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The Male Urethra

  1. Meatal Stenosis
    1. External urinary meatus is the narrowest part of male urethra. It may be a seat of congenital stenosis, or become stenosed after infection/scabbing or trauma. Meatus may become pinhole and it may lead to chronic retention/ enuresis/ or back pressure changes.
    2. Intervention is indicated whenever there is symptom, retention or cystoscopy is to be done and it cannot be passed through it. Treatment is meatotomy.
  2. Congenital Anomalies Of Urethra
    1. Urethral Stricture: Fossa navicularis and membranous urethra are the 2 most common sites MCU and IVP are important investigations. RGU is also helpful in defining the extent of stricture.
    2. Urethrocystoscopy should be performed in all the cases and therapeutic internal urethrotomy is performed at the same sitting.
    3. Posterior Urethral Valve: This is most common obstructive urethral lesion in male child. It occurs only male child and is present at the distal prostatic urethra. Presentation is varying degree of obstructive features and failure to thrive.
    4. Lab finding: Azotemia and uremia should be detected and treated.
      1. X-ray: MCU (Micturating custourethragram or voiding cystourethragram) is the best investion. Large amount of residual urine is found at initial catheterization.
      2. MCU shows obstruction at posterior urethra and VUR.
      3. USG: Detects large volume bladder with trabaculation, hydroureter and hydronephrosis. It may show dilated posterior urethra. and can be used, in-utero, to detect urethral valves.
      4. Cystoscopy: The valves are difficult to see at cystoscopy, because irrigating fluid sweeps them into open position.
    5. Treatment: Cystoscopic fugulration is the treatment of choice. If in a newborn, Bladder is excessively dilated with complete atony and presence of hydrouretronephrosis, first stage diversion may be done by vesicostomy or uretrostomy.
  3. Hypospadias:
    1. The urethral meatus opens on the ventral side of the penis just proximal to the tip of the glans penis. Incidence is 1 in 300 cases.
    2. Among most common congenital anomaly of male genitalia (Second to cryptorchism)
    3. Classification:
      a) Glandular: Opens on the proximal glans penis (it is most common type). No treatment required for glandular type. Q
      b) Coronal: Opens at coronal sulcus. Q
      c) Penile shaft
      d) Penoscrotal
      e) Perineal  
    4. Presentataion: Penis has a ventral curvature (Chordee), Prepuce is deficient ventraly and it is hooded on dorsal side.
    5. Meatus is usually narrow (requiring meatotomy). Penoscrotal and perineal hypospadis is usually associated with undescended testis.
    6. In perineal hypospadias scrotum is bifid, a buccal mucosa keratotyping should be done for sex determination. IVP is also indicated to detect additional congenital anomalies.
    7. Associated birth defect may include undescended testis, inguinal hernia, enlarged prostatic utricle.
    8. Surgical repair of hypospadias is performed in first year of life and best time is 6 – 10 month.
    9. Many surgical technique available (ASOPA surgical technique)
    10. If cordee is present cordee correction first followed by reconstruction of urethera.
    11. Circumcision is contra indicated before hypospadias repair.
  4. Urethral Stricture
    1. Etiology: Congenital, Inflammatory (gonorrheal, TB), Instrumental/ Traumatic (catheter induced, after TURP), Post-operative (prostatectomy, amputation of penis).
    2. Postgonorrheal: May occur at Bulb (70%),  penoscrotal junction or in spongy urethra. Patient is generally young and gives history of progressive decrease in caliber of urine. Diagnosis is made by urethrocystoscopy. MCU/RGU helps in determining the length of stricture. Treatment is Internal urethrotomy. 

Complication of urethral stricture.

