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Background: The varicocele is the most commonly diagnosed pre-pubertal andrological condition with an incidence of 10%–15% between adolescents. The aim of this study was to evaluate the efficacy of retroperitoneoscopic varicocelectomy (RV) in two Italian centres with particular attention to post-operative testicular volume and semen analysis after 18 years of life. Materials and Methods: From 1999 to 2010, 286 adolescents underwent retroperitoneoscopic left varicocelectomy. Of these patients, 67 were evaluated by clinical examination, ultrasound and semen analysis, allowing an adequate long-term follow-up. Results: Surgery was performed at a mean age of 13 years (range 10–17) without intraoperative complications. There were two recurrences (3%), two left testis hypotrophy (3%) and four hydroceles (6%), not yet undergone surgery because asymptomatic or without tension. Currently, 44 patients accepted to perform semen analysis which showed a reduction in sperm motility in 12 cases, with associated morphological alterations in 3 and reducing number of spermatozoa in one case. Conclusions: In consideration of morphological and biomolecular spermatic alterations reported in adolescent varicocele that could interfere with cellular migration, differentiation and nutrition, it is fundamental to consider the correction of varicocele, not only for the classical indications, but also as a choice for arresting the progressive damage that inevitably acts for several years on the adolescent testis. The RV in adolescents is a safe and feasible procedure for experienced paediatric laparoscopic surgeons with early good clinical outcomes, but more studies occur to understand the real impact of adolescent varicocelectomy on testicular function.

La diagnosi del morbo di Hirschsprung (MH) si esegue con esami per immagini (clisma opaco), tests funzionali come la Manometria Ano-Rettale (MAR) e studi immunoistochimici su biopsie rettali per suzione (BRS). L’approccio diagnostico più appropriato è ancora discusso dato che tutti i tests producono falsi positivi e falsi negativi ed ognuno presenta vantaggi e svantaggi. Lo scopo di questo lavoro è quello di valutare l’efficacia di un approccio diagnostico differenziato in base all’età per i pazienti con sospetto di MH. Materiali e Metodi: da Gennaio 2005 a Giugno 2007 sono stati esaminati tutti i pazienti giunti all’osservazione chirurgica per sospetto di MH. I pazienti sono stati divisi in due gruppi: A (età inferiore ad 1 anno) e B (età superiore ad 1 anno). I pazienti del gruppo A sono stati sottoposti a BRS e clisma opaco (CO), mentre quelli del gruppo B sono stati sottoposti a MAR per lo studio del tono dello sfintere anale interno e per la ricerca del Riflesso Inibitore Retto-Anale (RIRA), poi in base all’esito della MAR sono stati divisi in 5 sottogruppi ed hanno ricevuto un iter diagnostico-terapeutico diverso: B1, tono normale e RIRA presente (pulizia intestinale con soluzione a base di polietilenglicole (PEG) ad alto peso molecolare poi lassativi orali e clisteri settimanali per 2 mesi); B2, ipertono dello sfintere anale interno e RIRA presente (anestetico locale per 8 settimane associato al lassativo orale e clisteri settimanali per 2 mesi); B3, pazienti non collaboranti (sottoposti a BRS); B4, RIRA assente/dubbio (sottoposti a BRS e CO); B5, RIRA presente, ma scarsi risultati dopo terapia medica al follow up di 6 mesi (sottoposti a BRS e CO). I pazienti con BRS positive (aumentata attività dell’Acetilcolinesterasi associata ad assenza dei gangli) sono stati sottoposti ad intervento chirurgico di Pull-Through ano-rettale per via laparoscopica sec. Georgeson. Tutti i pazienti hanno seguito un follow up a 2 mesi (positivo se evacuazioni settimanali > 5 in corso di trattamento), poi a 6 mesi (positivo se evacuazioni settimanali > 3, senza trattamento). Risultati: I pazienti arruolati per questo studio sono stati 100 (55 maschi, 45 femmine), di cui 14 (età media 2 mesi) sono stati inseriti nel gruppo A, gli altri 86 (età media 6 anni) nel gruppo B. Il CO nei pazienti del gruppo A ha mostrato dilatazione del colon con cono di transizione in due casi, mentre le biopsie rettali per suzione hanno evidenziato assenza di cellule gangliari ed aumento delle fibre colinergiche nel 50% dei pazienti. Nel gruppo B1 sono stati inclusi 40 pazienti, 24 nel gruppo B2, i non collaboranti sono stati 4, mentre 18 sono stati inclusi nel gruppo B4 ed uno solo nel B5. Nel gruppo B sono stati eseguiti 19 CO (gruppi B4 e B5) e BRS in 23 pazienti (gruppi B3, B4 e B5). Al CO sono stati evidenziati dolicolon e megaretto nel 89% dei casi, mentre le BRS hanno evidenziato assenza di gangli ed aumento delle fibre colinergiche in 3 bambini (13%). L’intervento chirurgico è stato eseguito in 6 bambini del gruppo A e 2 del gruppo B, gli altri sono stati trattati altrove. Conclusioni: La MAR è un esame semplice e poco invasivo per studiare il meccanismo della defecazione nei bambini di età superiore ad un anno. L’approccio diagnostico differenziato in base all’età permette di selezionare i casi da sottoporre alle BRS e CO, esami invasivi che possono presentare complicanze. L’esecuzione delle BRS in casi selezionati permette di avere alti valori di positività (50% e 13%) evitando di estendere la procedura a tutti i pazienti con sospetto di MH.

