Original article
Clinical—testis
Testicular sparing surgery for small masses

https://doi.org/10.1016/j.urolonc.2009.12.021Get rights and content

Abstract

Objectives

To determine the proportion of benign testicular lesions among candidates for testicular sparing surgery (TSS) and to assess the safety and efficacy of this procedure.

Methods and Materials

Sixteen patients underwent surgical exploration for testicular tumors with TSS intent in our center. Surgery was performed via an inguinal approach with temporary cord occlusion and frozen section (FS) analysis of the lesions. Benign findings allowed for TSS, whereas cancer prompted total orchiectomy.

Results

The lesions measured 8–25 mm in the largest diameter. Eleven of the 16 lesions were benign (69%) and TSS was accomplished in these cases. Complete concordance was observed between the results of FS and permanent sections. Of the 5 patients with cancer, 3 had pure seminoma, and embryonal carcinoma and teratoma were found in 1 patient, each. Surveillance was applied in 4 of these patients, and chemotherapy was used in the patient with embryonal carcinoma. With an average follow-up duration of 48 months, all are alive and free of disease. All 11 patients in whom TSS was accomplished had an uneventful postoperative course, and with an average follow-up duration of 28 months, 9 have normal scrotal physical examination and ultrasound, whereas 2 patients were lost to follow-up.

Conclusions

Sixty-nine percent of testicular lesions under 25 mm are benign. TSS is safe and effective in patients with small benign lesions. Cancer is reliably detected by FS, and testicular exploration is not associated with local or distant recurrence in any of our patients.

Introduction

Radical orchiectomy has been the standard approach for solid testicular masses, offering both accurate diagnosis and adequate local control for primary tumors. Because over 90% of all palpable testicular tumors in adults are malignant [1], it is common practice to remove the entire testicle via the inguinal approach with no attempt to establish a histologic diagnosis before or during surgery. While this approach is reasonable for malignant tumors, removing the entire testicle in the case of small benign lesions is unnecessarily aggressive. Testicular sparing surgery (TSS) can be accomplished by careful dissection and resection of the mass from the normal surrounding testicular parenchyma. Partial orchiectomy appears to be safe and obviates the loss of a functional gonad with the subsequent emotional and physical related effects [2]. Contrary to the high proportion of cancer in all testicular masses, many of the small testicular lesions may be benign, making TSS an appealing alternative to radical orchiectomy in such cases [1], [3], [4], [5], [6]. Similarly, a high proportion of the nonpalpable testicular lesions are benign [7], [8], [9], [10].

Despite this, the best management of small testicular lesions remains controversial. Furthermore, the appropriate lesion size cutoff to guide whether to proceed with orchiectomy or TSS is undetermined, as are the reliability of frozen section (FS) analysis, and the clinical outcome of preserved gonads after partial orchiectomy.

Our aims were to determine the prevalence of benign testicular lesions in candidates for TSS, to assess the accuracy of FS examination, and to evaluate the clinical outcome of patients who have undergone TSS.

Section snippets

Patients and methods

In our institution, we retrospectively created a database on all patients who had undergone surgery for testicular tumors in the last 15 years. From that database, we identified 16 adult patients who underwent surgical exploration of a testis with TSS intent in our institution. In addition to these patients, TSS was also attempted in 2 other patients with solitary testicles and larger lesions (45 and 50 mm, respectively). Both patients had seminoma at FS analysis and, as the result, orchiectomy

Results

Of the 16 patients who underwent surgical exploration with TSS intent, benign lesions allowed for TSS in 11 (69%). FS correctly determined benign findings in all 11 patients in whom TSS was accomplished (100% accuracy). The clinical data and pathologic diagnosis of the 16 patients are shown in Table 1.

In 5 other patients in whom cancer was found during surgery, orchiectomy was completed. Histologic diagnoses in these patients included pure seminoma (3 patients), embryonal carcinoma and teratoma

Discussion

In this study, 69% of testicular tumors under 25 mm in size were benign, allowing for TSS. Partial orchiectomy was technically straight-forward, and no side effects were noted. Intraoperative diagnosis by FS analysis proved reliable and accurate in distinguishing between cancer and benign lesions, and this was used to direct the decision of orchiectomy versus TSS.

In the patients with cancer, deviation from the stringent principle of radical orchiectomy was not associated with local or distant

Conclusion

In contrast with the common knowledge that over 90% of all testicular tumors are malignant, the majority of small testicular masses are benign. TSS offers excellent local control for histologically proven benign testicular lesions, and it obviates the need to sacrifice an otherwise functional gonad.

Surgical exploration and FS examination should be used for all small testicular masses, and TSS may be applied when cancer is ruled out.

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