Testicular sparing surgery in small testis masses: A multinstitutional experience

Diagnosis and management of indeterminate testicular lesions

The sophistication and accessibility of modern-day imaging result in frequent detection of small or equivocal lesions of the testes. Traditionally, diagnosis of a testicular lesion with any possibility of malignancy would usually prompt radical orchidectomy. However, awareness is growing that a substantial proportion of these lesions might be benign and that universal application of radical orchidectomy risks frequent overtreatment. Given the potentially profound effects of radical orchidectomy on fertility, endocrine function and psychosexual well-being, particularly in scenarios of an abnormal contralateral testis or bilateral lesions, organ-preserving strategies for equivocal lesions should be considered. Image-based active surveillance can be applied for indeterminate lesions measuring ≤15 mm with a low conversion rate to surgical treatment. However, these outcomes are early and from relatively small, selected cohorts, and concerns prevail regarding the metastatic potential of even small undiagnosed germ cell tumours. No consensus exists on optimal surveillance (short interval (<3 months) ultrasonography is generally adopted); histological sampling is a widespread alternative, involving inguinal delivery of the testis and excisional biopsy of the lesion, with preoperative marking or intraoperative ultrasonographic localization when necessary. Frozen section analysis in this context demonstrates excellent diagnostic accuracy. Histological results support that approximately two-thirds of marker-negative indeterminate solitary testicular lesions measuring ≤25 mm overall are benign. In summary, modern imaging detects many small indeterminate testicular lesions, of which the majority are benign. Awareness is growing of surveillance and organ-sparing diagnostic and treatment strategies with the aim of minimizing rates of overtreatment with radical orchidectomy.

Critical elements of pediatric testicular germ cell tumors surgery

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.

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.

Radiological features characterising indeterminate testes masses: a systematic review and meta-analysis

CONTEXT

The use of scrotal ultrasonography (SUS) has increased the detection rate of indeterminate testicular masses. Defining radiological characteristics that identify malignancy may reduce the number of men undergoing unnecessary radical orchidectomy.

OBJECTIVE

To define which SUS or scrotal magnetic resonance imaging (MRI) characteristics can predict benign or malignant disease in pre- or post-pubertal males with indeterminate testicular masses.

EVIDENCE ACQUISITION

This systematic review was conducted in accordance with Cochrane Collaboration guidance. Medline, Embase, Cochrane controlled trials and systematic reviews databases were searched from (1970 to 26 March 2021). Benign and malignant masses were classified using the reported reference test: i.e., histopathology, or 12 months progression-free radiological surveillance. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool (QUADAS-2).

EVIDENCE SYNTHESIS

A total of 32 studies were identified, including 1692 masses of which 28 studies and 1550 masses reported SUS features, four studies and 142 masses reported MRI features. Meta-analysis of different SUS (B-mode) values in post-pubertal men demonstrated that a size of ≤0.5 cm had a significantly lower odds ratio (OR) of malignancy compared to masses of >0.5 cm (P < 0.001). Comparison of masses of 0.6-1.0 cm and masses of >1.5 cm also demonstrated a significantly lower OR of malignancy (P = 0.04). There was no significant difference between masses of 0.6-1.0 and 1.1-1.5 cm. SUS in post-pubertal men also had a statistically significantly lower OR of malignancy for heterogenous masses vs homogenous masses (P = 0.04), hyperechogenic vs hypoechogenic masses (P < 0.01), normal vs increased enhancement (P < 0.01), and peripheral vs central vascularity (P < 0.01), respectively. There were limited data on pre-pubertal SUS, pre-pubertal MRI and post-pubertal MRI.

CONCLUSIONS

This meta-analysis identifies radiological characteristics that have a lower OR of malignancy and may be of value in the management of the indeterminate testis mass.

The value of contrast-enhanced ultrasonography in differential diagnosis of primary testicular germ cell tumors and non-germ cell tumors over 50 years old

Background

Unlike young and middle-aged patients, seminoma is not common in patients with primary testicular tumors over the age of 50, so it cannot follow the general ideas and norms for diagnosing and treating testicular tumors, and its characteristics need to be considered separately.

Methods

The conventional ultrasonography and contrast-enhanced ultrasonography (CEUS) findings of primary testicular tumors in patients over 50 years old were retrospectively analyzed and compared with the pathological results to compare the diagnostic value of these two methods.

