Surgical Teaching Video Cast on Scrotal Swellings

Surgical Teaching Video Cast
Introduction
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.Selvaraj MS;Mch;FICS
Professor of Surgery
Melaka Manipal Medical college
Melaka Malaysia 75150

Must to know core clinical problems
1.Acute RLQ pain
2.Acute RUQ pain
3.Acute epigastric pain
4.Acute LLQ pain
5.Dysphagia
6.Abdominal lumps
7.Upper GI haemorrhage
8.Lower GI haemorrhage
9.Obstructive Jaundice
10.Breast lumps, mastalgia & nipple discharge
11.Neck swellings- Thyroid & non thyroidal
12.Groin swellings
13.Scrotal swellings
14.Limb ischemia- Acute & Chronic
15.Varicose veins
16.Renal & ureteric colic
17.Hematuria
18.Acute retention of urine

Scheme for Problem oriented
Case based Teaching
Scrotal Swellings
Testicular
Carcinoma
Varicocele Hydrocele
Testicular
Torsion
Epididymal
Cyst

Scrotal Swellings-
Introduction
• Various causes( Differential diagnosis) of scrotal swellings
• Applied Anatomy & Physiology
• Algorithm to clinch the correct diagnosis
• Unique teaching video cast consisting powerful teaching tools
 Classical clinical vignette with probable diagnosis
 The diagnosis in detail- only one pathology in each episode
 Mind map of the diagnosis
 Tabular column of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis

Causes of Scrotal Swellings
ACUTE PAINFUL
• Torsion testis
• Acute epididymo-orchitis
• Torsion of testicular
appendages
CHRONIC PAINLESS
• Hydrocele
• Epididymal cyst
• Spermatocele
• Chronic epididymo-
orchitis
• Testicular tumor
• Varicocele

Scrotal contents
• Purse like arrangement for lodgement of Testis on either sides
with a midline septum separating.
• Contents are: Testis, Epididymis, Vas Deferens, Testicular artery,
Pampiniform plexus of veins, Artery to the Vas, Lymphatics,
Areolar tissue, & coverings.
• Coverings of Testis: Skin, Dartos, External Spermatic fascia,
Cremasteric fascia, Internal Spermatic fascia, Tunica Vaginalis
Testis – 2 layers

Thank You
To watch the video version go to
Channel
“ Surgical Educator” in You
Tube
https://www.youtube.com/watch?v=UAn0pL8qUvs

SCROTAL SWELLINGS
Case No:1

OVERVIEW
• Various causes( Differential diagnosis) of scrotal swellings
• Classical clinical vignette with probable diagnosis
• The diagnosis in detail- only one pathology in each episode
• Mindmap of the diagnosis
• Tabular column of differential diagnosis depicting their
diagnosis
• References and feedback

Classical Clinical Vignette
Vaginal Hydrocele
• A 35-year-old male patient presents with right sided scrotal swelling of
two years duration. It is a progressively increasing painless swelling.
• O/E: the right side of the scrotum shows a swelling of 15 × 10 cm size
which is confined to the scrotum (can get above the swelling). The
surface of the swelling is smooth and borders are well-defined. There is
no local rise of temperature. The swelling is fluctuant and
transilluminant. It is not reducible.There is no cough impulse. The
right testis is not felt separately. On percussion it is dull.
• The spermatic cord is felt above the swelling and is tender.
• The contralateral testis and genitalia are normal. There is no evidence
of any mass or lymph nodes in the abdomen

Hydrocele- Etiopathogenesis
• A hydrocele is an abnormal collection of serous fluid in a part of
the processus vaginalis, usually the tunica vaginalis.
• A hydrocele can be produced in four different ways
• 1. By excessive production of fluid within the sac in secondary
hydrocele
• 2. By defective absorption of fluid in primary hydrocele
• 3. By interference with lymphatic drainage of scrotal structures
in filariasis
• 4. By connection with the peritoneal cavity via a patent processus
vaginalis in congenital hydrocele

