Incomplete Renal Duplex System with Lower Moiety Hydroureteronephrosis Due to Aberrant Blood Vessel.

INTRODUCTION: Duplex collecting system is a common congenital urinary system anomaly and is usually asymptomatic. Vascular variations associated with a duplex system are common but haven't been reported as obstructive. CASE REPORT: 14-month-old female had a right sided incomplete ureteral duplication complicated by lower pole hydroureteronephrosis due to distal ureteral obstruction by an aberrant vessel crossing the bifid ureters at ureteric junction of these bifid ureters. Prenatal imaging detected right hydronephrosis. Magnetic resonance suggested a diagnosis of duplicated ureters. At surgery, an aberrant artery compressed the lower moiety ureter at the bifid ureteric junction. The stenotic section was resected and ureter segments were anastomosed. The occluding small artery was not resected to preserve vascularization. DISCUSSION/CONCLUSION: An anatomical vascular variation can cause proximal ureteral dilatation and segmental hydronephrosis in a bifid system.

Exstrophy-Epispadias Complex Variants: A Hybrid Case.

The term exstrophy-epispadias complex refers to a group of midline defects ranging from epispadias to cloacal exstrophy. Bladder exstrophy is the most frequent malformation of this spectrum and it can present as a classical or a variant form. We report a case of a hybrid bladder exstrophy variant having some characteristics of both a duplicate bladder exstrophy and a superior vesical fistula.

Caecal duplication, a case report.

The caecum is one of the rarest sites of intestinal duplication cysts. The most common symptomatology includes vomiting, abdominal pain, abdominal distention, palpable mass and rectal bleeding. Most of the duplications are diagnosed within the first two years of life, including prenatal diagnosis. Only few cases of caecal duplication have been reported in the literature up to the present day. We are going to present a case of a five-years old girl with caecum duplication who reached our ward due to abdominal distension with no other symptoms.

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.

Varicocele and adolescents: semen quality after 2 different laparoscopic procedures.

The aim of this prospective study was to assess long-term functional results (spermiograms) in subjects who underwent laparoscopic varicocelectomy via either of 2 procedures (ligation or preservation of testicular artery). A total of 122 patients underwent laparoscopic varicocelectomy performed via either of the 2 different procedures: complete ligation of the spermatic vessels or preservation of the spermatic artery. After surgery when patients achieved 18 years, they were asked to undergo semen analysis. Spermiogram results were divided into 2 subgroups: "normal" and "abnormal." We analyzed volume, sperm count per mL, percentage of motile spermatozoa, percentage of normal spermatozoa, and percentage of vitality for each group. Both groups showed the same results in terms of "normal" and "abnormal" spermiograms (World Health Organization criteria), but analysis showed higher sperm concentration per mL, sperm motility, volume, vitality, and rate of morphologically normal sperm for the group with arteries preserved and "normal" spermiograms (P < .01). Analysis of data from the spermiograms showed that preservation of the testicular artery was the best possible option in terms of semen quality. Therefore, we believe that surgical treatment of varicocele should be carried out using procedures involving artery preservation.

Relationship between varicocele grade, vein reflux and testicular growth arrest.

The development of testicular hypotrophy (or testicular growth arrest) in pediatric patients with varicocele is the first indication for surgery. The aim of this study is to identify the correlation between grade of varicocele, grade of vein reflux and testicular growth arrest. Between 2000 and 2001, we recruited 226 patients affected by varicocele without testicular hypotrophy and with grades 2-3 spermatic vein reflux observed during Doppler velocimetry. Medical examinations carried out every 6 months allowed the assessment of varicocele grade, testicular volume, and grade of vein reflux. Other parameters considered in the study were: mean time of grade deterioration, mean time to onset of testicular growth arrest and the relationship between varicocele grade and testicular growth arrest. Deterioration of the condition was experienced in 92 patients (40%) in which 60 patients showed higher varicocele grades without testicular growth arrest, while 32 patients developed testicular growth arrest. There was a statistically significant relationship between testicular growth arrest and varicocele grades (grade 2 and 3) and between grade of reflux and testicular growth arrest. Although it is not possible to determine which patients will develop testicular growth arrest, the assessment of vein reflux allows the identification of those subjects who may potentially develop such a condition.

Recurrent abdominal pain in young pre-menarchal female: clinical and surgical observations.

The purpose of this study is to determine the role of surgical intervention in pre-menarchal patients with recurrent abdominal pain. Seventy-six pre-menarchal females aged 9-12 were examined for recurrent abdominal pain; during clinical observation blood tests were within normal values and abdominal and pelvic US showed no surgical or gynaecological problems. After laparoscopic appendectomy the patients' clinical-surgical findings were related to their age, relief of symptoms and histopathological findings. A total of 71% of patients showed positive surgical findings; 55.5% of these showed variations in the position of the appendix with mild inflammation and reactive pericaecal lymph nodes, 7.5% had a macroscopic inflammation with adhesions and 37% had a mild inflammation. Twenty-nine percent of patients had a normal appendix without adhesions, inflammations or infections. Histopathological examination showed a pathologic appendix in 60 cases (79%). Six months after surgery abdominal pain persisted in 18 patients out of 76 (23%). There is a statistically significant relationship between recurrent abdominal pain, surgical observation and relief of symptoms (P < 0.05). We believe that patients affected by recurrent abdominal pain need to be closely and simultaneously monitored. For this reason, laparoscopy should be considered and used with those patients suffering from frequent abdominal pain and discomfort.

