Nerve Sparing during Robot-Assisted Radical Prostatectomy Increases the Risk of Ipsilateral Positive Surgical Margins.

PURPOSE: Available published studies evaluating the association between nerve sparing robot-assisted radical prostatectomy and risk of ipsilateral positive surgical margins were subject to selection bias. In this study we overcome these limitations by using multivariable regression analysis. MATERIALS AND METHODS: Patients undergoing robot-assisted radical prostatectomy for prostate cancer at 4 institutions from 2013 to 2018 were included in the study. A multilevel logistic random intercept model, including covariates on patient level and side specific factors on prostate lobe level, was used to evaluate the association between nerve sparing and risk of ipsilateral positive margins. RESULTS: A total of 5,148 prostate lobes derived from 2,574 patients who underwent robot-assisted radical prostatectomy were analyzed. Multivariable analysis showed nerve sparing was an independent predictor for ipsilateral positive margins (OR 1.42, 95% CI 1.14-1.82). Other significant predictors for positive margins were prostate specific antigen density (OR 3.64, 95% CI 2.36-5.90) and side specific covariates including highest preoperative ISUP (International Society of Urological Pathology) biopsy grade (OR 1.58, 95% CI 1.13-2.53; OR 1.62, 95% CI 1.13-2.69; OR 2.11, 95% CI 1.39-3.59 and OR 4.43, 95% CI 3.17-10.12 for ISUP grade 2, 3, 4 and 5, respectively), presence of extraprostatic extension on magnetic resonance imaging (OR 1.42, 95% CI 1.03-1.91) and percentage of positive cores on systematic biopsy (OR 3.82, 95% CI 2.50-5.86). CONCLUSIONS: Nerve sparing was associated with an increased risk of ipsilateral positive surgical margins. The increased risk of positive margins should be considered when counseling patients who opt for nerve sparing robot-assisted radical prostatectomy.

Incremental value of transition zone and midline apical biopsy at baseline TRUS-guided biopsy for prostate cancer detection.

PURPOSE: To determine the diagnostic yield of transition zone (TZB) and midline apical biopsies (MAB) in baseline transrectal ultrasound (TRUS)-guided biopsies and to establish whether TZB and MAB for the diagnosis of prostate cancer (PCa) add clinical relevant information. METHODS: We performed baseline 9-core TRUS-guided biopsy in 412 consecutive subjects using sextant biopsies of the PZ (PZB), with an additional TZB on either side and a MAB at the prostatic apex. We determined the incremental diagnostic value of additional TZB an MAB to sextant PZB. RESULTS: Within a cohort of 412 patients with a median PSA of 7.5 ng/ml, 178 (43.2 %) patients were diagnosed with PCa upon baseline TRUS-guided biopsies. In 102 cases, at least one TZB was positive for PCa, with 6/412 (1.4 %) cases displaying PCa in the TZB only. MAB alone was positive for PCa in 4/412 (1.0 %) cases. One case (1/412; 0.2 %) had only a TZB and a MAB positive for PCa without positive PZB. Thus, 11/412 (2.7 %) of cases would not have been diagnosed with PCa at baseline TRUS-guided biopsy had only sextant PZ biopsy been performed. TZB detected a high-grade Gleason component (Gleason 4 and/or 5) not present in the PZB in 2.4 % of PCa cases. CONCLUSIONS: There is limited value for TZB and MAB in the context of sextant PZB at baseline TRUS-guided biopsies for PCa.

The predictive value of endorectal 3 Tesla multiparametric magnetic resonance imaging for extraprostatic extension in patients with low, intermediate and high risk prostate cancer.

