Is excision of testicular nubbin necessary in vanishing testis syndrome?

Background/Purpose

Vanishing Testes Syndrome¹ (VTS) is one of the most common causes of impalpable testes in children. The role of removal of testicular nubbins owing to malignant potential in VTS is unclear. We sought to evaluate whether testicular nubbins need to be excised owing to this potential.

The symptomatic carpal boss. Is simple excision enough?

We reviewed 48 patients with symptomatic carpal boss seen during the 10 year period 1985-1994. Thirty-one patients had undergone either local excision of the boss or arthrodesis of the affected carpometacarpal joint. The mean follow-up was 3 years and nine cases have been revised. Twenty-four patients remained symptomatic and considered that surgery had failed to relieve their symptoms. These findings are in sharp contrast to previous reports that suggest simple excision of the carpal boss gives uniformly good results.     

Extrafascial excision of the rectum or total meso-rectal excision?

Total mesorectal excision is a valuable technique in preventing local recurrences cancer. However the use of the word "mesorectum" is inaccurate anatomically, and the implication that total excision of all the perirectal fat contained within the perirectal fascia in all patients with rectal cancer will minimize local recurrences remains contentious. The term extrafascial excision of the rectum is more accurate. He may contribute as well to a better understanding of the surgical technique allowing all surgeons to improve their own results.     

Does retroperitoneal lymphadenectomy for testicular germ cell tumor require a different approach in the presence of horseshoe kidney?

PURPOSE: We report our management of stage II testicular nonseminomatous germ cell tumor in 2 patients with horseshoe kidney and discuss the technical challenges posed by this renal fusion anomaly. The embryology and clinical anatomy of horseshoe kidney are discussed with particular reference to the anomalous vascular pattern and routes of testicular lymphatic drainage in this setting. Modifications and innovations of the standard technique of retroperitoneal lymphadenectomy in the presence of horseshoe kidney are discussed in light of our experience with these patients at 2 major tertiary care cancer centers. The significance of contemporary advanced noninvasive radiological techniques, such as helical computerized tomographic angiography with digital 3-dimensional reconstruction and magnetic resonance angiography, in the surgical planning and safe performance of surgery is emphasized. MATERIALS AND METHODS: Two young male patients treated at 2 major American teaching hospitals who had coexistent stage II testicular nonseminomatous germ cell tumor and horseshoe kidney underwent salvage retroperitoneal lymph node dissection. RESULTS: There was no evidence of recurrence in these 2 patients 12 and 15 months after surgery, respectively. CONCLUSIONS: Horseshoe kidney poses special technical problems during retroperitoneal lymphadenectomy for testicular tumors due to anomalous renal and intra-abdominal vascular patterns. Helical computerized tomography angiography is useful for meticulous surgical planning and the safe performance of surgery in this setting.     

Surgical versus pathological excision margins—an excision too far?

A common observation by clinicians who surgically excise skin pathology is the discrepancy between the measured size of the surgical specimen and that of the measurements reported by the examining pathologist. This discrepancy can often be the difference between whether, in the case of skin malignancies, the patient requires further wider excision, follow-up and, in cases where relevant, discharge. Could it therefore mean that patients are needlessly undergoing further excisions that could be avoided with more careful attention to specimen measurements and specimen ‘shrinkage,’ both surgically and pathologically? We measured the length and width of skin lesions excised pre- and post-operatively and compared these measurements with the reported histopathological measurements. A significant difference in length (p?=?0.000) and width (p?=?0.001) exists between pre- and post-operative measurements. No significant difference exists between post-operative and pathological measurements of length (p?=?0.072) or width (p?=?0.157). Length of time preserved in 10% formalin did not make a significant difference to specimen size (p?=?0.47). The aim of clinicians is to excise fully all skin pathology relevant for excision, ensuring sufficient clear margins to prevent potential recurrence whilst trying to sacrifice as little ‘normal’ tissue as possible in the process. What this study helps to highlight is the fact that clinicians cannot take for granted the reported measurements on the histopathology reports, upon which subsequent clinical management on reported excision margins are often based, without taking into consideration documented excision margins and subsequent allowance for significant specimen shrinkage, often resulting, for malignancies, in further wider excisions that are potentially disfiguring, and in the authors opinion, in more cases than currently thought, unnecessary. If one also factors in the fact that malignant cells shrink less than both benign tumours and, most importantly, normal skin, then subsequent reported pathological margins may be increasingly inaccurate as the excision margins may indeed be greater.     

