Testicular Sarcoidosis: Diagnostic Approach and Management Strategies.

Sarcoidosis is a multisystem disorder which, in rare cases, can affect the urogenital tract. The clinical presentation of this benign inflammatory disorder can easily mimic that of testicular malignancy. Therefore, it is crucial to differentiate between these two entities, as misdiagnosis may lead to unnecessary surgical interventions, which have important implications for future fertility. While testicular cancer must always be ruled out, sarcoidosis should be considered in all patients presenting with a testicular mass. Here, we present a case of sarcoidosis with bilateral epididymal and testicular involvement. The diagnosis was made by frozen section and the patient was treated with corticosteroids.

Balancing continence function and oncological outcomes during robot-assisted radical prostatectomy (RARP).

• A critical point in the evaluation of the radical prostatectomy (RP) outcomes is whether patients who obtain good cancer control also obtain good functional results. • Specifically, urinary continence recovery seems to have a more relevant impact on the patient's health-related quality of life in comparison with potency recovery. Moreover, this functional outcome is relevant for all patients who underwent RP regardless of the execution of a nerve-sparing approach to preserve potency. • Data coming from robot-assisted RP (RARP) series show excellent results for early and definitive urinary continence recovery and for negative surgical margins. Unfortunately, no data are available about the combination of these two relevant outcomes after RARP. • In this review article, we describe our surgical technique to minimize the risk of urinary incontinence and positive surgical margins and summarize data concerning continence recovery and early oncological outcomes after RARP.

Percentage of positive biopsies predicts lymph node involvement in men with low-risk prostate cancer undergoing radical prostatectomy and extended pelvic lymphadenectomy.

OBJECTIVE: To evaluate preoperative predictive risk factors associated with lymph node metastases (LNM) in a cohort of low-risk prostate cancer (PCA) patients. PATIENTS AND METHODS: The charts of 499 patients were retrospectively reviewed to identify prognostic risk factors for the presence of LNM. Pathohistological data and Gleason score of the radical prostatectomy (RP) specimen, number of removed nodes, number of positive lymph nodes, and anatomical distribution of LNM were tabulated and evaluated. A correlation between clinical stage, preoperative serum prostate-specific antigen (PSA), biopsy Gleason score, number of biopsies taken, percentage of positive biopsies and the presence of LNM were calculated. All 499 men underwent retropubic RP and extended pelvic lymphadenectomy (EPLND). RESULTS: LNM were identified in 29 (5.8%) patients. A prediction model based on clinical stage, PSA, and biopsy Gleason score had a predictive accuracy of 79.2%. The addition of number of positive biopsies and % positive cores improved its predictive accuracy to 81.5% and 87.8%, respectively. The predicted frequency of LNM by the original nomogram was 7.4% and differed by less than 3% with the actual observation of LNM. The predictive accuracy of the nomogram was 81.5% as compared with 87.8% of the prediction model of this study. CONCLUSIONS: The percentage of positive cores involved with PCA is the most reliable predictor of LNM and indicates the need for EPLND. The Briganti nomogram has been validated and a general applicability for predicting the presence of LNM was proven.

Prognostic parameters, complications, and oncologic and functional outcome of salvage radical prostatectomy for locally recurrent prostate cancer after 21st-century radiotherapy.

BACKGROUND: Salvage radical prostatectomy (SRP) for radiorecurrent prostate cancer (PCa) is a second local treatment with curative intent in patients with true organ-confined recurrent PCa. OBJECTIVE: We evaluated preoperative prognostic risk factors to predict organ-confined, locally recurrent PCa after primary radiotherapy (RT). DESIGN, SETTING, AND PARTICIPANTS: Fifty-five men with biopsy-proven, locally recurrent PCa underwent SRP and extended pelvic lymph node dissection (ePLND) after external-beam radiotherapy (EBRT) or low- or high-dose brachytherapy. MEASUREMENTS: Prostate-specific antigen (PSA), clinical stage, biopsy Gleason score prior to RT and SRP, PSA nadir, time to recurrence, PSA doubling time (PSA DT), PSA prior to surgery, and pathohistology of the SRP specimen were analysed to predict organ-confined recurrent disease. Uni- and multivariate statistical analysis was performed. RESULTS AND LIMITATIONS: Forty (72.7%) and 15 (27.3%) patients demonstrated organ-confined and locally advanced PCa, respectively. Eleven patients (20%) and seven patients (12.7%) had lymph node metastases and positive surgical margins (PSM), respectively. On multivariate analysis, biopsy Gleason score prior to SRP (p=0.02), <50% positive biopsy cores (p=0.001), PSA DT >12 mo (p=0.001), and low-dose brachytherapy (p=0.001) were significant predictors of organ-confined PCa with negative surgical margins (NSM). Limitations of the study are its retrospective nature and the relatively low number of patients. CONCLUSIONS: SRP is a surgically challenging but effective secondary local treatment of radiorecurrent PCa with curative intent. The identified predictive parameters will help to select patients most suitable for SRP with long-term cure and good functional outcome.

