Radiofrequency as a method of localizing impalpable breast lesions.

BACKGROUND: The incidence of early stage breast cancer has risen as a result of increased detection of non-palpable tumors through the implementation of screening programs and greater public awareness. Performing breast-conserving surgery can be challenging due to the need for accurate localization of non-palpable breast lesions, particularly given the logistical difficulties associated with wire localization. After implementing a new technique for localizing non-palpable breast lesions (LOCalizerTM Radiofrequency identification TAG-Hologic®), a radiofrequency identification tag localization device manufactured by Hologic, Inc. in Marlborough, MA, was launched in 2017, our objective was to investigate its impact on surgical outcomes, whether there was an increase in re-excision rates for positive margins and whether the attainment of clear margins was dependent on the exact positioning of the RFID device. METHOD: A single-center single-arm interventional study, data were gathered both in a forward-looking manner for 1 year (prospectively) and by looking back at past records for 1 year (retrospectively) for a total period of two years. Individuals who were diagnosed with non-palpable breast lesions, as confirmed by histological analysis, or invasive breast cancer and who were scheduled to undergo breast-conserving surgery were eligible for inclusion in the study. The RFID (Radiofrequency Identification) method was used to localize the lesions prior to surgery. Either with a mammogram or ultrasound scan position of the Tag was recorded, including the distance of the lesion from the center of the lesion and the lesion depth from the skin in millimeters. The rate of re-excision was documented and examined in relation to the parameters mentioned above. RESULTS: Two hundred and twenty RFID Tags were inserted in two hundred and seventeen (three patient had bilateral tags insertion), patients aged between 30 and 85 had a localizer Tag inserted between Oct 2020 and Oct 2022. Three patients had non-palpable breast lesions in both breasts. Fourteen were inserted under stereotactic guidance and two hundred and six under ultrasound guidance. Ten patients subsequently had wire insertion also due to Tag position. Of 210 procedures, RFIF Tags within the lesion was seen in hundred and sixty patients (76.19 %). An additional 50 procedures were performed using the RFID Tag system, which were not directly related to the lesion but were deemed appropriate to proceed with. Out of a total of 220 procedures, positive margins were observed in 38 cases (17.27 %). Among these cases, eleven (28.94 %) involved the use of the RFID Tag system, not within the lesion but adjacent to it (within 15 mm surrounding the lesion). CONCLUSION: RFID is a good alternative to wire localization of non-palpable breast lesions. Re-excision rates are higher in patients with Tag outside the lesion compared to those with Tag within the lesion.

Does the contralateral testicular volume decide the need for diagnostic laparoscopy in cases of unilateral impalpable undescended testis?

BACKGROUND: This study aimed the evaluation of the value of the calculated volume of a normal testis to predict the status of its contralateral impalpable side and hence decide the importance of laparoscopic exploration. METHODS: Patients with unilateral impalpable undescended testis - as confirmed by clinical and sonographic examination- were enrolled in our prospective interventional study between November 2018 and August 2022 at Elshatby University Hospital, Faculty of Medicine, Alexandria University. The volume and three-dimensional diameter of the normal contralateral testis were measured by the pre-operative US using the formula: Volume = L x W x H x π/6, where L is the length, W is the width, H is the height, and was correlated with the intra-operative laparoscopic findings. RESULTS: Seventy-six patients were included in our study. The age of the studied patients ranged between 6 months and 4 years with a mean of 2.17 ± 1.30 years; most of them were between one and three years old. Forty-six patients (60.5%) have left-sided impalpable testis and 30 patients (39.5%) have right-sided impalpable testis. The calculated volume of the contralateral normal testis was significantly larger in those patients who had both blind ending vas and vessels (0.89 ± 0.16) and in those who had an atrophic testis passing through the deep inguinal ring (DIR) -which was excised through the inguinal region- (0.83 ± 0.20) than in those patients who had their testes intra-abdominal (0.53 ± 0.18) or passing through the DIR to the inguinal region (0.80 ± 0.19). (Kruskal Wallis test; p < 0.001*). CONCLUSIONS: The calculated sonographic volume of a normal testis can predict the status of its contralateral impalpable side significantly with sensitivity & specificity of 75.0% & 88.89% respectively and a cut-off point of ≤ 0.674; hence, helps in parent counselling preoperatively. TRIAL REGISTRATION: Name of the registry: Clinicaltrials.gov PRS. TRIAL REGISTRATION NUMBER: NCT05933811. Date of registration: 10-7-2023 (retrospectively registered). URL of trial registry record: https://clinicaltrials.gov .