Is routine primary retroperitoneal lymph node dissection still justified in patients with low stage non-seminomatous testicular cancer?

We present 8 years' experience of primary retroperitoneal lymph node dissection (RLND) in 190 patients with low stage non-seminoma; 154 patients had clinical stage I (CSI) and 36 had clinical stage IIa (CSIIa) disease. Of the 154 patients with CSI tumours, 33 had increased serum AFP and/or HCG before RLND (CSIM+) and 121 had normal tumour markers (CSIM-). Retroperitoneal lymph node metastases (pathological stage II) (PSII) were found in 38 of 121 patients with CSIM-, in 19 of 33 patients with CSIIM+ and in 26 of 36 patients with CSIIa. In a multivariate analysis, the presence of small vessel infiltration (demonstrated in histological sections of the primary tumour) and a prolonged tumour marker half-life were predictive factors for PSII. These 2 factors enabled a group of non-seminoma patients with CSI disease to be identified who had a 15% risk of retroperitoneal tumour growth (low risk group) as compared with a high risk group where 60 to 70% of patients had retroperitoneal lymph node metastases. Relapses occurred in 7 of 107 patients with PSI and in 6 of 83 patients with PSII disease; in the latter group, 5 relapses developed before the start of routine adjuvant chemotherapy; 6% of patients developed major post-operative complications. In addition, "dry ejaculation" was the principal side effect following RLND (unilateral RLND: 20/132 patients; bilateral RLND: 50/54 patients). The comparative cost to the health service during the first year of follow-up was estimated for low risk non-seminoma patients with CSI subjected to RLND and for those in whom a surveillance policy was adopted. The latter approach was preferable. It was concluded that a surveillance policy should be followed in low risk non-seminoma CSI patients provided that frequent follow-up is possible. A more active policy is recommended in high risk patients (e.g. adjuvant chemotherapy without RLND). Nerve-sparing RLND may be considered in patients with CSIIa disease and negative tumour markers.     

How worrisome is testicular microlithiasis?

PURPOSE OF REVIEW: Anecdotal reports of men developing testicular cancer after previous identification of microcalcifications on ultrasound generated significant concern in the literature about the relationship of testicular microlithiasis and testis cancer. Until 2001 little prospective data were available on the prevalence or natural history of testicular microlithiasis in the healthy male population. RECENT FINDINGS: Testicular microlithiasis is present in 5.6% of the male population between 17 and 35 years of age (14.1% in African Americans), far more common than testicular cancer (7:100,000). The majority of men with testicular microlithiasis will not develop testicular cancer. Previously recommended surveillance regimens using ultrasound, tumor markers or testicular biopsy are too costly and do not offer an improved outcome over testicular self-examination. SUMMARY: Testicular microlithiasis is common and while microcalcifications do exist in roughly 50% of germ cell tumors the majority of men with testicular microlithiasis will not develop testicular cancer. Increased emphasis on testicular examination is the recommended follow up for men identified with testicular microlithiasis.     

Can haematologic parameters be used to predict testicular viability in testicular torsion?

