Prepubertal testicular tumours and efficacy of testicular preserving surgery

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Testicular tumours in childhood are very rare. Historically, most of these tumours have been considered malignant, but more recent studies indicate that benign lesions, particularly teratoma, are much more frequent than previously thought. Testicular tumours in this age group have traditionally been treated with inguinal radical orchiectomy, but more conservative management has been proposed in view of the higher frequency of benign tumours. In children, most testicular tumours are benign, especially before puberty. A testis‐sparing procedure should be performed in children with a palpable testicular mass and negative tumour markers.

OBJECTIVE

? To report our experience of testicular tumours in children aged ≤13 years, including our experience with testis‐sparing surgery.

PATIENTS AND METHODS

? A retrospective study was performed of 15 patients with testicular tumours aged ≤13 years who presented at our centre between 1984 and 2008. The use of testis‐preserving surgery according to indication was investigated and outcomes were recorded.

RESULTS

? The clinical presentation was increased testicular size with a palpable mass in 80% of the cases. All 15 patients underwent surgery. The tumour was benign in 12 (80%) patients and malignant in three (20%) patients. ? Organ‐preserving surgery was planned and achieved in 11 patients (73%). ? Pathology of the tumourectomy specimens disclosed benign tumours in all cases: four epidermoid cysts, two teratomas, one juvenile granulosa cell tumour, one haemangioma, one lipoma, one fibrous hamartoma and one splenogonadal fusion. ? In four patients who underwent radical orchiectomy, pathology identified one yolk sac tumour (stage I), two mixed germ cell tumours and one gonadoblastoma.

CONCLUSIONS

? In children, most testicular tumours are benign, especially before puberty. A testis‐sparing procedure should be performed in children with a palpable testicular mass and negative tumour markers. ? The lesion, however, should be thoroughly excised to avoid recurrences.     

Testis sparing surgery for epidermoid cyst of the testis: A case report

A rare tumour of a prepubertal child, an epidermoid cyst, was excised with testicular preservation. Childhood testicular tumours are usually benign. Although epidermoid cysts of the testis may have teratomatous component, testicular teratomas are generally benign in the prepubertal child. For these reasons testis sparing surgery seems applicable in childhood epidermoid cysts.     

Testis sparing surgery for epidermoid cyst of the testis: A case report

A rare tumour of the prepubertal child, an epidermoid cyst was excised with testicular preservation. Childhood testis tumours are usually benign. Although epidermoid cystes of the testis may have teratomatous component, testicular teratomas are generally benign in the prepubertal child. For these reasons testis sparing surgery seems applicable in childhood epidermoid cysts.     

Benign cystic lesions of the tunica albuginea

We report 4 cases of benign testicular cysts arising from the tunica albuginea. A review of the literature yielded only 15 similar cases. The cysts appear in the anterior and lateral aspects of the testis, show ample connection to the albuginea and are lined by a cuboidal epithelium. Clinically, these cysts may be manifested as a tumour or painful swelling or are discovered incidentally. The possibility of a conservative surgical approach is discussed.     

Testicular epidermoid cyst: uncommon lesion of difficult preoperative diagnosis

Intratesticular epidermoid cysts are rare tumours that constitute one percent of all testicular masses. They are bening lesions that make differential diagnosis from malignant testicular tumours difficult. The absence of serum markers elevation and ultrasound imaging could support these lesions being bening epidermoid cysts, and in that case, conservative surgery is adequate. We present the case of a 22 years old patient who complains of a left testicular mass. In this case ultrasound diagnosis was non-specific and a left radical inguinal orchiectomy was performed.     

Cysts of the tunica albuginea. Report of 4 cases and review of the literature.

Four cases of benign testicular cysts arising from the tunica albuginea are reported. A review of the literature yielded only 4 more instances of such lesions. Clinically, these cysts may be manifested as a tumor or painful swelling, or are discovered incidentally. In 3 cases a diagnosis of testicular carcinoma was entertained and high inguinal orchiectomies were done. The possibility of a conservative surgical approach, as followed in 1 case, is discussed. These cysts appear in the anterior and lateral aspects of the testis, show ample connection to the albuginea and are lined by a cuboidal epithelium. Gland-like inclusion were found in the fibrous cystic walls and in the albuginea. The histogenesis of these lesions is discussed and evidence for a possible origin in mesothelial rests trapped during development is presented. The differential diagnosis of cystic lesion of the tests is reviewd briefly.     