Long-term Outcome of Laparoscopic Surgery for Nonpalpable Undescended Testis.

Aims and Objectives: The aim of this study was to objectively assess the long-term results of laparoscopic orchidopexy in patients who were diagnosed clinically to have nonpalpable undescended testis (UDT). Materials and Methods: All operated cases of nonpalpable UDT from January, 2000, to January, 2014, were reviewed. After informed consent, all patients were subjected to a color Doppler ultrasound examination to assess the location of the testis, its size, blood supply, and consistency. The size of the testis, operated and nonoperated, was noted down in volume using the formula of 0.71 × length × breath × height. Results: A total of 114 patients could be identified, who had undergone laparoscopy for nonpalpable UDT in the study period. Of these, 44 patients (54 units) underwent a color Doppler study to assess the testes. All the testes were found to lie in the scrotum with preserved blood supply. The volume of the operated unilateral testes (mean = 1.605 cm3) was smaller than the normal nonoperated side (mean = 2.524 cm3). The smaller testicular volume was observed in spite of maintained blood supply to the testes. In cases of bilateral UDT, both the testes were smaller in size (mean = 2.2 cm3), but were comparable to each other. In addition, the ultrasound examination revealed the presence of normal homogenous parenchyma of all the testes similar to the nonoperated side. Conclusion: Laparoscopic orchidopexy is a safe and effective option in the treatment of nonpalpable UDT. On a long-term basis, it is possible to achieve scrotal position along with preserved blood flow following laparoscopic orchidopexy in all patients suffering from nonpalpable UDT.

A series of the first 13 combined Magseed and Magtrace cases in a single centre in regional Victoria.

BACKGROUND: The standard journey for a patient with impalpable breast cancer wishing to undergo breast-conserving surgery involves placement of a guidewire and lymphoscintigraphy pre-operatively. Access to these procedures is limited in the regional centres, this scheduling can require overnight stays away from home and can delay theatre which can increase patient distress. The Sentimag technology uses magnetism for localisation of preoperatively inserted Magseeds (for impalpable breast lesions) and Magtrace (for sentinel node biopsy), avoiding guidewire placement and nuclear medicine. This study evaluates the first 13 cases using this combined technique by a single specialist breast surgeon in a regional centre. METHODS: Thirteen consecutive patients were enrolled with ethics approval. Magseeds were placed under ultrasound guidance preoperatively, and Magtrace was injected at the time of pre-operative consultation. RESULTS: The median age of patients was 60 (range 27-78). The average distance from hospital was 81.63 km (2.8-238 km). The average operating time was 1h54m (range 1 h 17 m-2 h 39 m) and the mean total journey time was 8h54m (range 6-23 h). The earliest time-out was 8:40 am. Re-excision rate was 23% (n = 3), however, in each re-excision case the lesions were in the axilla, were small (<15 mm) and were in patients with dense breasts on mammography. There were no significant adverse outcomes. CONCLUSION: In this preliminary study Sentimag localisation appears to be safe and reliable when used in combination. Re-excision rates were only slightly higher than reported in the literature and predicted to downtrend with ongoing learning curve.

Magnetic marker localisation in breast cancer surgery.

Since mammographic screening programmes were initiated, the spectrum of breast cancer has changed in terms of impalpable tumours, thus causing the development of new localisation methods, including magnetic markers. We offer herein an up-to-date review focused on two magnetic markers (Magseed, MaMaLoc) currently used in breast cancer surgery for the localisation of breast tumours or pathological axillary nodes. Magnetic marker localisation presents a safe and reliable method for breast tumour marking. Four currently available prospective studies demonstrate that the Magseed system has a negative margin rate and a successful localisation rate, both of which are comparable to standard marking systems used in breast cancer surgery. The main benefits of magnetic markers are that they require no radiation safety measures, and they offer the possibility of longer deployment times, thus simplifying surgery scheduling. The most important drawbacks are cost of the system, depth limitation and need for frequent probe recalibration.

What Is the Malignant Potential of Small (<2 cm), Nonpalpable Testicular Incidentalomas in Adults? A Systematic Review.

