Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel.

CONTEXT: The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial. OBJECTIVE: To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents. EVIDENCE ACQUISITION: A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion. EVIDENCE SYNTHESIS: Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates. CONCLUSIONS: Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown. PATIENT SUMMARY: In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear.

Radiotherapy for spermatic cord sarcoma.

OBJECTIVES: Spermatic cord sarcomas are rare paratesticular tumors affecting older men. Current management is based on small series, case reports, and literature reviews, with surgery still the mainstay of treatment. Local-regional recurrence is common after definitive surgery (~50%), but patients treated with adjuvant radiotherapy may have improved outcomes. METHODS: We reviewed the outcomes of 15 patients with intermediate-grade to high-grade spermatic cord sarcomas treated with radiation at our institution from 1974 to 2009. Patients were treated to 40 to 60 Gy using conformal opposed anterior-posterior/posterior-anterior ports to the scrotum, inguinal canal, and lower pelvic wall with various beam energies. Some patients were managed with surgical exploration and resection, followed by radiotherapy and/or definitive surgery. More recently treated patients had an initial biopsy, followed by preoperative radiation or planned resection with postoperative radiation therapy. RESULTS: No patient experienced a local recurrence. Two patients had regional nodal recurrences and 1 had distant metastases. All recurrences were in patients who had initial "exploration" with unexpected findings of sarcoma during surgery versus planned, definitive resection with planned adjuvant radiotherapy. At 5 years, overall survival was 53%, but cause-specific survival was 80%. Complications were minimal, with only 4 grade 2 or 3 toxicities and no grade 4 toxicities. CONCLUSIONS: Although most patients die from causes other than disease progression, this sarcoma carries grave morbidity. Optimizing the primary management is of utmost importance. Unplanned treatments complicate definitive therapy and increase the risk of local-regional contamination and recurrence. Proactive management is therefore consistent with sarcomas of other primary sites, ideally with preoperative radiotherapy and definitive resection.

Role of radiotherapy in the treatment of fibrosarcoma of the spermatic cord: a case report and review of the literature.

BACKGROUND: Spermatic cord sarcomas are rare. The therapeutic approach is based only on case reports and small series. The standard treatment is radical orchiectomy with wide local resection, while the role of adjuvant therapies is not clear. We present a case of fibrosarcoma of the spermatic cord treated with surgery and adjuvant radiotherapy. A review of the literature about the role of adjuvant treatments is also discussed. CASE REPORT: A 59-year-old man presented a right testicular mass of about 4 × 3 cm in size. Biopsy showed a high-grade polymorphous sarcoma, consistent with a diagnosis of poorly differentiated fibromyosarcoma. He underwent a right radical inguinal orchiectomy and adjuvant radiotherapy (total dose: 5940 cGy). During treatment the patient developed a G3 skin toxicity (RTOG score) in the inguinal fold. After a follow-up of 57 months, he is alive and without evidence of local or distant recurrence. No late toxicity was noted. CONCLUSION: The optimal adjuvant management of spermatic cord sarcoma is still uncertain. Looking at the literature, it seems that adjuvant radiotherapy can improve locoregional control and disease-free survival without additional late toxicity.

An intravital microscopy study of radiation-induced changes in permeability and leukocyte-endothelial cell interactions in the microvessels of the rat pia mater and cremaster muscle.

Using intravital microscopy and a closed window method, we measured irradiation-induced changes in the vascular permeability and cell interactions in microcirculation networks of the rat pia mater; the same effects were monitored in the cremaster muscle as a control. The closed cranial window has many advantages, including long-term direct visualization of microcirculation. The method allows for repeated testing of the same vessel or network, thereby reducing variability. The method also allows for measurement of permeability changes and the accompanying leukocyte-endothelial cell interactions in the same network or vessel, which permits correlative studies of these phenomena. However, this method is not without challenges. The optical conditions are difficult, because the brain is three-dimensional and its parenchyma is more complex than the thinner, flatter peripheral tissues. To overcome this limitation, we performed a dynamic background subtraction. The background is dynamically related to vessel intensity, and changes in intensity were determined by eliminating the effects of neighboring and underlying vessels. We applied this method to studying the effects of ionizing radiation on the blood-brain barrier (BBB) permeability and cell interactions and the modulation of these effects by anti-ICAM-1 antibodies. Our results demonstrate that this method is sensitive to changes in these properties of the BBB.

Seminoma in a renal transplant recipient.

A case is reported of testicular seminoma developing de novo 13 months post-transplantation. Two other post-transplant scrotal complications were noted, that is hydrocele and testicular atrophy. The question raised is what type of therapy would be best for this patient.