Organ preservation technique without ischemia in patients with testicular tumor.

OBJECTIVE: To determine the safety and efficacy of organ-sparing surgery (OSS) without ischemia in patients with testicular tumor. METHODS: From January 2003 to October 2010, marker-negative clinical stage I testicular tumors ≤ 30 mm and marker-positive tumors in case of a tumor in a singular testis were managed by an organ-sparing approach. After localization of the tumor by ultrasound and accurate staging, OSS was performed without ischemia. Frozen section analyses of the tumor and tumor bed biopsies were obtained. In cases of malignant germ cell tumor with a normal contralateral testis, an orchiectomy of the tumor-bearing testis was performed. In all other cases, the organ-preserving procedure was completed. RESULTS: A total of 65 patients underwent this approach. In 35 patients with a germ cell tumor on frozen section report (mean tumor size 1.4 cm; standard deviation ± 8.54 mm) and presence of a normal contralateral testis, a radical orchiectomy of the tumor-bearing testis was performed. Thirty-three organ-preserving procedures were completed in 30 patients without any complications (mean tumor size 0.9 cm; range, 0.2-2.0). No local or systemic recurrence was observed in all the 65 patients, and serum testosterone levels remained within normal limits in all but 2 patients. All patients are currently free of disease at a median follow-up of 52.5 months (range, 3-107). CONCLUSION: Our findings suggest that a "no-clamping" OSS technique is safe and feasible in selected tumor patients.

Organ-sparing surgery is the treatment of choice in benign testicular tumors.

PURPOSE: Ablation of the testis has been the reference standard for malignant and benign testicular tumors in the past. Nowadays, an organ-sparing surgery (OSS) can be attempted in special cases. Removal of a testis for a benign lesion should be avoided. In this retrospective survey, we analyze the results and long-term follow-up of OSS in benign testicular tumors. METHODS: Charts of all patients that underwent OSS because of a benign testicular tumor between 1999 and 2011 at our department were searched and the data from patients were collected. Before surgery, all patients underwent ultrasound (US) and complete staging. Surgery was performed under US or palpation guidance. Frozen-section examination of the tumor and tumor bed biopsies was obtained. All patients underwent postoperative follow-up. We retrospectively reviewed surgical technique, histology, epidemiology, and outcome in all patients. RESULTS: In the study period, 40 benign testicular tumors were surgically removed in 37 consecutive patients. Definitive histology did not report of any malignant histopathologic features in all patients. All patients are free of disease after a mean follow-up of 63 months (range 10-120). During this period, two patients developed a second leydig cell tumor (LCT) on the contralateral side; another patient had a second LCT within the same testicle, but on the opposite pole. All patients underwent a subsequent organ-sparing tumor resection. CONCLUSIONS: An overtreatment for benign testicular tumors should be avoided. Our initial results indicate that OSS in benign tumors is a safe, feasible treatment for patients.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection for low-volume, stage II, nonseminomatous germ cell tumor: first 100 patients.

BACKGROUND: Retroperitoneal lymph node dissection (RPLND) is indicated after chemotherapy in case of radiologic incomplete remission or teratomatous elements in orchiectomy specimens. Open RPLND is associated with considerable morbidity, but technical difficulty of postchemotherapy laparoscopic RPLND (L-RPLND) can be significant; therefore, literature concerning pc L-RPLND is sparse. OBJECTIVE: To evaluate feasibility and long-term oncologic outcome of postchemotherapy L-RPLND for clinical stage II disease at a single institution. DESIGN, SETTING, AND PARTICIPANTS: Records of patients with nonseminomatous germ cell tumor who underwent postchemotherapy L-RPLND between 1993 and 2010 were retrospectively reviewed. Unilateral template resection was used until a bilateral nerve-sparing approach was introduced in 2004. Follow-up investigations were performed at 3-mo intervals for the first 3 yr, every 6 mo for the next 2 yr, and annually thereafter. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: This was a descriptive analysis. RESULTS AND LIMITATIONS: The study cohort comprised 100 patients with stage II retroperitoneal disease (stage IIC: n=16; IIB: n=68; IIA with persisting tumor marker: n=16). Mean diameter of retroperitoneal masses before and after chemotherapy was 3.5 cm and 1.4 cm, respectively. Unilateral and bilateral templates were resected in 71 and 29 patients, respectively. Surgery was successfully completed in all but one patient, whose procedure was converted to open surgery due to bleeding. Mean operation time for unilateral and bilateral resection was 241 and 343 min, respectively. Mean blood loss was 84 ml. Postoperative complications were a large lymphocele in one patient and chylous ascites in another. Mean postoperative hospital stay was 3.9 d. L-RPLND specimens showed teratoma in 38 patients and active tumor in 2 patients. During a mean follow-up of 74 mo, one patient recurred. No recurrence was observed inside the applied surgical field. No patient died of tumor progression. After bilateral nerve-sparing postchemotherapy L-RPLND, 95.2% of patients reported antegrade ejaculation. CONCLUSIONS: Postchemotherapy L-RPLND performed by experienced hands is feasible and associated with low morbidity and high oncologic efficacy.

