Inguinal Approach Research Articles

Groin wound infection in vascular surgery. A one year institutional incidence

Introduction/ObjectivesSurgical site infection (SSI) in vascular surgery is a complication that may lead not only to healing problems, but also limb loss and risk of death. The incidence of surgical site infection at the groin after vascular procedures ranges among 3% to 44%. The aim of this study is to review the incidence of groin infection in our department and the degree of correlation between infection, known risk factors and preventing measures. MethodsRetrospective review of consecutive arterial vascular surgeries in a university central hospital during one year. Patients undergoing groin incisions were studied according to baseline demographics, clinical characteristics, active infection, previous inguinal access, antithrombotic therapy, indication for intervention, prophylactic antibiotic use, type of intervention and type of graft used. Wound site infections over a 30-day period were registered and graded based on Szilagyi classification. On patients with documented groin infection, the presentation timing, modality of treatment (surgical and non-surgical) and time of healing were recorded. Data were analyzed by using SPSS 18.0 version software. ResultsFrom January to December 2013, 1266 vascular surgeries were performed. Of these, 782 were arterial vascular procedures, 279 by inguinal approach, with a total of 358 groin incisions. Our base population included 241 patients (31 patients with more than one procedure in a year). Total infection rate was 4.7% (17/358 groin incisions). All Szilagyi I (n=4) resolved with antibiotic only; three of the ten Szilagyi II infections needed drainage/debridement at operation room; the other Szilagyi II resolved with antibiotic and wound care. All Szilagyi III infections (n=3) were treated with bypass removal, and in two patients an in situ revascularization was performed. These two patients died from sepsis. Identification of the infecting agent was possible in 9 patients, with the most common isolated agent being Pseudomonas. Hypertension was significantly associated with a higher risk of SSI (p=0.033). Discussion/ConclusionsIn our department, the infection rate of the inguinal approach equals the best international standards described. These results may be the outcome of a carefully planned strategy of infection control. Arising from the fact that groin SSI is a low incidence event, correlations between suspected risk factors and this infection are hard to establish. Longer follow-ups would be useful for identification of all groin infections.

Comparative study between the outcome of Laparoscopic Palomo and open inguinal Varicocelectomy

Background: The ideal method of varicocele treatment is a controversial issue. The present study was designed to compare the outcome of laparoscopic palomo and open inguinal varicocelectomy. Methods: The present quasi experimental study was conducted in the Department of Urology, Dhaka Medical College Hospital, Dhaka, between July 2010 and June 2012 to compare the outcome of open inguinal and laparoscopic Palomo approach of varicocelectomy. Purposively selected 50 patients were divided into equal two groups, Group A and Group B treated with open inguinal varicocelectomy and laparoscopic Palomo varicocelectomy respectively. Statistical analyses were done by using SPSS and p value <0.05 was considered as significant. Results: In the present study, mean age of the patients of Group A and Group B were 29.1 ± 2.0 and 28.9±1.5 years respectively. Among the patients of Group A developed neither hydroeele nor testicular atrophy, where as in patients of Group B 20% and 12% developed hydrocele and testicular atrophy respectively. The recurrence rate of varicocele was lower in the Group A than that in the Group B. The findings of semen analysis at 1st and 2nd follow up visits show that there was negligible improvement in semen quality in terms of sperm count, motility and morphology. Conclusion: Open inguinal varicocelectomy is better than laparoscopic palomo varicocelectomy. Although sooner return to work is achieved by laparoscopic varicocelectomy, complications are more frequent than the open inguinal method. DOI: http://dx.doi.org/10.3329/jdmc.v22i2.21527 J Dhaka Medical College, Vol. 22, No.2, October, 2013, Page 156-162

