Testicular sparing surgery for small masses

A Retrospective Analysis of 83 Patients with Testicular Mass Who Underwent Testis-Sparing Surgery: The Eurasian Uro-oncology Association Multicenter Study

INTRODUCTION

Herein, we analyzed the histopathological, oncological and functional outcomes of testis-sparing surgery (TSS) in patients with distinct risk for testicular cancer.

METHODS

This is a multicenter retrospective study on consecutive patients who underwent TSS. Patients were categorized in high- or low-risk testicular germ cell tumor (TGCT) according to the presence/absence of features compatible with testicular dysgenesis syndrome. Histology was categorized per size and risk groups.

RESULTS

TSS was performed in 83 patients (86 tumors) of them, 27 in the high-risk group. Fifty-nine patients had a non-tumoral contralateral testis present. Sixty masses and 26 masses were benign and TGCTs, respectively. No statistical differences were observed in mean age (30.9 ± 10.32 years), pathological tumor size (14.67 ± 6.7 mm) between risk groups or between benign and malignant tumors (p = 0.608). When categorized per risk groups, 22 (73.3%) and 4 (7.1%) of the TSS specimens were malignant in the high- and low-risk patient groups, respectively. Univariate analysis showed that the only independent variable significantly related to malignant outcome was previous history of TGCT. During a mean follow-up of 25.5 ± 22.7 months, no patient developed systemic disease. Local recurrence was detected in 5 patients and received radical orchiectomy. Postoperative testosterone levels remained normal in 88% of those patients with normal preoperative level. No erectile dysfunction was reported in patients with benign lesions.

CONCLUSION

TSS is a safe and feasible approach with adequate cancer control, and preservation of sexual function is possible in 2/3 of patients harboring malignancy. Incidence of TGCT varies extremely between patients at high and low risk for TGCT requiring a careful consideration and counseling.

What Is the Malignant Potential of Small (<2 cm), Nonpalpable Testicular Incidentalomas in Adults? A Systematic Review

CONTEXT

Unlike palpable lumps, a large number of nonpalpable testicular lesions found incidentally at ultrasound in asymptomatic postpuberal males are either benign tumours or non-neoplastic lesions. The prevalence of malignancy, however, is appraised based on small case series. Dedicated studies report a large number of patients, and systematic review articles are lacking.

OBJECTIVE

This systematic review is aimed to assess, from the analysis of the pooled data of the available literature, the incidence of benign tumours, malignant tumours, and non-neoplastic lesions, and to identify predictive characteristics for malignancy.

EVIDENCE ACQUISITION

A systematic review of PubMed, Scopus, Google Scholar, Turning Research Into Practice (TRIP) database, and the Cochrane Library was conducted on January 6, 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were retrieved reporting on adult asymptomatic men, with single, incidentally identified small testicular lesions, either fertile or infertile, with negative tumour markers and without specific risk factors for malignancy. Lesions ≤20 mm were considered small. Seventy-four studies were selected for inclusion in this analysis. Twenty-six additional publications have been retrieved by the bibliography quoted in the selected articles.

EVIDENCE SYNTHESIS

Pooled data of 1348 lesions in 1348 patients were collected. Of these lesions, 408 could be retrieved individually, 44.6% were benign, 27.2% were malignant, and 20.8% were non-neoplastic. Virtually all lesions <3 mm and 86.6% of lesions <5 mm were benign. Lesions >10 mm have a 38.14% probability of being benign. Hyperechoic lesions are likely benign. Fertility status does not affect the risk of malignancy.

CONCLUSIONS

Very small (<3 mm) and small (<5 mm) incidentally detected testicular lesions in asymptomatic postpuberal men with normal tumour markers could be frequently benign. More prospective studies are needed to better support this finding. Management strategies should be developed for these patients to reduce overtreatment.

PATIENT SUMMARY

Small testicular lesions are incidentally founded at ultrasound. It is not easy to distinguish a benign lesion from a malignant one. Results of this study are reporting a higher incidence of benign lesions with a diameter of <5 mm. More studies are needed to better understand the biology and the management strategy for small testicular lesions.