Ductal carcinoma in situ in a 15-year-old boy with gynaecomastia: a case report.

Carcinoma in situ of the male breast is rare, especially when associated with bilateral gynaecomastia and during puberty. Only two cases in adults and one during puberty have been described in the literature. We present the case of a 15-year-old boy whom we have been observing for about 2 years for puberal bilateral gynaecomastia, treated with bilateral exeresis of the mammary gland and subsequently re-operated with total bilateral mastectomy because the tissue removed presented atypical features upon histological examination. The authors believe, after a careful review of relevant literature, that this is the second case of intraductal carcinoma in the presence of gynaecomastia described during adolescence.

Phimosis and topical steroids: new clinical findings.

Phimosis has been defined as unretractable foreskin without adherences and/or a circular band of tight prepuce preventing full retraction. The aim of this study is to evaluate the efficacy (response rate) of topical steroids for the treatment of tight phimosis at different age stages. After using the same medication with different dosage schemes, a retrospective analysis was carried out to assess the efficacy of topical steroids in the treatment of tight phimosis. Patients were divided into three groups: group A (betamethasone scheme A), group B (betamethasone scheme B) and group C (control group). Remission of phimosis, with a complete exposure and without a narrowing behind the glans, was considered a complete response to treatment. The outcomes were then related to dosage scheme and patient's age. The dosage for group A was more effective than the dosage for groups B and C (control group). Phimosis resolved in 90% (group A), 72% (group B) and 56% (group C) of cases. A successful treatment was closely related to the age of patients at the beginning of steroid application. The results showed that treatment with topical steroids, which in general gives good results, proved to be much more successful in patients aged between 4 and 8 years, suggesting the efficacy of an early beginning of the treatment.

Longitudinal study of semen quality in adolescents with varicocele: to treat or not?

OBJECTIVES: To assess the role of varicocelectomy in pediatric patients through a careful semen analysis. METHODS: A total of 214 patients with grade 2 and 3 left idiopathic varicocele were enrolled. Of these 214 patients, 106 (group 1) were treated surgically for testicular hypotrophy, 54 (group 2) were treated surgically with a normal testis, and 54 with a normal testis (group 3) were observed with follow-up visits every 6 months. The spermiogram results for each group were divided into two subgroups: normal, if they met the evaluation criteria and abnormal in the remaining cases. RESULTS: The spermiogram analysis for groups 1 and 2 showed no statistically significant difference in terms of normal and abnormal spermiogram findings (P >0.01). Even though the patients included in group 3 had reported no testicular hypotrophy or pain, the qualitative semen analysis showed the same trend observed in patients affected by varicocele, but the difference was not statistically significant in the variables considered for the other groups (P >0.01). Preservation of the testicular artery in patients with hypotrophy was associated with better results in terms of semen quality. CONCLUSIONS: Testicular hypotrophy remains the most objective indication for surgical treatment of varicocele, and preservation of the testicular artery gives better results in terms of semen quality only in patients affected by testicular hypotrophy.

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.

Phimosis: stretching methods with or without application of topical steroids?

Phimosis has been defined as unretractable foreskin without adherences or a circular band of tight prepuce preventing full retraction. We suggested a new treatment protocol combining betamethasone with stretching exercises to reduce the number of patients requiring surgery for phimosis. Between January 2003 and September 2004, 247 boys aged 4 to 14 years (mean 7.6) were included in this consecutive, prospective, open study. Patients were treated with 0.05% betamethasone cream applied to the distal aspect of the prepuce twice daily for the first 15 days, then once daily for 15 more days. Preputial gymnastics started 1 week after topical application of betamethasone. Ninety-six percent of patients receiving 1 or more cycles of betamethasone showed complete resolution of phimosis. There was a significant difference (P < .001) in response rate between the study and control groups. Only 10 boys in the study group had no response to steroid and stretching. Treatment with topical steroids, combined with stretching exercises, is a suitable alternative to surgical correction (preputial plasty/circumcision).

Varicocele and retrograde adrenal metabolites flow. An experimental study on rats.

BACKGROUND: Idiopathic varicocele is one of the causes of potentially correctable male subfertility. The mechanisms causing spermatogenesis impairment have yet to be clarified. The aim of this study is to analyze the effects of renal and adrenal metabolite reflux on testicular exocrine function in a rat experimental model. MATERIALS AND METHODS: In the study, 45 male Lewis Stock adult rats, each weighing 300 g, were used. The rats were subdivided into three groups of 15 rats. In group A (control group) testicular volume and basal follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone levels were measured at the beginning of the study and after 9 months. In group B, varicocele was induced by means of rings introduced in the left renal vein in order to cause a renospermatic reflux. In group C, similarly to group B, varicocele was induced after removal of left adrenal gland. The effects of varicocele on testicular function were then analyzed 3, 6 and 9 months after surgery. After 9 months, all rats underwent testicular biopsy. RESULTS: Both groups B and C showed a reduction in testicular volume, an increase in FSH and a decrease in testosterone levels. These levels were higher in group B. Testicular histological assessment showed important structural abnormalities in group B rats. CONCLUSIONS: These data support the hypothesis that renal and adrenal metabolites enhance varicocele-induced testicular damage. This theory is supported both by hormonal impairment and testicular histological analysis.