Primary Vs Secondary Hydrocele
Primary Hydrocele
• Defective absorption of fluid
• Ex: Vaginal & infantile
hydroceles
• Attain moderate to big size
• Difficult to palpate testis
• Transillumination positive
• Consistency tensely cystic
• Tx: Jaboulay’s & Lord’s
operations
Secondary Hydrocele
• Excessive production of fluid
• Ex: Filariasis, tumor, trauma &
epididymo-orchitis
• Attain small size
• Testis easily palpable
• Transillumination negative
• Consistency Lax cystic
• Tx: Treat underlying causes

Composition of Hydrocele Fluid
• Color—Straw or amber colored.
• Composition—Water, fibrinogen, inorganic salts, albumin
and cholesterol crystals
• Hydrocele fluid normally won’t clot if it is drained into a
container but will clot immediately even if it comes into
contact with a drop of blood
• Following swellings contain cholesterol crystals viz.
hydrocele, branchial cyst, and dental and dentigerous cyst

Primary Hydrocele- Types
• 1.Congenital hydrocele
• 2. Funicular hydrocele
• 3. Infantile hydrocele
• 4. Encysted hydrocele of the
cord
• 5. Vaginal hydrocele-
commonest type
• 6. Bilocular hydrocele
• 7. Hydrocele of the hernial sac

Primary Hydrocele- Clinical features
• Moderate to big size swelling
• Cough impulse negative
• Get above the swelling positive
• Not reducible
• Consistency tensely cystic
• Transillumination positive
• Testis not felt separately
• Congenital hydrocele Diurnal
variation +
• Bilocular hydrocele Cross
fluctuation +
• Encysted hydrocele Traction test+
• Get above the swelling negative in
Infantile and Bilocular hydroceles
• Transillumination negative in
Hematocele, Pyocele, Chylocele and
thick sac

Hydrocele of Canal of Nuck
• Hydrocele of the canal of Nuck
is a condition in females.
• The cyst lies in relation to the
round ligament and is always
at least partially within the
inguinal canal.

Primary Hydrocele- Clinical Pictures

Primary Hydrocele- Complications
• Infection
• Pyocele
• Hematocele
• Atrophy of testis
• Infertility
• Hernia of hydrocele sac (rare)
• Rupture & calcifications

Primary Hydrocele- Treatment
• Congenital hydrocele- Inguinal herniotomy
• Adult vaginal hydrocele
Small sizeLord’s plication
Large sizeJaboulay’s operation Incision and eversion of sac
After evacuation, the sac with the testis is placed in a newly
created pocket between the fascial layers of the scrotum
Sharma and Jhawer’s technique.
• Encysted hydroceleInguinal herniotomy + incision and
drainage of the encysted hydrocele

Complications of surgery
• Reactionary haemorrhage Hematocele
• Infection
• Pyocele
• Sinus formation
• Recurrent hydrocele

Scrotal Swellings Ex & Px Hx Sx Dx Tx
1. Hydrocele Primary-Idiopathic
Secondary- under
lying pathology
Painless big
swelling; not
reducible
No cough impulse
Get above swelling+
Transilluminant+
Clinical
In doubt- USG of
scrotum
Lord’s operation
Jaboulay’s
operation
2. Epididymal
cyst &
Spermatocele
Degenaration of
epididymis, occlusion
of pathway
Swelling in
scrotum resembles
3rd testis
Testis palpable
separately; Chinese
lantern appearance
Clinical
USG of scrotum
Conservative
Excision
3. Varicocele Idiopathic
Absence of valves in
testicular veins
Worm like in upper
scrotum; infertility
Disappears on lying
down; Bag of worms
appearance
Clinical
USG color doppler
Varicocelectomy
Inguinal or
Retroperitoneal
4. Testicular
torsion &
Epididymo-
orchitis
Abnormal fixation and
lie of testis
UTI & trauma
Severe pain&
swelling scrotum
Nausea & vomiting
Tender hemi scrotum;
cremasteric reflex
absent
Clinical
USG color doppler
Explore,detorse,
orchiopexy or
orchidectomy
Conservative
5. Testicular
carcinoma
UDT, Kieinfelter’s
Germ cell- Seminoma
& Non seminoma
Non germ cell tumor
Painless heavy
swelling
Not reducible
Hard in consistency
Testis felt separately
Clinical; No FNAC
USG OF scrotum
High orcidectomy
with or without
RPLND+ RT+CT
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)

