RESUMO
Ureterocele decompression by endoscopic or open incision was the primary treatment in 59 children with 63 ureteroceles. Of these, 18 were intravesical and 45 were ectopic. The endoscopic or open incision adequately decompressed all intravesical ureteroceles and 37 of 45 ectopic ureteroceles (82%). After incision, the secondary operation rate was 17% for intravesical and 62% for ectopic ureteroceles. In our opinion, endoscopic or open incision must be considered a definitive treatment in the large majority of intravesical ureteroceles and is also valid in ectopic ureteroceles. In these cases, the early decompression obtained by this approach produced significant functional recovery, fewer urinary tract infections, and facilitated subsequent surgery in those patients requiring complete surgical reconstruction.
Assuntos
Endoscopia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Resultado do Tratamento , UreteroceleRESUMO
A case of malignant schwannoma occurring in an 11-year-old boy is described. To our knowledge, this is the third case of malignant juxta-adrenal schwannoma reported in the literature. It was misdiagnosed at the onset of the disease as a post-traumatic renal hematoma. Angiography revealed that the tumor derived its blood supply from collateral vessels of the aorta, splenic, and left gastric arteries. An analysis of the diagnosis, clinical course, and prognostic factors of this rare tumor is performed.
Assuntos
Neurilemoma , Neoplasias Retroperitoneais , Criança , Terapia Combinada , Diagnóstico Diferencial , Diagnóstico por Imagem , Humanos , Masculino , Neurilemoma/diagnóstico , Neurilemoma/epidemiologia , Neurilemoma/secundário , Neurilemoma/terapia , Prognóstico , Neoplasias Retroperitoneais/diagnóstico , Neoplasias Retroperitoneais/epidemiologia , Neoplasias Retroperitoneais/terapiaRESUMO
In severe vaginal malformations, when the distance between the upper vaginal pouch and perineum is too long (6 cm or more), reconstruction of the vagina can be performed by colonic interposition or by long cutaneous flaps obtained by the tissue expansion technique. Two female adolescents were treated using expanded labial skin flaps. Dissection and anastomosis between the vaginal remnant and cutaneous tube was performed by the transtrigonal approach. Results were satisfactory at 2.5-year follow-up. In our opinion, expanded labial skin-flap vaginoplasty has three main advantages: (1) it permits the construction of a large, soft, well-vascularized neovagina using non-hair-bearing labial skin; (2) it obviates postoperative dilations and prevents delayed strictures; and (3) a transtrigonal approach permits an easy vaginal dissection and a careful, tension-free anastomosis.
RESUMO
In severe vaginal malformations, when the distance between the upper vaginal pouch and perineum is too long (6 cm or more), reconstruction of the vagina can be performed by colonic interposition or by long cutaneous flaps obtained by the tissue expansion technique. Two female adolescents were treated using expanded labial skin flaps. Dissection and anastomosis between the vaginal remnant and cutaneous tube was performed by the transtrigonal approach. Results were satisfactory at 2.5-year follow-up. In our opinion, expanded labial skin-flap vaginoplasty has three main advantages: (1) it permits the construction of a large, soft, well-vascularized neovagina using non-hair-bearing labial skin; (2) it obviates postoperative dilations and prevents delayed strictures; and (3) a transtrigonal approach permits an easy vaginal dissection and a careful, tension-free anastomosis.
Assuntos
Hiperplasia Suprarrenal Congênita/cirurgia , Retalhos Cirúrgicos/métodos , Dispositivos para Expansão de Tecidos , Vagina/anormalidades , Vulva/cirurgia , Adolescente , Feminino , Humanos , Complicações Pós-Operatórias/cirurgia , Reoperação , Técnicas de Sutura , Vagina/cirurgiaRESUMO
The management of giant omphalocele remains a major surgical challenge. A staged approach is mandatory to achieve an uncomplicated reduction. The case of a child conservatively and successfully treated by progressive external compression of the herniated organs and viscera using an elastic bandaging is described here. The complete integration of the omphalocele content and the closure of the abdominal wall were obtained in 9 days. No ventilatory support was required. The procedure is easy, safe, effective and inexpensive. Large base and intact amniotic sac are prerequisites for feasibility.