The purpose of this study was to evaluate the predictive value of haematologic parameters for testicular survival in torsion. Children with testicular torsion (TT) treated in Beijing Children's Hospital from January 2006 to December 2018 were enrolled in this study. Patient data collected in this study included age, symptom duration, preoperative preparation time, cryptorchidism testicular torsion or not, spermatic cord torsion degree, orchiectomy/orchiopexy, testicular volume 3 months after operation by ultrasound in orchiopexy patients and haematologic parameters. The orchiopexy group comprised of 54 patients with a mean age of 135.6 ± 43.73 months, and the orchiectomy group included 58 patients with a mean age of 119.36 ± 60.82 months. The multivariate analysis showed that symptom duration (Odds Ratio = 1.11, p < 0.001), spermatic cord torsion degree (Odds Ratio = 1.006, p = 0.002) and mean platelet volume (MPV; Odds Ratio = 3.697, p = 0.044) were significant predictors of orchiectomy. The cut‐off value for MPV during window time for orchiectomy was 10.55 fl (10^?9 L) and provided a sensitivity of 47.8% and a specificity of 92.6%. This study found that symptom duration, spermatic cord torsion degree and MPV could be indicators of testicular viability in testicular torsion. MPV can provide valuable information before operation which can guide doctors and family members of the patients to select the appropriate treatment.     

Does midwifery-led intrapartum care require anaesthetic services?

The report of the Expert Maternity Group 'Changing Childbirth' (The Cumberlege Report) advocates a greater role for midwives in the care of the low risk pregnant woman, and has promoted much discussion about the future development of maternity services in the UK. At Leicester Royal Infirmary NHS Trust the 'Home from Home' delivery scheme provides midwifery-led antenatal and intrapartum care of women with uncomplicated pregnancies. We have performed a retrospective review of the requirements for anaesthetic services in this unit. During the 12 month review period 1610 women were admitted to the 'Home from Home' delivery scheme in labour. One hundred and eighty one women subsequently received anaesthetic intervention. Of this group, 137 (77.0%) required an epidural, 17 (9.6%) a spinal, 18 (10.1%) a general anaesthetic, 5 (2.8%) an epidural and a general anaesthetic and 1 (0.6%) an epidural and a spinal. Our results demonstrate that low risk pregnant women in labour being cared for in a midwifery led unit have a considerable need for anaesthesia and analgesia.     

Lobular neoplasia: is surgical excision warranted?

The treatment of breast cancer associated with lobular neoplasia detected on core needle biopsy (CNB) remains controversial. The purpose of this study was to review the prevalence of lobular neoplasia in CNB specimens and to correlate CNB pathology to final surgical pathology. Patients with lobular neoplasia were included for analysis in this retrospective review. Patients with concomitant malignant or atypical lesions were excluded. Method of initial diagnosis, clinical history, pathology results, and follow-up data were then analyzed. From January 1994 to December 2005, 5257 CNBs were performed at our tertiary level medical facility. Of patients with lobular neoplasia, 42 of 50 (84%) patients had atypical lobular hyperplasia, whereas 8 (16%) patients were diagnosed with lobular carcinoma in situ on CNB specimens. There were no associated malignancies in 21 patients who underwent immediate surgical excision. Of those patients who were serially followed, four developed malignancies at an average of 73 months after the sentinel diagnosis. Three of the four (75%) malignancies occurred in the ipsilateral breast. Patients with a diagnosis of lobular neoplasia by CNB should not routinely undergo an open surgical biopsy. Lobular neoplasia should only be considered a risk marker for future invasive breast cancer.     

The potenial relevance of interferon-gamma to human luteal regression

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The origins and time of appearance of focal testicular dysgenesis in an animal model of testicular dysgenesis syndrome: evidence for delayed testis development?