Influence of achieved paternity on quality of life in testicular cancer survivors.

OBJECTIVE: To investigate the influence of achieved/non-achieved paternity on quality of life (QoL) in testicular cancer (TC) survivors. PATIENTS AND METHODS: We invited TC survivors treated at our department between 1989 and 2006 to complete a QoL assessment, including the European Organisation for the Research and Treatment of Cancer QoL questionnaire, EORTC QLQ-C30 (version 3.0©)/+ TC26, and follow-up questions. A total of 311 TC survivors answered the questionnaire, of whom 207 patients who did not desire paternity were excluded. The remaining 104 patients who stated a desire for paternity after TC treatment were further divided in group A (TC survivors who achieved paternity; n = 51) and group B (TC survivors who did not achieve paternity; n = 53). The data obtained were statistically analysed. RESULTS: Significant differences between groups regarding QoL were detected for social functioning (P = 0.002), emotional functioning (P = 0.001), general QoL (P = 0.018), fatigue (P = 0.025), pain (P = 0.01), sleeping problems (P = 0.024), treatment satisfaction (P = 0.039), financial aspects (P = 0.006), sexual problems (P = 0.017), body image problems (P < 0.001), dyspnoea (P = 0.005) and cognitive functioning (P = 0.019). For all scales except 'sexual enjoyment', patients in group A were found to have a better long-term QoL than those in group B. CONCLUSIONS: Whilst acknowledging the shortcomings in retrospective analyses, we believe our data clearly underline the important impact on QoL for TC survivors of achieved paternity. Counselling patients early at diagnosis as well as using cryopreservation of semen in all potential patients before treatment (only excluding patients definitely claiming they do not wish to achieve paternity) should therefore be regarded as the standard of care.

Increased incidence of Leydig cell tumours of the testis in the era of improved imaging techniques.

OBJECTIVE: To report an observed high frequency of Leydig cell tumours (LCTs) diagnosed at our centre. PATIENTS AND METHODS: Charts of all patients who underwent surgery for a testicular tumour between 1999 and 2008 at our department were searched and data from patients with LCT were collected. Before surgery all patients underwent ultrasound and complete staging. In all but two patients with LCT an organ-sparing surgery was performed. Surgery was performed under ultrasound or palpation guidance. All patients underwent postoperative follow-up. We retrospectively reviewed surgical technique, histology, epidemiology and outcome in all LCT patients. RESULTS: In the study period, 197 testicular tumours were surgically removed of which 29 were diagnosed as LCT (14.7% of 197; further study group) in 25 patients. Mean age of patients with LCT was 45 years (range 21-68 years). Tumour size ranged from 1.2 to 80 mm (mean 10.23 mm). In two patients (8%) the lesion was palpable whereas incidental diagnosis was made in seven patients (28%). In the remaining patients diagnosis was made by ultrasound performed for testicular pain (six patients, 24%) or during infertility or erectile dysfunction evaluation (10 patients, 40%). Definitive histology reported no malignant histopathological features in all but one patient; this particular patient experienced tumour progression after 2 months and died from advanced disease 1 year later. All other patients are free of disease after a mean follow up of 56 months (range 7-93 months). During this period one patient developed a second LCT on the contralateral side; another patient had a recurrence within the same testicle, but on the opposite pole. Both underwent a subsequent organ-sparing tumour resection. CONCLUSION: The percentage of LCT (14.7% of all testicular tumours removed) was significantly higher than expected from the literature. One possible explanation for this phenomenon is the increasing use of better ultrasound technology and the subsequent increased detection of small nodules that have not been found in historical series. Use of 'observation-only' for very small lesions detected at infertility clinics is under debate.

