When is a Seminoma not a Seminoma? The Incidence, Risk Factors and Management of Patients With Testicular Seminoma With Discordant Elevated Serum Alpha-fetoprotein.

OBJECTIVE: To describe the incidence, clinical and demographic factors, and treatment patterns associated with discordant elevated alpha-fetoprotein (AFP) findings in patients with pure seminomatous histology. METHODS: We queried the National Cancer Database to identify patients with testicular germ cell tumors (GCT) diagnosed in 2011-2015. Patients were grouped based on histologic diagnosis and pre-operative serum AFP level. RESULTS: Of 18,616 patients diagnosed with testicular GCT, 53% (N = 9,849) had pure seminomatous histology, of whom 8.3% (N = 821) had an elevated serum AFP pre-operatively. Non-white patients with seminoma were more likely to have a pre-op elevated AFP (OR 1.42; 95% CI: 1.10-1.83); patients treated at higher volume centers were less likely to have a pre-op elevated AFP (0.66, 95% CI: 0.53-0.83). Patients with seminoma with elevated AFP received adjuvant radiation more frequently than those with NSGCT (Stage I: 15% vs 0.2%, P <.01; Stage II: 21.9% vs 0.1%, P <.01) and less frequently underwent retroperitoneal lymph node dissection (RPLND) (Stage 1: 1.9% vs 11.1% P <.01; Stage II: 8.8% vs 17.4%, P <.01). CONCLUSION: The detection of elevated serum alpha-fetoprotein (AFP) in patients with pure seminomatous testicular germ cell tumors (GCT) is a discordant finding that implies the presence of occult non-seminomatous GCT (NSGCT) elements. 8% of patients with pure seminomatous GCTs had diagnostically discordant elevated pre-operative AFP levels. Despite recommendations to manage these patients as NSGCT, patients with seminoma and elevated AFP were managed in a fashion comparable to those with seminoma and normal AFP levels.

Testicular Tumor Markers in the Spermatic Vein - Correlation to Pathology, Stage and Outcome.

OBJECTIVE: To report our findings in patients with determination of testicular tumor markers from the vena spermatica during inguinal orchiectomy. METHODS: In a retrospective setting, data of patients who underwent inguinal orchiectomy between January 2004 and December 2014 were analyzed. Cubital and testicular vein tumor markers were assessed and correlated to histology, clinical stage and outcome. RESULTS: A total of 90 patients (seminomatous: n = 53, non-seminomatous: n = 37) with a median age of 37 years were included. The mean follow-up was 109 months. Overall, 60% (n = 54) of patients had one or more positive tumor marker level in the cubital vein vs 88.9% (n = 80) in the testicular vein. Median tumor marker levels of hCGß in cubital and testicular vein were 1.9 U/l and 30.8U/l; the respective values for AFP were 2.9ng/ml and 2.4ng/ml and for hPLAP 49.9 mU/l and 418.9 mU/l. Differences in cubital vs testicular vein positivity were stage dependant and highest for pT1. Patients with seminomatous tumors had peripheral positivity of 59.3% vs 88.9% in the testicular vein (P = 0.003); in non-seminomatous patients the respective values were 61.1% and 88.9% (P = 0.02). All recurrent cancer patients under active surveillance (n = 5) were positive in the testicular vein. CONCLUSION: Virtually all testicular cancers shed tumor markers in the circulation. Differences in marker positivity (testicular vs testicular vein) were stage dependent (greatest in pT1), largely independent of histology and highest for hCGß. The prognostic value of testicular vein sampling remains speculative.

Did COVID-19 Affect Time to Presentation in the Setting of Pediatric Testicular Torsion?

OBJECTIVES: To determine if boys with acute testicular torsion, a surgical emergency requiring prompt diagnosis and treatment to optimize salvage of the testicle, delayed presentation to a medical facility and experienced an extended duration of symptoms (DoS), and secondarily, a higher rate of orchiectomy, during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Single-center, descriptive retrospective chart review of boys presenting with acute testicular torsion from March 15, to May 4, 2020 ("during COVID-19" or group 2), as well as for the same time window in the 5-year period from 2015 to 2019 ("pre-COVID-19" or group 1). RESULTS: A total of 78 boys met inclusion criteria, group 1 (n = 57) and group 2 (n = 21). The mean age was 12.86 ± 2.63 (group 1) and 12.86 ± 2.13 (group 2). Mean DoS before presentation at a medical facility was 23.2 ± 35.0 hours in group 1 compared with 21.3 ± 29.7 hours in group 2 (P < 0.37). When DoS was broken down into acute (<24 hours) versus delayed (≥24 hours), 41 (71.9%) of 57 boys in group 1 and 16 (76.2%) of 21 boys in group 2 presented within less than 24 hours of symptom onset (P < 0.78). There was no difference in rate of orchiectomy between group 1 and group 2 (44.7% vs 25%, P < 0.17), respectively. CONCLUSIONS: Boys with acute testicular torsion in our catchment area did not delay presentation to a medical facility from March 15, to May 4, 2020, and did not subsequently undergo a higher rate of orchiectomy.