References
• Hunt & Marshall’s clinical problems
in surgery 2nd edition
• Clinical surgery made easy- a
companion to PBL by Mohan De
silva 1st edition
• 100 cases in surgery 2nd edition
• Case files surgery 4th edition
• Clinical scenarios in surgery-
decision making 1st edition
• Surgery- a case based clinical
review 1st edition
• Surgery Review by Carlos Pestana
• Clinical surgery pearls by
Dr Dayananda Babu 2nd edition
• NMS casebook surgery 2nd edition
• General Surgery- Correlations &
clinical scenarios 1st edition
• Surgery review by Makary 3rd edition
• Surgery- Clinical cases uncovered by
Harold Ellis 1st edition
• Self- Life Surgery 1st edition

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SCROTAL SWELLINGS
Case No:2

OVERVIEW
• Various causes(Differential diagnosis) of scrotal swellings
• Classical clinical vignette with probable diagnosis
• The diagnosis in detail- only one pathology in each episode
• Mind map of the diagnosis
• Tabular column of differential diagnosis depicting their
diagnosis
• References and feedback

Classical Clinical vignette
Torsion Testis
• A 14-year-old boy presents with acute onset of right scrotal and
RLQ pain for the past 4 hours. He additionally reports nausea and
one episode of vomiting. He denies any similar past pain and
reports no history of trauma.
• O/E: the skin overlying the right side of the scrotum appears to be
slightly erythematous and edematous. The right testicle appears to
be lying significantly higher in the scrotum as compared to the left
testicle.
• The entire right testicle is exquisitely tender to palpation, whereas
the left one is nontender
• He has an absent cremasteric reflex on the right.

Torsion Testis- Etiopathogenesis
• Twisting of testis along with spermatic cordStrangulationNecrosis
• Common in neonates and in puberty
• Inversion of testis
• Strong muscular exertion or blunt trauma can trigger it
• Undescended testis undergo torsion frequently
• High insertion of tunica vaginalis- bell clapper deformity-predisposes
• There are 3 types of torsion- Extravaginal, intravaginal and mesorchial
• Extravaginal in neonates, intravaginal in adolescents

Torsion Testis- Types
In Neonates In Adolescents
Bell clapper
deformity

Torsion Testis- Clinical Features
• Sudden severe pain in hemiscrotum or both sides
• Nausea & vomiting
• Scrotal skin edematous and erythematous
• Testis exquisitively tender
• Affected testis at higher level because of twisting Deming’s sign
• Normal testis lying horizontally Angel’s sign
• Pain not relieved on elevation of scrotum Prehn’s sign
• Cremastric reflex absent in affected side

Torsion Testis- Clinical Features

Torsion Testis- Differential Diagnosis

Torsion Testis- Doppler USG
Central testicular blood flow Normal
Testis
No Central testicular blood flow but
excessive peripheral blood flow

• Ipsilateral side Exploration, detorsion and fixation orchiopexy
Detorsion is away from median raphae of scrotum like opening a
book
• Contralateral side Exploration and fixation orchiopexy
• In doubtful cases and nonavailability of Doppler USG Better to
explore rather than unduly delay the treatment
• Testicular salvage rate is 100% if surgery is done within 6 hrs
and it is 20% if surgery is delayed > 24 hrs
Torsion Testis- Treatment

• Hydatid of testis & epididymis Remnant of obliterated
Mullerian ducts
• Sudden Swelling and redness of hemiscrotum
• Tender Testis
• ‘Bluedot sign’ +ve
• Cremastric reflex intact
Torsion of Testicular appendages

