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Introduction High cord radical orchidectomy (HRCO) is accepted as the standard surgical approach in testicular cancer, however low cord orchidectomy (LCRO) can reduce the morbidity of operation without worsening the oncological outcomes. Methods We retrospectively re-examined the specimens of men to determine the level of spermatic cord invasion (SCI). Men who had proximal SCI with negative surgical margins after HRCO were assumed to have de-novo residual tumour if LCRO was performed. Others were assumed as oncologically similar. We examined the relation between pre-operative variables and SCI and proximal SCI to determine whether prediction of proximal SCI is possible. Results 196 patients were included. 22 (11%) had SCI and ten (5%) had proximal SCI. Four patients with proximal SCI had positive surgical margins even after HRCO and didn’t require additional local treatment. Six patients were assumed to have de-novo residual tumour if LCRO was performed. All six patients were metastatic and had systemic chemotherapy. High platelet count, tumour size, N stage, S stage and M stage were all significantly related with both SCI and proximal SCI (p < 0.05). Conclusion Due to low probability of SCI, we think LCRO can safely be performed to reduce morbidity in Stage 1 patients. Although there is a risk for residual tumour in Stage 2–3 patients, currently there is no data that residual tumour would impair the success of systemic chemotherapy. Therefore we can not assume that these patients would be negatively affected. Pre-operative data can be useful to predict the presence of proximal SCI and select appropriate patients for LCRO.

ObjectiveLittle is known at national level about how COVID-19 impacted acute surgical activity among children and young (CYP) people. This study investigated procedures for appendicitis and testicular torsion during the pandemic period – two common conditions where delays in treatment can result in preventable complications.MethodsAcute appendicitis and testicular pain admissions by 0–24s were extracted using England’s Hospital Episode Statistics. Time-series modelling, Mann-Whitney and Pearson’s Chi-squared test was used to compare the first 14-months of the pandemic cohort (February 2020 to March 2021) with the previous five-year pre-pandemic cohort. We report monthly trends in total admissions and admissions by deprivation quintile. We test for differences in median length of stay (LOS), 28-day readmission rates, orchidopexy and orchidectomy rates between pandemic periods. Results were stratified into age groups (0–4s, 5–9s and 10–24s) and appendicitis type (all, simple and complex).ResultsFigure 1 shows that admissions for appendicitis fell significantly in the early months of the pandemic. A similar pattern was observed for testicular torsion admissions. The absolute number of complex appendicitis admissions remained relatively stable, but the proportion of complex appendicitis rose early in the pandemic months. Among children aged 5–9, there was a significant reduction in the proportion of appendicitis admissions living in the most deprived quintile of households (Pre-pandemic:25.6% vs Pandemic: 22.7%, p=0.0012). There were statistically significant reductions in median LOS for appendicitis, but this was of limited clinical effect. Of those who had appendicectomies, only the 5–9s had significant reduction in 28-day total readmission rates (Pre-pandemic: 11.7% vs Pandemic: 9.1%, p=0.0002). Among the appendicitis admissions treated non-operatively, only the 10–24s had significantly higher 28-day readmission rates (Pre-pandemic: 18.1% vs Pandemic: 24.4%, p=0.0260). Figure 2 demonstrates that for those admitted for testicular torsion, orchidectomy rates rose in April 2020 for the 5–9s (+15.6% (7.9 to 23.3)) and 10–24s (+5.4% (0.9 to 10.0), but overall orchidectomy rates did not significantly change. Orchidopexy rates rose in the pandemic for the 10–24s (Pre-pandemic: 19.3% vs Pandemic: 23.2%, p<0.0001).ConclusionWe found a consistent reduction in acute surgical activity among CYP, with evidence of short-term periods of delayed presentations during pandemic peaks, without persisting overall increased complication rates. These results provide important national context to smaller sized studies reporting complications due to delays in surgery. Future research could examine how reduced activity impacted other healthcare settings and treatment pathways.Abstract 696 Figure 1

