K. Novak

Lymphatic-sparing laparoscopic varicocelectomy: a microsurgical repair

PURPOSE The division of lymphatic vessels during pediatric varicocelectomy is complicated by hydrocele formation, testicular hypertrophy due to intratesticular edema and decline in testicular function. To prevent these complications, we introduced a microsurgical lymphatic sparing dissection into laparoscopic varicocelectomy. MATERIALS AND METHODS We retrospectively compared outcomes in 104 boys who underwent microsurgical laparoscopic repair for grade II to III varicocele between April 1999 and December 2002 to a group of 67 boys operated on using conventional laparoscopy without lymphatic preservation between January 1997 and March 1999. Using 10x to 20x optical magnification, the lymphatic vessels were identified as colorless tubular structures that were easily separated and preserved. RESULTS After a mean followup of 17 months there was no significant difference in varicocele recurrence between the 2 groups (6.7% vs 8.9%, p = 0.56). Hydrocele formation and testicular hypertrophy occurred significantly less frequently after microsurgical repair (1.9% and 2.9%, respectively, vs 17.9% and 20.1% in the conventional group, p = 0.0003). No major complications were encountered. CONCLUSIONS Preservation of lymphatics in laparoscopic varicocelectomy is technically feasible, and decreases hydrocele formation and the development of testicular hypertrophy. This microsurgical modification is a safe and efficacious alternative for urologists skilled in reconstructive laparoscopy.

Division of Lymphatic Vessels at Varicocelectomy Leads to Testicular Oedema and Decline in Testicular Function According to the LH-RH Analogue Stimulation Test

OBJECTIVES To study the andrological outcome of the division of testicular lymphatic vessels at varicocelectomy in children and adolescents. METHODS Testicular size and basal and stimulated luteinizing hormone (LH) and follicle-stimulating hormone (FSH) values were determined prospectively in 86 patients with left unilateral varicocele grades II-III. 22 patients underwent lymphatic non-sparing surgery (LNS group), 10 of them with artery sparing (LNS/AS) and 12 without artery sparing (LNS/ANS), 23 patients underwent lymphatic sparing repair (LS group) and 41 patients were treated conservatively (NT group). RESULTS The LNS group demonstrated significantly greater left testicular enlargement at six weeks and one year following repair, left testicular hypertrophy developed in 31.8% and hydrocele in 22.7% of patients. Marked oedema of intertubular tissue and a varying degree of tubular injury was observed in boys surgically treated for hydrocele. In the LS group, neither hypertrophy nor hydrocele developed postoperatively, the LH stimulated values were lower than in LNS/ANS group (p<0.05) and the NT group (p<0.04), the FSH stimulated values were lower than in the LNS/ANS group (p<0.001). CONCLUSIONS Division of lymphatic vessels at varicocelectomy is associated with an excessive increase in testicular volume due to oedema, and with a reduced testicular function according to higher LH and FSH stimulated values. Preservation of lymphatics is strongly advised in varicocelectomy in adolescents to ensure better andrological outcome.

High incidence of cardiovascular complications in pheochromocytoma.