“Blue dot sign”

• Explore & Excise torsed appendages in early cases
• In delayed cases >48 hrs conservative treatment with
antibiotics & anti inflammatory drugs
Treatment

• Inflammation of epididymis & Testis due to infection or
trauma
• Sudden onset of pain in a hemiscrotum
• Commonly associated with UTI or trauma
• Thickened & Tender epididymis
• Pain relief by elevation of hemiscrotum Prehn’s sign
• Can be treated conservatively with antibiotics and
antiinflammatory drugs
Acute epididymo-orchitis

Acute Epididymo-orchitis
Doppler USG
USG Scrotum
• Thickened Epididymis
• Reactive Hydrocele
• Thick scrotal wall
Doppler USG
• Excessive blood flow to
Epididymis
• Normal testicular parenchymal
blood flow

Scrotal Swellings Ex & Px Hx Sx Dx Tx
1. Hydrocele Primary-Idiopathic
Secondary- under
lying pathology
Painless big
swelling; not
reducible
No cough impulse
Get above swelling+
Transilluminant+
Clinical
In doubt- USG of
scrotum
Lord’s operation
Jaboulay’s
operation
2. Epididymal
cyst &
Spermatocele
Degenaration of
epididymis, occlusion
of pathway
Swelling in
scrotum resembles
3rd testis
Testis palpable
separately; Chinese
lantern appearance
Clinical
USG of scrotum
Conservative
Excision
3. Varicocele Idiopathic
Absence of valves in
testicular vein
Worm like in upper
scrotum; infertility
Disappears on lying
down; Bag of worms
appearance
Clinical
USG color doppler
Varicocelectomy
Inguinal or
Retroperitoneal
4. Testicular
torsion &
Epididymo-
orchitis
Abnormal fixation and
lie of testis
UTI & trauma
Severe pain&
swelling scrotum
Nausea & vomiting
Tender hemi scrotum;
cremasteric reflex
absent
Clinical
USG color doppler
Explore,detorse,
orchiopexy or
orchidectomy
Conservative
5. Testicular
carcinoma
UDT, Kieinfelter’s
Germ cell- Seminoma
& Non seminoma
Non germ cell tumor
Painless heavy
swelling
Not reducible
Hard in consistency
Testis felt separately
Clinical; No FNAC
USG OF scrotum
High orcidectomy
with or without
RPLND+ RT+CT
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)

References
silva 1st edition
review 1st edition
• Short practice of surgery by Bailey
and Love 26th edition
• Shelf life surgery 1st edition

ThankYou
To watch the video version go to
Channel
Surgical Educator in You Tube
https://www.youtube.com/watch?v=HqHEf0krIng

SCROTAL SWELLINGS
Case No:3

Classical Clinical vignette
Epididymal Cyst
• A 45 years old male patient presented with a swelling in right side
of the scrotum for last 3 years which is increasing very slowly in
size. There is no pain over the swelling.
• O/E: There is a soft cystic swelling in relation to the head of the
right epididymis. The swelling has a lobulated surface and feels
like a bunch of grapes.
• Testis can be felt separately from the swelling
• The swelling is brilliantly transilluminant and has Chinese
lantern pattern appearance

Epididymal Cyst- Etiopathogenesis
• These are cysts in connection with the epididymis divided into the
following types:
• 1. Degeneration cysts occur due to cystic degeneration of the
epididymis Epididymal cyst
• 2. Retention cysts due to obstruction of the sperm conducting
mechanism Spermatocele Ex: after vasectomy

Epididymal Cyst- Clinical Features
• Most epididymal cysts occur in males over the age of 40 years
• An epididymal cyst usually contains clear fluid
• The variety that contains slightly grey, opaque, ‘barleywater’-like fluid
and few spermatozoa is sometimes termed a Spermatocele
• They are often multiple or multilocular and are frequently bilateral
and feels like bunch of grapes
• Brilliantly transilluminant “Chinese lantern pattern”
• Testis palpable separately
• Cysts are connected to the head of the epididymis, so lie above the
testis 3rd testis

