Idiopathic varicocele in children. Epidemiological study and surgical approach]. / Varicocele idiopatico in età pediatrica. Studio epidemiologico e approccio chirurgico.

BACKGROUND: Idiopathic varicocele is one of the most frequent conditions capable of reducing male fertility. Early detection and adequate therapy make it possible to prevent the infertility related to this disease. METHODS: The results of a clinical and instrumental (Doppler) epidemiological study conducted in 766 subjects of peripuberal age are reported. The clinical and functional results in those subjects undergoing surgery for varicocele. The technical options adopted for varicocele correction were either microsurgical venous bypass between the internal spermatic vein and the inferior epigastric vein or laparoscopic ligation of the internal spermatic vein in a retroperitoneal site. RESULTS: The epidemiological investigation conducted by the authors showed a high incidence (48.5% including the subclinical forms) of idiopathic varicocele in the male population. The clinical and instrumental (Doppler) follow-up carried out at 3, 6 and 18 months postoperatively showed satisfactory results, particularly in patients submitted to microsurgical venous bypass, with a relapse rate of only 2.6%. CONCLUSIONS: On the basis of the results obtained, the authors advocate an early surgical approach to varicocele. Among the corrective techniques available, microsurgical treatment is, in the authors' opinion, capable of yielding the best clinical and functional results.