[Preputioplasty in the treatment of phimosis in pediatric age. Indications and results]. / La prepuzioplastica nel trattamento della fimosi in età pediatrica. Indicazioni e risultati.

AIM: Phimosis is a common condition in the pediatric age. Circumcision has been the technique of choice for the surgical correction of this condition. As an alternative to circumcision different techniques of preputioplasty have been described in the last years. The aim of this paper was to report our experience with the preputioplasty technique in the treatment of phimosis in pediatric age. METHODS: A preputioplasty is performed for phimosis correction in 109 patients aged between 4 and 16 years. Patients with a sclerotic phimosis were not treated with preputioplasty. All the patients underwent frenulotomy with dorsal preputial plasty using a single dorsal incision. Only in 3 patients a double lateral incision was necessary. Patients were operated under general anesthesia with an average time of 8 min. RESULTS: Patients were followed-up at 8 days, 30 and 90 days postoperatively. The cosmetic result has been excellent in 90% of cases and good in 10%. The functional result has been excellent in all the patients. We observed 3 cases of infection and 8 cases of edema of the prepuce. These postoperative complications were all resolved with medical therapy. No recurrences have been observed. CONCLUSIONS: Preputioplasty is a safe and rapid technique that allows to obtain excellent cosmetic and functional results. In our opinion, preputioplasty should be the first choice technique for the treatment of phimosis in pediatric and adolescent age.

Preliminary report on nitric oxide-mediated oxidative damage in adolescent varicocele.

BACKGROUND: The current study was designed to characterize the process of nitric oxide (NO) and peroxynitrite generation through the determination of nitrotyrosine concentration in the dilated veins of varicoceles in adolescents. METHODS: Ten adolescents with a median age of 13 years (range 12-17) affected by a left idiopathic varicocele (grade II and III) were studied. Whole blood samples were withdrawn from a peripheral vein at time of induction of anaesthesia, and from a dilated spermatic vein before ligation. Peripheral blood samples from five adolescents undergoing minor surgical procedures were used as controls. The nitrotyrosine concentration was evaluated by a sandwich enzyme-linked immunosorbent assay (ELISA), using a monoclonal anti-nitrotyrosine antibody and Western blot analysis. RESULTS: Plasma nitrotyrosine concentrations were significantly greater in the spermatic vein when compared with the peripheral vein (P = 0.031). Nitrotyrosine in plasma of controls did not show any significant difference in comparison with peripheral samples from varicocele patients. Western blot analysis confirmed the above data. CONCLUSIONS: In adolescents with a varicocele, there is an increase in nitrotyrosine concentration within the spermatic vein that can cause protein nitration and cytotoxicity via its reaction with various molecular targets. This could have repercussions on both sperm and testis function. We conclude that an oxidative stress status is present and should be considered as an indication for varicocele treatment in the adolescent.

Utility of a scoring system in the diagnosis of acute appendicitis in pediatric age. A retrospective study.

BACKGROUND: Acute appendicitis is the most frequent cause of surgical emergency in pediatric age. The aim of this study has been to evaluate the diagnostic accuracy of a scoring system, retrospectively applied, to the clinical and laboratory parameters in patients with acute appendicitis. METHODS: A group of 156 patients admitted for acute abdominal pain and operated for appendectomy, in the last 3 years, has been included in the study. The mean age was 8.4 years. The modified Alvarado score has been used as scoring system: white count, neutrophil count, fibrinogen level, body temperature, resistance in the right iliac fossa, length of symptoms, nausea/vomiting. The score has been calculated for each patient. They were subdivided into 3 groups. Group I (score 1-4), no admission; Group II (5-6), admission and observation; Group III (7-10), surgery. This subdivision was then compared with the intraoperative notes. RESULTS: Patients were divided into 3 groups. Group I, 24 patients (15%); Group II, 34 patients (22%); Group III, 98 patients (63%). On the basis of the intraoperative notes 61 patients had acute appendicitis and 95 complicated acute appendicitis. In this last subgroup the score gave a percentage of patients to operate of 90.5%. CONCLUSIONS: With the present work we confirm the utility of a scoring system in the preoperative diagnosis of acute appendicitis and in our opinion it is a useful system for a first, rapid and economic evaluation in the pediatric emergency department.