Epididymal Cyst- Clinical Features

Epididymal Cyst Vs Spermatocele

Epididymal Cyst - Treatment
• Single large cyst  Excision of cyst
• Recurrent or multilocular cyst Excision + partial or total
epididymectomy
• No role for aspiration because cysts are multilocular
• Spermatocele if big aspiration or excision; If small no
intervention

References
silva 1st edition
review 1st edition
• Surgery- Clinical cases uncovered by
Harold Ellis 1st edition
• Shelf life surgery 1st edition

ThankYou
https://www.youtube.com/watch?v=hZovqzif3ck

SCROTAL SWELLINGS
Case No:4

• 30 years male patient presented with a swelling in the left side of
the scrotum for last 4years. The swelling started in the lower part
of the scrotum and subsequently the swelling is slowly increasing
in size and grown up to the root of the scrotum. The swelling
disappears on lying down position and reappears on standing and
walking
• Patient complains of dull aching pain in the left side of the scrotum
for last 6 months, the pain is more towards the evening when the
swelling enlarges in size
• There is no pain abdomen, no urinary complaints

Varicocele
• O/E: A mass of dilated vein feeling like a bag of worms is palpable
on the left side of the scrotum along the left spermatic cord
extending from the upper pole of the testis up to the superficial
inguinal ring
• No expansile impulse on cough is palpable, instead a thrill is
palpable. On lying down and on elevation of the scrotum the
swelling disappears
• On asking the patient to stand up the dilated veins reappeared.
The left testicular volume is smaller than the right one. Abdominal
examination is normal

Varicocele-Anatomy
• Surgical Anatomy: Pampiniform plexus of veins (15 – 20) draining the
testis and epididymis makes the major bulk of the spermatic cord. As
they ascend, the number is reduced to 12 and on reaching the
superficial inguinal ring they unite to form 4 veins. At the level of deep
ring they are 2 in number and in retroperitoneum, it forms single
testicular vein.
• Left testicular vein drains into left renal vein and right testicular vein
into inferior vena cava

Varicocele
• Dilatation and tortuosity of the pampiniform plexus of veins
• Seen commonly in men aged 15-30yrs and rarely after 40yrs.
• Occur in 15-20% of all males and 40% of all infertile males.
• Normal vein diameter of vessels of plexus- 0.5-1.5mm. Diameter
greater than 2mm- Varicocele.

Varicocele
• It is common on the left side5 reasons.
Left testicular vein is longer than right testicular vein
Left testicular vein enters at right angle to the left renal vein
Left testicular artery is arching over left testicular vein
A loaded sigmoid colon compressing left testicular vein
Left renal vein is compressed b/w the Aorta and SMA

Varicocele- Etiology
• 1.Idiopathic/Primary – due to incompetency of valves. 98% occur on
the left side
• 2.Secondary
 Pelvic or abdominal mass.
 Lt renal cell carcinoma with tumor thrombus in left renal vein.
 Nutcracker syndrome- SMA compressing left renal vein. Other
conditions- Retroperitoneal fibrosis or adhesions

Varicocele- Bag of Worms Appearance

Varicocele- Clinical Features
• The patient may have aching or dragging pain particularly after
prolonged standing.
• It can be differentiated from an omentocele by the peculiar feel of the
bag of worms.
• Many varicoceles are asymptomatic and found incidentally
• It is more common on the left side for reasons stated above
• Infertility: Varicocele is often associated with infertility. The scrotal
temperature is usually higher in the presence of varicocele and this
may impair spermatogenesis

Varicocele- Clinical Features
• Bow sign- hold varicocele b/w thumb and fingers, patient is asked to
bow- reduced in size
• On lying down it gets reduced; On standing up it reappears
• Long standing cases- affected side testis is reduced in size and softer.
Testis size can be measured by Prader orchidometer
• No expansile cough impulse present, but thrill present while coughing