Study of inguinal versus retroperitoneal approach in the treatment of varicocele

Objective The aim of the study was to assess the efficacy of the inguinal approach versus the retroperitoneal approach in the treatment of varicocele. Background Published results have shown that the inguinal approach has several advantages over the retroperitoneal approach in terms of lower incidence of recurrence, easier applicability, and greater safety. Patients and methods This prospective study was conducted from April 2013 to February 2014 in Menoufia University hospitals on 40 patients with primary varicocele and subfertility. The patients were randomly allocated into two groups of 20 patients each. Patients in group I underwent inguinal varicocelectomy, and patients in group II underwent retroperitoneal varicocelectomy. Results The ages of the 40 patients with suspected appendicitis ranged from 16 to 40 years. The mean age was 25.24 years in group I and 27.15 years in group II. Improvement in semen characteristics was seen in 80% of patients (16 in each group). Hematoma formation was observed in two (10%) cases in group I and in no cases in group II. One (5%) patient of group I had hydrocele formation. No testicular atrophy was noticed in the immediate postoperative period in either group. In two (10%) patients of group II there was no symptomatic relief. In group II there was no patient with symptomatic persistence. Conclusion The inguinal approach is superior to the conventional retroperitoneal approach in the treatment of varicocele, especially with respect to recurrence rate. Using inguinal approach varicocelectomy, identification and preservation of the testicular artery can be easily carried out. However, semen characteristics improved in both groups.

Inguinal Hernia Containing Uterus, Fallopian Tube, and Ovary in a Premature Newborn.

A female infant weighing 2,200 g was delivered at 34 weeks of gestation by vaginal delivery. She presented with an irreducible mass in the left inguinal region at 32 days of age. An ultrasonography (US) was performed and an incarcerated hernia containing uterus, fallopian tube, and ovary was diagnosed preoperatively. Surgery was performed through an inguinal approach; the uterus, fallopian tube, and ovary were found in the hernia sac. High ligation and an additional repair of the internal inguinal ring were performed. Patent processus vaginalis was found during contralateral exploration and also closed. The postoperative course was uneventful. After one year of follow-up, there have been no signs of recurrence.

Intraarterial CT Angiography Using Ultra Low Volume of Iodine Contrast - Own Experiences.

SummaryBackgroundHigh volume of intravenous contrast in CT-angiography may result in contrast-induced nephropathy. Intraarterial ultra-low volume of contrast medium results in its satisfactory blood concentration with potentially good image quality. The first main purpose was to assess the influence of the method on function of transplanted kidney in patients with impaired graft function. The second main purpose of the study was to evaluate the usefulness of this method for detection of gastrointestinal and head-and-neck haemorrhages.Material/MethodsBetween 2010 and 2013 intraarterial CT-angiography was performed in 56 patients, including 28 with chronic kidney disease (CKD). There were three main subgroups: 18 patients after kidney transplantation, 10 patients with gastrointestinal hemorrhage, 8 patients with head-and-neck hemorrhage. Contralateral or ipsilateral inguinal arterial approach was performed. The 4-French vascular sheaths and 4F-catheters were introduced under fluoroscopy. Intraarterial CT was performed using 64-slice scanner. The scanning protocol was as follows: slice thickness 0.625 mm, pitch 1.3, gantry rotation 0.6 sec., scanning delay 1–2 sec. The extent of the study was established on the basis of scout image. In patients with CKD 6–8 mL of Iodixanol (320 mg/mL) diluted with saline to 18–24 mL was administered at a speed of 4–5 mL/s.ResultsVasculature was properly visualized in all patients. In patients with impaired renal function creatinine/eGFR levels remained stable in all but one case. Traditional arteriography failed and CT-angiography demonstrated the site of bleeding in 3 of 10 patients with symptoms of gastrointestinal bleeding (30%). In 8 patients with head-and-neck bleeding CT-angiography did not prove beneficial when compared to traditional arteriography.Conclusions1. Ultra-low contrast intraarterial CT-angiography does not deteriorate the function of transplanted kidneys in patients with impaired graft function. 2. 3D reconstructions allow for excellent visualization of vascular anatomy of renal transplants. 3. Intraarterial CT-angiography is useful for detection of the bleeding site.

Single scrotal-incision orchidopexy for palpable undescended testis in children

ObjectiveTo evaluate the single scrotal-incision orchidopexy (SSIO) technique in patients with an undescended testis palpable in the inguinal canal or below the external inguinal ring. Patients and methodsBetween January 2011 and December 2013 we performed 100 SSIOs in 89 patients. The mean (range) follow-up was 9 (3–36) months. ResultsIn 88 testes the SSIO was performed with no difficulties. In four patients an additional dissection by opening the external ring and canal was necessary; none of these patients developed an inguinal hernia after surgery. In eight patients conversion to an inguinal approach was necessary because of difficulty in controlling the hernial sacs and inadequate mobilisation. At the follow-up assessment, of the 89 patients, none developed testicular atrophy, one (1%) had wound dehiscence and four (5%) had a scrotal haematoma. There was no statistically significant difference between the testicular size at baseline and that during the follow-up. At 3months after surgery the overall cosmetic result was excellent. ConclusionThe SSIO is minimal-access surgery allowing less dissection, less discomfort for the patient, rapid healing, excellent cosmetic results and a good success rate. This technique is safe and effective for undescended testes palpable in the inguinal canal or below the external inguinal ring.

