Is it necessary to place a surgical clamp early in the spermatic cord during testicular examination via inguinal approach? | Actas Urológicas Españolas (English Edition)

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "375" "paginaFinal" => "378" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "G. Gueglio, M. Bergero, S. Treiyer, C. Cristallo, M. Isola, O. Damia" "autores" => array:6 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Gueglio" "email" => array:1 [ 0 => "Servicio.urologia@hiba.org.ar" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Bergero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Treiyer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C." 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"apellidos" => "Damia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Hospital Italiano de Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Patología, Hospital Italiano de Buenos Aires, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Resulta necesaria la colocación de una pinza quirúrgica tempranamente en el cordón espermático durante la exploración testicular por vía inguinal?" ] ] "textoCompleto" => "IntroductionTesticular cancer accounts for about 1% of male tumors, and it is the most common malignancy in men between 15 and 35. In the U.S.A., 8400 new cases were described in 2009.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> Inguinal testicular exploration, with early placement of a surgical clamp in the spermatic cord, is considered the first step required to perform orchiectomy, essential for diagnosis, local staging, and as initial treatment in these patients.<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a>In recent decades, due to the development of new diagnostic methods, the improved understanding of the tumor biology, the high probability of survival with the multimodal treatment and the growing awareness of the potential benefits of testicular preservation in terms of health and quality of life, the need for radical orchiectomy as standard procedure in all testicular tumors has been questioned.<a class="elsevierStyleCrossRefs" href="#bib0025">5,7–17</a> This question has a special interest in the pediatric age when a conservative treatment wants to be suggested.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>The aim of this paper is to show whether there are cancer cells in the spermatic cord or not during inguinal testicular examination. If so, this finding could support the generally accepted idea that early ligation of the spermatic cord prevents the suspected tumor dissemination.Materials and methodsWe performed a prospective study on 38 patients diagnosed with testicular mass, who underwent inguinal testicular exploration between June 2008 and June 2010. Before the procedure, all the patients underwent: detailed medical history, general and testicular physical examination, testicular ultrasound, tumor markers including AFP (alpha fetoprotein), β-HCG (human chorionic gonadotropin-β), LDH (lactate dehydrogenase), and chest computed tomography (CT) scan without contrast and abdominopelvic with oral and endovenous contrast.Under general anesthesia, the patients underwent testicular exploration inguinally with early cord ligation by means of atraumatic surgical clamp performing frozen biopsy of the suspicious area. After confirming the diagnosis of malignant lesion, we proceeded to perform radical orchiectomy. We performed macroscopic and microscopic deferred pathologic examination of the surgical specimen, and the presence of tumor embolisms in lymphovascular structures of the spermatic cord was thoroughly evaluated at the different levels thereof by means of hematoxylin–eosin staining. The follow-up and subsequent treatment of the patients was performed following the parameters described in the guidelines on testicular cancer by the European Association of Urology.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>ResultsAll the patients underwent testicular examination inguinally. Ten patients (26.31%) were excluded from the analysis because the frozen biopsy revealed benign lesions. In the remaining 28 patients, radical orchiectomy was performed. In 16 cases, the testicle was the left one and the right one in 12. The mean age of the patients was 42 years (range: 21–82).Three (7.89%) patients had a history of cryptorchidism and three (7.89%) of contralateral testicular cancer. Twenty (52.63%) consulted a unilateral painless indurated mass and 18 (47.37%) testicular heaviness. Three (7.89%) had increased β-HCG and three (7.89%) AFP. In 5 patients (13%), subdiaphragmatic latero-aortic adenopathies smaller than 2cm (N1) were found. The surgical time was 52min (range: 37–92) and the time of temporary ligation of the cord 23min (range: 15–35).The TNM staging of the International Union Against Cancer 2002 of the assessed patients was: T1N0M0 in 21 patients, T1N1M0 in three patients, T2N0M0 in two patients, and T2N1M0 in two patients. The tumor markers were absent in the first postoperative control in all the patients. The histological data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The pathologic assessment of the spermatic cord showed no commitment of lymphovascular structures in any case.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Of the patients with nonseminomatous germ cell tumor (NSGCT), 8 received systemic chemotherapy (SCT) and one retroperitoneal lymphadenectomy, the specimen of the resected lymph nodes being negative for neoplastic cells. Of the patients with seminomatous tumor (SGCT), 5 underwent SCT, 4 radiotherapy, and 11 active surveillance.DiscussionTesticular cancer is a malignancy that affects young men of reproductive age, with a probability of favorable survival if diagnosed and treated early.<a class="elsevierStyleCrossRefs" href="#bib0005">1–5</a> Testicular examination inguinally and eventual inguinal orchiectomy is the preferred method for the diagnosis, staging, and treatment of this malignancy. Although this technique enables the local control of the disease, it can cause distortion of body image, of fertility, and of the endocrine function.<a class="elsevierStyleCrossRefs" href="#bib0020">4–6,16–19</a>In our study, 38 patients underwent testicular examination with placement of an atraumatic surgical clamp early in the spermatic cord, of which 28 (74%) underwent orchiectomy for testicular cancer. In benign lesions and stromal tumors of the testis, as well as in monorchid patients with small malignant lesion, radical orchiectomy implies overtreatment, these cases being able to be treated with conservative surgery.<a class="elsevierStyleCrossRefs" href="#bib0080">16–19</a> In our series, in 10 patients (26%) the explored testicular masses were for benign lesions, consistent with the observed data in the literature.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>Both in classical and conservative surgery for the treatment of testicular cancer, early atraumatic ligation of the cord<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a> is described as a safe and necessary step to prevent the spread of tumor cells away; but there is no scientific evidence to validate this surgical gesture.