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Date. So today, um our presentation will be on testicular cancer, er, and it's um surgical management, er, testicular cancer is quite a unique cancer in many ways and we'll hopefully be going through some of the key parts of it together um as well as how to assess patients with it, the diagnostic process, how um these processes may be applied to real world cases, appreciating the different types of testicular cancer, which can be a bit tricky to get your head around focusing on the management of germ cell tumors really because although there are other types of tumors, about 90 95% of them are germ cell testicular tumors. The other ones are much rarer and it's also about understanding the surgical management of early stage testicular cancer and I mean early boost because that's the surgical stage, other, other thing, other later stages um are, are less relevant er in this respect. Um given the er lack of surgical options um and also the postoperative management of early stage testicular cancer as well. So a starter, particularly cancer is uncommon. So we in neurology, we get a lot more referrals than we do. Uh actual cases seen, er, and despite often being aggressive, it generally has very good survival outcomes. Er, mostly because patients notice and present fairly early in their disease course, relative to other cancers management can involve surgery, radiotherapy and, or chemotherapy, multiple forms exist. Um, nevertheless, some of the treatment is often the same. Um, and the main tools that we use for our diagnosis is uh ultrasound and tumor markers for our assessment. So, as I said, relatively rare, it represents less than 1% of total UK cancers and just amongst men. So never mind all the women, it's the 17th, most common cancer among men. So it just goes to show it's not very common but nevertheless, is very important. Only 2400 diagnosed every year with testicular cancer. And it's generally a condition of younger men though with some important exceptions that need to be considered. So it's most common peak cages are between the ages of 15 and 49 and the peak cage er arises around 30 to 34. The incidence also has been rising since 1990. Um So that's something to consider. Um So still rare, but on the rise um and a very tiny percent of this small and rare cancer are bilateral. So most cases will be unilateral cancer and the patients won't develop cancer on the other side unless they're very unlucky risk factors. It's, it's quite challenging to actually say what are the risk factors because there are no clear causes of testicular cancer. Uh And the risk of testicular cancer is still small even in the presence of risk factors. So you can have all of the things that I've listed below and still have a low risk of cancer just because it's so rare. So known risk factors do include cryptorchidism. So that is an undescended testis um in childhood. Um So actually funnily enough, I saw a patient with an undescended testis today, he's an adult and so we need to counsel him about his risk um family history, of course, previous cancer, of course, these are, you know, you can say that for all types of cancers um HIV er congenital hypospadia. So hypospadia being a failure to have the fusion um of the ventral aspect of the penis and the glans penis together is a congenital abnormality. Um and er, in the UK, at least Caucasian men have been shown to be at higher risk. Testicular cancer typically presents, as I say in young men with a painless uh mass. So um that doesn't, that doesn't mean pain can't occur because in 10% they will have some pain. But realistically, patients presenting with severe pain, acute pain are, are less likely to have testicular cancer. Uh and the pain that patients may experience tends to sort of be dull, chronic and low grade compared to other scrotal pathologies that you might be able to think of the masses are usually firm, irregular, non tender and there's no erythema, although they may have a reactive hydrocele. So if you do transilluminate something, but you still feel something firmer irregular rather than fluid filled and fluctuant, er, definitely get an ultrasound and to be fair, if you're thinking about a hydrocele, it's probably worth getting an ultrasound anyway. Uh, just to confirm your diagnosis, testicular cancer can still occur in undescended testes. Um, and so just because the testis is still undescended, doesn't mean they can't get cancer. So, if you do find a patient with an undescended testis, um they may actually have cancer in that and they may have features of that in, in their uh undescended testis as well. Some patients may also have gynecomastia, er and that's partly due to some of the hormones that may be released as a result of testicular cancer. And of course, the metastatic features, again, part of most cancer diagnoses, weight loss, uh back pain from metastasis to the bone. And then if it metastasizes to lung, you might get hemoptysis and dyspnea differential diagnoses that we need to be aware of. Although of course, a lot of these presentations do have differences to the way testicular cancer is diagnosed are of course, include Hydrocele, which we've sort of already mentioned, like I say that's fluid. So it's going to feel very different to a hard craggy nasty mass, a varicocele. So uh distended um veins with the preform plexus again tends to not actually feel like cancer. But if you're not sure that's just something to think about, um, a hernia. So, don't forget, inguinoscrotal hernias can occur. But of course, with the hernias, you won't be able