Prevalence and Management of Incidental Testicular Masses-A Systematic Review

Management of incidentally diagnosed small testicular masses (STM) is controversial. Although there is the risk of malignancy, it might be realistic to safely seek preservation of testicles bearing benign masses. This study aims to systematically evaluate the evidence regarding prevalence of STMs, their benign or malignant histology and their management. We conducted a systematic literature search for studies reporting small or incidental testicular masses and their management by radical orchiectomy, testis sparing surgery (TSS) or ultrasound (US) surveillance. We initially screened 2126 abstracts and from these, 57 studies met the inclusion criteria. Testicular masses were detected in 1.74% of patients undergoing US examination. Regarding STMs removed by surgery, 41.12% were benign. Intraoperative frozen section examination (FSE) is a reliable tool to discriminate between benign and malignant testicular masses (average 93.05% accuracy), supporting TSS. Benign lesions were associated with smaller diameter (<1 cm 68.78% benign), were often hypoechoic and exhibited regular margins on US. Conclusions: Small testicular masses are often benign. Clinical and US patterns are not accurate enough for including patients in surveillance protocols and TSS paired with FSE is pivotal for precluding the removal of testicles bearing benign lesions. Future research might unveil new imaging tools or biomarkers to support clinical management.

Testicular Lesions in Infertile Men

OBJECTIVES

An increasing number of incidental testicular tumors are diagnosed in patients during infertility workup. The aim of this study was to evaluate the accuracy of frozen section examination (FSE) for the management of these tumors.

METHODS

We retrospectively studied a series of 46 testicular tumors diagnosed during exploration for infertility from 2000 to 2019 and submitted for FSE.

RESULTS

A diagnosis of malignancy was made in 23 cases on both gross examination (yellow-white or cream-colored nodules for seminomas) and FSE, then confirmed on final diagnosis in 22 of the cases. One seminoma reported on FSE was revised as being a Leydig cell tumor. The 23 other lesions were diagnosed as benign on FSE, including 11 Leydig cell tumors (yellow-brown nodules), 2 Leydig cell hyperplasias, and 10 whitish fibrous lesions. All Leydig cell lesions were confirmed except 1, which was reclassified as a Sertoli cell tumor. Of the 10 cases of fibrous lesions, 6 were associated with malignancy.

CONCLUSIONS

The high incidence of Leydig cell tumors and the accuracy of FSE for these lesions demonstrate the interest in FSE. In contrast, FSE is not reliable for fibrous lesions, and surgeons should be aware that a fibrosis result often corresponds with regressed tumors.

Incidental testicular masses and the role of organ-sparing approach

OBJECTIVES

The widespread use of ultrasonography for the investigation of common urological conditions, such as infertility or pain, has resulted in an increased incidence of incidental non-palpable testicular masses. The majority of these are expected to be benign therefore a conservative approach, either active monitoring or organsparing approach, is recommended. However, there are no clinical or radiological parameters which define the exact nature of such lesions and optimal patient selection criteria are lacking. In this comprehensive review we discuss the significance of incidental, small testicular masses (STMs) and the role of organ-sparing approach in the management of these lesions.

MATERIALS AND METHODS

A non-systematic search was performed using PubMed to identify articles that covered the following topics; clinical implications at diagnosis, role of imaging in identifying the malignant capabilities of a lesion, role of surgery and the final pathology.

RESULTS

Incidental STMs are routinely identified following ultrasound examination of infertile men. STMs usually measure a few millimeters in size and the majority of these are benign. Therefore, strict follow up or an organ-sparing approach, with utilisation of frozen section analysis (FSA), is favored for STMs. FSA has a high correlation with final pathology and prevents unnecessary orchidectomies. Advances in imaging, namely ultrasound and magnetic resonance imaging may provide enhanced assessment of STMs and guidance intraoperatively.

CONCLUSIONS

The optimal approach is not well defined and there is no specific clinical parameter that can predict the nature of STMs. The increasing incidence of small, benign testicular masses has resulted in the development of organ-sparing surgery to investigate and manage these lesions. Organ-sparing surgery has been shown to be practical and carries excellent oncological outcomes.

Oncological and functional outcomes of testis sparing surgery in small testicular mass: a systematic review

INTRODUCTION

The prevalence of testicular tumor is constantly increasing, with an estimated incidence rate of about 3-10 new cases per 100,000 males/per year. Radical orchiectomy or testis sparing surgery (TSS) are recognized therapeutic approaches in these cases. However, the risk for hypogonadism and infertility is higher with the former compared with the latter. The aim of this systematic review is to evaluate the oncological outcome and testicular function (endocrine and reproductive aspects) in patients who had undergone TSS for small testicular lesions.

EVIDENCE ACQUISITION

To accomplish this, 684 articles were retrieved and screened; 24 retrospective and two prospective studies were selected and finally included in this systematic review.

