==inizio objective==

Urachal adenocarcinoma is a rare and aggressive tumor that arises from the urachus. An en bloc resection of the urachus is recommended with either a partial cystectomy. However, there is no standard laparoscopic or robotic surgical technique for its operative management. In the present report, we describe our robotic-assisted laparoscopic technique for the treatment of a primary malignant urachal tumor.

==fine objective==

==inizio methodsresults==

In January 2016, a 37-year-old male reported recurrent gross hematuria. A pelvic ultrasound revealed a mass of 23 × 21 × 26 mm at the bladder dome connected with an antero-superior supravesical median small cystic mass of 20 × 19 × 16 mm, confirmed by a gadolinium-enhanced MRI. Cystoscopy demonstrated an erythematous mass < 3 cm whose biopsy confirmed to be an urachal adenocarcinoma. Further studies showed no metastatic spread. After institutional multidisciplinary meeting, a partial cystectomy with en bloc resection of the urachus were decided. After general anesthesia the patient was placed in Trendelenburg with arms against the body and legs in mid lithotomy position. Pneumoperitoneum was obtained through open technique, placing the camera trocar midline 8 cm above the umbilicus. Trocars for curved monopolar scissors (arm1) and bipolar forceps (arm 2) were placed 8 cm from each side of the midline at the level of the umbilicus. Trocar for Maryland grasper was placed at the left on the same line while assistant port (12 mm) was placed in the right side. Upon entry in the peritoneal cavity and the abdomen explored to exclude lesions, the dissection started from the internal part of the umbilicus, once the bladder was evidenced. The dissection was carried out cranially and laterally to the medial umbilical ligaments along the preperitoneal plane. Then an inverted V shaped incision form the internal umbilicus to the anterior bladder wall was performed. Bladder wall dissection began using the diathermy scissors 1 cm away from the tumor margin to identify the mucosa. The third arm was used to hold the bladder and served as a landmark. The urachus and the bladder resected part were removed to use endobag The bladder was sutured in three layers using V lock 3-zero. ==fine methodsresults== ==inizio results== Postoperative recovery was uneventful with removal of the drain on day 3 and the urinary catheter on day 10. Patient was discharged 4 days after surgery. The histological analysis of the specimen showed a pT2b moderately differentiated mucinous colloid adenocarcinoma of the urachus. Surgical margins were negative. 3 , 6 ,12 and 18 months after the operation, the patient was doing well with no sign of recurrence at the CT scan and flexible cistoscopy. ==fine results== ==inizio discussions== Urachal cancers arise from the urachus which is an embryological remnant of urogenital sinus and allantoid that usually involutes before birth and remains as the median umbilical ligament connecting the umbilicus to the dome of the bladder. The median umbilical ligament, located in the space of Retzius between the transversalis fascia anteriorly and peritoneum posteriorly, is approximately 5–6 cm in length [1,2,3]. Urachal cancer often presents at an advanced stage and has a poor prognosis. Surgery is the only curative treatment modality for the non-metastatic urachal carcinoma [4]. The role of pelvic lymph node dissection, radiation and/or chemotherapy is debatable in the literature [3]. An en bloc resection of the urachus and umbilicus is recommended with either a total or partial cystectomy [5,6]. Achieving negative surgical margins is crucial to achieve cure of urachal malignancies [7]. The excision of the umbilicus is considered imperative because it could be involved in 7 % of cases The extent of bladder resection is also debatable . However, it seems that survival is significantly more associated with the stage of the disease at presentation and the surgical margins rather than the extent of bladder resection [3]. That’s why bladder sparing techniques—understandably associated with less morbidity and better quality of life of patients compared to total cystectomy—are preferred. Although open surgical approach has been favored for decades, the minimal invasive approach has gained interest because it is associated with less operative pain, faster recovery, and better cosmetic results. In our opinion, due to the location of these tumors near the anterior abdominal wall and the importance of complete excision of the umbilicus and prevention of cancer spillage during the procedure, robotic-assisted transperitoneal approach should be the preferred approach. It allows direct access by only positioning the trocars 8 cm higher than the usual positioning for radical prostatectomy. A fine and precise dissection and a good view would facilitate dissection and avoid entering the urachus with the potential of spillage of the tumor containing fluid into the peritoneal cavity that would increase the risk of relapse. Distending the bladder with normal saline facilitates the dissection into the bladder wall to the level of the mucosa. The bladder should be completely emptied before cystotomy to minimize the risk of tumor spillage. The urinary catheter is clamped to avoid gas leak once the bladder is opened. The use of the third arm allows application of a controlled stable traction, thereby facilitating dissection, in a confined space, of the peritoneal and preperitoneal tissue from the transversalis fascia. This good exposure would help in avoiding the manipulation or entry of the tumor and would keep the limit of the tumor from inadvertently touching the surrounding viscera, thus preventing local tumor contamination and hematogeneous tumor spread [8]. Furthermore, the use of the third arm to hold the bladder near the tumor boundaries before deflating and opening the bladder helps in rapidly finding the landmarks and preventing injuries to the opposing wall. It is noteworthy to mention that the bladder is kept attached to the anterior bladder wall which facilitate the dissection and minimize the manipulation of the tumor. ==fine discussions== ==inizio conclusion== We demonstrate the feasibility of bladder sparing robot-assisted laparoscopic en bloc resection of urachus and umbilicus for urachal adenocarcinoma. ==fine conclusion== ==inizio reference== 1 Gopalan A, Sharp DS, Fine SW et al (2009) Urachal carcinoma: a clinicopathologic analysis of 24 cases with outcome correlation. Am J Surg Pathol 33:659–668 2 Molina JR, Quevedo JF, Furth AF, Richardson RL, Zincke H, Burch PA (2007) Predictors of survival from urachal cancer: a Mayo Clinic study of 49 cases. Cancer 110:2434–2440 3. Siefker-Radtke AO, Gee J, Shen Y et al (2003) Multimodality management of urachal carcinoma: the M. D. Anderson Cancer Center experience. J Urol 169:1295–1298 4. Zhang J, Wu J (2013) Options for diagnosis and treatment of urachal carcinoma. Asia Pac J Clin Oncol 9(2):117–122 5. Burnett AL, Epstein JI, Marshall FF (1991) Adenocarcinoma of urinary bladder: classification and management. Urology 37:315–321 6. D’Addessi A, Racioppi M, Fanasca A, La Rocca LM, Alcini E (1998) Adenocarcinoma of the urachus: radical or conservative surgery? A report of a case and a review of the literature. Eur J Surg Oncol 24:131–133 7. Molina JR, Quevedo JF, Furth AF, Richardson RL, Zincke H, Burch PA (2007) Predictors of survival from urachal cancer: a Mayo Clinic study of 49 cases. Cancer 110:2434–2440 8.Ashley RA, Inman BA, Sebo TJ et al (2006) Urachal carcinoma: clinicopathologic features and long-term outcomes of an aggressive malignancy. Cancer 107:712–720 ==fine reference==