Testis-sparing Surgery: A Single Institution Experience.

OBJECTIVE: To demonstrate the safety and efficacy of testis-sparing surgery (TSS) in 2 specific circumstances: small, nonpalpable masses suspected to be benign and masses suspicious for germ cell tumor in a solitary or functionally solitary testicle or bilateral disease. METHODS: Our institutional review board-approved testicular cancer registry was reviewed for men who underwent inguinal exploration with intent for TSS (2013-2020). The attempted TSS and completed TSS groups were evaluated for differences using Student's t test for normally-distributed variables, chi-squared and Fisher's exact tests for proportions, and Wilcoxon rank-sum test for nonparametric variables. RESULTS: TSS was attempted in 28 patients and completed in 14. TSS was completed only if intraoperative frozen section demonstrated benign disease, except for 1 patient with stage I seminoma and solitary testicle. Sensitivity and specificity of frozen section analysis was 100% and 93%, respectively. There were no significant differences in demographics between attempted vs completed TSS cohorts. Median tumor size was significantly smaller in the completed TSS cohort (1.0 cm vs 1.7 cm, P = .03). In patients with unilateral masses without history of testis cancer, the testis was successfully spared in 9 of 22 cases (41%). In patients with bilateral disease or germ cell tumor in solitary testis, the testis was spared in 5 of 6 cases (83%). At a median follow up of 12.2 months, all patients were alive, and 27 of 28 had no evidence of disease (96%). CONCLUSION: TSS is safe and effective for small, benign masses and in the setting of bilateral disease or tumor in a solitary testis.

Contemporary Trends in Presentation and Management of Spermatocytic Seminoma.

OBJECTIVE: To characterize the presentation and management of spermatocytic seminoma (SS) compared to classic seminoma in adults utilizing a large cancer registry. METHODS: Patients >18 years of age in the National Cancer Database from 2006 to 2016 who underwent orchiectomy for testicular tumors were identified. Demographics, oncologic characteristics, and treatment patterns were compared between patients with SS and classic seminoma. RESULTS: Of 53,481 adults receiving orchiectomy, 29,208 were diagnosed with classic seminoma and 299 (1%) with SS. Compared to patients with classic seminoma, SS patients were older (57 vs 39 years) and more likely to be African-American (odds ratio (OR) 1.8) and insured by Medicare (OR 2.0; all P <.05). SS patients had larger tumors on presentation (3-6 cm: OR 1.8; >6 cm: OR 1.8), but were less likely to have ≥pT2 stage (OR 0.5), regional nodal involvement (Clinical Stage II: OR 0.3), or distant metastatic disease (Clinical Stage III: OR 0.1; all P <.01). For postorchiectomy management, 73.6% of SS patients underwent surveillance while 24.5% had active treatment (retroperitoneal lymph node dissection, chemotherapy, radiation, or a combination). When stratified by year, there was an increasing trend toward surveillance compared to active treatment. CONCLUSION: SS is a rare germ cell tumor that typically presents as a larger tumor in older patients. Although these tumors are less likely to be characterized by advanced disease compared to classic seminoma, many patients have undergone aggressive postorchiectomy treatment in the past. Importantly, treatment trends have shifted toward surveillance in recent years with adjuvant therapy limited primarily to higher stage tumors.

French veterinarians' opinions and practices regarding early neutering of cats: a convenience sampling survey interpreted in an international context.

