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Saltzman AF, Hensley P, Ross J, Woo L, Billmire D, Rescorla F, Puri D, Patel S, Pierorazio P, Bagrodia A, Cary C, Cost NG. Critical elements of pediatric testicular germ cell tumors surgery. Semin Pediatr Surg 2023; 32:151343. [PMID: 38006835 DOI: 10.1016/j.sempedsurg.2023.151343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
Children, adolescents and young adults with testicular germ cell tumors require appropriate surgical care to insure excellent outcomes. This article presents the most critical elements, and their basis in evidence, for surgery in this population. Specifically, the importance of inguinal radical orchiectomy for malignant tumors, partial orchiectomy for prepubertal tumors and normal serum tumor markers, and the appropriate use of post-chemotherapy retroperitoneal lymph node dissection in those with residual retroperitoneal masses.
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Affiliation(s)
| | - Patrick Hensley
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Jonathan Ross
- Department of Urology, Rush University, Chicago, IL, USA
| | - Lynn Woo
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Deborah Billmire
- Department of Pediatric Surgery, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Frederick Rescorla
- Department of Pediatric Surgery, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Dhruv Puri
- Department of Urology, University of California San Diego, La Jolla, CA, USA
| | - Sunil Patel
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Aditya Bagrodia
- Department of Urology, University of California San Diego, La Jolla, CA, USA
| | - Clint Cary
- Department of Urology, Indiana University, Indianapolis, IN, USA
| | - Nicholas G Cost
- Division of Urology, Department of Surgery at the University of Colorado School of Medicine, Aurora, CO, USA; The Surgical Oncology Program, Children's Hospital Colorado, Aurora, CO, USA.
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Prevalence and Management of Incidental Testicular Masses-A Systematic Review. J Clin Med 2022; 11:jcm11195770. [PMID: 36233639 PMCID: PMC9573452 DOI: 10.3390/jcm11195770] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/07/2022] [Accepted: 09/27/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Grogg JB, Dursun ZH, Beyer J, Eberli D, Poyet C, Hermanns T, Fankhauser CD. Oncological and functional outcomes after testis-sparing surgery in patients with germ cell tumors: a systematic review of 285 cases. World J Urol 2022; 40:2293-2303. [PMID: 35821265 PMCID: PMC9427883 DOI: 10.1007/s00345-022-04048-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/07/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES In several urogenital cancers, organ-preserving surgery represents the preferred treatment approach, but in patients with testicular germ cell tumors (tGCTs), radical orchiectomy represents the standard of care. This study aimed to summarize published case series assessing oncological and functional outcomes after testis-sparing surgery (TSS) in patients with tGCTs. MATERIALS AND METHODS A systematic literature review and individual patient data meta-analysis were conducted of published cases with tGCT treated with TSS. RESULTS Of 2,333 reports, we included 32 reports providing data on 285 patients, including 306 testicles treated with TSS. Adjacent germ cell neoplasia in situ (GCNIS) was described in 43%. Hypogonadism and infertility after TSS were diagnosed in 27% and 18%. In patients undergoing adjuvant testicular radiotherapy, hypogonadism was diagnosed in 40%. Patients treated with adjuvant testicular radiotherapy after TSS exhibited a significantly lower incidence of local recurrence (2% vs. 50%, p < 0.001). Distant metastases after TSS were observed in 2%. CONCLUSION The current data questions the benefits of TSS in tGCT patients. If at all, TSS should only be offered to well-informed patients with a singular testicle, excellent compliance, a singular tumor less than 2 cm located at the lower pole of the testicle, and normal preoperative endocrine function. Unless patients plan to father a child within a short time frame, adjuvant testicular radiotherapy should be recommended after TSS. Radical orchiectomy remains the standard of care, but future studies may support the use of TSS in selected men.
