Heresy - Is there a role for ultrasound in management of the non-palpable testicle?

INTRODUCTION

AUA Guidelines do not support the routine use of ultrasound (US) in evaluation of boys with an undescended testicle (UDT) prior to urology referral. Multiple studies have demonstrated that real time US is inferior to a physical examination by a pediatric urologist in detecting an UDT. However, improved US technology, which now permits detection of the non-palpable testis located just proximal to the internal ring, may aid in guiding the surgical approach to the non-palpable testis. We evaluated US findings of boys deemed to have a non-palpable UDT and compared them to surgical findings.

OBJECTIVE

To assess the role of pre-operative ultrasonography in guiding surgical management in boys deemed to have a non-palpable testis by a pediatric urologist.

STUDY DESIGN

US of boys with a non-palpable UDT, as reported by a pediatric urologist on physical exam, during a 3-year period, were reviewed. All US were performed jointly by a technician and pediatric radiologist. Patient demographics, laterality, and intra-operative findings were assessed.

RESULTS

Thirty-one boys with a non-palpable testicle on physical exam underwent scrotal/inguinal/pelvis US at a median age of 7.5 months (IQR 2.5-12.3 months). Two patients had bilateral non-palpable testicles, 21 had a non-palpable left sided testicle and 8 had a non-palpable right sided testicle. Of the 33 non-palpable testes, 5 (15.2%) were identified in the inguinal canal. Sixteen (48.5%) were visualized in the lower pelvis just proximal to the internal ring and graded as intra-abdominal. Four (12.1%) nubbins or very atrophic testes were identified in the inguinal region or scrotum and 5 (15.2%) testes were not identified on US. Three (9.1%) testes were observed to be mobile between the lower pelvis just proximal to the internal ring and the inguinal canal. Of the 8 patients with testes that were identified in the inguinal canal, or mobile between the lower pelvis and inguinal canal, 7 avoided a diagnostic laparoscopy and underwent an inguinal orchiopexy. Of the 16 testicles located in the lower pelvis proximal to the internal ring, only 2 underwent laparoscopy/laparoscopic orchiopexy.

DISCUSSION

In cases of a non-palpable testicle following a physical examination by a urologist, an ultrasound can impact the operative plan, and allow for patients to avoid laparoscopy. In our cohort, 87.5% of non-palpable testes avoided laparoscopic surgery after ultrasound identification of a viable testis.

CONCLUSIONS

US in the evaluation of cryptorchidism can guide surgical management in select cases in which a testis is non-palpable following careful examination by a urologist.

Personalizing approaches to the management of metastatic hormone sensitive prostate cancer: role of advanced imaging, genetics and therapeutics

PURPOSE

To summarize contemporary and emerging strategies for the diagnosis and management of metastatic hormone sensitive prostate cancer (mHSPC), focusing on diagnostic testing and therapeutics.

METHODS

Literature review using PUBMED-Medline databases as well as clinicaltrials.gov to include reported or ongoing clinical trials on treatment for mHSPC. We prioritized the findings from phase III randomized clinical trials, systematic reviews, meta-analyses and clinical practice guidelines.

RESULTS

There have been significant changes to the diagnosis and staging evaluation of mHSPC with the integration of increasingly accurate positron emission tomography (PET) imaging tracers that exceed the performance of conventional computerized tomography (CT) and bone scan. Germline multigene testing is recommended for the evaluation of patients newly diagnosed with mHSPC given the prevalence of actionable alterations that may create candidacy for specific therapies. Although androgen deprivation therapy (ADT) remains the backbone of treatment for mHSPC, approaches to first-line treatment include the integration of multiple agents including androgen receptor synthesis inhibitors (ARSI; abiraterone) Androgen Receptor antagonists (enzalutamide, darolutamide, apalautamide), and docetaxel chemotherapy. The combination of ADT, ARSI, and docetaxel chemotherapy has recently been evaluated in a randomized trial and was associated with significantly improved overall survival including in patients with a high burden of disease. The role of local treatment to the prostate with radiation has been evaluated in randomized trials with additional studies underway evaluating the role of cytoreductive radical prostatectomy.

CONCLUSION

The staging and initial management of patients with mHSPC has undergone significant advances in the last decade with advancements in the diagnosis, treatment and sequencing of therapies.