CONTEXT: Unlike palpable lumps, a large number of nonpalpable testicular lesions found incidentally at ultrasound in asymptomatic postpuberal males are either benign tumours or non-neoplastic lesions. The prevalence of malignancy, however, is appraised based on small case series. Dedicated studies report a large number of patients, and systematic review articles are lacking. OBJECTIVE: This systematic review is aimed to assess, from the analysis of the pooled data of the available literature, the incidence of benign tumours, malignant tumours, and non-neoplastic lesions, and to identify predictive characteristics for malignancy. EVIDENCE ACQUISITION: A systematic review of PubMed, Scopus, Google Scholar, Turning Research Into Practice (TRIP) database, and the Cochrane Library was conducted on January 6, 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were retrieved reporting on adult asymptomatic men, with single, incidentally identified small testicular lesions, either fertile or infertile, with negative tumour markers and without specific risk factors for malignancy. Lesions ≤20 mm were considered small. Seventy-four studies were selected for inclusion in this analysis. Twenty-six additional publications have been retrieved by the bibliography quoted in the selected articles. EVIDENCE SYNTHESIS: Pooled data of 1348 lesions in 1348 patients were collected. Of these lesions, 408 could be retrieved individually, 44.6% were benign, 27.2% were malignant, and 20.8% were non-neoplastic. Virtually all lesions <3 mm and 86.6% of lesions <5 mm were benign. Lesions >10 mm have a 38.14% probability of being benign. Hyperechoic lesions are likely benign. Fertility status does not affect the risk of malignancy. CONCLUSIONS: Very small (<3 mm) and small (<5 mm) incidentally detected testicular lesions in asymptomatic postpuberal men with normal tumour markers could be frequently benign. More prospective studies are needed to better support this finding. Management strategies should be developed for these patients to reduce overtreatment. PATIENT SUMMARY: Small testicular lesions are incidentally founded at ultrasound. It is not easy to distinguish a benign lesion from a malignant one. Results of this study are reporting a higher incidence of benign lesions with a diameter of <5 mm. More studies are needed to better understand the biology and the management strategy for small testicular lesions.

Radioactive Seed Localization for Conservative Surgery of Nonpalpable Breast Cancer: Recommendations for Technology Implantation Program.

Background: The radioactive seed localization (RSL) is used in impalpable breast cancer conservative surgery to assist the surgeon in accurately locating and excising the lesion site. This study aims to present recommendations about the RSL program implementation in health institutions that perform breast cancer conservative surgery with intraoperative localization. Methods: An extensive literature review was performed. It comprehends: the committee responsible for implementation of the program actions; description of the necessary multidisciplinary team; the radiological safety committee role; the facility licensing; professionals training; material and instrumentation associated with the technique; and seed tracking system. Results: 13 topics are presented. The Program Implementation Committee must be formed by leaders from each department. The committee assumes responsibility for evaluating the necessary processes and presenting the schedule for program implementation. Since the procedure is classified as a nuclear medicine procedure it requires licensing. The Professional Team Formation, Education, and Training is a priority and simulation exercises are necessary. The Materials and Instrumentation Associated with the Technique must be well-know by the team and they should practice using radiation detectors. The seed must be always tracked, from moment they are received to discard. An Inventory for Tracking Seeds is provided. The Radiological Safety Aspects such as the ALARA principle are presented. A full description for the Radiological Procedure for Placing the seeds, the surgical removal and the Specimen Handling in Pathology focusing on how to locate the seed and retrieve them. After removed, the seeds can be placed in storage to wait for full radioactive decay or be returned to the manufacturer. Conclusions: The procedure has the advantage to increase to 2 months the time between insertion of the seed and the surgical removal. Regular multidisciplinary team meetings during program development are important to create a realistic timeline, having briefing meetings after the first 1-5 RSL cases and having annual or biannual follow-up meetings to discuss any issues or incidents. Abstract Graphic ImageCreated by Macrovector, obtained in Freepik at https://br.freepik.com/fotos-vetores-gratis/oncologia.This graphical abstract shows everything that is necessary to implement the RSL technique and are discussed in this paper. Highlights: This study present recommendations for RSL program implementation in hospitalsWas performed by an extensive descriptive and qualitative literature reviewTopics 1: Implementation Committee, Professional Team Training, InstrumentationTopics 2: Radiological Safety, Patient Consent, Radiological ProcessTopics 3: Surgical Procedure, Pathology, Seeds Disposal Completion.