EVIDENCE SYNTHESIS

Overall the TSS attempts were 1096 but TSS was definitively performed in 603 cases (55%). Frozen section examination was performed in 996 TSS attempts (22 out of the 26 studies selected) and showed a benign histology in 37-100% of cases, a malignant histology in 0-63%, and an inconclusive result in 0-16%, respectively. Five studies reported that a total of 22 patients were able to father after conservative surgery. None of these studies reported cases of hypotestosteronemia after surgery and a low prevalence (1.66%) of complications was associated with this type of surgery.

CONCLUSIONS

In conclusion, TSS showed to be safe and practicable if used according to the specific guidelines. It can be safely performed to treat recurrence eventually associated to local adjuvant radiotherapy when an intra-tubular neoplasia is present. Urologists can therefore consider TSS as an important means against testicular tumor in selected and well-informed patients.

Partial orchiectomy vs. radical orchiectomy for pediatric testis tumors

While radical orchiectomy remains the gold standard for testicular cancer, partial orchiectomy has become a well-accepted organ-sparing approach for benign testicular tumors in pre-pubertal patients. The aims of testicular-sparing surgery include prevention of over-treatment, preservation of future hormonal and reproductive function, and provision of a durable cure. For pre-pubertal patients, who have a high likelihood of benign lesions, partial orchiectomy provides effective treatment, owing to the high reliability of scrotal ultrasound (US) and intraoperative frozen section. In adolescent and young adult patients, who are more likely to harbor malignant pathology, the role of partial orchiectomy is less clear. Testis-sparing surgery is being reported with greater frequency in the adult literature for small testicular masses and for situations in which radical orchiectomy would result in an anorchia. More recently, a testis-sparing approach has also been described for carefully-selected post-pubertal pediatric patients. This review will highlight the role of partial orchiectomy in pediatric patients (<18 years old).

Organ-Sparing Surgery in Testicular Tumor: Is This the Right Approach for Lesions ≤ 20 mm?

Background: This study was conducted in order to analyze factors predicting malignancy in patients undergoing organ-sparing surgery (OSS) for small testicular lesions. Methods: Patients with small (≤20 mm) marker-negative clinical stage I testicular tumors were managed by OSS with tumor enucleation and frozen section examination (FSE) for the past 15 years at our institution. Benign and malignant cases were compared, focusing on preoperative and postoperative lesion sizes. Results: Eighty-nine patients were enrolled in this retrospective study. Ten (11.2%) of them were treated for synchronous bilateral tumors. Sixty-seven (67.7%) of ninety-nine lesions were benign, confirming a high concordance rate (98%) between FSE and final histology. Patients with benign tumors were significantly older than patients with malignant tumors (p = 0.026), and benign tumors were detected more frequently during urologic work-up of hormone disorders (p = 0.001). Preoperative tumor size was a strong predictor of malignancy (area under the curve (AUC) = 0.726; p < 0.001). According to the Youden index, the best cutoff to predict tumor dignity was 13.5 mm, resulting in a sensitivity and specificity of 53% and 85%, respectively. No cases of local recurrence or distant metastasis were confirmed after a median follow-up of 42 months. Conclusion: Our findings are consistent with previous reports, supporting an OSS approach in small testicular tumors whenever possible. Most tumors ≤ 20 mm were benign, and in the case of malignancy, OSS with FSE and consecutive orchiectomy is oncologically safe due to the high concordance rate of FSE and final histology, thus preventing a two-stage procedure.

Clinical presentation, management and follow-up of 83 patients with Leydig cell tumors of the testis: a prospective case-cohort study

STUDY QUESTION

When should ‘not so rare’ Leydig cell tumors (LCTs) of the testis be suspected, diagnosed, and treated?

SUMMARY ANSWER

LCTs are more frequent than generally believed, are associated with male infertility, cryptorchidism and gynecomastia, and should be treated conservatively (in compliant patients) with active surveillance, which appears to be a safe alternative to surgical enucleation.

WHAT IS KNOWN ALREADY

Increasing referrals for testicular imaging have led to an increase in findings of LCTs. The features and natural history of these tumors remain largely unknown, as the available studies are small and heterogeneous. LCTs were previously treated aggressively and follow-up data are lacking.