Excess of catecholamines in pheochromocytoma is usually accompanied with classical symptoms and signs. In some cases, severe cardiovascular complications (e. g., heart failure, myocardial infarction) may occur. We performed a retrospective analysis focused on the incidence of cardiovascular complications (classified as follows: arrhythmias, myocardial involvement or ischemia and atherosclerosis, cerebrovascular impairment) before the establishment of diagnosis of pheochromocytoma among 145 subjects treated in our hospital. Cardiovascular complications occurred in 28 subjects, but these subjects did not differ significantly from subjects without complications in age, gender, body mass index, paroxysmal symptoms, symptom duration, tumor dimension, catecholamine secretory phenotype, and incidence of hypertension or diabetes mellitus. Arrhythmias occurred in 15 subjects (2 arrhythmia types in 2 subjects): atrial fibrillation in 9 subjects, supraventricular tachycardia in 3 cases, and ventricular tachycardia in 2 patients. Significant bradycardia was noted in 3 cases. Five subjects presented with heart failure with decreased systolic function (takotsubo-like cardiomyopathy found in 2 cases). One subject suffered from hypertrophic obstructive cardiomyopathy. Seven subjects presented with non-ST-segment elevation myocardial infarction, 2 patients with ST-segment myocardial infarction, and 1 subject underwent coronary artery bypass grafting. Two subjects suffered from significant peripheral atherosclerosis. Among cerebrovascular complications, transient ischemic attack was found in 3 cases, 2 subjects suffered from stroke, and subarachnoidal bleeding occurred in 1 patient. One subject suffered from diffuse neurological impairment due to multiple ischemic white matter lesions. These data show relatively high incidence of cardiovascular complications (19.3%) in subjects with pheochromocytoma. Early diagnosis is mandatory to prevent severe complications in pheochromocytoma.

Long-term effect of specific treatment of primary aldosteronism on carotid intima-media thickness.

Background: Aldosterone has been shown to substantially contribute to the accumulation of different types of collagen fibres and growth factors in the arterial wall, thus increasing wall thickness. A previous study showed reduction of increased common carotid intima–media thickness (IMT) in patients with primary aldosteronism 1 year after adrenalectomy. Our study in patients with primary aldosteronism was aimed at comparing the long-term effect of adrenalectomy vs. spironolactone therapy on common carotid IMT regression. Method: Forty-two patients with confirmed primary aldosteronism (21 with aldosterone-producing adenoma treated by unilateral laparoscopic adrenalectomy, 21 treated with spironolactone) were investigated by carotid ultrasound at baseline and 1 and 6 years after the specific treatment. Results: There was a decrease in common carotid IMT from 0.956 ± 0.140 to 0.900 ± 0.127 mm (−5.9%; P < 0.05) at 1 year and to 0.866 ± 0.130 mm (−9.4%; P < 0.01) at 6 years after adrenalectomy; in the spironolactone group, common carotid IMT decreased from 0.917 ± 0.151 to 0.900 ± 0.165 mm (−1.8%; NS) at 1 year and to 0.854 ± 0.176 mm (−6.8%; P < 0.01) at 6 years of treatment. The magnitude of improvement at 1 year was significantly higher (by 70%; P < 0.05) in the adrenalectomy group; however, the difference (by 27%) became nonsignificant at 6 years. Comparing the adrenalectomy and spironolactone groups, there was no significant difference in blood pressure decrease after treatment. Conclusion: In the long term, spironolactone therapy in patients with primary aldosteronism had significant effect on regression of IMT, which was comparable to surgical treatment in patients with unilateral forms of primary aldosteronism.

Pseudoglandular myxoid adenoma of the adrenal gland.

Myxoid tumors of the adrenal cortex are rare. To the best of our knowledge, only 17 cases have been reported to date, including 10 carcinomas and 7 adenomas. The myxoid areas of these tumors are often evident grossly, and their extent is variable. We report on a case of a myxoid adenoma of the right adrenal gland in a 45-year-old male with a prominent pseudoglandular arrangement in more than 90% of the tumor mass, and with a minor component represented by anastomosing cords of tumor cells floating in pools of myxoid material. In addition, after extensive examination, we found foci of typical adrenocortical adenoma. Grossly, the tumor was yellowish without discernable gelatinous changes. Most of the tumor cells had a moderate amount of clear vacuolated cytoplasm and contained numerous oil-red-O-positive lipid droplets. Extracellularly, in the lumens of pseudoglands and on the background, we noticed myxoid material that stained positively with Alcian blue (pH 2.5) and weakly positively with mucicarmine and the PAS method. Immunohistochemical examination showed positivity of the tumor cells for vimentin and cytokeratin CAM5.2. Synaptophysin was weakly positive only focally. Cytokeratin AE1/AE3, EMA, and CEA were negative.