ESPU Meeting on Wednesday 19, April 2023, 16:35 - 17:15
16:35 - 16:38
S04-1 (OP)
Ciro ESPOSITO, Fulvia DEL CONTE, Roberto CARDONE, Roberto CARULLI, Benedetta LEPORE, Claudia DI MENTO, Annalisa CHIODI and Maria ESCOLINO
Federico II University Hospital, Pediatric surgery, Naples, ITALY
PURPOSE
Laparoscopic Palomo varicocelectomy using indocyanine green (ICG) fluorescent lymphography (FL) is a standardized procedure with low post-operative recurrence and hydrocele. Concerns remain regarding the safety of intra-testicular injection of the dye. This study aimed to assess the long-term outcomes of this innovative technique in terms of safety and efficacy.
MATERIAL AND METHODS
Forty-eight consecutive patients (mean age 14.8 years) undergoing laparoscopic Palomo varicocelectomy using ICG-FL over a 24-month period, were enrolled. Operative indication was high-grade varicocele in all patients and testicular hypotrophy in 21/48 (43.7%). Follow-up included clinical examination and testicular doppler ultrasound (US) at 1, 6, 12 months postoperatively, aiming to assess the varicocele persistence, onset of hydrocele and complications related to the intra-testicular injection.
RESULTS
ICG-FL allowed lymphatic sparing in all cases. No intra-operative complications neither systemic adverse reactions induced by ICG occurred. The median follow-up was 18.6 months (range 13-24). Self-limited scrotal hematoma following the intra-testicular injection occurred in one patient (2%). An intra-parenchymal millimetric hypoechogenic area at the injection site was observed on US in 2 (4%) patients and remained unmodified on subsequent follow-up. Persistent low-grade varicocele was noted in 2 (4%) patients, who did not require any re-intervention. No post-operative hydrocele occurred and 14/21 (66.6%) patients with hypotrophy reported significant testicular volume catch-up.
CONCLUSIONS
Laparoscopic Palomo varicocelectomy using ICG-FL was safe and effective, with low varicocele persistence/recurrence rate and no post-operative hydrocele. The ICG intra-testicular injection was equally safe, with no reported injuries for the testis and no adverse reactions for the patient.
16:38 - 16:41
S04-2 (OP)
Carlotta PLESSI 1, Nino GUARINO 2, Gabriele VASTA 1, Vito BRIGANTI 2 and Guido FIOCCA 2
1) Pediatric Surgery Unit, University of Siena, Department of Medical, Surgical and Neurological Sciences, Siena, ITALY - 2) Pediatric Surgery Unit, San Camillo Forlanini Hospital, Department of Women's and Children's Health, Roma, ITALY
PURPOSE
To describe our experience with antegrade sclerotherapy for the treatment of varicocele in children and adolescents and to evaluate the results of this technique in different pubertal stages.
MATERIAL AND METHODS
We retrospectively reviewed the clinical records of patients that underwent antegrade sclerotherapy in our center between 2005 and 2019, to have a follow up of at least 2 years. We divided our population into groups based on pubertal stage according to Tanner's classification. Pre-operative, intra-operative and post-operative data were collected. Finally, we assessed the association between Tanner's stage at surgery and outcomes.
RESULTS
During the study period, 828 patients underwent antegrade sclerotherapy at our clinic. Mean patient age was 14.2 years. 151 cases (18%) were Tanner I, 122 (15%) were Tanner II, 255 (31%) were Tanner III, 105 (13%) were Tanner IV, 195 (24%) were Tanner V. 677 (82%) underwent the procedure under local anesthesia or mild sedation. Mean operating time was 26 minutes. In the population with a follow-up until Tanner stage V (corresponding to 58%), the success rate was 97%. Data analyses revealed that there were no statistically significant differences among different Tanner's pubertal stages in terms of operative time (p=0.41) and outcome at 1 month (p=0.83), 6 month (p = 0.64) and at Tanner pubertal stage V (p=0.53).
CONCLUSIONS
Tauber's antegrade sclerotherapy is a reliable technique in the treatment of pediatric and adolescent varicocele, regardless of patients' pubertal stage. Its advantages include the possibility of avoiding general anesthesia, low complication rates and high success rates.
