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204 Challenging Concepts in Urological Surgery
https://t.me/med1917
Furthermore, there is a small but steadily increasing body of evidence that post- chemotherapy R- RPLND
in selected cases of small post- chemotherapy masses is safe both surgically and oncologically if performed
in specialist high- volume centres.
Surgery was performed using a robotic- assisted laparoscopic technique by a two-
consultant surgical team. The residual mass was adherent to the inferior vena cava.
Resection of the mass resulted in a small cavotomy which required repair. Lymphatics
were cauterized or clipped throughout the RPLND to reduce risk of postoperative
lymph leak. The operating time was 3 hours and blood loss 280 mL. The patient was
quite uncomfortable on the night of surgery but felt well the next day. There was 120
mL of serous fluid in the abdominal drain so the drain was left for a further 24 hours to
monitor for a lymphatic leak. He was very well on day 2 with only 10 mL in the drain
so the drain was removed and he was discharged home.
Histology of the surgical specimen showed 14 nodes with some evidence of ne-
crosis but no viable tumour seen. When the patient returned for his postoperative visit
he was well and with minimal pain. His erections and ejaculation were normal. He
was delighted with the pathological finding of no viable tumour. He therefore required
no further treatment and was placed on surveillance. He continued with counselling
support and remains an active member of an online group for TC survivors.
24
Learning point Surgery for residual masses post chemotherapy
When surgery is performed for residual masses following chemotherapy, ‘lumpectomy’ alone should
not be performed. All areas of primary metastatic disease sites must be completely resected usually
within 6 weeks of completing chemotherapy. There is increasing evidence supporting the oncological
safety of template dissections rather than radical bilateral dissections which allow preservation of
ejaculatory function
Histology of resected residual mass
If histology of the resected residual mass shows:
● No viable cancer or complete resection of viable cancer present in <10% of the total volume of the
specimen then no additional treatment is indicated
● Incomplete resection of viable cancer then two further cycles of cisplatin- based chemotherapy may
be given in certain groups (e.g. poor- prognosis patients).
20– 22
without compromising oncological outcomes.
14
A final word from the expert
TC is a disease of survivors. Given the excellent prognosis (survival rates >95%) of most patients
with TC, focus on high- quality survivorship— future well- being— at each stage of TC management
is crucial. Efforts should be made to preserve reproductive and hormonal function; minimize
morbidity of surgery, radiotherapy, and chemotherapy; and provide psychological support,
without compromising oncological outcomes.
The effect of TC treatment on male reproductive function depends on several factors,
including age at the time of cancer therapy, type and location of the cancer, and the
treatment(s) given. Both hypogonadism and infertility can occur as a result of TC and its
treatments. Primary assessment should therefore include both semen analysis and serum
hormone testing.
26,27
Testis- sparing surgery may be suitable in cases of synchronous bilateral testicular tumours,
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metachronous contralateral tumours, or tumour in a solitary testis. Tumour volume should be
<30% of overall testicular volume and oncological surgical rules respected. Onco- TESE (ex vivo
testicular sperm extraction from the affected testicle at the time of orchidectomy) can be offered
to patients who are azoospermic and have an abnormal or absent contralateral testis to preserve
future fertility.
26
Biochemical hypogonadism is prevalent in 5– 13% of patients following orchidectomy and
11– 27% following chemotherapy.27 Hormone levels should be checked at diagnosis and after
all treatments, and testosterone replacement offered. Patients should also be made aware of the
symptoms of hypogonadism such as fatigue and low libido.
The peri- and postoperative morbidity of RPLND is considerable. Many patients develop
retrograde ejaculation due to damaged superior hypogastric and lumbar splanchnic nerves
resulting in loss of ejaculation and the ability to conceive naturally. The use of unilateral and
nerve- sparing RPLND in appropriate cases, the utilization of minimally invasive techniques
where appropriate, and the centralization of this complex operation to high- volume specialist
centres has significantly reduced morbidity, mortality, and long- term sequelae.