Assuntos
Bandagens , Hérnia Umbilical/terapia , Músculos Abdominais/cirurgia , Elasticidade , Hérnia Umbilical/cirurgia , Humanos , Recém-Nascido , MasculinoRESUMO
Laparoscopic clipping and division of the internal spermatic vessels was performed without complications in 80 adolescents to treat varicocele. In four cases the procedure had to be converted to open surgery. Two of the cases were converted because of technical errors during CO2 insufflation and in two cases because dissection of the vessels was impossible owing to abnormal adhesion of sigmoid colon. At 6 months' follow-up there was only one relapse. Only one hydrocele was noted postoperatively, and testicular size did not decrease in any patient. The authors believe that laparoscopic varicocelectomy is a simple, safe, and effective surgical procedure, which could be proposed as an alternative to open surgical or percutaneous embolization approaches. However, much more experience is needed to obtain a definitive conclusion.
Assuntos
Laparoscopia , Varicocele/cirurgia , Adolescente , Criança , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Recidiva , Resultado do TratamentoRESUMO
"Acute scrotum" in infants and children is generally due to testicular torsion, torsion of the appendix of testis or acute orchiepididymitis. However they are other less frequent causes of "acute scrotum". The differential diagnosis is often very difficult. 265 consecutive cases of acute scrotum are reviewed. 47% of the all patients presented torsion of the appendix of testis, 26% torsion of testis and 26% acute orchiepididymitis. The torsion of testis was most frequent in children under 1 year (67%), in the older patients the torsion of appendix of testis was most frequent (46% in patients 1-6 years old, 57% in patients over 6 years). The value and limit of ultrasound, scrotal scintigraphy and doppler ultrasound are discussed and an algorithm for the diagnosis of causes of acute scrotum is presented. In equivocal cases, early surgical exploration may be necessary to exclude torsion of testis and to prevent testicular loss.
Assuntos
Escroto , Torção do Cordão Espermático/diagnóstico , Doença Aguda , Criança , Pré-Escolar , Emergências , Humanos , Lactente , Masculino , Torção do Cordão Espermático/cirurgiaRESUMO
Idiopathic varicocele is a neglected entity in classic pediatric textbooks. Yet vast epidemiologic studies revealed that the incidence of varicocele gradually increases in patients between 10 and 15 years old and is comparable to that of the adult male population. Clinically, the pediatric varicocele is often associated with smaller and hypotrophic testis; histologically it also is associated with pathological and progressive changes of the testis. We report on the preliminary results of a personal epidemiologic study and a comparative follow-up to value the efficacy of surgical correction in two groups of adolescent and adult patients. Early recognition and treatment of a severe varicocele with testicular hypotrophy may help to prevent in adults the infertility associated with this condition.
Assuntos
Varicocele , Adolescente , Criança , Humanos , Incidência , Masculino , Escleroterapia , Varicocele/classificação , Varicocele/epidemiologia , Varicocele/etiologia , Varicocele/fisiopatologia , Varicocele/terapiaRESUMO
The varicocele is still the most common correctable cause of male infertility. The epidemiologic studies revealed a gradually increasing incidence of varicocele in patients 10 to 18 years old, as height at the end of puberty as that of the adult male population. The pediatric varicocele is often associated with smaller and hypotrophic testis which presents also histological and progressive changes. Surgical correction of a varicocele in the adult usually produces poor results. In order to improve the fertility rate in adulthood an early varicocelectomy has been suggested. On the basis of our own studies and after a review of the literature, we conclude that all grade III varicoceles and grade II associated with testicular hypotrophy must be early operated on. This hearing provides a higher fertility rate and can prevent the reduced fertility associated with delayed varicocelectomy.
Assuntos
Varicocele/cirurgia , Adolescente , Atrofia , Criança , Humanos , Incidência , Masculino , Contagem de Espermatozoides , Testículo/patologia , Varicocele/epidemiologiaRESUMO
Impairment of fertility rate has been found to be associated with cryptorchidism. In this study we assessed the fertility of 172 adult subjects with unilateral and bilateral cryptorchidism who underwent surgical correction in pediatric age. Fertility has been evaluated by sperm analysis. Moreover test of function of spermatozoa membrane (swelling-test) and the research of antisperm antibodies (spermmar test) were carried out. The report presents data demonstrating that the fertility rate in patients with bilateral cryptorchidism is markedly reduced if compared with subjects affected by unilateral cryptorchidism. Azoospermia is present in 18% of bilateral cryptorchidism. The timing of surgery and the anatomical position of the cryptorchid testes do not seem to affect the fertility rate.