Solitary fibrous tumor of the spermatic cord: A case report and literature review.

A 31-year-old male patient with a six-year history of left inguinoscrotal swelling was admitted to the Second Xiangya Hospital (Changsha, China). The mass was not found to be associated with intraperitoneal pressure. Ultrasonography and computed tomography examinations demonstrated several solid, botryoidal masses involving the spermatic cord, with limited capacity of mobility. The demarcation between the masses and the left testicle was clear; thus, the masses were removed by a left spermatic cord tumor resection via a left inguinal approach, under epidural anesthesia. Positive staining of the tumor markers, CD34+, CD99+ and Bcl-2+, was confirmed by pathological examination following surgery, and a solitary fibrous tumor of the spermatic cord was diagnosed. No recurrence and metastasis were observed in the patient during the subsequent 25-month follow-up period.

Management of nonpalpable incidental testicular masses: experience with 10 cases.

To determine the proportion of benign and malignant testicular lesions among patients with nonpalpable incidental testicular masses. Ten patients with nonpalpable incidental testicular masses underwent surgical exploration. Surgery was performed via an inguinal approach with temporary cord occlusion and frozen section examination (FSE) of the lesions. Benign findings allowed for testicular sparing surgery (TSS), whereas cancer prompted total orchiectomy. The lesions measured 6-19 mm in the largest diameter. Four of the 10 lesions were benign (40%) and TSS was accomplished in these cases. Complete concordance was observed between the results of FSE and permanent histopathology examination. Of the six patients with cancer, four had pure seminoma and two were mixed germ cell tumor. Surveillance was applied in four of these patients, radiotherapy was used in one patient with seminoma and retroperitoneal lymph node dissection was done in one patient with mixed germ cell tumor. With an average follow-up duration of 24 months, all patients were alive and free of disease. All four patients in whom TSS was accomplished had an uneventful postoperative course, and after an average follow-up duration of 20 months, all had normal results in scrotal physical examination and ultrasound. Malignant lesion always should be considered in nonpalpable incidental testicular masses and surgical exploration is mandatory. TSS is safe and effective in patients with small benign lesions. Cancer is reliably detected by FSE.

The influence of antisperm antibodies, intratesticular haemodynamics and the surgical approach to varicocelectomy on seminal variables

ObjectiveTo evaluate the effect of antisperm antibodies (ASAs), hormonal levels, intratesticular haemodynamics and the surgical approach on the outcomes of varicocelectomy in infertile men, as assessed by seminal variables. Patients and methodsIn a prospective case-series study, 82 infertile men with varicocele (35 left and 47 bilateral) were evaluated. The preoperative assessment included a physical examination, semen analysis, assessment of ASAs in seminal plasma, hormonal levels (follicle-stimulating hormone (FSH), luteinising hormone and testosterone), and scrotal colour Doppler ultrasonography (CDUS) to measure the peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI) and pulsatility index. Patients were scheduled for varicocelectomy, with high ligation (Palomo) used in 40 patients (18, 45%, with left and 22, 55%, with bilateral varicocele), or an inguinal approach (Ivanissivich) with loupe magnification used in 42 (17, 40%, with left and 25, 60%, with bilateral varicocele). The men were reassessed at ⩾3months after surgery and according to the improvement in seminal variables (expressed as a ⩾50% increase in total motile sperm count, TMSC), patients were further categorised into ‘improved’ or ‘unimproved’. Binary logistic regression analysis was used to investigate the predictors of improvement. ResultsBefore surgery the ASAs were positive in 17 men (21%). There was no significant difference between the right and left sides in intratesticular haemodynamics. The TMSC was improved in 52 (63%) patients who had a significant improvement in the haemodynamic variables. Intratesticular haemodynamics, serum FSH and testosterone levels differed significantly between the improved and unimproved patients. Positivity for ASAs, the surgical approach and laterality of the varicocele were not significantly different, although the ASA-positive cases were characterised by a significant decrease in motility. Logistic regression analysis showed that the EDV, PSV, FSH, testosterone level and bilateral testicular volume (BTV) were significant predictors of improvement. ConclusionPositivity for ASAs is not a predictor of the outcome after varicocelectomy but affects only the motile fraction in positive cases, despite the improvement in other seminal variables and testicular haemodynamics, and regardless of the surgical approach. The EDV, PSV, FSH, testosterone and BTV were significant predictors of a successful outcome.

