The "V-I penoscrotal reconfiguration": A simple technique for the surgical treatment of congenital webbed penis.

OBJECTIVES: To describe a new penoscrotal reconfiguration technique, named "V-I penoscrotal reconfiguration" for the surgical reconstruction of a congenital webbed penis (CWP). METHODS: Twenty-one patients who underwent the "V-I penoscrotal reconfiguration technique" were included in this retrospective study. The CWP severity was assessed according to El-Koutby's classification. Demographic and clinical data, surgical data, and postoperative outcomes were scheduled and analyzed. Specifically, the postoperative follow-up included both physical and psychological assessments at 2 weeks, 1, 6, and 12 months after surgery. Parents' satisfaction degree was quantified by the Likert scale. RESULTS: CWP was grade 3 in 11 (52%) patients, 2 in five (24%), and 1 (24%) in five. Five (24%) CWP were isolated malformations, 11 (52%) were associated with phimosis, three (14%) with hypospadias, and two (10%) with hypospadias and phimosis. There were no postoperative complications and no cases of redo surgery. The cosmetic outcomes were excellent in all cases: the parents' satisfaction score was 4 in 17 (81%) cases and 3 (9%) in the other four cases. CONCLUSIONS: CWP may cause psychological distress and functional problems, especially during sexual intercourse. Its correction in childhood is advocated to prevent psychological and sexual issues. The "V-I reconfiguration technique" is simple, and easy with excellent cosmetic and functional outcomes.

Video-assisted anal fistula treatment (VAAFT) combined with ozonide oil dressing: standardization of technique in pediatric patients.

BACKGROUND: Anal fistula and perianal abscess are commonly acquired anorectal pathologies in children. Surgical treatment options commonly adopted are fistulotomy, fistulectomy, cutting seton placement, and more recently video-assisted anal fistula treatment (VAAFT). Optimal postoperative wound dressing remains debated. This study aimed to report our series of pediatric patients, who received VAAFT and postoperative wound dressing using ozonide oil. METHODS: All patients who underwent VAAFT between August 2018 and May 2023 were included in the study. Demographics, clinical features, pre-operative imaging, surgical details, outcome, and mid-term outcome data were retrospectively reviewed for each patient. All VAAFT procedures were performed under general anesthesia and using a 10-Ch fistuloscope. RESULTS: Thirty-three VAAFT procedures were performed in 30 patients over the study period. The median patient age was 5.7 years (range 1.75-14). Anal fistula was idiopathic in 26/30 (86.6%), iatrogenic in 2/30 (6.7%), and secondary to Crohn's disease in 2/30 (6.7%). The median duration of surgery was 23 min (range 18-40). All patients received ozonide oil dressing twice a day for 5 weeks postoperatively. The median hospital stay was 24 h (range 9-36). The median healing time was 28 days (range 17-39). With a median follow-up of 2 years (range 0.5-5), disease recurrence occurred in 3/30 (10%) patients with idiopathic fistula, who were re-operated using the same technique, with no further recurrence. No fecal incontinence or soiling was observed. CONCLUSION: Our series confirmed that VAAFT is a safe and effective technique to treat children with perianal fistula. The technique is versatile, allowing to treat fistulae of different etiologies. Postoperative course was painless and fast. Future comparative prospective studies are needed to better establish these conclusions.

Impact of COVID-19 on testicular function: a systematic review and meta-analysis.