to get above them and they'll be reducible unless they're in severe pain. In which case, they won't be reducible and need to be referred urgently to the general surgeons, an epididymal cyst. Um which again, you know, may be like a large sort of firm mass, but again, because it's fluid filled, it probably doesn't feel like a cancer that I do appreciate. It can be difficult to find just on examination. Er, and um, er, if you were to just sort of trust examination alone, you'd probably miss a fair few cancers if you think their appall cysts are always worth getting more investigations if you think that's necessary sperm granuloma. So that's just um, a granuloma as you see in, in other conditions. But with sperm, because the body is recognized it as sort of foreign. So it's walling it off, an abscess, obviously gonna um, have features of infection and a sebaceous cyst, which is a scrotal mass, which some people may say is, oh, there's a testicular mass there present, but actually it's a mass on the scrotum cos that's in the sebaceous glands within the scrotal skin. Um, so each of these have their own sort of presenting features. But if someone's present, you know, referring something they'd like you to see. They think it's one of these things, but actually you disagree. It could be because it's a testicular cancer. So I'm gonna ask um, a quick question to you guys. Uh, just before moving on, um, I've mentioned tumor markers. Um, and testicular cancer is one of those ones where we use tumor markers a lot, much more than in other cancers. So, could you, um, just have a guess, say in the chat, what tumor markers are required in testicular cancer? And what other blood tests would you consider for patients with testicular cancer? So I've had a PSA mentioned by someone. Yeah, fantastic. So I like some of those answers. Quite a few people saying L uh LDH which is correct. There's one more that hasn't been mentioned um er that I would definitely get, let's see if someone knows the answer. Yeah. So yeah, so now it's been mentioned. So a FP. So the main three are beta eight C alpha fetoprotein and LDH with LDH being more of a marker generally of, of tumor growth. It's not specific uh to testicular cancer. There are quite a few things that can have raised LDH. Um but it's just a more of a marker of of cancer progression and growth. So, yeah, well done. You've got all three of them. Now, the second question, what other blood tests would you consider for these patients? So people are saying PS I'm seeing quite a few people say PSA, I wouldn't normally get a PSA unless I'm thinking that they have pros prostate cancer. And actually given that most men with testicular cancer have, er, are young, um, most of them probably won't have prostate cancer. Obviously, there's gonna be a, a small number that will, but actually the crossover is not gonna be particularly high between the young testicular cancer patients and the older prostate cancer patients. So routinely I wouldn't get a PSA, I'm talking more generally speaking, thinking about what this patient's probably gonna need. Um, what might I get in preparation? That would be good. So, some people are saying CBC, which I think means complete blood counts if I'm not mistaken, er, we call it FBC here to be fair. Er, but yes, er, I II, if that is indeed complete blood count or full blood count, I definitely get a full blood count, er, clotting group and save absolutely. Um, all of these standard things. Um, because the patient's probably gonna need an operation. Er, and therefore if, if we do the operation, we do an FBC on the day. Oh, no, they're anemic, their anemia is too big and it's too risky to the operation. That means we get a delay. There's no point doing that clotting. Um, if I was worried about clotting, I'd get clotting, that's probably good to be complete and it's probably a, a good one to have sort of a baseline group and they've always useful if someone's going for an operation where they may lose a, a decent amount of blood you and of course, er, cos you want to just check their baseline renal function. Um, so that's, er, those are all the standard things that I would guess. Um, ca 19, um, I have heard ca 19.9 being used in pancreatic cancer, um, rather than testicular cancer, I wouldn't routinely get that one. And um as far as the serum testosterone is concerned, unless I had concerns that they did have a lower testosterone than average. For example, if they had um something like Klinefelters syndrome or a um disorder of sexual differentiation, um that wouldn't necessarily be needed, but again, they may have fertility issues. Some patients may well have fertility issues that neces necessitate a serum testosterone. So it sort of depends er er on the case. So some patients will, some patients won't need a testosterone and ACR P, if I thought there was infection, I'd get ACR P. But that sort of, again, it depends on what I thought at the time. Uh let's say, for example, someone was referred it as a potential infection. Um then, yeah, C RP. But if not, then no, and then alkaline phosphate. Um that could be useful if you genuinely thought there were bony metastases. Um But if I didn't think there were bony metastases, most patients probably won't have bony metastases and wouldn't normally get an ap. All right. Fantastic. Let's get back to the presentation, uh, like from beginning. So, yeah, other investigations, ideal management would include a same day ultrasound scan, um, because of the aggression of testicular cancer. Um, unfortunately, it can, uh, increase and progress, uh, within days rather than