Benign scrotal masses in children - some new lessons learned.

INTRODUCTION: A preponderance of benign intratesticular masses in pre-pubertal males encourages testicular-sparing surgery (TSS). OBJECTIVE: To review outcome of benign testicular lumps in children managed at a tertiary pediatric center more than 7.5years. METHODS: A retrospective review of pediatric benign testicular lesions from January 2008 to June 2015 was performed. RESULTS: There were twelve benign intratesticular tumors. Of these, 11 were in pre-pubertal males; comprising four teratomas, two epidermoid cysts, one dermoid cyst, two cases of Leydig cell hyperplasia, one cystic dysplasia of the rete testis and one large simple intratesticular cyst. We illustrate a case of Leydig cell hyperplasia presenting with precocious puberty limited to the ipsilateral hemi-scrotum. TSS was attempted in all 11 pre-pubertal cases, but successfully performed in seven. TSS was possible for a large testicular cyst seemingly replacing the entire testis, with evidence that the testis reconstituted itself after surgery. Recurrence of an epidermoid cysts reported. CONCLUSION: For the first time in the literature, this series reports Leydig cell hyperplasia presenting with ipsilateral hemi-scrotal changes of precocious puberty; shows evidence that the testis reconstitutes itself after TSS for a large cyst; and reports recurrence of an epidermoid cyst after TSS.

Vascular trauma in Western Australia: a comparison of two study periods over 15 years.

BACKGROUND: Royal Perth Hospital (RPH) has become Western Australia's only designated adult major trauma facility since a previous study of vascular trauma was conducted in 2001 at the same facility. The aim of this study is to identify changes in vascular trauma patterns over the two study periods and compare these changes with international literature. METHODS: All individuals presenting to RPH between January 2000 and December 2010 with vascular injury were identified from a prospective trauma database for this descriptive study. Injuries were classified using the Abbreviated Injury Score (AIS). RESULTS: The incidence of vascular trauma as a percentage of total trauma increased over the two study periods. The current 10-year study included 45 164 patients on the trauma database, of which 1205 patients (2.6%) sustained 1335 vascular injuries, an increase from 1% in the previous 5-year study at the same facility. Males aged 20-29 years were more frequently injured. Blunt trauma occurred more frequently than penetrating. The extremities, particularly the upper limbs were most commonly injured. The most common causes of injury for each region were as follows; motorbike crash (MBC), motor vehicle crash (MVC) and stabbing (neck, thorax and abdomen), MBC and MVC (lower limb) and piercing injuries (upper limb). Injury Severity Score (ISS) and mortality 43% (32 of 75) were highest for thoracic injuries, particularly thoracic aorta injury. Mortality rate has decreased. CONCLUSION: Vascular injuries in Western Australia are increasing. MVC are the most common cause of life threatening injury. Road safety interventions targeting young males are likely to reduce trauma.

Review of the radiation exposure during screening of surgically implanted central venous access devices.

PURPOSE: Ionizing radiation is used for the insertion of surgically implanted venous access devices (SIVADs) with children at the highest risk of cumulative radiation effects from these procedures. This study examines the radiation dose in a pediatric population during intraoperative radiological screening. METHODS: A retrospective study looked at all pediatric patients in a tertiary hospital between January 2008 and January 2014 who had a surgically implanted venous access device inserted using intraoperative fluoroscopy. Patient demographics, reason for SIVAD insertion, the type and method of insertion, fluoroscopy time and radiation dose area product were determined. RESULTS: A total of 505 patients had 682 SIVADs inserted, with 123 patients receiving multiple SIVAD over the six year period. There were two types of SIVAD inserted, 492 were totally implanted venous access devices (TIVAD) and 190 were tunneled central venous catheters (cuffed central line). Five hundred seven of the SIVAD inserted recorded the dose area product and fluoroscopy time. The median time for screening was 5seconds (range 1 to 275seconds) and the median dose area product was 0.00352mGym(2) (range 0.000001mGym(2) to 0.28mGym(2)). Of the 507 SIVAD that recorded the radiation data, 479 were open surgical cut-down insertion and 27 were percutaneous insertion. Percutaneously inserted surgically implanted venous access devices (mean 0.0060mGym(2)) had a longer dose area product than open insertion (mean 0.0034mGym(2); p=0.05). CONCLUSION: Screening of SIVAD involves low levels of radiation exposure and is comparable to a chest x-ray or a transatlantic flight. The excess lifetime cancer risk to patients is estimated to be very low and is considered to be outweighed by the benefits of insertion. Open surgical cut-down insertion has a significantly reduced radiation exposure compared to percutaneous techniques. Although radiation dose is higher with percutaneous procedures, the clinical effects are considered minimal, and the resultant radiation risk is estimated to be very low. Radiation dose should not determine technique of insertion of SIVAD.

Teres minor innervation in the context of isolated muscle atrophy.

PURPOSE: Teres minor atrophy occurs either in isolation, associated with other rotator cuff muscle pathologies or in quadrilateral space syndrome. In the latter condition, compression of the axillary nerve is the likely cause; however, the anatomy of the nerve to teres minor and how this may relate to isolated teres minor atrophy have not been extensively investigated. In light of the significance of teres minor atrophy in shoulder pathology, we performed a combined radiological and anatomical study of teres minor and its nerve supply. METHODS: Cadaveric dissection of nine shoulder specimens from eight cadavers was performed to investigate the anatomical variability in course, length and branching pattern of both the teres minor nerve and the axillary nerve. Radiological imaging and reports were analysed on all shoulder magnetic resonance images performed over a 1-week period at four radiology clinic locations in an attempt to identify the incidence of isolated teres minor atrophy and review teres minor atrophy in association with other shoulder pathology. Finally, we studied a case of isolated teres minor atrophy identified during a routine undergraduate dissection class. RESULTS: Considerable anatomical variation was noticed in cadaver dissections in the nerve(s) supplying teres minor muscle revealing several various points where it may be vulnerable to impingement or injury at along its course. Analysis of 61 shoulder MR images revealed two patients with shoulder complaints that had isolated teres minor atrophy. Case-based study of these two male patients revealed other associated shoulder injury but the presentation was markedly different and clinically distinct from quadrilateral space syndrome. CONCLUSION: Isolated teres minor atrophy is a relatively common shoulder pathology which appears to be clinically distinct from other syndromes with rotator cuff muscle atrophy including quadrilateral space syndrome. The exact aetiology is unknown but cadaveric dissection in this study suggests the considerable anatomical variation in both the origin and length of teres minor nerve(s) increase the risk of impingement and subsequent isolated teres minor atrophy.