Severe epididymal orchitis and total testicular infarction induced by Pseudomonas aeruginosa infection, and assessment of testicular endocrine function: A case report.

Epididymal orchitis is a common urological condition for which medical management is the primary treatment strategy. Although Pseudomonas aeruginosa is a common cause of nosocomial urinary tract infections, it rarely causes acute epididymal orchitis in adolescence and is difficult to treat. Furthermore, it may progress to potentially fatal complications such as global testicular infarction and late atrophy. Urinary tract infection(s) can harm the gonads and is a well-known cause of male infertility. This case study involved a 13-year-old boy with acute epididymal orchitis caused by P. aeruginosa infection, which led to testicular infarction. Testicular volume, and anti-sperm antibody, reproductive hormone, and serum inhibin B levels were monitored for six months, which revealed that left testicular volume was 1/20 of that of the right. Anti-sperm antibodies were negative, oestradiol level was elevated, but serum inhibin B level declined. This case report emphasises the importance of early treatment by implementing the use of antibiotic(s) to maximise the opportunity for testicular rescue. Testicular function on the healthy side must be monitored when testicular necrosis is detected.

Administration of a glypican-3 peptide increases the infiltration and cytotoxicity of CD8+ T cells against testicular yolk sac tumor, associated with enhancing the intratumoral cGAS/STING signaling.

BACKGROUND: Glypican-3 (GPC3) is highly expressed in testicular yolk sac tumor (TYST). GPC3 has been evaluated as a cancer vaccine for some types of tumors, but little is known on the effects of GPC3 peptide-based therapy on TYST. Here, we evaluated the antitumor effect of GPC3144-152 on TYST and its potential mechanisms. METHODS: GPC3144-152 -specific CD8+ T cells were induced by vaccine immunization and examined by ELISPOT. The CD8+ T cells were purified for testing their cytotoxicity in vitro against TYST cells by CCK-8 and TUNEL assays and in vivo against tumor growth. The influence of GPC3144-152 loading and/or cGAS silencing on the tumor growth, apoptosis and cGAS/STING signaling was tested by immunohistochemistry, immunofluorescence, flow cytometry, and Western blot. RESULTS: Vaccination with GPC3144-152 induced tumor-specific CD8+ T cells that secreted high levels of IFN-γ and granzyme B, and had potent cytotoxicity against TYST in a dose-dependent manner. Adoptive transfer of CD8+ T cells and treatment with GPC3144-152 significantly inhibited the growth of TYST tumors, but less effective for cGAS-silenced TYST tumors in vivo. Treatment with GPC3144-152 enhanced the infiltration of CD8+ T cells into the tumor environment and their cytotoxicity against TYST tumors in vivo by up-regulating granzyme B and IFN-ß expression, but down-regulating GPC3 expression in the tumors. Co-culture of CD8+ T cells with TYST in the presence of exogenous GPC3144-152 enhanced peptide-specific CD8+ T-cell cytotoxicity in vitro, accompanied by enhancing cGAS, γH2AX, TBK1, and IRF3 phosphorylation in TYST cells, but less effective in cGAS-silenced TYST cells. CONCLUSIONS: These data indicated that GPC3 peptide-specific CD8+ T cells had potent antitumor activity against TYST tumor, particularly for combined treatment with the peptide, which was partially dependent on the intratumoral cGAS/STNG signaling. GPC3 peptide vaccine may be valuable for the combination treatment of TYST.

Single-Site Laparoscopic Percutaneous Extraperitoneal Closure Versus Modified Transumbilical Two-Port Laparoscopic Suturing of the Hernia Sac for the Treatment of Pediatric Inguinal Hernia: Comparison of the Outcomes of Two Different Approaches.