Varicocele- Grading
• Grade I: Small varicocele which is palpable only when patient performs
Valsalva maneuver (expiration against a closed glottis).
• Grade II: Moderate sized. Easily palpable varicocele without Valsalva’s
maneuver
• Grade III: Large varicocele visible through the scrotal skin.
• Grade IV : Very much dilated and tortuous veins

Varicocele- Investigations
• Venous color doppler of the scrotum and groin-
-standing/ valsalva’s manoeuvre
• USG abdomen to look for kidney tumours.
• Seminal analysis  Oligospermia or azospermia

Varicocele- Indications for Surgery
• American Urological Society recommends that varicocele treatment
should be offered to the male partner of a couple attempting to conceive
when all of the following are present.
• A varicocele is palpable.
• The couple has documented infertility.
• The female has normal fertility or potentially correctable infertility
• The male partner has one or more abnormal semen parameters or sperm
function test results.
• The indications in adolescents- presence of significant testicular
asymmetry (>20%) demonstrated on serial examinations, testicular pain,
and abnormal semen analysis results.

Varicocele- Treatment
• Asymptomatic varicocele—No treatment is required, only scrotal support
and reassurance
• Symptomatic varicocele—Excision of the pampiniform plexus in the
inguinal canal after ligating them. Testis still has venous drainage via the
cremasteric veins
• VARICOCELECTOMY- The most common approaches are
• Inguinal (groin)-easier and safer.
• Retroperitoneal (abdominal)
• Suprainguinal extraperitonial( Palomo’s operation)Open & Laparoscopic
• Scrotal approach- For Gr 4

Varicocele-
• Non-surgical procedure.
• Steel coil or silicone balloon catheter is introduced into a vein below
the groin through a nick in the skin.
• Passed under X-ray guidance.
• Tiny metal coils or other embolizing agents introduced through the
catheter.
• No stitches needed.
• Patient can go back in 24hrs.
• Lower rates of complications. Less effective, higher recurrence(5-11%),
danger that the coil could migrate to the heart and cause death
Coil Embolization,

Varicocele-Complications
• Haemorrhage and scrotal haematoma
• Infection Pyocele
• Injury to testicular artery
• Injury to ilioinguinal nerve and pain
• Recurrence—5-10%

ThankYou
https://www.youtube.com/watch?v=jFqZimnOWd0

SCROTAL SWELLINGS
Case No:5

• A 22-year-old male presents with a left scrotal mass. He notes that he
was playing soccer about 5 weeks ago and sustained mild trauma to
the left hemi scrotum at that time. The trauma prompted him to
palpate his testicle, at which time he noted the mass. The patient
states that he had mild pain initially that resolved on its own and
denies any hematoma.
• He denies any pain at this time. He states that the mass does not seem
to be increasing in size and that it is approximately the size of a large
almond. The mass, he notes, seems to be “in the middle” of his left
testis.

Testicular Carcinoma
• On review of symptoms he denies subjective fevers, chills, dysuria,
gross hematuria, or urethral discharge
• O/E:Physical examination reveals a firm 2 cm mass within the left
testis. There is no pain to palpation. There are no epididymal
masses bilaterally, and the right testis is normal to examination.
Abdominal exam reveals no masses and no hepatomegaly.
• There are no supraclavicular nodes and no gynecomastia
• Laboratory analysis reveals a normal urinalysis and complete
blood count.