The creation of species-specific valid tools for pain assessment is essential to recognize pain and determine the requirement and efficacy of analgesic treatments. This study aimed to assess behaviour and investigate the validity and reliability of an acute pain scale in pigs undergoing orchiectomy. Forty-five pigs aged 38±3 days were castrated under local anaesthesia. Behaviour was video-recorded 30 minutes before and intermittently up to 24 hours after castration. Edited footage (before surgery, after surgery before and after rescue analgesia, and 24 hours postoperatively) was analysed twice (one month apart) by one observer who was present during video-recording (in-person researcher) and three blinded observers. Statistical analysis was performed using R software and differences were considered significant when p<0.05. Intra and inter-observer agreement, based on intra-class correlation coefficient, was good or very good between most observers (>0.60), except between observers 1 and 3 (moderate agreement 0.57). The scale was unidimensional according to principal component analysis. The scale showed acceptable item-total Spearman correlation, excellent predictive and concurrent criterion validity (Spearman correlation ≥ 0.85 between the proposed scale versus visual analogue, numerical rating, and simple descriptive scales), internal consistency (Cronbach's α coefficient >0.80 for all items), responsiveness (the pain scores of all items of the scale increased after castration and decreased after intervention analgesia according to Friedman test), and specificity (> 95%). Sensitivity was good or excellent for most of the items. The optimal cut-off point for rescue analgesia was ≥ 6 of 18. Discriminatory ability was excellent for all observers according to the area under the curve (>0.95). The proposed scale is a reliable and valid instrument and may be used clinically and experimentally to assess postoperative acute pain in pigs. The well-defined cut-off point supports the evaluator´s decision to provide or not analgesia.

Testicular torsion (TT) is an emergency requiring a prompt diagnosis and surgery to avoid irreversible changes and a complete loss of testis. The present study aimed to identify potential factors that may be predict a testicular salvage after TT in pediatric patients. Consecutive medical records of all children ≤16 years old with surgically confirmed TT over a period of five years (2011–2016) were collected. Patients were divided into 2 groups according to testicular viability and the type of treatment: Orchidectomy and orchidopexy. The differences between the two groups and potential predictors of testicular salvage were analyzed. Thirty-one boys with TT met the inclusion criteria and were included in the study. The mean age was 13.6 years (range, 10 days - 15.8 years). Testicular salvage was possible in 18 (58.1%) patients. The duration of symptoms and a lesser degree of torsion indicated a testicular salvage in children and adolescents with testicular torsion, but in multivariate analysis only duration of symptoms (time to surgical detorsion) was significantly associated with the risk of non-salvage. At follow-up, testicular atrophy affected 73.3% of the patients treated with orchidopexy. Duration of symptoms is the only predictor of successful testicular salvage following testicular torsion in children. It is associated with a substantial risk of testicular loss and atrophy.

Abstract Context Endogenous and exogenous androgens increase circulating erythrocytes and hemoglobin but their effects on erythrocyte lifespan is not known. Objective To investigate androgen effects on immature and mature erythrocyte lifespan in humans and mice using novel nonradioactive minimally invasive methods. Design Human erythrocyte lifespan was estimated using alveolar carbon monoxide concentration and blood hemoglobin in Levitt's formula in hypogonadal or transgender men before and up to 18 weeks after commencing testosterone (T) treatment. Erythrocyte lifespan was estimated in androgen receptor knockout and wild-type mice after T or DHT treatment of intact females or orchidectomized males using in vivo biotin labelling of erythrocyte surface epitopes for reticulocytes (Ter119+CD71+) and 2 markers of erythrocytes (CD45–, Ter119+CD71–) monitoring their blood disappearance rate by flow cytometry. Results Before treatment, hypogonadal and transgender men had marked reduction in erythrocyte lifespan compared with controls. T treatment increased erythrocyte lifespan at 6 weeks but returned to pretreatment levels at 18 weeks, whereas serum T and blood hemoglobin were increased by T treatment remaining elevated at 18 weeks. In mice, T and DHT treatment had higher erythrocyte (but not reticulocyte) lifespan but neither orchidectomy nor androgen receptor inactivation significantly influenced erythrocyte or reticulocyte lifespan. Conclusion We conclude that hypogonadal men have reduced erythrocyte lifespan and acute androgen-induced increase in circulating erythrocyte lifespan may contribute to the well-known erythropoietic effects of androgens, but longer term effects require further investigation to determine how much they contribute to androgen-induced increases in circulating hemoglobin.

Testicular cancer is a relatively rare malignancy, accounting for 1% of solid tumors in adult males and 5% of all urological tumors. Orchidopexy has been shown to lower the risk of testicular cancer, but it does not prevent it. A 20-year-old adult male presented with a painful and palpable mass in his right testicle. The patient had orchidopexy at six months old but had been asymptomatic until his recent hospital visit. There was no previous history of cancer. Tumor markers including AFP and β-HCG were found to be elevated. Preoperative ultrasonograghy (USG) showed a solid and cystic mass of the right testis with increased vascularization. Following these findings, the patient underwent an orchidectomy. Histopathology examination revealed mixed type NSGCT of embryonal and choriocarcinoma. However, after completing four cycles of chemotherapy, a CT scan evaluation showed an enlarged mass in the abdomen, which was confirmed to be a mature teratoma. In patients with a history of cryptorchidism, orchidopexy does not rule out the possibility of testicular cancer. Orchidopexy did reduce the risk of seminoma, but not nonseminomatous germ cell tumor, which in our case continued to develop a growing teratoma on the abdomen. It is essential to conduct long-term monitoring of patients who have undergone orchiopexy due to their risk of developing testicular cancer.