Primary new-onset hydroceles presenting in late childhood and pre-adolescent patients resemble the adult type hydrocele pathology

AimThe aim of this study was to investigate the presence of a patent processus vaginalis (PPV) in children of late childhood and pre-adolescence presenting with new onset hydrocele. Material and methodsAll males with hydrocele presenting at our department from January 2011 to January 2013 were followed. Patients with secondary hydroceles were excluded. Demographic data, medical history, clinical symptoms and signs relative to their pathology and U/S findings were recorded. According to their indications, patients were either operated or followed up. Patients surgically treated, consisted our study group. ResultsSixty patients were identified. Thirteen were followed until resolution of their hydrocele. Forty-seven patients were surgically treated. Twenty-seven had right sided hydrocele (57.44%), 13 had left sided hydrocele (27.66%) whereas in 7 patients the hydroceles were bilateral (14.9%). All patients were operated by an inguinal approach. In all 9 patients (19.14%) presenting with new-onset hydrocele at the age >10years (range: 10–15years), intraoperative exploration did not reveal a PPV. All patients were followed at least for 6months post-operatively. ConclusionEarly evidence shows that primary new onset hydroceles presenting in late childhood and pre-adolescence seem to be non-communicating and resemble the adult type hydrocele pathology.

Cancer du testicule: particularités cliniques et limites thérapeutiques en milieu hospitalier urologique au Sénégal

ObjectiveTo investigate the clinical features and limitations of therapeutic management of testicular cancer in Senegal. Patients and methodsThis is a retrospective study over 15 years period between January 1997 and January 2012. Twenty-two cases were collected but only 17 had complete data for analysis. ResultsThe average annual incidence was 1.13 cases per year, with a mean age of 27±9.5 years. The most affected age group was between 21 and 40 years.Clinical diagnosis was suspected by the presence of a scrotal swelling in10 cases and by empty scrotum associated with abdominal or pelvic mass in the remaining 7 cases. Orchiectomy was the main treatment option, done either by high inguinal approach in 8 patients or by trans- peritoneal route in other 7 patients. Histologically, a predominance of embryonic non seminomatous germ cell carcinoma was noted in 10 cases including infantile type in one case. Seven cases developed disease progression:3 cases of peritoneal carcinmatosis, 3 other cases of locoregional invasion with retroperitoneal lymphadenopathy and one case of pulmonary metastasis. At a mean follow up of six months, nine patients died, four were lost to follow up while the remaining four cases were still alive. ConclusionTesticular cancer is a rare tumor in Senegal and usually involves young people. Clinical diagnosis is always done at very advanced stage with a very high mortality rate.

Prospective double-blind preoperative pain clinic screening before microsurgical denervation of the spermatic cord in patients with testicular pain syndrome

Testicular pain syndrome (TPS), defined as an intermittent or constant pain in one or both testicles for at least 3months, resulting in significant reduction of daily activities, is common. Microsurgical denervation of the spermatic cord (MDSC) has been suggested as an effective treatment option. The study population comprised 180 TPS patients admitted to our outpatient urology clinic between 1999 and 2011. On 3 different occasions, patients were offered a double-blind, placebo-controlled temporary blockade of the spermatic cord. A single blockade consisted of 10mL 2% lidocaine, 10mL 0.25% bupivacaine, or 10mL 0.9% sodium chloride. If the results of these blockades were positive, MDSC was offered. All MDSCs were performed by a single urologist (M.T.W.T.L.) using an inguinal approach. Pain reduction was determined at prospective follow-up. This study evaluated 180 patients. Most patients (61.1%) had undergone a scrotal or inguinal procedure. Patients had complaints during sexual activities (51.7%), sitting (37.5%), and/or cycling (36.7%); 189 randomized blockades were offered to all patients. There was a positive response in 37% and a negative response in 51%. MDSC was performed on 58 testicular units, including 3 patients with a negative outcome of the blockades. At mean follow-up of 42.8months, 86.2% had a ⩾50% reduction of pain and 51.7% were completely pain free. MDSC is a valuable treatment option for TPS patients because in this study 86.2% experienced a ⩾50% reduction of pain. To prevent superfluous diagnostics and treatment, it is mandatory to follow a systematic protocol in the treatment of TPS.