PURPOSE: We determined the positive and negative predictive values of multiparametric magnetic resonance imaging for extraprostatic extension at radical prostatectomy for different prostate cancer risk groups. MATERIALS AND METHODS: We evaluated a cohort of 183 patients who underwent 3 Tesla multiparametric magnetic resonance imaging, including T2-weighted, diffusion weighted magnetic resonance imaging and dynamic contrast enhanced sequences, with an endorectal coil before radical prostatectomy. Pathological stage at radical prostatectomy was used as standard reference for extraprostatic extension. The cohort was classified into low, intermediate and high risk groups according to the D'Amico criteria. We recorded prevalence of extraprostatic extension at radical prostatectomy and determined sensitivity, specificity, positive predictive value and negative predictive value of multiparametric magnetic resonance imaging for extraprostatic extension in each group. Univariate and multivariate analyses were performed to identify predictors of extraprostatic extension at radical prostatectomy. RESULTS: The overall prevalence of extraprostatic extension at radical prostatectomy was 49.7% ranging from 24.7% to 77.1% between low and high risk categories. Overall staging accuracy of multiparametric magnetic resonance imaging for extraprostatic extension was 73.8%, with sensitivity, specificity, positive predictive value and negative predictive value of 58.2%, 89.1%, 84.1% and 68.3%, respectively. Positive predictive value of multiparametric magnetic resonance imaging for extraprostatic extension was best in the high risk cohort with 88.8%. Negative predictive value was highest in the low risk cohort with 87.7%. With an odds ratio of 10.3 multiparametric magnetic resonance imaging is by far the best preoperative predictor of extraprostatic extension at radical prostatectomy. CONCLUSIONS: For adequate patient counseling, knowledge of predictive values of multiparametric magnetic resonance imaging for extraprostatic extension is of utmost importance. High negative predictive value, important for decisions on nerve sparing strategies at radical prostatectomy, is only reached in low risk subjects.

External validation of nomograms including MRI features for the prediction of side-specific extraprostatic extension.

BACKGROUND: Prediction of side-specific extraprostatic extension (EPE) is crucial in selecting patients for nerve-sparing radical prostatectomy (RP). Multiple nomograms, which include magnetic resonance imaging (MRI) information, are available predict side-specific EPE. It is crucial that the accuracy of these nomograms is assessed with external validation to ensure they can be used in clinical practice to support medical decision-making. METHODS: Data of prostate cancer (PCa) patients that underwent robot-assisted RP (RARP) from 2017 to 2021 at four European tertiary referral centers were collected retrospectively. Four previously developed nomograms for the prediction of side-specific EPE were identified and externally validated. Discrimination (area under the curve [AUC]), calibration and net benefit of four nomograms were assessed. To assess the strongest predictor among the MRI features included in all nomograms, we evaluated their association with side-specific EPE using multivariate regression analysis and Akaike Information Criterion (AIC). RESULTS: This study involved 773 patients with a total of 1546 prostate lobes. EPE was found in 338 (22%) lobes. The AUCs of the models predicting EPE ranged from 72.2% (95% CI 69.1-72.3%) (Wibmer) to 75.5% (95% CI 72.5-78.5%) (Nyarangi-Dix). The nomogram with the highest AUC varied across the cohorts. The Soeterik, Nyarangi-Dix, and Martini nomograms demonstrated fair to good calibration for clinically most relevant thresholds between 5 and 30%. In contrast, the Wibmer nomogram showed substantial overestimation of EPE risk for thresholds above 25%. The Nyarangi-Dix nomogram demonstrated a higher net benefit for risk thresholds between 20 and 30% when compared to the other three nomograms. Of all MRI features, the European Society of Urogenital Radiology score and tumor capsule contact length showed the highest AUCs and lowest AIC. CONCLUSION: The Nyarangi-Dix, Martini and Soeterik nomograms resulted in accurate EPE prediction and are therefore suitable to support medical decision-making.

Preoperative PSMA-PET/CT as a predictor of biochemical persistence and early recurrence following radical prostatectomy with lymph node dissection.

BACKGROUND: This study aims to evaluate the predictive value of lymph nodes (LN) suspicious for metastases on preoperative prostate-specific membrane antigen (PSMA) PET/CT for biochemical persistence (BCP) and early biochemical recurrence (BCR) following robotic-assisted radical prostatectomy (RARP) with extended pelvic LN dissection (ePLND). METHODS: We evaluated 213 patients with intermediate and high-risk prostate cancer (PCa) who underwent clinical staging with preoperative 68Ga- or 18F-PSMA-PET/CT scan and subsequent RARP with ePLND. Patients were grouped as PSMA- or PSMA+ depending on their LN status on PSMA-PET/CT and subdivided according to histological LN status in pN0 or pN1. Diagnostic accuracy of PSMA-PET/CT for the detection of pN1 was evaluated. BCP was defined as a first postoperative serum PSA level ≥0.1 ng/mL 6-12 weeks following RP. Early BCR was defined as detectable PSA > 0.2 ng/mL within 12 months of follow-up. Univariable logistic regression analyses were used to evaluate the effect of PSMA+ on BCP and BCR. RESULTS: Forty patients (19%) were PSMA+. The overall incidence of pN1 was 23%. Sensitivity, specificity, PPV and NPV on a per patient level for the detection of pN1 was 29%, 84%, 35%, and 80% respectively. BCP was observed in 26 of 211 patients (12%) and early BCR in 23 of 110 patients (21%). The presence of PSMA+ was a significant predictor for BCP (OR 7.1, 2.9-17.1 95% CI) and BCR (OR 8.1, 2.9-22.6 95% CI). CONCLUSION: Preoperative PSMA-PET/CT may be a valuable tool for patient counseling for RARP and ePLND as it is a significant predictor for the risk of postoperative BCP and early BCR. We conclude that an ePLND should not be avoided in men with intermediate or high-risk PCa and preoperative negative PSMA-PET/CT, as 20% have microscopic LN metastasis.