脊柱外科中脑脊液漏的防治

目的：探讨脊柱外科中较常见并发症脑脊液漏的防治措施。方法：通过回顾性的方法对1995年1月－2000年5月发生的21例脊柱手术后脑脊液漏患者的临床资料进行分析总结。结果：经过术中、术后仔细的处理,21例脑脊液漏患者除1例保守治疗无效于21d再次开放切口修补硬膜外,其余20例患者全部经保守治疗后于6－36d内治愈,无1例发生脑脊髓膜炎;36例腰椎手术脑脊液漏患者随访术后3月－2年内发现形成脑脊液囊肿。结论：通过术中对硬脊膜损伤及时修补或堵塞,术后采取正确的保守治疗措施,绝大多数脑脊液漏均可治愈,极少数保守治疗无效者需开放切口,重新修补硬膜。对晚期形成的交通性或有症状的脑脊液囊肿,可 采取手术切除。     

Robotic-assisted transperitoneal nephron-sparing surgery for small renal masses with associated surgical procedures: surgical technique and preliminary experience

Small renal masses (T1a) are commonly diagnosed incidentally and can be treated with nephron-sparing surgery, preserving renal function and obtaining the same oncological results as radical surgery. Bigger lesions (T1b) may be treated in particular situations with a conservative approach too. We present our surgical technique based on robotic assistance for nephron-sparing surgery. We retrospectively analysed our series of 32 consecutive patients (two with 2 tumours and one with 4 bilateral tumours), for a total of 37 robotic nephron-sparing surgery (RNSS) performed between June 2008 and July 2012 by a single surgeon (G.C.). The technique differs depending on tumour site and size. The mean tumour size was 3.6 cm; according to the R.E.N.A.L. Nephrometry Score 9 procedures were considered of low, 14 of moderate and 9 of hight complexity with no conversion in open surgery. Vascular clamping was performed in 22 cases with a mean warm ischemia time of 21.5 min and the mean total procedure time was 149.2 min. Mean estimated blood loss was 187.1 ml. Mean hospital stay was 4.4 days. Histopathological evaluation confirmed 19 cases of clear cell carcinoma (all the multiple tumours were of this nature), 3 chromophobe tumours, 1 collecting duct carcinoma, 5 oncocytomas, 1 leiomyoma, 1 cavernous haemangioma and 2 benign cysts. Associated surgical procedures were performed in 10 cases (4 cholecystectomies, 3 important lyses of peritoneal adhesions, 1 adnexectomy, 1 right hemicolectomy, 1 hepatic resection). The mean follow-up time was 28.1 months ± 12.3 (range 6–54). Intraoperative complications were 3 cases of important bleeding not requiring conversion to open or transfusions. Regarding post-operative complications, there were a bowel occlusion, 1 pleural effusion, 2 pararenal hematoma, 3 asymptomatic DVT (deep vein thrombosis) and 1 transient increase in creatinine level. There was no evidence of tumour recurrence in the follow-up. RNSS is a safe and feasible technique. Challenging situations are hilar, posterior or intraparenchymal tumour localization. In our experience, robotic technology made possible a safe minimally invasive management, including vascular clamping, tumour resection and parenchyma reconstruction.     

Benign testicular tumors in children. Value of simple tumorectomy]

From 1984 to 1999, the authors observed 18 intratesticular tumours, 13 of which corresponded to benign lesions. The objective of this study is to define preoperative and intraoperative criteria of benign lesions in order to allow conservative management (simple excision or enucleation) and to analyse the results of this treatment. The 13 boys of this series were between the ages of 5 months and 14 years (mean: 7.1 years). The lesion presented as scrotal swelling in 12 cases and gynaecomastia in 1 case. Tumour markers (alphafoetoprotein, beta HCG) were at the limit of normal for age. Ultrasonography was performed in every case. In each case, treatment consisted of primary exposure of the pediclc with clamping then exteriorization and macroscopic examination of the lesion. Frozen section examination was performed in 11 cases. Treatment consisted of 9 enucleations and 4 orchidectomies. The final histology concluded on epidermoid cyst or simplified teratoma with exclusively ectodermal development in 4 cases, multi-differentiated teratoma in 2 cases, sex cord tumour in 2 cases, simple cyst in 2 cases, rete testis dysplasia in 1 case, cavernous haemangioma in 1 case, and vestigial cyst in 1 case. There was no discordance between the final histological examination and the frozen section examination. The mean follow-up is 4.4 years. No secondary atrophy and no local or distant recurrence was observed in the 9 cases of enucleation. In conclusion, testicular tumours are often benign in children. Selection based on a body of clinical, laboratory, radiological and frozen section histological evidence should allow carcinologically safe conservative surgery with an aesthetic, psychological and functional benefit for the child.     