Oncologic outcomes of neoadjuvant chemotherapy in patients with micropapillary variant urothelial carcinoma of the bladder

BACKGROUND

There is lack of consensus about the effectiveness of neoadjuvant platinum-based chemotherapy in patients with micropapillary variant urothelial carcinoma (MVUC) prior to radical cystectomy. We studied the association between neoadjuvant chemotherapy (NAC) and pathologic response (PR) among patients with micropapillary versus non-variant bladder urothelial carcinoma (UC).

METHODS

We queried the National Cancer Database to identify patients with localized UC and MVUC from 2004 to 2017. We restricted our analysis to patients who underwent radical cystectomy with or without NAC. We compared clinical, demographic, and pathologic characteristics associated with NAC. We used multivariable logistic regression and propensity score matching to examine the association between NAC and the occurrence of a pathologic complete response (pT0) and pathologic lymph node positivity (pN+). Kaplan Meier analyses and Cox proportional hazards models were used to assess overall survival (OS). We performed analyses among subsets of patients with clinical stage II (cT2) disease, as well as the entire cohort (cT2-T4).

RESULTS

We identified 18,761 patients, including 18,027 with non-variant UC and 734 patients with MVUC. Multivariable analysis revealed that NAC use was associated with greater odds of pT0 (9.64[7.62-12.82], P<0.001), and the association did not differ significantly between MVUC and non-variant UC. In a propensity matched analysis of patients with MVUC, NAC use was associated with higher odds of pT0 (OR 4.93 [2.43-13.18] P<0.001), lower odds of pN+ (OR 0.52 [0.26-0.92] P=0.047) and pathologic upstaging (OR 0.63 [0.34-0.97] P=0.042) in all stages. Similar findings were observed with cT2 disease. No significant association was seen between NAC and OS with MVUC (HR 0.89 [0.46-1.10] P=0.63), including the subset of patients with cT2 (HR 0.83 [0.49-1.06] P=0.58).

CONCLUSIONS

NAC is associated with similar pathologic and nodal responses in patients with localized MVUC and non-variant UC. Improvements in pathologic findings did not translate into OS in this retrospective hospital-based registry study.

Surveillance and office management of low-grade Ta bladder tumors

OBJECTIVE

Patients with low-grade (LG), grade 1-2, Ta bladder cancer (BC) will frequently have a "recurrence". However, they rarely progress in stage. Although current guidelines mention surveillance and office management for these new or recurrent tumors, transurethral resection (TURBT) is the most common treatment. The purpose of this study is to determine if surveillance and/or office cautery is safe.

MATERIALS AND METHODS

This study was conducted as a retrospective case series analysis of 45 patients who had recurrent LG Ta appearing bladder cancer (BC) and were managed primarily with surveillance and/or office cautery. Patients with carcinoma in-situ were excluded. The primary outcome was stage progression.

RESULTS

Median follow up was 62 months. 41 (91%) patients did not progress in stage. Three patients recurred with HG T1 BC; one is receiving systemic immunotherapy. One patient developed HG T2 BC and was treated with a bladder preservation protocol. 40 (89%) patients underwent office cauterization. Eleven received BCG and 26 received post-cautery intravesical chemotherapy. Five (11%) patients developed HG BC during follow up. No patients died. None of the 17 (38%) Hispanic patients had progression.

CONCLUSIONS

Active surveillance and/or office cautery for patients with small recurrent LG Ta bladder tumors is safe, reduces cost and improves quality of life by avoiding TURBTs.

Cachexia and bladder cancer: clinical impact and management

PURPOSE OF REVIEW

The purpose of this review is to describe the causes, management, and clinical outcomes associated with cachexia and related components including sarcopenia, among patients with bladder cancer (BCa).

RECENT FINDINGS

Cachexia in patients with BCa is associated with poorer outcomes after radical cystectomy (RC), radiation, and chemotherapy. Nutritional supplements and novel pharmaceutical agents including magnolol, flucoidan and Anamorelin are currently undergoing investigation for their potential use in BCa patients with cachexia.