BACKGROUND: Although data are still needed, early neutering of cats appears to be as safe as neutering at the traditional age of six months or older and beneficial to the individual and the population. The aim of this observational study was to obtain an overview of veterinarians' opinions and practices about feline early neutering (ie, until the age of four months). METHODS: In this retrospective work, a web survey was distributed to French practitioners. RESULTS: A total of 609 veterinarians returned the survey. Majority of the veterinarians (56 per cent) reported never performing early neutering, 42 per cent reported performing it inconsistently, and 2 per cent reported consistently performing it. When carried out, it was mainly on kittens from commercial breeding, following breeders' request, and performed at the age of three months. An overwhelming majority (93 per cent) of veterinarians performing early neutering reported no incidents. Veterinarians who did not practise early neutering neutered mostly (81 per cent) kittens from four to six months of age. CONCLUSION: In conclusion, early neutering is still not a common practice among French veterinarians. Opinions differed as to its advantages and disadvantages, although reported incidents were scarce. Veterinarians who do not perform early neutering reported a lack of interest in this practice rather than reluctance.

Type of Androgen Deprivation Therapy and Risk of Dementia Among Patients With Prostate Cancer in Taiwan.

Importance: It remains unclear whether androgen deprivation therapy (ADT) is associated with subsequent dementia risk in patients with prostate cancer. There are limited data regarding dementia risk across ADT types. Objective: To examine the association between all-cause dementia, including Alzheimer disease (AD), and different ADT types in patients with prostate cancer. Design, Setting, and Participants: This cohort study used linked data from the Taiwan National Cancer Registry, the National Health Insurance Research Database, and the Taiwan National Death Registry. A cohort of 23 651 patients with newly diagnosed prostate cancer between January 1, 2008, and December 31, 2015, was identified and followed up from 1 year after diagnosis until December 31, 2017. Data analysis was performed between January 2019 and May 2020. Exposures: Patients who received and did not receive ADT, including gonadotropin-releasing hormone (GnRH) agonists, orchiectomy, or antiandrogen monotherapy. Main Outcomes and Measures: The primary outcomes were all-cause dementia or AD. Stabilized inverse probability of treatment weighting was used to balance baseline covariates. The association between dementia and various ADT types was examined using the Cox proportional hazards model. Furthermore, a multivariate Cox proportional model with age as the time scale was conducted for complementary comparison. Results: In the cohort of 23 651 male patients (median [interquartile range] age, 73 [66-79] years), 6904 (29.2%) did not receive ADT, 11 817 (50.0%) received GnRH agonists, 876 (3.7%) received orchiectomy, and 4054 (17.1%) received antiandrogen monotherapy. Overall, 1525 patients were diagnosed with incident dementia (1.72 per 100 person-years) during a median (interquartile range) follow-up of 3.46 (1.92-5.51) years. Compared with those who did not receive ADT, those using antiandrogen monotherapy showed an increased risk of dementia (weighted hazard ratio [HR], 1.34; 95% CI, 1.16-1.55) and AD (weighted HR, 1.52; 95% CI, 1.13-2.04). The risk of dementia was similar between GnRH agonist use or orchiectomy and no ADT use (GnRH agonist: weighted HR, 1.13; 95% CI, 1.00-1.28; orchiectomy: 1.00; 95% CI, 0.74-1.37). Several sensitivity analyses revealed consistent findings for both outcomes. Conclusions and Relevance: In this study, the use of antiandrogen monotherapy was associated with increased risk of dementia or AD, while GnRH agonist use and orchiectomy had no significant difference compared with patients who did not receive ADT. Further prospective studies are warranted to confirm these findings.

Evaluation of intrinsic and extrinsic risk factors for dog visceral hemangiosarcoma: A retrospective case-control study register-based in Lazio region, Italy.

The genetic and breed susceptibility of visceral hemangiosarcoma in dogs has been studied, but there is no evidence of environmental risk factors as reported in human medicine. We conducted a case-control study in which the sampling population was the list of canine oncology cases of the Animal Tumour Registry of Lazio region, Italy (2009-2017). We defined cases as dogs with visceral hemangiosarcoma and controls as dogs affected by another neoplasm. The ratio between controls and cases was 3:1. Analysed variables were: age, weight, sex, reproductive status, size, breed, nutrition habit, living environment and location of the house. We performed a preliminary univariate analysis to select potential risk factors (p-value < 0.2) then entered in a forward stepwise logistic regression model. Ninety-three cases enrolled in the study were compared with 279 controls. The multivariable logistic regression identified age, reproductive status and breed as significant risk factors. Results showed an increasing risk with increasing age for age classes 6-10 and > 10 years old (OR = 9.69, 95 % CI: 1.21-77.62; OR = 14.01, 95 % CI: 1.65-119.03). Neutered animals (male and female) were at greater risk compared to intact ones. The breeds at greatest risk were German shepherd (OR = 4.17, 95 % CI: 1.25-13.86) and mixed breed (OR = 3.50, 95 % CI: 1.44-8.51). The last finding could be explained by the genetic origin of the animals, which may include German shepherd or another possible breed at risk. No other individual or environmental variables were identified as risk factors. The findings of this work indicate that genetic predisposition is the key element in visceral hemangiosarcoma development.