Training novice robot surgeons: Proctoring provides same results as simulator-generated guidance.

To understand the influence of proctored guidance versus simulator generated guidance (SGG) on the acquisition dexterity skills in novice surgeons learning RAS (robot assisted surgery). Prospective non-blinded 3-arm randomised controlled trial (RTC). Exclusion criteria: previous experience in RAS or robotic surgery simulation. The participants were assigned to three different intervention groups and received a different form of guidance: (1) proctored guidance, (2) simulator generated guidance, (3) no guidance, during training on virtual reality (VR) simulator. All participants were asked to complete multiple questionnaires. The training was the same in all groups with the exception of the intervention part. Catharina Hospital Eindhoven, The Netherlands. A total of 70 Dutch medical students, PhD-students, and surgical residents were included in the study. The participants were randomly assigned to one of the three groups. Overall, all the participants showed a significant improvement in their dexterity skills after the training. There was no significant difference in the improvement of surgical skills between the three different intervention groups. The proctored guidance group reported a higher participant satisfaction compared to the simulator-generated guidance group, which could indicate a higher motivation to continue the training. This study showed that novice surgeons. Significantly increase their dexterity skills in RAS after a short time of practicing on simulator. The lack of difference in results between the intervention groups could indicate there is a limited impact of "human proctoring" on dexterity skills during surgical simulation training. Since there is no difference between the intervention groups the exposure alone of novice surgeons to the robotic surgery simulator could possibly be sufficient to achieve a significant improvement of dexterity skills during the initial steps of RAS learning.

Structured robot-assisted surgery training curriculum for residents in Urology and impact on future surgical activity.

To gain insight into the availability of training for robot assisted surgery (RAS) and the possibility to perform RAS during Dutch residency curriculum and to analyze the effects on surgical skills by the introduction of an advanced course in RAS for residents. A combination of a validated snap shot survey and a prospective cohort study. Structured advanced RAS training including virtual reality (VR) simulation, dry and wet lab facility at ORSI academy (Belgium). A snap-shot survey has been sent to all the residents and specialists in Urology graduated during the years 2017-2020 in Netherlands. Among residents, only last year residents (5th and 6th year) have been considered for the RAS training. Although most of the residents (88.2%) and young urologists (95%) were asked to follow a basic training or meet basic requirements before starting RAS, the requirements set by the educators were different from center to center. Some of them were required to attend only an online course on RAS, whereas others were asked to achieve threshold scores at VR simulator and participate in a standardized course at a training institute. The attendance to a structured advanced course in RAS showed a significant increase in surgical skills. Our study shows residents in urology are allowed to perform RAS during their residency though the criteria for starting RAS differ significantly amongst the teaching hospitals. To guarantee a basic level of skills and knowledge a structured, (multi-step) training and certification program for RAS should be implemented.

Linking surgical skills to postoperative outcomes: a Delphi study on the robot-assisted radical prostatectomy.

OBJECTIVE: To develop an assessment instrument for the evaluation of surgical videos to elucidate the association between surgical skills and postoperative outcomes after a robot-assisted radical prostatectomy (RARP). DESIGN: A Delphi study consisting of two consecutive online surveys and a consensus group meeting. SETTING: Urology departments of general, teaching and university hospitals in the Netherlands. PARTICIPANTS: All Dutch urologists with a specialization in RARP. RESULTS: Of 18 invited experts, 12 (67%) participated in the first online survey. In the second round, 9 of the 18 invited experts participated (50%). The Delphi meeting was attended by 5 of the 18 (27%) invited experts. The panel identified seven surgical steps with a possible association to postoperative outcomes. The experts also expected an association between adverse postoperative outcomes and the frequency of camera removals, the number of stitches placed, the amount of bleeding, and the extent of coagulation. These factors were incorporated into an assessment instrument. CONCLUSIONS: Experts in the field of RARP achieved consensus on 7 surgical steps and 4 aspects of the RARP procedure that may be related to adverse postoperative outcomes. The resulting assessment instrument will be tested in future research to determine its validity.