INTRODUCTION: Studies investigating the effects of SARS-CoV-2 on male reproductive function are few and heterogeneous, and results are often conflicting. This systematic review and meta-analysis was carried out on studies conducted in men with active or anamnestic SARS-CoV-2 infection to evaluate its consequences on the male sex hormone profile and semen parameters. MATERIALS AND METHOD: This meta-analysis follows the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols. PubMed, Scopus, Cochrane, and Embase databases were searched to identify relevant studies. We originally selected 3553 articles. After the eligibility phase, 16 articles met our inclusion criteria encompassing 11 case-control studies and 5 cohort studies (2 prospective and 3 retrospective studies). We performed the quantitative analysis with Comprehensive Meta-Analysis Software. Cochran-Q and heterogeneity (I2) indexes were used to assess statistical heterogeneity. Sensitivity analysis and publication bias tests were also performed. RESULTS: Overall, 1250 patients with active or recent (up to 80 days before) COVID-19 infection and 1232 matched healthy controls were included. Sperm concentration, total sperm count, and total motility were significantly lower in patients compared with controls. Patients also showed lower levels of total testosterone and follicle-stimulating hormone, and higher levels of luteinizing hormone, 17ß-estradiol, and prolactin compared with healthy controls. None of the included studies found the presence of SARS-CoV-2 mRNA in the semen of infected patients. CONCLUSION: The present systematic review and meta-analysis suggests the presence of an association between SARS-CoV-2 infection and primary testicular damage manifested with a picture of altered steroidogenesis and worsening spermatogenesis. The absence of the virus in the seminal fluid indicates a low possibility of sexual transmission of the infection to partners and offspring. However, our findings mostly show short-term follow-up, while few studies have considered the long-term consequences of the viral infection, thus further studies are needed to evaluate the long-term consequences on male reproductive health.

Indocyanine Green (ICG)-Guided One-Stage Delayed Bladder Closure and Radical Soft-Tissue Mobilization (Kelly Procedure) For Bladder Exstrophy Repair: The First Experience.

The vascular supply of the pelvic structures and the external genitalia can be easily injured during the one-stage delayed bladder closure and radical soft-tissue mobilization (Kelly procedure) for bladder exstrophy surgical repair. Aiming to help surgeons assessing and confirming tissue perfusion and viability, indocyanine green (ICG)-based laser angiography was incorporated into the operative approach to reduce the risk of ischemic injuries. The EleVision IR system (Medtronic Ltd) was adopted to confirm the identification of the vascular pedicles and assess the tissue perfusion in real-time in a 5-month-old with bladder exstrophy undergoing the one-stage delayed bladder closure and radical soft-tissue mobilization (Kelly procedure). ICG (0.15 mg/kg) was intravenously administered at 6 key steps during surgery with the ability to be re-dosed every 15 minutes. ICG-based laser angiography helped to confirm the correct identification of the vascular structures during surgery and to assess tissue perfusion in real-time. Blood flow did not change considerably after initial dissection or upon approximating the pubis symphysis. At the end of the procedure, good penile perfusion was shown, proving that no direct injury or substantial compression of the pudendal vessels had occurred following the mobilization and the reconstructive phase. ICG-based laser angiography proved to be safe, effective, and easy to employ and should be considered as a reasonable adjunct for tissue perfusion assessment and operative decision-making in patients undergoing bladder exstrophy Kelly repair.

Glans dehiscence after severe hypospadias repair. Is it a real complication? Clues from a study in post-pubertal patients.

INTRODUCTION: Glans dehiscence (GD) is reportedly a common complication after proximal hypospadias repairs. However, the need for surgical correction is controversial. The aim of this study was to assess awareness, risk factors, and outcome of GD in post-pubertal patients. The agreement with surgeon assessment was also evaluated. METHODS: The design was retrospective. All consecutive patients treated for proximal hypospadias between 2000 and 2011 were included. The presence of GD was self-reported, and the participants could optionally upload a photograph for surgeon assessment. Cosmetic and functional outcomes were assessed by validated questionnaires (HOSE, PPPS, KINDL®, IIEF-5). Results were compared between patients with and without GD. RESULTS: Of 219 patients, 34 (16%) participated. Fourteen of them (41%) self-reported GD. Eighteen patients (8%) also uploaded a photograph and, in ten of them (56%), the surgeon noted the presence of GD with poor agreement [k = - 0.444 (95 CI - 0.856 to - 0.033)] with patient report. Patients self-reporting GD had had more frequently a penile curvature at diagnosis (12/14 = 86%, p = 0.01), and had undergone a single-staged repair (100% vs. 65%, p = 0.03). No difference was found in cosmetic and functional outcomes. Results were similar also comparing groups with and without GD as assessed by the surgeon. CONCLUSION: GD was a common finding after severe hypospadias repair. It was more common in case of surgeon assessment with poor agreement between patients and surgeons. GD did not prove to have clear clinical implications. Therefore, in our opinion, surgical repair of GD should be recommended only on patients request.

