Treatment of varicocele with transfemoral retrograde sclero-embolization in pediatric patients under local anesthesia.

AIM: Varicocele treatment in pediatric age is still under discussion. The aim of this study was to present our experience with transfemoral retrograde sclero-embolization in pediatric patients and varicocele under local anesthesia METHODS: Between December 2008 and December 2011, 184 patients aged between 10 to 14 years with left varicocele were treated. Study inclusion criteria were: grade II or III left varicocele; previous inguinal surgeries and contraindications to general anesthesia. Sclero-embolization included the following procedures: right femoral access under local sedation (carbocaine). Mean time of intervention, recurrence and persistence rates as well as early and late complications were also considered. RESULTS: During the study period 184 cases were treated with the radiological technique, 172 of which proved to be successful. In 10 cases a continent valve was found and it was therefore impossible to use this technique (5.4%); two cases had rupture of the vein with consequent spillage of the contrast agent. Twelve cases (6.5%) showed recurrence after 3 months. No patient reported postoperative pain. CONCLUSION: This technique proved to be efficient and reliable. It can be performed under local sedation and it involves fewer complications than traditional techniques. The use of such technique allows preservation of the spermatic artery and is free from complications like testicular atrophy and hydrocele.

Serum inhibin B levels before and after varicocelectomy in early adolescence.

BACKGROUND: Whereas no clear relationship has been observed between varicocelectomy and serum inhibin B levels in men, in adolescents comparison between inhibin B levels before and after varicocelectomy is lacking. AIM: To evaluate the effect of varicocele surgical treatment on inhibin B levels in adolescents at the beginning of puberty compared to a group of healthy adolescents. SUBJECTS AND METHODS: We studied 28 adolescents in Tanner 2 pubertal stage with a grade III left-sided varicocele (patients) compared to 13 age and pubertal stage-matched healthy adolescents (controls). All patients underwent blood tests to determine serum inhibin B levels before and 6 months after varicocelectomy by Palomo procedure. For comparison we investigated inhibin B levels in controls and repeated this test 6 months later. Testicular ultrasound was performed for patients only. RESULTS: Baseline inhibin B concentrations of patients and controls were 109.90 ± 40.26 and 109.33 ± 38.34 pg/ml, respectively. No significant changes were observed in patients' inhibin B concentrations after varicocelectomy (116.00 ± 42.65 pg/ml), or in controls during the 6 months' follow-up (99.12 ± 30.09 pg/ml). Doppler examination after treatment shows a complete resolution of varicocele in all the patients without alterations in testicular parenchyma. CONCLUSIONS: Varicocelectomy performed on adolescents at T2 pubertal stage might be useful to avoid alteration in inhibin B production and consequently in testicular function. Further studies are necessary to confirm the prognostic value of inhibin B levels and the benefit of early varicocelectomy in preserving the fertility of these adolescents.

Microsurgical spermatico-epigastric venous anastomosis in the treatment of varicocele in children: assessment of long-term patency.

AIM: To demonstrate the long-term patency of microsurgical anastomoses between the internal spermatic vein and the inferior epigastric vein, constructed in the treatment of essential varicocele in paediatric patients to supplement ligation of the spermatic veins. MATERIALS AND METHODS: We submitted 66 patients to inguinopelvic colour-flow Doppler ultrasonography. The patients had been treated 18 - 36 months earlier for essential varicocele by microsurgical inguinal ligation of the testicular venous pedicle and anastomosis between the internal spermatic vein and the inferior epigastric vein. RESULTS: Preoperatively, the 66 patients operated on at ages ranging from 10 to 16 years (13 +/- 1.4) presented with Dubin and Amelar grade II (14 patients) or grade III (52 patients) left varicocele with ipsilateral testicular hypotrophy. The postoperative follow-up showed 2 cases of persistence of disease and 3 cases of persistence of "medium" spermatic vein reflux without clinical evidence of varicocele. Seven patients developed left hydrocele which resolved spontaneously in 5 cases, whereas in 2 cases it proved necessary to perform an eversion of the tunica vaginalis of the testis. The results obtained in patients treated for Coolsaet type I varicocele (64 patients) were as follows: long-term patency of the anastomosis was observed in 58/64 patients (90.6 %); in 4 patients (6.2 %) the left inferior epigastric vein presented a position in relation to the homologous artery that prevented adequate sampling and thus made it impossible to assess the patency of the anastomosis; in 2 patients (3.1 %) the anastomosis was closed. In the two patients who had submitted to anastomosis for Coolsaet type III varicocele, colour-flow Doppler failed to identify the shunt. CONCLUSIONS: The results of this study demonstrate that microsurgical anastomosis between the internal spermatic vein, and the inferior epigastric vein remains competent in the long term, thus confirming the validity of this technique for the treatment of essential varicocele in children.

Treatment of neonatal chylous ascites using a modified Denver peritoneovenous shunt: a case report.

Chylous ascites is rarely observed in newborns. Its etiology is not always readily identifiable. The authors report a patient with idiopathic chylous ascites resistant both to conservative treatment with total parenteral nutrition plus diuretics and to dietary treatment (milk with a low-fat content and medium-chain triglycerides). Surgical correction of an associated intestinal malrotation and an annular pancreas failed to resolve the ascites and we therefore placed a modified Denver peritoneovenous shunt. Six months after placement of the shunt, the patient was in good general condition, with restoration of normal oral feeding and regular growth in terms of height and weight. Clinical and ultrasonographic follow-up examinations have not revealed the presence of ascitic fluid in the peritoneal cavity.