The undescended testis in children and adolescents part 2: evaluation and therapeutic approach.

Undescended testis (UDT) is defined as failure of a testis to descend into the scrotum and it is a common reason for consultation in pediatric urology. As extensively discussed in "The undescended testis in children and adolescents: part 1", the failure of a testis to descend alters testicular germ-cells development, increasing the risk of infertility and testicular cancer in adulthood. Here, we present the second part of our review and analysis of this topic with the aim to propose an updated and well-informed approach to UDT together with a treatment flow chart that may be useful to guide pediatric surgeons and urologists in the care of these patients. The main goal of the management of patients with UDT is to diminish the risk of infertility and tumor development and is based on the clinical findings at the time of diagnosis.

Use of wire-guided and radio-guided occult lesion localization for non-palpable breast lesions: A systematic literature review and meta-analysis of current evidence.

Breast cancer screening has seen an increase in the detection of non-palpable breast lesions. Wire guided localisation (WGL) and Radio-guided occult lesion localisation (ROLL) are well established modalities of localisation of non-palpable breast lesions in the UK. We aimed to compare the outcomes of WGL and ROLL in this updated meta-analysis. We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words as well as relevant MESH-terms. We also searched Medline (02/03/2021), Embase and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Outcomes considered were re-excision rates, margin involvement, specimen volume and weight, accurate localisation of lesions and operative time. We assessed the risk of bias in included studies and performed random effects meta-analyses using Review Manager (version 5.3). Heterogeneity was estimated using the I2-statistic. Nine included studies enrolled 1096 patients undergoing localization in breast surgery (534 in WGL and 562 in ROLL). There was a statistically significant benefit in favour of ROLL for non-involved resection margins (OR 0.60; 95% CI, 0.44-0.97); based on seven studies. Nine trials assessed operative time favouring ROLL (OR 1.95; 95% CI, 0.27-3.63). No significant difference in re-excision rates was reported (OR 1.42; 95% CI, 0.83-2.43) based on seven studies. Current evidence favourably supports ROLL, compared to WGL, with respect to margin involvement, localisation and operative time in the treatment of non-palpable breast lesions.

Wired for Surgical Success: Our Experience with Preoperative Ultrasound-Guided Wire Localization of Impalpable Breast Lesions.

Aims The purpose of this study was to review our experience with preoperative ultrasound-guided wire localization and to identify our rate of successful localization and subsequent excision. Materials and Methods At our institution, we performed preoperative wire localization for 28 impalpable breast lesions in 27 women (1 patient underwent wire localization for bilateral breast lesions), between April 2016 and August 2019. We used a Toshiba APLIO2 ultrasound machine and a linear probe (7-12 MHz) to visualize lesions and needle-wire systems comprising a 20-gauge needle with preloaded wire to localize lesions. We analyzed the percentage of specimen mammograms with wire in situ and percentage of excised specimens showing margins free of tumor, along with imaging features, BI-RADS (Breast Imaging-Reporting and Data System) categories, and histopathological and molecular diagnosis of the lesions. Results All specimen mammograms confirmed the presence of wire in situ, except one (96.4%); in the latter case, postponement of surgery due to intractable cough was suspected to have caused wire displacement. All malignant specimens showed margins free of tumor (100%). Conclusions Our results show that wire localization is extremely effective in providing crucial preoperative insight into the precise location of an impalpable lesion. Despite the advent of nonwire localization devices such as radioactive seeds, radar reflectors, magnetic seed markers, and radiofrequency identification tags, wire localization remains the most widely practiced method, especially in resource-limited settings. Its high degree of accuracy serves as a key factor in the successful outcome of breast conservation surgery for impalpable breast lesions.

The role of radiological surveillance in the conservative management of incidental small testicular masses: A systematic review.

Objective: The increasing use of scrotal ultrasonography (US) for non-cancerous indications has led to greater detection of incidental, small testicular masses. Operative intervention is currently the mainstay of treatment for all testicular tumours; however, despite the low malignant potential of small, incidental masses, little is known about conservative management using radiological surveillance. Methods: A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted and studies meeting the inclusion criteria were reviewed for patient outcomes. Results: A total of 293 patients across six studies underwent radiological surveillance for an incidental small testicular mass. Infertility was the main indication for investigation and all studies used US as the surveillance modality. A total of 37 patients (12.6%) underwent surgical exploration during follow-up, with only 10 (3.4%) found to have malignant disease at histology. Conclusions: Radiological surveillance of incidental small testicular masses is safe when used for select patient groups due to the high probability of benign disease, although optimal patient selection criteria and a well-defined protocol are lacking. This approach could be considered in patients with incidental, impalpable testicular masses of ≤5 mm in diameter displaying no significant size increase or internal vascularity on US and with negative tumour markers, as the probability of malignancy in these patients is low.