Twenty-Five-Year Experience with Minimally Invasive Splenectomy in Children: From Minilaparotomy to Use of Sealing Devices and Indocyanine Green Fluorescence Technology: Tips and Tricks and Technical Considerations.

Background: This study aimed to review our 25-year experience with pediatric laparoscopic splenectomy (LS) and describe tips, tricks, and technical considerations. Methods: The records of 121 children, undergoing minimally invasive splenectomy in the last 25 years (1996-2021), were retrospectively reviewed. Median patient age was 10.2 years (range 7-17). The patients were grouped according to the period: G1 (1996-2005) included 31 patients undergoing open splenectomy using left subcostal minilaparotomy (G1a) and 28 receiving LS using supine position (G1b); G2 (2006-2021) included 62 patients undergoing LS using lateral decubitus. A five-trocar technique was adopted in G1b, with the spleen removed through a Pfannenstiel incision. In G2, we preferred to use lateral decubitus, 10-mm 30° optic, only four trocars, and sealing devices. In such cases, the spleen was placed in an endobag, finger-fragmented, and extracted through the umbilicus. Furthermore, indocyanine green (ICG) fluorescence was used in the last 4 G2 patients to clearly identify the vascular anatomy. Results: The median operative time was 65 minutes in G1a, 125 in G1b, and 95 in G2. Complications occurred intraoperatively in 14 cases (11.5%): 5 bleedings during dissection (G1b), 4 endobag breakages during spleen removal (G2); 3 spleen capsule breakages during removal (G1a); and 2 instrumentation failures (G2). No conversions to open occurred. Median hospital stay was 6 days in G1a and 4 days in G1b and G2. Conclusions: LS is a standardized and effective procedure in children and is preferable to mini- or conventional open splenectomy. Our 25-year experience showed that major complications may occur even in expert hands, mainly during hilar dissection or spleen extraction. Technically, sealing devices and ICG fluorescence were helpful to perform a safer and faster procedure. We believe that lateral decubitus and 30° optic should be considered technical key points to provide excellent organ exposure and easier dissection of hilar structures.

Symptomatic Parapelvic Cysts in Children: Anatomical and Histological Features, Diagnostic Pitfalls and Urological Management.

BACKGROUND: Symptomatic parapelvic cysts (PPC) are rare entities. Our objective is to highlight specific features of PPC to avoid a misdiagnosis of UPJ obstruction. METHODS: We retrospectively reviewed the records of children managed between 2012-2017. RESULTS: All four patients (18 months-8 years) presented with acute renal colic with a large intra-sinusal liquid mass (42-85 mm) on ultrasound, evoking a diagnosis of UPJ obstruction. On preoperative renal scintigraphy (n = 3) there was no dilatation of the renal pelvis and ipsilateral differential function was impaired in 2. Diagnosis of PPC was suspected preoperatively in three children (CT scan (n = 1); MRI (n = 2)) and made peri-operatively (n = 1). Preoperative retrograde pyelography (n = 3) and a further intraoperative retrograde pyelography with methylene blue (n = 1) did not identify communication with the cyst. No renal pelvis was identified in two patients. De-roofing of the cyst was curative in all cases at 5 years mean follow-up (no leakage, cyst recurrence or loss of function) and all 4 patients became asymptomatic after surgery. Histology demonstrated a single flat epithelial cell layer. Renal function normalized in one patient but remained impaired in the other. CONCLUSION: In case of symptoms of UPJ obstruction with a medial renal liquid mass on ultrasound, PPC should be considered when no dilatated pelvis on renal scan is identified. In such cases, a complementary imaging work-up is mandatory prior to surgery.