STUDY DESIGN, SIZE, DURATION

A case-cohort study of consecutive patients diagnosed with LCTs over a 10-year period was prospectively enrolled from 2009 to 2018 and compared to matched cohorts of patients with seminomas or no testicular lesions screened in the same timeframe.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 9949 inpatients and outpatients referred for scrotal ultrasound, a total of 83 men with LCTs were included. Enrolled subjects underwent medical history and clinical examination and were asked to undergo routine blood tests, hormone investigations (FSH, LH, total testosterone, estradiol, inhibin B, sex hormone-binding globulin (SHBG), prolactin), and semen analysis. Patients who consented also underwent contrast-enhanced ultrasound, elastography, gadolinium-enhanced scrotal magnetic resonance imaging, and hCG stimulation test (5000 IU i.m.) with serum total testosterone and estradiol measured at 0, 24, 48, and 72 hours.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 83 patients diagnosed with LCTs were compared against 90 patients diagnosed with seminoma and 2683 patients without testicular lesions (NoL). LCTs were diagnosed by enucleation (48.2%), orchiectomy (13.3%), or clinical surveillance (38.5%). Testicular volume, sperm concentration, and morphology were lower (P = 0.001, P = 0.001, and P < 0.001, respectively) in patients with LCTs than in the NoL group. FSH, LH, and SHBG were higher and the testosterone/LH ratio was lower in LCTs than in the NoL group (P < 0.001). The LCT group showed higher SHBG (P = 0.018), lower sperm concentration (P = 0.029), and lower motility (P = 0.049) than the seminoma group. Risk factors for LCTs were cryptorchidism (χ² = 28.27, P < 0.001), gynecomastia (χ² = 54.22, P < 0.001), and low testicular volume (χ² = 11.13, P = 0.001). Five cases were recurrences or bilateral lesions; none developed metastases during follow-up (median, 66 months).

LIMITATIONS, REASONS FOR CAUTION

This study has some limitations. First, hCG and second-line diagnostic investigations were not available for all tumor patients. Second, ours is a referral center for infertility, thus a selection bias may have altered the baseline features of the LCT population. However, given that the comparison cohorts were also from the same center and had been managed with a similar protocol, we do not expect a significant effect.

WIDER IMPLICATIONS OF THE FINDINGS

LCTs are strongly associated with male infertility, cryptorchidism, and gynecomastia, supporting the hypothesis that testicular dysgenesis syndrome plays a role in their development. Patients with LCTs are at a greater risk of endocrine and spermatogenesis abnormalities even when the tumor is resected, and thus require long-term follow-up and prompt efforts to preserve fertility after diagnosis.

LCTs have a good oncological prognosis when recognized early, as tissue-sparing enucleation is curative and should replace orchiectomy. Conservative surgery and, in compliant patients, active surveillance through clinical and radiological follow-up are safe options, but require monitoring of testicular failure and recurrence.

STUDY FUNDING/COMPETING INTEREST(S)

The project was funded by the Ministry of University and Research Grant MIUR 2015ZTT5KB. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

ALCeP trial (ClinicalTrials.gov Identifier: NCT01206270).

Organ-sparing procedures in GU cancer: part 2-organ-sparing procedures in testicular and penile tumors

PURPOSE

Organ-sparing surgery (OSS) is recommended in selected patients with testicular tumors and penile cancer (PC). The functional and psychological impacts of organ excision for these genital tumors are profound. In this review, we summarize the indications, techniques and outcomes of OSS for these two tumors.

METHODS

PubMed^® was searched for relevant articles up to December 2018. For Testicular sparing surgery (TSS) search, keywords used were; testicular tumors alone and in combination with "testicular sparing surgery", "partial orchiectomy" and outcomes. For penile conserving surgery (PCS), keywords used were: penile cancer alone and in combination with "penile conserving surgery", "partial penectomy" and outcomes. Because of the low quality of available evidence, a narrative rather that systematic review has been performed.

RESULTS

Indications of TSS are tumors ≤ 2 cm in solitary testis or bilateral tumors and no rete testis invasion. Prerequisites include normal testosterone and luteinizing hormone levels and patient compliance with follow-up. Indications for PCS are distal penile lesions with clinical stage ≤ T1. Adequate penile stump (3 cm) is required after surgery to maintain forward urine stream. Frozen section helps to reduce the risk of recurrence. Local recurrence after PCS is not associated with reduced survival and can be managed with another PCS in selected patients. The reported oncological and functional outcomes following TSS and PCS are adequate.

CONCLUSIONS

In properly selected patient OSS in testicular and penile tumors has a comparable oncological outcome to total organ excision with added advantages of preserving organ function and psychological well-being.