Monocyte and neutrophil activity after minor surgical stress.

BACKGROUND/PURPOSE: Surgical stress produces changes in the immune status of patients. In adults, major surgery causes immunosuppression, whereas minor operations stimulate immune responses. In children, the immunologic response to surgery has not been elucidated completely. The authors investigated the effects of minor surgery on immune response by analyzing neutrophil and monocyte phagocytosis and oxidative burst activity. METHODS: Sixteen children undergoing elective minor surgery were enrolled. Blood samples were collected before the operation (at time of induction of anesthesia), at the end of operation, and 72 hours after surgery. Neutrophil and monocyte phagocytosis and oxidative burst activity were studied using a flow cytometric method. RESULTS: Phagocytosis and oxidative burst increased significantly at the end of the operation, both in neutrophils (7.4% and 14.3%, respectively) and monocytes (11.6% and 27%, respectively). The increase was only significant for monocytes (17.5%) 72 hours after surgery. White cell count did not show any significant changes. There was no significant correlation between phagocytosis, oxidative burst activity, and white cell count or neutrophil and monocyte count. CONCLUSIONS: This study shows that minor surgery in children induces immune activation by increasing neutrophil and monocyte phagocytosis and oxidative burst activity. Further studies are required to understand the molecular basis of these findings.

Nitric oxide production is increased in the spermatic veins of adolescents with left idiophatic varicocele.

BACKGROUND/PURPOSE: The existence of an excessive release of nitric oxide (NO) within dilated spermatic veins has been recorded in adults with varicocele suggesting a high oxidative stress. The authors investigated whether NO overproduction is already present in the dilated veins of adolescent varicocele and which enzymatic isoforms in the spermatic vein could be expressed. METHODS: The study group consisted of 10 adolescent patients affected by left idiophatic varicocele of grade II and III. The increase in NO production was established by determination of serum concentration of L-hydroxyarginine (L-NHA) and Nitrite/nitrate (NOx). Both endothelial and inducible NOsynthase (NOS) were investigated by Western blot analysis and by immunohistochemical localization using specific monoclonal fluorescein conjugated antibodies. RESULTS: Serum L-NHA levels were significantly greater in the spermatic veins when compared with the peripheral veins 176.8 +/- 32.3 micromol/L versus 3.38 +/- 0.64 micromol/L (P =.0004 Similarly, NOx levels were increased, respectively, 68.2 +/- 16.7 nmol/mL versus 12.9 +/- 2.65 nmol/mL (P =.029). Endothelial NOS was localized in the spermatic vein of varicocele patients, but not overexpressed; the inducible isoform was not detected. CONCLUSIONS: Adolescents with varicocele already present an increase in NO within dilated veins. The dilated spermatic vein is not the major source for the increase in NO level. These results could have an implication in the natural history of adolescent varicocele and in programming the ideal time for surgical treatment.

Nitric oxide synthase patterns in normal and varicocele testis in adolescents.

OBJECTIVE: To determine if the testes of normal adolescents can produce nitric oxide (NO), by assessing NO synthase (NOS) activity, and whether this activity changes in adolescents with left idiopathic varicocele. PATIENTS AND METHODS: After obtaining informed consent, testicular biopsies were obtained from eight adolescents (mean age 16.4 years; controls) who underwent surgery for inguinal hernia or hydrocele, and from 20 adolescents (mean age 16.2 years) operated for left idiopathic varicocele. Inducible and endothelial NOS (iNOS and eNOS) isoforms were investigated in the biopsy specimens by immunohistochemical localization and Western blot analysis using specific fluorescein-conjugated antibodies. RESULTS: Both normal and pathological samples expressed eNOS at the level of vessels and Leydig cells. The iNOS was expressed in Leydig cells of normal testes and over-expressed in Leydig cells of varicocele testes. CONCLUSION: Leydig cells of adolescent testes constitutively express iNOS. Under pathological conditions, e.g. varicocele, iNOS is up-regulated and is a possible source of NO overproduction. These results could be useful in explaining the pathogenesis of both testis and sperm dysfunction in varicocele.

