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Response to letter to the editor re ‘Is routine excision of testicular remnants in testicular regression syndrome indicated?’
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MODEL
Journal of Pediatric Urology (2016) xx, 1
Response to letter to the editor re ‘Is routine excision of testicular remnants in testicular regression syndrome indicated?’ We read the response to our article from our esteemed colleagues with gratitude, as one of the main reasons for the publication of our series was to initiate debate within the paediatric surgical and urological community about this controversial topic. We are also grateful for the opportunity to answer their concerns. For the first concern that they raise about the lack of adult urological case reports, we couldn’t agree more, as we state in our discussion: ‘It is still unclear as to whether these remnants have a future malignancy risk, as there is only one case of intratubular germ cell neoplasia (ITGCN) in the literature and this was not immune-histochemically supported’. For their second concern there are a number of different points raised. The first is the use of an inguinal approach for our explorations. In all of our patients there was a clinically impalpable testicle pre-operatively; we feel this is different from the subgroup who have a scrotal remnant that can be palpated and who may indeed not even undergo surgical intervention. The scrotal approach to an orchidopexy has been described with great results for many years, and so the use of a scrotal approach for testicular regression syndrome (TRS) exploration is probably a valid approach, just not one that we use. The second is that all TRS specimens are within the scrotum, as they are secondary to a perinatal torsion event. We agree that the descended testicle does not become fixed in the scrotum until 2e4 months postnatally, and we have discussed this in our manuscript. The prenatal torsion theory for TRS is supported by the presence of haemosiderin-laden macrophages in the resected specimens, but it is worth noting that this is not the only proposed mechanism. In our series, 35% of specimens had this histological finding, including some of
the intra-abdominal TRS specimens. For this reason, although perinatal torsion no doubt does occur within the scrotum, it likely also occurs during inguinoscrotal descent. In our clinical experience, perinatal torsion usually presents postnatally with an enlarged, firm, non-tender intra-scrotal testicle rather than testicular remnant, as it is a late antenatal event. We welcome the debate on this topic as it will no doubt remain controversial. Although the natural history of the germ cells that we have found are unknown and they may regress with time, our data support their resection, as 10% had germ cells present. Although the risk of future malignancy is likely to be very low, it is absent post-resection. We have performed these inguinal explorations for a clinically impalpable testicle so there is no change in our operative management. For clinically palpable scrotal testicular remnants this is no doubt a different subgroup of patients, and the outcome of these patients is not answered by our series. Ramesh Mark Nataraja* Monash Children’s Hospital, Paediatric Surgery & Urology, 246 Clayton Road, Clayton, Melbourne, Victoria 3168, Australia Department of Paediatrics, Monash University, Clayton Campus, Melbourne, Australia Feilim L. Murphy Department of Paediatric Surgery & Urology, St George’s Heathcare NHS Trust, Blackshaw Road, London SW17 0QT, UK *Correspondence to: R.M. Nataraja, Monash Children’s Hospital, Paediatric Surgery & Urology, 246 Clayton Road, Clayton, Melbourne, Victoria 3168, Australia E-mail addresses: ram.nataraja@ monashhealth.org, [email protected] (R.M. Nataraja) Received 15 June 2016 Available online xxx
DOI of original article: http://dx.doi.org/10.1016/j.jpurol.2016.05.044. http://dx.doi.org/10.1016/j.jpurol.2016.06.008 1477-5131/ª 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Nataraja RM, Response to letter to the editor re ‘Is routine excision of testicular remnants in testicular regression syndrome indicated?’, Journal of Pediatric Urology (2016), http://dx.doi.org/10.1016/j.jpurol.2016.06.008
MODEL
Journal of Pediatric Urology (2016) xx, 1
Response to letter to the editor re ‘Is routine excision of testicular remnants in testicular regression syndrome indicated?’ We read the response to our article from our esteemed colleagues with gratitude, as one of the main reasons for the publication of our series was to initiate debate within the paediatric surgical and urological community about this controversial topic. We are also grateful for the opportunity to answer their concerns. For the first concern that they raise about the lack of adult urological case reports, we couldn’t agree more, as we state in our discussion: ‘It is still unclear as to whether these remnants have a future malignancy risk, as there is only one case of intratubular germ cell neoplasia (ITGCN) in the literature and this was not immune-histochemically supported’. For their second concern there are a number of different points raised. The first is the use of an inguinal approach for our explorations. In all of our patients there was a clinically impalpable testicle pre-operatively; we feel this is different from the subgroup who have a scrotal remnant that can be palpated and who may indeed not even undergo surgical intervention. The scrotal approach to an orchidopexy has been described with great results for many years, and so the use of a scrotal approach for testicular regression syndrome (TRS) exploration is probably a valid approach, just not one that we use. The second is that all TRS specimens are within the scrotum, as they are secondary to a perinatal torsion event. We agree that the descended testicle does not become fixed in the scrotum until 2e4 months postnatally, and we have discussed this in our manuscript. The prenatal torsion theory for TRS is supported by the presence of haemosiderin-laden macrophages in the resected specimens, but it is worth noting that this is not the only proposed mechanism. In our series, 35% of specimens had this histological finding, including some of
the intra-abdominal TRS specimens. For this reason, although perinatal torsion no doubt does occur within the scrotum, it likely also occurs during inguinoscrotal descent. In our clinical experience, perinatal torsion usually presents postnatally with an enlarged, firm, non-tender intra-scrotal testicle rather than testicular remnant, as it is a late antenatal event. We welcome the debate on this topic as it will no doubt remain controversial. Although the natural history of the germ cells that we have found are unknown and they may regress with time, our data support their resection, as 10% had germ cells present. Although the risk of future malignancy is likely to be very low, it is absent post-resection. We have performed these inguinal explorations for a clinically impalpable testicle so there is no change in our operative management. For clinically palpable scrotal testicular remnants this is no doubt a different subgroup of patients, and the outcome of these patients is not answered by our series. Ramesh Mark Nataraja* Monash Children’s Hospital, Paediatric Surgery & Urology, 246 Clayton Road, Clayton, Melbourne, Victoria 3168, Australia Department of Paediatrics, Monash University, Clayton Campus, Melbourne, Australia Feilim L. Murphy Department of Paediatric Surgery & Urology, St George’s Heathcare NHS Trust, Blackshaw Road, London SW17 0QT, UK *Correspondence to: R.M. Nataraja, Monash Children’s Hospital, Paediatric Surgery & Urology, 246 Clayton Road, Clayton, Melbourne, Victoria 3168, Australia E-mail addresses: ram.nataraja@ monashhealth.org, [email protected] (R.M. Nataraja) Received 15 June 2016 Available online xxx
DOI of original article: http://dx.doi.org/10.1016/j.jpurol.2016.05.044. http://dx.doi.org/10.1016/j.jpurol.2016.06.008 1477-5131/ª 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Nataraja RM, Response to letter to the editor re ‘Is routine excision of testicular remnants in testicular regression syndrome indicated?’, Journal of Pediatric Urology (2016), http://dx.doi.org/10.1016/j.jpurol.2016.06.008