Collaborative Review – Testis CancerOrgan-Sparing Surgery for Adult Testicular Tumours: A Systematic Review of the Literature☆
Introduction
Radical orchidectomy is currently considered the standard treatment for testis tumours of malignant or unknown origin [1], [2]. In the last 2 decades, however, due to the improvement in oncologic outcome and growing attention devoted to functional issues of cancer survivorship, the management of testis tumours has started to evolve in favour of conservative surgery, mirroring the current trend of organ preservation in the treatment of several other cancers [3].
Until the late 1980s, urologic surgeons followed the axiom that testes harbouring any suspicious mass had to be removed, based on the historically reported very low (<1%) prevalence of benign testis tumours and the belief that intraoperative biopsies in the presence of malignancy would invariably induce tumour seeding [4], [5]. Conversely, in the recent past, a higher proportion of histologically proven benign testis tumours has become apparent [6], [7] and frozen section examination (FSE) has achieved higher diagnostic accuracy, thus obviating the need for an immediate radical orchidectomy [8], [9]. Furthermore, the widespread use of high-frequency ultrasonography has led to a marked increase in the number of incidentally detected and small testis tumours, most of which have been shown to be benign [10]. Finally, there is growing awareness of the potential advantages of testis preservation over traditional extirpative surgery in terms of health-related quality-of-life issues, namely preservation of fertility, preservation of endocrine function thereby avoiding the risk of late-onset hypogonadism, and preservation of male body image [11]. The question has therefore emerged whether or not the entire testis needs to be sacrificed without exception in every case of a known or suspected malignancy.
The objective of the present review is to analyse systematically the cumulative evidence for testis-sparing surgery (TSS) as a treatment option for adult malignant tumours of different histology, including critical notes on operative technique, indications, complications, and oncologic and functional outcome.
Section snippets
Evidence acquisition
A systematic literature search using the Medline/PubMed database for full-length papers and including both medical subject heading and free text protocols was performed up to September 30, 2009. Entry terms were testi* sparing OR preserving surgery, hemiorchiectomy, partial orchidectomy, and testi* lesion OR mass OR neoplasm OR tumour OR germ cell cancer OR germ cell tumour OR seminoma* OR non seminoma* OR teratoma OR intraepithelial neoplasia OR carcinoma in situ OR gonadal stromal tumour OR
Evidence synthesis
The search generated 97 full-length papers and 2 congress abstracts. From the retrieved material, 68 relevant full-length papers and 2 congress abstracts were selected for final analysis. Two personal communications were also included. There are no randomised controlled trials comparing TSS and radical orchidectomy; only case reports and retrospective outcome studies on TSS are available (maximum level of evidence 2c).
Conclusions
The traditional dogma equating the diagnosis of any testis tumour to immediate radical orchidectomy has been challenged by the clinical experience accumulated in the last two decades.
Due to the low incidence of testis tumours and the long accrual time, no randomised controlled trials comparing TSS and radical orchidectomy are available and will hardly ever be conducted. However, increasing evidence from retrospective outcome studies with medium- and long-term follow-up suggests that TSS is a
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