Laparoscopic Versus Open High Ligation for Adolescent Varicocele: A 6-year Single Center Study

Ultrasonic Scalpel vs. Polymeric Clip Laparoscopic Varicocelectomy in Adolescents with Symptomatic Varicocele

Background: The aim of this study was to investigate treatment outcomes in adolescents who underwent laparoscopic surgery with an ultrasonic scalpel for symptomatic varicocele compared with adolescents who underwent surgery with a polymer clip. Methods: A total of 270 adolescents with a median age of 16 (interquartile range, IQR 13-17) years were included in the study. Taking into account the laparoscopic varicocelectomy technique used, the patients were divided into two groups. In the first group (n = 151), a polymer clip was used, while in the second group (n = 119), an ultrasonic scalpel was used to resect the spermatic vessels. The primary outcome measure was the effect of the laparoscopic technique used on treatment outcomes (postoperative complications and recurrence rates). Secondary outcomes were the duration of surgery and anesthesia and the length of hospital stay. Results: The duration of the surgical procedure (12 min (IQR 11, 15) versus 15 min (12, 19), p = 0.029) and anesthesia (21.5 min (16, 29.5) versus 28 min (23, 34), p = 0.003) was shorter in the group of adolescents in whom laparoscopic varicocelectomy was performed with an ultrasonic scalpel than in the group in which a polymer clip was used. No statistically significant difference was found between the groups studied in terms of length of hospital stay, recurrence rate (p >0.999), and complications (p = 0.703). There were no cases of testicular atrophy in either group. In the group of patients who underwent laparoscopic varicocelectomy with an ultrasonic scalpel, a slightly higher incidence of hydroceles was found (n = 4, 3.4%) than in the group in which a polymer clip was used (n = 2, 1.3%) (p = 0.410). At six-month follow-up, it was found that the majority of patients showed moderate or significant improvement in the spermogram after laparoscopic varicocelectomy (n = 85, 89.5%). In addition, the subjective discomfort or pain disappeared in the majority of patients (n = 71, 93.4%). The testicular volume increased significantly in 132 adolescents (89.8%). Conclusions: Laparoscopic varicocelectomy with a polymer clip or ultrasonic scalpel is safe and effective in adolescents with symptomatic varicocele. Treatment outcomes after laparoscopic varicocelectomy are the same regardless of whether a polymer clip or an ultrasonic scalpel is used to resect the spermatic vessels. The use of an ultrasonic scalpel for resection of the spermatic vessels shortens the overall duration of surgery and anesthesia.

Outcome following the surgical management of varicocele in children and adolescents: a systematic review and meta-analysis

Background

The ideal surgical approach for the management of varicocele in children and adolescents remains controversial. Several techniques are available including artery- or lymphatic-sparing with optical magnification (via open inguinal or sub-inguinal approach), laparoscopic, antegrade and retrograde embolization/sclerotherapy.

Objectives

We aimed to appraise the clinical outcomes of these techniques in children and adolescents.

Data Sources and Methods

A systematic review was conducted (1997-2023). Meta-analysis or proportional meta-analysis for non-comparative studies (Freeman-Tukey transformation) using the random effects model was conducted. Results are expressed as overall proportion % and 95% confidence interval (CI).

Results

We identified 1910 studies; 632 duplicates were removed, 1278 were screened, 203 were reviewed and 56 were included, with 12 reporting on 2 different techniques (total of 68 data sets). Optical magnification via inguinal approach (498 cases): recurrence 2.5% (0.6-5.6), hydrocele 1.6% (0.47-3.4), testicular atrophy 1% (0.3-2.0), complications 1.1% (0.2-2.6); optical magnification via sub-inguinal approach (592 cases): recurrence 2.1% (0.7-4.4), hydrocele 1.26% (0.5-2.3), testicular atrophy 0.5% (0.1-1.3), complications 4% (1.0-8.8). Laparoscopic with mass-ligation/division (1943 cases): recurrence 2.9% (1.5-4.6), hydrocele 11.4% (8.3-14.9); complications 1.5% (0.6-2.9); laparoscopic with lymphatic-sparing (974 cases): recurrence 2.4% (1.5-3.5), hydrocele 1.2% (0.45-3.36), complications 1.2% (0.05-3.9); laparoscopic with artery-sparing (228 cases): recurrence 6.6% (2.3-12.9), hydrocele 6.5% (2.6-12.0). Antegrade embolization/sclerotherapy (403 cases): recurrence 7.6% (5.2-10.4), hydrocele 0.8% (0.17-1.9), technical failure 0.6% (0.1-1.6), complications 4.0% (2.3-6.1); retrograde embolization/sclerotherapy (509 cases): recurrence 6.9% (4.6-9.5), hydrocele 0.8% (0.05-2.5), technical failure 10.2% (4.6-17.6), and complications 4.8% (1.0-11.2).