Complicated total esophagogastric dissociation: case report.

The Authors describe a case of massive haemorragic gastritis in a child who previously underwent total oesophagogastric dissociation without complementary pyloroplasty. The complication was successfully treated by an emergency resection of the fundus. The Authors believe that the complication was probably related to vagal denervation with consequent gastric stagnation and hypergastrinaemia.

Congenital true pancreatic cyst in pediatric age: case report.

Congenital pancreatic cysts are rare lesions in pediatric age. We present a case of congenital true pancreatic cyst in otherwise asymptomatic boy aged 4 years. Clinical history, laboratory, imaging, immunohistological findings and surgical treatment are also described.

Secondary omental torsion in children: report of two cases and review of the literature.

Torsion of the greater omentum (TGO) may be due to a congenital abnormal attachment of its free edge. There are no specific symptoms that allow a preoperative differential diagnosis of this condition from common pathologies such as acute appendicitis. Attachment of the omentum to the large bowel and the absence of concomitant diseases make it possible to distinguish TGO secondary to a congenital attachment anomaly from omental infarction, primary TGO, and TGO secondary to an acquired attachment anomaly (attachment to cysts, tumours, hernias, surgical scars, or perforated bowel segments). Resection of the ischaemic portion of the omentum permits complete resolution of the clinical symptoms. The authors report two cases of TGO in children due to abnormal attachment of the greater omentum to the ascending and transverse colon, respectively.

[Idiopathic varicocele in children. Epidemiological study and surgical approach]. / Varicocele idiopatico in età pediatrica. Studio epidemiologico e approccio chirurgico.

BACKGROUND: Idiopathic varicocele is one of the most frequent conditions capable of reducing male fertility. Early detection and adequate therapy make it possible to prevent the infertility related to this disease. METHODS: The results of a clinical and instrumental (Doppler) epidemiological study conducted in 766 subjects of peripuberal age are reported. The clinical and functional results in those subjects undergoing surgery for varicocele. The technical options adopted for varicocele correction were either microsurgical venous bypass between the internal spermatic vein and the inferior epigastric vein or laparoscopic ligation of the internal spermatic vein in a retroperitoneal site. RESULTS: The epidemiological investigation conducted by the authors showed a high incidence (48.5% including the subclinical forms) of idiopathic varicocele in the male population. The clinical and instrumental (Doppler) follow-up carried out at 3, 6 and 18 months postoperatively showed satisfactory results, particularly in patients submitted to microsurgical venous bypass, with a relapse rate of only 2.6%. CONCLUSIONS: On the basis of the results obtained, the authors advocate an early surgical approach to varicocele. Among the corrective techniques available, microsurgical treatment is, in the authors' opinion, capable of yielding the best clinical and functional results.

[Reconstruction of the vas deferens: an experimental study on the rat]. / Ricostruzione deferenziale. Studio sperimentale sul ratto.

BACKGROUND: A microsurgical technique for reconstruction of the vas deferens on an absorbable transanastomotic stent in the rat is described. METHODS: A microsurgical end-to-end anastomosis of the vas deferens was performed in a group of 10 rats (group A) by suturing with Nylon 10-0 interrupted stitches. In another 10 rats (group B) the same microsurgical anastomosis was performed after insertion of a 0.5 cm long intraluminal chromic catgut 4.0 stent. RESULTS: Sixty days postoperatively all 20 animals were submitted to roentgenography of the vas deferens. The vas deferens proved radiographically undetectable in 8/10 rats in the unstented group A (80%), whereas the entire course of the vas could be traced in 9/10 rats in group B (90%). CONCLUSIONS: The encouraging results obtained with this alternative technique, even on structures of limited diameter, suggests that it may be possible to use this procedure in children.

[Cryptohypospadias: Surgical approach and long-term results]. / Cripto-ipospadia: Approccio chirurgico e risultati a distanza.

BACKGROUND: Chordee without hypospadias is a rare morphological abnormality of the penis capable of interfering with sexual function. Usually, cases of chordee without hypospadias require surgical correction, and the aim of this study is to assess the efficacy of the techniques normally used in this pathology. METHODS: The authors analyze the surgical outcomes achieved in 34 patients presenting various degrees of ventral or lateral curvature of the erect penis and operated on in our department over the past 22 years. Twenty-nine subjects attended for follow-up, including 13 who have now reached adulthood. RESULTS: The milder forms of chordee without hypospadias (Horton and Devine type III and lateral deviations of the penis) all benefited from minor surgery (dermal grafts and Nesbit dorsal plication of the contralateral penile tunica albuginea) and were corrected with a single operation. The most serious forms of chordee without hypospadias where the hypoplasia variously affected the corpus spongiosum, Buck's fascia and the dartos fascia (Horton and Devine types I and II), were submitted to a supplementary extensive urethral mobilization or occasionally a urethroplasty and one-third of them presented persistent residual curvature. CONCLUSIONS: The authors advocate a more aggressive surgical approach (urethroplasty and/or patches on the ventral tunica albuginea as an alternative to urethral mobilisation) in subjects with more pronounced defects.