==inizio objective==

To present a very rare case of a patient with an adult type of GCT of the testis, treated with testis sparing surgery.

==fine objective==

==inizio methodsresults==

We describe a case of a 32 years old patient, who was admitted to our department with suspicion of tumor in the left testis. The ultrasonography showed a 15 mm hypo-echoic, vascularised lesion in the upper pole of the left testis. The patient had no history of cryptorchidism and his past medical history was not significant, including only a spontaneous pneumothorax, when he was 18 years old. The patient denied decreased libido or erectile disfunction in the months before. Alpha-fetoprotein (alfa-FP), human chorionic gonadotropin (HCG) and lactate dehydrogenase (LDH) were normal. During the operation a frozen section was request as usual in our department, before to perform a radical treatment. The lesion was little, intra-parenchymal and simple to remove, without infiltration of the surrounding tissue. The pathologist suspected a GCT and the surgeon decided to perform a testis sparing surgery, waiting for the definitive histology.

==fine methodsresults==

==inizio results==

The postoperative course was uneventful and the patient was released from the hospital the day after the operation without complications. The definitive histology confirmed the previous report of adult-type GCT; the lesion measured 1.5 cm and showed to be not infiltrating. There was no evidence of angio-invasion or necrosis. The tumor was composed of clusters of cells with scanty cytoplasm in a predominantly micro-follicular pattern; very few mitosis could be seen. The immunohistochemical study showed positivity for calretinin, inhibin, CD-99 and beta-catenin while chromogranin, cytokeratin and melan-A were negative. A computed tomography showed absence of lymph node enlargement or distant metastases. The patient underwent regular follow up without any other surgery: an ultrasound of the testicles was done every 3 months; 6 months after surgery an abdominal ultrasound and a chest X-ray were performed and after one year the patient has well done and shows no signs of residual disease on ultrasound and computed tomography.

==fine results==

==inizio discussions==

Granulosa cell tumors (GCT) of the testis belong to the sex-cord stromal tumors and represent 4-5% of all testicular tumors (1). They were described for the first time in 1952 and they can be divided in two distinct groups, the juvenile type and the adult type. Although the juvenile-type represents only 1-4% of pre-pubertal testicular tumors, it’s the most common testis neoplasm in the first 6 months of life (2). The adult type is instead extremely rare and occurs at any age after puberty with only a limited number of reported cases to date: after a review of the literature we have found only 51 published cases, mostly isolated as case report (1, 2, 3). Unlike the juvenile type, which is typically benign, 20-25% of the adult type has been reported to be malignant with a metastatic potential even after 10 years: the retroperitoneal lymph nodes are the most common metastatic regions but liver, lung and bone metastases have been also described. Gynecomastia, erectile disfunction and decreased libido may be present in 20-25% of the cases, due to hormonal or chromosomal abnormalities. Because of his low incidence and the lack of data, the prognosis is not really known and consequently it’s almost difficult to decide what surgery to perform and if a radical treatment is really needed. Testis-sparing surgery could be offer in selected cases by small, intra-parenchymal lesions, if frozen sections are suspicious for a GCT, waiting for the definitive histologic diagnosis: by angio-invasion, necrosis, infiltrating margins and severe nuclear atypia or elevated mitotic count (4) a delayed radical orchiectomy could be performed although no cut-off for the tumor size is offered in the guide lines. A personalized follow-up is required.

==fine discussions==

==inizio conclusion==

The adult-type GCT is a rare entity, which can be malignant in 20-25% of the patients. The reported case showed, that testis sparing surgery is safe in very selected cases, if frozen sections are available and if the definitive histology shows no risk factors.

==fine conclusion==

==inizio reference==

1) Giulianelli R, Mirabile G, Vincenti G, Pellegrino F, Soda G. A very rare case of adult-type granulosa cell tumor. Arch Ital Urol Androl 2015; 87 (1): 98-99
2) Mohapatra A, Potretzke AM, Knight BA, Han M, Figenshau RS. Metastatic Granulosa Cell Tumor of the Testis: Clinical Presentation and Management. Case Report in Urology 2016: 1-4.
3) Al Alao O, Gul T, Al-Ani A, Bozom A, Al-Jalham K. Adult-type granulosa cell tumor of the testis: report of a case and review of the literature. Arab J Urol 2016; 14: 44-49
4) Cornejo KM, Young RH. Adult granulosa cell tumors of the testis: a report of 32 cases. AJSP 2014; 38 (9): 1242-1250

==fine reference==

==inizio objective==

We present a small series of 11 consecutive patients with testicular sex-cord stromal tumors (TSCST), with the intent to evaluate the possibility to standardize the surgical treatment.

==fine objective==

==inizio methodsresults==

Between 2005 and 2016 a TSCST was diagnosed in 11 patients at our department. The age ranged from 14 to 83 years. The blood screening with alpha-fetoprotein (alfa-FP), human chorionic gonadotropin (HCG) and lactate dehydrogenase (LDH) was assessed preoperative in all patients. All patients underwent inguinal access to the testis. During the operation frozen sections were request before to choose the definitive surgical strategy and a TSS was performed always in case of TSCST, waiting for the definitive histology, before to perform a radical orchidectomy. A thoracic and abdominal computed tomography was performed after the surgery. The follow-up was scheduled according with the European Association of Urology guide-lines for testicular tumors.