Testis-sparing surgery for testicular masses: current perspectives

INTRODUCTION

Males who present with a palpable testis nodule are likely to have malignant germ cell tumor in >90% of cases. Therefore radical orchiectomy remains the standard of care for intratesticular tumors. However, due to the recent developments of high-frequency probes in ultrasonography, the incidence of detecting a small non-palpable testis tumor is higher and higher. These lesions are thought to be benign in more than 60-80% of cases, thus a radical orchiectomy should be considered an overtreatment. In addition to that, radical orchiectomy might cause infertility, psychological issues and endocrine disorders, hence an organ-sparing procedure in such cases should be pursued.

EVIDENCE ACQUISITION

Only fourteen reliable retrospective studies met the inclusion criteria. No prospective randomized trials have appeared in Medline database.

EVIDENCE SYNTHESIS

This review of the current literature has confirmed the safety and efficacy of testicular-sparing surgery in selected patients: 1) monorchid patients; 2) bilateral testis masses; 3) normal patients with a small, non-palpable masses detected with US, as long as the dimension of the lesion is up to 3 cm and not greater that 30% of the total volume of the organ.

CONCLUSIONS

According to the literature, testis sparing surgery is a safe and feasible procedure for patients presenting a benign small testis mass. The enthusiasm found in the literature should however be tempered as the small number of patients reported in the studies coupled with the absence of a prospective trial represent important limits that need to be overtaken. Therefore more robust and well-designed studies are needed.

Germ Cell Neoplasia in situ (GCNIS) in Testis-Sparing Surgery (TSS) for Small Testicular Masses (STMs)

Purpose: The testis-sparing surgery (TSS) is surgical technique accepted for small testicular masses (STMs). Frozen section examination (FSE) is an essential assessment at the time of TSS. The aim of this study is to measure the maximum distance of the foci of ITGCN from STMs. Methods: In our hospital between June 2010 and October 2017 a total of 68 patients with STM underwent a TSS. All the testis specimens were totally embedded and processed via the whole-mount method and a diagnosis of germ cell tumor with GCNIS were made. The distance between STMs and GCNIS were calculated by two pathologists directly on the slides considering for the third dimension the number of the paraffin blocks in which the foci of GCNIS were found. Results: The STMs were classic seminoma in 62 out 68 cases, embryonal carcinoma in 4 cases, while in 2 case a diagnose of mixed germ cell tumor were made. The size of the STMs was between 0.5 and 2 cm and the foci of GCNIS were observed in seminiferous tubules very closed to SMTs or as skip lesions in the surrounding testicular parenchyma, dispersed in normal testis. In 48 out of 68 cases (70.5%) foci of GCNIS were at the distance from SMTS of 1.5 cm or below and in 60 out of 68 cases (88%) at the distance of 2 cm or below The distance of GCNIS from the STMs was not related to the histological subtype of the germ cell tumor, while there is a linear correlation between size of the STMs and the distance of foci of GCNIS (p = 0.0105; r = 0.9167). Conclusion: Our data showed that foci of ITGCN were not observed beyond 2.5 cm from the STM. In particular we demonstrated that exist a linear correlation between size of STMs and distance of the foci of GCNIS from STMs (p = 0.0105; r = 0.9167). In conclusion mapping the tissue around the tumor not randomly but in targeted areas could reduce the false negative biopsies of the testis with GCNIS, increasing the radicality of the TSS procedure.

Testis sparing surgery for small testicular masses and frozen section assessment

Introduction

We present our experience with patients who had suspected testicular masses, managed by a frozen section assessment and testicular sparing surgery.

Material and methods

We performed a retrospective review of all patients over the last 5 years, who underwent a frozen section assessment and testicular sparing surgery for small testicular lesions. The frozen section assessment was compared with the final histology.

Results

Twelve patients were identified. The mean age of patients was 40 years (22–58 years). The mean lesion size was 9.8 mm (3–18 mm). Presentations varied: a testicular lump was palpable in 7 patients and 3 patients were referred due to infertility with a subsequent ultrasound, which showed incidental testicular lesions. Two patients presented with testicular pain. Tumour marker levels were within the normal limits in all patients.

The frozen section assessment correctly determined 10 out of 12 (83%) lesions, showing 1 (8%) lymphoma, 2 (17%) seminomas, 3 (25%) fibrosis, 3 (25%) low-grade Leydig cell tumours and 1 (8%) adenomatous tumour. The frozen section reported a benign epidermal cyst in 1 case, whilst the final histology showed a pre-pubertal type teratoma, a rare and low risk tumour. One patient (8%) had an indeterminate lesion, which proved to be a benign adenomatous tumour on final histology. All malignant cases were correctly identified.

There was no malignancy in 9 out of 12 (75%) patients therefore they had testicular sparing surgery. Three patients had orchidectomy, two due to a seminoma and one due to an indeterminate lesion. One patient developed a postoperative haematoma requiring antibiotics but there were no other complications.