Is testicular microlithiasis a really innocent condition? its effects on oncological outcomes of germ cell testicular cancer: an observational study / ¿Son las microlitiasis testicular realmente un síntoma sin transcendencia? Sus efectos en los resultados oncológicos en el cáncer de testículo: estudio observacional

OBJECTIVES: Although it is a well known condition that presence of testicular microlithiasis (TM) with the co-occurrence of specific risk factors such as history of previous germ cell testicular cancer (GCTC), infertility, undescended testes or atrophic testes have high risks for GCTC development,TM is still a controversial topic. Its effects on oncological outcomes have still not been investigated in detail. In this study, we aimed to evaluate whether the presence of TM has an effect on GCTC prognosis and oncological outcomes. METHODS: Seventy five patients among 93 patients who underwent radical orchidectomy between January 2010 and February 2016 were selected and divided into two groups. Group I consisted of 51 patients without TM. Group II consisted of 24 patients with TM. Each groups were compared in terms of demographic datas, prognostic risk factors, complete blood count parameters and oncological outcomes. RESULTS: During the median follow-up of 58 (1-106) months, a significantly higher local recurrence rate (54.2% vs. 3.9%, p < 0.001), distant metastasis rate (58.3% vs. 5.9%, p < 0.001) and lower cancer-spesific survival rate (45.8% vs. 94.1%, p < 0.001) were observed in patients with TM. In this group, the duration of recurrence-free survival (47.65±9.45 vs.101.96±2.80 months, p < 0.001), metastasis-free survival (49.50±8.88 vs. 100.00±3.36 months, p < 0.001) and cancer-specific survival (54.37±8.76 vs. 100.19±3.25 months, p < 0.001) were also statistically lower. In multivariate analysis, â-hCG, LDH, neutrophil/ lymphocyte ratio, monocyte/lymphocyte ratio and the presence of undescended testis were found as independent predictive factors for local recurrence, distant metastasis and cancer-specific survival. Red blood cell distribution width and the presence of testicular microlithiasis were found to be independent predictive factors for local recurrence. CONCLUSION: According to our results, bilateral TM was associated with higher rates of local recurrence, distant metastasis and cancer spesific mortality in presence of risk factors, regardless of classic or limited microlithiasis

OBJETIVO: Aunque es bien conocida la presencia de microlitiasis testiculares con el desarrollo de cáncer testicular, la infertilidad, teste no descendido o atrofia testicular, aun es un tema controvertido. Los efectos en los resultados oncológicos no han sido estudiados en detalle. En este estudio, nuestro objetivo ha sido evaluar la presencia de microlitiasis en los resultados oncológicos del cáncer de testículo. MÉTODOS: Un total de 75 pacientes fueron incluidosen el análisis de un total de 93 pacientes que recibieron una orquiectomía radical entre enero 2010 y febrero 2016. Los pacientes se dividieron en 2 grupos: I- consta de 51 pacientes sin microlitiasis, II consta de 24 pacientes con microlitiasis. Ambos grupos fueron comparados en términos de variables demográficas, factores de riesgo, analítica sanguínea y resultados oncológicos. RESULTADOS: La mediana de seguimiento fue de 59 meses (1-106). Se observó un incremento significativo de la recurrencia local (54,2% vs. 3,9%, p < 0,001), metástasis a distancia (58,3% vs. 5,9%, p < 0,001) y bajada de la supervivencia cáncer especifica (45,8% vs. 94,1%, p < 0,001) en pacientes con microlitiasis. En este grupo, la duración de la superviviencia libre de recurrencia (47,65 ± 9,45 vs.101,96 ± 2,80 meses, p < 0,001), supervivencia libre de metástasis (49,50 ± 8,88 vs. 100,00 ± 3,36 meses, p < 0,001) y supervivencia cáncer especifica (54,37±8,76 vs.100,19 ±3, 25 meses, p < 0,001) fueron también menores. Al estudio multivariado, Beta-hCG, LDH, neutrophil/lymphocyte ratio, monocyte/lymphocyte y la presencia de testes no descendido fueron factores independientes predictores de recurrencia local, metástasis a distancia y supervivencia cáncer-especifica. La distribución de los hematíes y la presencia de microlitiasis fueron factores independientes de recurrencia local. CONCLUSIONES: Las microlitiasis bilaterales se asocian a mayor tasa de recurrencia local, metástasis a distancia y supervivencia cáncer especifica, independientemente de su tamaño

Utilization and Outcomes of Surgical Castration in Comparison to Medical Castration in Metastatic Prostate Cancer.