Do alpha-reductase inhibitors prevent prostate cancer? 2008 practice guideline from the American society of clinical oncology and American urological association.

As new guidelines on the use of 5-alpha-reductase inhibitors (5-ARIs) for prostate cancer chemoprevention produced by the American Society of Clinical Oncology (ASCO) and American Urological Association (AUA) have recently been published, the use of 5-ARIs is becoming of increasing interest. We analyzed the current evidence to support the use of 5-ARIs in the prevention of prostate cancer. We therefore compared the new guidelines of the ASCO and AUA with the current data concerning the use of 5-ARIs in the prevention of prostate cancer. At present, there is still an open debate going on whether or not it is advisable to incorporate the use of 5-ARIs as chemopreventive agents in daily practice.

Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection.

BACKGROUND: The anatomical extent of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) has been discussed controversially for many years. OBJECTIVE: To evaluate the necessity of PC-RPLND with modified or radical template resection in patients with advanced nonseminomatous germ-cell tumors (NSGCT) and residual masses following systemic chemotherapy. DESIGN, SETTING, AND PARTICIPANTS: The charts of 152 consecutive patients who were treated at two tertiary referral centers were retrospectively reviewed. INTERVENTION: All patients underwent PC-RPLND, with 54 and 98 patients undergoing a radical template resection and 98 patients undergoing a modified template resection. Modified template resection was performed if the location of the residual mass corresponded to the primary landing zone of testis cancer and the residual mass measured < or = 5 cm in diameter. In all other cases a full bilateral PC-RPLND was chosen. MEASUREMENTS: The following data were analyzed: location of the residual mass, extent of surgery, length of surgery, treatment-associated complications, nerve-sparing approach, adjunctive surgical procedures, postoperative morbidity, duration of hospital stay, early and late complications, relapse rates, cancer-specific survival rates, and overall survival rates. RESULTS AND LIMITATIONS: Overall, 84 patients (55.2%) had necrosis/fibrosis, 45 (29.6%) had mature teratoma, and 23 (15.1%) had vital cancer in the surgical specimens. Antegrade ejaculation was preserved in 85% and 25% of patients undergoing modified and bilateral PC-RPLND (p=0.02), respectively. Eight recurrences (5.2%) were observed after a mean follow-up of 39 mo (range 6-105 mo): one patient had an in-field relapse following modified PC-RPLND, and seven patients had recurrences outside the boundaries of full bilateral PC-RPLNDs. The 2-yr disease-free survival rates were 78.6% and 92.8% for bilateral and modified PC-RPLND, respectively. The limitations of this study were a short follow-up, a limited number of patients, and the retrospective nature of the study. CONCLUSIONS: Full bilateral PC-RPLND is the standard approach to extensive residual masses. In well-defined masses a modified template PC-RPLND does not interfere with oncologic outcome but decreases treatment-associated morbidity.

Postchemotherapy retroperitoneal lymph node dissection in advanced germ cell tumours of the testis.

OBJECTIVES: To review the role of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in patients with advanced testicular germ cell tumours (TGCT) with special attention towards the indication, surgical technique, and oncological outcome. METHODS: A structured review of the literature until May 2007 using the PubMed database was performed. RESULTS: According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is indicated only if a PET scan performed 6-8 wk after chemotherapy is positive. In nonseminomatous TGCT, PC-RPLND is indicated for all residual radiographic lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication, which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%; however, it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemorefractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. CONCLUSION: PC-RPLND represents a major part of the management of advanced TGCT undergoing inductive chemotherapy. Complete resection of all residual masses after primary chemotherapy results in a long-term disease-free survival of 95%. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.