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.

Treatment of varicocele with transfemoral retrograde sclero-embolization in pediatric patients under local anesthesia.

AIM: Varicocele treatment in pediatric age is still under discussion. The aim of this study was to present our experience with transfemoral retrograde sclero-embolization in pediatric patients and varicocele under local anesthesia METHODS: Between December 2008 and December 2011, 184 patients aged between 10 to 14 years with left varicocele were treated. Study inclusion criteria were: grade II or III left varicocele; previous inguinal surgeries and contraindications to general anesthesia. Sclero-embolization included the following procedures: right femoral access under local sedation (carbocaine). Mean time of intervention, recurrence and persistence rates as well as early and late complications were also considered. RESULTS: During the study period 184 cases were treated with the radiological technique, 172 of which proved to be successful. In 10 cases a continent valve was found and it was therefore impossible to use this technique (5.4%); two cases had rupture of the vein with consequent spillage of the contrast agent. Twelve cases (6.5%) showed recurrence after 3 months. No patient reported postoperative pain. CONCLUSION: This technique proved to be efficient and reliable. It can be performed under local sedation and it involves fewer complications than traditional techniques. The use of such technique allows preservation of the spermatic artery and is free from complications like testicular atrophy and hydrocele.

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.

Lactobacillus paracasei subsp. paracasei F19 in Bell's stage 2 of necrotizing enterocolitis.

AIM: The aim of this trial is to evaluate the role Lactobacillus paracasei in Bell's stage 2 in order to prevent the clinical progression to stage 3. METHODS: A prospective study was approved and started in December 2008. Patients were infants with birth weight 600 to 1500 g. One group received probiotic supplementation (L. paracasei susp.paracasei F-19) and the control group received only standard medical treatment. The primary outcome was the progression to stage 3 as defined by Bell's modified criteria. Inclusion and exclusion criteria were created and discussed with parents before treatment. RESULTS: Thirty-two patients (stage 2 NEC) were considered eligible for the study. Group A: 18 patients and Group B: 14 patients. Three patients in group A and six patients in group B had a clinical history of Bell's stage 3 NEC (P<0.05); oral supplementation of L. paracasei reduced the clinical progression of NEC. It was considered that an improvement in intestinal motility might have contributed to this result. CONCLUSION: The use of Lactobacillus paracasei subsp. paracasei F-19 is safe; the low progression rate to stage 3 NEC suggests that the use of this probiotic in stage 2 NEC could be a valuable therapeutic option.

Conservative management of accessory spleen torsion in children.

Accessory spleen torsion is very rare condition especially in children. The aim of this study is to report the conservative treatment option. In April 2009 we observed a 10-year-old child affected by hereditary spherocytosis who reported acute abdominal pain without fever or vomiting. At hospitalization all blood tests were within normal value. Abdominal ultrasounds showed an increase in spleen volume and a solid round-shaped hypoechogenic formation with hyperechogenic areas in the lower pole without vascolarisation on color-Doppler scan. These findings suggested torsion of the accessory spleen. We opted for a conservative approach: analgesics on demand and antibiotics. After a week symptoms resolved spontaneously and patient was discharged in good health conditions. Follow-up ultrasound scans were performed at one week, three-six months and one year after hospitalization and showed a progressive reduction of the dimensions of the solid round-shaped formation. Accessory spleen torsion needs to be added to the differential diagnosis of cases of acute abdomen in children. Ultrasounds with eco-color-Doppler scans seem to be the best option for the diagnosis of such condition in the pediatric age since other diagnostic methods are more invasive and require sedation of patients. Once accessory spleen torsion is correctly diagnosed it is possible to opt for its conservative treatment.

Necrotizing enterocolitis in multiple gestations: comparison with singletons.

AIM: The purpose of this study is to describe the incidence of necrotising enterocolitis in multiple pregnancies and compare it with single pregnancies, pinpointing any risk and morbidity factors. METHODS: A retrospective study of patients admitted to the neonatal pathology department of our hospital was carried out. The period considered was January 2002 to January 2009. All clinical records of patients who have developed NEC or suspected NEC were reviewed. Inclusion criteria were created. Risk factors and any other contributing causes in the two main groups (with and without NEC) were analysed. RESULTS: During the study period we considered 409 babies born from multiple pregnancies and 895 from single pregnancies. Ninety-three from multiple pregnancies and 241 from single pregnancies were considered suitable for the study. The percentage of NEC in multiple pregnancies (18%) was higher than in the singles (4%) (P<0.05). The patients with suspected NEC or advanced NEC showed a longer time between birth and the first meconium discharge (5 vs. 2 days, P<0.05). The patients who received intestinal washing from the second day did not develop NEC (<0.05). Mortality was associated with the lower gestational age and a low Apger score at the first minute (P<0.05). CONCLUSION: Analysis shows that the incidence of NEC is higher in multiple pregnancies only if we consider gestational age or in association with severe prematurity. A gestational age <28 weeks and a low Apgar score at the first minute are risk factors for both categories.

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.

An unusual case of extra-abdominal desmoid tumour.

Desmoid tumour is relatively rare and generally non-metastatisizing lesion of mesenchymal origin composed of fibrous tissue and fitting in the group of aggressive fibromatosis; it is a locally aggressive proliferative soft-tissue lesion with controversial nature. This tumour accounts for 0.03% of all tumours and 3% of soft-tissue tumours with annual incidence of two to four cases per million. Although desmoid tumours are more common in persons aged 10-40 years than in others, they do occur in young children and older adults; in children the sex incidence is equal. This is a rare case of extra-abdominal desmoid tumour in a 14-year-old girl affected by spastic tetraparesis. To our knowledge no similar cases are present in literature to date.

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.

Prenatal sonographic evaluation of male genitalia development.

AIM: The aim of this study was to evaluate the sonographic development of normal fetal male genitalia. METHODS: A longitudinal study was performed on 60 male fetuses. The development of penis, prepuce and presence of testes in scrotum were observed with a high resolution transabdominal ultrasonography between weeks 11 and 40. RESULTS: The overall success of identifying correctly the fetal male gender increased with gestational age from 46% to 80%, and 96% at 12, 13 and 14 week, respectively. The number of the scans performed in relation to the gestational age from week 11 to week 14 improves the ability to assign the male gender and to report the penile length (P<0.05); the earliest observations of descend testis were at 24 weeks. The bilateral observation of testicular descend was at 31 weeks in 98% of fetuses. CONCLUSION: Development of male genitalia is easy evaluated through the pregnancy. This could be useful to early identify male genitalia abnormalities.

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.

Bladder exstrophy variants.

In the literature it is possible to find many case reports of bladder exstrophy variants, although a thorough classification with all possible associated malformations is not yet available. On the basis of a rare case observed at their Department, the authors studied the embryology of these conditions and their associated malformations. The purpose of this study is to review the literature currently available and suggest a classification for bladder exstrophy variants. Despite the rarity of these variants, surgeons need to know all possible associated malformations in order to have the most complete and correct clinical picture of their patients.

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.