BACKGROUND: Androgen deprivation therapy (ADT) is the gold standard for metastatic prostate cancer, which can be achieved either by surgical or medical castration. In this study, we evaluated the trends of utilization of surgical castration and also assess the survival differences of patients who underwent surgical castration when compared with those who underwent medical castration. MATERIALS AND METHODS: The National Cancer Database was used to identify patients with metastatic prostate cancer from 2004 to 2014. Cochran-Armitage tests were used to assess temporal trends in the proportion of patients receiving surgical castration relative to medical castration. Logistic and Cox regression models were utilized to estimate the odds of utilization of surgical castration and the effect of castration on overall survival (OS). RESULTS: A total of 33,585 patients with metastatic prostate cancer were identified; 31,600 (94.1%) had medical castration, and 1985 (5.9%) underwent surgical castration. There was significant decline in the trend of utilization of surgical castration from 8.6% in 2004 to 3.1% in 2014. On multivariable analysis, being of a non-Caucasian race, having lower median income levels, having non-private insurance, and earlier years of diagnosis were found to be associated with increased odds of choosing surgical castration over medical castration. Notably, the odds of surgical castration were lower at academic centers. On univariable analysis, a survival difference between castration modality was evidenced (P < .01); 5-year OS for medical castration and surgical castration were 24.3% and 18.2%, respectively. However, on multivariable analysis, there was no OS difference between surgical castration and medical castration (P = .13). CONCLUSIONS: In this large contemporary analysis, the utilization of surgical castration has declined over time, with no OS difference when compared with medical castration. Increasing the utilization of surgical castration could help reduce health care expenditures. With rising health care costs, patients and physicians need to be aware of treatment options and their financial implications.

Prolonged hormonal therapy and external beam radiation independently increase the risk of Persistent Hypogonadism in men treated with prostate brachytherapy.

PURPOSE: To identify variables that predict persistent hypogonadism and castration in patients with prostate cancer (PCa) treated with brachytherapy (BT). MATERIALS AND METHODS: A retrospective analysis was performed on 1,053 patients receiving BT ± external beam radiation therapy (EBRT) ± hormone therapy (HT) for NCCN low, intermediate, or high-risk PCa between 1990 and 2011. Patients were categorized as not receiving HT (n = 438, 41.6%), ≤6 months (n = 317, 31.1%) or > 6 months (n = 298, 28.3%) of HT. 572 (54.3%) received BT alone, and 481 had combination therapy. The five- and 10-year freedom from persistent hypogonadism (T < 280 ng/dL) and castration (T < 50 ng/dL) for each group was evaluated with Kaplan-Meier estimates. Multivariable cox proportional hazards models were used to compare the risk of persistent hypogonadism and castration at a median followup of 6.5 years (posttreatment to final T) (IQR: 4.3-9.1 years; range: 1.0-19.2 years). RESULTS: The 5-year freedom from hypogonadism rates were 92.4%, 88.9%, and 87.0% for patients with no HT, ≤ 6 months and >6 months of HT, respectively (10-year rates: 66.7%, 55.3%, 40.5%); p < 0.01. The 5-year freedom from castration rates were 99.2%, 98.0%, and 98.4%, respectively (10-year rates: 97.9%, 95.5%, 90.9%); p = 0.078. Number of months of HT (HR = 1.04, p = 0.030) and BT with EBRT vs. BT alone (HR = 1.56, p = 0.010) significantly increased the risk of persistent hypogonadism. Number of months of HT was the only variable which increased the risk of persistent castration (HR = 1.09, p = 0.014). CONCLUSIONS: The addition of EBRT to BT is an independent risk factor for persistent hypogonadism. Prolonged HT additionally increases the risk of persistent hypogonadism and castration.

Different androgen deprivation therapies might have a differential impact on cognition - An analysis from a population-based study using time-dependent exposure model.