SUMMARY

Cachexia is a hypercatabolic state thought to be caused by an immune-regulated release of cytokines and disruptions of molecular pathways within the tumor microenvironment and systemically. Nutritional deficiencies in patients with BCa also contribute to cachexia and sarcopenia. Patients with BCa -related cachexia and sarcopenia experience worse survival and therapeutic outcomes after RC, chemotherapy, and radiation therapy. Patients with cachexia also experience more postoperative complications after RC. The management of cachexia in patients with BCa remains challenging and requires timely identification, and multidisciplinary management including nutritional supplementation, physical therapy, palliative care, and pharmacological agents. Clinical trials and human studies are still required to determine which pharmacological agents are optimal for BCa cachexia.

Utility of PSA Density in Predicting Upgraded Gleason Score in Men on Active Surveillance With Negative MRI

OBJECTIVES

To determine whether PSA density (PSAD), can sub-stratify risk of biopsy upgrade among men on active surveillance (AS) with normal baseline MRI.

METHODS

We identified a cohort of patients with low and favorable intermediate-risk prostate cancer on AS at two large academic centers from February 2013 - December 2017. Analysis was restricted to patients with GG1 cancer on initial biopsy and a negative baseline or surveillance mpMRI, defined by the absence of PI-RADS 2 or greater lesions. We assessed ability of PSA, prostate volume and PSAD to predict upgrading on confirmatory biopsy.

RESULTS

We identified 98 patients on AS with negative baseline or surveillance mpMRI. Median PSA at diagnosis was 5.8 ng/mL and median PSAD was 0.08 ng/mL/mL. Fourteen men (14.3%) experienced Gleason upgrade at confirmatory biopsy. Patients who were upgraded had higher PSA (7.9 vs 5.4 ng/mL, P = .04), PSAD (0.20 vs 0.07 ng/mL/mL, P < .001), and lower prostate volumes (42.5 vs 65.8 mL, P = .01). On multivariate analysis, PSAD was associated with pathologic upgrade (OR 2.23 per 0.1-increase, P = .007). A PSAD cutoff at 0.08 generated a NPV of 98% for detection of pathologic upgrade.

CONCLUSION

PSAD reliably discriminated the risk of Gleason upgrade at confirmatory biopsy among men with low-grade prostate cancer with negative MRI. PSAD could be clinically implemented to reduce the intensity of surveillance for a subset of patients.

Parenchymal cytokine expression precedes clinically observed ischemia in dorsal flaps in the rat

Cytokines have been implicated as pivotal mediators of the wound-healing process. An understanding of the production and interaction of cytokines may lead to a better appreciation of the complex mechanisms of flap ischemia. The potential would then exist for novel diagnostic and therapeutic approaches to prevent and reverse damage to the endangered flap. The goal of this study was to determine the expression of parenchymal cytokines at various time points during flap ischemia. Punch biopsies were obtained from McFarlane dorsal flaps in the Sprague-Dawley murine model. We examined cytokine mRNA profiles for interleukin 1 alpha (IL-1 alpha), IL-2, IL-6, basic fibroblast growth factor (b-FGF), gamma-interferon (gamma IFN), transforming growth factor beta (TGF-beta), and platelet-derived growth factor A chain (PDGF-alpha) using in situ hybridization. Samples were taken from 0 to 48 hours postoperatively, with n = 3 for each time point. Eight hours postoperatively there was an abrupt peak of parenchymal cytokine expression at the bases of the flaps. Clinically at this time the flaps appeared completely viable without evidence of ischemic change. Leukocyte cytokine production peaked at 16 hours, when distal flap ischemia was evident clinically. These findings demonstrate an early peak of cytokine expression prior to clinical evidence of ischemia.

Association of down-regulation of cytokine activity with rat hind limb allograft survival

