15-Year varicocelectomy outcomes in pediatric age: Beware of genitofemoral nerve injury.

BACKGROUND: Varicocele affects 15% of adolescents. The main postoperative complications are recurrence and hydrocele; nerve injury is rarely reported. OBJECTIVE: The aims of this study are: to assess the complications after laparoscopic varicocelectomy, namely nerve injury; and to assess if nerve injury is more frequent using "hot" or "cold" ligation. STUDY DESIGN: Retrospective study of varicocele cases submitted to laparoscopic correction in our department from April 2006 to March 2020. Parameters analyzed were: age, clinical findings, surgical indication, operative technique, and outcomes. Comparison was done between the "cold" versus "hot" vessel section technique. RESULTS: 110 patients, with median age 14-years-old, were included. Most cases were on the left side and grade 3. Fifty patients (45%) presented complications: 21% recurrence; 18% hydrocele; and 3% genitofemoral nerve injury. Nerve injury was independent of the technique used. DISCUSSION: Genitofemoral nerve injury is a complication with unknown cause and all cases are related to laparoscopic technique. It was suggested that "hot" methods of ligation of the vessels can lead to higher incidence of the lesion, but that was not corroborated in our analysis. Possible explanations for its occurrence are: a wide peritoneal window opening created with electrocautery near the internal inguinal ring; and additional dissection required to isolate the testicular veins from the artery. Prospective studies are needed to clarify the real incidence of genitofemoral nerve injury and its causes. CONCLUSIONS: Laparoscopic varicocelectomy seems to be safe and effective, although complications remain frequent regardless of the technique used. Genitofemoral nerve injury is a complication rarely described that may require rehabilitation, and so awareness for this problem is of paramount importance.

Simultaneous Testicular and Appendix Testis Torsion: A Novel Clinically Relevant Association.

ABSTRACT: Torsion of the appendix testis (TAT) and testicular torsion (TT) are the most common causes of acute scrotum in the pediatric population. They usually present as separate conditions and have distinct managements. We report a unique case of a 16-year-old boy with concomitant TAT and TT. The role of TAT as a trigger factor to TT is addressed, and its clinical repercussion on the management of acute scrotum is discussed.

Manual detorsion in testicular torsion: 5 years of experience at a single center.

PURPOSE: Testicular torsion is one of the most common causes of acute scrotum in pediatric age. The present study aimed to evaluate the role of preoperative manual detorsion in the management of testicular torsion. METHODS: Retrospective data analysis of pediatric patients treated for acute testicular torsion at a tertiary center over the last 5 years. Manual detorsion was attempted by surgeon's preference. Successful manual detorsion was defined as complete pain resolution with a normal color Doppler ultrasound. All patients underwent surgical exploration. Patient data analyzed included: age, pain duration, site of onset, attempt of manual detorsion, pain relief after manual detorsion, color Doppler ultrasound results, surgical findings and outcome. RESULTS: One hundred twenty-two patients were included. Manual detorsion was attempted in 48% (58/122) cases. Manual detorsion was successful in 26% (15/58) patients. In the unsuccessful, residual cord torsion was found at surgery in 27.5% (16/58); in the remaining 27, there was no cord torsion at surgery. Five patients (5/15) with successful manual detorsion underwent elective orchiopexy. Gonadal loss after manual detorsion (9%, 5/58) occurred after unsuccessful manual detorsion, all submitted to emergency surgery. CONCLUSIONS: Testicular torsion warrants prompt detorsion. Manual detorsion is simple, immediately available, and maximizes testis salvage. A successful maneuver permits nonemergency orchiopexy. An algorithm for the management of testicular torsion that includes an attempt of manual detorsion prior to surgery is proposed. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level IV.

Biliary Atresia - Clinical Series.