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>In our casuistry, all the patients who underwent radical orchiectomy underwent detailed pathologic examination of the spermatic cord, no lymphovascular tumor embolisms being identified at the different levels of the cord in any of the samples analyzed. This finding was therefore independent of the tumor type and the stage of the lesions.Not only do we not know if the placement of an atraumatic surgical clamp in the spermatic cord is oncologically safe, but it also seems that this gesture may have functional implications in the patients who retain the gonad. Studies with animals show that the cord clamp in rats produces histological changes in body temperature and leads to irreversible histological changes (testicular parenchyma necrosis) the longer the ischemia time is.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Patterns of testicular ischemia have also been established after testicular torsion in rats.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>The loss of testicular parenchyma has potentially negative long-term consequences in the exocrine and endocrine function of the gonad,<a class="elsevierStyleCrossRef" href="#bib0115">23</a> and it appears to be related with ischemia associated with temporary ligation of the cord, one of the possible causes of this condition.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> For this reason, some experts now refrain from using clamps occluding the cord, because the benefits that this surgical step offers have never been appropriately tested.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Not performing it seems especially reasonable when preservation of testicular function in patients with germ cell tumor in a solitary testis is carried out.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Taking into account the increasingly frequent use of conservative techniques to treat testicular injury, the need to reduce the traumatic events during surgery raises new questions.In short, the classic surgical gesture consisting of early cord clamping has no scientific basis. However, as we cannot claim that not performing it is oncologically safe either, it is worthwhile to establish the unknown factor and carry out studies with a larger number of patients to respond to this question, which possibly results in defining safe and less traumatic surgical techniques that make it possible to preserve the testis and its functionality.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres101695" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec88861" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres101694" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec88862" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-07-06" "fechaAceptado" => "2011-07-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec88861" "palabras" => array:5 [ 0 => "Orchiectomy" 1 => "Surgery" 2 => "Testes" 3 => "Testicular cancer" 4 => "Spermatic cord" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec88862" "palabras" => array:5 [ 0 => "Orquiectomía" 1 => "Cirugía" 2 => "Testículos" 3 => "Neoplasia testicular" 4 => "Cordón espermático" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveThe presence of tumor cells in the spermatic cord was evaluated in patients undergoing inguinal testis study in order to assure if the placement of a clamp in it was necessary to avoid tumor dissemination. Materials and methodsInguinal testis studies were performed over a two-year period in 38 patients diagnosed of testicular mass. The presence of tumor cells in blood vessels or lymph nodes of the cord was evaluated in all of the patients. ResultsTesticular tumors were found in 28 patients (20 seminoma, 5 mixed tumor and 3 embryonal) with an average age of 42 (range: 21–82) years. There were T1N0M0 21; T1N1M0 3; T2N0M0 2 and T2N1M0 2 cases, respectively. Independently of the stage and tumor lineage, tumor cells in the cord vessels were not observed in any of the cases through the pathology study. ConclusionIn our causistics, it seems that the surgical act consisting of the placement of a clamp early in the cord lacks a scientific foundation. However, this study does not make it possible to state that not performing this maneuver during the surgical procedure is oncologically safe. Thus, a precedent is established to perform studies with a larger number of patients who will make it possible to corroborate this observation. This would result in less traumatic and safer surgical techniques that would allow conserving the testis and its functionality." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoSe evalúa la presencia de células tumorales en el cordón espermático en pacientes sometidos a exploración testicular inguinal, con intención de avalar si la colocación de una pinza en el mismo resulta necesaria para evitar la diseminación tumoral. Material y métodosDurante dos años se realizó exploración testicular inguinal a 38 pacientes con diagnóstico de masa testicular. En todos los pacientes se evaluó la presencia de células tumorales en los vasos sanguíneos o linfáticos del cordón. ResultadosExistió neoplasia testicular en 28 pacientes (20 seminoma, 5 tumor mixto y tres carcinoma embrionario) con una edad promedio de 42 años (rango 21-82). Fueron T1N0M0 21 casos, T1N1M0 tres, T2N0M0 dos y T2N1M0 dos, respectivamente. Independientemente del estadio y estirpe tumoral, en ninguno de los casos el examen de anatomía patológica evidencio células tumorales en los vasos del cordón. ConclusiónEn nuestra casuística parece que el gesto quirúrgico consistente en colocar una pinza precozmente en el cordón carece de fundamento científico. Sin embargo, este estudio tampoco permite afirmar que no realizar esta maniobra durante el procedimiento quirúrgico sea oncológicamente seguro. Se establece así un precedente para realizar estudios con mayor número de pacientes que permitan corroborar esta observación, lo que redundará en técnicas quirúrgicas menos traumáticas y seguras que permitan preservar el testículo y su funcionalidad." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gueglio G, et al. ¿Resulta necesria la colocación de una pinza quirúrgica tempranamente en el cordón espermático durante la exploración testicular por vía inguinal? Actas Urol Esp. 2012;36:375–8." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "LVE: lymphovascular embolism; RTI: rete testis infiltration; n: number of cases; TIN: intratubular neoplasia." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Cell line \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Histopathologic characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Embryonal carcinoma (EC)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/28</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TIN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seminoma (S)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20/28 (18s classical, 1s sarcomatoid, 1s anaplastic)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TIN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mixed tumor (MT)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5/28</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TIN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184248.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Histopathological findings of the cases with testicular cancer." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increasing incidence of testicular cancer worldwide: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. 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Is it necessary to place a surgical clamp early in the spermatic cord during testicular examination via inguinal approach?

