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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

[Cryptohypospadias: Surgical approach and long-term results]. / Cripto-ipospadia: Approccio chirurgico e risultati a distanza.

BACKGROUND: Chordee without hypospadias is a rare morphological abnormality of the penis capable of interfering with sexual function. Usually, cases of chordee without hypospadias require surgical correction, and the aim of this study is to assess the efficacy of the techniques normally used in this pathology. METHODS: The authors analyze the surgical outcomes achieved in 34 patients presenting various degrees of ventral or lateral curvature of the erect penis and operated on in our department over the past 22 years. Twenty-nine subjects attended for follow-up, including 13 who have now reached adulthood. RESULTS: The milder forms of chordee without hypospadias (Horton and Devine type III and lateral deviations of the penis) all benefited from minor surgery (dermal grafts and Nesbit dorsal plication of the contralateral penile tunica albuginea) and were corrected with a single operation. The most serious forms of chordee without hypospadias where the hypoplasia variously affected the corpus spongiosum, Buck's fascia and the dartos fascia (Horton and Devine types I and II), were submitted to a supplementary extensive urethral mobilization or occasionally a urethroplasty and one-third of them presented persistent residual curvature. CONCLUSIONS: The authors advocate a more aggressive surgical approach (urethroplasty and/or patches on the ventral tunica albuginea as an alternative to urethral mobilisation) in subjects with more pronounced defects.

[Reconstruction of the vas deferens: an experimental study on the rat]. / Ricostruzione deferenziale. Studio sperimentale sul ratto.

BACKGROUND: A microsurgical technique for reconstruction of the vas deferens on an absorbable transanastomotic stent in the rat is described. METHODS: A microsurgical end-to-end anastomosis of the vas deferens was performed in a group of 10 rats (group A) by suturing with Nylon 10-0 interrupted stitches. In another 10 rats (group B) the same microsurgical anastomosis was performed after insertion of a 0.5 cm long intraluminal chromic catgut 4.0 stent. RESULTS: Sixty days postoperatively all 20 animals were submitted to roentgenography of the vas deferens. The vas deferens proved radiographically undetectable in 8/10 rats in the unstented group A (80%), whereas the entire course of the vas could be traced in 9/10 rats in group B (90%). CONCLUSIONS: The encouraging results obtained with this alternative technique, even on structures of limited diameter, suggests that it may be possible to use this procedure in children.

[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.

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.

[Vascular traumatic lesions in childhood and adolescence]. / Lesioni traumatiche vascolari in età pediatrica e adolescenziale.

The authors report their experience about 35 peripheric vascular injuries in childhood and adolescence. They analyze the epidemiological and clinical data and underline the usefulness of careful clinical and instrumental diagnosis. In order to obtain the best result they stress the importance of early revascularization by suturing in short lesions and by autologous tissue in longer lesions. Furthermore, they stress the importance of repairing venous injuries. Bone fractures have to be stabilized before vascular repair, subject to this not requiring prolonged ischemia. The authors conclude that only a multidisciplinary approach can ensure better results.

[Morgagni's hernia in infancy]. / Ernia di Morgagni in età infantile.

Morgagni's hernia is an uncommon type of diaphragmatic hernia fairly exceptional in pediatric age. A case of Morgagni's hernia, observed by chance in a 15-month-old infant, is presented. The authors present the fundamental embryogenic stages of the diaphragm and stress the clinical manifestations and diagnostic procedures to reach the diagnosis, as well as the advantages of early treatment in order to prevent possible complications.