Effects of Selenium Supplementation on Sperm Parameters and DNA-Fragmentation Rate in Patients with Chronic Autoimmune Thyroiditis.

BACKGROUND: Selenium (Se) is an essential component of selenoenzymes, which have catalytic and antioxidant functions. A low Se status has been reported in patients with chronic autoimmune thyroiditis (AT) who benefit from Se supplementation. The role of Se in male reproduction is still a matter of debate. Although Se and selenoenzymes ensure sperm viability and protect against increased oxidative stress, only a few studies have assessed the effects of the administration of Se alone on sperm parameters, providing contrasting results. AIM: The aim of this study was to assess the effects of oral Se supplementation on conventional sperm parameters and DNA fragmentation (SDF) in patients with AT of reproductive age with normal thyroid function. PATIENTS AND METHODS: Only patients with AT and normal thyroid function were selected for this study. All included patients underwent oral Se supplementation at the dose of 83 µg once daily (Syrel®, IBSA) for six months. Sperm conventional parameters, SDF, and thyroid function were assessed before and at the end of the treatment. RESULTS: Twenty AT patients with normal weight were enrolled. After Se supplementation, they showed a higher sperm concentration, a higher percentage of sperm with progressive motility, and a higher percentage with normal morphology. They also had lower semen leukocyte concentration, and a lower percentage of spermatozoa with DNA fragmentation compared with pre-treatment values. Free-thyroxine serum levels increased significantly, whereas free triiodothyronine showed an upward trend. The thyroid-stimulating hormone did not change significantly. CONCLUSION: Se supplementation may represent a possible non-hormonal therapeutic choice for the treatment of male infertility, although further studies are needed to confirm this evidence. The possible thyroid hormone dependency of these findings needs to be clarified.

Giammusso corporoplasty for the treatment of isolated congenital ventral penile curvature: Results and long-term follow-up.

The aim was to retrospectively evaluate our experience in a large series of patients affected by isolated congenital ventral penile curvature, surgically treated using a previously described modified incisional corporoplasty. Two hundred and six patients with isolated congenital ventral penile curvature underwent a modified incisional corporoplasty. Mean age at surgery was 20.7 ± 5.5 years, and degree of ventral curvature was 60 ± 23°. After the point of maximum convexity identification, Buck's fascia was vertically opened along the deep dorsal vein, which was partially ligated, resected and removed. Tunica albuginea was then longitudinally incised and transversally closed. Post-operative follow-up examination was performed at 2 weeks, 6, 12 and 24 months and then annually. Surgical time was 79 ± 12 min. At follow-up, 189 out of 198 patients (95%) were completely satisfied, four patients (2%) complained a recurrence of penile curvature, and 6 (3%) complained about shortening of the penis. None of the patients had any interference with sexual activity. One patient (0.5%) showed erectile dysfunction 5 years after surgery, but there was no organic dysfunction during examination. The proposed technique allows correction of ventral congenital penile curvature without dorsal neurovascular bundle manipulation, resulting in minimum trauma of the erectile tissue, without injury to nerve fibres.

Long-Term Follow-Up of Testicular Microlithiasis in Children and Adolescents: Multicenter Prospective Cohort Study of the Italian Society of Pediatric Urology.

Introduction Testicular microlithiasis (TM), characterized by the presence of intratubular calcifications in a single or both the gonads, is an uncommon entity with unknown etiology and outcome in pediatric and adolescent age. In this study, the results of a multicenter long-term survey are presented. Materials and Methods From 11 units of pediatric urology/surgery, patients with TM were identified and yearly, followed up in a 7-year period, adopting a specific database. The recorded items were: age at diagnosis, presenting symptoms/associated abnormalities, ultrasonographic finding, surgery and histology at biopsy, if performed. Results Out of 85 patients, 81 were evaluated yearly (4 patients lost to follow-up). TM was bilateral in 66.6% of the patients. Associate genital abnormalities were present in 90%, more frequently undescended/retractile testis (23.4%) and varicocele (22.2%). TM remained unchanged at 4.7 years follow-up in 77 patients (93.8%) and was reduced in 4 patients after 1 to 5 years of inguinoscrotal surgery. Orchiectomy was performed in three patients (3.7%), one for severe testicular hypoplasia and two for seminoma (2.5%), respectively, concurrent and metachronous to diagnosis of TM. Tumorectomy with parenchymal sparing surgery was performed in a teratoma associated with TM. Conclusion TM is a controversial entity, often associated with several inguinogenital features, which rarely can recover. Testicular malignancy, although present in TM, has not proven definitively associated to microliths. Proper counseling, yearly ultrasound, and self-examination are long-term recommended.