Pre-operative localization of impalpable breast lesions using iodine 125 seeds: Placement accuracy and multidisciplinary challenges.

INTRODUCTION: The number of impalpable breast lesions requiring pre-operative lesion localization (PLL) continues to increase. The use of Radio-guided Occult Lesion Localization with Iodine 125 Seeds (ROLLIS) offers multiple benefits for the multidisciplinary team (MDT), but is not without challenges. AIMS: The aims of this audit were to review our multidisciplinary team's experience following introduction of ROLLIS as standard of care for PLL, identify challenges and evaluate seed placement accuracy (SPA). RESULTS/OUTCOMES: Over a nineteen month period, 327 seeds were inserted: 96% of single seed localizations were within 10 mm, 91% within 5 mm and 42% within or in contact with the lesion (or marker clip surrogate) on post-insertion two view mammography. Each component of the MDT reported on benefits of the ROLLIS program and challenges faced. Examples included: an undetectable seed in the operating room, a seed damaged in pathology during specimen processing, suboptimal seed position requiring hook-wire localization (HWL) and delayed seed removal in a patient who initially refused to return for surgery. CONCLUSION: ROLLIS results in high seed placement accuracy. Despite clear advantages, use of ROLLIS presents some multidisciplinary challenges. Robust patient information, training of new staff and adherence to strict policies and protocols are required to ensure safe delivery of a ROLLIS program.

Preoperative localisation techniques in breast conservative surgery: A systematic review and meta-analysis.

The preoperative localisation of non-palpable lesions guided by breast imaging is an important and required procedure for breast-conserving surgery. We conducted a systematic review and meta-analysis of the literature on the comparative impact of different techniques for guided surgical excision of non-palpable breast lesions from reports of clinical or patient-reported outcomes and costs. A literature search of PubMed, ISI, SCOPUS and Cochrane databases was conducted for relevant publications and their references, along with public documents, national and international guidelines, conference proceedings and presentations. From 5720 retrieved articles screened through title and abstract, 5346 were excluded and 374 assessed for full-text eligibility. For data extraction and quality assessment, 49 studies were included. Results of this review demonstrate that Radioactive Seed Localisation (RSL) and Radioactive Occult Lesion Localisation (ROLL) outperform Wire in terms of involved margins and reoperations. Between RSL and ROLL, there is a tendency to favour RSL. Similarly, Clip-guided localisation seems preferred when compared to ROLL, however further studies are needed. In summary, there seems to exist evidence that RSL and ROLL are better than Wire, representing potential alternatives, with a quick learning curve, better scheduling and management issues. Although, for recent techniques, more research is needed in order to achieve the same level of evidence.

Testicular remnant "nubbin" and incidental ectopic adrenal cortical rests: A case series and systematic review.

AIM: To determine whether excising a testicular remnant or nubbin is necessary and perform a systematic review of the incidental ectopic adrenal cortical rest associated with undescended testis. MATERIAL AND METHODS: A retrospective analysis of impalpable undescended testis was carried out between May 2016 and June 2019. The demographic data, intra-operative findings and histopathological diagnosis were analyzed. In conjunction with this, systematic search of PUBMED and EMBASE database was performed by using the search terms "undescended testis" AND "ectopic adrenal tissue". Data was collected for demographic characteristics, size and appearance of ectopic adrenal cortical rest and histopathology. Quantitative data has been presented as medians. Categorical variables have been presented as percentages. RESULT: We encountered 43 cases of impalpable undescended testis, out of which, nubbins were identified in 9 cases. Incidence of EACT in nubbin and impalpable UDT was 2/9 (22.22%) and 2/43 (4.7%) respectively. None of the excised nubbin had germ cells. On Systematic review, EACT associated with UDT was seen in 90/2501 (3.6%), while its association with testicular nubbin has been reported only once before in a case report. CONCLUSION: A testicular nubbin is a condition wherein no viable testicular tissue can be grossly identified in a case of impalpable testis. Even when germ cells are not found in the excised nubbin, the presence of ectopic adrenal cortical rest make them prone to later malignant transformation. Association of EACT with UDT has been consistently reported but there is scarcity of such documentation in association with testicular nubbin.