Retrospective multicentre study of carboplatin monotherapy for clinical stage I seminoma.

OBJECTIVE: • To evaluate, in a retrospective multicentre study, the long-term oncological efficacy and morbidity of using carboplatin as an alternative treatment for patients with clinical stage I seminoma. PATIENTS AND METHODS: • Patients with clinical stage I seminoma treated with two cycles of adjuvant single-agent carboplatin (400 mg/m² body surface) from February 1990 until September 2008 were retrospectively identified. • A database was created (including information on patient characteristics, initial tumour staging, tumour marker levels, follow-up, oncological outcome, treatment side effects and long-term side effects), descriptive analyses were performed and the data were compared with those available in the literature. RESULTS: • Of 282 stage I seminomas identified in 276 patients, risk factors for progression (pT2/3, vessel invasion or tumour diameter ≥ 4 cm) were detected in 48.2% of tumours. • Chemotherapy was well tolerated, with patients experiencing only mild nausea. Bone marrow suppression was common (leucopaenia in 36.7% and thrombocytopaenia in 50.5% of patients, mainly grade 1/2). Neither neutropenic fever, nor any bleeding complication occurred. • During a mean follow-up of 75 months, three patients (1.06%) developed a retroperitoneal recurrence within the first 2 years after receiving adjuvant treatment and were salvaged by cisplatin-based chemotherapy. A contralateral second testicular germ cell tumour was diagnosed in five patients. CONCLUSIONS: • Two cycles of carboplatin monotherapy are highly effective and very well tolerated by all patients. The frequency of contralateral tumours appears to be reduced. • Despite the lack of a randomized trial, the available data in the literature suggest that the administration of two cycles instead of one cycle could lead to a reduction in recurrence rates of ≈50%.

Routine scrotal ultrasonography during the follow-up of patients with testicular cancer leads to earlier detection of asynchronous tumours and a high rate of organ preservation.

OBJECTIVE: To compare outcomes of patients with asynchronous tumours detected before and after the introduction of scrotal ultrasonography (SUS) during routine follow-up examinations. PATIENTS AND METHODS: Since January 2001 SUS was also used during the follow-up of patients with testicular cancer. A series of 16 consecutive patients with asynchronous bilateral testicular tumours diagnosed while still complying with routine follow up investigations were identified and divided into two groups; group A was diagnosed by palpation only, before 2001, and group B was diagnosed after 2000. The groups were compared statistically for the interval between asynchronous tumours, clinical stage, tumour diameter at the time of diagnosis and rate of testis-sparing surgery. RESULTS: All tumours in group A were diagnosed by palpation, but only two in group B were palpable at the time of diagnosis. The mean tumour diameter was statistically significantly smaller in group B (1.2 cm) than in group A (2.68 cm); testis-sparing surgery was used in all of group B and only three patients in group A. After organ-sparing surgery all patients had normal testosterone levels. All patients after organ-sparing surgery had adjuvant scrotal radiotherapy because of germ cell tumour, and no patient had a local recurrence. CONCLUSION: Our data indicate that using SUS for the remaining testicle in routine follow-up visits of patients with testicular cancer leads to the earlier detection of smaller tumours and, consequently, a higher rate of organ preservation. The maintenance of physiological endocrine function might finally result in a better quality of life.

Increasing patient comfort by optimized postoperative administration of intravesical mitomycin C.

