UNASSIGNED: The ideal surgical approach for the management of varicocele in children and adolescents remains controversial. Several techniques are available including artery- or lymphatic-sparing with optical magnification (via open inguinal or sub-inguinal approach), laparoscopic, antegrade and retrograde embolization/sclerotherapy.
UNASSIGNED: We aimed to appraise the clinical outcomes of these techniques in children and adolescents.
UNASSIGNED: A systematic review was conducted (1997-2023). Meta-analysis or proportional meta-analysis for non-comparative studies (Freeman-Tukey transformation) using the random effects model was conducted. Results are expressed as overall proportion % and 95% confidence interval (CI).
UNASSIGNED: We identified 1910 studies; 632 duplicates were removed, 1278 were screened, 203 were reviewed and 56 were included, with 12 reporting on 2 different techniques (total of 68 data sets). Optical magnification via inguinal approach (498 cases): recurrence 2.5% (0.6-5.6), hydrocele 1.6% (0.47-3.4), testicular atrophy 1% (0.3-2.0), complications 1.1% (0.2-2.6); optical magnification via sub-inguinal approach (592 cases): recurrence 2.1% (0.7-4.4), hydrocele 1.26% (0.5-2.3), testicular atrophy 0.5% (0.1-1.3), complications 4% (1.0-8.8). Laparoscopic with mass-ligation/division (1943 cases): recurrence 2.9% (1.5-4.6), hydrocele 11.4% (8.3-14.9); complications 1.5% (0.6-2.9); laparoscopic with lymphatic-sparing (974 cases): recurrence 2.4% (1.5-3.5), hydrocele 1.2% (0.45-3.36), complications 1.2% (0.05-3.9); laparoscopic with artery-sparing (228 cases): recurrence 6.6% (2.3-12.9), hydrocele 6.5% (2.6-12.0). Antegrade embolization/sclerotherapy (403 cases): recurrence 7.6% (5.2-10.4), hydrocele 0.8% (0.17-1.9), technical failure 0.6% (0.1-1.6), complications 4.0% (2.3-6.1); retrograde embolization/sclerotherapy (509 cases): recurrence 6.9% (4.6-9.5), hydrocele 0.8% (0.05-2.5), technical failure 10.2% (4.6-17.6), and complications 4.8% (1.0-11.2).
UNASSIGNED: The recurrence rate varies between 2.1% and 7.6% and is higher with the embolization/sclerotherapy techniques. Post-operative hydrocele rate varies between 0.8% and 11.4% and is higher with the laparoscopic mass-ligation/division technique. Testicular atrophy has not been reported with the laparoscopic and embolization/sclerotherapy techniques. The retrograde embolization technique is associated with 10% technical failure (inability to complete the procedure). The laparoscopic lymphatic-sparing technique is characterized by the lowest recurrence rate, incidence of hydrocele and other complications, and no reports of testicular atrophy.

OBJECTIVE: Vasovasostomy is a cost-effective procedure for the reversal of vasectomy. A water-tight adequately blood-supplied mucosal anastomosis is required for better outcomes. This review aimed to compare the outcome of vasovasostomy performed by three different techniques: macroscopic, pure microsurgical, and robot-assisted microsurgical techniques.
METHODS: Scopus, Web of Science, PubMed, Embase, and Cochrane library databases were searched for relevant studies from January 1901 to June 2023. We conducted our quantitative syntheses using the inverse variance method in OpenMeta software. The study\'s protocol was registered on PROSPERO.
RESULTS: This review involved 95 studies of different designs, with a total sample size of 48,132. The majority of operations were performed bilaterally, and participants were monitored for up to 10 years. The pooled patency rate was the highest following robot-assisted vasovasostomy (94.4%), followed by pure microsurgical vasovasostomy (87.5%), and macroscopic vasovasostomy (83.7%). The pooled pregnancy rate following purely microsurgical vasovasostomy was higher than that of macroscopic vasovasostomy (47.4 vs. 43.7%). Definitive pregnancy rates in robotic vasovasostomy are yet to be determined.
CONCLUSIONS: Patency outcomes for vasovasostomy were best with robot-assisted microsurgical technique, followed by pure microsurgical technique, and conventional macroscopic technique. Further investigations of robot-assisted microsurgical vasovasostomy outcomes and randomized control trials are required to support this evidence.