Myofibroblasts in adolescent varicocele: an ultrastructural and immunohistochemical study.

Myofibroblasts of the testes play an important role in the morphofunctional integrity of the seminiferous tubule. Previous studies in adults with varicocele have demonstrated an involvement of this cell population that tends to transform into fibroblasts. The aim of the present study was to try and verify the morphological features of myofibroblasts in the adolescent with left idiophatic varicocele. Twenty-two testicular biopsies were obtained from adolescents (aged 13-18 years, mean 15.8) and operated for left idiophatic varicocele. Biopsies were processed for electron microscopy (TEM) and immunofluorescence studies. The latter determined the level of myofibroblasts by using alpha-smooth muscle isoactin, a specific marker of myofibroblasts and, hence, excluding fibroblasts. TEM observations revealed a normal ultrastructure of myofibroblasts that was similar to that for the controls but an increased presence of extracellular matrix. The immunofluorescence study always demonstrated strong cell positivity to anti alpha-smooth muscle isoactin as also seen in the controls. This study demonstrates that adolescents with varicocele have well preserved myofibroblasts and do not show any evidence of transformation into fibroblasts, this has already been demonstrated in adult varicocele. These observations could represent an important factor for the understanding of the reversal of growth failure of the testes observed after early treatment.

A possible role of the plasmalemmal cytoskeleton, nitric oxide synthase, and innervation in infantile hypertrophic pyloric stenosis. A confocal laser scanning microscopic study.

In reference to a possible neuropathy in the pathogenesis of infantile hypertrophic pyloric stenosis (IHPS), previous studies have described alterations in peptidergic transmission while others have recently attributed an important role to nitrinergic activity. Little attention has been given to the organization of the extracellular matrix (ECM) and the constituent cytoskeleton and subsarcolemma of the pyloric smooth-muscle cell. To study a possible relationship between neuronal and muscular elements in IHPS, 9 biopsies from patients with IHPS and 5 biopsies of normal pylorus were examined using immunohistochemical techniques with regard to the distribution of nerve cells and fibers (bNOS and PGP 9.5) and the ECM (laminin) and cytoskeleton (talin, vinculin, dystrophin, alpha-smooth iso-actin, desmin) components of the pyloric muscle. Our results showed anti-protein gene product 9.5 and b-nitric oxide synthase immunoreaction respectively reduced or absent in nerve fibers with a positive reaction inside the ganglion cells. An uneven distribution of the ECM component laminin was evident, together with a negative immunoreaction to talin and dystrophin. The imunolocalization of vinculin, alpha-smooth iso-actin, and desmin was similar to the controls. Our findings suggest that there is a close relationship between the nerve and muscle elements in the pathophysiology of IHPS and that non-alteration of some elements of cytoskeleton organization can play an important role in regaining pyloric function after pyloromyotomy.

[The treatment of varicocele in adolescence]. / Il razionale del trattamento del varicocele nell'adolescente.

Varicocele treatment in adolescents should be considered as a prophilactic procedure. It is known, in-fact, that the venous reflux is responsible for damage to the testis that worsen by time. For this reason patients with grade II or III varicocele and reduced size of the testis must be considered for treatment. A right approach to varicocele should consider the different etiopathogenetic factors. Type I varicocele can be easily treated with embolization of the spermatic vein during the diagnostic phlebographic procedure. For type II and III in which is present an iliac hypertension must be considered a surgical correction with selective ligation of intra- and extrafunicular veins together with a microsurgical spermatico-epigastric anastomosis so to allow a better venous drainage of the testis. The Authors present their experience on 20 selected cases of varicocele treated by selective inguinal veins ligation and microsurgical anastomosis. They underline the importance to search and ligate, using the microscope, when dilated, the external spermatic vein or cremasteric (ligated in 9 cases), the deferential veins (ligated in 18 cases) and the gubernacular veins (ligated in 16 cases). These last can be recognized only after testicular exteriorization. It is also important to avoid lymphatic and testicular artery ligation. The results obtained were good with no recurrence, testicular atrophia or hydrocele.