Case report: retroperitoneoscopic tumor nephrectomy during pregnancy.

When considering laparoscopic tumor nephrectomy during pregnancy, questions will arise about the consequences of the increased abdominal pressure (IAP) for uterine-placental perfusion and the impact of carbondioxide insufflation on the fetus. These considerations should be weighed against the advantages for the mother, in term of shorter convalescence and decreased wound problems. This situation presents the urologists with a dilemma. At 16 weeks of gestation, a 30-year-old woman underwent a retroperitoneoscopic tumor nephrectomy. This case report and the following discussion highlight the key issues involved in laparoscopic surgery during pregnancy. In theory, laparoscopy in pregnancy carries some specific hazards, which may influence fetal outcome. First, the elevation of IAP may lead to alterations in placental perfusion, and second, CO2 insufflation may disturb the acid-base balance. However, in a study covering more than 2 million pregnancies, no difference was found in fetal mortality or malformations after laparoscopic surgery for non-obstetric reasons compared with open surgery. Animal experiments have demonstrated an IAP of 15 mm Hg or less to cause almost no reduction in the uterine-placental blood flow. According to our limited experience and with the support of the literature, pneumo(retro)peritoneum during pregnancy seems to be safe.

Sexual dysfunction in nonseminoma testicular cancer patients is related to chemotherapy-induced angiopathy.

PURPOSE: To establish the prevalence of sexual dysfunctions after different treatment modalities for nonseminomatous testicular germ cell tumor (NSTGCT) and to investigate whether treatment-induced angiopathy and neuropathy is related to sexual dysfunction. PATIENTS AND METHODS: A questionnaire assessing sexual dysfunction was sent to 255 NSTGCT survivors. Polychemotherapy (PCT) regimens (cisplatin, vinblastine, and bleomycin [PVB], vinblastine substituted by etoposide [BEP], or cisplatin substituted by carboplatin [CEB], etoposide combined with cisplatin [EP], or with ifosfamide and cisplatin [VIP] were compared regarding treatment-induced angiopathy and neuropathy. Sexual dysfunctions were related to Raynaud's phenomenon and acral paresthesia. RESULTS: Among the 215 responders, 56 (26%) had been treated by orchidectomy and surveillance, 42 (19.6%) by PCT, and 117 (54.4%) by PCT and resection of residual retroperitoneal tumor mass (RRRTM). Overall, loss of libido was reported by 19.1%, decreased arousal by 11.2%, erectile dysfunction by 12.1%, decreased intensity of orgasm by 20%, and ejaculatory problems by 28%. Patients treated with PVB suffered more often from Raynaud's phenomenon compared with those treated with other regimens (40.4% v 29%; P < .05) and from paresthesia (31.6% v 14.7%; P < .05). Patients with Raynaud's phenomenon had more often erectile dysfunction (28.8%) compared with those without (8.4%) (P < .05). CONCLUSION: Compared with orchidectomy alone, PCT, with or without RRRTM, induced more often posttreatment sexual dysfunction. Compared with other chemotherapeutic regimens, signs of angiopathy and neuropathy were most prevalent in those treated with PVB. Erectile dysfunction was related to the chemotherapy-induced Raynaud's phenomenon but not to acral paresthesia.

Current concepts about testicular cancer.