BACKGROUND: Androgen deprivation therapy (ADT) remains the mainstay treatment for locally advanced or metastatic prostate cancer (PC). However, potential effects of ADT treatment on neurocognitive dysfunction remain unclear. The present study was conducted to assess the relation between ADT treatment and risk of cognitive decline in Asian men with PC. METHODS: A population-based cohort of 24,464 men with PC, each newly diagnosed between 2000 and 2008, was selected from the Taiwan National Health Insurance Database. Subjects were further grouped by treatment as non-ADT (n = 4685) or ADT (n = 12,740), members of the latter subjected to bilateral orchiectomy or medical treatment (ie, luteinizing hormone-releasing hormone agonists, antiandrogens, or combination therapy). A multivariable Cox proportional hazard model with ADT as time-dependent covariate was used to generate adjusted hazard ratios (HRs) of subsequent cognitive decline, including dementia, Alzheimer's disease (AD), and Parkinson's disease (PD). RESULTS: ADT showed a significant association with overall risk of cognitive decline (HR = 1.51, 95 % CI: 1.31-1.74), especially for PD, dementia, and non-Alzheimer dementia (non-AZD). When stratified by various ADT regimens, antiandrogen-only recipients displayed significantly heightened risks of subsequent AD, non-AZD, and PD. However, combined androgen blockade also imposed an increased risk of PD. There was no apparent correlation between duration of ADT exposure and cognitive dysfunction. CONCLUSIONS: Various ADT therapies may have disparate impacts on cognitive function. Prospective studies exploring pertinent clinical characteristics more fully are needed to confirm these findings.

A retrospective internet-based survey of French cat breeders about early-age neutering.

OBJECTIVES: The aim of this study was to analyse cat breeders' application of and opinions concerning early-age (ie, <16 weeks old) neutering in cats in France. METHODS: This study analysed a retrospective cohort. A web survey was designed for French cat breeders and was published in June 2017 on the Facebook page of Livre Officiel des Origines Félines, the official feline studbook for purebred cats born in France. The early-age cat neutering habits, opinions and expectations of breeders were collected. RESULTS: A total of 999 breeders returned the questionnaire. Almost half of the breeders (49%) reported consistently requesting neutering of kittens before selling them, 32% claimed that they never requested it and the remaining 19% reported that they inconsistently requested it. When performed, 83% of breeders had kittens neutered at 12 weeks of age; for a large majority of these breeders (94%), the neutering was undertaken on their own initiative. Various reasons for neutering were provided, including the prevention of uncontrolled breeding, short- and long-term welfare benefits for neutered cats, and practical and economic reasons. Reported incidents related to early-age neutering were scarce. Nearly half of breeders who did not apply early-age neutering to their kittens cited a veterinarian's unwillingness to perform the surgery as a cause. CONCLUSIONS AND RELEVANCE: A large majority of surveyed French cat breeders supported early-age neutering that would occur before kittens were sold, most of the time at the age of 3 months. These breeders reported high satisfaction with early-age neutered cats, with a low number of incidents and accidents reported.

A comparison of clinical outcomes of acute testicular torsion between prepubertal and postpubertal males.

SHORT INTRODUCTION/BACKGROUND: Surgical intervention for acute testicular torsion can require either orchiopexy or orchiectomy. The decision of which surgery to perform is dependant on the amount of time that the testicle experienced ischemia and the viability of the testicle after reperfusion. OBJECTIVE: It is hypothesized that (1) there is a difference in orchiectomy and orchiopexy rates between prepubertal and postpubertal males with acute testicular torsion and (2) presenting symptoms may vary between the two age groups as prepubertal males may present with atypical symptoms, which could result in delayed presentation and diagnosis. STUDY DESIGN: A retrospective chart review was conducted on pediatric patients who were diagnosed with acute testicular torsion between June 2010 and August 2017. Demographic and clinical characteristics were extracted: age, ethnicity, referral pattern, primary insurance status, symptoms at presentation, prior history of ipsilateral testicular pain or intermittent torsion, recent trauma to genitalia, duration of symptoms (hours), gradual vs. acute onset of symptoms, time/weekday/season at presentation, and time interval from arrival at the study institution to surgical intervention (minutes). Patients were categorized into two groups: prepubertal group (age 1-12 years) and postpubertal group (age 13-18 years). Statistical analyses were performed using R, version 3.3.1. RESULTS: Ninety-one patients were included in the study. The overall orchiectomy rate was 30.8%. More prepubertal males underwent orchiectomy than postpubertal males (42.4% vs. 24.1%, respectively). Prepubertal males were more likely to present with abdominal pain than postpubertal males (27.3% vs. 10.3%, respectively). Those who underwent orchiectomy were more likely to present with longer duration of symptoms, testicular swelling, and abdominal pain than those who underwent orchiopexy. The risk of orchiectomy decreased by 14% per 1-year increase in age (odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.94-1.00, p = .009). A steady decline in the proportion of patients undergoing orchiectomy was seen from 1 to 12 years of age. DISCUSSION: This study found that prepubertal males are at higher risk for orchiectomy than postpubertal males. The risk of orchiectomy decreases by 14-16% per 1-year increase in age. Prepubertal males are more likely to present with atypical symptoms and delayed presentation and diagnosis, leading to delayed surgical intervention. It is important for providers to perform a genital examination in prepubertal males who present with abdominal pain to rule out acute testicular torsion. Patients presenting with longer duration of symptoms, testicular swelling, and abdominal pain are at higher risk for orchiectomy. No correlation was found between orchiectomy rate and ethnicity, referral status, primary insurance status, and time/weekday/season at presentation. CONCLUSION: Among patients presenting to a tertiary pediatric hospital with acute testicular torsion, prepubertal males (younger than 12 years) are at higher risk for orchiectomy than postpubertal males. Prepubertal males are more likely to present with atypical symptoms which results in delayed presentation and diagnosis, leading to delayed in surgical intervention.