==fine methodsresults==

==inizio results==

All lesions were intraparenchimal and detected in ultrasound. No patient presented gynecomastia. Alpha-FP, HCG and LDH were negative in all patients. The intra-operative histology showed a TSCST in 10 patients, which were treated with TSS. In 1 patient was performed an orchiectomy, because the frozen section suspected a seminom but the definitive histology showed a TSCST. The tumor-size ranged from 7 to 40 mm. There was no evidence of angioinvasion, margin infiltration or necrosis in the definitive histology. The mitosis-index was low in all patients (<1%). All postoperative courses were uneventful and the patients were discharged one day after the operation without complications. The computed tomography showed absence of lymph node enlargement or distant metastases in all patients. Follow-up ranged from 10 to 108 months (mean 43.8 months), every 6 months for 5 years and then every year. All patient are free from disease and alive except one, who died after 108 months for other reasons. ==fine results== ==inizio discussions== Testicular sex-cord stromal tumors (TSCST) arise from nongerminal cell lines of the male testis and represent 3-5% of all testicular tumors (1): the most common subtype is represented from Leydig cells tumors (75-80%) but this group of tumors includes also Sertoli and Granulosa Cell tumors, mixed and undifferentiated tumors, thecomas and fibromas. They can occur at any age with a range from 12 to 76 years in previous reports. The most common clinical presentation is a palpable testicular mass. Gynecomastia, erectile disfunction or decreased libido are reported in one third of patients. The great majority of these tumors show a good clinical outcome but a malignant behavior has been reported in about 10% of all cases (2, 3). Because of his low incidence and the lack of data with prospective studies, their management remain controversial: the guide-lines recommend an organ-sparing procedure in every small ultrasound-detected, non palpable intraparenchimal lesion to obtain a histological diagnosis and, in case of malignancy, to perform a delayed orchiectomy but they don't give a cut-off for the tumor size (3, 4). The potential malignancy and the difficulty to individuate the unfavourable cases can be an element for urologists to perform a radical surgery and the testis-sparing surgery (TSS) can remain only an option (5). Our small prospective series shows, that a TSS could be safely performed in case of TSCST by frozen sections, when the tumor size doesn’t exceed 4 cm and when the lesion is easy to resect, leaving sufficient testicular parenchyma, with a very low risk to perform a delayed radical surgery. In presence of one or more pathologic risk factors in the definitive histology a radical surgery should always be considered. Although the good prognosis of these tumors we remark the need of a regular follow up. ==fine discussions== ==inizio conclusion== By sex cord-stromal tumors on frozen sections a TSS is safe and could be performed, waiting for the definitive histology, with a very low incidence of a delayed orchiectomy. ==fine conclusion== ==inizio reference== 1) Acar C, Gurocak S, Sozen S. Current treatment of testicular sex cord-stromal tumors: critical review. Urology 2009; 73: 1165-1171 2) Loeser A, Vergho DC, Katzenberger T, Brix D, Kocot A, Spahn M, Gerharz EW, Riedmiller H. Testis-sparing surgery versus radical orchiectomy in patients with Leydig cell tumors. Urology 2009; 74: 370-372 3) Rove KO, Maroni PD, Cost CR, Fairclough DL, Giannarini G, Harris AK, Schultz KAP, Cost NG. Pathologic risk factor for metastatic disease in postpubertal patients with clinical stage I testicular stromal tumors. Urology 2016; 97: 138-144. 4) Giannarini G, Dieckmann KP, Albers P, Heidenreich A, Pizzocaro G. Organ-sparing surgery for adult testicular tumors: a systematic review of the literature. European Urology 2010; 57: 780-790 5) Nicolai N, Necchi A, Raggi D, Biasoni D, Catanzaro M, Piva L, Stagni S, Maffezzini M, Torelli T, Farè E, Giannantempo P, Pizzocaro G, Colecchia M, Salvioni R. Clinical outcome in testicular sex cord stromal tumors: testis sparing surgery vs radical orchiectomy and management of advanced disease. Oncology 2015; 85: 402-406 ==fine reference==

==inizio objective==

We want present a case of synchronous bilateral seminoma . Bilateral testicular neoplasia is a rare situation normally treated with bilateral radical orchiectomy which has important consequences in men, renders the patient infertile and dependent on exogenous androgens (1.3).