¿Resulta necesaria la colocación de una pinza quirúrgica tempranamente en el cordón espermático durante la exploración testicular por vía inguinal?

G. Gueglioa,

Corresponding author

Servicio.urologia@hiba.org.ar

Corresponding author.

, M. Bergeroa, S. Treiyera, C. Cristalloa, M. Isolab, O. Damiab

a Servicio de Urología, Hospital Italiano de Buenos Aires, Argentina

b Servicio de Patología, Hospital Italiano de Buenos Aires, Argentina

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Testicular cancer accounts for about 1&#37; of male tumors&#44; and it is the most common malignancy in men between 15 and 35&#46; In the U&#46;S&#46;A&#46;&#44; 8400 new cases were described in 2009&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Inguinal testicular exploration&#44; with early placement of a surgical clamp in the spermatic cord&#44; is considered the first step required to perform orchiectomy&#44; essential for diagnosis&#44; local staging&#44; and as initial treatment in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent decades&#44; due to the development of new diagnostic methods&#44; the improved understanding of the tumor biology&#44; the high probability of survival with the multimodal treatment and the growing awareness of the potential benefits of testicular preservation in terms of health and quality of life&#44; the need for radical orchiectomy as standard procedure in all testicular tumors has been questioned&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7&#8211;17</span></a> This question has a special interest in the pediatric age when a conservative treatment wants to be suggested&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this paper is to show whether there are cancer cells in the spermatic cord or not during inguinal testicular examination&#46; If so&#44; this finding could support the generally accepted idea that early ligation of the spermatic cord prevents the suspected tumor dissemination&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a prospective study on 38 patients diagnosed with testicular mass&#44; who underwent inguinal testicular exploration between June 2008 and June 2010&#46; Before the procedure&#44; all the patients underwent&#58; detailed medical history&#44; general and testicular physical examination&#44; testicular ultrasound&#44; tumor markers including AFP &#40;alpha fetoprotein&#41;&#44; &#946;-HCG &#40;human chorionic gonadotropin-&#946;&#41;&#44; LDH &#40;lactate dehydrogenase&#41;&#44; and chest computed tomography &#40;CT&#41; scan without contrast and abdominopelvic with oral and endovenous contrast&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Under general anesthesia&#44; the patients underwent testicular exploration inguinally with early cord ligation by means of atraumatic surgical clamp performing frozen biopsy of the suspicious area&#46; After confirming the diagnosis of malignant lesion&#44; we proceeded to perform radical orchiectomy&#46; We performed macroscopic and microscopic deferred pathologic examination of the surgical specimen&#44; and the presence of tumor embolisms in lymphovascular structures of the spermatic cord was thoroughly evaluated at the different levels thereof by means of hematoxylin&#8211;eosin staining&#46; The follow-up and subsequent treatment of the patients was performed following the parameters described in the guidelines on testicular cancer by the European Association of Urology&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">All the patients underwent testicular examination inguinally&#46; Ten patients &#40;26&#46;31&#37;&#41; were excluded from the analysis because the frozen biopsy revealed benign lesions&#46; In the remaining 28 patients&#44; radical orchiectomy was performed&#46; In 16 cases&#44; the testicle was the left one and the right one in 12&#46; The mean age of the patients was 42 years &#40;range&#58; 21&#8211;82&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Three &#40;7&#46;89&#37;&#41; patients had a history of cryptorchidism and three &#40;7&#46;89&#37;&#41; of contralateral testicular cancer&#46; Twenty &#40;52&#46;63&#37;&#41; consulted a unilateral painless indurated mass and 18 &#40;47&#46;37&#37;&#41; testicular heaviness&#46; Three &#40;7&#46;89&#37;&#41; had increased &#946;-HCG and three &#40;7&#46;89&#37;&#41; AFP&#46; In 5 patients &#40;13&#37;&#41;&#44; subdiaphragmatic latero-aortic adenopathies smaller than 2<span class="elsevierStyleHsp" style=""></span>cm &#40;N1&#41; were found&#46; The surgical time was 52<span class="elsevierStyleHsp" style=""></span>min &#40;range&#58; 37&#8211;92&#41; and the time of temporary ligation of the cord 23<span class="elsevierStyleHsp" style=""></span>min &#40;range&#58; 15&#8211;35&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The TNM staging of the International Union Against Cancer 2002 of the assessed patients was&#58; T1N0M0 in 21 patients&#44; T1N1M0 in three patients&#44; T2N0M0 in two patients&#44; and T2N1M0 in two patients&#46; The tumor markers were absent in the first postoperative control in all the patients&#46; The histological data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The pathologic assessment of the spermatic cord showed no commitment of lymphovascular structures in any case&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Of the patients with nonseminomatous germ cell tumor &#40;NSGCT&#41;&#44; 8 received systemic chemotherapy &#40;SCT&#41; and one retroperitoneal lymphadenectomy&#44; the specimen of the resected lymph nodes being negative for neoplastic cells&#46; Of the patients with seminomatous tumor &#40;SGCT&#41;&#44; 