14,21– 25
Long- term side effects of chemotherapy for TC can include hearing loss, gastric symptoms,
lung damage, and peripheral neuropathy. Current chemotherapy regimens aim to minimize
these; for example, administration of cisplatin over 5 days instead of 3 days reduces incidence
of hearing impairment and tinnitus.7 A large multinational prospective trial has shown that
delivery of chemotherapy in high- volume centres is associated with better outcomes: higher
cumulative doses, lower toxicity and treatment- related mortality, and more frequent use of postchemotherapy resection of residual masses.
28
Finally, although TC is highly ‘curable’, this does not lessen the emotional toll on patients, the
effects of which should not be underestimated. The levels of psychological distress reported by
TC survivors is between 9% and 27%.29 Psychosocial morbidity includes uncertainty about the
future, feelings of inadequacy, fear of stigmatization, anxiety, depression, and symptoms of posttraumatic stress disorder. Comprehensive TC services should offer easy access to counselling
and actively encourage involvement in TC communities to ensure that TC survivors have a good
quality of life after cure.
205Case 20 Metastatic testicular cancer
References
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correlation in pathologic conditions of the scrotum. Radiographics. 2007;27(5):1239– 1253.
2. Northern Ireland Cancer Registry, Queens University Belfast. Incidence by stage 2010– 2014.
Belfast: Northern Ireland Cancer Registry; 2016.
3. Howard GC, Nairn M; Guideline Development Group. Management of adult testicular germ
cell tumours: summary of updated SIGN guideline. BMJ. 2011;342:d2005.
4. Baniel J, Roth BJ, Foster RS, Donohue JP. Cost- and risk- benefit considerations in the
management of clinical stage I non- seminomatous testicular tumors. Ann Surg Oncol.
1996;3(1):86– 93.
5. Giannatempo P, Greco T, Mariani L, et al. Radiotherapy or chemotherapy for clinical stage
IIA and IIB seminoma: a systematic review and meta- analysis of patient outcomes. Ann
Oncol. 2015;26(4):657– 668.
6. Weissbach L, Bussar- Maatz R, Flechtner H, Pichlmeier U, Hartmann M, Keller L. RPLND
or primary chemotherapy in clinical stage IIA/ B non- seminomatous germ cell tumors: results of a prospective multicenter trial including quality of life assessment. Eur Urol.
2000;37(5):582– 594.
206 Challenging Concepts in Urological Surgery
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7. Krege S, Boergermann C, Baschek R, et al. Single agent carboplatin for CS IIA/ B testicular
seminoma. A phase II study of the German Testicular Cancer Study Group (GTCSG). Ann
Oncol. 2006;17(2):276– 280.
8. Brierley JE, Gospodarowicz MK, Wittekind C, eds. TNM Classification of Malignant
Tumours. 8th ed. Chichester: Wiley- Blackwell; 2017.
9. Peyret C. Tumeurs du testicule. Synthèse et recommandations en onco- urologie. [Testicular
tumours. Summary of onco- urological recommendations.] Prog Urol. 1993;2:60– 64.
10. Mead GM, Stenning SP. The International Germ Cell Consensus Classification: a new prognostic factor based staging classification for metastatic germ cell tumours. Clin Oncol (R
Coll Radiol). 1997;9(4):207– 209.
11. Zengerling F, Hartmann M, Heidenreich A, et al. German second- opinion network for testicular cancer: sealing the leaky pipe between evidence and clinical practice. Oncol Rep.
2014;31(6):2477– 2481.
12. Chung PW, Gospodarowicz MK, Panzarella T, et al. Stage II testicular seminoma: patterns of
recurrence and outcome of treatment. Eur Urol. 2004;45(6):754– 759.
13. Gillessen S, Powles T, Lim L, Wilson P, Shamash J. Low- dose induction chemotherapy with
Baby- BOP in patients with metastatic germ- cell tumours does not compromise outcome: a
single- centre experience. Ann Oncol. 2010;21(8):1589– 1593.