Contribution of celioscopy in the early diagnosis of ovarian cancers]

Four hundred and eighty-one patients with an ovarian cyst considered to be benign on the basis of clinical and ultrasonographic findings underwent diagnostic laparoscopy. All malignant tumours (9 cases) were recognized by diagnostic laparoscopy and were treated immediately via laparotomy. When a cyst was identified as being benign on laparoscopy, the diagnosis was always confirmed by histological examination. Sixty one patients (64 cysts) were treated via laparotomy immediately after laparoscopy for the following reasons: malignant or suspicious lesions (19 cases) dense adhesions or anatomical conditions making laparoscopic surgery difficult (42 cases). 420 patients (444 cysts) were treated by laparoscopic surgery with either intraperitoneal cystectomy or transparietal cystectomy. The postoperative course following laparoscopic surgery for annexal cysts was uneventful in 417 cases (3 patients developed a complication).     

Surgical treatment of hydatid disease of the liver. An experience from outside the endemic area

Hydatid disease is quite rare in European countries outside the endemic areas. It occurs most frequently in the liver and lungs. Surgery remains the main treatment modality for hydatid disease of the liver. There is still considerable debate as to whether the best approach is conservative surgery or radical surgery in which the cyst is totally removed including the pericyst by total pericystectomy or partial hepatectomy. We report the results of our 15-year experience with this type of surgery. A series of 35 consecutive patients operated on for hydatid disease of the liver from January 1985 to December 2000 was analysed (18 women and 17 men with a mean age of 47.7 years). The most common complaints were pain (59%), hepatomegaly and intra-abdominal masses (37%). The cysts were single in 23 patients and multiple in 12, and were found in the right lobe in 21 cases (59%), in the left lobe in 9 cases (26%), and in both lobes in 5 (15%). In one patient (2.8%), concomitant extrahepatic (splenic) disease was present. The diameter of the cysts ranged from 3.5 to 20 cm (mean value: 9.5 cm). Patients were subdivided according to the kind of surgery (radical versus conservative) and period of operation (group 1: 1985-1992; group 2: 1993-2000). With the increase in surgical skills and the advent of new techniques, radical surgery (12 cystoperistectomies, 3 left lobectomies and 3 segmentectomies) came to be performed more frequently than conservative surgery in the second period (18/20 in group 2 versus in 7/15 group 1) with low complication rates, a 3.7% mortality rate and similar operative time (175 min versus 145 min) and hospital stay (16.8 days versus 19.2 days) as compared to the conservative approach. The policy of applying radical surgery whenever feasible can be implemented with acceptable morbidity and near zero mortality. Radical surgery, however, needs to be applied judiciously, and there is still an important role for conservative surgery.     

Laparoscopic treatment of solid and cystic tumors of the liver. Study of 33 cases

AIM OF THE STUDY: Laparoscopic liver surgery is still in its early stages. The aim of this study was to report our experience in the laparoscopic management of solid and cystic liver tumours. PATIENTS AND METHODS: From April 1991 to December 1999, 32 patients with various lesions of the liver underwent laparoscopic liver surgery. One group of patients presented with cysts (n = 15) (11 giant solitary cysts and 4 polycystic liver diseases) and one group of patients presented with solid tumours (n = 18): focal nodular hyperplasia (n = 8), haemangioma (n = 6), adenoma (n = 2), isolated metastasis from a colonic cancer (n = 1) and hepatocellular carcinoma (n = 1). Fifteen cyst fenestrations and eighteen liver resections were performed via a laparoscopic approach including 1 right lobectomy, 5 left lateral segmentectomies, 2 subsegmentectomies IVb, 1 segmentectomy III and 9 non-anatomical resections. RESULTS: Conversion to laparotomy was performed in one case (3%) at the end of the operation (patient who had successfully undergone left lateral segmentectomy for hepatocellular carcinoma) to check the resection margins and surgical transection had been performed in healthy parenchyma. Mean diameter of solid tumours was 6.5 cm and 15.7 cm for solitary cysts. The mean operating time for hepatic resections was 232 minutes. There was no postoperative mortality. Complications occurred in one case for each group and consisted in intestinal stricture through a port site requiring intestinal resection. Mean postoperative hospital stay was 5.6 days for solid tumours and 7.5 days for cystic lesions. In the group of cystic lesions, the recurrence rate was 50% with a 5.5-months follow-up. CONCLUSION: Laparoscopic liver surgery can be safely performed, but requires a good experience in open hepatic surgery and laparoscopic surgery. The laparoscopic approach is indicated in patients with symptomatic or atypical benign solid tumour, giant solitary cyst and polycystic liver disease, located anteriorly on the liver. Indications for malignant lesions have not been clearly defined and require further information.     