Conclusions

Our findings demonstrate that partial orchidectomy with a frozen section assessment is useful in small testicular masses and testicular sparing surgery can be considered in order to prevent a radical orchidectomy in selected patients.

Testis-sparing surgery: Experience in 13 patients with oncological and functional outcomes

INTRODUCTION

We present oncological and functional outcomes of patients who underwent testis-sparing surgery (TSS).

METHODS

Overall, 13 patients were included. Mean patient age was 29.9±12.5 years. In five patients, TSS was performed for sequential bilateral testicular tumours. One patient underwent concurrent left radical orchiectomy and right TSS. In eight patients with normal contralateral testis, seven underwent left and one underwent right TSS.

RESULTS

Mean pathological tumour size was 14.6±12.5 mm. Intraoperative frozen section evaluation of the mass was performed in eight patients that revealed benign lesions. No intraoperative tumour bed biopsies were taken in this patient group. Regarding the remaining five patients, intraoperative tumour bed biopsies were taken and testicular intraepithelial neoplasia (TIN) was reported in two (40%) patients; no local testicular radiotherapy was given postoperatively. Tumour pathology was malignant in all but one lesion, including Leydig cell tumour (n=1), seminoma(n=2), embryonal carcinoma (n=1), and adenomatoid tumour (n=1). During 47.2±22.5 months of followup, local recurrence was detected in one patient who underwent radical orchiectomy. No additional local recurrence or systemic metastasis was identified in other patients with malignant lesions. For patients with malignant tumours, of the three patients with a normal preoperative testosterone levels, testosterone level was normal in one patient (with no erectile dysfunction [ED]) and was decreased in two patients (with ED) following TSS. No ED was reported in the nine patients with benign lesions.

CONCLUSIONS

In carefully selected cases, TSS appears to be a safe, feasible procedure with adequate cancer control that could preserve sexual function.

Paratesticular Fibrous Pseudotumors

Paratesticular fibrous pseudotumors (PFPs) are rare pathologies with quite wide and variable topographic-morphological features. It is difficult to distinguish PFPs from malignant masses. Treatment can be done by resection of the mass. We reported a young patient’s findings about this rare pathology.

Organ-sparing surgery for testicular tumours

PURPOSE OF REVIEW

Testicular cancer represents the majority of testicular masses, and radical orchiectomy is still considered the standard-of-care. Testis-sparing surgery (TSS) can be an alternative to radical surgery in patients with small testicular tumours, bilateral or solitary testis masses. The aim of this manuscript is to review the current indications, oncological and functional outcomes of TSS.

RECENT FINDINGS

Our review confirmed that literature lacks studies with a high level of evidence on comparing TSS with radical surgery. Indications for TSS are controversial, specifically for patients with normal contralateral testis. For nonpalpable testicular masses less than 2 cm, bilateral tumours and solitary testis mass, TSS seems to be a viable treatment option. Frozen-section examination is a critical tool for assessment at the time of TSS that allows for diagnosis of benign from malignant tumours and evaluation of margin. TSS has been shown to be associated with less fertility alterations, hormonal deficit and potential lower impact on sexual and psychosocial aspects. Intermediate to long-term follow-up results have not revealed any significant risk of local and/or distant recurrences after TSS.

SUMMARY

TSS is well tolerated and feasible for selected patients with testicular mass without compromising oncological and functional outcomes. Further studies with a higher level of evidence are needed to confirm these findings.

Fibrous pseudotumors of the testis: The balance between sparing the testis and preoperative diagnostic difficulty

OBJECTIVE

To determine a paradigm that will be helpful for urologists to manage fibrous pseudotumors, which are a very rare condition of the testis.

MATERIAL AND METHODS

We retrospectively evaluated the patients with fibrous pseudotumors in our uropathological database from 1995 to 2013. Patients who had tumor markers and ultrosonography (USG) screening before surgery and a final pathology report of a fibrous pseudotumor were included in the study.

RESULTS

In total, 838 patients with a testis mass were evaluated. Only 6 of these patients met the inclusion criteria. The mean age was 34 years (min: 20, max: 72). Serum tumor markers were in the normal range for all patients. The scrotal tumors were not clearly related to the testis parenchyma, and the radiologists could not definitively determine the nature of the masses (benign or malignant). A concomitant hydrocele was detected in 2 patients. After inguinal exploration, radical orchiectomy was performed in one patient with an ipsilateral atrophic testis, and biopsies were taken from the lesions for frozen section analysis in the other 5 patients. Pathologists reported benign tumors for all of these patients based on the frozen sections, and testicular sparing surgery was then performed in these 5 patients.

