Torsion of intraabdominal testicular tumors. A case report.

BACKGROUND: Torsion of an intraabdominal testicular tumor is a rare event. We report a new case and review the literature. METHODS: A review of the literature was carried out in order to identify reported cases of an intraabdominal testicular tumor undergoing torsion of its vascular pedicle. Data on histologic type, common presenting signs and symptoms, radiographic studies, and adjuvant therapy were tabulated. RESULTS: There are 36 reports of an intraabdominal testicular tumor presenting with torsion. The most common histologic types, in descending order, were seminoma, sarcoma, teratoma, embryonal carcinoma, and choriocarcinoma. Common presenting signs and symptoms included pain and/or tenderness, fever, nausea and/or vomiting, and a palpable mass. Most seminoma patients received adjuvant radiation therapy whereas one patient with choriocarcinoma received adjuvant chemotherapy. CONCLUSIONS: Although a rare event, the diagnosis of torsion of an intraabdominal testicular tumor should be considered in any patient presenting with an acute abdomen and a history of cryptorchidism. The presence of a mass may raise the index of suspicion. Preoperative investigation with computed tomography scanning may aid surgical planning.

Nonpalpable intratesticular masses detected sonographically.

PURPOSE: There is controversy concerning the implications of impalpable testicular masses. We examine the sonographic findings and pathology of such tumors. MATERIALS AND METHODS: Between 1985 and 1994, 3,019 scrotal ultrasound studies were performed for various indications and 15 impalpable masses were discovered. RESULTS: Pathological study revealed 5 seminomas, 6 nonseminomas, 2 "burned-out" tumors, 1 lipoma and 1 granuloma. CONCLUSIONS: Impalpable intratesticular masses are likely to be malignant. Any young man with retroperitoneal or visceral masses should undergo scrotal ultrasound. A testicular mass is likely to be the primary cancer but it may be regressed. Persistent scrotal pain may be a presentation of malignancy and should be evaluated with ultrasound.

A review of scrotal violation in testicular cancer: is adjuvant local therapy necessary?

High inguinal orchiectomy is the standard initial treatment for suspected testicular carcinoma. Nonstandard surgical approaches (scrotal violations), including scrotal orchiectomy, open testicular biopsy and fine needle aspiration, have historically been condemned as significantly compromising patient prognosis. Patients with scrotal violation are often subjected to potentially morbid or disfiguring local therapies. In addition, patients with scrotal violations are usually disqualified from surveillance protocols. A review was conducted of all published series of testicular cancer patients in whom scrotal violation occurred. A meta-analysis was then performed to choose a subset for critical analysis on the effect of scrotal violation on patient prognosis. Of 1,182 cases included in the final analysis scrotal violation occurred in 206. The rates for local recurrence, distant recurrence and survival were analyzed separately for all patients, patients with stage I disease and patients with pure seminoma or nonseminomatous germ cell tumor. Additionally, the effect of local treatment for scrotal violation on prognosis was examined. Although statistically significant differences were found in the local recurrence rate among the scrotal violation and inguinal group studies, the overall local recurrence rates were small (2.9% versus 0.4%, respectively). There were no statistical differences in distant recurrence or survival rates in all groups analyzed. Patients with scrotal violation who did not receive any local therapy fared as well as those who did receive local therapy. Although the standard treatment of primary testicular cancer remains high inguinal orchiectomy, these data suggest that scrotal violation does not impart a significantly worse overall prognosis. These data would also indicate that patients with stage I disease and scrotal violation should not necessarily be disqualified from surveillance protocols or subjected to adjuvant local therapy.

Retro-peritoneoscopy: anatomical rationale for direct retroperitoneal access.

Although the upper urinary tract resides at an extraperitoneal location, the traditional laparoscopic approach to these organs has been transperitoneal. Several investigators have advocated using a direct approach to the retroperitoneum to minimize risks associated with transperitoneal surgery. We performed autopsy and radiographic studies in an effort to define the location of the retroperitoneum relative to surface anatomy. These investigations indicate that the peritoneal reflection was consistently anterior to the posterior axillary line. Moreover, when a patient was placed in the lateral position, the anteroposterior extent of the potential retroperitoneal space increased 2-fold. Based on these studies, a technique for direct retro-peritoneoscopy was initiated and successfully performed in 21 of 23 patients. Direct access to the retroperitoneum can be performed in a reliable and safe manner.

Laparoscopic nephrectomy for renal neoplasms.

Laparoscopic nephrectomy has been shown to be an effective minimally invasive technique for treating benign renal disease requiring surgical excision. However, its application to approach renal malignancy has been limited. Herein, we report on 8 patients with renal tumor who underwent a laparoscopic nephrectomy. All kidneys were removed within Gerota's fascia, and in 3 patients with upper pole tumors, the adrenal gland was also removed en bloc. With limited follow-up of seven to thirty-five months (mean 14 months), there has been no clinical or radiographic evidence of tumor recurrence. We believe that laparoscopic radical nephrectomy with strict adherence to oncologic surgical principles is a practical, less invasive alternative in select patients with renal tumors.

Complications of laparoscopic surgery.

As with all surgical procedures, prevention and proper patient selection is the key to avoid complications. High-risk patients should be clearly identified from the outset. Properly maintained equipment, along with a thorough working knowledge of all instrumentation is essential. An often overlooked but vital aspect of laparoscopy is the laparoscopy team, including anesthesia and nursing personnel. A final point: there is no substitute for experience in avoiding laparoscopic complications. A survey by Phillips et al. found the complication rate for physicians who had performed fewer than 100 laparoscopic procedures to be almost four times greater than surgeons with more experience. A survey of eight centers active in urologic laparoscopic surgery reported that 10-20 pelvic lymph node dissections were necessary before they felt comfortable and 25-50 cases before they were proficient with the procedure. Since the learning curve with laparoscopy is initially quite steep, urologists beginning to apply the technique should work closely with experienced laparoscopic surgeons.

Genital swelling secondary to leakage from continuous ambulatory peritoneal dialysis: computerized tomography diagnosis.

We report a case of acute genital swelling in a patient receiving continuous ambulatory peritoneal dialysis. Physical examination did not identify or localize any defect. Computerized tomography demonstrated extravasation into the left groin and scrotum. Surgical repair of an inguinal hernia resulted in complete resolution of the genital swelling.

The pathophysiology of ureteral obstruction.

Ureteral obstruction can have a variety of causes intrinsic or extrinsic to the kidney. The effects of obstruction are examined from the perspectives of duration, severity, totality, and the presence of complicating factors. There is a difference in the postobstructive pathophysiology depending on whether one or both ureters were obstructed. Atrial natriuretic peptide may be important in postobstructive diuresis, and preliminary evidence suggests a role for it as protection against nephron ischemia in acute obstruction. The potential for recovery of renal function after relief of obstruction depends on the duration and degree of obstruction, the condition of the contralateral kidney, and the presence or absence of infection. Ability to acidify the urine to pH < 6.0 preoperatively may be a good predictor of the recovery potential of an obstructed kidney. Urine concentrations of lysosomal enzymes such as N-acetylglucosaminidase also may be useful for this purpose, as may measurement of creatinine clearance in urine obtained from a nephrostomy tube.