Diagnosis and management of indeterminate testicular lesions.

The sophistication and accessibility of modern-day imaging result in frequent detection of small or equivocal lesions of the testes. Traditionally, diagnosis of a testicular lesion with any possibility of malignancy would usually prompt radical orchidectomy. However, awareness is growing that a substantial proportion of these lesions might be benign and that universal application of radical orchidectomy risks frequent overtreatment. Given the potentially profound effects of radical orchidectomy on fertility, endocrine function and psychosexual well-being, particularly in scenarios of an abnormal contralateral testis or bilateral lesions, organ-preserving strategies for equivocal lesions should be considered. Image-based active surveillance can be applied for indeterminate lesions measuring ≤15 mm with a low conversion rate to surgical treatment. However, these outcomes are early and from relatively small, selected cohorts, and concerns prevail regarding the metastatic potential of even small undiagnosed germ cell tumours. No consensus exists on optimal surveillance (short interval (<3 months) ultrasonography is generally adopted); histological sampling is a widespread alternative, involving inguinal delivery of the testis and excisional biopsy of the lesion, with preoperative marking or intraoperative ultrasonographic localization when necessary. Frozen section analysis in this context demonstrates excellent diagnostic accuracy. Histological results support that approximately two-thirds of marker-negative indeterminate solitary testicular lesions measuring ≤25 mm overall are benign. In summary, modern imaging detects many small indeterminate testicular lesions, of which the majority are benign. Awareness is growing of surveillance and organ-sparing diagnostic and treatment strategies with the aim of minimizing rates of overtreatment with radical orchidectomy.

Early percutaneous antegrade-retrograde rendezvous repair of a transected ureter-a real therapeutic option.

A 46-year-old female underwent elective laparoscopic hysterectomy. Seven days post-operatively, she presented with urinary leak from the vagina. Computed tomography urogram demonstrated a right complete ureteric transection with leakage of urine into the pelvis and fistulation into the vagina. A rendezvous procedure was performed via a retrograde cystoscopic approach during which a guidewire was used to cannulate the right ureteric orifice and coiled in the retroperitoneal cavity. Subsequently, via a right percutaneous nephrostomy, a guidewire was advanced through the site of ureteric transection, which was followed by a snare catheter to bring the retrograde wire externally. A nephroureteric stent was then inserted. Twelve weeks later, the nephroureteric stent was exchanged for a ureteric stent for 6 months. A subsequent retrograde ureterogram showed complete healing of the ureter. The ureteric stent was removed and follow-up ultrasounds revealed no hydronephrosis. Percutaneous rendezvous procedures represent an effective option to treat this challenging condition.