16:41 - 16:44
S04-3 (OP)
Vincenzo DOMENICHELLI 1, Stefania GURGONE 2 and Ennio FOPPIANI 3
1) AUSL della Romagna, Surgery - Pediatric Surgery Unit, Rimini, ITALY - 2) AUSL della Romagna, Surgery - Anesthesia and Intensive Care Unit, Rimini, ITALY - 3) Psychiatrist out patients, Private clinic, Torino, ITALY
PURPOSE
This study compares the patient prospective after undergoing antegrade percutaneous embolization of the testicular veins (APETV) under local anesthesia or under hypnosis.
MATERIAL AND METHODS
Eighteen patients age 12-17 years with symptomatic grade 2-3 left sided varicocele underwent APETV either with brachial or femoral access. They were prospectively randomized in two groups: A) procedure performed under local anesthetic, B) procedure performed under hypnosis without local anesthetic. The following outcomes were measured: length and subjective perceived length of the procedure, perceived pain in a scale between 0 and 10, perceived anxiety in a scale between 0 and 10. T student test was used to compare group A and group B. Data are presented as median (IQR) and a power <0.05 was considered significant.
RESULTS
Eight patients underwent the procedure under local anesthesia and 10 under hypnosis. Two of the patients in group B (20%) required local anesthesia. Length of the procedure was 30.0 minutes in group A and 36.50 minutes in group B (p=0.003); subjective perceived length of the procedure was 22.50 minutes in group A and 15.00 minutes in group B (p=0.134), perceived pain was 4.50 in group A and 4.50 in group B (p=0.785); perceived anxiety was 4 in group A and 2 in group B (p=0.044).
CONCLUSIONS
APETV under hypnosis in paediatric age is feasible in 80% of the patients. It effectively reduces the patient anxiety. The length of procedure was related to operators more than patients. Hypnosis and local anesthetic have the same efficacy on pain
16:55 - 16:58
S04-4 (OP)
Carlos DELGADO MIGUEL 1, Virginia AMESTY 2, Susana RIVAS 2, Roberto LOBATO 2, María José MARTINEZ-URRUTIA 2 and Pedro LÓPEZ-PEREIRA 2
1) La Paz Children's Hospital, Paediatric Surgery, Madrid, SPAIN - 2) La Paz Children's Hospital, Pediatric Urology, Madrid, SPAIN
PURPOSE
Doppler ultrasound constitutes the gold standard for the diagnosis of testicular torsion (TT), although sometimes the spermatic cord twisting and absence of testicular flow are difficult to visualize. To date, no laboratory markers have been shown to be useful for preoperative TT diagnosis. The aim of this sdudy is to analyze the role of the neutrophil-to-lymphocyte ratio (NLR) as a predictor of pediatric TT.
MATERIAL AND METHODS
A retrospective single-center case-control study was performed in patients with ultrasound suspicion of TT, in whom surgical testicular examination was performed between 2016-2020. Patients were divided into two groups according to the intraoperative findings: TT group (testicular torsion), defined as spermatic cord twisting on itself around its longitudinal axis at least 360º, and non-TT group (no torsion). Demographics, clinical, ultrasound and laboratory features at admission were analyzed. Sensitivity and specificity were determined by the area under the curve (AUC) represented on the receiver operating characteristic (ROC) curves.
RESULTS
A total of 159 patients were included (117 TT group; 42 non-TT group), with no demographic or clinical differences. TT group patients presented significantly shorter median time since symptoms onset (4 vs. 8 hours; p<0.012). Laboratory inflammatory test were significantly higher in TT group: Leukocytes (10,900x103/µl vs. 7,980x103/µl; p<0.001), neutrophils (8,050x103/µl vs. 3,350x103/µl; p<0.001) and NLR (4.6 vs. 1.1; p<0.001). In ROC curve analysis, NLR presented the highest AUC (0.903), significantly higher than all other laboratory and ultrasound parameters. NLR of 2.3 was the cut-off point with maximum sensitivity (86.9%) and specificity (94.8%).
CONCLUSIONS
This is the first study to analyze the usefulness of NLR in predicting the diagnosis of TT in patients with clinical and ultrasound suspicion. NLR should be considered as a predictor of pediatric TT in cases with nuclear ultrasound suspicion that may help to anticipate the urgent surgical treatment in these patients.