  1. Urinary retention                     
  2. Urethral diverticulum
  3. Periurethral abscess                
  4. B/L hydronephrosis
  5. Urinary injection                       
  6. Urinary calculus.                     
  7. Hernia hemorrhoids or rectal prolapse.
  1. Instrumental Treatment:
    Instrumental dilatation can be done with Gum-elastic bougies, Filiform bougie, Filiform bougie with followers, Lister’s metal bougie.
  2. Surgical Treatment:
    1. External urethrotomy.
    2. Internal urethrotomy.
    3. Urethroplasty:
      1. Resection and end to end anastomosis. (Anterior urethral stricture with <2 cm. in size)
      2. Johanson’s urethroplasty:
      3. The structure is layed open in first stage. Q Then after 3-4 months urethra is reconstructed by adjacent skin.
      4. For reconstruction of urethra either perineal skin flap (Blandy), or a scrotal tunnel (Turner-Warwick) or an island flap technique can be used (Orandi). 
Urethral Ca
  • Mc site- bulbo- membranous urethra
  • Membranous Urethra – 60%
  • Penile Urethra- 30%
  • Prostatic Urethra- 10%
  • MC type- SCC
  • Rx- Sx- TURP/ Penectomy
  • 2nd Rx- RTh
A 45 yr old female is diagnosed having superficial, grade II transitional cell carcinoma of the urinary bladder. Which of the following is not true about regarding this patient? (AIPG 2011)
A. Smoking do not predispose to this cancer
B. Recurrence will occur for which she may need repeated fulguration
C. There are no effective anti-cancer drugs for bladder cancer
D. There is 70% chance that she eventually will need cystectomy in next 5 yrs.
Ans. C There are no effective anti-cancer drugs for bladder cancer.(Ref. Harrison’s 17th/pg. 591)
  1. Priapism
  • Priapism is painful prolonged erection. It is idiopathic in 60% of cases and in remaining 40% it is caused by diseases (Sickle cell disease, Leukemia, pelvic tumour & pelvic infection), Penile trauma, Spinal cord tumour or medications.
  • The most common cause of prapism in adult involves agent used to treat erectile dysfunction. The most cause in children is sickle cell disease. Worldwide in general most common cause is idiopathic.

Cause of priapism

  1. Idiopathic (Most common)
  2. Systemic disease
    1. Sickle cell anemia – Polycythemia        
    2. Thalassemia                                    
    3. Total parenteral nutrition                    
    4. Fabry’s disease                                               
    5. Dialysis                                                
    6. Vasculitis                                          
    7. Fat embolism                                        
    8. Spinal cord stenosis                                       
    9. Cauda equina compression                  
    10. Gout Amyloidosis                                            
    11. Prostate cancer                                    
    12. Bladder cancer                                
    13. Leukemia                                                  
    14. Renal carcinoma                                            
    15. Melanoma                                            
    16. Pharmacologic causes.                 
    17. GU trauma


Causes of Low- and High-Flow Priapism
Sickle cell trait and disease
Leukemia (especially chronic myelogenous leukemia
Total parenteral nutrition (especially with 20% lipid infusion)
Medications (e.g., sildenafil, trazodone, chlorpromazine, topical and systemic cocaine)
Intracavernosal injections
Malignant penile infiltration
Hyperosmolar intravenous contrast
Spinal cord injury (usually self-limiting with no treatment required)
Spinal or general anesthesia (usually self-limiting with no treatment required)
Perineal or penile trauma