Conclusion

The recurrence rate varies between 2.1% and 7.6% and is higher with the embolization/sclerotherapy techniques. Post-operative hydrocele rate varies between 0.8% and 11.4% and is higher with the laparoscopic mass-ligation/division technique. Testicular atrophy has not been reported with the laparoscopic and embolization/sclerotherapy techniques. The retrograde embolization technique is associated with 10% technical failure (inability to complete the procedure). The laparoscopic lymphatic-sparing technique is characterized by the lowest recurrence rate, incidence of hydrocele and other complications, and no reports of testicular atrophy.

Prospective Comparison of Local Anesthesia with General or Spinal Anesthesia in Patients Treated with Microscopic Varicocelectomy

It is unclear whether local anesthesia (LA) is a viable and safe alternative to general anesthesia (GA) or spinal anesthesia (SA) for microscopic varicocelectomy. As a result, we designed a prospective trial to compare the pain relief, complications, and cost of LA with GA or SA in subinguinal microscopic varicocelectomy (MSV), using the propensity score matching method (PSM). This prospective study was conducted in a tertiary hospital from February 2021 to April 2022. Patients who underwent subinguinal MSV for varicocele were enrolled. The perioperative visual analog scale (VAS) scores, anesthesia-associated side effects, and cost data were recorded, and PSM analysis was performed. Finally, 354 patients were included, of whom 61.0% (216) were treated with LA, and 39.0% (138) underwent GA or LA. After PSM, the patients in the LA group exhibited lower VAS scores both three hours and one day after surgery, and a lower incidence of postoperative analgesic requirement; a lower ratio of patients who experienced anesthesia-associated side effects was also observed in the LA group, compared with the GA or SA group (all p < 0.001). The rate of perioperative satisfaction for patients was higher, the hospital stays and days to return to normal activity were shorter, and the cost was less in the LA group than in the patients in the GA or SA group (all p < 0.001). This prospective PSM cohort demonstrated that LA has the advantages of perioperative pain relief, reduced anesthesia-associated side effects, and cost, compared with GA or SA. It indicated that LA is an effective and safe technique for subinguinal MSV, and may guide clinical practice.

The Effect of Subcutaneous and Intraperitoneal Instillation of Local Anesthetics on Postoperative Pain after Laparoscopic Varicocelectomy: A Randomized Controlled Trial

Background: The main goal of the present randomized clinical trial was to investigate the effects of subcutaneous administration of two different local anesthetics at trocar incision sites at the abdominal wall in combination with intraoperative intraperitoneal instillation of local anesthetics, on the character of postoperative pain, in adolescents who underwent laparoscopic varicocelectomy. Methods: A total of 60 patients with a median age of 16 years, who received laparoscopic varicocele repair, were included in this randomized clinical trial. The patients were randomly assigned to three study groups receiving 2% lidocaine, 0.5% levobupivacaine, or the control group. The Visual Analogue Scale (VAS) was used by a blinded nurse at four different time points (2, 6, 12 and 24 h after the surgery) to measure pain intensity. Results: The significant effect of time on the pain intensity (p = 0.001) was found. Additionally, the interaction between time and different local analgesics (p < 0.001) was observed. In patients in whom 0.5% levobupivacaine has been used, significantly lower VAS pain scores were recorded at each time point assessed, in comparison with the patients who received 2% lidocaine or the patients from the control group in whom no local anesthetic was applied (p < 0.001). Furthermore, in patients in whom 2% lidocaine was administrated, significantly lower pain levels according to VAS were reported than in those from the control group, except for the time point at 24 h after surgery when pain levels were comparable. Concerning the postoperative pain control, the number of patients who requested oral analgesics postoperatively was significantly lower in the group of patients in whom local anesthetic was administrated intraoperatively (2% lidocaine—n = 4, 20%; 0.5% levobupivacaine—n = 1, 5%) compared to the patients who did not receive any local anesthetic during the surgery (n = 13; 65%) (p < 0.001). Conclusion: A significant reduction in postoperative pain intensity and analgesics consumption in patients undergoing laparoscopic varicocelectomy who received intraoperative local anesthetic was observed. The best effect on postoperative pain intensity, according to the VAS score, was achieved by 0.5% levobupivacaine.