14. Laguna MP, Albers P, Algaba F, et al. EAU guidelines on testicular cancer. European
Association of Urology. 2020. https:// uroweb.org/ wp- content/ uploads/ EAU- Guidelines- onTesticular- Cancer- 2020.pdf
15. Dieckmann KP, Radtke A, Geczi L, et al. Serum levels of microRNA- 371a- 3p (M371 test)
as a new biomarker of testicular germ cell tumors: results of a prospective multi- centric
study. J Clin Oncol. 2019;37(16):1412– 1423.
16. Oldenburg J, Alfsen GC, Lien HH, Aass N, Waehre H, Fossa SD. Post- chemotherapy retroperitoneal surgery remains necessary in patients with non- seminomatous testicular cancer
and minimal residual tumor masses. J Clin Oncol. 2003;21(17):3310– 3317.
17. Hartmann JT, Candelaria M, Kuczyk MA, Schmoll HJ, Bokemeyer C. Comparison of histological results from the resection of residual masses at different sites after chemotherapy for
metastatic non- seminomatous germ cell tumours. Eur J Cancer. 1997;33(6):843– 847.
18. Carver BS, Shayegan B, Serio A, Motzer RJ, Bosl GJ, Sheinfeld J. Long- term clinical outcome after post- chemotherapy retroperitoneal lymph node dissection in men with residual
teratoma. J Clin Oncol. 2007;25(9):1033– 1037.
19. Ehrlich Y, Brames MJ, Beck SD, Foster RS, Einhorn LH. Long- term follow- up of cisplatin
combination chemotherapy in patients with disseminated non- seminomatous germ cell tumors: is a post- chemotherapy retroperitoneal lymph node dissection needed after complete
remission? J Clin Oncol. 2010;28(4):531– 536.
20. Hiester A, Nini A, Fingerhut A, et al. Preservation of ejaculatory function after
postchemotherapy retroperitoneal lymph node dissection (PC- RPLND) in patients with testicular cancer: template vs. bilateral resection. Front Surg. 2018;5:80.
21. Donohue JP, Foster RS. Retroperitoneal lymphadenectomy in staging and treatment. The
development of nerve- sparing techniques. Urol Clin North Am. 1998;25(3):461– 468.
22. Heidenreich A, Pfister D, Witthuhn R, Thüer D, Albers P. Post- chemotherapy retroperitoneal
lymph node dissection in advanced testicular cancer: radical or modified template resection. Eur Urol. 2009;55(1):217– 224.
23. Stepanian S, Patel M, Porter J. Robot- assisted laparoscopic lymph node dissection for testicular cancer: evolution of the technique. Eur Urol. 2016;70(4):661– 667.
24. Schwen ZR, Gupta M, Pierorazio PM. A review of the outcomes and technique for roboticassisted laparoscopic retroperitoneal lymph node dissection for testicular cancer. Adv Urol.
2018;3:140– 145.
25. Flechon A, Tavernier E, Boyle H, Meeus P, Rivoire M, Droz JP. Long term oncological outcome after post- chemotherapy retroperitoneal lymph node dissection in men with metastatic non- seminomatous germ cell tumour. BJU Int. 2010;106(6):779– 785.
26. Moody JA, Ahmed K, Yap T, Minhas S, Shabbir M. Fertility management in testicular
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cancer: the need to establish a standardised and evidence- based patient- centric pathway.
BJU Int. 2019;123(1):160– 172.
27. Oldenburg J. Hypogonadism and fertility issues following primary treatment for testicular
cancer. Urol Oncol. 2015;33(9):407– 412.
28. Feuer EJ, Sheinfeld J, Bosl GJ. Association between number of patients treated and patient
outcome in metastatic testicular cancer. J Nat Cancer Inst. 1999;91(10):816– 818.