weeks and months as it is for other cancers. So, for example, prostate cancer and kidney cancer are usually quite slow growing, uh, compared to testicular cancer. So, if I can get it on the same day, I will. Er, and I've, and I've been in that scenario before where I got a same day scan and it really impacted the patient's care. Um So I'm very glad I did it. Um but if that's not possible because it's a time where there's no ultrasound scan where they can't do it minimum within two weeks, absolute minimum. Ideally before we've mentioned er the er tumor markers um and a staging CT scan um to assess for distant metastases and for lymph node metastases. Um as you would again, in all cancers, you get some sort of staging imaging modality in order to see what's going on with the rest of the body. And this image here is just to demonstrate what you might see in a patient with um testicular cancer. Um you can see er with the eye of faith, this bit is darker than this bit and that's because this tissue is more densely packed and therefore, um er it has a different sonography to the rest of it. Er, and thus marketing as a cancer, you can see it's got well demarcated edges. You can see it's discrete and you can see it's um, sort of, er, it's not in, it's not multifocal and that's how testicular cancer tends to be as well. So, metastatic spread, generally speaking, the testes drain to the paraaortic lymph nodes, er, which may be reported in act scan as retroperitoneal lymph nodes. Er they usually mean the same thing. Um and some patients may need a lymph node dissection if they have their operation. So you have to keep that in mind in terms of the anatomy, um the parallel to the aorta. So when doing any sort of aspiration or operation dissection, you have to be really mindful that you're close to the most important vessels in the body as you're doing that as well. So it's important to be aware of that in terms of distant metastasis, the lungs tend to be the first sign of visceral metastatic spread. And so that's why that staging ct thorax is so important. So now going into the types of cancer, germ cell tumors, over 95% will be germ cell tumors. That's why we're gonna focus on that. But touch on the other sorts of cancer that you may see within the germ cell bracket. You have seminoma, you have non seminoma within the non-seminomatous group, you have your teratomas. So that's formed from all three germ cell layers. If you remember your back to your embryology, you've got your um ectoderm, your mesoderm and your endoderm, er, most cancers will form from one of these three, but teratomas form from all three and therefore they have multiple characteristics. Er, but then you have the features from the, er, embryonic features, like your yolk sac and your chio um er, er choriocarcinomas as well. And the non germ cell tumor groups are a rare group. We have obviously lymphomas and sarcomas that can form in all parts of the body. And that's why it's important to be aware of those. The testes are no different, even though it's rare to have um things in that part of the body, but you have your sertoli cell and your Leydig cell tumors. Um And so if you remember your sertoli cells are these uh sperm production, er, engines within the testes and your Leydig cells produce your testosterone. So they, your endocrine cells within the testes as well. Ok. Just to note lymphomas, if you see, er, er, older gentlemen. So I'm talking sort of over 65 with a testicular mass that may represent cancer. It turns out to be cancer. Chances are, it's actually lymphoma, er, just because that will tend to occur in older defended patients just the same as it does. Normally seminomad also have different subclasses. So you have anaplastic, classical and spermatocytic seminomad as well. Uh But generally speaking, people talk about seminoma versus non seminomad cancers. Er, and then within the non sema, non seminomad, they, they can classify that a bit more. So, what is a germ cell? Um going back to a bit of histology. Um well, they're derivatives of your spermatozoa and your ova. Um er, and so germ cells produce your gametes basically, er, and they often form in the testes and the ovaries and they may also occur in extragonadal sites as well. So, some residual germ cells may remain in ectopic sites after embryogenesis and they're very rare. So, example sites may include the mediastinum, the retroperitoneum, the pineal gland and the sacrococcygeal region. So you may indeed find germ cell tumors outside of the um testes and the ova um in very rare cases, er, but nevertheless, similarly aggressive in importance. Er, and some germ cell oncologists will er have some treatments that are very um weird and wonderful for these kinds of cancers. Gem cell tumors made me malignant or benign. Er and teratomas er are tumors within er, they form tissues that are not normally present at that site and that's because they have that all three germ cell layer feature to them. The rate of seminomad and non-seminomatous germ cell tumors occur at around the same rate. So, one is not more common than the other. It's, it's roughly a 5050 spread. There are slight differences in the types of patients that get them, but as I said they all tend to occur in younger patients. Seminoma, seminoma are more common between the ages of 35 and 45. Uh With the classical seminomad being by far the most common um non-seminomatous tend to occur in a younger population 20 to 35. And the most common forms are teratoma and embryonal cell carcinoma back to our tumor markers. A lot of the time your tumor markers are actually gonna be um er