OBJECTIVE: To evaluate the surgical outcomes of single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) and modified transumbilical two-port laparoscopic suturing (M-TTLS) of the hernia sac for the treatment of pediatric inguinal hernia (PIH) and determine whether one approach was superior to another. METHODS: From January 2014 to June 2017, a total of 599 children had undergone SLPEC or M-TTLS in our department. SLPEC and M-TTLS were the most frequently performed single-site laparoscopic procedures for PIH in our department, which represented the extraperitoneal and intraperitoneal approaches, respectively. All patients were followed up at the out-patients' clinics and the medical records were reviewed with respect to all operative outcomes. RESULTS: There were 412 patients undergoing SLPEC and 187 patients undergoing M-TTLS, of which 358 hernias were on the right side, 172 on the left and 69 bilaterally. Two hundred and thirty-one unilateral hernias with contralateral patent processus vaginalis underwent contralateral repair at the same session. Mean operation time was 10.81 minutes in unilateral repair and 17.00 minutes in bilateral repairs, respectively. The perioperative complications included minor extraperitoneal hematoma in four (0.44%) patients, recurrence in one (0.11%), hydrocele in five (0.56%), and contralateral metachronous inguinal hernia in three (1.00%). No other complication developed in either group. There was no significant difference of complications between the two approaches except for the longer operation time in M-TTLS. CONCLUSIONS: Both SLPEC and M-TTLS were the safe and effective methods for PIH. The complications were comparable for M-TTLS and SLPEC, but operation time was significantly longer in M-TTLS than in SLPEC.

Is two-port laparoendoscopic single-site surgery (T-LESS) feasible for pediatric hydroceles? Single-center experience with the initial 59 cases.

INTRODUCTION: Although T-LESS is increasingly being used to treat pediatric inguinal hernia, there is no study regarding T-LESS for pediatric hydrocele. OBJECTIVE: To further evaluate the feasibility of T-LESS and present our single-center experience for repair of pediatric hydroceles. STUDY DESIGN: From January 2016 to July 2016, all boys undergoing T-LESS for hydrocele in our institute were retrospectively reviewed. A laparoscope and a needle-holding forceps were introduced at umbilicus. A round needle with silk suture was stabbed through the abdominal wall. The peritoneum around the internal ring was sutured continuously in a clockwise direction. After a complete purse-string suture, a triple knot was performed by using a single-instrument tie technique. The contralateral patent processus vaginalis (PPV) was repaired simultaneously if present. RESULTS: Overall, 59 boys with hydrocele were included (22 on the left side, 32 on the right side, and 5 bilaterally) (Table). During the procedure, all hydroceles were observed with a PPV but the fluid needed to be aspired in 39 boys. A contralateral PPV was present in 24 boys with unilateral hydrocele, and finally 88 repairs were performed. Mean operative time was 18.3 min for unilateral repair and 27.5 min for bilateral repair, respectively. All procedures were uneventful besides a minor injury to the inferior epigastric vessels. After a mean follow-up of 10.7 months, neither recurrence nor other postoperative complication was observed. There were no visible scars on the abdominal wall. DISCUSSION: Compared with open repair of pediatric inguinal hernia and hydrocele, laparoscopic surgery had several advantages, such as exploration of contralateral PPV, identification of rare hernias, diminished postoperative pain, improved cosmesis, faster recovery, and fewer complications. Differing from the laparoscopic retroperitoneal approach, T-LESS included no subcutaneous tissue in the ligature, and its knot was completely in the peritoneal cavity which could radically prevent the severe pain and suture granuloma in the ligated region. Furthermore, the skin incisions after T-LESS were hidden in umbilicus, which could achieve an excellent cosmetic result. By performing T-LESS for pediatric hydroceles, the current study showed very satisfactory results, such as high success rate, minor complication, and excellent cosmesis. However, because of the difficult learning curve of T-LESS, some technical details (e.g. avoiding injury to the spermatic cord, completely suturing the peritoneal folds and reducing disturbance between the instruments) still need to be improved in the future. CONCLUSION: T-LESS appears to be a safe and effective method for repair of pediatric hydroceles.

Subcutaneous endoscopically assisted ligation of spermatic vessels (SEAL-SV) using an epidural-&-spinal needle: a novel technique to repair adolescent varicocele.