Cytokines are short-acting protein modulators of many physiologic processes including graft rejection. An understanding of the production, action, and interaction of cytokines may lead to better appreciation of the complex mechanism of graft rejection. The potential would then exist for more selective and less-toxic means of modulating the immune response. A rat hind limb allograft model with major immunohistoincompatibility was used to study the local mRNA expression of IL-1 alpha, IL-2, IL-6, gamma interferon (gamma INF), platelet-derived growth factor-alpha (PDGF-alpha), basic fibroblast growth factor (FGF), and transforming growth factor-beta (TGF-beta) during acute allograft rejection. A 14-day postoperative course of immunosuppressive therapy with FK506 or rapamycin was administered. In situ hybridization was performed on serial full-thickness skin punch biopsies of the untreated rejecting limb allograft and compared with tissue from treated allografts, isografts, and to normal limb tissue. A sequential pattern of cytokine mRNA expression was demonstrated which progressed in a time-dependent manner and paralleled observed clinical rejection. Maximal cytokine mRNA expression correlated with peak graft rejection. Cellular expression of IL-1 alpha, IL-2, IL-6, gamma-INF, FGF, and TGF-beta mRNA was suppressed with FK506 to below isograft levels, and clinical rejection was not observed with the doses, routes, and schedules used. Rapamycin was ineffective in suppressing cytokine expression, and allograft rejection was not prevented. Isografts demonstrated no evidence of rejection. The in situ hybridization technique demonstrates a time-dependent, selective expression of cytokines within rejecting allograft tissue, and the modification of this response with immunosuppressive therapy. Down-regulation of cytokine expression is associated with clinical allograft survival.

Scarless wound healing: implications for the aesthetic surgeon

Recent developments in surgery and basic science research offer aesthetic surgeons the prospect of scarless repair. Studies in fetal wound healing provide both cellular and molecular models of optimal tissue healing without scar formation. Furthermore, craniofacial surgeons may one day operate on cleft lip, cleft palate, and other congenital malformations in utero. Cytokine research has begun to unravel possibilities for modulating the wound-healing inflammatory response in hopes of limiting scar formation. This article presents research on these developments and comments on their possible applications to aesthetic surgery.

Reduction mammaplasty for gigantomastia using inferiorly based pedicle and free nipple transplantation

Patients with gigantomastia have severely distorted anatomical breast structures. Reduction mammaplasty in such cases using the inferiorly based pedicle containing the nipple-areola complex can be technically difficult, yield poor results, and cause postoperative complications such as nipple necrosis and loss. Alternative traditional methods such as amputation mammaplasty with free nipple-areola transplantation usually results in a flattened, nonaesthetic breast with poor projection. This unacceptable result is due to the lack of central breast tissue required for normal anatomical projection. Herein, we describe a method of reduction mammaplasty for gigantomastia combining free nipple transplantation and an inferiorly based pyramidal parenchymal flap for augmentation of breast fullness and nipple projection.

Light microscopic and immunohistochemical features in serial biopsies of epidermal versus dermal allografts

The local immune response to allograft dermis and epidermis was studied in a rat skin-graft model. Biopsies taken at varying times after transplantation were analyzed using routine light microscopy and a panel of monoclonal antibodies. The dermis appeared to be spared by the rejection process, whereas the epithelium and adnexal elements of the dermis were destroyed. The persistence of dermis transplanted across major histoincompatibilities may allow it to be useful in reconstructing large skin losses.

Efficacy of rapamycin and FK 506 in prolonging rat hind limb allograft survival

OBJECTIVE

Graft rejection and the toxicity of current immunosuppressive regimens preclude the application of microsurgical advances to transplantation of limbs or other nonessential parts. If limb transplantation is to become a clinical reality, newer, safer, more effective immunosuppressive agents are needed.

SUMMARY BACKGROUND DATA

Rapamycin (RPM) and FK 506 are fungal macrolide antibiotics with effective immunosuppressive properties demonstrated in several animal models. RPM is more potent and effective than is FK 506 in rat cardiac allografts and has demonstrated synergy with cyclosporine (CsA) in limb allograft models.

METHODS

An orthotopic rat hind limb allograft model (Brown-Norway [RT-1n] to Lewis [RT-1(1)] rats was used. RPM (doses, 3.0, 4.5, and 6.0 mg/kg/day) was administered intraperitoneally on postoperative days 1 to 14. FK 506 (6 mg/kg/day) was administered orally on postoperative 1 to 14 and 1 to 90 and at rejection onset (10 mg/kg/day for salvage). CsA with RPM (postoperative days 1 to 14) was used to assess synergy, with CsA alone serving as the control. Other controls included untreated and placebo-treated allografted animals. The permutation test and Mann-Whitney test were applied to the data.