==fine objective==

==inizio methodsresults==

Patient (pz) 42 years old,with normal levels of testosterone, he had perfomed the seed conservation. At other sites, at the target examination of bilateral ultrasonoghrapy tumefaction: multiple heterogeneous bilateral linfonodes It is performed pet / tac, then it is performed bilateral orchifunicolectomy by inguinal way (sett15), fifteen days after performed control pet, then tac T / B aimed at the verification of some highlighted and persistent lymph node areas to the previous radiological examination. Two months after, cycle of chemotherapy with carboplatin is performed Follow-up performed with half-yearly markers evaluation, pet annual alternating with tac torax without contrast and annual addominal and inguinal ultrasound

==fine methodsresults==

==inizio results==

In the pre-operative pet (18 f fdg), pathological hyperaccumulation is set up at the level of the didyms, more modest metabolic activity at the lymphonodal level of the external right iliac, para-aortic and retro-angolomandibular left.
Bilateral orchifuniculectomy: extemporaneous examination compatible with germline neoplasia in both sites, on the left, seminoma, pT2 Nx
Invasion rete testis and angiovascular invasion, absent necrosis, present intratubular neoplasia, funicular resection margin and vaginal tumor-free vaginal tunic. Nodule larger left size 3 cm.
Right. major nodule, 4 cm with histological examination superimposable to the contralateral. Postoperative pet detects persistence of lymph node areas of hyperaccumulation, which are then reactive. Actually the follow up and maintenance with testosterone performed by us is negative

==fine results==

==inizio discussions==

Testicular germinative neoplasia happens predominantly in 15 to 45-year old men. On 2-4 % of the cases there is bilateral in seminomas (1-2) Many studies have been done partial orchiectomy to have the patient got infertile, but without residual disease or need for androgenic supplements, but follow criteria for selection of patients.(1.2.4.5)

==fine discussions==

==inizio conclusion==

Bilateral radical orchiectomy still remains as standard treatment for bilateral testicular neoplasia.
Testis-sparing surgery may be indicated in case of benign tumours, incidentally discovered non palpable tumours, but no it doesn t the case . the dimention is larger. (1.5)

==fine conclusion==

==inizio reference==

1. SYNCHRONOUS BILATERAL SEMINOMA Arch. Esp. Urol. 2011; 64 (1): 69-73
Ricardo Oliveira Soares, Tiago Pinto Correia, André Cardoso, Artur Oliveira e Silva, Manuel Cerqueira, Frederico Carmo Reis, Martinho Almeida and Rui Prisco.
Urology Department. Hospital Pedro Hispano Unidade Local de Saúde de Matosinhos. EPE. Matosinhos Portugal.
2 A case of synchronous bilateral testicular seminoma.Nat Clin Pract Urol. 2008 Jul;5(7):397-401. doi: 10.1038/ncpuro1133. Epub 2008 Jun.
Resnick MJ1, Canter D, Brucker BM, Kutikov A, Guzzo TJ, Wein AJ.
3. Urol, 1999; 54 (4): 714-8 risk factor assessment in patients with bilateral germ cell tumors. Albers P, Goll A, Bierhoff E, Achoeneich G, Muller S. Clinical course and histopathologyc
4.Cancer Centre. Cancer, 2002; (95) 2: 1228-33 Bilateral testicular germ cell tumors: 20-year experience at M.D. Anderson Che M, Tamoli P, Ro Y, Park J, Ro J, Ayala R:
5. Risk of contralateral testicular cancer: a population-based study of 29 515 U.S. men Fossa S, Chen J, Schonfeld S, McGlynn K, Mcmaster M, Travis L J Natl Canc Inst, 2005; 97 (14): 1056-66

==fine reference==