We describe a novel technique of subcutaneous endoscopically assisted ligation of spermatic vessels (SEAL-SV) using a modified epidural-&-spinal needle. This technique achieves very cosmetic and minimally invasive outcomes. We have successfully performed SEAL-SV for five consecutive boys and considered it a simple, safe, and effective procedure for adolescent varicoceles.

A systematic review and meta-analysis concerning single-site laparoscopic percutaneous extraperitoneal closure for pediatric inguinal hernia and hydrocele.

BACKGROUND: Single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac/processus vaginalis has been widely performed for repair of inguinal hernia/hydrocele in children. However, a variety of surgical instruments and techniques were used, and significant differences existed among the SLPEC reports. METHODS: A literature search was performed for all available studies concerning SLPEC for pediatric inguinal hernia/hydrocele in PubMed, Embase and Cochrane library. The surgical details and operative outcomes were pooled and analyzed with software StataSE 12.0. RESULTS: 49 studies fulfilled the predefined inclusion criteria of this review and 37 studies were finally included in the meta-analysis. The mean incidence of CPPV was 29.1% (range 5.73-43.0%). The average of mean operative time was 19.56 min (range 8.30-41.19 min) for unilateral SLPEC and 27.23 min (range 12.80-48.19 min) for bilateral SLPEC. The total incidence of injury, conversion, recurrence, hydrocele formation, knot reaction, severe pain, and scrotal swelling was 0.32% (range 0-3.24%), 0.05% (range 0-0.89%), 0.70% (range 0-15.5%), 0.23% (range 0-3.57%), 0.33% (range 0-3.33%), 0.05% (range 0-4.55%), and 0.03% (range 0-1.52%), respectively. There was no development of testicular atrophy. Subgroup analyses showed an inverse correlation between the injury incidence and adoption of assisted forceps, hydrodissection, and blunt puncture device, between the conversion rate and adoption of hydrodissection, between the recurrence/hydrocele incidence and adoption of assisted forceps, hydrodissection, nonabsorbable suture and the preventive measures to avoid ligating the unnecessary subcutaneous tissues, and between the rate of knot reaction and adoption of assisted forceps, hydrodissection, and the preventive measures. CONCLUSIONS: SLPEC was a well-developed procedure for repair of pediatric inguinal hernia/hydrocele. Adoption of assisted forceps, hydrodissection, nonabsorbable suture, and the preventive measures to avoid ligating the unnecessary subcutaneous tissues could significantly reduce the intra- and postoperative complications.

[Single scrotal-incision orchidopexy without ligation of processus vaginalis for palpable undescended testis].

OBJECTIVE: To determine the feasibility and short-term effect of single scrotal-incision orchidopexy (SSIO) without ligation of the processus vaginalis (PV) in the treatment of palpable undescended testis (PUDT). METHODS: This retrospective study included 109 cases of PUDT (125 sides) and 15 cases of impalpable undescended testis (IUDT). The former underwent SSIO without PV ligation (group A, n = 53) or standard inguinal orchidopexy with PV ligation (group B, n = 56) while the latter received laparoscopic exploration (group C). We analyzed the success rate of SSIO in the management of PUDT, postoperative complications, and incidence rates of hernia and hydrocele, and compared the relevant parameters between groups A and B. RESULTS: The median age of the PUDT patients was 1.4 (0.6－11.0) years. Group A included 24 cases of left PUDT (2 with hydrocele), 20 cases of right PUDT (1 with hydrocele), and 9 cases of bilateral PUDT, the success rate of which was 95.1%. Group B consisted of 27 cases of left PUDT, 22 cases of right PUDT (3 with hernias), and 7 cases of bilateral PUDT. The rate of PV patency in the PUDT patients was 80.8% (101/125). Laparoscopic exploration of the 15 IUDT patients revealed 2 cases of congenital testis absence, 6 cases of testis dysplasia, all treated by surgical removal, 3 cases of staying around the inner ring, descended by inguinal orchidopexy, and the other 4 treated by laparoscopic surgery. The incisions healed well in all cases, with no testicular atrophy, inguinal hernia or hydrocele. CONCLUSIONS: Single scrotal-incision orchidopexy without PV ligation is a safe and feasible procedure for the treatment of palpable undescended testis, which avoids the risk of inguinal hernia or hydrocele.