Ref: Sabiston Textbook of Surgery, 18th Edition Ch 77
  • The corpora cavernosa is tense and rigid while spongiosum is flaccid. There is buildup of highly viscous, poorly oxygenated venous blood, which if continues for days may lead to interstitial edema & fibrosis of corpora cavernosa and impotency.
  • Treatment:
  1. Ketamine hydrochloride IM or IV is effective in 50% of cases.
  2. Epidural or spinal anaesthesia can also be used.
  3. With the use of large bore needle sludged blood is removed from cavernosa.
  4. Intracavernosal irrigation of adrenergin drugs.
  5. Creating a shunt between glans and cavernosa by Travenol needle (Winter’s technique).
  6. Creating a shunt by anastomosing Superficial dorsal vein to cavernosa.(Berry’s technique).
  7. Other shunts described are, Spongeosum to cavernosa by perineal anastomosis ans sephanous vein to cavernosa.
Low flow priapism: Intra cavernosal phenylephrine is the drug of choice and first line treatment. The next step is aspiration of corpora cavernosa followed by saline irrigation. If these two intervention are unsuccessful, additional solution of phenylephrine may be used for irrigation. If medical treatment fails it warrants for surgical management.
  • Surgical treatment:
  1. Transglanular to corpus cavernosal scalpel or needle core biopsy (Ebbehoj or Winter technique) Cavernosal – Saphenous Vein Shunt
  2. El-Ghorab procedure if winter technique fails
  3. Gray hack shunt – Quackel shunts are cavernosal – spongiosum shunts U/L or B/L.
  4. High flow priapism – Treatment focuses on identification and obliteration of secondary fish los, followed by selective arterial embolization. Surgical intervention may be necessary.
  1. Peyronies Disease (AIIMS May 09)
    1. This is also called plastic induration of penis and characterized by Painful erection.
    2. Deviation of penis toward the site of plaque.
    3. There is palpable dense fibrous plaque of varying size involving the tunica albugina.
    4. Spontaneous remission occur in 50% of cases.
  1. Initial treatment is reassurance only.
  2. Excession of fibrotic plaque with flap cover.
  3. Nesbitt operation – over correction on contralateral side.
  4. In other cases p-aminobenzoic acid powder or vit. E tablets are given. Excision of plaque with dermal graft or tunica vaginalis graft is also done.
  1. Phimosis
    Phimosis is a condition where foreskin cannot be retracted over the glans. Other than congenital cause, it may be caused by poor local hygiene and chronic infection. Calculi and squamous cell Ca. may develop under the foreskin. Treatment is circumcision. 
A 4 yr old boy has Prepucial adhesions and ballooning of prepuce during voiding. Which of the following would be most appropriate Rx: (AIPG 2011)
A. Wait and watch policy                               
B. Circumcision      
C. Dorsal slit           
D. Release of adhesions and dilatation
Ans. B Circumcision.
  1. Parahimosis
    The foreskin once retracted cannot be replaced in the normal position. It is seen after forceful retraction of phimosed prepuce and after catheterization where foreskin is not pulled over the glans. Later on there is formation of tight constriction ring, which further increases glans edema. Treatment is hylase injection in prepuce to decrease edema then try for reduction. In late stages circumcision should be done.
  2. Penile Carcinoma
    1. Premalignant Cutaneous Lesion: Cutaneous horn, Leukoplakia, Viral infections like Condyloma acuminate (caused by HPV and associated with SCC), Bowenoid papulosis, Kaposi’s sarcoma (Occur as elevated painful bleeding papule).
    2. Squamous Cell Carcinoma
      1. This constitutes <1% of all malignancy. Incidence is 1-2 / lac. Mean age of presentation is 55-58years. SCC
      2. May be exophytic or flat.
      3. Metastasis is earlier in flat or ulcerative lesion. Buck’s fascia acts as temporary barrier.
      4. Earliest metastasis is to the inguinal nodes.
      5. The prepuce and glans drains to superficial inginal nodes (superficial to fascia lata), While glans drains to
      6. deep inguinal lymph nodes.
      7. Penile carcinoma is most frequent on the glans, prepuce and coronal sulcus.
      8. Diagnosis is made by excisional biopsy. The strongest prognostic indicator for survival is nodal mets.