5 underwent SCT&#44; 4 radiotherapy&#44; and 11 active surveillance&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Testicular cancer is a malignancy that affects young men of reproductive age&#44; with a probability of favorable survival if diagnosed and treated early&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a> Testicular examination inguinally and eventual inguinal orchiectomy is the preferred method for the diagnosis&#44; staging&#44; and treatment of this malignancy&#46; Although this technique enables the local control of the disease&#44; it can cause distortion of body image&#44; of fertility&#44; and of the endocrine function&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6&#44;16&#8211;19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In our study&#44; 38 patients underwent testicular examination with placement of an atraumatic surgical clamp early in the spermatic cord&#44; of which 28 &#40;74&#37;&#41; underwent orchiectomy for testicular cancer&#46; In benign lesions and stromal tumors of the testis&#44; as well as in monorchid patients with small malignant lesion&#44; radical orchiectomy implies overtreatment&#44; these cases being able to be treated with conservative surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;19</span></a> In our series&#44; in 10 patients &#40;26&#37;&#41; the explored testicular masses were for benign lesions&#44; consistent with the observed data in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Both in classical and conservative surgery for the treatment of testicular cancer&#44; early atraumatic ligation of the cord<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> is described as a safe and necessary step to prevent the spread of tumor cells away&#59; but there is no scientific evidence to validate this surgical gesture&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In our casuistry&#44; all the patients who underwent radical orchiectomy underwent detailed pathologic examination of the spermatic cord&#44; no lymphovascular tumor embolisms being identified at the different levels of the cord in any of the samples analyzed&#46; This finding was therefore independent of the tumor type and the stage of the lesions&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Not only do we not know if the placement of an atraumatic surgical clamp in the spermatic cord is oncologically safe&#44; but it also seems that this gesture may have functional implications in the patients who retain the gonad&#46; Studies with animals show that the cord clamp in rats produces histological changes in body temperature and leads to irreversible histological changes &#40;testicular parenchyma necrosis&#41; the longer the ischemia time is&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Patterns of testicular ischemia have also been established after testicular torsion in rats&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The loss of testicular parenchyma has potentially negative long-term consequences in the exocrine and endocrine function of the gonad&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and it appears to be related with ischemia associated with temporary ligation of the cord&#44; one of the possible causes of this condition&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> For this reason&#44; some experts now refrain from using clamps occluding the cord&#44; because the benefits that this surgical step offers have never been appropriately tested&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Not performing it seems especially reasonable when preservation of testicular function in patients with germ cell tumor in a solitary testis is carried out&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Taking into account the increasingly frequent use of conservative techniques to treat testicular injury&#44; the need to reduce the traumatic events during surgery raises new questions&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In short&#44; the classic surgical gesture consisting of early cord clamping has no scientific basis&#46; However&#44; as we cannot claim that not performing it is oncologically safe either&#44; it is worthwhile to establish the unknown factor and carry out studies with a larger number of patients to respond to this question&#44; which possibly results in defining safe and less traumatic surgical techniques that make it possible to preserve the testis and its functionality&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "identificador" => "xres101695"
          "titulo" => array:5 [
            0 => "Abstract"
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            3 => "Results"
            4 => "Conclusion"
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        1 => array:2 [
          "identificador" => "xpalclavsec88861"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres101694"
          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Objetivo"
            2 => "Material y m&#233;todos"
            3 => "Resultados"
            4 => "Conclusi&#243;n"
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec88862"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Materials and methods"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflict of interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-07-06"
    "fechaAceptado" => "2011-07-25"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec88861"
          "palabras" => array:5 [
            0 => "Orchiectomy"
            1 => "Surgery"
            2 => "Testes"
            3 => "Testicular cancer"
            4 => "Spermatic cord"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec88862"
