Antonio Savanelli

Laparoscopy-Assisted Orchidopexy: An Ideal Treatment for Children with Intra-Abdominal Testes

BACKGROUND AND PURPOSE The investigation of a child with a nonpalpable testis is probably the most frequent indication for laparoscopy in pediatric patients. The objective of this study was to evaluate the results and advantages of laparoscopy-assisted orchidopexy performed without dividing the spermatic vessels. PATIENTS AND METHODS During a 3-year period, 85 boys with nonpalpable testes (NPT) (91 testes overall) underwent laparoscopic diagnostic exploration. Twenty-five patients (27.4%) showed an intra-abdominal testis (IAT): 24 underwent a laparoscopy-assisted orchidopexy (LAO) without sectioning of the spermatic vessels, and one, whose inner spermatic vessels were not adequately long for LAO without tension, underwent a two-step Fowler-Stephens (FS) procedure. The technique consists of dissection and mobilization of the inner spermatic vessels and the vas deferens from the posterior peritoneum, sectioning of the gubernaculum attachments, and bringing down of the testis into the scrotum through the internal inguinal ring, if open, or through a neo-inguinal ring created medial to the epigastric vessels. RESULTS Surgery lasted between 40 and 80 minutes (median 60 minutes). All the testes were brought down into the scrotum. There was only 1 (4%) intraoperative complication, which occurred in the second patient operated on with this procedure. He experienced an iatrogenic rupture of the spermatic vessels secondary to excessive traction. CONCLUSION Laparoscopic orchidopexy is the logical extension of diagnostic laparoscopy for the evaluation of NPT. Concerning the technique, we believe that LAO with intact spermatic vessels could be considered the treatment of choice in the patient with IAT, as it does not affect normal testicular vascularization. Alternatively, in the case of very high IAT (more than 3 cm from IIR), an FS procedure may be considered.

Long-Term Outcome of Laparoscopic Fowler-Stephens Orchiopexy in Boys With Intra-Abdominal Testis

PURPOSE We reviewed the records of 36 pediatric patients operated on between 1990 and 1997 for high intra-abdominal testes, using the 2-step Fowler-Stephens procedure via laparoscopy. MATERIALS AND METHODS Patients were followed for 10 to 17 years. Three patients who had undergone the second stage by open procedure were excluded from study. The 33 remaining patients were contacted by telephone, and 12 (7 with right and 5 with left intra-abdominal testes) agreed to undergo clinical and instrumental examination. Patient age ranged from 13 to 26 years (average 14.7). All patients underwent clinical examination and volumetric measurement of both testes using color Doppler ultrasound. RESULTS Two of the 12 patients (16.7%) had an atrophic testis in the scrotum and 10 (83.3%) had a viable testis in the scrotum. The operated testis was always smaller than the normal testis, despite the good vascularization detected on echo color Doppler ultrasound. One patient had ultrasound evidence of bilateral microcalcifications with normal vascularization. Mann-Whitney test showed there was a statistically significant difference between the volume of the operated testis and the normal testis. CONCLUSIONS It is extremely difficult to perform studies on the long-term outcome of surgical procedures. We describe the outcome at more than 10 years postoperatively, and demonstrate that greater than 83% of patients who underwent a 2-step Fowler-Stephens procedure using laparoscopy had satisfactory results. The operated testis was always significantly smaller compared to the normal testis but was well vascularized.

Comparison of five different hormonal treatment protocols for children with cryptorchidism.

OBJECTIVE To compare the effects of medical therapy on boys with cryptorchidism, a prospective study was carried out in five groups of patients over a 30-month period. MATERIAL AND METHODS A total of 439 boys with undescended testicles were enrolled; their ages ranged between 6 months and 13 years (median 4.2 years). Of these, 327 had true unilateral and 112 bilateral undescended testicles. In 115 patients surgery was performed directly either because the condition was associated with inguinal hernia or because the child had undergone previous inguinal surgery; hormonal treatment was attempted in the remaining 324 patients. Human chorionic gonadotrophin (hCG) was administered to 113 patients (34.8%), luteinizing hormone-releasing hormone (LH-RH) to 85 (26.2%), a combination of LH-RH and hCG to 64 (19.7%), human menopausal gonadotrophin (hMG) to 35 (10.8%) and a combination of hMG and hCG to 27 (8.3%). RESULTS Overall, testicular descent was achieved in 27.7% (90/324) of patients: specifically, in 38.2% (36/94) of boys with bilateral undescended testicles (both testes in 22/36, one testis only in 14/36) but in only 23.4% (54/230) of those with unilateral undescended testicles (p = 0.007). The correlation between the type of therapy and testicular descent can be summarized as follows: hCG, 39/113 (34.5%); LH-RH, 25/85 (29.4%); hCG+LH-RH, 19/64 (29.6%); hCG+hMG, 7/27 (25.9%); hMG alone, 0/35 (0%). CONCLUSIONS In our experience, pharmacological treatment seems to yield better results in cases of bilateral than unilateral cryptorchidism. hCG seems to be equally effective as LH-RH for the treatment of cryptorchidism in approximately 30% of cases; the combination of these two drugs does not seems to increase the success rate. The use of hMG alone is ineffective. We believe that hormonal treatment can lead to acceptable results in boys with cryptorchidism, without relevant adverse effects.