BACKGROUND: The outcomes and morbidity following treatment for persistent or varicocele recurrence remain controversial.
OBJECTIVE: To conduct a systematic review relating to the outcomes following treatment (any surgical or radiological) for varicocele persistence/recurrence.
METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Prospective and retrospective observational or interventional studies were included until March 2022. Outcomes were pregnancy rate, improvements in semen parameters after treatment compared with those at baseline, pain control, complication rates, and repeat treatment approach. Men of any age with any-grade persistent/recurrent varicoceles were included.
RESULTS: Of 913 articles identified, 18 with 1073 patients were eligible for inclusion. The mean time between the first and repeat treatment ranged between 5.3 and 73.3 months. The indication for repeat treatment was infertility in eight and pain control in six out of 18 studies, whereas four did not provide details for the indication. Of the patients with recurrent/persistent varicoceles initially treated using a radiological intervention, 83.8% underwent another radiological procedure, whereas 16.2% underwent a surgical procedure. Of those initially treated with a surgical procedure, 77.8% underwent a further surgical procedure, whereas 22.2% underwent a radiological procedure. The rate of success of repeat treatment was 60-100%. The reported complications were as follows: hydrocele (up to 16%), testicular atrophy (up to 2%), scrotal hematoma (up to 1.6%), wound infection (up to 6.6%), chronic pain (up to 2.9%), injury to other organs (up to 10%), and thrombophlebitis (up to 5.8%). The rate of symptom resolution was >90% for pain control. Pregnancy rates were 17-58% at 12-month follow-up. Semen parameters improved after repeat treatment compared with that at baseline in 87.5% of studies. The main limitations are the high risk of bias according to the Newcastle and Ottawa Scale, heterogeneity of the included studies, and small simple size.
CONCLUSIONS: Treating any grade of persistent/recurrent varicoceles has a good rate of success, pregnancy, and pain control, but there is still a risk of complications. Repeat treatment with the same interventional modality is feasible. The level of evidence is overall low.
RESULTS: In this systematic review on persistent or recurrent varicoceles, we showed that repeat treatment with radiological or surgical procedures was feasible, with good success, pregnancy, and pain control rates at follow-up. However, repeat treatment was associated with a higher risk of complications than reported in the published literature relating to patients having their first intervention.

OBJECTIVE: Vascular perfusion research has been dedicated to identify inexpensive, effective, and easy to use methods to assess free flap perfusion for both buried and non-buried flaps.
METHODS: Systematic review of complications in patients underwent Head and Neck microsurgical reconstruction and vascular implantable Doppler monitoring.
RESULTS: Sixteen articles were included for qualitative analysis. 2535 (92.2%) patients received IDP monitorization. Venous thrombosis was the most common vascular complication effecting 28 (1.1%). Regarding complications potentially related to the use of the IDP, just one study described the presence of granuloma formation along the suture line in 2 (0.07%) patients.
CONCLUSIONS: Our findings indicated that Cook-Swartz IDP will represents a safe and effective device for FF monitoring in HN reconstructive micro-surgery. A detailed prospective registration of the results and complications related to the use of IDP remains mandatory to precisely estimate results, cost, and complications.

BACKGROUND: Blood blister aneurysms (BBAs) are rare aneurysms affecting non-branched points of intracerebral arteries. Due to their small size and fragility, BBAs are prone to rupture, and can be challenging to diagnose and treat. Several treatment options have been suggested yet there is no consensus regarding the best modality to reduce morbidity and mortality.
METHODS: A systematic review of the literature was conducted searching for articles discussing the treatment of BBAs. Inclusion criteria included: articles published between January 2010 and August 2020, English language, with each paper including at least 15 patients. Studies included required detailed reporting of patient demographics, treatment, and patient outcomes (including complications, recurrence, neurologic functional status, and mortality).
CONCLUSIONS: A total of 25 studies with 883 patients were included. Most were female (n = 594, 67.3%) and aneurysms were overwhelmingly located in the supraclinoid internal carotid artery (99%). Aneurysms were variable in size and mostly presented with subarachnoid haemorrhage. Endovascular treatment (n = 518, 58.7%) was more common than microsurgery (n = 365, 41.1%) while only 2 patients were managed conservatively. Complications were more common in patients treated microsurgically. Microsurgical procedures had an unfavorable outcome (mRS 4-6, GOS 1-3) rate of 27.8% (n = 100/360) while that of endovascular procedures was 14.7% (n = 70/477). Endovascular procedures had a lower mortality rate than microsurgical interventions (8.4% vs 11%).
CONCLUSIONS: This review demonstrates that endovascular treatment of blood blister aneurysm has reduced morbidity and mortality when compared with microsurgical treatment. Small sample sizes and substantial study heterogeneity makes strong conclusions difficult.

When evaluating brain arteriovenous malformations (bAVMs) for microsurgical resection, the natural history of bAVM rupture must be balanced against the perioperative risks. It is therefore adamant to have a reliable surgical grading system, balancing these important factors. This study systematically reviews the literature in order to identify and assess the quality of grading systems with regard to microsurgical bAVM treatment. A systematic literature review was performed to provide an overview of all available bAVM grading systems relevant for microsurgical treatment evaluation and to assess the most comprehensive grading system specifically for each subgroup of bAVM (i.e., unruptured, ruptured, and posterior fossa). Screening of 865 papers revealed thirteen grading systems for bAVM microsurgical risk stratification. Among them, two systems were specifically developed for ruptured bAVM and one specifically for posterior fossa bAVM. With one system being fundamentally different for supratentorial bAVM, the remaining nine systems used the same parameters: \"size,\" \"eloquence,\" \"venous drainage,\" \"arterial feeders,\" \"age,\" \"nidus compactness,\" and \"hemorrhagic presentation\". This study provides a comprehensive overview of all available bAVM grading systems relevant for surgical risk stratification. Furthermore, in the absence of a universal system appropriate to score all bAVMs, a workflow for selection of the best applicable scoring system in accordance with bAVM subgroups is presented.