          "palabras" => array:5 [
            0 => "Orquiectom&#237;a"
            1 => "Cirug&#237;a"
            2 => "Test&#237;culos"
            3 => "Neoplasia testicular"
            4 => "Cord&#243;n esperm&#225;tico"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The presence of tumor cells in the spermatic cord was evaluated in patients undergoing inguinal testis study in order to assure if the placement of a clamp in it was necessary to avoid tumor dissemination&#46;</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Inguinal testis studies were performed over a two-year period in 38 patients diagnosed of testicular mass&#46; The presence of tumor cells in blood vessels or lymph nodes of the cord was evaluated in all of the patients&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Testicular tumors were found in 28 patients &#40;20 seminoma&#44; 5 mixed tumor and 3 embryonal&#41; with an average age of 42 &#40;range&#58; 21&#8211;82&#41; years&#46; There were T1N0M0 21&#59; T1N1M0 3&#59; T2N0M0 2 and T2N1M0 2 cases&#44; respectively&#46; Independently of the stage and tumor lineage&#44; tumor cells in the cord vessels were not observed in any of the cases through the pathology study&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our causistics&#44; it seems that the surgical act consisting of the placement of a clamp early in the cord lacks a scientific foundation&#46; However&#44; this study does not make it possible to state that not performing this maneuver during the surgical procedure is oncologically safe&#46; Thus&#44; a precedent is established to perform studies with a larger number of patients who will make it possible to corroborate this observation&#46; This would result in less traumatic and safer surgical techniques that would allow conserving the testis and its functionality&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se eval&#250;a la presencia de c&#233;lulas tumorales en el cord&#243;n esperm&#225;tico en pacientes sometidos a exploraci&#243;n testicular inguinal&#44; con intenci&#243;n de avalar si la colocaci&#243;n de una pinza en el mismo resulta necesaria para evitar la diseminaci&#243;n tumoral&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Durante dos a&#241;os se realiz&#243; exploraci&#243;n testicular inguinal a 38 pacientes con diagn&#243;stico de masa testicular&#46; En todos los pacientes se evalu&#243; la presencia de c&#233;lulas tumorales en los vasos sangu&#237;neos o linf&#225;ticos del cord&#243;n&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Existi&#243; neoplasia testicular en 28 pacientes &#40;20 seminoma&#44; 5 tumor mixto y tres carcinoma embrionario&#41; con una edad promedio de 42 a&#241;os &#40;rango 21-82&#41;&#46; Fueron T1N0M0 21 casos&#44; T1N1M0 tres&#44; T2N0M0 dos y T2N1M0 dos&#44; respectivamente&#46; Independientemente del estadio y estirpe tumoral&#44; en ninguno de los casos el examen de anatom&#237;a patol&#243;gica evidencio c&#233;lulas tumorales en los vasos del cord&#243;n&#46;</p> <span class="elsevierStyleSectionTitle">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En nuestra casu&#237;stica parece que el gesto quir&#250;rgico consistente en colocar una pinza precozmente en el cord&#243;n carece de fundamento cient&#237;fico&#46; Sin embargo&#44; este estudio tampoco permite afirmar que no realizar esta maniobra durante el procedimiento quir&#250;rgico sea oncol&#243;gicamente seguro&#46; Se establece as&#237; un precedente para realizar estudios con mayor n&#250;mero de pacientes que permitan corroborar esta observaci&#243;n&#44; lo que redundar&#225; en t&#233;cnicas quir&#250;rgicas menos traum&#225;ticas y seguras que permitan preservar el test&#237;culo y su funcionalidad&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Gueglio G&#44; et al&#46; &#191;Resulta necesria la colocaci&#243;n de una pinza quir&#250;rgica tempranamente en el cord&#243;n esperm&#225;tico durante la exploraci&#243;n testicular por v&#237;a inguinal&#63; Actas Urol Esp&#46; 2012&#59;36&#58;375&#8211;8&#46;</p>"
      ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">LVE&#58; lymphovascular embolism&#59; RTI&#58; rete testis infiltration&#59; <span class="elsevierStyleItalic">n</span>&#58; number of cases&#59; TIN&#58; intratubular neoplasia&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Cell line&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Histopathologic characteristics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">Embryonal carcinoma &#40;EC&#41;</td><td class="td" title="\n
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                  \t\t\t\t">3&#47;28</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TIN&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " rowspan="3" align="left" valign="\n
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                  \t\t\t\t">Seminoma &#40;S&#41;</td><td class="td" title="\n
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                  \t\t\t\t">20&#47;28 &#40;18<span class="elsevierStyleHsp" style=""></span>s classical&#44; 1<span class="elsevierStyleHsp" style=""></span>s sarcomatoid&#44; 1<span class="elsevierStyleHsp" style=""></span>s anaplastic&#41;</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">TIN&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">RTI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mixed tumor &#40;MT&#41;</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#47;28</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TIN&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2011.07.006