Thoracoscopic resection of bulky intrathoracic benign lesions

Background: Video-assisted thoracic surgery (VATS) is used for the diagnosis and treatment of some mediastinal lesions. However, large-size tumours are usually approached by thoracotomy or sternotomy. We report our experience of a full thoracoscopic approach for bulky intrathoracic lesions. Methods: From November 2002 to March 2007, 14 patients with a bulky intrathoracic mass were referred for resection. The study group consisted of eight females and six males with a mean age of 44 years (range: 13–74). We defined as bulky a mass with a minimal cross-sectional diameter equal to or larger than 50 mm, as measured on the specimen by the pathologist. Results: Thoracoscopic resection was completed in all patients. In 4 cases, the mass originated from the pleura, and in 10 cases from the mediastinum. The larger diameter of the lesion ranged from 50 mm to 160 mm, with a median of 90.2 mm. Operative time, calculated from insertion of the first trocar to skin closure, ranged from 40 to 190 min (mean: 102). Mean chest drain duration was 2.1 days (range: 1–4 days) and the mean hospital stay was 4.3 days (range: 3–11 days). There were no major postoperative complications. The final pathological diagnoses were the following: solitary fibrous tumours of the pleura (4), benign thymic cysts (2), teratomas (2), bronchogenic cyst (1), benign thymoma (1), pleuropericardial cyst (1) and benign neurogenic tumours (3). Conclusions: With experience and use of appropriate instrumentation, resection of bulky intrathoracic lesions by thoracoscopy is feasible and safe. It should be considered as a reliable alternate for tumours that are benign and most often asymptomatic.     

Simple cysts of the testis in children: preoperative diagnosis by ultrasound and excision with testicular preservation

We report on 2 children with simple cysts of the testis who were treated with excision and testicular preservation. To our knowledge both cases represent the first report of conservative surgery for these lesions in children. In 1 case the diagnosis of a simple intratesticular cyst was made by ultrasound. This patient was followed conservatively until enlargement resulted in excision of the cyst with preservation of the gonad. In the other case the diagnosis was made intraoperatively and simple excision of the lesion with testicular sparing was performed. High resolution real-time ultrasound should be performed routinely for all suspected testicular masses in children. Benign testicular tumors are more common than in adults and ultrasound may permit identification of lesions that can be excised locally with testicular preservation. Should the diagnosis of a simple, small intratesticular cyst be made by ultrasound regular followup may be appropriate. Should enlargement occur surgical excision can be done with the possibility of gonadal preservation.     

Early management of pathological fractures in children

The management of pathological fractures in children remains controversial. The indications for surgical treatment are unclear and the need for histological diagnosis before or after definitive treatment is not clearly defined. We reviewed retrospectively the records of all patients under the age of 16 years who presented over the past 7 years with a fracture as the first manifestation of bone pathology. There were 23 patients (16 boys and 7 girls) of an average age of 12 years and 2 months (range 4.1-15.8 years). There were nine cases of fracture through a simple bone cyst, five cases of fibrous dysplasia, two giant cell tumours, three aneurysmal bone cysts, one chondroblastoma, and three cases of Ewings sarcoma. After review of our cases we propose a simple algorithm for the safe early management and assessment of paediatric pathological fractures. We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. Most lesions should eventually be biopsied. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intra medullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.     

Clinical characteristics of intraspinal facet cysts following microsurgical bilateral decompression via a unilateral approach for treatment of degenerative lumbar disease

Purpose

Primary intraspinal facet cysts in the lumbar spine are uncommon, but it is unclear whether cyst incidence increases following decompression surgery and if these cysts negatively impact clinical outcome. We examined the prevalence, clinical characteristics, and the risk factors associated with intraspinal facet cysts after microsurgical bilateral decompression via a unilateral approach (MBDU).

Methods

We studied 230 patients treated using MBDU for lumbar degenerative disease (133 men and 97 women; mean age 70.3 years). Clinical status, as assessed by the Japanese Orthopedic Association (JOA) score and findings on X-ray and magnetic resonance images, was evaluated prior to surgery and at both 3 months and 1 year after surgery. The prevalence of intraspinal facet cysts was determined and preoperative risk factors were defined by comparing presurgical findings with clinical outcomes.