Ascending testis after repair of pediatric inguinal hernia and hydrocele: A misunderstood operative complication.

INTRODUCTION: Ascending testis (AT) is a rare complication after repair of an inguinal hernia/hydrocele. However, there has been some controversy concerning the AT following laparoscopic and open procedures. OBJECTIVE: To review the experience of, and discuss the associated mechanisms with, testicular ascent after pediatric inguinal hernia/hydrocele surgery. STUDY DESIGN: A retrospective review of the medical records of male children who underwent inguinal hernia/hydrocele repair at the present hospital between January 2000 and December 2014. Those who underwent subsequent orchiopexies due to ipsilateral cryptorchidism were identified. The ATs that were misdiagnosed, caused by improper operation, and retractile testes were excluded. The Poisson distribution evaluated the incidences of subgroups. RESULTS: A total of 17,295 inguinal hernias and hydroceles were repaired on 12,849 males; of whom, 10 testes (0.058%) developed ATs on nine individuals postoperatively (Summary Table). The difference of AT incidences between subgroups was insignificant (P > 0.05), except for that grouped by the age at initial operation (cutoff = 1 year, P = 0.008; cutoff = 2 years, P = 0.012). During orchiopexy, extensive adhesions were found in the inguinal canal only in the two cases following open repair. The hernia sac/processus vaginalis remained intact in the canal of AT after laparoscopic repair, and partial after open herniotomy. DISCUSSION: It was generally assumed that testicular ascent after repair of an inguinal hernia/hydrocele was caused by adhesion of the spermatic cord. However, the cord was not dissected during laparoscopic procedure, so adhesion was not the major reason for AT following laparoscopic surgery. The sac/processus were partially excised during open repair, but kept intact in laparoscopic procedure. Therefore, remnants of the sac/processus might play a greater role in postoperative testicular ascent than adhesions. Furthermore, it was found that AT incidence after the repair was not higher than that in 'normal' males. Ascending testis was probably not an operative complication, but a natural descent process of testis independent of the operation. Moreover, the testis descended further due to dissection of the cord and excision of the sac/processus, so the AT incidence was extremely low following open operation. From this point of view, open repair of an inguinal hernia/hydrocele was probably a protective factor for preventing testicular ascent. CONCLUSION: Ascending testis is rare in male pediatric patients who have had repair of an inguinal hernia/hydrocele. Currently, the mechanism of testicular ascent is still unclear, and should be further investigated in the future.

Single-site laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural and spinal needle: excellent results in 1464 children with inguinal hernia/hydrocele.

BACKGROUND: Laparoscopic percutaneous extraperitoneal closure (LPEC) of the internal ring is a well-developed procedure for pediatric inguinal hernia and hydrocele. To reduce the skin incisions and improve the cosmesis, single-site LPEC (SLPEC) has been developed with numerous techniques and instruments. In this study, we described our modifications of SLPEC using an epidural and spinal needle in a large pediatric population. METHODS: From February 2013 to February 2016, 1464 pediatric patients who underwent SLPEC in our hospital were retrospectively reviewed. A 5-mm laparoscope was introduced at the subumbilicus. An 18-gauge epidural needle with a silk suture loop was introduced into the corresponding skin of the internal ring. The needle was advanced extraperitoneally on the medial side of the ring. The suture loop was pushed into peritoneal cavity by the spinal needle. The epidural needle was withdrawn to the roof of the internal ring and then kept advancing along the lateral side. Aided by the spinal needle and laparoscope, a long suture loop was sent into the first loop in peritoneal cavity. The long suture loop was pulled out of the abdominal wall by picking up the first loop, and the internal ring was closed by knotting the suture extracorporeally. The contralateral patent processus vaginalis (CPPV) was simultaneously repaired if present. RESULTS: In total, 981 patients presented with inguinal hernia and 483 with hydrocele. A CPPV was present in 483 patients with unilateral pathology and thus simultaneously repaired. The hydrodissection technique and grasping forceps were used in 290 and 113 patients, respectively. The median operation time was 11 min (7-18 min) and 18 min (10-30 min) for unilateral and bilateral inguinal hernias/hydroceles, respectively. There was no development of intra- or postoperative complications. CONCLUSIONS: SLPEC using an epidural and spinal needle can be performed with excellent results in pediatric inguinal hernias and hydroceles.

