Cut-off time for surgery and prediction of orchiectomy in spermatic cord torsion: a retrospective multicentric study over 15 years.

PURPOSE: Cut-off time to avoid orchiectomy relies on small series of patients. The objective was to determine the cut-off time to avoid orchiectomy in torsion of the spermatic cord in a large cohort. METHODS: We performed a retrospective multicenter study (TORSAFUF cohort) of patients with suspected spermatic cord torsion between 2005 and 2019. All patients aged > 12 years who were suspected of having a torsion of the spermatic cord in 14 University Hospitals in France were included (n = 2986). Patients for whom data on pain duration were not available (n = 923) or for whom the final diagnosis was not torsion of the spermatic cord (n = 807) were excluded. The primary outcome was orchiectomy. The secondary outcomes were testicular survival time and the prediction of orchiectomy with the duration of pain. RESULTS: 1266 patients were included with an orchiectomy rate of 12% (150 patients). The mean age was 21.5 years old in the salvage group and 23.7 years old in the orchiectomy group (p = 0.01), respectively. The median time from the onset of pain to surgery was 5.5 (IQR = 5) hours in the salvage group and 51.1 (IQR = 70) hours in the orchiectomy group (p < 0.0001). The risk of orchiectomy increased after a time cut-off of 6 h 30. A delay of 15 h 30 in pain duration was found to predict orchiectomy (sensitivity: 0.81; specificity: 0.87). CONCLUSIONS: Pain duration can predict the probability of salvaging the testicles and performing orchiectomy. Rapid intervention should be recommended, regardless of the time elapsed from the onset of pain.

The male external urethral sphincter is autonomically innervated.

INTRODUCTION: The aim of the present study was to describe autonomic urethral sphincter (US) innervation using specific muscular and neuronal antibody markers and 3D reconstruction. MATERIAL AND METHODS: We performed en-bloc removal of the entire pelvis of three male human fetuses between 18 and 40 weeks. Serial whole mount sections (5 µm intervals) were stained and investigated. The sections were stained with Masson's trichrome and Eosin Hematoxylin, and immunostained with: anti-SMA antibody for smooth muscle; anti-S100 antibody for all nerves; and anti-PMP22 antibody, anti-TH antibody, anti-CGRP antibody, anti-NOS antibody for somatic, adrenergic, sensory and nitrergic nerve fibers, respectively. The slides were digitized for 3D reconstruction to improve topographical understanding. An animated reconstruction of the autonomic innervation of the US was generated. RESULTS: The external and internal US are innervated by autonomic nerves of the inferior hypogastric plexus (IHP). These nerves are sympathetic (positive anti-TH antibody), sensory (positive anti-CGRP antibody), and nitrergic (positive anti-NOS antibody). Some autonomic fibers run within the neurovascular bundles, posterolaterally. Others run from the IHP to the posteromedial aspect of the prostate apex, above an through the rectourethral muscle. The external US is also innervated by somatic nerves (positive anti-PMP22 antibody) arising from the pudendal nerve, joining the midline but remaining below the rectourethral. CONCLUSIONS: This study provides anatomical evidence of an autonomic component in the innervation of the external US that travels in the neurovascular bundle. During radical prostatectomy, the rectourethral muscle and the neurovascular bundles are to be preserved, particularly during apical dissection.

The Use of Doppler Ultrasound for Suspected Testicular Torsion: Lessons Learned from a 15-Year Multicentre Retrospective Study of 2922 Patients.

BACKGROUND: Use of Doppler ultrasonography (DUS) for patients with suspected testicular torsion (TT) is highly controversial and remains debated, as it can delay surgery and its performance may vary. OBJECTIVE: To assess the role, impact, safety, and performance of DUS in the management of patients with suspected TT before scrotal exploration. DESIGN, SETTING, AND PARTICIPANTS: The TORSAFUF cohort retrospectively included patients older than 12 yr who underwent surgery for suspected TT in 14 academic hospitals between 2005 and 2019. Perioperative data and surgical and DUS reports were collected. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinical factors influencing DUS utilisation were analysed using multivariate logistic regression. The orchidectomy rate and delay to surgery were compared by group with and without DUS receipt using one-to-one propensity score (PS) matching to assess imaging safety. For the group with preoperative imaging, DUS performance was evaluated using a contingency table. RESULTS AND LIMITATIONS: Overall, 2922 patients were included, of whom 956 (32.7%) underwent DUS before surgery. DUS was more likely to be performed in older patients (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.1-1.2), those who experienced progressive onset of pain (OR 1.5, 95% CI 1.1-2), and patients who presented at the emergency department more than 6 h after their first scrotal symptoms (OR 2.3, 95% CI 1.9-2.8). After PS matching, DUS receipt was not significantly associated with orchidectomy but the delay to surgery was 1 h longer. DUS demonstrated strong sensitivity of 85.2% (95% CI 82.1-88.3%) and specificity of 52.7% (95% CI 48.8-56.6%). The performance was better for younger patients and for those with time since onset of pain of >6 h. CONCLUSIONS: In this large retrospective study, DUS before surgery was safe, feasible, and useful in selected cases with suspected TT, but it should not delay or replace surgery in cases with a strong clinical suspicion. PATIENT SUMMARY: We analysed the performance and safety of an ultrasound scan of the scrotum before surgery for patients with a suspected twisted testicle (TT). This scan before surgery was not associated with a higher risk of negative outcomes but was only moderate in accurately diagnosing TT. Surgery to correct TT should not be delayed.

Morbidity, perioperative outcomes and complications of robot-assisted radical prostatectomy in kidney transplant patients: A French multicentre study.

OBJECTIVE: Evaluate the safety, feasibility and efficiency of robot-assisted radical prostatectomy (RARP) in kidney transplant recipients, performed in high-volume French referral centres, and describe intra- and postoperative, oncological and functional outcomes. MATERIALS AND METHODS: A multicentre study was conducted on prospective RARP databases from 5 centres between 2008 and 2017. We retrospectively identified a first group (G1) of transplant patients. The following data were collected: age, body mass index, prostate-specific antigen, ISUP score, TNM stage, stratification according to d'Amico, renal function, renal disease, time between renal transplant and prostate cancer (PCa), operating time, bleeding, pre- and postoperative complications (according to Clavien). Group 1 data were matched with a second group (G2) of nontransplanted PTRA patients. RESULTS: A total of 321 patients were included (G1 N = 39 and G2 N = 282). The median operating time was 180 minutes (interquartile range 125-227) for G1 and 150 minutes (120-180) in G2 (P = 0.0623) and the median bleeding volume was 150 mL (150-400) and 250 mL (175-400), respectively (P = 0.1826). No grafts were damaged by RARP. Postoperative complication rate was significantly higher in G1: 51.2% vs. G2: 8.2% with a majority of minor complications (41%) according to Clavien Dindo (P < 0.001). Pathological assessment was as follows in G1: T2 = 28 (71.8%), T3 = 11 (28.2%), and G2: T2 = 206 (73.3%), T3 = 75 (26.7%) (P = 0.77). Postoperative ISUP scores were mainly grade 1: G1 = 14 (35.9%) vs. 99 (35.2%) in G2 and grade 2: respectively 18 (46.1%) 94 (33.5%). The rate of positive surgical margins was comparable in both groups: 13.2% for transplant patients vs. 18.1% (P = 0.65). Renal function was not significantly different at one year (P = 0.07). The median follow-up was 47.9 months (42.3; 52.5). CONCLUSION: RARP is conceivable to treat localized prostate cancer in kidney transplant recipients. This procedure does not appear to have any negative impact on graft renal function and cancer prognosis.