STAGING: Jackson’s classifiaction

  1. Stage I: Tumor confine to glans prepuce or both
  2. Stage II: Tumour extending to shaft of penis.
  3. Stage III: Tumour with inguinal metastasis, which is operable.
  4. Stage IV: Tumours involving adjacent structures or inoperable ing. Mets, or Distant mets.
  • Treatment:
  1. Surgery: Options are Circumcision (recurrence is common), Partial amputation (2 cm. margin should be included), Total amputation with perineal urethrostomy.
  2. Radiation Therapy (6000 rads) 
Stage Tis, Ta, T1: Treatment is local surgery and regular follow up for 2 years for inguinal nodes. In cases of glans lesion inguinal block dissection should be done.
Stage T2, T3: Local surgery + Inguinal nodal dissection
Any T + N1-3: Local surgery + Bilateral node dissection.
Any T, any N + M1 or T4: Only palliative measures.
The Testis And The Scrotum
  1. Undescended Testis: The testis is arrested in some part of its descent to scrotum.
  2. Ectopic Testis: Testis is abnormally placed outside this path.
  3. Cryptorchidism:
    1. A true UDT must be distinguished from a retractile testis.
    2. Retractile testes can usually be manipulated from the inguinal canal to a scrotal position.
    3. These testes can be expected to spontaneously descend into a normal scrotal position over time.
    4. Thus, no specific therapy is needed beyond careful long-term follow-up.
    5. When a unilateral gonad is palpated in the inguinal canal, but cannot be manipulated into a scrotal position, an orchidopexy is performed.
    6. This early intervention may permit postnatal germ cell development to proceed normally. The orchidopexy is done through an inguinal incision.
    7. In about 90% of cases of UDT, there is an associated inguinal hernia, which is repaired at the same time.
    8. If the testicle is unable to be brought into a scrotal position after mobilization alone, a Fowler-Stephens technique may be applied.
      1. Incidence: Preterm infants-30%. Full-term infants- 3.5%. At 1 years- 0.8%. Adults-0.8%.
      2. Risk Factors for cryptorchism
        • Regular alchohol intake during pregnancy
        • Exposure to pesticides
        • Low birth weight
        • Gestational diabetes
        • Twins
        • Familial
      3. Classification: Abdominal location, Canalicular (placed in the inguinal canal), Ectopic.
      4. Diagnosis: A short course of hCG is used to differentiate between anorchia or nonpalpable testis. High levels of basal gonadotrophins suggests anorchia.
        • USG is helpful if the testis is in the inguinal canal. USG is the initial investigation.
        • CT Scan and MRI are useful in cases of impalpable testis. MRI more sensitive than CT.
        • Laparoscopy has now become the investigation of choice. A blind ending testicular vessel signifies that testis is absent. It also helps in deciding about immediate surgery or Clip the testicular vessel (if cord is short), and second stage orchidopexy.
Cryptorchidism treated at what age (AIIMS Nov 09)
A.1-2 yrs                          
B. Puberty
C. Neonate                      
D. Infancy
Ans D. Infancy
  1. Complications:
  • Malignancy (Seminoma followed by embryonal cell carcinoma are the 2 most common malignancy), More susceptible to trauma, associated inguinal hernia, torsion, Atrophy and infertility.
  • Cryptorchidism is also seen in association with Klinefilter syndrome, Noonan syndrome and Pader-Wili syndrome.
  1. Treatment: Is Surgical. Testis is brought down to the scrotum and fixed in the dartos pouch, or by narrowing the neck of scrotum or is passed through the scrotal septum (Ombredanne’s operation). Best time of operation 6 months.
Ideal time of operation for Rx of unilateral undescended testis? (AIPG 2011)
A. At birth                        
B. 6 months           
C. 12 months                         
D. 2 yrs
Ans. B. 6 months.(Ref. Shwartz 8th/1506, Ref: Nelson 18th Edition chapter 545)
  • Torsion Of The Testis
  1. This is commonly seen in 12-20 years who gives history of sudden severe pain in one of the scrotum and development of edema.
