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Concept: Spermatic cord

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We report a hitherto not documented case of primary mucinous cystadenoma arising in the spermatic cord within the right inguinal canal of a78-year-old man. The tumor was painless, hard and mobile. A computed tomography scan on the pelvis revealed an oval shaped, low attenuation mass, measuring 5.0x2.5x2.1 cm, that was present adjacent to the vas deferens. Grossly, the excised mass was multicystic mucinous tumor, filled with thick mucoid materials. Microscopically, the cystic wall was irregularly thickened. The cystic epithelium commonly showed short papillae lined by a single layer of columnar to cuboidal mucinous epithelial cells without significant stratification or cytologic atypia. Goblet cells were also frequently present. Immunohistochemically, the neoplastic cells showed positive reaction to carcinoembryonic antigen, cytokeratin 20, CDX2, epithelial membrane antigen, and CD15. However, they were negative for PAX8 and Wilms' tumor 1 protein. Pathological diagnosis was a papillary mucinous cystadenoma of the spermatic cord. Although mucinous cystadenoma in this area is extremely rare, it is important that these lesions be recognized clinically and pathologically in order to avoid unnecessary radical surgery. Virtual slides The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1720965948762004.

Concepts: Cancer, Oncology, Anatomical pathology, Cystic fibrosis, Neoplasm, Respiratory epithelium, Vas deferens, Spermatic cord

27

Testicular infarction is an uncommon finding in paediatric age and is usually due to testicular torsion or trauma causing venous rupture with thrombosis and/or arteriolar obstruction. Other causes of segmental infarction of the testes are represented by polyarteritis nodosa, thromboangioiitis obliterans and hypersensitivity angiitis. A few cases of testicular infarction due to epididymitis have been described in the literature related mainly to adult patients. Epididymitis is usually treated in the outpatient setting with close follow-up, but according to our present experience, and reviewing the literature, there may be some cases in which, surgical exploration is mandatory in order to avoid testicular damage.

Concepts: Hospital, Andrology, Testicle, Testicular cancer, Polyarteritis nodosa, Epididymis, Spermatic cord, Testicular torsion

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Testicular pain syndrome (TPS), defined as an intermittent or constant pain in one or both testicles for at least 3 months, resulting in significant reduction of daily activities, is common. Microsurgical denervation of the spermatic cord (MDSC) has been suggested as an effective treatment option. The study population comprised 180 TPS patients, admitted to our outpatient urology clinic between 1999 and 2011. On three different occasions, patients were offered a double-blind, placebo-controlled temporary blockade of the spermatic cord. A single blockade consisted of 10 mL 2% lidocaine, 10 mL 0.25% bupivacaine or 10 mL 0.9% sodium chloride. If the results of these blockades were positive, MDSC was offered. All MDSCs were performed by a single urologist (MTWTL) using an inguinal approach. Pain reduction was determined at prospective follow-up. 180 patients were evaluated. Most patients (61.1%) had undergone a scrotal or inguinal procedure. Patients had complaints during sexual activities (51.7%), sitting (37.5%) and/or cycling (36.7%). 189 randomized blockades were offered to all patients. There was a positive response in 37% and a negative response in 51%. MDSC was performed on 58 testicular units including 3 patients with a negative outcome of the blockades. At mean follow-up of 42.8 months, 86.2% had a ⩾50% reduction of pain and 51.7% were completely pain free. MDSC is a valuable treatment option for TPS patients as in this study 86.2% experienced a ⩾50% reduction of pain. To prevent superfluous diagnostics and treatment, it is mandatory to follow a systematic protocol in the treatment of TPS.

Concepts: Sodium chloride, Testicle, Sodium, Male reproductive system, Scrotum, Spermatic cord, Testicular torsion, Blockade

1

- Testicular germ cell tumors with lymphovascular invasion (LVI) are staged pT2, and those with spermatic cord involvement are staged pT3.

Concepts: Gene, Germ cell tumor, Germ cell, Spermatic cord

1

The ubiquitous use of polypropylene mesh in hernia surgery has spawned a new clinical syndrome: chronic post-herniorrhaphy neuralgia. A subset of that clinical picture is dysejaculation, sexual pain, and orchialgia. We propose to identify the processes that lead to that pain.