In the past 20 years, testicular cancer, which occurs in the young, has become a curable malignancy; 90% of the patients treated will achieve long-term survival. However, there is a significant morbidity associated with the management of the disease process. The literature was reviewed concerning the current treatment strategies and prognosis, as well as the long-term sequelae of the various diagnostic and therapeutic procedures. Surveillance has become a key element in the management of patients with a primary (stage I) testicular non-seminoma. Although approximately 25% of these patients will relapse, 100% survival can be achieved with cisplatin in combination with etoposide and bleomycin (BEP). Patients with a disseminated non-seminoma are usually treated with 4 courses of BEP; an 80% survival rate can be achieved. The long-term effects of chemotherapy include Raynaud's phenomenon, acral paraesthesia, hyperlipidaemia, nephrotoxicity, infertility and hormonal disturbances. Retroperitoneal lymph node dissection or resection of residual disease following chemotherapy are associated with a low mortality and morbidity rate, ejaculatory dysfunction excepted. However, with specific modifications in technique (e.g. nerve-sparing) antegrade ejaculation can be preserved in the majority of patients. Radiotherapy is used in stage I and II seminoma. With the conventional dose of 25-30 Gy to the retroperitoneal and ipsilateral iliac lymph nodes, temporary dysfunction of the germ and Leydig cells of the remaining testis may occur by scatter radiation. Patients with advanced seminoma are treated with cisplatin-based chemotherapy. To date, testicular cancer patients can receive appropriate curative treatment with acceptable acute toxicity, depending on the therapy given. The detrimental effects of late toxicities require careful study and follow-up. However, little attention is paid currently to quality of life aspects, in particular the impact of the disease and its treatment on general well-being, including sexual function.

Glyburide-induced cholestatic hepatitis and liver failure. Case-report and review of the literature.

As sulphonylurea derivatives are used ubiquitously, the possibility that they may cause liver disease deserves attention. In contrast to the known pattern of reversible parenchymal liver disease due to sulphonylurea derivatives, we describe a fatal case of glyburide-induced cholestatic hepatitis with liver failure.

Ampullary carcinoid and neurofibromatosis: case report and review of the literature.

A 49-year-old woman is reported with an ampullary carcinoid and von Recklinghausen's neurofibromatosis, presenting with melaena. On upper GI-endoscopy a tumour of the ampulla of Vater was seen. Histochemical examination revealed a carcinoid tumour. A review of the literature shows that patients with von Recklinghausen's neurofibromatosis are at increased risk for developing tumours of neuroectodermal origin, with the ampulla of Vater as predilection site. Therefore, early diagnostic evaluation, primarily by gastroduodenoscopy, for malignancies in patients with von Recklinghausen's neurofibromatosis and abdominal discomfort is recommended. Surgical removal is the only therapy so far evaluated.

[Relationship between duodenal diverticuli, gallstones and duodenal and pancreaticobiliary disorders]. / Verband tussen duodenumdivertikels, galstenen en duodenale en pancreato-biliaire afwijkingen.

OBJECTIVE: To determine the relationship between duodenal diverticula and the prevalence of bile duct stones, and between duodenal diverticula and pancreatic pathology and/or duodenal inflammation. DESIGN: Retrospective descriptive study. SETTING: Department of Internal medicine, Division of Gastroenterology/Hepatology, University Hospital Maastricht. METHODS: The medical records were reviewed of 273 consecutive patients in whom an endoscopic retrograde cholangiopancreatography (ERCP) had been performed for the first time during the period 1991-1992. Clinical data such as previous history of cholecystectomy and ERCP findings such as presence of a duodenal diverticulum, its location (juxtapapillary or circumpapilary), and possible concomitant pancreaticobiliary disorders and/or duodenal inflammation were evaluated. RESULTS: Duodenal diverticula were present in 49 out of 273 patients (18%(: 30 patients with a juxtapapillary, 18 patients with a circumpapillary duodenal diverticulum and one patient with both types. A history of cholecystectomy was not reported more frequently in patients with a diverticulum than in those without. At the time of ERCP investigation, gallbladder stones were not diagnosed more frequently in diverticulum patients. A significantly higher prevalence of common bile duct stones was found in diverticulum patients than in those without (53% versus 22%, p = 0.001). Pancreatic pathology was not related to the presence of duodenal diverticula (p = 0.441). Furthermore. duodenitis and duodenal ulcers were significantly more prevalent in diverticulum patients than in those without (18% versus 7% for duodenitis, p = -0.049; 14% versus 2% for duodenal ulcers, p = 0.001). CONCLUSIONS: Duodenal diverticula were not only associated with common bile duct stones, but were also related to duodenitis and duodenal ulcers. Pancreatic pathology appeared not to be related to duodenal diverticula.

[The use of corticosteroid cream to treat phimosis]. / Behandeling van fimosis met corticosteroïdcrème.