Evaluation of the nonradioactive inducible magnetic seed system Magseed for preoperative localization of nonpalpable breast lesions - initial clinical experience.

INTRODUCTION: Many early-stage breast cancers are not palpable and thus must be localized before surgery. Detecting these lesions is crucial before they become clinically symptomatic to avoid morbidity and mortality. Nowadays, there are several new alternative techniques to traditional needle/wire localization available. These methods allow for better surgical margins, decreased costs and operating room delays, as well as improved patient satisfaction. The purpose of this study is to evaluate the nonradioactive inducible magnetic seed system Magseed (Endomagnetics Ltd, Cambridge, UK) for preoperative localization of nonpalpable breast lesions. To our knowledge, this report documents the first clinical experience with Magseed in Poland. MATERIAL AND METHODS: A single-institution case report of 10 women with nonpalpable breast lesions localized and excised by using the Magseed surgical guidance system between November 2017 and May 2018. RESULTS AND CONCLUSIONS: Magseed is an easy, sensitive and effective localization method. It is beneficial for oncoplastic outcomes and for scheduling efficiency, which overcomes many limitations of other localization methods. Surgical specimen margins were evaluated in 90% of cases as negative, with no additional re-excision. Only one patient with ductal carcinoma in situ had a positive tumor margin at the axillary side.

Methylation profiling in promoter sequences of ATM and CDKN2A (p14ARF/p16INK4a ) genes in blood and cfDNA from women with impalpable breast lesions.

The objective of the present study was to evaluate the epigenetic changes occurring in early stages of breast cancer. The present study investigated the methylation profile of the ATM, p14ARF and p16INK4a promoters in total blood and plasma cell-free DNA (cfDNA) from women with impalpable breast lesions compared with in total blood of a control cohort of women without breast lesions. The samples were evaluated using the methylation-specific PCR method. The Fisher's exact test was used to evaluate statistical significance between the methylation and clinical variables. A total of 111 women were evaluated, including 56 women with impalpable breast cancer (39/56 also had paired plasma cfDNA) and 55 women in the control cohort (55 blood DNA). For blood DNA from women with malignant impalpable breast lesions, p16INK4a exhibited the greatest percentage of methylation (48%), followed by ATM (37.5%) and p14ARF (27%) promoters, regardless of age variation. For plasma cfDNA, the methylation rates for ATM, p14ARF and p16INK4a were 26, 26 and 10%, respectively. The methylation rates for the blood DNA of controls were the lowest for ATM (9%), p14ARF (7%) and p16INK4a (7%). The women with impalpable breast lesions (benign and malignant lesions) exhibited the highest methylation rate, regardless of age, compared with the paired plasma cfDNA and controls. This epigenetic change was statistically significant for the promoters of ATM (P=0.009) and p16INK4a (P=0.001) (impalpable breast lesions vs. control). The present study demonstrated that epigenetic changes occurring in the ATM and CDKN2A genes detectable in liquid biopsy were associated with the development of impalpable breast lesions.

How far can one-stage laparoscopic Fowler-Stephens orchiopexy be implemented in intra-abdominal testes with short spermatic vessels?