negative because only about 51% actually have raised tumor markers and not all of your tumors um will secrete all of the tumor markers if that makes sense. So, 90% of your non-seminomatous germ cell tumors secrete A FP and B to A CG and choriocarcinomas always secrete B2 H CG. So, if your B2 A CG is low, you can rule out that type of cancer. Whereas your seminomad um tend not to secrete beta HCG and LDH and your seminoma do not secrete A FP. So again, if it secretes A FP, it's probably not a seminoma. Er and in addition, most of them are not gonna secrete anything anyway, tumor marker, half lives are important um because you need to know about the doubling time. Uh if you're monitoring patients for cancer, so not for diagnosis, but if you're monitoring a patient's tumor markers, um and its doubling time is going up and up and up. That means um the tumor marker, half life um is important to know about. Um So that's why it's important for that rather than diagnosis. Er, and I've got the er number of days for the half life is there? Um B2 H CG being particularly low compared to the others. So as I say, you good for aiding er cancer diagnosis but not themselves diagnostic er and not specific as well. So you probably know this already. But as I've mentioned LDH generic marker of tumor growth. A FP for example, can be raised in hepatocellular carcinoma and other types of cancer. Uh beta HCG is raised in pregnancy and is obviously the thing that we use to test whether someone's pregnant or not. Um And so yeah, clearly um not the be all and end all but still useful nevertheless, er for monitoring response to treatment for recurrence um and also for diagnosis as well. So I remember once I was asked in a, in an ay about the use of tumor markers and a lot of the time people use it for uh diagnosis uh in their answers, but actually knowing how useful they are for monitoring and recurrence monitoring. Um and for differentiating between types of cancer is important as well. The way we classify prognosis is sort of into good and not so good. Um I'm not going to just read out everything on this very busy slide. Uh It's more to appreciate um the use of tumor markers for looking at prognosis. Um So ie lower tumor markers, a higher tumor marker patients will have a worse prognosis. So it's good for that as well. Obviously, looking at the metastasis, uh elements, seeing if they have no lymph nodes where they have different um uh distant metastases. And then looking at the good prognosis group, looking at how good our five year progression free and survival is over 90% for our nonsomatic tumors and nearly over 90% for our Seminomad tumors, which reflects the er, good rate of treatment. Um, equally, we can see how does prognosis worsen. Well, it's actually because um if we can see our tumor markers are above a certain range and again, it's to do with the presence or absence er, of nodal metastases or distant metastases showing the importance of our staging CT scan as well. And again, to illustrate the point, poor prognosis group patients will have higher uh tumor markers will have more metastases. And of course, unfortunately, the five year survival progression free and overall plummets after this stage as well. Er, to, er, round half um 50% in terms of progression free and about two thirds for five years overall survival. So it really makes a big difference. One good news though, er, is that seminomad cancers are classed, um, are never classed as having a poor prognosis just because they tend never to have a poor prognosis. Um which again illustrates how this is quite a nice cancer to be involved with in terms of survival staging is done via the classic TNM staging way. Um Again, no need to know a massive amount of the detail. Uh Just to illustrate that we uh again, use the size of the tumor for the T staging. Um The er PT four patients will have invasion into the scrotum, but your PT 1 to 3 patients will not have any invasion into the scrotum. It doesn't affect management in any way. Obviously, if it's invading into the scrotum, you may consider something called a hemi scrotectomy, er where you remove the datas and the skin overlying that region. Er because otherwise, if you don't, the cancer is just going to come back and you're going to get an R one resection, er rather than R not section, it's going to be positive margins, not negative margins. And then again, with your N staging M staging, it's just the presence or absence of nodes or the presence or absence of metastases er with a differentiation being made between the lung mets um or non er so um or non lung mets. So, sperm banking, this is a part of the surgical management that we really need to be aware of and that people are not so aware of. Um So orchidectomy, which is the name of the radical surgery that we do to treat. Testicular cancer does not lead to complete infertility in patients who have a functioning single testis. So you can have one testicle and have sufficient fertility to have as many Children as you would like. Um it just means you have reduced fertility but you have enough to be able to have Children. So that's fine. Nevertheless, you never know uh when a patient's other testicle er may be dysfunctional. You, you don't know if that other testicle is going to develop another disease in the future. And so actually, because they've only got that testicle um that subfertility may result in infertility. So patients always get or should always get, I should say um an offering for sperm banking and most patients will take it up. Um patients also who receive chemo. So not all the patients that