Clinical Challenge: A Rare Testicular Tumor.

We present the case of a 22-year-old male that comes to the Urology clinic with the incidental finding of a testicular mass. Typical findings in echography will guide us towards the diagnosis of an epidermoid cyst.1,2 This type of infrequent benign tumor is responsible for only around 2% of all testicular tumors.1 Because of this low incidence literature regarding epidermoid cysts is scarce. Treatment has been susceptible to change throughout the years.6 In this clinical case we challenge readers to review a rare tumor and to choose the most appropriate treatment for our patient.

Prospective study of diagnostic accuracy in the detection of high-grade prostate cancer in biopsy-naïve patients with clinical suspicion of prostate cancer who underwent the Select MDx test.

OBJECTIVES: This study aimed to externally validate the diagnostic accuracy of the Select MDx test for Significant prostate cancer (Sig PCa) (ISUP > 1), in a contemporaneous, prospective, multicenter cohort with a prostate-specific antigen (PSA) between 3 and 10 ng/ml and a non-suspicious digital rectal examination. METHODS AND PARTICIPANTS: For all enrolled patients, the Select Mdx test, the risk calculator ERSPC3 + DRE, and a prostatic magnetic resonance imaging (MRI) were carried out. Subsequently, a systematic 12-core trans-rectal biopsy and a targeted biopsy, in the case of a prostate imaging-reporting and data system (PIRADS) > 2 lesion (max three lesions), were performed. To assess the accuracy of the Select MDx test in the detection of clinically Sig PCa, the test sensitivity was evaluated. Secondary objectives were specificity, negative predictive value (NPV), positive predictive value (PPV), and area under the curve (AUC). A direct comparison with the ERSPC + DRE risk calculator and MRI were also performed. We also studied the predictive ability to diagnose Sig PCa from the combination of the Select MDx test with MRI using clinical decision-curve analysis. RESULTS: There were 163 patients enrolled after meeting the inclusion criteria and study protocol. The Select MDx test showed a sensitivity of 76.9% (95% CI, 63.2-87.5), 49.6% specificity (95% CI, 39.9-59.2), 82.09% (95% CI, 70.8-90.4) NPV, and 41.67% (95% CI, 31.7-52.2) PPV for the diagnosis of Sig PCa. COR analysis was also performed, which showed an AUC of 0.63 (95% CI, 0.56-0.71). There were no differences in the accuracy of Select MDx, ERSPC + DRE, or MRI. The combination of Select MDX + MRI showed the highest impact in the decision-curve analysis, with an NPV of 93%. CONCLUSION: Our study showed a worse performance for the SelectMdx test than previously reported, within a cohort of patients with a PSA 3-10 ng/ml and a normal DRE, with results similar to those from ERSPC + DRE RC and MRI, but with an improvement in the usual PSA pathway. A combination of the Select Mdx test and MRI could improve accuracy, but studies specifically evaluating this scenario with a cost-effective analysis are needed.

Risk Prediction Tools Available for Germline BRCA1/2 Mutations Underperform in Prostate Cancer Patients.

Early identification of germline BRCA1/2 mutations may be relevant for the management of patients with prostate cancer (PC) and to prevent future breast and ovarian cancers in their relatives. Several prediction tools have been developed to estimate the likelihood of a germline BRCA1/2 mutation and are widely used to optimize screening in breast and ovarian cancer patients. We aimed to elucidate the proportion of PC patients with known BRCA1/2 mutations who would have qualified for testing using two risk calculation models (BRCAPRO and the Manchester scoring system [MSS]). We analyzed 106 families with known BRCA1/BRCA2 mutations, including 23 with PC cases. Only 30% and 48% of PC patients who were known BRCA1/BRCA2 mutations carriers would have qualified for testing using BRCAPRO and MSS, respectively. A median of two breast and/or ovarian cancer cases per family had occurred between the first PC identified in a carrier and the cancer case leading to germline testing. PATIENT SUMMARY: We tested two models developed to predict the probability of inherited BRCA1/BRCA2 mutations and found that these tools underperform in men with prostate cancer and should not be used to optimize testing in this population.

Prospective urodynamic model for prediction of urinary incontinence after robot-assisted radical prostatectomy.

OBJECTIVES: To assess the preoperative urodynamic predictors of urinary incontinence (UI) 1 year after robot-assisted radical prostatectomy (RARP) and to design a nomogram capable of predicting its occurrence. MATERIALS AND METHODS: Our prospective study included 58 previously continent patients who underwent RARP, in most cases, bilateral nerve-sparing and bladder neck preservation. A urodynamic examination including a urethral pressure profile was performed preoperatively. Multivariate analysis was used to assess the predictors for the need to use 1 or more pads/day and a nomogram was constructed. RESULTS: There was a 20.6% incidence of UI at 1 year after RARP. Bladder compliance, maximum urethral closure pressure and the development of bladder outlet obstruction, correlated well with the incidence of UI on the multivariate analysis (p = 0.043, 0.001, and 0.05, respectively). CONCLUSION: Bladder compliance <27.8 ml/cm H2O, maximum urethral closure pressure <50.3 cm H2O and the bladder outlet obstruction are independent urodynamic factors correlating with UI after RARP. The new nomogram can objectively predict a patient likelihood of requiring 1 or more pads/day 1 year after RARP with a good accuracy.