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Affiliation(s)
- Josias Bastian Grogg
- grid.7400.30000 0004 1937 0650Department of Urology, University of Zurich, Zurich, Switzerland
| | - Zeynep Hafza Dursun
- grid.7400.30000 0004 1937 0650Department of Urology, University of Zurich, Zurich, Switzerland
| | - Joerg Beyer
- grid.5734.50000 0001 0726 5157Department of Oncology, Inselspital Bern, University of Bern, Bern, Switzerland
| | - Daniel Eberli
- grid.7400.30000 0004 1937 0650Department of Urology, University of Zurich, Zurich, Switzerland
| | - Cedric Poyet
- grid.7400.30000 0004 1937 0650Department of Urology, University of Zurich, Zurich, Switzerland
| | - Thomas Hermanns
- grid.7400.30000 0004 1937 0650Department of Urology, University of Zurich, Zurich, Switzerland
| | - Christian Daniel Fankhauser
- grid.7400.30000 0004 1937 0650Department of Urology, University of Zurich, Zurich, Switzerland ,grid.413354.40000 0000 8587 8621Department of Urology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
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Ory J, Blankstein U, Gonzalez DC, Sathe AA, White JT, Delgado C, Reynolds J, Jarvi K, Ramasamy R. Outcomes of organ-sparing surgery for adult testicular tumors: A systematic review of the literature. BJUI COMPASS 2021; 2:306-321. [PMID: 34568872 PMCID: PMC8462801 DOI: 10.1002/bco2.77] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective To perform a systematic review on the effects of testicular sparing surgery (TSS) on the oncological, functional, and hormonal outcomes of adults with testicular tumors. Methods A literature search was performed after PROSPERO registration (CRD42020200842) and reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methods. We conducted a systematic search of Medline (Ovid), Embase, Cochrane CENTRAL, CINAHL, Scopus, Web of Science, ClinicalTrials.gov, and the WHO/ICTRP from inception to November 20, 2020. Manuscripts and published abstracts were included if they involved testis-sparing surgery (TSS) and contained data on any outcomes related to fertility, hormonal parameters, or oncological control, or if they evaluated surgical technique. Results Our initial search yielded 3,370 manuscripts, with 269 of these screened for full-text eligibility. After our exclusion criteria were applied, 32 studies were included in the final analysis. Oncological outcomes were obtained from 12 studies (average follow-up 57.8 months), functional data from 26 studies (average follow-up 49.6 months), fertility information from 10 studies (average follow-up 55.8 months), and data on nonpalpable tumors from 11 studies (average follow-up 32.1 months). Oncological control appears to be excellent in studies that reported these outcomes. Presence of germ cell neoplasia in situ was controlled with adjuvant radiation in nearly all cases. Functional outcomes are also promising, as development of primary and compensated hypogonadism was rare. Semen parameters are poor preoperatively among men with benign and malignant testis tumors, with occasional decline after TSS. Frozen section analysis at the time of surgery appears to be very reliable, and the majority of nonpalpable tumors appear to be benign. Conclusions TSS is a safe and efficacious technique with regards to oncological control and postoperative hormonal function based on retrospective, noncontrolled studies. TSS avoids unnecessary removal of benign testicular tissue, and should be given serious consideration in cases of nonpalpable, small tumors under 2 cm. In cases of malignancy, TSS can safely avoid anorchia in men with bilateral tumors and in men with solitary testicles. The use of the operating microscope, while theoretically promising, does not necessarily lead to better outcomes, however data are limited.
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Affiliation(s)
- Jesse Ory
- Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Udi Blankstein
- Department of Surgery, Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Daniel C Gonzalez
- Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Aditya A Sathe
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joshua T White
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Carlos Delgado
- School of Medicine and Health Science, Tecnologico de Monterrey, Monterrey, Mexico
| | - John Reynolds
- Department of Health Informatics, Miller School of Medicine, University of Miami, Calder Memorial Library, Miami, FL, USA
| | - Keith Jarvi
- Department of Surgery, Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Ranjith Ramasamy
- Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA
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Cozzi DA, Ceccanti S. Testis tumors in prepubertal boys: A plea for zero-ischemia testis-sparing surgery. J Pediatr Urol 2021; 17:603-604. [PMID: 34366253 DOI: 10.1016/j.jpurol.2021.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Denis A Cozzi
- Pediatric Surgery Unit, Sapienza University of Rome, AOU Policlinico Umberto I, Rome, RM 00161, Italy.
| | - Silvia Ceccanti
- Pediatric Surgery Unit, Sapienza University of Rome, AOU Policlinico Umberto I, Rome, RM 00161, Italy
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6
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Favilla V, Cannarella R, Tumminaro A, DI Mauro D, Condorelli RA, LA Vignera S, Ficarra V, Cimino S, Calogero AE. Oncological and functional outcomes of testis sparing surgery in small testicular mass: a systematic review. Minerva Urol Nephrol 2021; 73:431-441. [PMID: 33949185 DOI: 10.23736/s2724-6051.21.04330-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Vincenzo Favilla
- Section of Urology, Gaetano Barresi Department of Human and Pediatric Pathology, University of Messina, Messina, Italy
| | - Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy -
| | - Antonio Tumminaro
- Section of Urology, Department of Surgery, University of Catania, Catania, Italy
| | - Davide DI Mauro
- Section of Urology, Department of Surgery, University of Catania, Catania, Italy
| | - Rosita A Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Sandro LA Vignera
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Vincenzo Ficarra
- Section of Urology, Gaetano Barresi Department of Human and Pediatric Pathology, University of Messina, Messina, Italy
| | - Sebastiano Cimino
- Section of Urology, Department of Surgery, University of Catania, Catania, Italy
| | - Aldo E Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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7
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Ceccanti S, Pecorella I, Schiavetti A, Andreoli G, Ciardi A, Cozzi DA. Zero-ischemia testis-sparing surgery for probably benign pediatric testicular tumors. Pediatr Surg Int 2021; 37:673-676. [PMID: 33649880 DOI: 10.1007/s00383-021-04865-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 11/26/2022]
Abstract
Permanent ischemia-induced testicular damage may occur as early as 30 min in prepupertal rats. With the goal of potentially enhancing testicular function and fertility preservation, we performed testis-sparing surgery (TSS) without ischemia for testicular lesions in select children with negative markers and high likelihood of benignity on ultrasonography. Preliminary experience suggests that off-clamp TSS should be more liberally encouraged, especially in infants and prepubertal children, given their particularly vulnerable spermatic cord elements.