CONCLUSION

If scrotal tumors are detected by ultrasonography in patients with normal tumor markers, and the tumor cannot be clear distinguished from the testis, these patients might have a fibrous pseudotumor, and organ-sparing surgery can be performed on these patients.

Testis-Sparing Surgery in Small Testicular Masses Not Suspected to Be Malignant

Fifteen patients with small testicular masses not suspected to be malignant were included in the study, and permanent and frozen section analyses were evaluated. As a result frozen analysis, preoperative externalization of the suspected malignancy with a physical examination, ultrasonographic evaluation, and serum tumor marker analysis were concluded as key points for accurate decision making between TSS and radical orchiectomy.

BACKGROUND

We aimed to determine the safety, efficacy, and the concordance of permanent and frozen section analysis (FSA) of testis-sparing surgery (TSS) in patients who had small testicular masses that were not suspected to be malignant.

PATIENTS AND METHODS

Fifteen patients who underwent TSS were included in the study. TSS was performed for the patients who had testicular lesions <25 mm and testicular lesion volume <30% of the whole testis. All patients had normal serum tumor marker levels and ultrasonographic evaluation did not indicate malignancy. Surgery was performed via an inguinal approach with temporary cord occlusion and FSA of the lesions. Benign findings allowed for TSS, and cancer prompted total orchiectomy.

RESULTS

The mean patient age was 25.33 (range, 20-36) years. The predominant complaint was swelling (9 patients). The mean lesion diameter was 16 mm (range, 5-26 mm). Fourteen of all cases (93%) had benign pathology and underwent TSS. Only 1 patient, whose FSA revealed malignant formation, underwent radical orchiectomy. Final pathology of this patient was seminoma. Complete histopathologic concordance was observed between the results of frozen and permanent sections. TSS was performed with no intra- or postoperative complications. After a mean follow-up of 23 months (range, 6-44 months) all patients, except 3 who were lost to follow-up, were free of disease.

CONCLUSION

The main key points for accurate decision-making between TSS and radical orchiectomy are intraoperative FSA and preoperative externalization of possible suspected malignancy with physical examination, ultrasonographic evaluation, and serum tumor marker analysis.

The role of testis-sparing surgery in children and adolescents with testicular tumors

Organ-sparing approaches have been applied to the treatment of a variety of urologic tumors in both the realms of adult and pediatric urology, with the goals of minimizing overtreatment of benign lesions, preserving function, and providing durable cure. The predominance of benign tumors in prepubertal patients and the reliability of both ultrasound and intraoperative frozen sections have resulted in a marked shift toward testis-sparing approaches over the last few decades. The role of testis sparing in the adolescent population is presently unclear, although there have been increasing reports of successful organ-sparing surgery for testis tumors in the adult literature. This review presents recent trends in testis-sparing approaches for both pediatric and adolescent patients, the operative technique, and some of the controversies related to testis-sparing surgery.

Fourteen-year experience with the intraoperative frozen section examination of testicular lesion in a tertiary university center

Most testicular tumors are germ cell neoplasias. The number of incidentally detected small-sized, nonpalpable testicular lesions is increasing with the use of high-frequency ultrasound for infertility or trauma. These lesions are benign in 80% of cases and can be treated by organ-sparing surgery on the basis of frozen section examination (FSE). We assess the reliability of FSE in testicular and paratesticular lesions and its possible impact on surgical management. We performed a retrospective review of intraoperative FSE in testicular/paratesticular lesions at Geneva University Hospital during a 14-year period. A total of 170 cases were identified, with 159 testicular and 11 paratesticular lesions. The FSE results, permanent sections, and orchiectomy slides were reviewed and compared. Frozen section examinations were reported to be benign in 9 paratesticular and in 43 testicular lesions, and malignant in 2 paratesticular and 105 testicular lesions. Comparing FSE and final diagnosis, FSE correctly identified all nontumor lesions. There was a failure rate of 3.5% to identify tumor. Specificity was 100%, sensitivity was 95%, positive predictive value was 100%, and negative predictive value was 89%. Frozen section examination is a highly sensitive and specific intraoperative procedure, which allows to differentiate between benign and malignant testicular and paratesticular lesions, with a possibility of organ-sparing surgery when they are benign.