Children with complex medical issues often present different comorbidities that cause feeding difficulties. Gastrostomy is often helpful, and should be performed when nutritional supplementation is necessary for longer than 6 weeks. Recently, different techniques have been used for gastrostomy in children. The authors report on their experiences regarding the diagnostic and therapeutic management of children requiring gastrostomy. All patients managed in the last 10 years were reviewed, retrospectively. Everyone underwent investigation to exclude gastroesophageal reflux disease (GERD). A total of 148 patients: 111 cases (75%) were neurologically impaired patients, 18 (12%) had complex heart disease, 10 (6%) had metabolic diseases, 4 (3%) had fibrosis cystic, 4 (3%) had muscle disease, and one had chromosomopathy. After investigation, 49 patients had GERD. PEG was performed in 101 cases (68%), laparo-assisted gastrostomy was performed in 44 cases (29.7%), open gastrostomy was performed in three cases. At follow-up, all patients reported weight gain, but 13 cases had major complications. Currently, the surgeon has the possibility of choosing between several safe techniques for gastrostomy. In our experience, PEG is the most useful technique for patients without GERD, while a laparo-assisted technique is better for patients who require laparoscopic fundoplication.

Infant dyschezia is a functional gastrointestinal disorder that occurs in children less than nine months of age. This disorder causes much anxiety among parents who consult different physicians when suspecting major intestinal problems. The aim of this study is to verify whether infant dyschezia involves an anatomic abnormality (redundancy) of the colon. In this retrospective study (48 months) we analyzed all the children younger than 9 months who came to our attention through the suspicion of gastrointestinal abnormality (Hirschsprung’s disease, anorectal malformations, colonic disorders or constipation). They all had a complete medical history, clinical examination and diagnostic tests, such as blood samples, suction rectal biopsy, a study of stool characteristics and, finally, a contrast enema. In cases with infant dyschezia, different colonic sizes and rectosigmoid length were measured, which created a ratio with the diameter of the second lumbar vertebra. These values were compared with those reported in the literature as normal for the age of one year. Of the 24 patients evaluated (mean age 4 months), 9 were excluded for different diagnoses (aganglionic megacolon, hypothyroidism, constipation). The comparison of the ratios obtained in the remaining 15 cases showed a significantly higher rectosigmoid length (redundancy) in children with dyschezia, 18.47 vs. 9.75 (p < 0.001). The rectosigmoid redundancy, a congenital anomaly already reported as a cause of refractory constipation, may be present in children with infant dyschezia.

Since laparoscopy has been proposed in the management of the nonpalpable testis (NPT), this technique has been widely diffused among pediatric surgeons and urologists, but its application is still debated. We conducted a retrospective review to highlight how diagnostic and surgical indications for laparoscopy are selective and should be targeted to individual patients. From 2015 to 2019, 135 patients with NPT were admitted to our surgical division. Of these, 35 were palpable on clinical examination under anesthesia and 95 underwent laparoscopy. The main laparoscopic findings considered were: intra-abdominal testis (IAT), cord structures that are blind-ending, completely absent, or entering the abdominal ring. The patients’ mean age was 22 months. In 48 cases, an IAT was found, and 42 of these underwent primary orchidopexy while 6 had the Fowler–Stephens (FS) laparoscopic procedure. Of the first group one patient experienced a testicular atrophy while two a reascent of the testis. In the FS orchidopexy group, one patient had testicular atrophy. Cord structures entering the internal inguinal ring were observed in 35 children, and all were surgically open explored. In 3 cases of these, a hypotrophic testis was revealed and an open orchidopexy was executed. In the remaining the histological examination revealed viable testicular cells in four patients and fibrosis, calcifications, and hemosiderin deposits in the others. Eleven patients presented with intrabdominal blind-ending vessels and one a testicular agenesia. A careful clinical examination is important to select patients to submit to laparoscopy. Diagnostic laparoscopy, and therefore, the anatomical observation of the testis and cord structures are strictly related to develop a treatment plan. In IAT, many surgical strategies can be applied with good results. Laparoscopy offers a concrete benefit to the patient.