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Affiliation(s)
- Silvia Ceccanti
- Pediatric Surgery Unit, Sapienza University of Rome, AOU Policlinico Umberto I, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Irene Pecorella
- Department of Radiological, Oncological, Pathological Sciences, Sapienza University of Rome, AOU Policlinico Umberto I, 00161, Rome, RM, Italy
| | - Amalia Schiavetti
- Pediatric Oncology Unit, Sapienza University of Rome, AOU Policlinico Umberto I, 00161, Rome, RM, Italy
| | - Gianmarco Andreoli
- Pediatric Radiology Unit, Sapienza University of Rome, AOU Policlinico Umberto I, 00161, Rome, RM, Italy
| | - Antonio Ciardi
- Department of Radiological, Oncological, Pathological Sciences, Sapienza University of Rome, AOU Policlinico Umberto I, 00161, Rome, RM, Italy
| | - Denis A Cozzi
- Pediatric Surgery Unit, Sapienza University of Rome, AOU Policlinico Umberto I, Viale Regina Elena, 324, 00161, Rome, Italy.
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8
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Koschel SG, Wong LM. Radical inguinal orchidectomy: the gold standard for initial management of testicular cancer. Transl Androl Urol 2020; 9:3094-3102. [PMID: 33457282 PMCID: PMC7807348 DOI: 10.21037/tau.2019.12.20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Radical inguinal orchidectomy with division of the spermatic cord at the internal inguinal ring is the gold standard for diagnosis and local treatment of testicular malignancies. The technique is well established and described in detail in this paper, collating methods from various surgical textbooks and articles. We also discuss pre-operative considerations including fertility counselling and potential testicular prosthesis at time of orchidectomy, and the importance of contemplating differential diagnoses such as para-testicular sarcoma and primary testicular lymphoma (PTL) prior to performing radical orchidectomy (RO). The evidence and indications for new surgical techniques to treat local testicular malignancies are also described, including testis sparing surgery (TSS) and spermatic cord sparing orchidectomy.
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Affiliation(s)
- Samantha G Koschel
- Department of Urology, St. Vincent's Hospital Melbourne, Melbourne, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Lih-Ming Wong
- Department of Urology, St. Vincent's Hospital Melbourne, Melbourne, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
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9
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Woo LL, Ross JH. Partial orchiectomy vs. radical orchiectomy for pediatric testis tumors. Transl Androl Urol 2020; 9:2400-2407. [PMID: 33209713 PMCID: PMC7658131 DOI: 10.21037/tau-19-815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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).
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Affiliation(s)
- Lynn L Woo
- Department of Pediatric Urology, Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Jonathan H Ross
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
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10
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Organ-Sparing Surgery in Testicular Tumor: Is This the Right Approach for Lesions ≤ 20 mm? J Clin Med 2020; 9:jcm9092911. [PMID: 32917055 PMCID: PMC7565605 DOI: 10.3390/jcm9092911] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/07/2020] [Accepted: 09/07/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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11
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Raison N, Warrington J, Alnajjar HM, Muneer A, Ahmed K. The role of partial orchidectomy in the management of small testicular tumours: Fertility and endocrine function. Andrology 2020; 8:988-995. [PMID: 32167663 DOI: 10.1111/andr.12786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 01/31/2020] [Accepted: 03/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Radical orchidectomy in patients who are subsequently diagnosed with benign testicular tumours represents an overtreatment due to the deleterious effects on endogenous testosterone, fertility and body image. For these reasons, the option of partial orchidectomy (PO) should be considered in certain groups of patients. Patients with bilateral tumours (synchronous or metachronous) or a solitary testis where the lesion is no greater than 30% of the volume of the testis could be considered for a PO. Evidence has shown that PO is effective for small testicular masses with excellent survival and recurrence rates. OBJECTIVES Highlight the feasibility of maintaining post-operative fertility or normal semen parameters and endocrine function following PO. MATERIALS AND METHODS Data for this review were obtained through a search of the PubMed database. Papers were required to be in English and focus on adult human males. RESULTS Eligible and relevant papers were assessed for data regarding fertility, semen parameters and endocrine function following PO for a small testicular mass (STM). CONCLUSION It is possible to preserve both fertility and endocrine function after PO. Although patients may still require adjuvant radiotherapy for concomitant intratubular germ cell neoplasia (ITGCN) which results in subfertility, endocrine function is still conserved. However, it is possible to postpone radiotherapy and continue with clinical surveillance for the purposes of fertility preservation.