  2. Predisposing causes are
    1. Inversion of testis (most common).
    2. High investment of tunica vaginalis.
    3. Clapper bell like deformity.
    4. The initiating factor is spasm of cremaster which inserts obliquely in the cord.
  3. Main D/D is Epididymoorchitis. If the scrotum is lifted onto the pubis, pain due to orchitis is relieved but if due to torsion it gets worsened (Prehn’s sign). In early stages epididymis may be felt anterior to the testis.
  4. Diagnosis is confirmed by coloured Doppler study.
  5. Transscrotal exploration is option of choice. If presentation within 6 hrs. It is both diagnostic and therapeutic (Orchidopexy)
  6. Most accurate investigation is 99m Tc pertechnetate scan.
  7. Torsion is a twisting of the spermatic cord upon itself that results in obstruction of the blood vessels supplying the testis and epididymis. It is usually the result of anomalous suspension of the testes within the scrotum.
  8. Torsion is more common in children in 12-18 years of age, peak at 13 years, but accounts for 20% of acute scrotal pathology in post-pubertal males.
  9. Testicular torsion and acute epididymitis or epididymo-orchitis are the most common causes of an acute scrotal pain.
  10.  Differentiating between these entities is often difficult on physical examination and testicular sonography with pulsed and color Doppler examination is helpful in this regard.
  11. On sonography, the torsed testicle is usually enlarged and hypoechoic compared with the contralateral normal testicle, and may contain echogenic areas representing hemorrhage. Common extra-testicular findings include an enlarged epididymis, skin thickening and reactive hydrocele formation.
  12. The gray-scale findings are not specific and may also be seen in epididymo-orchitis. However, decreased or absent blood flow within the testicle on Doppler examination indicates acute torsion.
  13. Radionuclide imaging with Tc-99m pertechnetate can complement ultrasound in differentiating torsion from epididymo-orchitis.
  14. There is diminished or absent blood flow to the torsed testicle compared to increased blood flow in epididymitis or orchitis. Delayed images in torsion show increased peripheral activity around a cold testicle.
  15. Prompt diagnosis and treatment of testicular torsion is essential for testicular salvage. If surgery is performed within 6 hours after the onset of symptoms, the testis can be saved in about 70% of cases. Delayed treatment results in a much lower salvage rate.
  16. Treatment is immediate exploration derotation and fixation of the testis. Results are good if the surgery is done within 6 hours and orchidectomy if done after 48 hours.
  17. Torsion are sometime called “Winter syndrome” 1 because they often happen in winter.
  18. Testicular torsion in neonates may not produce symptoms and is usually only noted after the testicle has atrophied.
  19. Torsion in children and young adults is intravaginal—the testicle and the inner layer of the tunica vaginalis rotate.
  20. The anatomic predisposition to torsion affects both testicles; therefore, the contralateral testicle should be similarly repaired.
  • Varicocele
  1. Varicocele is dilation of the pampiniform plexus. Left side is more commonly affected. Isolated right sided varicocele, sudden appearance of varicocele or persistence of dilated veins in supine position should be investigated further to role out RCC. Presenting features are pain and infertility. On examination it is felt like a bag of worms.
  2. Treatment is surgical and consists of ligation of vein by scrotal, low inguinal or high inguinal routes.
  3. Etiology
    1. 1st degree- idiopathic
    2. 2nd degree- Left renal cell carcinoma
  4. Varicocele & Spermatogenesis-
    1. Unilateral Varicocele keeps the testis at 2.5*C higher temperature.
  5. Clinical Features-
    1. Left- 95%.
    2. Hot climate, tall & thin men, pendulous scrotum.
    3. Vague dragging discomfort, feel like a bag of worms.