have testicular cancer, but some of them will also suffer chemotherapy related infertility. Uh And so that is also something that we need to be aware of banking involves taking three semen samples and the samples are frozen and stored for up to 10 years. Patients must be screened for blood borne viruses. They may still provide samples, but it's just something to be aware of. We don't want to be passing down anything on to the next generation that we can avoid. Um unfortunately, after a period of time, patients have to pay for sperm banking. I think it's up to the er first five years is free in the UK. But thereafter you have to start paying a fair bit um in, in the region of a few 1000 a year for sperm banking just to keep the sperm they're present in the freezers. So, in order to understand the surgery, um, we need to understand a bit of the anatomy. So I've gone through a bit of it there. Um, part of the reason why we have undescended testes is because the testes don't originate in the scrotum. They originate in the abdomen and descend through the inguinal canal. Er, and that's also why men have er, an inguinal canal more susceptible to hernias. They descend into the scrotum during development and are guided by something through er, called the gubernaculum. They're suspended from the abdomen via the spermatic cord, which also runs through the inguinal canal. Um, and er, the er spermatic cord carries the testes, neurovascular supply, lymph supply and the vas deferens which carry the sperm er, through the system into the outside world. Er, in order to er pass on the genetics testes are in case by multiple er, scrotal and fascial layers. And those are really important to consider when you're doing scrotal surgery. For example, scrotal exploration, er, needing to appreciate the different thin layers that you need to dissect very carefully layer by layer as you're going through. Um and they're separated by the scrotal septum. So, um the testes do have that physical separation with datos muscle. And here is an illustration of that journey from the abdomen through the inguinal canal and guided by the gubernaculum which er recedes during adult life to become a ligament um that can be observed when exploring the scrotum as well. Uh You can appreciate some of the muscular and fragile layers that are carried through uh as the patient as the as the testicle is descending, as well as the um processus vaginalis, which forms the tunica vaginalis, er which is important to appreciate. Um again when doing scrotal exploration or a hydrocele repair or an epididymal cyst repair and indeed is so important during orchidectomy as well. Here's an illustration. Um I always used to like this illustration when I was in medical school and studying for my MRC S exam, er, just of all the scrotal layers um that we need to think about when thinking about the scrotum, doing any sort of surgery, but also thinking about the er, inguinal anatomy because we need to appreciate that. Actually, we're doing something that's going into the abdomen, um, appreciating the deep inguinal ring, the superficial inguinal ring, but also appreciating the boundaries of the um inguinal canal. And if someone can just mention the er anterior border, particularly er, that we need to be aware of when doing an orchidectomy of the inguinal canal in the chat. And I'll be very impressed with that as well because that's important anatomical landmarks. We need to be able to make sure that we're seeing um the er, er superficial inguinal ring when we're doing our orchidectomy as that will allow us to know that we've gone far enough with our resection. And again, here's again, some of my favorite images. Um If anyone hasn't discovered teach me anatomy yet, I'd 100% recommend using Teach me anatomy because it's, uh, it, it really got me through my, er, anatomy exams. Um, but we can see here. I hope someone in the chats mentioned that the anterior wall is covered by the external oblique um, upon urosis. Er the floor is done by the inguinal ligaments, er posterior wall by the trans basalis fascia and the roof from the internal oblique um hardened up by the transversus abdominis immediately also strengthened by the conjoint tendon as well. Why am I going through all of this? Well, it's important er when we do our orchidectomy um because um of how we actually do radical orchidectomy. Um and you'll see that in a moment um because it's not necessarily in the way that you might think it's certainly not the way I thought when we, when I first started uh revising for my surgical exams fine, the testes have an elliptical shape, shape and a vertical line. Er So if you're seeing a testis with a horizontal line, it may represent a testicular torsion. So that's something that we need to be aware of. The left testis is often lower than the right, but not always. The testes are also surrounded by fibrous capsules that separate interlocus. Um er and that then forms also and that, sorry that is formed by the tunica albu er, which is, er, lining the testicles, er, and preventing exposure of the seineri tubules and the sperm. This, as we sort of mentioned, the totally cells are your spermatozoa factories and your Leydig cells are your testosterone factories. Er, and they're important for our testicular function as well if anyone has any questions about this anatomy. Um, I'm happy to go through it again. Er, and uh, happy to sort of answer questions in the chat. I do appreciate, uh, some people might not have done anatomy for a few years. Um, it might be confusing but we all love talking about anatomy and surgery, so I'm happy