Prognostic factors for relapse in patients with clinical stage I testicular cancer: protocol for a Danish nationwide cohort study.

INTRODUCTION: Approximately one-fourth of patients with clinical stage I testicular germ cell cancer will relapse within 5 years of follow-up. Certain histopathological features in the primary tumour have been associated with an increased risk of relapse. The available evidence on the prognostic value of the risk factors, however, is hampered by heterogeneity of the study populations included and variable reporting of the histopathological features. The aim of this study is to identify pathological risk factors for relapse in an unselected large nationwide cohort of patients with stage I disease. METHODS AND ANALYSIS: All incident cases of stage I testicular germ cell cancer diagnosed in Denmark between 2013 and 2018 will be identified using the nationwide prospective Danish Testicular Cancer (DaTeCa) database. Archived microscopic slides from the orchiectomy specimens will be retrieved through linkage to the Danish Pathology Data Bank and reviewed blinded to the clinical outcome. The DaTeCa database includes 960 stage I seminoma patients with expected 185 relapses and 480 patients with stage I non-seminoma with expected 150 relapses. A minimum follow-up period of 3 years of all patients will be ensured. Predefined prognostic variables will be investigated with regard to relapse in univariable and multivariable analysis using the Cox proportional hazards model. ETHICS AND DISSEMINATION: This study protocol has been approved by the Regional Ethics Committee (Region Zealand, Denmark) and the Danish Data Protection Agency. All data will be managed confidentially according to legislation. Study results will be presented at international conferences and published in peer-review journals.

Testis-sparing Surgery for Pediatric Leydig Cell Tumors: Evidence of Favorable Outcomes Irrespective of Surgical Margins.

OBJECTIVE: To review our single institution experience, exploring the role of testis-sparing surgical resection in a cohort of children with Testicular Leydig cell tumors (LCTs). MATERIALS AND METHODS: We reviewed all consecutive children presenting with testicular tumors between 2003 and 2017 (n = 66), excluding patients with alternative pathologies (n = 57). Subsequently data were collected on age at surgery, laterality, type of surgery, operative time, presenting symptoms, serum markers, imaging findings, frozen section, final pathology, and follow-up. RESULTS: During the study period, a total of 9 (9/66; 14%) children were treated for LCT of the testis. Age at surgery was 8.4 ± 1.7 years and the majority (7/9; 77%) had unilateral disease. Most presented with a testicular mass, and 3 (33%) complained of testicular pain. None of the patients had elevated tumor markers. The primary method of management was ultrasound-guided testis-sparing surgery, with an operative time of 98.5 ± 58.7 minutes. Mean tumor size was 15 ± 10.8 mm (range 5-40 mm). In 2 of 6 patients with positive margins radical orchidectomy was performed without residual disease encountered. At a mean follow-up of 31.8 ± 26.3 months (range 2-87) none of the patients demonstrated disease recurrence. CONCLUSION: Our data suggest that LCT in children is associated with a good prognosis, and that TSS is a reasonable surgical approach without detrimental perioperative morbidity or negative long-term outcomes. Moreover, positive margins should not prompt a reflex decision for completion of orchidectomy.

Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion.