    4. 2nd degree Varicocele does not show reducibility of swelling and the cough
    5. impulse is also negative.
  6. Investigation Of Choice- Color Doppler
    1. Operation only for symptomatic cases.
    2. Embolisation of the testicular vein under radiographic control is probably the Rx of choice.
    3. Simplest procedure is ligation of the testicular vein- (PALAMO’s OPERATION) as high as possible. Recently
    4. done laparoscopically.
    5. Alternative or collateral channel is the cremasteric vein. 
  • Fournier’s Gangrene
  1. Fournier gangrene is a necrotizing fasciitis involving the soft tissues of the male genitalia.
  2. Pathophysiology: Necrosis of the superficial and deep fascial planes, Fibrinoid coagulation of the nutrient arterioles, Polymorphonuclear cell infiltration, Microorganisms identified within the involved tissues. Common causative organisms include: Streptococcal spp, Staphylococcal spp, Enterobacteriaceae spp, Anaerobic organisms & Fungi
  3. Clinical: Fever and lethargy may be present for 2-7 days. Intense genital pain and tenderness that is usually associated with edema with progressive erythema of the overlying skin . Dusky appearance of the overlying skin; subcutaneous crepitance Obvious gangrene of a portion of the genitalia; purulent drainage from wounds
    1. Risk factors for developing FG include alcoholism, diabetes, malnutrition, advanced age, and peripheral vascular disease.
    2. The hallmark of FG is a rapid progression from the signs and symptoms of cellulitis to blister formation and foul-smelling necrotic lesions.
    3. Infection may spread along fascial planes, and hence the exterior skin findings may represent only a small proportion of the underlying infected and necrotic tissue.
    4. The diagnosis of FG is a surgical emergency because progression from genitalia to perineum to abdominal wall may occur extremely rapidly (often within hours).
    5. The exclusion of FG, therefore, should be a priority during every consultation for soft tissue infection of the genitalia.
  • Blood tests
    To assess the immunologic stress induced by the infectious process. Blood cultures should be drawn to assess the presence of septicemia.
  • Plain film radiography
  1. Initial imaging study should be a plain radiograph that may show moderate to large amounts of soft tissue gas or foreign bodies.
  2. Demonstration of soft tissue gas or detection of subcutaneous crepitance is an absolute indication for surgical exploration.
  • Ultrasonography
    This can be utilized to detect fluid or gas within the soft tissues. In addition, US can assess the blood flow to the testis if testicular torsion is in the differential diagnosis.
  1. Medical therapy: Treatment involves the institution of broad-spectrum antibiotics. The antibiotic spectrum should cover Staphylococcus, Streptococcus, the Enterobacteriaceae and anaerobes. If initial tissue stains (KOH) show fungi, add Amphotericin B.
  2. Surgical therapy: All necrotic tissue must be excised. The skin should be opened widely to expose the full extent of the underlying fascial and subcutaneous tissue necrosis.
  3. Suprapubic cystostomy is utilized when urethral drainage of the bladder is not possible. Appearance of, healthy granulation tissue signifies the time to proceed to reconstruction.
Options for reconstruction
  1. Primary closure of the skin, if possible
  2. Local skin flap coverage
  3. Split thickness skin grafts
  4. Muscular flaps, which are used to fill a cavity (eg, ischiorectal space)
Testicular Tumour
99% of the testicular tumour are malignant and constitute 1-2% of malignant tumours of males. Undescended testis is a very important predisposing factor. It is more common on the right side. Q
  • Risk factors for testicular tumor.
  1. Cryptorchism
  2. H/O testicular cancer in contralateral testis.
  3. Gonadial dysgenesis
  4. Prenatal exposure to high estradiol
  5. Chemical carcinogens
  6. Trauma
  7. Orchitis
  8. Any cause of testicular atrophy. 
Most common Testicular tumor in prepubertal life? (AIIMS May 08)

