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.

Vas deferens anomalies in paediatric age.

Vas deferens anomalies have been observed with high incidence in cystic fibrosis patients, whereas the overall incidence in the general population is estimated less than 0.05%. Vas deferens anomalies are sometimes associated with renal abnormalities and they are due to a damage occurring within the first weeks of gestational age. In other cases they can be the expression of a mild form of cystic fibrosis. The authors report on 7 patients with 10 anomalies of vas deferens: 2 patients with cystic fibrosis; 3 patients with urinary tract anomalies; 2 patients with no evidence of cystic fibrosis and without urinary tract anomalies. It is suggested that every patient presenting with vas deferens anomalies and no evidence of cystic fibrosis should be further evaluated with renal ultrasound; moreover all patients without evidence of both cystic fibrosis and renal anomalies should have genetic investigations.

[A rare case of acute scrotum. Thrombophlebitis from ectasia of the left pampiniforme plexus]. / Raro caso di scroto acuto. Tromboflebite su ectasia del plesso pampiniforme destro.

The acutely painful scrotum may be due to testicular torsion, twisted testicular appendages, twisted spermatic cord or epididymitis. Most rarely it occurs as a result of a testicular trauma, orchitis, idiopathic scrotal edema, idiopathic infarction of testis and vaginalis tunica or testicular neoplasm; a spontaneous thrombosis of the spermatic vein vessels is quite unusual. A rare case of thrombosis of a dilated pampiniform plexus which occurred in a 6 year-old child is reported and its clinical presentation, diagnosis and treatment is discussed. The difficulty in making such a diagnosis is stressed since thrombosis of the spermatic vein is quite a rare entity; a conservative approach is suggested as a treatment of choice whenever a definite diagnosis is made, otherwise surgical intervention (ligation of the spermatic vein, if necessary) is required in order to rule out any other urologic emergency.

Congenital cystic mesoblastic nephroma.

Congenital mesoblastic nephroma is a relatively rare infantile renal tumor. It comprises 3-6% of renal masses in childhood and 50% during the neonatal period. Most mesoblastic nephroma occur in the newborn period, with 80% of the cases being reported within the first month of life. Macroscopically the tumor is composed of a solid mass of different sizes tending to invade the surrounding structures and renal parenchyma. The authors report a case of cystic mesoblastic nephroma of the cellular subtype, with diffuse areas of hemorrhage and necrosis. The tumor was treated by surgical excision with radical nephrectomy and the child is doing well 4 years after the operation.

Ectopic anus in childhood.

The treatment of ten cases of ectopic anus is presented in this paper. The association of constipation with perineal anus due to alignment disturbance of the external sphincter triple loop system during evacuation has been described by Hendren (1978), Leape and Ramenofsky (1978), Upadhyaya (1984) et al. Hendren, Leape and Ramenofsky described two valid surgical techniques for this association. In this paper we describe the effect of non-invasive treatment in patients affected by symptomatic "primary" perineal anus. We also describe the effect of posterior anal transplant via the perineum in six infants and children with vulvar anus. This approach gave good results within three months without having to perform more complex operative techniques (Peña for example). Posterior anal transplant leads not only to an esthetic improvement but also to an improvement in fecal continence, which is sometimes deficient due to reduced anorectal angulation. It appears to us that an adequate perineal spur plays an important complementary role in the complex mechanism which controls fecal continence.

[Diagnostic imaging in constipation]. / Il contributo dell'imaging nella stipsi.

Diagnostic imaging modalities play a key role in the definition of the possible causes of constipation. Barium Enema (BE), Defecography (DG), Intestinal Transit Time (ITT), Computed Axial Tomography (CT) and Magnetic Resonance (MR) are necessary diagnostic tools for the identification either of the possible organic causes of the disease or of the functional disorders. The ITT evaluation is the main investigation to look for functional colic constipation; this method is in fact able to distinguish between the hypertonic type (in which the fecal progression is slowed down to such an extent that radiopaque markers accumulate in the most proximal part of the colon) and the atonic one (characterized by a global slowing down with the markers distributed along the whole colon). DG gives very accurate dynamic documentation of the pathologic alteration of the rectum-anal conduit, as well as of the disease of the supporting and anchoring system and of the levator complex; this type of investigation allows the definition (characterisation) of the different types of the functional rectum-anal constipation. Even in this case TAC and RM can greatly contribute to the definition of the whole picture of the constipation.

Should primary megaureter be treated d'emblée in the neonate?

Since 1969 Hendren and other AA. proposed a radical correction of high obstructive uropathy in neonatal age. This was accepted by most surgeons for pyelo-ureteral joint stenosis, but it may not be accepted in third grade refluent or nonrefluent megaureter. In such an eventuality the lesion may require transient ureterostomy or nephrostomy; this option is necessary in renal insufficiency, but it was not codified for unilateral defects. The results of immediate corrective surgery (Cohen or Politano-Leadbetter ureteral reimplantation) were recently evaluated in 103 patients with 141 primary megaureters. Ninety per cent of infants and children more than six months old recovered, while 6 per cent had fair results, 4 per cent poor results. Only sixty two per cent of infants under six months improved, while 35 per cent and 3 per cent had respectively fair and poor results. "Fair" results were represented by patients with unmodified renal condition (14 per cent) and patients who underwent two or three operations to obtain renal improvement (21 per cent). If the final outcome seems in any case positive, we think a two-stage operation in the third grade megaureter of the neonate is still preferable to a risk of complications and unforeseen reoperations.