What's the deal with the abdoimno-scrotal hydrocele?

As it's name implies, an abdomino-scrotal hydrocele is a hydrocele that extends into the peritoneal cavity. It is a rare variant that makes up 3% of pediatric hydroceles. A recent meta-analysis by Dout et al published in the Journal of Pediatric Surgery looked at a total of 116 cases of abdomino-scrotal hydroceles in an attempt to better define this entity in terms of natural history, management, and clinical implications.

The authors describe a wide variability in natural history reported; ranging form hydroceles that spontaneously resolved to ones that continued to grow. The management strategies were equally varied; ranging from a combined inguinal/laparoscopic approaches to a more simple scrotal approach.

What I found most useful in this study was the association between these hydroceles and testicular dysmorphism.  Based on this report, the incidence of dysmorphism was around 28%. This was felt to be related to the amount of pressure exerted by these hydroceles on the surrounding tissue, including the testicular vessels.

This is relevant because it suggests that there may be benefit to more urgent intervention for an abdomino-scrotal hydrocele compared to the garden-variety non-communicating hydrocele, which one may opt to observe for a period of time.

Encephalitis associated with ovarian tumors

It is one thing to learn something new every day, but another to come across something you have never heard of.

Enter anti-NMDAR encephalitis secondary to ovarian teratomas.

Anti-NMDAR encephalitis syndrome is a constellation of psychiatric symptoms, memory changes, altered level of consciousness, and/or central hypoventilation due to the interaction of antibodies to NMDAR (receptor in brain tissue) with the hippocampus.

This condition can present at any age group, and can be associated with teratomas (in 50% of females above 12 years of age with anti NMDAR encephalitis); mainly the ovarian type.  It is the second most common type of autoimmune encephalitis, and is believed to be the result of interaction of auto antibodies to NMDAR (generated in response to ectopic neuronal tissue in the teratoma) with the hippocampus.  The diagnosis is confirmed with anti-NMDAR antibodies in the blood or CSF.

The treatment for this condition consists of immune therapy (steroids/plasmapharesis/IV immunoglobulin), tumor resection, and possible need for immune suppression.

80% of patient have substantial improvement of symptoms within 24 months of initiation of therapy.  During this time, the risk of relapse is 12%.

News to me.

Reference:

Tiltulaer et al.  Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis Lancet Neurol (2013) 12:2-157

Neonatal testicular torsion: what are the options?

This read stemmed from a hallway conversation I had with my favorite French-Canadian urologist (and not because he's the only FCU I know). I had been under the impression that, unlike ovarian torsion (where you detorse the ovary and give it a chance regardless of how it looks because of the possibility of viable tissue surviving), an orchiectomy for testicular torsion with ischemia was mandatory. The rationale behind that is the theory that leaving a necrotic testicle behind results in contralateral testicular injury. This injury results from an autoimmune response that occurs because of a breach in the hematotesticular barrier on the ischemic side. Well, that turned out to be erroneous thinking.

Djahangirian et al discussed this subject in a recent outcome study from Quebec and noted that the concern for the breach of the hematotesticular barrier applies to pubertal boys only (I should have figured that one out myself, given that you need sperm to form antisperm antibodies!!). Their main discussion was regarding the different management options for neonatal testicular torsion (NTT), which is defined as torsion detected within 30 days of birth, and constitutes 5% of all cases of testicular torsion. They discussed management rationales for the affected testicle as well as the contralateral one (which is presumed to be at risk of torsion too). Regarding the management of the torsed testicle, they noted that a prenatally torsed testicle (which constituted 50% of their cases) had no chance of survival so emergent surgery in an attempt to salvage the testicle was not recommended, and the options were elective orchiectomy or observation. In cases where the torsion occurs postnatally (the other 50%), and because of a slim chance of salvage (mostly in patients who present with signs of discomfort only), emergent exploration was indicated.

As to the management of the contralateral testicle (which they noted could torse in 5% of cases, either synchronously or metachronously), they suggested that elective orchidopexy, and even observation with strict instructions to the parents regarding the signs of torsion, were viable options.

Between medico-legal concerns and guaranteed sleepless nights, observation of the contralateral testicle does not sound like a reasonable option to me, so I would stick to an exploration with orchiectomy and contralateral pexy.

Timing of surgical management of neonatal testicular torsion. Djahangirian et al. Journal of Pediatric Surgery (2010) 45, 1012-1015

Cryptorchidism and testicular cancer

Prevalence of undescended testicles (UDT) is 3-4% at birth. The rate of UDT drops to 1% at 12 months, given that 2/3 of UDT demonstrate descent by age 3 months. The rate of UDT is higher in preterm infants, with no increased risk of malignancy in testes that descend spontaneously in the first 3-12 months. Infants (term or preterm) should be allowed to reach an adjusted gestational age of 12 months before orchidopexy is performed.

Using a meta analysis of current literature, the authors set out to answer 5 questions regarding cryptorchidism:

1. What is the RR of testicular cancer in a cryptorchid or formerly cryptorchid testis?

The historically quoted increased risk for testicular cancer (RR = 48) considered a substantial overestimate. The true RR for testicular cancer was found to be 4-6 in the undescended testes.

2. What is the relative risk for malignancy in the contralateral, normally descended testis?

Historically, it was believed that the contralateral, normal testis has a 5-10% chance of malignancy. Based on current literature, the authors identified no increased risk for malignancy in the contralateral testis.

3. Does relocating the testis affect the type of testicular cancer

Uncorrected cryptorchidism carries a higher risk for seminoma, while a corrected conditions carries a higher risk for non-seminomatous malignancies.

4. Does orchidopexy decrease the risk of malignancy

Relative risk of testicular cancer in the undescended testicle after operative correction depends on patient age at time of orchidopexy. When performed before the age of 10-12 years, the RR of testicular cancer is between 2 and 3. When orchidopexy is performed after age of 12, the RR is 2-6 times that of patients who undergo surgery before age 10-12 (this is comparable to the risk in uncorrected UDT).

5. Is there a risk of malignant degeneration in testicular remnants?

The risk of malignant degeneration from atrophic testes, resulting from perinatal spermatic cord torsion, is minimal.



Reference: Cryptorchidism and testicular cancer: Separating fact from fiction. Wood MW, Elder JS. Journal of Urology (2009);181:452-61