Assuntos
Criptorquidismo/complicações , Infertilidade Masculina/etiologia , Contagem de Espermatozoides , Adulto , Anticorpos/análise , Humanos , Masculino , Oligospermia/diagnóstico , Espermatozoides/imunologiaRESUMO
A range of epididymal and vasal anomalies (EVA), varying from ductal patency aberrations to abnormal attachments of the epidydimis to the testis or even complete absence, exists in boys with cryptorchidism, but there are few studies of normal controls for comparison. In the present study anatomy of testicular-epididymal relationships were recorded in 517 cryptorchid patients (423 unilateral and 94 bilateral) and in 192 boys who underwent inguinal exploration for inguinal hernia or hydrocele. The postmortem anatomic relationship of the testis and epididymis in 50 adults was also examined. The operative findings were divided into two groups: simple variants of normal and forms of complete anatomic disconnection of the spermatic ducts (EVA). We were unable to find EVA in the control groups. In contrast EVA was present in the 20% of cryptorchid patients. The incidence was 16.5% in unilateral cryptorchidism and 26% in bilateral cases, in 17% of whom the EVA was bilateral. According to the literature and our previous study azoospermia is present in about 18-20% of adults operated upon in childhood for bilateral cryptorchidism. Our present study may suggest that azoospermia in adults operated on for bilateral cryptorchidism could be partially related to some forms of bilateral occlusion or interruption of the spermatic ducts.
Assuntos
Criptorquidismo/complicações , Epididimo/anormalidades , Oligospermia/etiologia , Adulto , Criança , Epididimo/anatomia & histologia , Humanos , Masculino , Túbulos Seminíferos/anormalidadesRESUMO
Management of the nonpalpable testis is controversial and can be difficult as shown by the multiple modalities for evaluation and proposed treatment. In our opinion, laparoscopy is the ideal first step in the management of patients with a nonpalpable testis, having a great reliability in locating or confirming absence of an occult testis. Accurate preoperative assessment and localization will assist in selecting the appropriate surgical approach either laparoscopic, laparoscopic-assisted, or open procedure. Laparoscopy was performed on 74 patients with 86 nonpalpable testis. The technique has been demonstrated to be extremely safe and lead to diagnosis in 100% of cases. Surgical management of nonpalpable testis was directly performed by laparoscopy identifying intra-abdominal vanishing testis and locating an intra-abdominal or inguinal testis. The two-stage Fowler-Stephens orchiopexy was performed in 41 patients. The first stage consisted of laparoscopic clip ligation of the spermatic vessels. Of these, 32 underwent the second stage by vas-based orchiopexy; all testes, but one, showed a normal size and consistency. To conclude, we advocate the use of laparoscopy in all boys with nonpalpable testis.
Assuntos
Criptorquidismo/diagnóstico , Criptorquidismo/terapia , Laparoscopia/métodos , Adolescente , Criança , Pré-Escolar , Criptorquidismo/cirurgia , Humanos , MasculinoRESUMO
A varicocele first develops in early adolescence and it can negatively affect testicular growth, histology and function. The use of early varicocelectomy to prevent severe testicular damage and sub-infertility in adulthood seems to be incontrovertible. However there is a difference of opinion as to the proper surgical procedure of varicocele ablation. To date, the inguinal and high retroperitoneal approaches are the most commonly accepted methods. However significant postoperative morbidity is common, with a recurrence rate ranging from 1 to 25% and return to normal activity often is prolonged. This considerations have prompted many to search for alternative techniques. The Authors performed laparoscopic clipping and division of the internal spermatic vein or the internal spermatic vessels in 55 adolescents to treat varicocele. Indications for the operation were third degree varicocele and second degree with testicular hypotrophy. At a mean 6 months follow-up, they did not observe either relapses or complications; no hydrocele was noted and testicular size did not decrease in any patient. In the Authors' experience and opinion, laparoscopic varicocelectomy is a simple, safe, effective and minimally invasive surgical procedure and it can be proposed as a viable alternative to open traditional surgical methods.
Assuntos
Laparoscopia/métodos , Varicocele/cirurgia , Adulto , Criança , Humanos , MasculinoRESUMO
Surgery is the cornerstone in the management of congenital bronchopulmonary diseases. This term include a wide spectrum of malformative anomalies subdivided clinically into cystic and solid lesions. Bronchogenic cyst (BC), cystic adenomatoid malformation (CAM) and congenital lobar overinflation (CLO) are congenital cystic lesions. Pulmonary sequestration (PS) and pulmonary arteriovenous malformation (PAM) are congenital solid lesions. As a group, congenital bronchopulmonary diseases require removal in order to reduce potentially life-threatening infection and respiratory distress. Bronchopulmonary infections and neoplasms constitutes acquired bronchopulmonary diseases. Improvement in antibiotic therapy has reduced the place of surgery in the current treatment of bronchopulmonary infections. At present, the failure of medical therapy and the appearance of complications are the most common indications for operative treatment. Although these problems are not as common now, at times they required surgical intervention. Finally bronchopulmonary neoplasms are unusual in the pediatric age group. As a result, experience with the diagnosis, management and prognosis is limited. However, the complete surgical resection offers the best chance for survival in the large majority of cases.