RESULTS

The mean survival times were assessed as follows: (1) control (placebo, untreated), 5 days; (2) RPM groups, 9.5, 10.6, and 8.7 days; (3) 14-day FK 506, 28 days; (4) 90-day FK 506, > 90 days; (5) CsA, 17.3 days; and (6) CsA with RPM, 19.3 days. FK 506 significantly prolonged graft survival compared with RPM (Permutation Test, p < 0.001 and Mann-Whitney Test, p < 0.05). FK 506 salvage reversed early rejection. High-dose RPM produced significant toxicity. Synergy between CsA and RPM was not demonstrated.

CONCLUSIONS

FK 506 prolongs allograft survival, reverses early rejection, and prevents rejection without clinical toxicity when given continually. RPM does not prevent rejection in this model and produces significant toxicity at high doses. FK 506 may be a first step in making limb transplantation a clinical reality in reconstructive surgery.

Successful treatment of coccidioidomycosis osteomyelitis in an infant

A 10-month-old Hispanic male infant with expansile lesions of the third metacarpal and proximal phalanx positively diagnosed as Coccidioides immitis osteomyelitis is presented. Treatment consisted of combined surgical debridement and systemic antifungal therapy and resulted in complete resolution of the lesions. Treatment was guided by clinical response and complement fixation titers. Osteomyelitis is a relatively infrequent manifestation of disseminated coccidioidomycosis. Neonates and infants appear to be more susceptible to the development of dissemination, but less likely to develop toxicity due to systemic therapy. Current therapy consists of concomitant surgical excision of involved lesions and systemic antifungal therapy. Complement fixation titers correlate closely with clinical response to therapy and are useful in detecting subclinical recurrences.

The rectus abdominis muscle in difficult problems of hand soft tissue reconstruction

When soft tissue losses in the hand require flap reconstruction, local tissue is preferred. Distant flaps should be reserved for major or unusually complex tissue losses which preclude the use of local flaps. We have used the rectus abdominis muscle as either a pedicled or a free flap with an overlying split thickness skin graft for several such complex soft tissue problems. Functional and cosmetic results have been excellent with minimal donor site morbidity. While not the initial choice for distant tissue used in hand reconstruction, the rectus abdominis muscle can solve several complex soft tissue problems in the hand.

Composite in situ vein bypass for upper extremity revascularization

Chronic upper extremity arterial insufficiency is rare. Consequently, major reports specifically limited to the topic are scarce, and the clinical experience is small. In addition, symptomatology, diagnostic criteria, and guidelines for surgical management remain ill-defined. In the lower extremities, however, in situ vein bypass has been attempted for nearly three decades. This technique offers many advantages over traditional revascularization methods. Although the procedure has become popular for the lower extremity, no report of its use in the upper extremity is found in the literature. We report what may be the first case in which in situ bypass was used in the upper extremity for a threatened limb secondary to diabetic occlusive vascular disease complicated by a previous shunt used for hemodialysis. Revascularization of the upper extremity using the in situ vein bypass technique may offer a new alternative to traditional methods of revascularization.

Reconstruction of a large chest wall defect with a musculocutaneous free flap using anterolateral thigh musculature

Reconstruction of a large postmastectomy irradiated chest wall defect was accomplished with a large musculocutaneous free flap of anterolateral thigh musculature and skin. The vascular anatomy of the donor area allows a very substantial flap and skin island to be transferred, leaving a well-tolerated donor defect.

Limb allotransplantation in the rat: extended survival and return of nerve function with continuous cyclosporin/prednisone immunosuppression

We report the variability of the rejection process among the several tissues of a limb allograft. We used a rat hind limb allograft model transplanting across a well-defined minor histocompatibility barrier (Fischer RT-1(1v1)), donor animals, and Lewis (RT-1(1)) recipient animals. Continuous cyclosporin and prednisone immunosuppression was used. Four immunosuppressive regimens all produced extended limb survival. The rejection process was most severe and difficult to control in the skin. Nonskin tissues reverted to a nearly normal appearance after a period of cellular infiltration 2 to 3 weeks posttransplantation. Clinical and electromyographic evidence of nerve regeneration and end-organ reinnervation was demonstrated in long-term surviving animals.