Leiomyomatosis peritonealis disseminata in association with Currarino syndrome

BackgroundLeiomyomatosis peritonealis disseminata (LPD) is a rare disease in which multiple smooth muscle or smooth muscle-like nodules develop subperitoneally in any part of the abdominal cavity. No reports of multiple congenital malformations associated with LPD have been found in the English literature.Case presentationA 27 year-old patient referred to our gynaecology unit for pelvic pain, amenorrhoea, stress incontinence, chronic constipation and recurrent intestinal and urinary infections. Multiple congenital malformations had previously been diagnosed. Most of these had required surgical treatment in her early life: anorectal malformation with rectovestibular fistula, ectopic right ureteral orifice, megadolichoureter and hemisacrum.An ultrasound scan and computed tomography performed in our department showed an irregular, polylobate, complex 20 cm mass originating from the right pelvis that reached the right hypochondrium and the epigastrium. The patient underwent laparotomy. The three largest abdominal-pelvic masses and multiple independent nodules within the peritoneum were progressively removed. The histological diagnosis was of LPD.ConclusionThe case we report is distinctive in that a rare acquired disease, LPD, coexists with multiple congenital malformations recalling a particular subgroup of caudal regression syndrome: the Currarino syndrome.

Laparoscopic Treatment of Inguinal Hernia in the First Year of Life

BACKGROUND Laparoscopic inguinal hernia repair is rarely reported in the first year of life. In this article, we report our experience to emphasize the advantages of this procedure in this age range. PATIENTS AND METHODS In a 2-year period, we operated on 315 patients for unilateral inguinal hernia by using laparoscopy. Fifty of 315 patients (15.9%) had less than 1 year of age. This study focused on this group of 50 children (36 boys and 14 girls). The age range was 1-12 months (median, 6.7) with a median body weight of 5.5 kg (range, 3.7-9). As for a technical point of view, we used modified laparoscopic herniorraphy, according to the Montupet technique. After sectioning the sac distally to the ring, the periorifical peritoneum was closed by using a purse-string suture of a nonresorbable suture. RESULTS The median operating time was 22 minutes (range, unilateral, 7-30; bilateral, 12-42). All the procedures were performed in a day hospital setting. As for laparoscopic findings in 22 of 50 patients (44%), we found a contralateral patency of the processus vaginalis. In these 22 cases, we performed a bilateral herniorraphy. In 1 girl (2%), we found a coexistence of indirect hernia and a direct hernia on the right side. Both orifices were sutured in laparoscopy. We recorded only 1 minor complication (2%); a problem with needle extraction. With a minimum follow-up of 1 year, we have had only 1 recurrence (1.3%) on 73 herniorraphies performed. CONCLUSIONS We believe that laparoscopic repair of inguinal hernia in boys under 1 year of age by expert hands is a safe, effective procedure to perform. Its ability to simultaneously repair all forms of inguinal hernias, together with contralateral patencies, has cemented its role as a viable alternative to conventional repair.

Bochdaleck diaphragmatic hernia, complicated by an antenatal gastric perforation, presenting as a pneumothorax and a perforative peritonitis

The presentation of congenital diaphragmatic hernia (CDH) at birth may fall outside the typical features (cyanosis, tachypnea and respiratory failure), manifesting, instead, also with others pictures that make the diagnosis difficult or even impossible. We report a case of CDH presenting as a pneumothorax and a perforative peritonitis due to an antenatal gastric perforation.