Nutrition in pediatric age, if properly adapted to the various developmental phases, can be considered the first prevention tool for the most common pathologies of this age [...]

COVID-19 may cause intussusception in infants. We report on a case of severe ileo-colic intussusception in an infant with COVID-19 who required an ileo-colic resection. A literature review revealed 9 other cases with COVID-19 and intussusception. In this article, we will discuss the management and treatment of the first reported case of intussusception associated with COVID-19 in Italy.

Isolated tubal torsion (ITT) is a rare cause of acute abdominal pain. Preoperative diagnosis is difficult because of a lack of specific signs. Surgery is recommended to preserve the integrity of the tube. Seven patients of median age of 13 years (range 9 to 15) came to our observation for worsening abdominal pain, nausea and vomiting. On admission, all girls had blood tests and ultrasound. Laparoscopy was performed for diagnosis in all cases. The girls had one-month and one-year ultrasound and clinic follow up. In all cases diagnosis was delayed, median 66 hours after the onset of symptoms and laparoscopy showed necrosis of the Fallopian tube. In five girls a laparoscopic salpingectomy was performed. In the other two, an open salpingectomy was necessary because of pelvic adhesions. Histology showed a hemorrhagic infarction of the Fallopian tubes. At follow up all patients were asymptomatic with normal ovaries, but one ovarian cyst. In the differential diagnosis of acute abdominal pain in children or female adolescents the possibility of ITT should be considered for a conservative treatment. Laparoscopy allows for definitive diagnosis and treatment. Isolated tubal torsion (ITT) is a rare cause of acute abdominal pain. Preoperative diagnosis is difficult because of a lack of specific signs. Surgery is recommended to preserve the integrity of the tube. Seven patients of median age of 13 years (range 9 to 15) came to our observation for worsening abdominal pain, nausea and vomiting. On admission, all girls had blood tests and ultrasound. Laparoscopy was performed for diagnosis in all cases. The girls had one-month and one-year ultrasound and clinic follow up. In all cases diagnosis was delayed, median 66 hours after the onset of symptoms and laparoscopy showed necrosis of the Fallopian tube. In five girls a laparoscopic salpingectomy was performed. In the other two, an open salpingectomy was necessary because of pelvic adhesions. Histology showed a hemorrhagic infarction of the Fallopian tubes. At follow up all patients were asymptomatic with normal ovaries, but one ovarian cyst. In the differential diagnosis of acute abdominal pain in children or female adolescents the possibility of ITT should be considered for a conservative treatment. Laparoscopy allows for definitive diagnosis and treatment.

Background: Pediatric cholelithiasis unrelated to hematological disorders is an increasing disease. We analyzed our experience in the surgical treatment of these cases to evaluate risk factors, clinical presentation, intervention and follow-up. Methods: From January 2010 to December 2016, we retrospectively recorded all data (hematological study, familiarity, use of lithogenic drugs and parenteral nutrition) of cholecystectomies for cholelithiasis not related to hematological diseases. The body mass index (BMI) was calculated (obesity if > 25), medical treatment, surgery and follow-up were evaluated. All patients underwent ultrasound for diagnosis and major biliary tract assessment prior to surgery. All patients had a 1-year follow-up. Results: There were twenty-four cases (eight males), with a median age of 11.2 years. Predisposing factors were familiarity in 19, use of lithogenic drugs in 5 and total parental nutrition (TPN) in 3. Median BMI was 19.8 kg/m2, with BMI > 25 kg/m2 in eight cases. Regarding the clinical presentation, 14 had acute pain in the right upper quadrant, 5 had cholecystitis and 5 had non-specific abdominal pain. The medical treatment lasted 6 months in all, except for five (three operated after 2 months and two after 12 months). Preoperative ultrasound did not show stones in the biliary tract. MRI was performed in three cases for suspected malformation of the biliary tract (negative). Laparoscopic cholecystectomy was performed in all cases: mean intervention time was 95 min. A case of postcolecystectomy syndrome was found. At follow-up, all were asymptomatic, except two (recurrent abdominal pain). Conclusion: Main predisposing factors are familiarity and obesity. Preoperative ultrasound in our series replaced the intraoperative study of the biliary tract. Laparoscopic cholecystectomy is the gold standard.