Aggressive surgical therapy after irradiation failure in treatment of cancer of the oral tongue

Fifty-three consecutive unrandomized patients with squamous cell cancer of the oral tongue were retrospectively studied to compare the results of an aggressive surgical approach performed as primary therapy or as salvage after irradiation failure. Twenty-five patients underwent surgery primarily, while 23 of 28 patients treated with curative irradiation required surgical salvage. Tumor staging was equivalent between the two groups. Local recurrences at the site of origin of the tumor within two years postoperatively were significantly more frequent in salvage patients (10.0%) than in primary surgical patients (5.5%). Cervical lymph node recurrences within five years were more frequent in the salvage surgery group (74.8% v 36.7%). Systemic metastases developed in a similar proportion in both groups. Determinate five-year survivals were nearly identical (55.2% v 55.5%). Although recurrence rates were significantly higher after irradiation and salvage surgery, an aggressive surgical effort in patients who are irradiation failures can result in five-year survival rates matching those of surgical patients.

Early histopathologic changes in experimentally replanted extremities

Early serial histologic changes in replanted extremities have not been well defined; their contribution to a suboptimal functional result is unknown. With the use of a rat hind limb replantation model to address this question, we studied tissues of the replanted legs by light microscopy from 1 to 60 days after replantation. Although early lesions were consistent with ischemic injury, the chronic preparations were remarkably normal, and the lesions were more consistent with denervation. Poor function in clinical replantations may be a reflection of more pronounced versions of these pathologic lesions.

Facial fractures in trauma victims: the influence of treatment delay on ultimate outcome

To obtain objective data on the consequences of delayed treatment of facial fractures we reviewed the records of 220 patients who had suffered facial fractures concomitantly with extrafacial trauma severe enough in its own right to warrant hospital admission. Fractures studied were those of the mandible, maxilla, zygoma, and frontal sinus. Seventy-three patients fit inclusion criteria. Most injuries occurred in motor vehicle accidents. Associated extrafacial injuries were common and frequently multiple, the more serious of which generally took priority over the facial injuries in the triage system. The two most common reasons for delay were instability of the patient's neurological status, or initial non-recognition or poor definition of the facial fracture. Delays in treatment ranged from 0 to 24 days. In patients with mandible fracture only, delay of up to 24 days in definitive treatment led to no noticeable increase in morbidity due to malocclusion, infection, or nonunion. In no other facial fracture did treatment delay lead to an increased incidence of complications. Retrospective analysis of the patients who did suffer complications almost always revealed predisposing conditions that placed these patients at higher risk for poor results.

The treatment of earlobe keloids by surgical excision and postoperative triamcinolone injection

Thirty-one earlobe keloids in 20 patients were treated by complete surgical excision and three postoperative injections of .1 to .2 ml of 40 mg per milliliter of triamcinolone solution at four-week intervals beginning three weeks postoperation. Only 1 recurrence developed in a follow-up of twelve to sixty-two months.

The use of methyl methacrylate in a two-stage correction of Crouzon's/Apert's deformity

We have employed a two-stage operative approach to the correction of Crouzon's/Apert's deformity. Extensive use of methyl methacrylate in cranioplasty and frontal bone advancement is employed to obtain finely detailed contours with excellent stability. By adhering to principles of separation of oral contamination and the methyl methacrylate, as well as the provision of adequate soft tissue coverage of the methyl methacrylate, the problems of infection and soft tissue breakdown can be minimized.

Results of conservative surgery for middle ear cholesteatoma

A retrospective study was carried out to analyze treatment results for cholesteatoma at the University of Iowa Hospitals and Clinics. All patients undergoing primary surgical treatment from January 1, 1969 to December 31, 1973 were followed through October 1976. Treatment failures were based on the occurrence of postoperative cholesteatoma. The probability of being disease free for periods up to five years after original surgery was then estimated for each type of operation. Postoperative cholesteatoma occurred after atticotomy in 17%, intact canal wall mastoidectomy in 35%, and modified radical mastoidectomy in 9%. The postoperative cholesteatoma rate in the group having intact canal wall mastoidectomy was more than twice as high for those patients under age nine. The likelihood of being disease free five years after intact canal wall surgery was estimated to be 36% using the life table method. Disease recurrence was significantly higher after intact canal wall surgery compared to other surgical methods. The effectiveness of this method should be evaluated in a randomized, prospective manner to minimize patient selection and treatment bias.