Roland Donat

Screening for metabolic syndrome and testosterone deficiency in patients with erectile dysfunction: results from the first UK prospective study

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

Intratubular germ cell neoplasia of the human testis: heterogeneous protein expression and relation to invasive potential

Testicular germ cell cancer develops from premalignant intratubular germ cell neoplasia, unclassified cells that are believed to arise from failure of normal maturation of fetal germ cells from gonocytes (OCT4+/MAGEA4−) into pre-spermatogonia (OCT4−/MAGEA4+). Intratubular germ cell neoplasia cell subpopulations based on stage of germ cell differentiation have been described, however the importance of these subpopulations in terms of invasive potential has not been reported. We hypothesized that cells expressing an immature (OCT4+/MAGEA4−) germ cell profile would exhibit an increased proliferation rate compared with those with a mature profile (OCT4+/MAGEA4+). Therefore, we performed triple immunofluorescence and stereology to quantify the different intratubular germ cell neoplasia cell subpopulations, based on expression of germ cell (OCT4, PLAP, AP2γ, MAGEA4, VASA) and proliferation (Ki67) markers, in testis sections from patients with preinvasive disease, seminoma, and non-seminoma. We compared these subpopulations with normal human fetal testis and with seminoma cells. Heterogeneity of protein expression was demonstrated in intratubular germ cell neoplasia cells with respect to gonocyte and spermatogonial markers. It included an embryonic/fetal germ cell subpopulation lacking expression of the definitive intratubular germ cell neoplasia marker OCT4, that did not correspond to a physiological (fetal) germ cell subpopulation. OCT4+/MAGEA4− cells showed a significantly increased rate of proliferation compared with the OCT4+/MAGEA4+ population (12.8 versus 3.4%, P<0.0001) irrespective of histological tumor type, reflected in the predominance of OCT4+/MAGEA4− cells in the invasive tumor component. Surprisingly, OCT4+/MAGEA4− cells in patients with preinvasive disease showed significantly higher proliferation compared to those with seminoma or non-seminoma (18.1 versus 10.2 versus 7.2%, P<0.05, respectively). In conclusion, this study has demonstrated that OCT4+/MAGEA4− cells are the most frequent and most proliferative cell population in tubules containing intratubular germ cell neoplasia, which appears to be an important factor in determining invasive potential of intratubular germ cell neoplasia to seminomas.

Estrogen secretion from a malignant sex cord stromal tumor in a patient with complete androgen insensitivity

We report on a 68-year-old patient with complete androgen insensitivity syndrome (testicular feminization syndrome) in whom an estrogen-secreting malignant sex cord stromal tumor developed in an intraabdominal testis. We believe this to be the first such case to document estrogen secretion by the tumor.

Circumcision standards: can we improve further?

Lv et al.1 present a newly designed disposable circumcision device. The device cuts the foreskin and closes the skin edges with staples simultaneously. Their results suggest a fast operating time, low complication rate, and high patient satisfaction. This device is easy to operate and can be used with local anesthesia alone. In an age when several African countries consider mass circumcision to reduce HIV transmission rates,2,3 physicians have been looking for a simple and safe circumcision method that can easily be taught to others. Provided the results can be replicated by others, this device appears to be an ideal tool for adult mass circumcisions. It has the distinct advantage over the Shang Ring and other penile clamps of immediately removing the skin and the device rather than leaving the ring and await subsequent skin necrosis and healing. In this study, the Shang Ring resulted in higher postoperative pain scores. The cost and general availability for the device have not been discussed and may potentially be a limiting factor for some health services. The device is also not suitable for patients with foreskin adhesions or a buried penis, who will continue to need surgical skills and a manual circumcision. Secondly, there is a novel approach to the circumcision anesthetic using 5% lidocaine cream alone rather than a penile block with 10 ml 2% lidocaine injection. Patients given 5% lidocaine cream alone had less intraoperative pain than those receiving an injection. However, other variables such as shorter surgical times with the device and technique and volume of the lignocaine injection may have influenced intraoperative pain levels. In my own practice, I use a mixture of 10 ml 1% lidocaine, 10 ml 0.5% bupivacaine, and 10 ml normal saline. A volume of 20 ml is injected as penile block and ring block, leaving 10 ml in the rare case of residual discomfort. Using this technique my patients are usually completely pain free during surgery. However, the idea of anesthesia with cream alone will certainly appeal more to patients than an injection. A further prospective study comparing anesthesia with lidocaine cream versus injection to clarify the suitability and benefit of surface analgesia alone for standard circumcision is required. Thirdly, the concept of measuring healing time is introduced, which raises the interesting question of objectively defining when a wound is healed and whether this can be assessed on a daily basis. Skin edge healing was quicker when a healthy skin edge was left using a ring-shaped blade compared to skin edges with thermal injury from electrocautery incision or healing following pressure necrosis.* Intuitively this makes sense. In the United Kingdom, the National Institute for Health and Clinical Excellence also advises against skin incisions with electrocautery on grounds of increased infection rates.4 Despite these limitations, the new device is an exciting development and high patient satisfaction combined with low complication rates commend its further use, ideally with additional prospective data collection to confirm its benefits further.

How Painful is Adult Circumcision? A Prospective, Observational Cohort Study

PURPOSE Men are particularly concerned about pain after circumcision. Concerns about pain can be a reason to refuse surgery. We assessed the severity of postoperative pain and investigated factors that may influence postoperative pain. MATERIALS AND METHODS We performed a prospective, observational cohort study in patients undergoing circumcision. Patients were asked to complete a questionnaire using a visual analog scale for pain (severity range 0 to 10) on days 1 to 3, 7 and 21, and record the analgesia used, complications and time off work. Other data recorded were patient age, clinical indication for surgery, foreskin retractility, presence of adhesions and histology. RESULTS Of 211 questionnaires 112 were returned (53.1%). Mean patient age was 46.4 years. The most common clinical indication for circumcision was phimosis (75% of patients). Postoperative pain was scored as mild to moderate, including a mean of 2.4 on days 1 to 3, 2.1 on day 7 and 0.5 on day 21. Patients younger than 35 years (p = 0.025) and patients with wound infection (p = 0.036) had higher pain scores. Only 11 patients (9.8%) had severe pain at any time during recovery, including 8 with wound problems. Average ± SD time off work in the employed population was 6.6 ± 6.5 days, including 5 days for light work and 11 days for heavy physical activity. CONCLUSIONS Pain is mild to moderate after circumcision in adults under general anesthesia with an intraoperative penile block. Severe pain is rare and mostly related to complications. Younger patients generally have more discomfort.