Many of the boys diagnosed with 'phimosis', who are referred for circumcision, do not have a dermatopathology and thus there is no indication for surgery. If an unretractable prepuce causes hygienic problems, and also in the case of dermatopathology, topical corticosteroid application may be an effective alternative to circumcision. In a literature search 13 studies were found on the effectiveness and the safety of topical steroid application for phimosis. Three of the studies were placebo controlled. A total of 1121 boys with an unretractable prepuce were treated with a topical corticosteroid, which was mostly applied twice daily. After a treatment duration of 4 to 8 weeks, about 75% of the patients achieved complete retractability of the prepuce. In the studies evaluated, local or systemic adverse effects were not noted. Different types of corticosteroids gave similar results. Topical corticosteroid application for the treatment of unretractable prepuce complaints seems to be effective and safe, and is therefore recommended before surgical intervention is considered.

Typhoid perforation. A review of the literature since 1960.

Typhoid fever is still a major health problem in the developing parts of the world, with an estimated annual incidence of 540 per 100,000. Probably one of the most lethal complications of typhoid fever is ileal perforation, which affects especially young men. We reviewed the literature published after 1960 on typhoid perforation in different developing countries, with special attention to the incidence and outcome of typhoid perforation. Information was obtained on a total number of 1,990 cases of typhoid perforation in 66,157 patients with typhoid fever, published in 52 reports all over the world. The overall frequency of intestinal perforation in typhoid fever was 3% with an overall mortality rate of 39.6%. In an endemic area of typhoid fever, the diagnosis of typhoid perforation should be made on physical examination. Surgery is perferable to medical treatment.

Sexual functioning after treatment for testicular cancer: comparison of treatment modalities.

BACKGROUND: This retrospective study evaluates changes in sexual functioning after treatment for testicular cancer and investigates whether there is a relationship with different treatment modalities. METHODS: A self-reported questionnaire was sent to 337 men who had been treated for testicular cancer at the University Hospital Groningen between 1977 and 1994. Medical information was obtained from the patient records. RESULTS: A response was received from 287 men (85%); 264 patients were included in this study (78%). The mean patient age at follow-up was 37.7 years (range, 17-71 years). The mean follow-up period was 6.7 years (range, 0.25-18 years). Decrease in sexual functions was reported by 40% of patients (decrease in libido: 19%; arousal: 12% erection: 12.5%; orgasm: 19%; and ejaculation: 26%). Moreover, 23.5% of patients responding reported decreased sexual activity and 12.5% were dissatisfied with their sexual functioning. Patients with Stage II-IV nonseminoma who had been treated with polychemotherapy (PCT) with or without resection of residual retroperitoneal tumor mass (RRRTM) (PCT +/- RRRTM) reported a significantly sharper decrease in sexual functioning than patients who had been followed with a wait-and-see policy (W & S) (Stage I nonseminoma patients). It was noteworthy that patients treated by PCT alone reported more sharply decreased sexual functioning than patients treated by PCT + RRRTM. Patients treated by radiotherapy (Stage I-IIA seminoma) did not report findings significantly different from the W & S group. CONCLUSIONS: Testicular cancer patients are at risk for reduced sexual functioning, especially when treated by chemotherapy, with or without resection of residual tumor. Although chemotherapy may influence somatic aspects of sexual functioning, it appears that psychologic factors arising from the confrontation with testicular cancer play a strongly mediating (if not determining) role.

Cisplatin-based chemotherapy changes the incidence of bilateral testicular cancer.

BACKGROUND: The introduction of cisplatin-based chemotherapy has remarkably increased the survival of testicular cancer patients. With this success, the concern for a contralateral testicular tumor has increased. The aim of this study was to investigate whether the risk for contralateral testicular tumor development was influenced by cisplatin-based chemotherapy. METHODS: The incidence of a contralateral testicular tumor among 365 consecutive patients with a nonseminoma testicular tumor, diagnosed in the period 1980 and 1995, was established and related to previous therapy. RESULTS: Eleven of 365 men (3%) developed a contralateral testicular tumor. After a total of 2403 person-years at risk, 4 of 225 chemotherapy-treated patients (1.8%) developed a contralateral testicular tumor, and 7 of 140 patients (5%) treated with orchidectomy alone developed a contralateral tumor. In comparison to this surveillance subgroup, patients previously treated with chemotherapy have a relative risk of 0.30 to develop a second testicular tumor. CONCLUSIONS: In Dutch men with a nonseminoma testicular tumor, the incidence of a contralateral testicular tumor is 3%, which is 60-fold the expected incidence rate of testicular cancer. A three times lower incidence rate of a contralateral testicular tumor was found in the chemotherapy subgroup compared with those on surveillance. This supports the hypothesis that cisplatin-based chemotherapy may eradicate carcinoma in situ or early testicular cancer.