Assuntos
Brônquios/anormalidades , Pneumopatias/congênito , Pneumopatias/cirurgia , Adolescente , Malformações Arteriovenosas/cirurgia , Bronquiectasia/cirurgia , Cisto Broncogênico/congênito , Cisto Broncogênico/cirurgia , Displasia Broncopulmonar/cirurgia , Sequestro Broncopulmonar/cirurgia , Criança , Pré-Escolar , Empiema Pleural/cirurgia , Humanos , Lactente , Recém-Nascido , Abscesso Pulmonar/cirurgia , Enfisema Pulmonar/cirurgiaRESUMO
Management of the nonpalpable testis is controversial and can be difficult as shown by the multiple modalities for evaluation and proposed treatment. In our opinion, laparoscopy is the ideal first step in the management of patients with a nonpalpable testis, having a great reliability in locating or confirming absence of an occult testis. Accurate preoperative assessment and localization will assist in selecting the appropriate surgical approach either laparoscopic, laparoscopic-assisted, or open procedure. Laparoscopy was performed on 74 patients with 86 nonpalpable testis. The technique has been demonstrated to be extremely safe and lead to diagnosis in 100% of cases. Surgical management of nonpalpable testis was directly performed by laparoscopy identifying intra-abdominal vanishing testis and locating an intra-abdominal or inguinal testis. The two-stage Fowler-Stephens orchiopexy was performed in 41 patients. The first stage consisted of laparoscopic clip ligation of the spermatic vessels. Of these, 32 underwent the second stage by vas-based orchiopexy; all testes, but-one, showed a normal size and consistency. To conclude, we advocate the use of laparoscopy in all boys with nonpalpable testis.
Assuntos
Criptorquidismo , Laparoscopia , Adolescente , Criança , Pré-Escolar , Criptorquidismo/diagnóstico , Criptorquidismo/cirurgia , Humanos , MasculinoRESUMO
A retrospective, long-term urodynamic study was performed in order to follow the evolution of the urodynamic patterns in 55 unselected patients previously affected by posterior urethral valves (PUV). The mean maximum cystometric capacity (MCC) values progressively increased over time and, on long-term follow-up, were just above 2 standard deviations (SD). The mean compliance values were clearly reduced in the first urodynamic studies after valve ablation, and only after a mean of 5 years follow-up did they approach the lower limits of normal. The small compliance and capacity (SCC) group showed two trends of evolution: a more numerous subgroup tended toward progressive normalization while a second subgroup (<20%) showed mean compliance values below normal limits, with reduced (-2 SD) MCC persisting at long-term follow-up. The number of patients in this group decreased over time. In contrast, we were able to show a significant increase in patients with myogenic failure. In this group scheduled voiding using the Valsava maneuver in conjunction with a regimen of double or triple micturition was usually succesful in modifying the course, normalizing MCC, reducing residual urine, and also eliminating incontinence. Finally, initial urodynamic investigations in the fulguration and vesicostomy groups showed a much higher percentage of SCC bladders in the latter group (83.5% vs. 35%). However, at long-term examinations the urodynamic parameters were nearly identical in both groups, showing that temporary bladder defunctionalization does bot adversely affect future detrusor activity. No direct relationship between urodynamic abnormalities and renal insufficiency could be shown, however, the majority of patients with reduced glomerular filtration rates still showed urodynamic dysfunction at long-term follow-up. In the authors' opinion, serial urodynamic investigations in association with serial evaluation of the evolution of upper urinary tract and renal function are mandatory for correct PUV management and provide useful guidelines for avoiding incorrect treatment and obtaining better long-term results.