Percutaneous Endoscopic Gastrostomy Tubes Can Be Considered Safe in Children: A Single-Center 11-Year Retrospective Analysis

Background and Objectives: When the human body is disabled to naturally ingest food through the mouth, enteral or parenteral nutritional support should be started. Percutaneous gastrostomy (PEG) is a flexible feeding tube that is inserted into the stomach through the abdominal wall in patients who will need long-term enteral nutrient intake. The aim of this study is to analyze clinical characteristic of children at the time of PEG placement as well as to determine indications, complications and outcomes associated with PEG at the Department of Pediatrics of the University Hospital of Split. Materials and Methods: Retrospective analysis of the medical records of patients treated from 2010 to 2020 was performed. The following data were collected from medical records: age, gender, information about nasogastric feeding before PEG placement, indication for PEG insertion, duration of PEG, procedure-related complications and treatment outcomes. Malnutrition was determined according to the z-score range for BMI for age and sex. According to the indication for PEG placement, patients were divided into five categories: central nervous system (CNS) diseases, neuromuscular diseases, genetic disorders, metabolic diseases, and group of children with polytrauma. Results: A total of 40 patients with median age of 110 months were included in study. At the time of PEG placement, most patients had deviations in body weight and height compared to expected values for age and sex. The most common underlying diagnoses were diseases of the central nervous system. Minor complications were found in 13 (35%) of patients. One patient (2.7%) developed major complication (gastrocolic fistula) and consequently underwent reoperation. The median duration of PEG in patients with complications before the need for replacement was 27 months, and in patients without complications, 43 months. Conclusions: Negative deviations of z-score body weight, body height, and body mass index could indicate the need for possible earlier placement of PEG. PEG can be considered as a safe therapeutic option in children since PEG-related complications, mostly in minor forms, were found in a small number of patients.

Assessment of seminal cystatin C levels in infertile men with varicocele: A preliminary study

Varicocele has been raised as a contributor to male infertility supported by the improvement of sperm parameters after varicocelectomy. Cystatin C (Cys C) has been linked to several cellular changes that are common in male infertility cases associated with varicocele such as apoptosis and autophagy. This preliminary study aimed to assess the seminal levels of Cys C in infertile oligoasthenoteratozoospermic (OAT) men associated with varicocele that have been shown to have spermatic vein vasodilation and active death pathway. Overall, 60 men were investigated being divided into two equivalent groups-infertile OAT men with varicocele who underwent varicocelectomy and healthy fertile men as a control group. These men were subjected to history taking, clinical examination, semen analysis and assessment of seminal Cys C pre and 6 months post-varicocelectomy. The results showed a significant increase of seminal Cys C in infertile OAT men with varicocele than the fertile control (55.57 ± 25.6 ng/ml versus 10.78 ± 1.88 ng/ml, p = .001). Seminal Cys C was a significantly decreased post-operative than its pre-operative level (34.69 ± 14.02 versus 55.57 ± 25.6 ng/ml, p = .01). These results show a potential role of Cys C in varicocele-induced infertility.

The Safety and Effectiveness of Laparoscopic Pyloromyotomy Using 3-mm Electrocautery Hook versus Open Surgery for Treatment of Hypertrophic Pyloric Stenosis in Infants

BACKGROUND

The standard of treatment for infants with hypertrophic pyloric stenosis is still pyloromyotomy. Recently, in most of the pediatric surgery centers laparoscopic pyloromyotomy has become popular. The aim of the present study is to compare the outcomes of treatment in infants with hypertrophic pyloric stenosis between traditional open approach and laparoscopic pyloromyotomy using 3-mm electrocautery hook.

