Elsevier

European Urology

Volume 57, Issue 5, May 2010, Pages 780-790
European Urology

Collaborative Review – Testis Cancer
Organ-Sparing Surgery for Adult Testicular Tumours: A Systematic Review of the Literature

https://doi.org/10.1016/j.eururo.2010.01.014Get rights and content

Abstract

Context

According to current guidelines, radical orchidectomy is the standard treatment for testis tumours of malignant and unknown origin. Testis-sparing surgery (TSS) has recently been proposed as an alternative option in selected cases.

Objective

Our aim was to analyse the cumulative evidence for TSS in the treatment of adult malignant tumours of different histology, including notes on operative technique, indications, complications, and oncologic and functional outcome.

Evidence acquisition

A systematic literature search of the Medline/PubMed database for full-length papers reporting on TSS for adult malignant tumours was performed up to September 2009. Bibliographies of retrieved articles and review articles were also examined. Only those articles with complete data on operative technique, complications, and oncologic or functional outcome were selected. Furthermore, published abstracts at major urologic meetings in the last decade (1999–2009) and guidelines on testis cancer from major oncologic and urologic medical associations were searched and evaluated.

Evidence synthesis

No randomised controlled trials have compared TSS and radical orchidectomy; only retrospective outcome studies and case reports on TSS are available. In patients with small malignant germ cell tumours arising in both or in solitary testes, TSS coupled with local adjuvant radiotherapy ensures good oncologic control and is associated with a preserved endocrine function in most cases. In patients with small Leydig cell tumours, TSS can also be performed with elective indications (healthy contralateral testes), provided that pathology fails to reveal aggressive features. Finally, TSS is an option for patients with small ultrasound-detected, nonpalpable tumours even with elective indications because the incidence of benign definitive histology is high at approximately 80%. The overall complication rate is low (<6%). Data on exocrine and endocrine gonadal function, male body image, and health-related quality of life after TSS are still immature.

Conclusions

TSS can be safely adopted for the treatment of carefully selected cases of tumours of different histology. Prospective multicentre studies are warranted to further qualify TSS as a treatment option to be recommended as an alternative to radical orchidectomy and to explore the perceived functional advantages of testis preservation.

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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