Results

Of the 13 primary testicular tumors, 8 were primary lymphomas. Conventional ultrasound of 13 cases of testicular tumors showed hypoechoic with rich blood flow, and it was difficult to identify the type accurately. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of conventional ultrasonography in diagnosing non-germ cell tumors (lymphoma and Leydig cell tumor) were 40.0%, 33.3%, 66.7%, 14.3%, and 38.5%, respectively. CEUS findings: 7 of 8 lymphomas showed uniform hyperenhancement. 2 cases of Leydig cell tumors showed uniform high enhancement. 2 cases of seminoma and 1 case of spermatocytic tumor showed heterogeneous enhancement, with necrosis in the interior. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy rate of non-germ cell tumor diagnosis according to the non-necrotic area of CEUS were 90.0%, 100.0%, 100.0%, 75.0% and 92.3%, respectively. Compared with conventional ultrasound, the difference was statistically significant (P=0.039).

Conclusions

Primary testicular tumors in patients over 50 years old are mainly lymphoma, and CEUS is significantly different between germ cell tumors and non-germ cell tumors. Compared with conventional ultrasound, CEUS can distinguish testicular germ cell tumors from non-germ cell tumors more accurately. Preoperative ultrasonography is significant for accurate diagnosis and can guide clinical treatment.

Testicular Neoplasms: Primary Tumour Size Is Closely Interrelated with Histology, Clinical Staging, and Tumour Marker Expression Rates-A Comprehensive Statistical Analysis

The role of primary tumour size (TS) in the clinical course of testicular tumours is incompletely understood. We retrospectively evaluated 641 consecutive patients with testicular neoplasms with regard to TS, histology, clinical stage (CS), serum tumour marker (STM) expression and patient age using descriptive statistical methods. TS ≤ 10 mm was encountered in 13.6% of cases. Median TS of 10 mm, 30 mm, 35 mm, and 53 mm were found in benign tumours, seminomas, nonseminomas, and other malignant tumours, respectively. In cases with TS ≤ 10 mm, 50.6% had benign tumours. Upon receiver operating characteristics analysis, TS of > 16 mm revealed 81.5% sensitivity and 81.0% specificity for detecting malignancy. In subcentimeter germ cell tumours (GCTs), 97.7% of cases had CS1, and CS1 frequency dropped with increasing TS. Expression rates of all STMs significantly increased with TS. MicroRNA-371a-3p (M371) serum levels had higher expression rates than classical STMs, with a rate of 44.1% in subcentimeter GCTs. In all, TS is a biologically relevant factor owing to its significant associations with CS, STM expression rates and histology. Importantly, 50% of subcentimeter testicular neoplasms are of benign nature, and M371 outperforms the classical markers even in subcentimeter tumours.

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.

Precocious puberty related to Leydig cell testicular tumor: the diagnostic imaging keys

BACKGROUND

We report the challenging case of a 6-year-old boy with precocious puberty related to histologically proven Leydig cell tumor.

CASE PRESENTATION

Multiparametric ultrasound and magnetic resonance imaging (MRI) was performed. Interesting findings were scarcely or never reported in children and differed from adults Leydig cell tumors s such as the hyperechogenic halo surrounding the lesion and the dominant central vascularization using ultrasensitive Doppler. MRI revealed an enlarged testicle with strong enhancement of a tumor, a tumor apparent diffusion coefficient (ADC) of 600 × 10-3 mm2/s and a lower ADC value of the non-tumor parenchyma compared to the contralateral testis (ADC = 800 × 10-3 mm2/s vs 1100 × 10-3 mm2/s), attributed to the spermatogenesis induced by hormonal impregnation.

CONCLUSION

We illustrate multiparametric US and MRI findings of a pediatric Leydig cell tumor, including the imaging changes attributed to local hormone secretion, which may be helpful in similar cases.

Incidental Findings and How to Manage Them: Testis- A WFUMB Position Paper

Testicular incidentalomas are non-palpable, asymptomatic lesions, most frequently detected on ultrasound examinations. Each incidentaloma should undergo a standardized diagnostic workup to exclude malignancy and recognize other potentially significant non-malignant conditions that may first present with an incidental finding on scrotal ultrasound. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on management of testicular incidentalomas and describes efficient management strategies with particular reference to the role of ultrasound techniques.

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.

Testis-sparing surgery for testicular tumors in children: a 20 year single center experience and systematic review of the literature

PURPOSE

Although surgical therapy for testicular tumors (TT) is often radical orchidectomy, tumor resection with preservation of healthy testicular parenchyma has been proposed. This study herein reports a 20 year single center experience applying testicular sparing surgery (TSS) as a primary operative strategy in pediatric patients. A systematic literature review summarizes the utility and outcomes of TSS in appropriately selected patients.

METHODS

Pediatric patients with TT who underwent TSS between 1997 and 2018 were studied. TSS was indicated if patients presented evidence of adequately spared healthy testicular parenchyma on preoperative ultrasound and negative serum tumor markers. A systematic review of the literature was also performed.