RESUMO
We report the results of a medium-term follow-up study of 52 patients with bilateral, massive primary vesicorenal reflux (PVRR) with renal damage at presentation. Ten infants between 2 and 5 months of age, with a total of 19 renal units, had a temporary vesicostomy followed by ureteral reimplantation after 12-15 months; 42 patients with 81 renal units had primary ureteral reimplantation. The postoperative observation period covered 9.5 years on average (20 months - 21.5 years). The study showed that: (1) urinary specific gravity remained reduced in about 61% of patients; (2) proteinuria improved significantly, in a direct proportion to the favorable evolution of renal function; (3) the frequency of acute pyelonephritis decreased significantly from 98% to 23%. Postoperatively, 27 patients (51%) had one or more episodes of urinary tract infection (UTI) and 12 (23.0%) still had episodes of acute pyelonephritis. (4) At follow-up 7 patients (13.5%) had stable hypertension, while 3 others had unstable hypertension (19.2%); 8 had chronic renal insufficiency or end-stage renal disease. When only adolescents more than 12 years old were considered, the incidence of hypertension increased to 34.4% (10.29). (5) Some renal scarring developed despite successful antireflux surgery, and parenchymal growth, which was severely impaired prior to surgery, restarted although it remained below - 2 standard deviations from the mean. (6) In the overall series glomerular filtration rates (GFR) significantly improved after successful surgery. However, this improvement was much more evident in patients operated upon within the 1st year of life and in those who had had a temporary vesicostomy. In the subgroup of patients operated upon after 6 years of age, successful surgery had no effect on the further decline of renal function when this was already severely compromised. We conclude that early antireflux surgery or, in selected cases, temporary vesicostomy followed by ureteral reimplantation was effective in significantly improving GFR and sharply decreasing febrile UTIs in patients with massive bilateral PVRR and renal damage at presentation.
RESUMO
From January 1972 to June 1993, 166 patients with posterior urethral valves (PUV) were treated in our surgical department, 59 with a milder form of PUV (upper urinary tract [UUT] complication rate 29%) and 107 with a severer form (UUT complication rate 96.3%). Only the latter group was studied for long-term (mean 9.3 years) evaluation of the UUT and renal function. A temporary vesicostomy was the primary treatment in 25 patients. Indications for temporary diversion were very young age and/or low birth weight, severe and bilateral UUT complications, and severe renal damage. All the other patients were treated by primary endoscopic valve fulguration. After removal of the lower urinary tract obstruction, vesicorenal reflux (VRR) resolved spontaneously or was ameliorated in 59.2% of the renal units. Spontaneous normalization or evident amelioration were found at long-term follow-up in nearly 70% of dilated, non-refluxing ureters. Ureteral reimplantation was performed on 41 of the 202 dilated or refluxing ureters (surgical rate 20.3%). The surgical failure rate requiring reoperation was 5% (2/41). The prerequisite for successful reimplantation was a large-capacity, stable, and compliant bladder. Ten nephroureterectomies were carried out for unilateral, massive VRR and renal dysplasia; 1 late nephrectomy was performed for arterial hypertension. The evolution of renal function showed statistically significant overall improvement, which was more evident in patients diagnosed and treated in the 1st month of life (P = 0.000) than in those treated between 1 and 12 months (P = 0.004) or after 1 year of age (P = 0.025). Renal function considerably improved in the vesicostomy group (P = 0.000). Thirteen patients (12.4%) are now either dead (2) or have end-stage renal disease (6) or chronic renal insufficiency evolving toward end-stage renal disease (5); 5 of these 13 were treated by vesicostomy in the first days or months of life, and at presentation the glomerular filtration rate (GFR) was less than 25 ml/min . 1.73 m(2). Determination of basic GFR and, even more, functional renal reserve is relevant in predicting the long-term evolution. In the author's opinion, vesicostomy is the procedure of choice in very ill newborns or infants. Aggressive management with early surgical reconstruction is rarely justified, because frequently UUT complications resolve spontaneously or clearly improve, and their surgical treatment has limited and very precise indications.
RESUMO
We report the results of a long-term follow-up study in 78 children with urethral strictures. The ages ranged from 1 month to 20 years and the follow-up from 8 months to 15 years (average 5.9 years). Balloon dilation was the primary treatment in 66 patients. Manipulative management (balloon dilation and endoscopic urethrotomy) was performed in 68 cases and was successful in 55. There were no complications. Balloon dilation alone provided an 80% success rate (53/66). Twenty-two patients were treated by one-stage urethroplasty, with an overall 95.5% success rate. The surgical repair was performed in 12 patients as a secondary procedure after failure of conservative treatment. Our data do not support the rather poor results usually reported in the pediatric literature associated with the balloon dilation technique.
RESUMO
Vast epidemiologic studies have shown that varicocele becomes manifest at the beginning of sexual maturation and its incidence gradually increases in patients between 10-16 years. This percentage is 16-18% in adolescents and is comparable to that of the adult male population. Since varicocele first appears in early adolescence and its gonadotoxic effect increases with age, the possibility of improved fertility rate with early varicocelectomy has been suggested. We report the results of a comparative follow-up study to value the efficacy of surgical correction in two groups of adolescent and adult patients. Our study shows that early recognition and treatment of a severe varicocele provide a higher fertility rate and can prevent the reduced fertility rate associated with delayed varicocelectomy.