INTRODUCTION: Biliary atresia is the main cause of death by hepatic failure and the main indication for liver transplant in children. This study aims to analyze the population with this diagnosis, treated between 2000 and 2015 at Hospital de São João. MATERIAL AND METHODS: Descriptive, observational, and retrospective study, including the patients with biliary atresia, diagnosed and treated between January 1, 2000 and December 31, 2015. We analyzed epidemiologic, clinical, biochemical, and image data, as well as registered complications and present status. RESULTS: Eighteen patients were evaluated. The median age at time of Kasai portoenterostomy was 63 days of life, with better prognosis for those patients who had surgery before 72 days. The procedure was successful in 2/3 of cases. There was a significant association between recurrent cholangitis and survival. Five cases of transplant and 2 deaths, one of them after transplant, were registered. Survival with native liver was 77.8%, 72.2%, and 64.2% at 1, 5, and 10 years of follow-up, respectively. DISCUSSION: The presentation and evolution of patients was similar to other studies. However, there was a higher surgical success and survival rates at 5 and 10 years of follow-up than most series. Age at surgery and recurrence of cholangitis were the only factors significantly related to prognosis. CONCLUSION: In spite of the low number of patients (1,125/year), our results were similar to those of other reference centers.

INTRODUÇÃO: A atresia das vias biliares representa a principal causa de morte por insuficiência hepática e a principal indicação para transplante hepático em idade pediátrica. O objetivo deste estudo é analisar a população com este diagnóstico, tratada entre 2000 e 2015 no Hospital de São João. MATERIAL E MÉTODOS: Estudo descritivo, observacional e retrospetivo, incluindo-se doentes com atresia das vias biliares diagnosticados e tratados entre 1 de Janeiro de 2000 e 31 de Dezembro de 2015. Foram analisados dados epidemiológicos, clínicos, bioquímicos, imagiológicos, idade à data da cirurgia, complicações ocorridas e o estado atual. RESULTADOS: Foram avaliados 18 doentes. A idade mediana à data da portoenterostomia de Kasai foi de 63 dias de vida, verificando-se um melhor prognóstico nos pacientes operados antes dos 72 dias. Foi constatada drenagem biliar adequada em 2/3 dos casos aos 6 meses. Verificou-se uma associação significativa entre a ocorrência de episódios recorrentes de colangite e a sobrevida. Registaram-se 5 transplantes e 2 óbitos, um dos quais pós-transplante. A sobrevida com fígado nativo foi de 77.8%, 72.2% e 64.2% ao 1º, 5º e 10º anos de seguimento, respetivamente. DISCUSSÃO: A apresentação e evolução dos pacientes coincidiu, de um modo geral, com o descrito na literatura. No entanto, constatou-se uma taxa de sucesso operatório e de sobrevida com fígado nativo aos 5 e 10 anos superiores à maioria das séries. A idade à data de cirurgia e a recorrência dos episódios de colangite foram os únicos fatores que se mostraram significativamente relacionados com o prognóstico. CONCLUSÃO: Apesar do número reduzido de doentes (1,125/ano), foram registados resultados comparáveis a outros centros de referência.

Application of Bonelike® as synthetic bone graft in orthopaedic and oral surgery in veterinary clinical cases.

Autologous bone remains the gold standard grafting substrate for bone fusions used for small gaps and critical defects. However, significant morbidity is associated with the harvesting of autologous bone grafts and, for that reason, alternative bone graft substitutes have been developed. In the present case series, a glass-reinforced hydroxyapatite synthetic bone substitute, with osteoinductive and osteoconductive proprieties, was applied. This synthetic bone substitute comprises the incorporation of P2O5-CaO glass-based system within a hydroxyapatite matrix, moulded into spherical pellets with 250-500 µm of diameter. A total of 14 veterinary clinical cases of appendicular bone defects and maxillary / mandibular bone defects are described. In all clinical cases, the synthetic bone substitute was used to fill bone defects, enhancing bone regeneration and complementing the recommended surgical techniques. Results demonstrated that it is an appropriate synthetic bone graft available to be used in veterinary patients. It functioned as a space filler in association with standard orthopaedic and odontological procedures of stabilization, promoting a faster bone fusion without any local or systemic adverse reactions. This procedure improves the animals' quality of life, decreasing pain and post-operative recovery period, as well as increasing bone stability improving positive clinical outcomes.