Preputial reconstruction in hypospadias repair.

OBJECTIVE: In principle, the prepuce can be reconstructed during hypospadias repair, but the procedure has not gained wide acceptance and preputial reconstruction (PR) is surrounded by several controversies. MATERIAL AND METHODS: A review is provided of the technique for PR, how PR combines with the other steps of hypospadias repair, the risks of complications related to the urethroplasty and specific to PR, and the results of PR with particular regard to the relevance for the patient and his family. RESULTS: PR can be important for patients requiring hypospadias repair and their parents. It can be performed in almost all patients with distal hypospadias except perhaps those with the most asymmetrical prepuces or severe ventral skin deficiency. PR does not seem to increase urethroplasty complications, but combination of PR with tubularisation of the urethral plate urethroplasty seems to offer the best chance of success. Specific complications occur in around 8% of patients and include partial or complete dehiscence of the prepuce and secondary phimosis. To prevent the latter, the reconstructed prepuce should be easily retractile at the end of surgery. Technical modifications can help to achieve this goal. Cosmetically, reconstructed prepuces are not fully normal, but the abnormality could be less important for a patient and his parents that the complete absence of the prepuce. CONCLUSION: On the basis of the evidence summarised above, an algorithm for PR in patients with distal hypospadias is proposed. PR can be offered to the vast majority of distal hypospadias patients, although some modification of the technique for hypospadias repair can be required. Retractility of the reconstructed prepuce at the end of surgery seems paramount for final success.

Does Preputial Reconstruction Increase Complication Rate of Hypospadias Repair? 20-Year Systematic Review and Meta-Analysis.

INTRODUCTION: We performed a systematic review of the literature on preputial reconstruction (PR) during hypospadias repair to determine the cumulative risk of preputial skin complications and the influence of PR on urethroplasty complications, namely, fistula formation and overall reoperation rate of the repair. MATERIALS AND METHODS: A systematic search of the literature published after 06/1995 was performed in 06/2015 using the keyword "hypospadias." Only studies on the outcome of PR in children, defined as dehiscence of the reconstructed prepuce or secondary phimosis needing circumcision, were selected. A meta-analysis of studies comparing PR vs. circumcision was performed for the outcomes "hypospadias fistula formation" and "reoperation rate." RESULTS: Twenty studies were identified. Nineteen reported the outcome of PR in 2115 patients. Overall, 95% (2016/2115) of patients undergoing PR had distal hypospadias. The cumulative rate of PR complications was 7.7% (163/2115 patients), including 5.7% (121/2115 patients) preputial dehiscences and 1.5% (35/2117 reported patients) secondary phimoses needing circumcision. A meta-analysis of seven studies comparing patients undergoing PR vs. circumcision showed no increased risk of urethral fistula formation associated with PR, odds ratio (OR) (Mantel-Haenszel, Fixed effect, 95% CI), 1.25 (0.80-1.97). Likewise, two studies comparing the overall reoperation rate did not show an increased risk of reoperation associated with PR, OR (Mantel-Haenszel, Random effect, 95% CI), 1.27 (0.45-3.58). CONCLUSION: PR carries an 8% risk of specific complications (dehiscence of reconstructed prepuce or secondary phimosis needing circumcision), but does not seem to increase the risk of urethroplasty complications, and the overall reoperation rate of hypospadias repair.