BACKGROUND: Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology. OBJECTIVE: We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsion or ACT) for acute testicular torsion in a 2-year period. STUDY DESIGN: Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4 h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97 cases of acute torsion from 2004 to 2016 as a control. RESULTS: Time from ED triage to OR start decreased from a median 196 min (interquartile range [IQR] 137-249 min) to 127 min (IQR 100-148 min; P < 0.0001) for all cases of acute torsion. In the control group, 72% of cases met the USNWR criteria for acute treatment of torsion. After ACT implementation, 100% of cases reached the OR within the 240 min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P = NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway. DISCUSSION: In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy. CONCLUSIONS: The multidisciplinary creation and implementation of a clinical pathway for the care of acute testis torsion has significantly decreased the time from ED to OR in our institution. However, overall orchiectomy rate was not significantly affected.

Can haematologic parameters be used to predict testicular viability in testicular torsion?

The purpose of this study was to evaluate the predictive value of haematologic parameters for testicular survival in torsion. Children with testicular torsion (TT) treated in Beijing Children's Hospital from January 2006 to December 2018 were enrolled in this study. Patient data collected in this study included age, symptom duration, preoperative preparation time, cryptorchidism testicular torsion or not, spermatic cord torsion degree, orchiectomy/orchiopexy, testicular volume 3 months after operation by ultrasound in orchiopexy patients and haematologic parameters. The orchiopexy group comprised of 54 patients with a mean age of 135.6 ± 43.73 months, and the orchiectomy group included 58 patients with a mean age of 119.36 ± 60.82 months. The multivariate analysis showed that symptom duration (Odds Ratio = 1.11, p < 0.001), spermatic cord torsion degree (Odds Ratio = 1.006, p = 0.002) and mean platelet volume (MPV; Odds Ratio = 3.697, p = 0.044) were significant predictors of orchiectomy. The cut-off value for MPV during window time for orchiectomy was 10.55 fl (10-9  L) and provided a sensitivity of 47.8% and a specificity of 92.6%. This study found that symptom duration, spermatic cord torsion degree and MPV could be indicators of testicular viability in testicular torsion. MPV can provide valuable information before operation which can guide doctors and family members of the patients to select the appropriate treatment.

Does the source of referral affect outcomes for paediatric testicular torsion?

INTRODUCTION: This single centre study retrospectively analysed the intraoperative findings relative to source of referral for emergency scrotal explorations performed in a tertiary level paediatric surgery department. METHODS: All patients who underwent emergency scrotal exploration under the care of paediatric surgeons in our unit between April 2008 and April 2016 were identified. Clinical data were obtained from contemporaneous records. RESULTS: Over the 8-year study period, 662 boys underwent emergency scrotal exploration: 6 (1%) were internal referrals, 294 (44%) attended our emergency department (ED) directly, 271 (41%) were referred from primary care and 91 (14%) were transferred from other hospitals. Excluding procedures in neonates, testicular torsion was present in 100 cases (15%). Testicular detorsion with bilateral 3-point testicular fixation was performed in 66 (66%) and orchidectomy with contralateral fixation in 34 (34%) where the torted testis was non-viable intraoperatively. The orchidectomy rate in the presence of torsion was 23% in ED referrals (12/52), 43% in primary care referrals (12/28) and 50% for transfers (10/20). The difference in rates between ED referrals and patients transferred from other hospitals was significant (p=0.026). There was no significant difference in median age between any of the groups (p=0.10). CONCLUSIONS: Boys undergoing emergency scrotal exploration had a higher orchidectomy rate when transferred from other hospitals to our unit. This difference was statistically significant when compared with boys presenting directly to our ED. This supports advice from The Royal College of Surgeons of England for undertaking paediatric scrotal explorations in the presenting hospital when safe to do so rather than delaying the care of these patients by transferring them to a tertiary paediatric surgical unit.

[Result of the STAMPEDE trial; plausibility and practical consequences]. / Resultaten van de STAMPEDE-trial.

Recently, the results of the STAMPEDE trial arm H were reported. This trial investigated the effect of radiotherapy to the prostate only on the overall survival of patients with metastatic prostate cancer. Although on the whole the findings of the trial were negative, a significant increase in survival was noted in the prespecified subgroup of patients with a low metastatic burden. As only a few analyses were prespecified, the direction of the subgroup effect was prespecified and consistent with previous observations from the separate but comparable HORRAD trial. The subgroup effect was large and independent of other subgroup variables, and as there is a solid biological rationale for these results, they are to be considered trustworthy, and are likely to change clinical practice. Further research should focus on better specification of the low metastatic burden subgroup, if other locally ablative treatments such as surgery are equivalent, and if ablation of all metastatic lesions would give additional benefit.