Comprehensive prediction model of urinary incontinence one year following robot-assisted radical prostatectomy.

OBJECTIVES: Urinary incontinence (UI) still remains one of the major functional complications after robot-assisted radical prostatectomy (RARP). As the cause for UI is multifactorial, it is quite difficult to make a prediction preoperatively. Considering intraoperative and postoperative risk factors, besides the preoperative ones, we designed an incontinence prediction model, administered 1 month after the surgery, in order to identify incontinent patients at 1 year. PATIENTS AND METHODS: We retrospectively reviewed 244 patients who underwent RARP at our institution. Only 209 patients had sufficient data, a 1-year follow-up and were continent preoperatively. The association of UI with the risk factors was assessed by univariable and multivariable regression models. RESULTS: There was a 17.2% global UI rate at 1 year after RARP. Only age-adjusted Charlson comorbidity index, erectile function assessed by International Index of Erectile Function-5, prostate volume, nerve-sparing status and 24-hour urine loss at 1 month correlated with UI (p = 0.032, 0.009, 0.031, 0.018 and <0.001, respectively). The accuracy of the prediction model of UI was 92.8% (c-index), with an area under the curve of 91.9%. CONCLUSION: Age-adjusted Charlson comorbidity index, International Index of Erectile Function-5, prostate volume, nerve-sparing status and 24-hour urine loss at 1 month after RARP can predict an individual's risk of UI at 1 year after RARP with good accuracy. Further external validation is required in order to generalize the use of this model.

[Treatment of childhood lithiasis using extracorporeal shock wave lithotripsy]. / Tratamiento de litiasis infantil mediante litotricia extracorpórea por ondas de choque.

OBJECTIVES: We evaluated the efficiency of extracorporeal shock wave lithotripsy (ESWL) in the treatment of pediatric urolithiasis, analyzing results and complications in our series. METHODS/RESULTS: 20 patients (16 males and 4 females) with ages from 2 to 17 years were evaluated. Twelve patients presented left side lithiasis (60%). The size of the stone was measured in cm2 areas. 6 cases (30%) presented with lower calyx stones and 5 cases (25.9%) with stones in the pelvic ureter. 2 patients required JJ catheter insertion. Mean number of shock waves per session was 2,650 (range: 1,000-3,800). The Dornier Lithotripter S and Dornier MFL-5000 lithotripsy machines were used in the range of 10-120 Kv and 14-23 Kv respectively. Follow-up evaluation was performed at one week and three months from treatment, including abdomen x-ray to obtain fragmentation and elimination percentages. In our series total fragmentation was achieved in 100% of the cases, without any patient with partial fragmentation (fragments > 5 mm). Elimination percentages were satisfactory, with a 65% total elimination and 30% partial elimination (residual fragments < 5 mm) within one week. One patient had no elimination at all. CONCLUSIONS: After the results obtained in our series, we consider external shock wave lithotripsy the first treatment option in cases of pediatric urolithiasis.

Tratamiento de litiasis infantil mediante litotricia extracorpórea por ondas de choque / The treatment of pediatric urolithiasis by extracorporeal shock wave lithotripsy

OBJETIVOS: Tratamos de evaluar la efectividad del tratamiento con litotricia extracorpórea por ondas de choque (LEOC) en la litiasis infantil, analizando los resultados y complicaciones de nuestra serie. MÉTODO/RESULTADOS: Se evaluaron un total de 20 pacientes (16 varones y mujeres) con edades comprendidas entre 2 y 17 años. Doce pacientes presentaron litiasis en el lado izquierdo (60 por ciento). El tamaño del cálculo fue medido en cm2 de superficie. En 6 de los casos (30 por ciento) la litiasis se localizó a nivel calicial inferior y en 5 casos (25,9 por ciento) a nivel de uréter pelviano. Dos pacientes requirieron la colocación de catéter doble J. El número de ondas medio por sesión fue de 2650 (rango: 1000-3800).Los litotriptores utilizados fueron Dornier Lithotripter S y Dornier MFL-5000, utilizando un rango de kilovoltaje de entre 10-120 en la primera y 14-23 en la segunda. Se efectuó una evaluación a la semana y a los 3 meses del tratamiento mediante radiografía simple de abdomen, obteniendo porcentajes de fragmentación y eliminación.En nuestra serie la fragmentación total alcanzó un 100 por ciento de los casos, no objetivando ningún paciente con fragmen tación parcial (fragmentos >5 mm). Los porcentajes de eliminación fueron satisfactorios con un 65 por ciento de eliminación total y una eliminación parcial (quedando fragmentos residuales <5 mm) del 30 por ciento en la primera semana. En 1 paciente no se produjo eliminación alguna. CONCLUSIONES: Tras los resultados obtenidos en nuestra serie, consideramos la LEOC como la primera opción terapéutica a realizar en caso de litiasis infantil (AU)

[Extracorporeal shock-wave lithotripsy as treatment of lithiasis in horseshoe kidney]. / Litotricia extracorpórea por ondas de choque como tratamiento de la litiasis en riñones en herradura.