English

METHODS: 60 Years male patient presented with rapidly growing, firm swelling in the left inguino scrotal region. The lesion was not reducible, no cough impulse. High frequency USG of the inguinal region showed a hypo echoic soft tissue lesion with good vascularity. F.N.A cytology was reported as spindle cell neoplasm with few atypical cells. In an attempt to do open biopsy by inguinal approach, the well encapsulated swelling was found along and easily separable from cord structures, and was removed in total. HPE with immunohistochemistry confirmed it as spindle cell sarcoma. After confirming no residual tumor in the inguinal canal by C.T scan and no evidence of increased mitotic activity anywhere by whole body PET scan, the tumor board decided no further treatment, but regular follow-up on this patient.

Diagnosis of Testicular Choriocarcinoma: A Case Study

Testicular cancer, although relatively rare, is the most common malignancy in men at the age of 15 to 35 years. Germ cell tumor (GCT) is the most common testicular tumor (90%-95%) and peak age of incidence is between 20 years to 50 years. Choriocarcinoma is very rare in male as a pure testicular tumor (<1%) but may be seen as a component of mixed GCT. These tumors characteristically secrete hCG (human chorionic gonadotrophin) into the serum, which use as an important serum tumor marker for these tumors. A 30 years old male presented to us with the complaints of hard feeling of the left testis for 6 months which was initiated with mild pain but the size of the testis was unchanged. On examination there was an indurated area (2cm X 2cm) at lower part of the left testis and epididymis felt separately. He had no history crypto-orchidism, orchitis and scrotal trauma. Ultrasonogram showed a mixed echoic mass lesion (13 X 10mm) at infero-medial aspect left testis with an epididymal cyst. On laboratory investigation his ?-hCG and AFP level were 306 MIU/L(high) & 6.3 IU/L respectively. Contrast enhanced CT scan of the whole abdomen revealed no abnormality except enlarged lymph node (> 1 CM) in right lower lung. Fine needle aspiration cytology (FNAC) showed features of chronic orchitis. We explored his left testis because of high ?-hCG through inguinal approach and suspected testicular tissue was sent for frozen section biopsy which also revealed inconclusive findings. On the basis of his high ?-hCG, we performed left radical orchidectomy. Histopathology of the left testis showed features of Choriocarcinoma, epididymis and spermatic cord were normal. According to TNM classification, AJCC (American Joint Committee on Cancer) staging and international germ cell consensus prognostic classification it was T3N0MISI, stage IIIa and intermediate prognosis group respectively. Postorchidectomy ?-hCG dropped to 7.3 MIU/ML. Now he is on systemic chemotherapy BEP(bleomycin, etoposide, cisplatin). Choriocarcinoma, though is a rare malignancy, it may affect young men in the prime of life and is the most aggressive histologic variant of germ cell tumor. But it has a good prognosis if diagnosed early and treated accurately. Serum ?-hCG level plays most important role in diagnosis, in monitoring therapy and follow-up of patients with choriocarcinoma. DOI: http://dx.doi.org/10.3329/bmj.v40i2.18514 Bangladesh Medical Journal 2011 Vol.40(2): 60-62

Impact of Hemiscrotectomy on Outcome of Patients with Embryonal Paratesticular Rhabdomyosarcoma: Results from the Cooperative Soft Tissue Sarcoma Group Studies CWS-86, 91, 96 and 2002P