METHODS

A total of 125 infants, 104 (83.2%) males, with median age 33 (interquartile range, IQR 24, 40) days, who underwent pyloromyotomy because of hypertrophic pyloric stenosis, between 2005 and 2021, were included in the retrospective study. Of that number 61 (48.8%) infants were allocated to the open group and 64 (51.2%) to the laparoscopic group. The groups were compared in regards to time to oral intake, duration of surgery, the type and rate of complications, rate of reoperations, frequency of vomiting after surgery, and the length of hospital stay.

RESULTS

No differences were found with regards to baseline characteristics between two investigated groups. Laparoscopic approach was associated with significantly better outcomes compared to open approach: shorter duration of surgery (35 min (IQR 30, 45) vs. 45 min (40, 57.5); p = 0.00008), shorter time to oral intake (6 h (IQR 4, 8) vs. 22 h (13.5, 24); p < 0.00001), lower frequency of postoperative vomiting (n = 10 (15.6%) vs. n = 19 (31.1%)), and shorter length of postoperative hospital stay (3 days (IQR 2, 3) vs. 6 days (4.5, 8); p < 0.00001). In regards to complications and reoperation rates, both were lower in the laparoscopic pyloromyotomy group but the differences were not statistically significant (p = 0.157 and p = 0.113, respectively). The most common complication in both groups was mucosal perforation (open group, n = 3 (4.9%); laparoscopic group, n = 2 (3.1%)) followed by wound infection in open group, n = 3 (4.9%). No cases of wound infection were recorded in the laparoscopic group.

CONCLUSION

Open and laparoscopic pyloromyotomy are equally safe and effective in treatment of hypertrophic pyloric stenosis. Laparoscopic technique is associated with faster recovery, shorter duration of surgery and shorter duration of hospital stay.

The Effect of Single and Triple Testicular Biopsy Using Biopty Gun on Spermatogenesis in Pubertal Rats

Simple Summary

Nowadays, a punch biopsy is a simple, reliable and inexpensive method for different types of tissue sampling. Equally, it is the method of choice for obtaining testicular tissue samples for pathohistological analysis and sperm for intracytoplasmic sperm injection. The results of this study clearly showed that a single biopsy has little effect on the biopsied testis, especially on total fertility. Triple biopsy showed by the same parameters that histological and immunohistochemical consequences were more significant compared to single but without a significant effect on overall fertility. Sperm analysis showed that single and triple biopsies did not have a significant effect on sperm count, motility and morphology. In addition, both single and triple punch biopsies of one testicle did not significantly affect the overall fertility potential of pubertal rats.

Abstract

Background: The aim of this study was to compare consequences in single and triple testicular biopsy by biopty gun in pubertal rats using histological and immunohistochemical analysis. Methods: Thirty-two Sprague-Dawley male rats were used as the experimental model. The rats were randomly divided into three study groups. The rats from the first group (n = 12) received a single-biopsy of upper pole of the left testis, while the rats from the second group (n = 10) received triple-biopsy of upper and lower poles and lateral surface of left testis. The third group (n = 10) was a control group. On the eightieth day after the biopsy in all rats bilateral orchiectomy and funiculectomy were performed to obtain testicular tissue and sperm for analysis. The consequences of the puncture were observed by pathohistology, immunohistochemistry and semen analysis. Results: The results of the study showed lower percentage of sperm count (14.5 mill/mL vs. 16 mill/mL, p = 0.130), sperm motility (24.6% vs. 32.7%, p > 0.05), abnormal sperm (30% vs. 27%, p > 0.05), atrophic tubules (21% vs. 6%, p < 0.001), volume (1.7 mL vs. 2.28 mL, p < 0.01) and apoptotic index (1.56 vs. 1.19, p = 0.650) in the testes with a triple-biopsy compared to the testes with a single-biopsy. Semen analysis showed a borderline significant difference between the group with triple-biopsy where sperm count was lower than it in the control group (14.5 mill/mL vs. 17.5 mill/mL, p = 0.05). A single-biopsy has little effect on the testis, especially on overall fertility. A triple-biopsy showed higher degree of the testicular damage but without a significant impact on overall fertility. Semen analysis showed that single- and triple-biopsies did not have a significant effect on sperm count, motility and morphology. Conclusion: Biopty gun procedure is a cheap, simple and reliable method for testicular biopsy in rats without a significant effect on sperm count, motility and morphology.