OBJECTIVES: Horseshoe kidney is the most frequent renal congenital anomaly, with an estimated general population prevalence of 1/400-500. This entity may be asymptomatic for the entire lifetime, or produce symptoms from associated complications such as lithiasis, hydronephrosis, or recurrent infections. The incidence of lithiasis varies between 20% and 80% of the patients. The treatment of lithiasis in this entity is controversial due to problems derived from the anatomy of the kidney and its drainage when stones are treated with external shock wave lithotripsy (ESWL). We tried to evaluate the efficacy of ESWL treatment and to establish the ideal conditions in which this technique may be considered treatment of choice. METHODS & RESULTS: A total of 25 patients were evaluated (17 males and 8 females). Patient age ranged from 8 to 75 year old. Three patients presented with bilateral lithiasis. 27 renal units were treated, 18 of which were left (66.7%) and 7 right. Stone size was measured in cm2 of surface. Lithiasis was located at the renal pelvis in 13 cases (48.1%), and lower calyx in 7 (25.9%). Four patients required JJ stent insertion. Mean number of shock waves per session was 3480 (range 1000-4000). Two Shock wave generators were used for treatment, the Dornier lithotripter S and the Dornier MFL-5000, with a range of 10-120 KV for the first one and 14-23 KV for the second. Follow up KUB X-rays were performed at 3, 6 and 12 months to evaluate fragmentation and elimination rates. In our series total fragmentation was 85.2%, and partial fragmentation (fragments > 6 mm) 14.8%. Elimination rates were satisfactory with 37.4% total elimination, and 48.1% partial elimination (Fragments < 6 mm). 14.8% of the patients had no elimination at all. CONCLUSIONS: We consider ESWL the first therapeutic option for cases of lithiasis with a mean area 4 cm2 or less and pelvic location. In case of great lithiasic areas other therapeutic options should be considered (open surgery or percutaneous nephrolithotomy) either in monotherapy or complementary to ESWL.

Litotricia extracorpórea por ondas de choque como tratamiento de la litiasis en riñones en herradura / External shock wave lithotripsy as treatment for lithiasis in horseshoe kidney

OBJETIVO: El riñón en herradura es la anomalía congénita renal más frecuente con una prevalencia aproximada en la población de 1 de cada 400-500 personas. Dicha entidad puede cursar de forma asintomática durante toda la vida o producir sintomatología derivada de complicaciones como litiasis, hidronefrosis e infecciones recurrentes. La incidencia de litiasis oscila entre un 20 per cent y un 80 per cent de pacientes con dicha anomalía. Se trata de un entidad en la que el tratamiento de elección de las litiasis se encuentra aún en controversia debido a los problemas derivados de la propia anatomía del riñón y su drenaje cuando las litiasis son tratadas con litotricia extracorpórea por ondas de choque (LEOC).Tratamos de evaluar la efectividad del tratamiento con LEOC estableciendo las condiciones ideales en la que dicha técnica puede ser considerada de elección en el tratamiento de estos casos. MÉTODO Y RESULTADO: Se evaluaron un total de 25 pacientes (17 varones y 8 mujeres) con edades comprendidas entre 8 y 75 años. Tres pacientes presentaron litiasis bilateral. Se trataron 27 unidades renales, de las cuales 18 fueron izquierdas (66,7 per cent) y 7 derechas. El tamaño del cálculo fue medido en cm2 de superficie. En 13 de los casos (48,1 per cent) la litiasis se localizó a nivel piélico y en 7 casos (25,9 per cent) en cáliz inferior. Cuatro pacientes requirieron la colocación de catéter doble J. El número de ondas medio por sesión fue de 3480 (rango: 1000-4000).Los generadores utilizados fueron Dornier Lithotripter S y Dornier MFL-5000, utilizando un rango de kilovoltaje de entre 10-120 en la primera y 14-23 en la segunda. Se efectuó una evaluación a los 3, 6 y 12 meses del tratamiento mediante radiografía simple de abdomen, objetivando porcentajes de fragmentación y eliminación. En nuestra serie la fragmentación total alcanzó un 85,2 per cent, quedando con fragmentación parcial (fragmentos >6 mm) un 14,8 per cent.Los porcentajes de eliminación fueron satisfactorios con un 37,4 per cent de eliminación total y una eliminación parcial (fragmentos residuales <6 mm) del 48,1 per cent. En un 14,8 per cent de pacientes no se produjo eliminación alguna. CONCLUSIONES: Consideramos la LEOC como la primera maniobra terapéutica a realizar en caso de litiasis con una superficie media menor de 4 cm2 y localización piélica. En caso de grandes superficies litiásicas deberían considerarse otras opciones terapéuticas (cirugía abierta o nefrolitotomía percutánea) como monoterapia o complementarias al tratamiento con LEOC (AU)