Children with paratesticular rhabdomyosarcoma have a favorable prognosis. Surgical treatment problems include inadequate primary transscrotal approaches, incomplete tumor resections and the need for secondary hemiscrotectomy. We evaluated the need for hemiscrotectomy regarding local relapse and outcome. A total of 173 patients with a diagnosis of paratesticular rhabdomyosarcoma were enrolled in the Cooperative Soft Tissue Sarcoma Studies between 1986 and 2008. Of the patients 17 were excluded due to an incomplete data set and alveolar histology. Thus, a total of 156 patients with embryonal subtype were analyzed. All patients were treated according to study protocols, which included multiagent chemotherapy, tumor resection and/or radiotherapy. Mean ± SD 5-year overall survival rate was 91.5% ± 2.4% for patients with embryonal rhabdomyosarcoma. A total of 28 patients underwent transscrotal approaches initially. Of these patients 12 were treated with hemiscrotectomy (mean ± SD 5-year event-free survival 91.7% ± 8%) and 16 without hemiscrotectomy (93.8% ± 6.1%). Additionally 13 of 156 patients underwent an inguinal approach with hemiscrotectomy due to suspicious tumor infiltration of the scrotal skin (mean ± SD 5-year event-free survival 84.6% ± 10%). Relapse was observed in 3 of 12 patients after transscrotal approach with hemiscrotectomy (locoregional lymph node in 1 and metastasis in 2). One metastatic relapse was observed in the group undergoing a transscrotal approach without hemiscrotectomy. One of 13 patients treated with an inguinal approach and hemiscrotectomy had locoregional relapse and died of disease. Hemiscrotectomy seems not to be mandatory in patients after transscrotal approaches regarding outcome and local relapse. Nevertheless, hemiscrotectomy probably should be performed if the scrotal skin is infiltrated.

Comparison of inguinal versus classic approach for obturator nerve block in patients undergoing transurethral resection of bladder tumors under spinal anesthesia

Background:Selective obturator nerve blockade (ONB) is an effective option to prevent adductor spasm during transurethral resection of bladder tumors (TURBT) involving the lateral wall under spinal anesthesia (SA). The classic approach is less popular as the obturator nerve is deep seated and associated with vascular injury. The inguinal approach was described as a safer alternative. This randomized clinical study was undertaken to compare the ease of block, the success rate and complications of the classic pubic and superficial inguinal approach for ONB.Materials and Methods:A total of 30 patients scheduled to undergo TURBT under SA were administered bilateral ONB. Inguinal approach recently described by Choquet was performed on one side and classic approach described by Labat was performed on the other side in random order using a nerve stimulator. The ease of block, success rate (number of attempts to accomplish the block) and complications were noted and compared between both the approaches. Chi-square analysis was performed to compare the ease of approach of the two techniques. Non-parametric analyses using Mann Whitney test was used to compare the number of attempts to accomplish the block in each approach. A value of P < 0.05 was considered statistically significant.Results:The ease of block (P = 0.09) and the median number of attempts to accomplish the block (P = 0.45) were comparable between the two approaches. The incidence of vascular injury was higher in classic approach (P = 0.056).Conclusions:Inguinal approach is a useful alternative to classic approach block for patients undergoing TURBT under SA.

The retroperitoneal, inguinal approach to distal part of the ureter.

IntroductionThe inguinal approach to the distal part of the ureter allows the surgeon to perform various types of procedures and is considered to be one of the minimally invasive techniques in pediatric surgery. We aim to describe our initial experience with the surgery of the distal ureter performed through an inguinal mini–incision.Material and methodsBetween March 2012 and June 2013, 8 patients were treated using a minimally invasive inguinal technique. The indications for surgical correction were single system primary obstructive megaureter, obstructive megaureter of the upper pole in a duplex kidney and distal ureteral stones. In all patients with single system obstructive megaureter and significant hydronephrosis, ureterocutaneostomy was performed. In one patient with duplex system primary obstructive megaureter and significant hydronephrosis of the upper pole, ureteroureterostomy of the dilated ureter to the normal caliber ureter in the distal part was performed. In the second patient with duplex system primary obstructive megaureter and reduced marker excretion of the upper pole in renal scintigraphy, ureterocutaneostomy was performed. In both cases of distal ureteral stones, deposits were removed by a simple incision.ResultsWe did not observe any perioperative or postoperative complications. The imaging studies have shown that ureteral dilatation decreased in all but one child in whom the upper pole and the ureter were resected due to lack of function.ConclusionsThe inguinal approach allows for the adequate visualization of the distal ureter, creating the conditions for implementation of the various procedures, reduces the risk of retrovesical plexus injury and minimizes visible scars.