We retrospectively reviewed the results of transscrotal orchidopexy in the surgical management of palpable testis. From January 2014 to June 2017, 130 male children with a total of 140 palpable undescended testes (UDT) underwent transscrotal orchidopexy. The charts were retrospectively reviewed for demographic data, preoperative position and mobility of the testis, patency of the peritoneal vaginal duct (PVD), and post-operative complications. The resting position of the testis and its traction towards the scrotum were assessed before surgery and under anaesthesia. The mean age of the patients was 4.6 years. The position of the testis assessed at surgery was in most cases at the external inguinal ring (62.8%), at the neck of the scrotum (15.7%), in the inguinal canal (12.8%), or in an ectopic position (8,5%). A PVD was found in 66 testes (47.1%). Two surgical cases required an inguinal incision. In each patient, the postoperative course was unremarkable. The testicle at 1-year follow-up was in a scrotal position in 134 cases, but 6 patients required a second surgical intervention for re-ascent of the testis. No testicular atrophy or inguinal hernias were observed. Transscrotal orchidopexy is a simple and effective procedure for the treatment of palpable UDT. The incidence of complications is low and manageable, with rapid postoperative recovery and early resumption of normal activities.

Introduction: Human chorionic gonadotropin (hCG) has an important role in the regulation of reproduc- tive system and a high capacity to stimulate angio- genesis by secretion of vascular endothelial growth factor (VEGF). It could be also used for medical treatment of cryptorchidism, as it stimulates Leydig cells to produce testosterone, but its use has been discussed. Aim of the study was to evaluate the tes- ticular morphological changes due to cyclic admini- stration of hCG possibly related to VEGF effect. Methods: 80 pre-puberal male Sprague-Dawley rats were randomly divided in two groups hCG (50 U/I/ Kg) (n = 55/S) and placebo (n = 25/C) treated. The animals were sacrificed respectively after one (S1 n = 10; C1 n = 5), two (S2 n = 10; C2 n = 5) and three weeks of hCG or placebo treatment (S3 n = 35; C3 n = 15); a blood serum was obtained for evaluation of plasmatic testosterone. The testis, prostates, epidi- dymides and seminal vesicles were drawn and weight- ed. Specimens were fixed in formalin and coloured by hematoxylin-eosin. Morphometric analysis of Leydig cell number, nuclear area and perimeter was carried out. Immunoistochemistry for VEGF has been per- formed with the avidin-biotin peroxidase technique. Statistical differences between groups, each of differ- ent age, were calculating using Student’s T-test. Re- sults: After the first week of hCG treatment it has been observed an increased testicular weight and volume (+/−6%) in experimental respect to control group. This result was not observed after the second and third week of treatment. Significant variations were also observed in the mean prostate weight, whereas mean seminal vesicles weight was significant in the S2 and S3 groups respect to control. In the hCG treated rats it has been observed a poor differ- entiation of the seminiferous epithelium, with high Leydig cell evidence and increased intertubular eosi- nophilic material. An interstitial edema was demon- strated without inflammatory cell changes. Morpho- metric analysis confirmed an increased number of Leydig cells that were always strongly immunostained for VEGF. Low-medium reactivity was present in spermatogonial, peritubular, endothelial and Sertoli cells. Testosterone plasmatic values showed a statisti- cally significant and progressive increase. Conclu- sions: hCG treatment clutters the germinative line and modifies VEGF testicular expression, suggesting its role in male reproductive system. The increased number of Leydig cells and the immunostaining for VEGF suggests an intense interstitial and metabolic arrangement. The morphologic modifications induced by hCG treatment and its influence on testis function raise the question about its use in the medical treat- ment of cryptorchidism.

An electrophoretically homogeneous preparation of endo-polygalacturonase (poly(1,4-α- d -galacturonide)glycanohydrolase, EC 3.2.1.15) from culture filtrates of Rhizoctonia fragariae, a pathogenic agent in strawberry plants, was resolved into two isoenzymes when subjected to isoelectrofocusing in a narrow pH range. The isoelectric points of the two isoenzymes were 6.76 ± 0.03 and 7.08 ± 0.05 . The two polygalacturonases exhibited similar substrate specificity, pH optimum and pattern of degradation of sodium polypectate. The two enzymes consisted of a sigle polypeptide chain which had an apparent molecular weight of 36 000 as determined by gel filtration on Sephadex G-100.