to discuss again. So, management before going on, I just want to ask a question about how, um, oh gosh, I didn't share the slides. I've just realized that fine, my apologies. Um, er, before moving on, I'd like to ask a question. How do you think we approach radical Ectomy? Um, what sort of incision do you think that we, er, make? And, um, er, how is that related to the anatomy? I will say that the slides, er, will come up and will be, er, performed. Um, er, the slides get automatically upload and I upload a sort of a, er, downloadable form for the slide. So there's a video and the slide. So I do apologize for that as my fault. Um, but yes, thank you. So, yeah, an inguinal incision. Very good. So there are two ways of doing orchidectomy. Um, there's the Inguinal approach and the Scrotal approach and when doing a radical orchidectomy, we always go via the Inguinal approach. But let's say, for example, there's, um, we need to do an orchidectomy due to, um, let's say 48 gangrene or severe infection. Um, or let's say, for example, er, it's due to um, a testicular torsion, er, and they cut off the blood supply, then we do it via the scrotal approach because we don't need to do the radical surgery. So I'm hopefully sharing it now. Um given the mistake that was made the last time, it's worth asking whether you can see the slides. Er, so apologies for that. Uh Just let me know. Um and if you'd like me to go back to do anything, I can er, happily go back and go through things again. Er, but if not, I can crack on untrusted. So radical orchidectomy, as you can see, an inguinal incision is made um with relation to the pubic cubicle. Er, and of course, the ace um given the fact that we are more interested er, in the er, testicle and the spermatic cord rather than in a hernia where you're more interested in the inguinal canal. Um, and the er, defect that's causing the hernia, uh our incision tends to be more medial er, than the incision made for inguinal hernias. So, a, a medial inguinal incision is made um after palpating the tubercle. So it's lateral to that. Um we dissect the skin using the blade and use the diathermy to er to dissect away through the fatty layers. So your scar is fascia, er and your campus fascia and that's then to identify the spermatic cord, you can see quite nicely demonstrated in this image um that we tend to put a ring around the spermatic cord Um because the spermatic cord can be really, really challenging er, to um keep in place. A spermatic cord has a nasty habit of pinging back into the abdomen. Um And once you've done that, it's really difficult to retrieve it back. And so it's best to either tie a suture around it so you can always retrieve it, um or clamp it and again, so it's not gonna go anywhere. Um because unfortunately, it has that nasty sort of elastic feature to it. Yeah, obviously ensuring that we mark the site of incision, doing all these basics are important. Er, but once we can, er, be sure that we've got the right site and we've done this surgery, we've opened up, um, we then start to mobilize the testis such that it moving through the, uh, the um, scrotum up into our incision site along with the gubernaculum, along with the epididymis, along with the er, vessels, the veins, the lymph, the, the vas deferens, um so that we can get rid of all of these features, er, together and that's what separates it from being a simple orchidectomy to a radical orchidectomy. Um because we're taking everything that we can in association with the testis, whereas in your um simple orchidectomy that you do through the scrotal approach, because you're not going as high up into the um inguinal region, you're not gonna take all of these um vessels, you're not gonna take all of these um er features of the chord as high as you would in the er radical approach. And therefore you're gonna get all of them and therefore any cancer that's spread up the spermatic cord or any other malignant features will be removed. Whereas in that simple approach, it won't be removed. You can again, quite er on the right hand side of this image, you can see quite nicely how they've clamped the spermatic cord. Um The way one of my bosses will do it is they'll clamp it um as proximately as they can. And I attach two more clamps and then go in between the most proximal and the second most proximal clamp with a simple incision where it is removed. Um And that again, prevents er the um er taking too little of the er spermatic cord in the testicle. Um but it also prevents um the cord from being pinged away because you've clamped it down. Fantastic. I should also mention that the incision is made parallel to the inguinal ligaments and that is because it is on the Langer lines. And so therefore, er helps with our healing as well as possible and therefore, prevents us from having a situation where the healing is not so good. The size of our incision does depend on the size of the testis and the tumor um as sounds obvious, but sometimes you do get patients with very big tumors that just need larger incisions. And so you may have to go more laterally. As I said, we tend to go more medially than you would in a hernia. Uh just because of the um the location of where we want to make our incision. It's really important to identify the ilioinguinal nerve. Um and the ilioinguinal nerve is important. Um I'd be very impressed if someone can tell me what sections er, of the skin, the ili inguinal nerve supplies. Er, but it safe to say it's a sensory neuron, a sensory nerve um that if we transfix, er and if we suture in the wrong place, it can lead to significant postoperative