Concepts: Medicine, Surgery, Polypropylene, Spermatic cord

1

TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urologic history and physical exam to assess risk of testis torsion. The parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1), and high-riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy amongst non-urologic providers is unknown. We assessed the utility of the TWIST score when collected by non-urologic non-physician providers, mirroring the ER evaluation of acute scrotal pain.

Concepts: Evaluation, Assessment, Psychometrics, Andrology, Testicle, Scrotum, Spermatic cord, Testicular torsion

0

The case is presented of a post-lung transplant patient, ASA III, proposed for orchiectomy due to testicular cancer. A combination of iliohypogastric (ILH), ilioinguinal (ILI) and genitofemoral (GF) nerve block together with sedation was used as anaesthetic technique. The inguinal area received sensory innervation mainly from ILI, ILH and GF nerves. The genital branch of the GF nerve supplies innervation to skin of the anterosuperior portion of the scrotum. When performing the echo-guided block of GF nerve, it is necessary to identify the spermatic cord, and administer the local anaesthetic on the inside and periphery of the cord. Peripheral nerve blocks are a valid option for complex patients. Its main advantage is the anaesthesia and analgesia level that it provides without the haemodynamic instability associated with general or neuraxial anaesthesia. GF nerve block provides hemi-scrotal anaesthesia, allowing manipulation and intervention in the inguinal-scrotal area, complementing the anaesthesia provided by ILI and ILH nerve blocks.

Concepts: Testicle, Anesthesia, Scrotum, Local anesthetic, Nerve block, Lumbar plexus, Spermatic cord, Genital branch of genitofemoral nerve

0

A 39-year-old man presented with a 2-day history of worsening constant, dull diffuse lower abdominal pain with associated constipation and known history of left undescended testicle. He was evaluated at an outside hospital where a non-contrasted CT scan revealed a 20 cm well-circumscribed soft tissue mass within the pelvis.He was referred and further imaging revealed a 12 cm heterogeneous mass with foci of air that appeared to be contiguous with the left spermatic cord. This constellation of findings could represent torsion of undescended left testicle with infarction or underlying malignancy. Tumour markers were only significant for elevated lactate dehydrogenase of 1445. A subsequent ultrasound-guided biopsy of the mass demonstrated seminoma.Surgical resection revealed a large intra-abdominal mass emanating from the left spermatic cord with 270° of torsion. There appeared to be a left atrophic remnant testicle at the base of the mass with final pathology confirming the diagnosis of classic seminoma.

Concepts: Cancer, Oncology, Abdominal pain, Testicle, Testicular cancer, Irritable bowel syndrome, Lactate dehydrogenase, Spermatic cord

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Testicular torsion is the most concerning underlying cause of acute scrotal pain that can lead to loss of the affected testicle. Whether a torted testicle can be salvaged surgically is directly affected by prompt presentation and diagnosis. This study aims to evaluate the awareness of testicular torsion amongst Irish parents and evaluate their response to a potential torsion.

Concepts: Parent, Andrology, Testicle, Testicular cancer, Scrotum, Spermatic cord, Epididymitis, Testicular torsion

0

The International Society of Urological Pathology held a conference on issues in testicular and penile pathology in Boston in March 2015, which included a presentation by the testis macroscopic features working group. The presentation focused on current published guidance for macroscopic handling of testicular tumors and retroperitoneal lymph node dissections with a summary of results from an online survey of members preceding the conference. The survey results were used to initiate discussions, but decisions on practice were made by expert consensus rather than voting. The importance of comprehensive assessment at the time of gross dissection with confirmation of findings by microscopic assessment was underscored. For example, the anatomic landmarks denoting the distinction of hilar soft tissue invasion (pT2) from spermatic cord invasion (pT3 category) can only be determined by careful macroscopic assessment in many cases. Other recommendations were to routinely sample epididymis, rete testis, hilar soft tissue, and tunica vaginalis in order to confirm macroscopic invasion of these structures or if not macroscopically evident, to exclude subtle microscopic invasion. Tumors 2 cm or less in greatest dimension should be completely embedded. If the tumor is >2 cm in greatest dimension, 10 blocks or a minimum of 1 to 2 additional blocks per centimeter should be taken (whichever is greater).

Concepts: Cancer, Andrology, Testicle, Testicular cancer, Male reproductive system, Epididymis, Spermatic cord, Rete testis