Antonio Spagnoli

A ten-year experience of Brescia-Cimino arteriovenous fistula in children: Technical evolution and refinements

PURPOSE The arteriovenous fistula (AVF) of Brescia-Cimino fulfills nearly all of the criteria for an optimal access for chronic hemodialysis, such as long-term patency rate, low complication rate, and respect of vascular morphologic features. Alternative dialytic methods (i.e., external shunts and vascular grafts) cannot easily be applied to pediatric patients, and in addition, these methods are responsible for higher complication rates. METHODS From January 1985 to December 1994, 112 Brescia-Cimino AVFs were performed in 90 children (average age, 5.5 years; range, 5 months to 18 years). The average weight of the children was 28 kg (range, 6.5 to 54 kg); 16% of AVFs were performed in children who were less than 5 years old, and 18% in children who were less than 15 kg in body weight. RESULTS Chronic renal failure was caused by a nephropathy in 53 cases (14 with a nephrotic syndrome), and 37 cases had a uropathy. In all cases a phlebography was performed before the microsurgical treatment. Since 1994 an inflatable tourniquet has been placed on the selected upper arm because of an optimal exsanguination of the operating field. The primary patency rate was obtained in all but six of the children; 35% of AVFs had either immediate or late complications. Thrombosis was the most frequent complication that we observed. In comparison with 79% of late thrombosis, 60% of early thrombosis was cured. Of the 80 AVFs, 63.5% with a 4-year follow-up are still patent. CONCLUSION We emphasize the following two conclusions: first, microsurgery is essential to create AVFs with good results in children as well as in adult patients; and second, the results improved after the adoption of an upper-arm exsanguination and ischemia (pressure range, 400 mm Hg to 600 mm Hg) that avoided spasm of the vessels with a final 35% reduction in surgical time.

Abdominoscrotal hydrocele: a reliable surgical technique

Abdominoscrotal hydrocele (ASH) consists of two large sacs, both abdominal and scrotal, connecting with the inguinal channel. The diagnosis is made only by ultrasound scan. Surgical treatment is mandatory since no spontaneous resolution has been reported. A new surgical procedure used successfully to treat 11 patients with ASH is described.

Abdominoscrotal hydrocele in childhood : report of four cases and review of the literature

Abdominoscrotal hydrocele is rare in adults and almost exceptional in children. The abdominal extension of the fluid collection may be properitoneal or retroperitoneal, and the processus vaginalis may be patent or obliterated. The pathogenesis is unclear. Pressure alone cannot explain this phenomenon, but may coexist with a preformed abnormality of the tunica vaginalis. The diagnosis should be suspected in the presence of a large hydrocele associated with an ipsilateral abdominal mass. Ultrasonography confirms the diagnosis with no need of other investigations. Complete surgical excision is preferable.

Simplifying the surgical approach to glanular and coronal hypospadias: Longitudinal urethral incision and glanuloplasty

OBJECTIVE Meatal advancement with glanuloplasty incorporated (MAGPI) is an appropriate approach for most glanular and coronal hypospadias. The very low incidence of complications with this technique (i.e., fistulas, meatal regression and stenosis) makes MAGPI very competitive if compared with other approaches proposed for similar anatomical defects. In certain cases, however, the MAGPI approach has led to an unsatisfactory neo meatus; instead of a natural slit-like appearance, the meatus can look too rounded and puckered. METHODS The last 84 patients referred to our unit with indications suitable for MAGPI (mean age 39 months) were operated on using a novel approach: the glanuloplasty was associated with a simple deep urethral plate incision, extending along the urethral channel, and left unsutured. RESULTS At minimum follow up of 12 months two meatal regressions to mid glans were recorded. No meatal stenosis was seen in this series. CONCLUSION This approach allowed us to achieve a conical glans with a natural looking meatus, avoiding urethral sutures.

Paratesticular pilomatricoma: a new location.

Abstract. The first case of pediatric paratesticular pilomatricoma is reported. Differential diagnosis with other more common lesions in such a site is the main issue. Conservative surgery is the treatment of choice. Follow-up is recommended, since most pilomatricomata are benign, but rarely malignant transformation may occur.

Complete Scrotal Agenesis: New Surgical Approach Using Self-inflating Tissue Expander

Complete agenesis of the scrotum is an extremely rare entity: to date, only 8 cases have been reported. The authors describe 1 case carrying a heterozygous genomic variant in exon 17 of the MAP3K1 gene, whose surgical treatment included osmotic prosthesis implant to achieve reconstruction of a new scrotum. By constant and gradual expansion, self-inflating prothesis avoids patient discomfort and facilitates orchiopexy.