A testicular dysgenesis-like syndrome is induced in rats by fetal exposure to di(n-butyl) phthalate (DBP). A key feature of this is the formation of focal dysgenetic areas comprising malformed seminiferous cords/tubules and intratubular Leydig cells (ITLC), but how and why these arise remains unclear. The present study has used combinations of cell-specific markers and immunohistochemistry to address this. The results show that focal dysgenetic areas and ITLC first appear postnatally at 4-10 days of age, but this only occurs in treatment groups in which formation of fetal Leydig cell aggregation is induced between e17.5 and e21.5. Extreme variability in the formation and size of the Leydig cell aggregates probably accounts for the equally extreme variation in occurrence and size of focal dysgenetic areas postnatally. DBP-induced fetal Leydig cell aggregation traps Sertoli and other cells within the aggregates, but it is unclear why this happens nor why cords fail to form prenatally in these cell mixtures but do elsewhere in the fetal testis. The present studies show that differentiation of the fetal Leydig cells is drastically delayed at e15.5 after DBP exposure, which may be indicative of a wider delay in testis cell development and organisation, and this might account for some of the unexplained findings.     

Is a cystogram necessary after bladder cuff excision?

ObjectiveNephroureterectomy with bladder cuff excision is the current gold standard for the treatment of upper-tract urothelial carcinoma (UTUC). Currently, routine follow-up cystogram is performed prior to Foley catheter removal to evaluate the bladder cuff excision wound. The aim of this study was to investigate the role of the postoperative cystogram in the bladder cuff excision procedure.Materials and methodsThis was a retrospective study of 193 patients diagnosed with UTUC post nephroureterectomy and bladder cuff excision between January, 2010, and January, 2016. Patient demographics, performance of cystogram, types of bladder cuff excision, and postoperative outcomes were recorded. Patients were classified into two groups depending on whether or not routine postoperative cystogram was performed.ResultsA total of 125 patients were included in this study and, of these, 102 patients underwent routine cystogram on Postoperative Day 7 (Group 1), while 23 patients underwent Foley catheter removal on Postoperative Day 7 without any imaging studies (Group 2). Univariate analysis showed no differences in age, sex, comorbidities, surgical approach, or stage of the primary tumor. No patient from either group had urinoma, pelvic abscesses, and tumor growth from bladder cuff wound was not observed in any patient within the 1-year postoperative follow-up period. Both groups of patients had a similar rate of postoperative urinary tract infections with sepsis (p = 0.639), time to Foley catheter removal (p = 0.630), time to drainage tube removal (p = 0.264), and length of hospitalization (p = 0.373).ConclusionFoley catheter removal on Postoperative Day 7 after nephroureterectomy with bladder cuff excision without routine cystogram appears to be safe in the majority of the UTUC patients. A large, multi-institutional study is required before this method can be recommended for widespread clinical practice.     

Is total excision of spinal neurenteric cysts possible?

Spinal neurenteric cysts are intradural cystic lesions. These represent a part of the spectrum of developmental anomalies. These are rare lesions. Most of the data in literature is review of case reports. This made us evaluate our results of 23 cases and review the literature. This is a retrospective study of 23 patients managed at our institute over 20 years. The slides were retrieved and histopathological features studied. Twenty patients were less than 30 years old and 21 were males. Follow-up was available for 21 patients with mean duration of 71 months (range 2 months to 23 years). The typical presentation was backache with progressive neurological deficits pertaining to the level. Atypical presentations as acute onset, recurrent episodic events and aseptic meningitis were also noted. The cervicothoracic region was the most common site. 16 patients had cyst in intradural extramedullary plane and seven had intramedullary location. Associated vertebral anomalies as hemivertebrae, Klippel-Feil and spina bifida were noted in seven patients. There were two histological types of cysts with no correlation between the type of cysts and associated vertebral anomalies and extent of outcome. Partial excision though had higher risk of recurrence, was not associated with poorer outcome. Dorsal approach is an acceptable route with reasonably good results for this lesion. Spinal neurenteric cysts present at younger age with varied clinical presentations. These are commonly located intradurally ventral to the cord. Histological types have no effect on the outcome. Total excision is the choice of treatment. However, partial excision is a feasible option in intramedullary lesions and when significant adhesions occur. Although associated with higher risk of recurrence, the outcome is still good in these patients on re-excision.