Results

Thirty-eight patients (16.5 %) developed intraspinal facet cysts within 1 year postoperatively, and 24 exhibited cysts within 3 months. In 10 patients, the cysts resolved spontaneously 1 year postoperatively. In total, 28 patients (12.2 %) had facet cysts 1 year postoperatively. The mean JOA score of patients with cysts 1 year postoperatively was significantly lower than that of patients without cysts. This poor clinical outcome resulted from low back pain that was not improved by conservative treatment. Most cases with spontaneous cyst disappearance were symptom-free 1 year later. The preoperative risk factors for postoperative intraspinal facet cyst formation were instability (OR 2.47, P = 0.26), scoliotic disc wedging (OR 2.23, P = 0.048), and sagittal imbalance (OR 2.22, P = 0.045).

Conclusions

Postoperative intraspinal facet cyst formation is a common cause of poor clinical outcome in patients treated using MBDU.     

Ten years of diagnostic ultrasound in renal disease

Observations with diagnostic ultrasound in renal disease over a 10-year period are reviewed. The advantages of diagnostic methods involving the least possible discomfort to the patient are emphasized. Ultrasonography is regarded as a reliable non-invasive method for the diagnostic differentiation between renal tumours and cysts. It was used by the authors for this purpose in 740 cases. Renal tumours were found by this method in 622, and renal cysts in 118 cases. Of the 740 patients, 726 underwent surgery. The preoperative ultrasonic diagnosis of renal tumour proved to be correct in 91.8 per cent, that of renal cyst in 88.9 per cent of the respective surgical cases. Ultrasonography also lends itself to the follow-up of polycystic disease of the kidney, being suited for its early diagnosis, as well as to its identification in the stage of renal failure when the traditional diagnostic methods are no longer practicable.     

Testicular lesions other than germ cell tumours: feasibility of testis-sparing surgery

OBJECTIVE

To review all non‐germ‐cell testicular lesions presenting at our institution and to determine the feasibility of testis‐sparing surgery for these patients.

PATIENTS AND METHODS

All surgery for testicular masses between June 1995 and June 2005 were reviewed retrospectively. Patients with atrophy, germ cell tumours, infection or torsion were excluded. The study comprised men who had radical orchidectomy for suspected germ‐cell tumour but had other final pathology, and those where testis‐sparing surgery was attempted for a presumed benign lesion.

RESULTS

Thirteen patients with lesions appropriate for the study were identified; all but one had a palpable lesion. The lesions could be categorized as inflammatory (three hyalinized fibrosis, two sarcoidosis, one chronic inflammation), cystic (one epidermoid cyst, one unilocular cyst), benign neoplasms (two adenomatoid tumours, one Leydig cell tumour, one capillary haemangioma) or malignant neoplasms (one lymphoma). Based on the preoperative impression, testis‐sparing surgery was attempted in eight of the lesions and was successful in six where it was attempted. In the other five, testis‐sparing surgery was not attempted because the preoperative impression was that of a germ cell tumour. Testis‐sparing surgery was successful in only six of the 13 patients with these lesions.

CONCLUSION

Testis‐sparing surgery might be possible if there is significant suspicion of a benign lesion. If frozen‐section analysis is equivocal, a radical orchidectomy is required. Testis‐sparing surgery was feasible in highly selected cases.     

Bilateral Epidermoid Cysts of the Testis: Report of a Case with Preservation of 1 Testis

Epidermoid cysts of the testis are rare, benign lesions. Of approximately 200 reported cases only 1 was bilateral. We report a case of bilateral epidermoid cysts treated with preservation of a testis. Diagnostic criteria, ultrasound evaluation and surgical management are discussed. The potential for testicular conservation is emphasized.     

Diagnosis and treatment of renal angiomyolipoma

A series of nine patients surgically treated for histologically verified renal angiomyolipoma is presented. Only one patient had extrarenal stigmata of tuberous sclerosis. No evidence of malignancy was found. In three cases a preoperative diagnosis was achieved with computed tomography (CT), use of which is recommended in evaluation of renal tumours. Six angiomyolipomas were solitary and three bilateral. Abdominal or flank pain was present in eight cases and perirenal haemorrhage in four. Solitary tumours were treated with nephrectomy. For bilateral tumour, nephrectomy and conservative renal surgery were used in two cases and bilateral nephrectomy and kidney transplantation were performed in the third case. When adipose tissue containing renal tumour is demonstrated at CT, conservative surgery should be considered.