OBJECTIVE: To report a prospective controlled study to compare the acceptance of two different ways of administering intravesical mitomycin C, as the immediate intravesical administration of chemotherapy after surgery decreases the risk of recurrence in patients with superficial bladder cancer, but response rates are variable, partly because of inadequate drug delivery and thus an adequate administration time is important for optimum oncological efficacy. PATIENTS AND METHODS: Between October 2004 and June 2005, 60 patients were divided after transurethral resection of superficial bladder cancer into two groups. Both groups received an intravesical instillation of 40 mg mitomycin C diluted in 40 mL distilled water at

Early results of bladder-cancer screening in a high-risk population of heavy smokers.

OBJECTIVE: To report first results of an early bladder-cancer detection programme, and to evaluate the detection rate and the diagnostic value of the tests used. SUBJECTS AND METHODS: Urine samples of 183 screened subjects with a history of smoking of > or =40 pack-years were collected for analysis with a urinary dipstick test for haematuria, the nuclear matrix protein-22 test (BladderChek, Matritech, Inc., Newton, MA, USA), voided urine cytology and a molecular cytology test (UroVysion, Abbott Molecular Inc., Des Plaines, IL, USA). Participants with at least one positive test result had a further evaluation including cystoscopy and radiological imaging. The subjects' risk factors, test results and histological findings were analysed. RESULTS: In all, 75 subjects had at least one positive test result and were evaluated further; abnormal histological findings were detected in 18 (24% of those who had cystoscopy, 9.8% of the original 183), 15 of those in the urinary bladder, with pTaG1 (one), carcinoma in situ (two), dysplastic lesions (11) and one an inverted papilloma. In the upper urinary tract, two urothelial tumours (pTaG1 and pTxN2G3) and one renal cell carcinoma (pT1G2) were detected by computed tomography. In summary, six of 183 subjects (3.3%) had a histologically confirmed malignant tumour and another 12 (6.6%) were identified with a possible pre-cancerous lesion of the urinary tract. The urinary dipstick, BladderChek, cytology and UroVysion detected (i.e. were true-positive in) nine (50%), one (6%), seven (39%) and 11 (61%) of the 18 tumours found, while they failed to detect nine (50%), 17 (94%), 11 (61%) and seven (39%) of these lesions, respectively. Omitting the urine dipstick test, the BladderChek, cytology or UroVysion from the test setting could have spared 40, five, two or one subjects(s) from unnecessary invasive interventions; however, three, none, two or six lesions, would have been missed. More positive screening tests per subject was associated with a higher probability of a (pre)-malignant lesion. CONCLUSION: Screening a high-risk group with a history of smoking of > or =40 pack-years showed a significant proportion (3.3%) with malignancy. These first results are encouraging and warrant continuation of the screening programme. In this series the most efficient screening tool was the combination of UroVysion, cytology and urinary dipstick testing. Of special scientific interest will be the follow-up of those patients with a possible pre-cancerous lesion.

Organ-sparing surgery does not lead to greater antisperm antibody levels than orchidectomy.

OBJECTIVE: To assess a possible development of antisperm antibodies (ASA), present in a high percentage of infertile patients, after organ-sparing surgery for small testicular tumours, to identify any additional immunogenic effect of this procedure compared with standard orchidectomy. PATIENTS AND METHODS: Samples of sera were assessed from 54 men who had had surgery between 2000 and 2005 for testicular tumour; the men were divided into two groups, i.e. group A (23) had had organ-sparing tumour resection and group B (31) had had inguinal orchidectomy. Other possible causes of ASA besides testicular tumour were excluded in all patients. The blood samples were obtained during follow-up visits and the circulating ASA in serum determined using an enzyme-linked immunosorbent assay. RESULTS: The mean (range) tumour diameter was statistically significantly greater (P < 0.03) in group B, at 33.6 (2-130) mm, than in group A, at 12 (2-30) mm. There were significantly more stromal tumours in group A than group B (P < 0.02). Most importantly, the mean (range) ASA levels were not statistically significantly (P > 0.3) higher in group A, at 29 (15-59) U/mL, than in group B, at 24.8 (12-39) U/mL. There was also no statistically significant correlation between ASA levels and clinical stage, length of follow-up after therapy, patient age, tumour size and type of histology. CONCLUSION: From these data, organ-sparing surgery does not lead to greater ASA levels than orchidectomy and patients are therefore at no greater risk of developing an autoimmune infertility.