Cryptorchidism and testicular torsion (TT) are relatively common conditions in clinical practice; however, sparse information about cryptorchid TT is available in the current literature. We retrospectively reviewed the clinical characteristics, treatment modalities, and long-term outcomes of pediatric patients treated for acute cryptorchid TT. We found eight patients with unilateral acute cryptorchid TT with a prevalence of 8.9% (8/90) among all TT cases. The left testis was affected in six patients. The median age of patients at the time of the surgery was 65 months (interquartile range (IQR) 4–136 months). The median duration of symptoms was 16 h (IQR 9–25 h), while the median time to treatment was 60 min (IQR 59–63 min). The most common symptoms were pain (abdominal and inguinal) and inguinal mass with no palpable testis in the ipsilateral hemiscrotum. Preoperative color Doppler ultrasonography revealed absent or decreased testicular blood flow in the affected testes in 7/8 of patients. Various degrees of testicular torsion (median 540°, min 360°, max 1260°) were found during surgery. A necrotic testis that led to orchidectomy was found in 4/8 of patients. The median follow-up period was 42.6 months (IQR 12.5–71.2 months), revealing only one patient with testicular atrophy. The final testicular salvage rate was 35%. Greater awareness among caregivers and primary care physicians about acute cryptorchid TT is required to improve their timely diagnosis and treatment. A physical examination of the external genitalia and inguinal regions should be mandatory to attain a proper diagnosis and treatment without delay.

Conventional ultrasonography (US), including greyscale imaging and colour Doppler US (CDUS), is pivotal for diagnosing scrotal pathologies, but it has limited specificity. Historically, solid focal testicular abnormalities often led to radical orchidectomy. This retrospective study evaluated the utilisation of contrast-enhanced ultrasound (CEUS) and strain elastography (SE) in investigating intratesticular focal abnormalities. A total of 124 cases were analysed. This study underscored the superior diagnostic capabilities of CEUS in detecting vascular enhancement in all malignant cases, even those with undetectable vascularity by CDUS. It also highlighted the potential of CEUS in identifying distinctive vascular patterns in benign vascular tumours. Definitive confirmation of benignity could be obtained when the absence of enhancement was demonstrated on CEUS. While SE alone offered no distinctive advantage in differentiating between benign and malignant pathologies, we demonstrated that incorporating a combination of CEUS and SE into the evaluation of focal testicular abnormalities could improve diagnostic performance metrics over conventional CDUS. Our findings underscore the role of advanced ultrasound techniques in enhancing the evaluation of focal testicular abnormalities in clinical practice and could aid a shift towards testis-sparing management strategies.

During postnatal development of the rat epididymis, a change in the expression of gap junction proteins, or connexins (Cxs), occurs, in which Gjb2 (Cx26) and Gja1 (Cx43) levels in the proximal epididymis are decreased, while Gjb1 (Cx32), Gjb4 (Cx30.3) and Gjb5 (Cx31.1) levels increase. The mechanism(s) responsible for the switch in Cx expression is unknown. The aim of this study is to identify the mechanisms responsible for the decrease in GJB2 protein levels and the increase in other Cxs during postnatal development. Results indicate that decreased Gjb2 expression for 48 h does not alter the expression of other Cxs in RCE-1 principal cells, suggesting a lack of compensatory expression. Sequence analysis of both Gjb2 and Gjb1 promoters identified common multiple response elements to steroid hormones. Using RCE-1 cells, we observed that dexamethasone increased Gjb2 mRNA levels by twofold after 48 h, while estradiol had no effect. Orchidectomy in rats resulted in a significant increase in GJB2 and decreased GJB1 in the caput and corpus epididymidis. Changes in Cxs protein levels were prevented by testosterone in orchidectomized rats. Similar results were observed in the prostate, another androgen-receptive organ. LNCaP cells, which are androgen-responsive, showed that exogenous dihydrotestosterone (DHT) decreased Gjb2 mRNA levels by approximately 50% concomitant with a 1.5-fold increase in Gjb1 levels. Using a GJB1 promoter construct we showed that DHT could induce transactivation of the luciferase transgene, while transactivation of two GJB2 promoters were unaltered. Results indicate that androgens and glucocorticoids regulate the expression of epididymal Cxs.