[Ladder step strategy for surgical repair of congenital concealed penis in children].

OBJECTIVE: To assess the feasibility of the ladder step strategy in surgical repair of congenital concealed penis in children. METHODS: This study included 52 children with congenital concealed penis treated in the past two years by surgical repair using the ladder step strategy, which consists of five main steps: cutting the narrow ring of the foreskin, degloving the penile skin, fixing the penile skin at the base, covering the penile shaft, and reshaping the prepuce. The perioperative data of the patients were prospectively collected and statistically described. RESULTS: Of the 52 patients, 20 needed remodeling of the frenulum and 27 received longitudinal incision in the penoscrotal junction to expose and deglove the penile shaft. The advanced scrotal flap technique was applied in 8 children to cover the penile shaft without tension, the pedicled foreskin flap technique employed in 11 to repair the penile skin defect, and excision of the webbed skin of the ventral penis performed in another 44 to remodel the penoscrotal angle. The operation time, blood loss, and postoperative hospital stay were 40－100 minutes, 5－30 ml, and 3－6 days, respectively. Wound bleeding and infection occurred in 1 and 5 cases, respectively. Follow-up examinations at 3 and 6 months after surgery showed that all the children had a satisfactory penile appearance except for some minor complications (2 cases of penile retraction, 2 cases of redundant ventral skin, and 1 case of iatrogenic penile curvature). CONCLUSIONS: The ladder step strategy for surgical repair of congenital concealed penis in children is a simple procedure with minor injury and satisfactory appearance of the penis.

Contralateral metachronous hernia following negative laparoscopic evaluation for contralateral patent processus vaginalis: a meta-analysis.

OBJECTIVE: To conduct a meta-analysis of contralateral metachronous inguinal hernia (CMIH) that originated from negative laparoscopic evaluation for contralateral patent processus vaginalis (CPPV) in children who presented with a unilateral inguinal hernia and to determine the incidence of and factors associated with such a CMIH. MATERIALS AND METHODS: A PubMed search was performed for all studies concerning laparoscopic repair or evaluation of inguinal hernia in children. The search strategy was as follows: (laparoscop* OR coelioscop* OR peritoneoscop* OR laparoendoscop* OR minilaparoscop*) AND ("inguinal hernia" OR "metachronous hernia") AND child*. Inclusion criteria included unilateral inguinal hernia in children, negative laparoscopic evaluation of CPPV, without history of contralateral inguinal surgery previously, and clearly reporting CMIH development or not. Editorials, letters, review articles, case reports, animal studies, and duplicate patient series were excluded. RESULTS: Twenty-three studies comprising 6091 children with negative CPPV fulfilled the inclusion criteria and were included in the final analysis, of whom 80 (1.31%) subsequently presented with a CMIH. Subgroup analysis showed that CMIH incidence was lower through an umbilical approach than via an inguinal one (0.85% versus 1.78%, P=.009). As for the transinguinal approach, there was a CMIH incidence of 0.78% and 2.05%, respectively, for laparoscopy with a small angle (30° and 70°), whereas there was no CMIH development for that with a large angle (110°, 120°, and flexible). A high pneumoperitoneum pressure (>10 mm Hg, >12 mm Hg, and >14 mm Hg) was usually associated with a slightly higher CMIH incidence than a low one (≤10 mm Hg, ≤12 mm Hg, and ≤14 mm Hg), all without significant difference. CMIH incidence was slightly lower for using a broad CPPV definition than for using a narrow one (0.64% versus 1.35%, P=.183). CONCLUSIONS: CMIH following negative laparoscopic evaluation for CPPV was a rare but possible phenomenon. Choosing the transumbilical approach, transinguinal laparoscopy with a large angle, low-pressure pneumoperitoneum, and broad CPPV definition would probably reduce the occurrence of such CMIHs.

