Objective of our study was to define a diagnostic-therapeutic pathway for proper treatment of not-palpable testicular masses, that may be benign in 38% of cases. Since the intraoperative diagnosis is difficult to reach in particular in small lesion (< 8 mm) and the risk of tissue loss in frozen section analysis occurs frequently, we propose a diagnostic flow chart for the best management of small testis lesions. This proposed protocol has to be shown in details to physicians and patients, who must understand the clinical implications and the risk to undergo a second radical surgery. CLINICAL PROTOCOL TO NOT-PALPABLE TESTIS LESIONSWe present a diagnostic-therapeutic protocol for patients affected by not-palpable testicular masses, with maximum diameter lower than 15 mm and negative testicular markers. This approach follows our clinical practice. UltrasoundAll men underwent scrotal ultrasound in our hospital to confirm type, dimension and localization of the lesion. Ultrasound characteristics of the lesion were then verified at the confirmatory ultrasound by expert operator and last generation of ultrasound machine. If the lesion was not confirmed by confirmatory ultrasound or it is extra-testicular lesion, the patient was proposed for ultrasound follow-up. Once the small testicular mass was confirmed at our hospital, the therapeutic indication for all cases was testicular exploration with inguinal access. This technique can be associated to intraoperative ultrasound, equipped with linear probe, in order to obtain the relative certainty of the size of the nodule and negative surgical margins, which of course will be subsequently verified by the pathologist. In figures, we report ultrasound images of three cases of our who underwent surgery for epidermoid cyst (Figure 2), Leydig tumor (Figure 3), and seminoma (Figure 4). SurgerySurgical exploration, using intraoperative ultrasound was done without clamping the spermatic cord. The surgical technique involved the removal of the neoplastic nodule and 3 additional biopsies of the surrounding parenchyma (two distant and one next to the mass) sent for definitive histology. Smaller masses (< 8 mm) were usually sent for definitive histology, while larger masses (8-15 mm) were sent to the pathologist for intraoperative frozen sections. Pathologist confirmed size and completeness of surgical margins, by macroscopic view. If the nodule was large enough to be cut for frozen section, then a microscopic description of malignant pattern was reported.

Infection due to prostate biopsy afflicted more than 5% of patients and is the most common reason for hospitalization. A large series from US SEER-Medicare reported that men undergoing biopsy were 2.26 times more likely to be hospitalized for infectious complications within 30 days compared with randomly selected controls. The factors predicting a higher susceptibility to infection remain largely unknown but some authors have higlighted in the etiopathogenesis the importance of the augmented prevalence of ciprofloxacin resistant variant of bacteria in the rectum flora. We present one case of sepsis after transrectal prostate biopsy in a patient with history of pancreatic surgery. Based on our experience patients candidated to prostate biopsy with transrectal technique with history of recent major surgery represent an high risk category for infective complication. Also major pancreatic surgery should be consider an high risk category for infection. A transperineal approach and preventive measures (such as rectal swab) should be adopted to reduce biopsy driven infection. antibiotics presented 9 days after 12 core transrectal prostate biopsy. Ciprofloxacin 1000 mg extended release was given before biopsy according local guidelines (4), preoperative urine culture was negative. The patient was submitted in the June 2013 to cephalo-pancreatic-duodenectomy and reconstructive surgery due to a carcinoma of Vater papilla; surgical recovery was complicated by infection and treated with attention. During hospitalization he was treated with prolonged antibiotics (imipenem-cilastatin). We consider a review of the literature to establish factors associated with higher susceptibility to infection and to highlight possible relationship between pancreatic surgery and risk of infective complications during prostate biopsy. Pubmed search was performed using key words: prostate biopsy; urosepsis; pancreatitis and pancreatic surgery, 76 papers were retrieved and 25 were considered as pertinent to our aim. RESULTThe infective course showed 2 episodes of recurrence with fever and urine culture positive for E. coli with multidrug resistant. The first hospital admission: after an empiric therapy with ciprofloxacin the patient was treated with i.v. association (ceftriaxone and piperacillintazobactam) for 10 days, then discharged with oral antibiotics. After 15 days, the second hospital admission was due to fever (39°C) and urinary symptoms and the hospital stay was 5 days. Transrectal ultrasound was negative for abscess or significant post-void urinary residue. A second cycle of i.v. antibiotic association (ceftriaxone and piperacillin-tazobactam) resolved the fever. Further follow-up was uneventful. DISCUSSIONSeveral reports have recently suggested an increased rate of infective complications following transrectal prostate biopsy in both North America (5) and Europe (6). The reasons for this increase and the factors associated with a higher susceptibility to infection remain largely unknown. Based on our experience, candidates to transre...