OBJECTIVE: The aim of the study was to compare the outcome of the prospective cohort who had one-stage laparoscopic Fowler-Stephens orchiopexy (LFSO) with an earlier, similar cohort who had a two-stage LFSO. Both cohorts included only intra-abdominal testes (IATs) with short spermatic vessels. STUDY DESIGN: The present study initially included all patients between the age of six months and preschool age, presenting with an IAT to the authors' tertiary clinic from January 2012 to December 2014. Only intra-abdominal testes with short testicular vessels, correlating to type 3A, 3B and 4A as per the updated Ain Shams classification, were included in this study. One-stage LFSO was performed on all patients. Patients with bilateral intra-abdominal testes had the procedure performed on the contralateral side 6-8 weeks later. Follow-up was performed at 6, 12 and 36 months postoperatively by means of Doppler ultrasound in the first two visits. A similar subgroup of the historical cohort from years 2002 to 2010 had a two-stage LFSO, with the second stage being performed 12-16 weeks later. In bilateral cases, a three-interval surgery based on two-stage LFSO was performed, with a follow-up at 6 months postoperatively. RESULTS: The recent cohort included 16 IATs (10 unilateral and 3 bilateral). The median age of the patients was 1.41 years. At 6-month follow-up, 4 testes were found atrophic (25%), whereas the remaining 12 testes (75%) were viable. In those viable, only half of them had a low scrotal position. No difference was found at 12- or 36-month follow-up. Doppler ultrasound confirmed adequate intratesticular blood flow at 6 and 12 months postoperatively. In the similar subgroup of the historical cohort, 3 of 25 (12%) testes were found atrophied at six months postoperatively, with only one testis (4%) having a high scrotal position. In a comparison of both cohorts, the two-stage LFSO was found to be associated with a halving of the testicular atrophy rate (p value = 0.401) and a higher incidence of low scrotal position (p value = 0.004). A comparison of both cohorts is shown in the summary table. CONCLUSION: Although one-stage LFSO may seem tempting, it still holds a higher rate of testicular atrophy, which is not justified. LEVEL OF EVIDENCE: Level III (Case-control study).

The Diagnosis and Treatment of Impalpable Testes at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia.

Background Impalpable testes may be caused by atrophy, congenital dysgenesis/agenesis, or the presence of testes at unusual sites. Early intervention can improve patient outcomes. The recommended age for surgery ranges from 6 to 18 months. Objective To investigate the diagnosis, treatment, and outcomes of impalpable testes and sensitivity and specificity of ultrasonography to diagnose impalpable testes at King Salman Armed Forces Hospital (KSAFH), Tabuk, Saudi Arabia. Methods We conducted a retrospective study to review cases of impalpable testes admitted to KSAFH, Tabuk, Saudi Arabia from January 1, 2015 to May 20, 2019. Fifty patients diagnosed with impalpable testes were treated surgically in our center during the period. Patients' data were tabulated, and statistical analysis was performed using Statistical Package for Social Sciences software (SPSS, version 22; IBM, Armonk, NY).  Results We included 50 patients in our study, with a total number of 66 impalpable testes. The median age at diagnosis was 7 months, while the median age at surgery was 17.5 months. The median interval between diagnosis and surgery was 8.5 months, with 44% of cases undergoing surgery after the age of 1.5 years. Two-thirds of the cases were unilateral. The most common site was intracanalicular (57.6%) followed by intra-abdominal (34.8%). The testicular size was average in 36.4%, small in 42.4%, and atrophic in 21.2% of the evaluated cases.  Conclusions The overall sensitivity of ultrasonography was 56.1% (it correctly detected the location of 37 out of 66 impalpable testes). The sensitivity of ultrasonography for the detection of intra-abdominal testes was 43.5%, while that of intracanalicular testes was 71.1%.

Localization of impalpable breast lesions and detection of sentinel lymph nodes through magnetic methods.

PURPOSE: The most commonly used technique for guiding the surgical removal of impalpable breast lesions is wire-guided localization (WGL). Potential complications of WGL include wire migration, wire transection, patient discomfort, and pneumothorax. Recently, another possibility for preoperative localization of breast lesions trough small steel seeds was developed. A magnetic handheld probe can be used both for localization of breast lesions and sentinel lymph nodes (SLNs) detection. METHODS: In this study, we used a new technology for localizing breast lesions in conjunction with sentinel nodes (SLNs) detection through SPIO nanoparticles; both detected using a magnetic probe. The technique uses small steel markers (Magseed®) with magnetic properties, which are placed in breasts under ultrasonographic or mammographic guidance. 41 localization seeds were placed in 38 patients. In 27 patients with malignant tumors, simultaneous use of magnetic method for SLNs detection was used. RESULTS: In all 38 patients, breast lesions were accurately localized using this method. No interference between Magseed signals and SPIO tracer signals were observed during magnetic probe measurements. All tumors were exscised with tumor-free surgical margins. The SLN biopsy was successful in all patients undergoing this procedure. The SLN median detection rate was 3 nodes. CONCLUSIONS: The new magnetic methods are reliable alternatives for localizing breast lesions and SLN detection. They are well tolerated by patients and they can avoid the disadvantages of WGL. They have the potential to make tumor localization and SLN biopsy procedures possible in facilities without a nuclear medicine department or where radioisotope availability is limited.