Comparison of scrotal antegrade sclerotherapy and laparoscopic Palomo surgery in treatment of adolescent varicocele: A 15-year review.

INTRODUCTION/OBJECTIVE: Varicocele is a common condition seen in adolescence and associated with adult subfertility. Numerous types of intervention have been described with differences in success and complication rates. This study aims to review and compare the surgical outcomes of laparoscopic Palomo surgery and scrotal antegrade sclerotherapy at our center. STUDY DESIGN: A retrospective analysis was done of all patients younger than 18 years old with idiopathic varicocele treated operatively between February 2001 and December 2016. Demographics such as age at operation, side, varicocele grade, operative date, and types of operation were collected. Primary outcomes were clinical recurrence, defined as any grading noted on follow-up within 1 year post-op and post-operative hydrocele. Secondary outcomes were operative time, length of stay, and other surgical complications. Mann-Whitney U test, independent t test and chi-square tests were used for analysis. All p-values were two-sided and considered statistically significant at p ≤ 0.05. RESULTS: A total of 119 patients fit the criteria, of whom 117 patients were included in data analysis (Table). Sixty-two patients had laparoscopic Palomo surgery (LPS) and 55 had scrotal antegrade sclerotherapy (SAS). Clinical recurrence (grade 2-3) within 1 year was similar between the two groups, with four out of 48 patients in the SAS group and six out of 62 patients in the LPS group (8.4% in SAS vs. 9.7% in LPS, p = 1.00). Of the 11 patients who had recurrence in the SAS group, seven had grade 1 recurrence (14.5%), two (4.2%) had grade 2 recurrence, and two (4.2%) had grade 3 recurrence. For the LPS group, 17 out of 62 patients had clinical recurrence within 1 year, of whom 11 (17.7%) had grade 1 recurrence, one (1.6%) had grade 2, and five (8.1%) had grade 3 recurrence. Post-operative hydrocele was significantly higher in the LPS group; there was none in the SAS group but 11 patients in the LPS group (0% in SAS vs. 17.7%, p = 0.002). Three patients had clinically significant hydrocele requiring Jaboulays' procedure. Complications other than hydrocele were noted in three patients in the SAS group and one patient in the LPS group (5.5% in SAS vs. 1.6% in LPS, p = 0.158). None required operative intervention. No conversion to open procedure was seen in the LPS group and there were no perioperative complications. Mean operative time was 62.9 min in the SAS group and 60.7 min in the LPS group (p = 0.624). Mean length of stay was 17.5 h in the SAS group and 31.7 h in the LPS group (p < 0.001). CONCLUSION: Both SAS and LPS are safe procedures for treatment of adolescent varicocele with similar clinical recurrence rate within 1 year. SAS has a significantly lower rate of post-operative hydrocele.

Venous Malformation and Localized Intravascular Coagulopathy in Children.

Aim Localized intravascular coagulopathy (LIC) has been described in adults with venous malformation (VM) but rarely reported in children. This study aims to determine the prevalence of LIC in children with VM and associated risk factors. Methods Patients younger than 18 years with VM from 2010 to 2014 were reviewed. Diagnosis was confirmed by Doppler ultrasound and/or magnetic resonance imaging. Demographics data and VM characteristics including volume, site, extension, painful symptoms, and palpable phleboliths were studied. Plasma D-dimer level of greater than 500 ng/mL was considered as abnormal. Results Total 24 children were included, of whom 8 were boys. Median age of presentation was 9 months (range: 0-12 years). Head-and-neck VM occurred in 17 (70.8%) patients and 3 (12.5%) had multifocal lesions. Seven (29.2%) patients had VM volume greater than 10 mL. Five (20.8%) patients had painful symptoms. Palpable phleboliths were found in two patients. Plasma D-dimer was raised in eight cases (33.3%). One patient with Klippel-Trenaunay syndrome (KTS) had D-dimer level of 5,000 ng/mL. Raised D-dimer was found in 23.5% of small VM (volume < 10 mL) and 57.1% of large VM (p = 0.167). D-dimer was significantly raised in multifocal VM (p = 0.028) and showed increasing trend in lesions with palpable phleboliths (p = 0.101). All patients had sclerotherapy performed with indications (cosmesis 41.7%, enlarging lesion 29.2%, pain 20.8%, bleeding 8.3%). Perioperatively, bolus intravenous fluid and mannitol were given to selected patients. All patients had VM volume reduction after sclerotherapy. There were no major thromboembolic complications. Conclusion LIC with raised D-dimer level occurred in one-third of pediatric VM. It was more common in large, multifocal VM and in those with palpable phleboliths or KTS.

Changes in Nasal Configuration Following Primary Rhinoplasty: Direct Anthropometric Measurement in Patients With Complete Unilateral Cleft Lip and Palate.