Systematic review and meta-analysis of studies comparing the perimeatal-based flap and tubularized incised-plate techniques for primary hypospadias repair.

PURPOSE: To conduct a systematic review and meta-analysis of studies comparing the perimeatal-based flap (PBF) and tubularized incised-plate (TIP) techniques for primary hypospadias repair and determine whether the two techniques had similar reported outcomes. METHODS: The PubMed, Embase and Cochrane databases were searched using the terms: hypospadias, Snodgrass, TIP*, tubularized incised plate, tubularized incised-plate, Mathieu*, perimeatal-based flap, perimeatal flap, meatal-based flap and meatal based flap. No other limits were used. Inclusion criteria included: primary hypospadias repair only; both including the PBF and TIP techniques; at least one of the quantitative outcomes obtainable from study; comparative studies. RESULTS: Twelve studies fulfilled the inclusion criteria and were included in the final analysis. Meta-analysis showed that there were no significant differences between the two techniques when comparing fistula (OR = 1.47; 95 % CI: 0.82-2.63; P = 0.20), meatal stenosis (OR = 0.53; 95 % CI: 0.24-1.16; P = 0.11), and wound dehiscence (OR = 0.82; 95 % CI: 0.24-2.84; P = 0.76). Both the studies which assessed cosmesis objectively showed a consistent better cosmetic result of the TIP technique (P < 0.05). CONCLUSION: There were no significant differences of complication rates between the two techniques, and the TIP technique was usually of better cosmesis. Given the large clinical heterogeneity among studies, future more well-designed studies with full data and uniform criterion were awaited.

Robot-assisted versus laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: an updated systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to perform an updated systematic review and meta-analysis to compare robot-assisted pyeloplasty (RP) with laparoscopic pyeloplasty (LP) with regard to perioperative results. MATERIAL AND METHODS: A search was performed for all available studies comparing the effect of RP versus LP for ureteropelvic junction obstruction (UPJO), published up to August 2012 in PubMed, Embase, Cochrane Library and Science Direct. Three reviewers independently conducted the determination of eligibility, quality assessment and data extraction for each study. All analyses were performed with Review Manager 5.1.5.0 software. RESULTS: In total, 12 studies meeting the eligibility criteria were identified for meta-analysis data extraction, including 347 cases of RP and 299 cases of LP. Meta-analysis showed that RP was associated with a 18.76 min reduction in suturing time [weighted mean difference (WMD) = -18.7 6 min, 95% confidence interval (CI) -28.76 to -8.76, p = 0.0002] and a 0.75 day decrease in mean length of hospital stay (WMD = -0.75 days, 95% CI -1.10 to -0.40, p < 0.0001) compared with LP. There were no obvious differences between the approaches in operative time (WMD = -19.44 min, 95% CI -40.20 to 1.31, p = 0.07), complication rate [odds ratio (OR) = 0.65, 95% CI 0.38 to 1.12, p = 0.12] or success rate (OR = 1.32, 95% CI 0.42 to 4.12, p = 0.64). CONCLUSION: For patients with UPJO, RP appears to achieve equivalent perioperative results to LP, except that RP has a shorter suturing time and shorter length of hospital stay. Given the significant heterogeneity, inevitable selection bias and limited number of studies, more high-quality clinical studies are needed.