Testicular Carcinoma-Epidemiology
• The most common malignancy to affect young men.
• There is a peak frequency in early childhood, and a larger peak
incidence between 20 and 35 years of age. Uncommon after age 40.
• Occurs in whites more than African-Americans.
• It is a curable cancer

Testicular Carcinoma-Risk Factors
• Men with cryptorchid (undescended) testes (intra-abdominal testes
with the highest risk). It is important to note that both testicles are at
risk.
• Surgical placement of the testis into the scrotum does not decrease
malignant risk, but facilitates surveillance.
• Testicular cancer in the contralateral testis
• Family H/O Testicular Cancer
• Klinefelter’s syndrome

Clinical features
• Painless enlargement of the testicle
• Firmness of the testicle; Lax Secondary hydrocele
• Back or abdominal pain secondary to retroperitoneal (inter-aortocaval)
lymphadenopathy.
• Weight loss. Lt supraclavicular LN +
• Enlarged retro peritoneal LN; Hepatomegaly;
• Dyspnea secondary to pulmonary metastasis.
• Gynecomastia secondary to hormonal secretions

Clinical features

Testicular Carcinoma- Classification

Testicular Carcinoma- Histology

Seminoma vs Nonseminoma

Testicular Carcinoma- Workup
• Testicular self-examination(TSE) or by a clinician
• USG of Scrotum
• CT scan/magnetic resonance imaging (MRI) of abdomen and pelvis to
assess for metastasis and lymphadenopathy
• Tumor markers—α-fetoprotein (AFP), human chorionic gonadotropin
(HCG), and lactic dehydrogenase (LDH).
• Tissue diagnosis- high inguinal orchidectomy (diagnostic &
therapeutic) – Chevassu maneuver
• Trans-scrotal biopsy – contraindicated

Testicular Carcinoma- USG Scrotum

Testicular Carcinoma-Tumor Markers
• AFP : Normal value < 16 ngm/ml; Half life 5 to 7 days; Raised in
 Pure embryonal Ca
 Terato Ca
 Yolk sac tumor
 Mixed tumor
 REMEMBER: AFP Not raised is Pure Choriocarcinoma or Pure
Seminoma

Testicular Carcinoma-Tumor Markers
• HCG: Normal value < 5 IU/ml; Half life 24 to 36 hrs; Raised in
 Chorio carcinoma  100%
 Embryonal carcinoma  60%
 Terato carcinoma  55%
 Yolk sac tumor 25%
 Seminomas  7%
• LDH: Normal value 105 to 333 IU/ L; Half life 1 day
 -Not diagnostic
 -prognostic marker
 - correlates tumor burden

Testicular Carcinoma- Treatment
Goals
• Treatment should be aimed at one level higher then the clinical stage
• Seminomas- radiosensitive
• Non seminomas- radio-resisitant hence best treated with surgery
• Advanced disease or mets- chemotherapy
• Radical inguinal orchidectomy is the standard first line therapy
• Lymphatic spread first to the RETRO-PERITONEAL NODES
• Early hematogenous spread rare
• Bulky tumors or metastatic tumors initially down staged with
Neoadjuvant chemotherapy

• Surgical approach: High radical inguinal orchiectomy
• Trans-scrotal biopsy of the testis or a trans-scrotal orchiectomy
should not be performed
• Early seminoma: Orchiectomy + retroperitoneal x-ray therapy (XRT).
• Advanced seminoma: Orchiectomy, and combination chemotherapy
followed by restaging
• Stage I nonseminoma: Orchiectomy + retroperitoneal lymph node
dissection (RPLND) or surveillance

• Stage II Nonseminoma: The optimal management of this group of
patients is controversial. RPLND can be curative but have a high
relapse rate. If relapse occurs, chemotherapy can be given as
adjunctive therapy. Alternatively, chemotherapy can be given prior to
RPLND
• Advanced stage Nonseminoma: Orchiectomy + chemotherapy ± tumor
reductive surgery.
• The most commonly used chemotherapeutic regimen: EBP (etoposide,
bleomycin, cisplatin).The prognosis of seminomas is excellent due
to its exquisite sensitivity to radiation!

Testicular Carcinoma - Mindmap

Scrotal Swellings- Diagnostic Algorithm

Testicular Carcinoma- Treatment Algorithm

ThankYou
https://www.youtube.com/watch?v=xz0ZbzgR0RM

Surgical Teaching Video Cast on Scrotal Swellings

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