pain. Um or if we indeed we identify it and we decide to not preserve it, it can lead to numbness, which patients don't tend to er, complain too much of, but we just need to make them aware because they suddenly lose sensation over a section of their body. It is a structure that runs outside of the spermatic cord, but within the inguinal canal. So, it's closely related to our anatomy. Um, and because of the, again, close and small nature of everything, it may be very challenging to preserve this nerve and it can also be very easy, er, to accidentally, er, damage it, er, put a suture through it and therefore, er, cause significant pain after an operation. And I have seen that done unfortunately. And I've seen the patient afterwards and they, they are in a lot of pain sign. Ok. There may be also a need to dissect the um er er er inguinal ring as well in order to allow for greater amounts of the cord to be er exposed and therefore to be removed during this operation as well. Some cases will require that and others won't. And it's also important to do a transfixion, transfixion stitch er within our spermatic cords. Um So that when we do um suture it back up, there is no hemorrhage or leaking or any other issues related to the spermatic cord. Because of course, you have cut through vessels, you've cut through, of course, testicular artery and from peripheral flex uh veins and lymph vessels. So you don't want there to be a collection or a hemorrhage or a leaker that you can avoid uh and even better if you can avoid a seroma as well. So that transfixion stitch will be done usually with vicryl uh with your strongest stitch as you possibly can. And again, it's good to put that stitch in fairly early so that you can identify the cord when necessary. Yeah, contralateral testicular biopsy. Um again, not normally done but 5 to 9% of testicular cancer patients have a contralateral carcinoma in situ. Er, and it's recommended by the European Association of Urology, er for men under 40 particularly if they have uh a contralateral testicular volume of below 12 mils. So it's probably an atrophic testis that's not particularly well functioning. A history of cryptorchidism and subfertility. Anyway, biopsies tend to be taken from both the superior and inferior poles of the testis, er, and may or may not be done with ultrasound guidance testicular prosthesis. Yeah. So, um patients may be offered to have a testicular prosthesis. That's what they look like. You get them in various different sizes depending on the size of the patients uh and descending depending on the size of the other testicle. Um, they tend to just be small, medium large, very large. Um It can help patients come to terms with their surgery and cosmetically. Um and also they don't delay having chemotherapy. So usually if you're gonna do one, you do one at the time of the orchidectomy rather than later on if you can. Um but if not, um then it can be done at a later stage if patients want to, but they present with their own issues. Um Of course, everything, every prosthesis that you put into a patient um can become infected and need to be removed at a later date can be associated with pain, cosmetic dissatisfaction, of course, um, mismatch over size, um, potentially they could rupture as well. Er, and they can cause their own sort of issues. Abscesses may form around them. Um, and so actually a lot of patients don't bother, er, they're perfectly happy, er, coming to terms with the surgery without them and it means they avoid any pote potential complications that can arise from them as well. Um, personally, I've seen quite a few complications happen with prosthesis. Um, we've had to take one out. Um, and it can be, er, er, quite challenging to do so because of all of the tissues that you've gone through in your original surgery, er, will be fibrosed up, er, and so cutting through fibrous tissue, er, which is always much more difficult to, er, dissect through than, er, non fibrous healthy tissue, postoperative management. So, of course, again, postoperative staging ct is important. Most patients, even if they have metastases will consider to have a orchidectomy to remove the primary site of cancer and therefore hopefully, um prevent any future deterioration or spreader or advancement of the cancer. Um, so it can still be useful. Of course, we send our testicle off for histological analysis and it's key for prognostication, deciding future management chemotherapy. Er, and also for um, seeing about the risk of the patient as well, all patients should have their tumor markers repeated in one week to see if there's a response or if there's a good fall in the tumor markers, that helps us see if there's any risk of metastases or indeed uh retained sections of cancer due to positive resection margins, all patients should go under tumor surveillance may be considered for chemo and or radiotherapy. Er and as I mentioned before, there may be a need for lymph node dissection er for those with positive or indeterminant pa para aortic lymph nodes. Fantastic. So I've discussed some of the risk factors um as I said, no seminomad can be considered to be high risk. Um but the histological risk factors in seminomad, of course, in choose are T staging um which is just tumor size and invasion into the retest. So, again, related to tumor size in general, um non-seminomatous cancers, again, it depends on whether it's invading into the lymphovascular structures uh of the peritumoral tissue. Uh And again, this is common for a lot of cancers. So, lymphovascular invasion is usually a po a negative sign in most cancers. And