Role of testis sparing surgery in the conservative management of small testicular masses: oncological and functional perspectives

INTRODUCTION

Radical orchiectomy (RO) is still considered the standard of care for malignant germ cell tumours, which represent the vast majority of the palpable testicular masses. In those patients diagnosed with small testicular masses (STMs), testis-sparing surgery (TSS) could be an alternative treatment to RO. The aim of this updated review is to evaluate the current indications for TSS, and discuss the oncological and functional results of patients who had undergone organ-sparing surgery for STMs.

EVIDENCE ACQUISITION

A non-systematic review of the Literature using the Medline database has been performed, including a free-text protocol using the terms "testis-sparing surgery", "testicular sparing surgery", "partial orchiectomy", "testis tumour", "sex cord tumour", and "testis function". Other significant studies cited in the reference lists of the selected papers were also evaluated.

EVIDENCE SYNTHESIS

No randomized controlled trials comparing TSS with radical orchiectomy have been reported yet. In those patients with normal contra-lateral testis, the use of TSS is still controversial. In selected cases of gonadal masses < 2 cm, TSS seems to be a safe and feasible treatment option. Frozen section examination allows us to discriminate between benign and malignant neoplasms during TSS. Intermediate and long-term follow-up results showed no significant risk of local and distant recurrences in the main series reported in the literature.

CONCLUSIONS

TSS is an effective treatment for STMs in selected patients, limiting the unnecessary surgical over-treatments, without compromising the oncological and functional outcomes. Further studies are needed in order to confirm the oncological safety.

Focal Surgery in Testis Cancer: Current State of the Art

Radical orchiectomy is the standard treatment of testicular neoplasia causing androgen insufficiency, infertility and psychological stress. Focal surgery allows the preservation of fertility, endocrine function and integrity of the genital anatomy, with preservation of the image of the male body.

The EAU guidelines suggest focal surgery in case of synchronous bilateral tumours, metachronous contralateral tumours, tumour in solitary testis with normal pre-operative testosterone levels, when the tumour volume is less than 30% of the testicular volume.

There are two focal surgical techniques: tumorectomy and polar resection, followed by biopsies and frozen section of the resection bed. In case of benign tumours, the treatment is often curative. In case of malignancy, carcinoma in situ is frequently found in the surrounding tissues. Adjuvant treatment with chemotherapy or radiotherapy is performed with a fair success rate.

These adjuvant treatments reduce or delete the functional benefits achieved by conservative surgery. The evidence of the literature suggests that focal surgery is a valid option for all patients with testicular tumours that are not palpable and small sized, with the advantage of avoiding unnecessary radical orchiectomy in most of cases.

Therefore, the selection criteria for focal surgery are the mass size (less than 25 mm) and a safety distance of the tumor from the rete testis, in order to preserve testicular vascularization.

A close follow-up with ultrasound, testicular markers and radiological examinations is mandatory in case of germ cell neoplasia treated conservatively in patients with indications for conservative surgery.

The predominance of benign histology in small testicular masses

OBJECTIVES

To evaluate the concordance between testicular tumor size and benign histology in order to identify a cut-off size, below which the rate of benign lesions would be highest.

METHODS AND MATERIALS

During the years 1995-2008, we performed 131 consecutive testicular operations for testicular tumors. Ten of these were testicular preserving surgery, whereas the other 121 patients had radical orchiectomy. We searched for the rate of benign lesions in the following 3 groups of tumor diameter: 10 mm or less, 11-20 mm, and greater than 20 mm. ROC analysis was used to find the optimal size cut-off below which the rate of benign lesions would be highest.

RESULTS

Benign lesions were found in 11 patients (8%), including epidermoid cyst (n = 4), Leydig cell tumor (n = 3), fibrosis (n = 1), adenomatoid tumor (n = 2), and 1 patient with a simple cyst. Small tumor size strongly correlated with benign histology. The mean diameter of benign vs. malignant lesions was 15 mm and 41 mm, respectively (P < 0.05). The rate of benign lesions in tumors with a diameter of 10 mm or less, 11-20 mm and greater than 20 mm was 50%, 17%, and 2%, respectively. Receiver Operating characteristic (ROC) analysis with 87% sensitivity and 83% specificity revealed a cut-off value of 18.5 mm tumor diameter below which the proportion of benign lesions was 38.5% compared with 2% above it (P < 0.05).

CONCLUSIONS

While benign lesions comprise only 8% of all testicular tumors, their proportion among small lesions is much higher. With a size cut-off of 18.5 mm, 38.5% of smaller lesions are benign. These findings support consideration of testicular exploration for small testicular lesions aiming at preservation rather than predetermined radical orchiectomy.