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Affiliation(s)
- Nicholas Raison
- MRC Centre for Transplantation, Guy's Hospital Campus, King's College London, London, UK
| | - Jake Warrington
- MRC Centre for Transplantation, Guy's Hospital Campus, King's College London, London, UK
| | - Hussain M Alnajjar
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Asif Muneer
- NIHR Biomedical Research Centre, University College London Hospital, London, UK
| | - Kamran Ahmed
- MRC Centre for Transplantation, Guy's Hospital Campus, King's College London, London, UK.,Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Urology, Kings College Hospital, Kings Health Partners, London, UK
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12
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Patel HD, Gupta M, Cheaib JG, Sharma R, Zhang A, Bass EB, Pierorazio PM. Testis-sparing surgery and scrotal violation for testicular masses suspicious for malignancy: A systematic review and meta-analysis. Urol Oncol 2020; 38:344-353. [PMID: 32192891 DOI: 10.1016/j.urolonc.2020.02.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 02/04/2020] [Accepted: 02/19/2020] [Indexed: 12/17/2022]
Abstract
Radical inguinal orchiectomy is the standard of care for men diagnosed with a testicular mass suspicious for germ cell tumor (TGCT). Nontraditional approaches to management, including testis-sparing surgery (TSS) and scrotal orchiectomy, occur in clinical practice. We systematically reviewed studies evaluating outcomes after TSS and scrotal violation for the management of a suspected TGCT. We used PubMed, Embase, and the Cochrane Central Register of Controlled Trials (January 1980-December 2018) to search for studies addressing morbidity and oncologic outcomes after TSS or scrotal violation for testicular masses concerning for TGCT. Paired reviewers independently screened abstracts for inclusion, sequentially extracted data, and assessed study quality. Twenty-one studies were included (10 TSS, 11 scrotal violation). Risk of local recurrence after TSS on meta-analysis was 7.5% after 3 to 5 years (absolute proportion reported in studies: 10.9%). Aggregated rates of positive margins (1.4%) and testicular atrophy (2.8%) across studies were low with 7.1% of patients requiring subsequent androgen therapy. Scrotal violation led to a higher aggregate risk of local recurrence compared to no scrotal violation (2.5% vs. 0.0%, P < 0.001) but did not appear to impact subsequent metastasis and survival in the short term (3-5 years). Most patients received adjuvant therapy after scrotal violation with 9.3% found to harbor residual primary tumor after scrotal scar excision. TSS carries a quantifiable risk of local recurrence after 3 to 5 years despite the majority receiving adjuvant radiation or chemotherapy. Scrotal violation carries a risk of local recurrence but does not appear to impact subsequent metastasis and survival in the short term.
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Affiliation(s)
- Hiten D Patel
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Mohit Gupta
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph G Cheaib
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ritu Sharma
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, MD
| | - Allen Zhang
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, MD
| | - Eric B Bass
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, MD; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Phillip M Pierorazio
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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Abstract
In any man with a solid testicular mass, cancer should be considered until proven otherwise. Radical inguinal orchiectomy is the treatment of choice in patients with testis mass. Placement of a testicular prosthesis is safe with a very low complication rate and should be offered to all patients undergoing radical orchiectomy. In patients with widespread or life-threatening advanced disease, delayed orchiectomy following chemotherapy is recommended. Testis-sparing surgery can be performed in highly selected patients with solitary testicle mass, bilateral testicular tumors, or strong suspicion of a benign lesion.
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14
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Pfister D, Paffenholz P, Haidl F. Testis-Sparing Surgery in Patients with Germ Cell Cancer: Indications and Clinical Outcome. Oncol Res Treat 2018; 41:356-358. [DOI: 10.1159/000489346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/18/2018] [Indexed: 01/19/2023]
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15
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Woo LL, Ross JH. The role of testis-sparing surgery in children and adolescents with testicular tumors. Urol Oncol 2015; 34:76-83. [PMID: 26094168 DOI: 10.1016/j.urolonc.2015.05.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/04/2015] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Lynn L Woo
- Department of Pediatric Urology, Rainbow Babies & Children׳s Hospital/University Hospitals Case Medical Center, Cleveland, OH.
| | - Jonathan H Ross
- Department of Pediatric Urology, Rainbow Babies & Children׳s Hospital/University Hospitals Case Medical Center, Cleveland, OH
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