The statistics are updated each day

Year/Month	Html	Pdf	Total

2023 March	1	2	3
2018 March	9	0	9
2018 February	5	2	7
2018 January	9	0	9
2017 December	8	1	9
2017 November	10	1	11
2017 October	16	2	18
2017 September	10	1	11
2017 August	12	1	13
2017 July	13	2	15
2017 June	20	9	29
2017 May	14	4	18
2017 April	11	3	14
2017 March	14	42	56
2017 February	22	2	24
2017 January	13	0	13
2016 December	24	8	32
2016 November	21	2	23
2016 October	37	7	44
2016 September	25	5	30
2016 August	29	1	30
2016 July	13	1	14
2016 June	19	4	23
2016 May	20	5	25
2016 April	20	13	33
2016 March	33	13	46
2016 February	26	13	39
2016 January	31	13	44
2015 December	12	5	17
2015 November	9	2	11
2015 October	13	8	21
2015 September	13	7	20
2015 August	13	8	21
2015 July	7	3	10
2015 June	11	5	16
2015 May	19	7	26
2015 April	16	9	25
2015 March	21	4	25
2015 February	18	1	19
2015 January	36	2	38
2014 December	59	5	64
2014 November	28	4	32
2014 October	29	6	35
2014 September	45	4	49
2014 August	35	4	39
2014 July	37	2	39
2014 June	12	4	16
2014 May	6	1	7
2014 January	5	1	6
2013 December	13	2	15
2013 November	8	1	9
2013 October	12	1	13
2013 September	6	2	8

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