Efficacy of spermatic vein ligation in patients affected by high grade left varicocele

To study the effect of high grade varicocele treatment in infertile patients. Seventy-five patients were selected by the following criteria: infertility persisting for more than 1 year; abnormal semen parameters; no other infertility-related disease; no obvious causes of infertility in the subject's partner; basal eco-color Doppler ultrasound demonstrating continuous reflux in the spermatic vein. All patients considered for the study had at least a six months period from the diagnosis to the surgery due to waiting list, choice of the patient or time needed to complete diagnostic evaluation of the couple. The surgical procedure was performed through an inguinal approach. All enrolled patients were counseled to have unprotected intercourse during the ovulation period in order to maximize the probability of pregnancy within the 6-month preoperative period. The achievement of pregnancy and semen parameters were recorded during the preoperative and postoperative period. Two of the seventy-five patients were excluded because of persistent varicocele after surgery. The preoperative pregnancy rate was 1.3% (1 couple). The postoperative pregnancy rate was 42.5%. The stratification of pregnancies by semester showed a significantly higher rate in the first postoperative period (p = 0.0012). Mean time to conception was 13.5 months. Mean preoperative sperm count was 17.6x10(6)/mL compared to 19.7x10(6)/mL in the postoperative period (p < 0.0001). Mean percentage of progressive sperm motility was 13.7%, compared to 17.6% in the postoperative period (p < 0.0001). Mean percentage of normal sperm morphology was 7.6%, compared to 15.2% postoperatively (p < 0.0001). Surgical treatment of high grade varicocele proved to effectively treat associa¬ted infertility by improving seminal parameters and pregnancy rate in our patient cohort.

Two Cases of Metachronous Bilateral Obturator Hernia Repaired with an Ultrasonic Probe Followed by Elective Surgery via the Inguinal Approach

Two Cases of Metachronous Bilateral Obturator Hernia Repaired with an Ultrasonic Probe Followed by Elective Surgery via the Inguinal Approach

Gonadal germ cell tumors in children and adolescents.

Pediatric germ cell tumors (GCT) are rare tumors: 80% are benign, 20% malignant (2-3% of all malignant pediatric tumors). The gonadal sites (ovary and testis) account for 40% of cases.Ovarian GCTs:Represent 30% of GCTs and 70% of neoplastic ovarian masses, being the most common ovarian neoplasms in children and teenagers. Benign and immature forms (teratomas) constitute about 80% of all ovarian GCTs, malignant forms represent 20% increasing during adolescence. The most common malignant entity in children is the yolk sac tumors (YST); dysgerminoma is frequent during adolescence and being bilateral in 10% of cases. Presentation is similar in malignant and benign lesions; abdominal pain (70-80%) and lower abdominal mass are common symptoms. Evaluation of alpha-fetoprotein (αFP) or beta subunit of human chorionic gonadotropin (βHCG) is essential to address the nature of the tumors: Their elevation means presence of malignancy. Surgery includes intraoperative staging procedures and requires ovariectomy or ovarosalpingectomy for malignant lesions, but may be conservative in selected benign tumors. Since malignant GCTs are very chemosensitive, primary chemotherapy is recommended in metastatic or locally advanced tumors.Testicular GCT:Represent 10% of pediatric GCT, and about 30% of malignant GCT with two age peaks: Children <3 years may experience mature teratoma and malignant GCTs, represented almost exclusively by YST, while adolescents may also show seminomas or other mixed tumors. The main clinical feature is a painless scrotal mass. Surgery represents the cornerstone of the management of testicular GCTs, with an inguinal approach and a primary high orchidectomy for malignant tumors, while a testis-sparing surgery can be considered for benign lesions. A retroperitoneal lymph node (LN) biopsy may be necessary to define the staging when the involvement of retroperitoneal LN is uncertain at imaging investigations.Conclusion:Patients with gonadal malignant GCTs fare better than those with extragonadal mediastinal germ cell tumors (MGCTs) and survival rate exceeds 90% in localized forms. Chemotherapy has significantly improved the outcome of malignant forms since the introduction of platinum based regimens. The surgical procedure has to be performed in agreement with the ongoing protocols.