BACKGROUND: With the recent advances of surgical adjuncts including presurgical naso-alveolar molding and postoperative nasal stenting, information on the anthropometric evaluation of cleft lip nasal symmetry after primary rhinoplasty is lacking. METHOD: Twenty-nine nonsyndromic patients with complete unilateral cleft lip and palate undergoing modified rotation advancement cheiloplasty with synchronous primary rhinoplasty in our center were prospectively recruited in our study. All of them received our center's peri-operative management protocol, including presurgical naso-alveolar molding and postoperative nasal stenting. Direct anthropometric measurements of their nasal configuration were documented when they were anesthetized for primary lip repair at 3 months of age and for the primary palate repair at 12 months of age. Their nasal configurations were analyzed before primary rhinoplasty and at 9 months after rhinoplasty. RESULTS: There is a statistically significant change in nasal symmetry at 9 months after the primary rhinoplasty. There is no significant correlation between the nasal configuration before and at 9 months after the primary rhinoplasty. CONCLUSIONS: With significant relapse of nasal deformity at 9 months after the primary rhinoplasty despite the use of presurgical naso-alveolar molding and postoperative nasal stenting, overcorrection of the nasal configuration at primary rhinoplasty should be considered for optimal long-term nasal symmetrical outcome.

Retroperitoneal pelvic packing for haemodynamically unstable pelvic fractures in children and adolescents: a level-one trauma-centre experience.

PURPOSE: This study aims to review the outcomes of haemodynamically unstable paediatric patients with pelvic fractures undergoing protocol intervention of retroperitoneal pelvic packing (RPP) with external fixation and angiography. METHODS: From 2004 to 2011, consecutive patients younger than 19 years treated in our centre for haemodynamically unstable pelvic fractures were retrospectively reviewed. From 2008, protocol intervention triad of external fixation, RPP, and angiography with embolization was implemented. RESULTS: Before 2008, only 2 boys with fall injuries received intervention. One received initial angiography showing extravasation near iliac bifurcation. Laparotomy proceeded without embolization for multiple visceral injuries, but he succumbed postoperatively. The other had persistent bleeding after external fixation but became stabilized after embolization. After 2008 protocol implementation, 5 youngsters received the triad of interventions for unstable pelvic fractures. Mean age was 15.4 yrs. The mean injury severity score was 42 (18-66) with 62.5% mean probability of survival (6.8-98.8%). The mean operating time for RPP was 23 mins (20-35 mins). One boy died of rapid exanguination intraoperatively. The other 4 youngsters recovered for rehabilitation. CONCLUSION: Fall from heights is a major cause for severe pelvic injuries in our locality. RPP is a simple effective procedure to include in protocol intervention for pelvic fractures. This case series suggests it helps improve haemostasis and survival in unstable young patients, although larger cohorts will be necessary to validate this.

Hong Kong Chinese parents' attitudes towards circumcision.

OBJECTIVE: To investigate Hong Kong Chinese parents' knowledge and attitudes towards phimosis and circumcision. DESIGN: Questionnaire survey. SETTING: Four primary schools in Hong Kong. PARTICIPANTS: Anonymous questionnaires were sent to Chinese parents of boys, aged 6 to 12 years old, studying in primary school Grades 1 to 6. Their social backgrounds, attitudes and beliefs towards phimosis and circumcision were enquired into. RESULTS: The parents of 1479 pupils answered the questionnaire, giving a response rate of 95.8%. In all, 10.7% of schoolboys had undergone circumcision, and 11.8% of the fathers were circumcised. Regarding non-circumcised boys, 28.9% of their parents believed that their sons had phimosis and 15.6% believed they would require circumcision later. Among these parents, 57.9% would consider circumcision for their boys in public hospitals, 96.9% thought that public institutions should provide such service, and 82.6% thought that doctors' opinions were most important when deciding about circumcision. Most parents believed that circumcision could prevent balanitis (82.8%) and improve hygiene (81.8%). Significantly more parents from Mainland China and of lower social class believed that circumcision could improve cosmesis, growth of the penis, sexual potency and fertility, and prevent sexually transmitted diseases and penile cancer. CONCLUSION: Circumcision is not widely practised in Hong Kong. However, it can be a potential burden on surgical services in public hospitals. There are misconceptions concerning phimosis and circumcision, especially in parents from Mainland China and from lower socio-economic classes. Doctors' opinions are the most important factor guiding parental decisions on circumcision. Thus, family physicians' advice and education are important to avoid unnecessary circumcisions.

Early post-operative interleukin-6 and tumor necrosis factor-α levels after single-port laparoscopic varicocelectomy in children.

PURPOSE: Laparoendoscopic single-site surgery has recently been described in children and regarded as an improved technology leading to less pain and better cosmetic outcome. Compared to the traditional three-port method, it is not known if the single-port method is less invasive. The aim of this study was thus to investigate the post-operative acute inflammatory response in order to evaluate surgical stress in the two surgical approaches in children. METHODS: A prospective, single blinded, case-control study was carried out. Thirteen male patients who presented with unilateral varicocele were divided into two groups. Six children underwent single-port laparoscopic procedure, while the other seven children underwent three-port laparoscopic procedure. Pre-operative and post-operative blood samples were taken for the measurement of tumor necrosis factor-α (TNF-α) and interleukin 6 (IL-6) using ELISA. Demographics including the operation time, and complications were recorded. Data between the two groups were analyzed using unpaired t-test and a p value of <0.05 was taken as statistically significant. RESULTS: The mean age of patients was 14.5 years (range 12-19 years). There was no significant difference between the two groups in terms of operative time, nor there was any complication recorded. The change in serum TNF-α and IL-6 concentrations pre- and post-operatively between the single-port group and three-port group was not statistically significant. Overall, patients in the two groups showed excellent satisfaction in terms of post-operative cosmesis. CONCLUSION: Single-port laparoscopic varicocelectomy is safe, effective and produces excellent cosmesis with minimal surgical stress.