16:58 - 17:01
S04-5 (OP)
Amanda RAINES, Nicolas FERNANDEZ, Jennifer AHN, Mark CAIN, Byron JOYNER, Kathleen KIERAN, Paul MERGUERIAN and Margarett SHNORHAVORIAN
Seattle Children's Hospital, Urology, Seattle, USA
PURPOSE
Currently viability in testicular torsion is determined by surgeon’s subjective assessment. Objective perfusion assessment tools are lacking.
Indocyanine green (ICG) is a fluorescent dye widely used to evaluate tissue perfusion. Use in testicular torsion is limited with no series or protocols published.
We aimed to develop and implement a standardized protocol using ICG in testicular torsion.
MATERIAL AND METHODS
This was a single institution pilot study on ICG use in testicular torsion using Stryker SPY PHI system and novel quantification software, SPY-QP. A standardized protocol for use of ICG in testicular torsion was developed in an adaptive process.
ICG is dosed prior to testicular detorsion and after delivery of the contralateral testicle. ICG uptake is quantified using SPY-QP and images of ICG uptake are obtained prior to detorsion, immediately after detorsion, and before and after the second dose of ICG.
RESULTS
ICG was used in seventeen cases of testicular torsion with twelve orchiopexies and four orchiectomies.
Of those removed, we noted no to very low ICG uptake with SPY-QP measurements of 0-7% when compared to a median ICG uptake in the orchiopexy group of 74.5% (p= 0.003) (Table 1). The pathology of all four showed necrosis.
At early post operative follow up there was no evidence of atrophy in those undergoing orchiopexy.
Table 1
|
Characteristic |
Orchiopexy |
Orchiectomy |
P value |
|
Median time from symptom onset to presentation (Hrs) |
7 (IQR: 5-9) |
35.75 (IQR: 22-26) |
0.02* |
|
Median degree of torsion |
360 (IQR: 157-675) |
540 (IQR: 360-720) |
0.28 |
|
Median maximum ICG uptake immediately after detorsion (%) |
53.5% (IQR: 51-63) |
0% (IQR: 0) |
n/a |
|
Median maximum ICG uptake after delivery of contralateral testicle (%) |
74.5% (IQR: 58-105) |
2% (IQR: 1-4.5) |
0.003* |
CONCLUSIONS
A standardized protocol for ICG use in testicular torsion was successfully developed and implemented. Early results indicate our protocol provides objective and quantitative assessment of testicular perfusion.
17:01 - 17:04
S04-6 (OP)
Inês BRAGA, Catarina BARROSO, Sofia MARTINHO, Jorge CORREIA-PINTO and Rúben LAMAS-PINHEIRO
Hospital de Braga, Portugal, Pediatric Surgery department, Braga, PORTUGAL
PURPOSE
The standard procedure in case of unsalvageable testis after testicular torsion (TT) is orchiectomy and, if the patient desires to place a testicular prosthesis, this step is commonly deferred. Orchiectomy and simultaneous intravaginal testicular prosthesis placement (sTPT) has already been described. Since 2018, our department has implemented the sTPT using a single median raphe incision; it is our aim to assess the feasibility, effectiveness and safety by comparing the outcomes of simultaneous and deferred testicular prosthesis placement (dTPT).
MATERIAL AND METHODS
The files of patients submitted to emergent scrotal exploration due to TT, between 2011 and 2022, were retrospectively analyzed and those with unsalvageable testis submitted to orchiectomy and testicular prosthesis placement were included in this study. The patients were divided in two groups: sTPT group and the dTPT group.
RESULTS
In total, 177 were submitted to emergent scrotal exploration and 32 patients fulfilled the inclusion criteria: 13 in sTPT group and 19 in dTPT group. The groups were identical for: age, clinical presentation and diagnosis. Statistically significant differences were found in operative time (sTPT: 51.9±17.1; dTPT: 36.9±18.0 minutes, p=0.028) and duration of follow-up (sTPT: 29.9±15.1; dTPT: 75.2±27.0 months; p<0.001). No major complications were reported in both groups, namely infection or prosthetic device rejection. In group dTPT, 4 patients presented high testicular implant positioning, both submitted to inguinal placement approach (p=0.139).
CONCLUSIONS
The sTPT is feasible and easily implemented in the department's practice. While sparing the patient from a second procedure, the sTPT demonstrated to be as safe and effective as dTPT. Although larger studies are needed, the scrotal approach might result in a better prosthesis' positioning.