RESULTS

12 cases met full inclusion criteria with 10 of 12 subjects in the prepubertal age group. Follow-up was 73 months (range 18-278 months). Only a single male patient (GSCCT) presented with early recurrence and orchidectomy was then performed. No cases of postoperative testicular atrophy were identified. Sexual maturation (Tanner stage) expected for age in each patient was documented. Review of the literature identified 34 published studies including 269 patients (94% prepubertal). Pathologic lesions here were mainly mature teratoma(s)-(62%) with a follow-up period of 4 years. Recurrent tumors were observed in only three patients (1.1%) notably two Leydig Cell Tumors and one Teratoma. Testicular atrophy reportedly occurred in only one single case (0.37%).

DISCUSSION

TSS is a feasible alternative to radical orchidectomy in pediatric male patients with localized TT and negative tumor markers. Long term follow-up is essential to monitor testicular growth, puberty with sexual development and psychological male health.

Unusual clinical scenarios in Urology and Andrology

This collection includes some unusual cases and how they were diagnosed and treated. Case 1: A case of a patient with primary hyperthyroidism presenting with a submucosal ureteral stone after endoscopic lithotripsy was described. After multiple endoscopic treatment, the stone was successfully removed by open ureterolithotomy recovering ureteral patency and normal renal function. Case 2: A case of burned-out testicular cancer with atypical lymphatic spread (stage II A) was presented. After right orchiectomy and complete remission of tumor markers, due to atypical metastases location and uncertain histology, the patient was treated with systemic therapy based on bleomycin, etoposide and cisplatin (PEB). At re-staging after chemotherapy computed tomography showed reduction of all node metastases and an observation protocol was proposed. Case 3: A patient was readmitted to hospital after 12 days from an uneventful Robot-Assisted Radical Prostatectomy (RARP) for prostate cancer due to lower abdominal pain plus abdominal distension, nausea and constipation not responsive to medical therapy. Computed Tomography showed colon and small bowel dilatation without any evidence of anatomical or mechanical obstruction. Laparoscopic abdominal exploration confirmed bowel distension without evidence of obstructing lesions. Ogilvie's Syndrome or acute colonic pseudo-obstruction (ACPO) was diagnosed. The patient fully recovered and was discharged six days after the procedure. Case 4: A case of recurrent Acute Idiopathic Scrotal Edema (AISE) was diagnosed on clinical signs together with the decisive help of pathognomonic ultrasound findings as the "fountain sign". Case 5: Small bilateral testicular nodules were diagnosed in a 30-years old patient undergoing scrotal ultrasound in follow up of acute lymphoblastic leukemia. Ultrasound guided testis sparing surgery was performed demonstrating Leydig cell tumors.

The sclerosing Sertoli cell tumor of the testis is an extremely rare entity

We present the case of a 31-year-old single male patient, who was admitted through emergency unit with painless hard nodule of his left testis of 6 months’ duration. Ultrasound scan of the scrotum showed a fairly well-defined hypo echoic area in the left testicular parenchyma in its middle part, measuring approximately 10 × 9 mm in size. We performed left inguinal radical orchidectomy. Histopathology examination of the left testis revealed sclerosing Sertoli cell tumor (SSCT) of the testis. This is a very rare testicular tumor with very few published case reports. Systemic examination was performed to exclude systemic metastasis. SSCT is characterized by the presence and aggregates of tubules of Sertoli cells, separated by a sclerotic intercellular matrix formed by fibrotic connective tissue.

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).

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).

Partial orchiectomy: The Princess Margaret cancer centre experience

INTRODUCTION

Radical orchiectomy (RO) is the standard treatment for a testis cancer. Organ sparing surgery can be considered in the setting of a solitary functioning testis or bilateral tumors. It has also been suggested as an alternative to RO for small lesions. In this study we report our partial orchiectomy (PO) experience.

METHODS

We performed a retrospective review using our prospectively maintained database analyzing PO.

RESULTS

Between 1983 and 2018, 77 patients underwent PO. Mean age was 31.3 years (range 17-56). A lesion was palpable in 70 (90.9%) and median lesion size 14.1 mm (range 3-35 mm). Reasons for PO included ``small lesion" in 39 (50.6%); solitary functioning testis in 30 (39%); bilateral lesions in 6 (7.8%); or assumed benign lesion in 1 (1.3%). Median follow-up was 43.5 months (range 1-258). Lesion histology was benign in 25 (32.5%). A positive surgical margin was noted in 6 (7.8%) with none developing local or distant recurrence. Sixteen (20.8%) patients underwent salvage ipsilateral RO at a median of 3 months (range 0-46). Reasons for salvage RO included a radiologically detected lesion in 7, palpable lesion in 4, positive surgical margin in 3 and adverse pathology in 2 patients. Malignant histology was present in 12 (75%) of the salvage RO specimens. There were no reported Clavien-Dindo Grade 3 to 5 complications.