Hypothesis on etiopathogenesis, congenital or acquired, of an imperforate distal ureter: a case report.

INTRODUCTION: Ureteral atresia is a rare disease usually associated with a non-functioning kidney. Its association with other urinary anomalies is rare. CASE PRESENTATION: In this study we discuss the possibility of congenital or acquired etiology of a right imperforate distal ureter. Here we report the case of 11-month-old white boy with a right ureteropelvic junction obstruction. He underwent a right pyeloplasty when he was 11-months old, and 3 weeks after surgery a cystoscopy was performed. Two months after the first operation, he underwent a right ureteral meatoplasty and a new pyeloplasty. CONCLUSIONS: To the best of our knowledge, few cases of imperforate distal ureter have been described in the literature. The suspicion of a non-patent terminal ureter, occurring during upper urinary tract surgery, must be intraoperatively clarified to preserve the renal function and to avoid more complex surgical approaches.

Risk of Malignancy and Need for Surgery in Pediatric Patients with Morris or Y-chromosome Turner Syndrome: A Multicenter Survey.

STUDY OBJECTIVE: The management of intersex patients with Y-chromosome Turner or Morris syndrome remains a challenge. We report our experience with a multicenter European survey. DESIGN: We collected the data on 18 patients (mean age 10.2 years, range 2-17 years) with Morris (10 patients) or Turner (8 patients) syndrome harboring the Y chromosome who were treated in 1 of 6 European centers of pediatric surgery between 1997 and 2013. All patients were evaluated by use of a multidisciplinary diagnostic protocol. All patients received a bilateral gonadectomy via laparoscopy; only 1 center performed ovarian cryopreservation. Seven patients received a concomitant genitoplasty. Operative notes and histology were reviewed for details. RESULTS: No conversions to laparotomy and no complications were recorded. For the patients receiving only the gonadectomy, the length of hospital stay was 24-48 hours, whereas for the patients receiving an associated genitoplasty, it was 6-10 days. Specimens were negative for tumors in 83.3% of cases, whereas in 3 patients (16.6%), benign abnormalities (Sertoli cell hyperplasia in 1 patient and ovotestis in 2 patients) were recorded. A malignant tumor was not recorded in our series. CONCLUSION: If the risk of malignancy is considered as the main indication for surgery in case of Turner or Morris syndrome, on the basis of our study, this indication should be reevaluated. However, based on the non-negligible rate of benign abnormalities reported in our series (16.6%), the performance of cryopreservation to preserve fertility and the possibility of performing genitoplasty during the same anesthetic procedure represent additional valid indications for surgery.

Clinical considerations, management and treatment of fever of unknown origin caused by urachal cyst: a case report.

INTRODUCTION: Urachal cysts are rare congenital anomalies that often prompt referral to the paediatric general surgeon because of their associated complications such as infection, abdominal pain and the young age at presentation. In this report we describe a rare case of fever of unknown origin caused by an urachal cyst which was successfully treated with incision and drainage only. Since the first description of urachal anomalies by Cabriolus in 1550, few cases have been reported and, until now, only one case of infected urachal cyst presenting as fever of unknown origin has been described in the literature. Moreover, the spontaneous resolution of an urachal cyst without excision is extremely rare. CASE PRESENTATION: We report our experience in the management and treatment of an infected urachal cyst that occurred in a 12-year-old Caucasian girl who presented to our Department of Paediatric Surgery with a 30-day history of evening fever. The urachal cyst was treated only with incision and drainage through a minimally invasive laparoscopic approach. CONCLUSIONS: The incision and drainage of an infected urachal cyst is a simple and safe procedure. It assures a complete recovery and avoids potential surgical complications related to the total excision of the urachal cyst. This report may provide important clues regarding the management of this rare anomaly and we emphasise the importance for paediatricians, who should consider the possibility that a fever of unknown origin can be caused by an urachal cyst, and for surgeons and urologists, because it suggests that conservative treatment of this rare anomaly should be considered when possible.