again, t staging is is similar for most cancers. So you'll see that written in a lot of different types of malignancy, it's no different for testicular cancer. Ok. In terms of um future management, this histology is really important, er because if patient has t one disease and no lymphovascular invasion invasion, they should get surveillance for cancer with tumor markers, er and potentially with CT scans. In the first instance Um and then if not willing um to have the um surveillance, they should have chemotherapy er just in case. So patients with cancer get better chemotherapy B ep. So that's with bleomycin etoposide and CISplatin. Um and then patients with higher stage tumors rather than having surveillance as the first option. And chemotherapy as your second option should actually have chemotherapy as the first option. And then if unwilling should go under surveillance um just showing uh the importance of those two factors as well. Ok. So again, t one patients, no ne not necessarily going to get chemotherapy. Whereas our PT two and above patients will, will, should normally get chemotherapy sign that chemotherapy remains the standard treatment for patients with metastatic and advanced disease. Um Of course, orchidectomy will not treat the the remaining metastatic tumor. Only chemotherapy will do that. Uh but it can also help with preventing er progression and advancement and indeed, as can er getting rid of any residual tumor within the lymph nodes as well. Um So that's with the management of metastatic disease, but of course, many patients with metastatic disease may not be fit for surgery. Uh they may not want surgery. And so we need to consider the, the palliative options open to these patients, consider what they want, consider their genuine life expectancy and what difference our interventions are going to make because actual, you know, there's no point performing a whole operation or putting someone through chemotherapy if actually, their life expectancy is not going to be particularly higher and it's not what they want either. So, we have to provide that holistic approach to managing patients with these um uh stage disease uh as well as um for our patients with early stage disease summary. Thank you very much for listening, by the way. Sorry for this technical difficulties that occurred earlier on. Er, but testicular cancer is a rare condition that generally affects younger men. Early stage prognosis is usually excellent following orchidectomy. There are many forms of testicular tumor and many of them can be very aggressive. Indeed. And there's different types of risk stratification based on the tumor size and the features of the tumor. Um and whether it's spread to lymph nodes or to other visceral sites. So I need to be aware of that. I need to appreciate the importance of histology er to our diagnosis and prognosis. Understanding the diagnostic process is really important to avoid treatment delays. The importance of ultrasound scan, the importance of getting um tumor markers nice and early and getting them seen in clinic as early as possible so that they can be put on the next available list for an orchidectomy. Radical inguinal orchidectomy is the standard treatment method and appreciating the postoperative care for these patients uh is important when performing radical orchidectomy. We have to appreciate the risks associated with this um particularly with respect to some of the key anatomical landmarks. Um making sure that we're aware of the ileal inguinal nerve and making sure that we're aware of the importance of ensuring that the cord does not pin back into the abdomen, as we mentioned before. Um, because that's also something that can really affect patients um, outcomes. Thank you very much. I'm happy to go back, er, and rediscuss anything or if there are any new questions happy to go through all of these, Um, er, and then go through anything else. But if not, I really would appreciate some feedback. Er, I'll send out a feedback form after this. Um If you have any other um, questions that you think of afterwards, if you can contact me, that's all fine. Uh We are putting on another session next week um at 730 about upper urothelial tract cancers. So it'd be great to see as many of you guys uh there as possible. The s the slides, er, will be uploaded, er, and the recording will be present so you can watch this back and have a look at the slides at your leisure. Um, and yeah, once again, thanks for coming. Yeah. Ok. Ok. Uh Thanks very much for everyone for coming. Um, I hope you have a lovely um, evening or afternoon or morning depending on where you are in the world. Uh I do appreciate patient. Uh, you guys, er, come from all over and, uh which I do find fascinating. Er, you guys come from all over the world. Um, if there's any sort of differences you've seen in the local practice where you are, just let me know. It'd be interesting to find out what they do in other countries, uh, obviously quite UK focused, er, with, with what we see. I think it's pretty UK slash European cos we have the European Association guidelines, um, that we follow as well. Uh, someone from Portsmouth. Fantastic. Yeah, I'm, I'm actually not based too far from Portsmouth in, in West Sussex, so not too far away. So there are no questions, guys, don't worry about it. Um, I, I'm happy to be contacted if you have any more questions. Um, and yeah. Um, of course, please sign up for next week. Just, uh, there's nothing else. Uh, I'll leave you for this week again. Once again. Um, apologies for the not, not sharing all the slides always and take it easy. Mhm. Yeah.