CONCLUSION

Organ sparing surgery is a safe and feasible approach to small testis lesions. For the third with benign disease, and even those with malignant histology, a RO can be avoided in carefully selected patients.

[Testicular tumors in prepubertal boys-organ preservation possible more often than expected]

In prepubertal boys, testicular tumors are rare with an incidence between 2 and 5/million. In contrast to testicular tumors in adolescents and adults, more than 2/3 of these tumors are benign. Unfortunately, in Germany in most cases, only malignant tumors (usually yolk sac tumors) are reported to the study center (MAKEI IV and now V). Therefore, the incidence in Germany is unknown. Since the introduction of polychemotherapy in the 1970s, the prognosis of malignant testicular tumors has improved enormously and has become a curable disease, even in the case of recurrence. Today the orchiectomy, which was usually carried out in the past, appears to be no longer justified in most prepubertal boys due to the high incidence of benign tumors. It has been shown in various studies that organ-sparing surgery in germ cell tumors (epidermoid cysts, teratoma); gonadal stoma tumors (Sertoli, Leydig and granulosa cell tumors) and cystic lesions (intratesticular cysts and tubular ectasia of the rete testis) is reliable and safe. In cases with preoperative significantly increased AFP (caution: norm values not valid in the first year of life) and a clear testicular tumor in the ultrasound (yolk sac tumor) or if no testicular parenchyma is sonographically detectable, orchiectomy can still be carried out. Today orchiectomies in prepubertal boys should be an exception and the reasons for an orchiectomy must be well documented.

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.

Radical and testis-sparing surgery for primary testicular tumors: A single-center experience

The aim of the present study was to assess the oncological and functional outcomes of testis-sparing surgery (TSS) for testicular tumors compared with radical orchiectomy (RO) in a single center. A retrospective comparative cohort study was conducted in Changzheng Hospital. Patients were identified using the hospital information system from January 1999 to December 2016, collecting all of the data regarding clinical, treatment and prognostic profiles. Patient follow-up was also executed to obtain information on patients' survival status, serum markers profiles, disease progression, androgen substitution requirement and paternity status. In total 158 patients were enrolled into the cohort study, including 23 TSS cases. The TSS procedure was primarily conducted in younger patients (average age, 31.9 vs. 47.7 years) or those with smaller tumors (average tumor diameter, 26.0 vs. 51.5 mm). The overall survival and recurrence free survival revealed no differences in the two groups, suggesting similar oncological outcomes. Kaplan-Maier analysis demonstrated a higher cumulative paternity rate in the TSS group than in RO group, indicating a possible advantage of preserving patients' fertility in TSS over RO. TSS with proper adjuvant therapies proved to be a promising alternative in the avoidance of emasculation, infertility, life-long androgen substitution and other psychosexual difficulties, as the oncological outcomes were not inferior to RO in the selected cases. However, further investigation is required in order to assess its oncological and functional values.

Testicular Cancer-Surgical Treatment

Testicular Germ Cell Tumor (GCT) is the most common solid tumor in men between the ages of 20-44. Men diagnosed with GCT have excellent survival rates due to advances in the multimodal treatment paradigm of chemotherapy, radiation therapy, and surgery. When considering the adequate treatment, several variables should be investigated and known to select the proper procedure. Therefore, when considering Testicular Intra-Epithelial Neoplasia, organ-sparring treatment, such as radiotherapy or organ-sparring surgery should be considered, reaching a cure rate of 98%. However, when the case is of a seminoma or a non-seminoma, orchiectomy is usually the chosen procedure, reaching an oncological cure rate of 80-85%, when there is no metastasis. Retroperitoneal Lymph Node Dissection (RPLND) is generally considered as a treatment option for non-seminomas, when lymph nodes are compromised. There are three different RPLND techniques: open, laparoscopic, and robotic. The open approach is as effective as the other two in its oncological efficiency. Although, when considering both laparoscopic and robotic approach, hospital stays are significantly reduced, better cosmetic results, and less complications when compared to the open approach. Both laparoscopic and robotic approaches require extensive experience and have a steep learning curve, while also providing similar outcome, however, recent studies have been pointing out a slight increase of advantages on the robotic approach. Therefore, further studies are necessary to assert the robotic approach superiority. Also, it is noteworthy that new technologies are on the rise, improving the laparoscopic approach, requiring further studies after their uses are consolidated.

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.