BACKGROUND: An unruptured brain arteriovenous malformation (bAVM) is a complex pathological entity with the potential to lead to disabling or fatal intracranial hemorrhage. The treatment approaches for these lesions have included microsurgical resection, endovascular embolization, stereotactic radiosurgery (SRS), and medical management or any combination of these modalities. However, the optimal treatment approach for unruptured bAVMs has not yet been determined. In the present case, we used SRS strategically to downgrade an AVM to allow for improved resectability.
METHODS: A 28-year-old woman had presented with 10 years of headaches and was found to have a Spetzler-Martin grade IV AVM not amenable to resection. She underwent targeted SRS only of the deep portions of the AVM, resulting in a decrease of the AVM to grade III. Subsequent microsurgical resection was successful in complete removal of the AVM. At the 1-year follow-up examination she had no deficits.
CONCLUSIONS: We have proposed a protocol of using focused SRS to eliminate the portions of the AVM that confer an increased surgical risk. SRS, followed by microsurgical resection, could represent an optimal treatment strategy for high-grade AVMs with difficult surgical anatomy.

Traumatic penis amputation is a urological emergency. Although repair techniques have been well described in literature, failure of replantation and its causes are poorly understood and reported. The aim of this study is to evaluate the treatment and prognosis of microsurgical replantation of penile amputation with a relative long-term ischemia, and review related literatures to summarize relevant clinical experiences. We report two cases of penile amputation and microsurgical replantation performed in our hospital in August 2016. In the first case, the patient was injured by sharp scissors due to family conflict, while in the second case, it was a mechanical injury. For both cases, microsurgical approaches were adopted. After the microsurgical replantation, both the patients recovered well and showed normal urination, erectile function, return of sensations and satisfactory cosmetic appearance. With the development of microsurgical techniques, the successful re-anastomosis of blood vessel and nerve can increase the survival and functional recovery of the penis even in cases exceeding 10 hours of ischemia. This provides greater possibility of graft survival with minimum complication.

We report here a case of intraventricular schwannoma. This location is rare. Our patient was a 68-year-old female with a large intraventricular lesion of the body of the lateral ventricle on the right side. Brain magnetic resonance imaging (MRI) revealed this lesion. After a right parietotemporal craniotomy, microsurgical excision using neuronavigation was performed to completely remove the tumor. Histological and immunohistochemical examination confirmed the diagnosis of intraventricular schwannoma devoid of atypical features. Postoperative MRI showed macroscopically complete tumor removal with no recurrence after 12 months of follow-up. A review of the literature identified 32 such cases published to date.

BACKGROUND: The pituitary adenoma causing acromegaly is typically resected through a transsphenoidal approach and visualized with an operating microscope or endoscope. We undertook a systematic review and meta-analysis examining the clinical efficacy of endoscopic and microsurgical approaches.
METHODS: Relevant studies using either endoscopic or microscopic transsphenoidal approaches for growth hormone pituitary adenomas were identified until February 2016. Data were extracted and analyzed according to predefined clinical end points.
RESULTS: We identified 31 studies, in which 950 patients underwent endoscopic transsphenoidal resection and 2137 patients underwent microsurgical transsphenoidal resection. Patients undergoing microsurgery were less likely to present with hypothyroidism (10.7% vs. 19.1%, P = 0.033, 462 vs. 156 patients) and less likely to have macroadenomas (66.9% vs. 83.8%, P ≤ 0.001, 1484 vs. 884 patients); adenomas with cavernous sinus invasion (21.3% vs. 44.4%, P = 0.036, 592 vs. 558 patients); and a lower mean tumor volume (17.84 vs. 20.54 mm3, P = 0.012, 158 vs. 248 patients). Patients treated via the endoscopic approach were more likely to achieve remission for noninvasive macroadenomas (83.8% vs. 66.9%, P ≤ 0.001, 115 vs. 365 patients). Sinusitis (15.6% vs. 2.6%, P < 0.001, 241 vs. 295 patients) and intraoperative cerebrospinal fluid leak (21.6% vs. 1.0%, P = 0.022, 697 vs. 127 patients) were more common in patients treated endoscopically, and meningitis (0.7% vs. 1.7%, P = 0.027, 511 vs. 1513 patients) was more common in patients undergoing a microsurgical approach.
CONCLUSIONS: Our study shows the clinical utility of the endoscopic approach and demonstrates potential benefits including increased remission rates with noninvasive macroadenomas and a lower rate of meningitis.