Is the risk of hypertension an indication for prophylactic nephrectomy in patients with unilateral multicystic dysplastic kidney

Objective: Surgery is still proposed by some as the treatment of choice for unilateral multicystic dysplastic kidney (UMCDK) because of the potential complications of hypertension, infection and malignant change. The purpose of this study is to demonstrate that the risk of hypertension does not justify routine nephrectomy. Material and Methods: We report 41 cases of UMCDK, treated between 1980 and 2001, 28 of whom were male (68%). Twenty‐one patients were nephrectomized (51%). Twenty patients (49%) underwent clinical and ultrasound follow‐up. Blood pressure was controlled every 3–4 months (over a period ranging from 9 months to 6 years) and an ultrasound scan was performed every 6 months during the first 2 years, and annually thereafter. Results: In the patients treated non‐operatively we observed a progressive spontaneous involution of their multicystic dysplastic kidneys and the total absence of complications such as hypertension or malignancy. Conclusion: It is reasonable to conservatively manage patients with UMCDK by means of repeated ultrasound examinations and blood pressure control.

Preputioplasty associated with urethroplasty for correction of distal hypospadias: A prospective study and proposition of a new objective scoring system for evaluation of esthetic and functional outcome

OBJECTIVE Most surgical procedures for correction of hypospadias involve the removal of foreskin resulting in a circumcised penis. We report our experience and the medium-term results in the reconstruction of the foreskin during the correction of distal hypospadias. MATERIALS AND METHODS Between January 2007 and December 2011, 445 patients aged between 8 and 120 months underwent surgical correction of hypospadias. In 354 out of 445 patients, we performed the reconstruction of the foreskin. Urethroplasty was performed according to either the TIPU (tubularized incised urethral plate urethroplasty; Snodgrass) technique (233/354, 66%) or MAGPI (meatal advancement glanduloplasty incorporated) procedure (121/354, 34%). In 91 out of 445 patients urethroplasty was performed using classic TIPU technique and they were circumcised. The cosmetic and functional results were evaluated using the Hypospadias Objective Penile Evaluation (HOPE) scoring system. RESULTS At a 12 months follow-up, 300 patients (84.7%) had retractable foreskin while 54 patients (15.3%) required postoperative steroid application. We had a total complication rate of 8.7%. As for preputioplasty, 16 patients (4.5%) had partial or total dehiscence of the reconstructed foreskin, one patient was circumcised for persistent phimosis (0.2%). As for urethroplasty complications, we recorded 11 fistulas (3.1%) and three stenosis (0.9%). The complication rate of the control group of circumcised patients was of 3.3% (2 fistulas [2.1%] and 1 stenosis [1.2%]). CONCLUSIONS Our experience shows that foreskin reconstruction can be performed successfully in selected patients with distal hypospadias. However, preputioplasty add an additional 4.7% complication rate. As for the complications of urethroplasty, it seems that preputioplasty does not increase the incidence of complications on the urethra reconstruction. We propose a new objective scoring system (modified HOPE score) for evaluation of esthetic and functional outcome.

One-trocar ileo-colic resection in a newborn infant with a cystic lymphangioma of the small-bowel mesentery.

We report a case of a newborn with a cystic lymphangioma of the small-bowel mesentery discovered antenatally at ultrasound and confirmed postnatally at computed tomography scan. The lesion together with the caecum and the last centimeters of ileum were resected by using only one trocar positioned lateroumbilically. In this paper, we describe the advantages of MIS to treat newborn with abdominal masses.

Risk of Malignancy and Need for Surgery in Pediatric Patients with Morris or Y-chromosome Turner Syndrome: A Multicenter Survey.

STUDY OBJECTIVE The management of intersex patients with Y-chromosome Turner or Morris syndrome remains a challenge. We report our experience with a multicenter European survey. DESIGN We collected the data on 18 patients (mean age 10.2 years, range 2-17 years) with Morris (10 patients) or Turner (8 patients) syndrome harboring the Y chromosome who were treated in 1 of 6 European centers of pediatric surgery between 1997 and 2013. All patients were evaluated by use of a multidisciplinary diagnostic protocol. All patients received a bilateral gonadectomy via laparoscopy; only 1 center performed ovarian cryopreservation. Seven patients received a concomitant genitoplasty. Operative notes and histology were reviewed for details. RESULTS No conversions to laparotomy and no complications were recorded. For the patients receiving only the gonadectomy, the length of hospital stay was 24-48 hours, whereas for the patients receiving an associated genitoplasty, it was 6-10 days. Specimens were negative for tumors in 83.3% of cases, whereas in 3 patients (16.6%), benign abnormalities (Sertoli cell hyperplasia in 1 patient and ovotestis in 2 patients) were recorded. A malignant tumor was not recorded in our series. CONCLUSION If the risk of malignancy is considered as the main indication for surgery in case of Turner or Morris syndrome, on the basis of our study, this indication should be reevaluated. However, based on the non-negligible rate of benign abnormalities reported in our series (16.6%), the performance of cryopreservation to preserve fertility and the possibility of performing genitoplasty during the same anesthetic procedure represent additional valid indications for surgery.