29. Fleer J, Hoekstra HJ, Sleijfer DT, Hoekstra- Weebers JE. Quality of life of survivors of testicular
germ cell cancer: a review of the literature. Support Care Cancer. 2004;12(7):476– 478.
207Case 20 Metastatic testicular cancer
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SECTION 9
Functional, female,
and neurourology
Case 21 Benign prostatic enlargement and acute urinary retention
Case 22 Chronic retention, renal failure, and diuresis
Case 23 Urge urinary incontinence
Case 24 Stress urinary incontinence
Case 25 Bladder pain syndrome/ interstitial cystitis
Case 26 Female urinary retention
Case 27 Neurogenic bladder
Case 28 Genitourinary prolapse
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21
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CASE
Benign prostatic enlargement
and acute urinary retention
Emma Papworth, Joseph Jelski, and
Hashim Hashim
Expert commentary Hashim Hashim
Case history
A 60- year- old man presents to the urology outpatient department complaining of
lower urinary tract symptoms (LUTS). On questioning, he describes mixed storage
and voiding symptoms, including urinary frequency, urgency, nocturia, and reduced
flow. He denies any episodes of urinary incontinence. He completes an International
Prostate Symptom Score (IPSS) questionnaire with a score of 19 demonstrating moderate symptom severity. His bother score is 6.
Breakdown of his IPSS score:
● Incomplete emptying 3; frequency 3; intermittency 2; urgency 3; weak stream 3;
straining 2; nocturia 3.
● Voiding/ storage ratio >1, indicating a slight predominance of voiding symptoms.
Clinical tip Assessment of male LUTS
There are a number of validated tools for the assessment of male LUTS including the IPSS and the
International Consultation on Incontinence Modular Questionnaire for Male Lower Urinary Tract
Symptoms (ICIQ- MLUTS). The most commonly used is the IPSS, which has been shown to be reliable
and reproducible.
IPSS:
● Seven questions on symptoms and one question on quality of life.
● Max score: 35.
● Mild: 0– 7; moderate: 8– 19; severe: 20– 35.
ICIQ- MLUTS:
● Twenty- four questions, individual bother score for each symptom.
When using the IPSS, missing the symptoms of hesitancy and urgency urinary incontinence (UUI)
may significantly affect the management, and hence affect the clinical outcome. These symptoms
are better detected by the ICIQ- MLUTS questionnaire. The ability to assess bother associated with
individual symptoms using the ICIQ- MLUTS enables treatment to be individualized and enables a
more patient- centred approach to the assessment of male LUTS.
1
A frequency/ volume chart confirms consumption of between four and five cups
of coffee each day with frequent small- volume voids and no evidence of leaking or
212 Challenging Concepts in Urological Surgery
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Figure 21.1 Uroflowmetry.
nocturnal polyuria. A flow test performed in clinic reveals a reduced maximum flow
rate (Qmax) of 10 mL/ s with a voided volume of 199 mL and a post- void residual of 80
mL (Figure 21.1). Digital rectal examination reveals a mildly enlarged, benign- feeling
prostate with a prostate- specific antigen level of 2.8 ng/ mL.
Clinical tip Uroflowmetry
To prepare for a flow test, a patient will need to have a comfortably full bladder, usually needing to
consume between 500 and 1000 mL of fluid prior to attending. The test can take up to 2– 3 hours.
Flows are only useful if a there is at least 150 mL in the bladder. Some patients are unable to fill to
significant volumes and this is important to know prior to starting the test and will be evident on
the bladder diary. The International Continence Society ‘Good Urodynamics Practice’ guidelines2
recommend one representative flow. In practice, patients are usually asked to do two flows to
ensure that an adequate and representative flow is obtained. Patients should be asked if the flow was
illustrative of their day- to- day flow, if not then it should be repeated.
The patient should be told to avoid compressing/ squeezing the urethra during voiding in order to
limit the ‘squeeze artefact’, and should not allow ‘wandering/ cruising’ around the funnel, which may
lead to an inaccurate result.