A. Seminoma                               
B. Teratoma                           
C. Yolk sac tumor                   
D. Leydig cell tumor
Ans. C. Yolk sac tumor

Types: (Classified into germ cell tumour (Seminoma) & non germ cell tumour)

Classification of Testicular Tumors
1. Germ Cell Tumors
A. Seminoma
i. Classic (typical)                            ii. Atypical                              iii. Spermatocytic
B. Nonseminomatous
i. Embryonal carcinoma                    ii. Teratoma                           iii. Mature
iv. Immature                                   v. Mature or immature with malignant transformation
vi. Choriocarcinoma                         vii. Yolk sac tumor (endodermal sinus tumor)
2. Sex Cord and Stromal Tumors
Sertoli's cell tumor
Leydig's cell tumor
Granular cell tumor
Mixed types (e.g. Sertoli-Leydig tumor)
Mixed Germ Cell and Stromal Elements
Adnexal and Paratesticular Tumors
Adenocarcinoma of rete testis
Miscellaneous Tumors
Testicular metastasis
  1. Seminoma: (40%), Commonest between 35-40 years. Histologically consists of round cells with clear cytoplasm and acidophilic nucleoli, arranged in sheets. Tumour is firm and smooth. Metastasis occurs through lymphatics to para-aortic lymph nodes. Blood born mets are rare. It is most radiosensitive neoplasm.
  2. Teratoma: (32%), Arise in rete testis from totipotent stem cells and contains elements of ectoderm, endoderm and mesoderm. Surface is irregular. It has been classified into:
    1. Differentiated Teratoma: (1%) It is a true benign tumour consisting of cartilage muscle bone & glandular elements.
    2.  Tetratocarcinoma (Malignant teratoma intermediate): (30%), Contains some definitely malignant and undifferentiated tissue. Depending on the severity, it has been divided in type A & B.
    3. Embryonal carcinoma (Malignant teratoma anaplastic): (15%), Composed of undifferentiated cells of embryonal nature. AFP is always raised. It is a radiosensitive tumour.
    4. Choriocarcinoma (Malignant teratome trophoblastic): (1%), Contains syncitial mass. Produces bHCG. Hematogenous spred is very common.
  3. Interstitial cell tumours: Leydig cell tumour ( causes musulanization) and sertoli cell tumour (causes feminazation).
Tumorigenic model for germ cell tumors of the testis.
  • Presentation: Patient presents with a nodule or painless testicular enlargement. 10% of patient may present with pain (epididymitis or hemorrhage). In 10% presentation is due to metastasis (suraclavicular node, cough and dyspnoea, bone pains or limb edema. Gynecomastia (5%) is due to increased bHCG). Secondary hydrocele is seen in 10%.
  • Investigations
    1: X ray chest.                
    2: Ultrasonography.            
    3: Tumour markers:
  Seminoma Teratoma Teartocarcinoma Embryonal Choriocarcinoma
hCG (%)                                     7-10% 25 57 60 100
AFP (%) 0 38 64 70 0
Percutaneous biopsy or FNA scrotum for testicular neoplasm is not recommended, has no role.
The degree of elevation of tumor marker is a prognostic index and the post treatment levels have been shown to be reliable marker of residual disease.
4: CT Scan abdomen.                          
5: IVP.                    
6: Lymphangiography.                       
7: Gallium scan.
Stage I: Lesion in testis only
Stage II: Nodal involvement below diaphragm only
           A: < 2 cm in size
           B: 2 – 5 cm in size
           C: > 5 cm in size
Stage III: Nodes above diaphragm
Stage IV: Pulm. Or Hepatic mets
The commonest tumour in children is Yolk sac tumour.

TNM Classification of Tumors of the testis
T – Primary tumor
TX:  Cannot be assessedsss
T0:  No evidence of primary tumor
Tis:  Intratubular cancer (CIS)
T1:  Limited to testis and epididymis, no vascular invasion
T2:  Invades beyond tunica albuginea or has vascular invasion
T3:  Invades spermatic cord
T4:  Invades scrotum
N – Regional lymph nodes
NX: Cannot be assessed
N0: No regional lymph node metastasis
N1: Lymph node metastasis £2 cm or multiple nodes, none more than 2 cm and <6 nodes positive
N2: Nodal mass > 2 cm and £ 5cm or ³ nodes positive
N3: Nodal mass >5 cm
M- Distant metastasis
MX: Cannot be assessed
M0: No distant metastasis
M1a: Distant metastasis present in nonregional lymph nodes or lungs
M1b:  Nonpulmonary visceral metastases
S – Serum tumor markers
SX:  Markers not available
S0:  Marker levels within normal limits
S1:  Lactic acid dehydrogenase (LDH) <1.5 X normal and hCG <5000 mIU/mL and AFP < 1000 ng/mL
S2:  LDH 1.5 – 10 X normal or hCG 5000 – 50,000 mIU/ mL or AFP 1000 -10,000 ng/mL
S3:  LDH >10 X normal or hCG >50,000 mIU/mL or AFP > 10,000 ng/mL
Tumor histology & tumor stage are of primary importance in determining the prognosis of testicular tumor.
  • Treatment:
A 6 years female child has urine retention and constipation. On imaging studies, a retrorectal complex mass was found. The likely diagnosis is? (AIIMS May 08)
A. Duplication cyst                                         
B. Sacrococcygeal teratoma
C. Meningocele                                              
D. Neuroblastoma
Ans. B.  Sacrococcygeal teratoma

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