A flow test should be visually reviewed to ensure that any spurious results are identified (do not rely
on the electronic printed report only). If there is considerable doubt as to the veracity of the test,
pressure– flow studies are indicated after failure of medical and conservative therapy.
Learning point Flow rates
Of men with a Qmax <10 mL/ s, about 90% will be obstructed on pressure– flow urodynamic criteria.
The remaining proportion of patients will have a low- pressure, low- flow situation with reduced
contractility— detrusor underactivity.
Of men with a flow rate of >15 mL/ s, 75% will not have bladder outlet obstruction (BOO).3 The
remainder with good flow may have a high- pressure high flow situation where increased detrusor
work compensates for a degree of obstruction. A reduced flow rate is a risk factor for symptomatic
progression to urinary retention (UR).
3
The patient’s general practitioner had tried an alpha- 1 antagonist (tamsulosin 400
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mcg once a day); however, the patient had stopped taking this due to retrograde
ejaculation.
Evidence base Medical therapy for LUTS
Monotherapy with alpha antagonists/ blockers is recommended for all men with uncomplicated LUTS.
Meta- analysis of alpha- blocker trials has demonstrated a reduction in symptoms of 30– 40% and a
durable improvement in flow rates of 16– 25%.
Finasteride (5- alpha reductase inhibitor) does not appear to be as effective as a single agent; however,
data have shown the importance of this drug in reducing disease progression. The PLESS study shows
a reduction in UR (57%) and the need for a transurethral resection of the prostate (TURP; 55%) over
5
4 years.
Results from the MTOPS6 and CombAT7 studies have demonstrated significant benefit from
combination therapy with an alpha antagonist and 5- alpha reductase inhibitor.
BAUS guidelines8 recommend the use of combination treatment for those with bothersome LUTS,
prostatic obstruction, and risk factors for progression.
4
213Case 21 Benign prostatic enlargement and acute urinary retention
Following initial consultation, management of the patient’s storage symptoms are
prioritized as these were reported to be the most bothersome to his quality of life. To
manage his overactive bladder (OAB) symptoms, the patient is advised to reduce consumption of bladder irritants including caffeinated drinks, bearing in mind the small
proportion of caffeine in decaffeinated preparations. The patient is also given bladder
re- training advice to include prolongation of time between voids and the technique of
double voiding to aid bladder emptying. Fluid manipulation and reduction of fluid by
25% is advised as long as the patient drinks >1 L a day.9 If conservative measures
fail, use of an anticholinergic/ antimuscarinic or beta- 3 agonist medications is recommended. Various antimuscarinic preparations are available which can be trialled according to efficacy and degree to which the patient experiences side effects.
Unfortunately, the patient goes on to develop a urinary tract infection and presents
in UR. He is catheterized, restarted on tamsulosin, and goes on to successfully void
following a trial without catheter one week later.
Learning point Risk factor for acute urinary retention
A number of risk factors for acute urinary retention (AUR) have been identified as shown in Table 21.1.
Table 21.1 Risk factors for acute urinary retention
Risk factor AUR relative risk
PSA >1.4 ng/ mL 2.0
Prostate volume >30 mL 3.0
IPSS >7 3.2
Qmax <12 mL/ s 3.9
Age >70 vs 40– 49 years 10– 11
11
Learning point OAB
● OAB occurs in both men
and women. It is a symptom
complex expressed by the
patient and should not be
confused with detrusor
overactivity, which is a
urodynamic diagnosis.
● About 80% of men who
have OAB will have detrusor
overactivity and about 55% of
10
women.
● OAB can coexist with other
common conditions such as
benign prostatic obstruction
(BPO), stress incontinence, and
nocturnal polyuria.
In view of this episode of UR and ambiguity as to the causality of symptoms, uro-
dynamics were requested at this stage (Figure 21.2).
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