Testicular sparing surgery in small testis masses: A multinstitutional experience

Abstract

Introduction: The incidence of benign testicular tumors is increasing in particular in small lesion incidentally found at scrotal ultrasonography. Primary aim of this study was to perform radical surgery in malignant tumor. Secondary aim was to verify the efficacy of the diagnostic-therapeutic pathway recently adopted in management of small masses with testis sparing surgery in benign lesions. Materials and methods: In this multicenter study, we reviewed all patients with single testis lesion less than 15 mm at ultrasound as main diameter. We applied the diagnostic-therapeutic pathway described by Sbrollini et al. (Arch Ital Urol Androl 2014; 86:397) which comprises: 1) testicular tumor markers, 2) repeated scrotal ultrasound at the tertiary center, 3) surgical exploration with inguinal approach, intraoperative ultrasound, and intraoperative pathological examination. Definitive histology was reviewed by a dedicated uro-pathologist. Results: Twenty-eight patients completed this clinical flowchart. The mean lesion size was 9.3 mm (range 2.5-15). Testicular tumor markers were normal except in a case. Intraoperative ultrasound was necessary in 8/28 cases. We treated 11/28 (39.3%) with immediate radical orchiectomy and 17/28 (60.7%) with testis-sparing surgery. Definitive pathological results were: malignant tumor in 6 cases (seminoma), benign tumor in 10 cases (5 Leydig tumors, 2 Sertoli tumors, 1 epidermoid cyst, 1 adenomatoid tumor, 1 angiofibroma), benign disease in 11 (8 inflammation with haemorragic infiltration, 2 tubular atrophy, 1 fibrosis), and normal parenchyma in 1 case. We observed a good concordance between frozen section examination and definitive histology. Any malignant tumor was treated conservatively. Any delayed orchiectomy was necessary based on definitive histology. Conclusions: The incidence of benign lesions in 60% of small testis lesions with normal tumor markers makes orchiectomy an overtreatment. Testicular sparing surgery of single testicular nodules below 15 mm is a safe option, but requires a standardized pathway in diagnosis. Our pathway has shown good reliability and security profile to be applied in a multicenter management for small scrotal masses. Our study has shown the reliability of the diagnostic-therapeutic pathway in the management of single testicular masses. The higher incidence of benign lesions in 60% of patients makes often orchiectomy an overtreatment.

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

“…In the infertile population, testicular tumors have been reported as 20-fold more frequent than in the general population, due to screening and related disorders identified as risk factors (cryptorchidism, Klinefelter’s syndrome, or gonadal dysgenesis syndrome) (Raman et al , 2005). The recent literature includes several series of small incidental, asymptomatic, non-palpable testicular tumors discovered due to the increase in referrals for scrotal US (Ates et al , 2016; Bozzini et al , 2013; Carmignani et al , 2004; Colpi et al , 2005; De Stefani et al , 2012; Djaladat, 2015; Drudi et al , 2016; Eifler et al , 2008; Galosi et al , 2016; Gentile et al , 2013; Giannarini et al , 2007; Hopps and Goldstein, 2002; Isidori et al , 2014; Lagabrielle et al , 2018; Leroy et al , 2003; Ma et al , 2017; Mancini et al , 2007; Muller et al , 2006; Paffenholz et al , 2018; Powell and Tarter, 2006; Raman et al , 2005; Scandura et al , 2018; Sheynkin et al , 2004; Shilo et al , 2012a; Shilo et al , 2012b). Most of these studies demonstrated a high prevalence of LCTs among nonpalpable masses, with an overall mean prevalence value of 26.6% [18.3–34.9 95% CI] (Table I), in contrast to large palpable testisticular tumors, which are malignant in >90% of cases (Bozzini et al , 2013, Elert et al , 2002; Giannarini et al , 2008; Sheynkin et al , 2004).…”

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

“…7 Several previous papers reported even higher incidence of benign pathology (up to 60%) of tumors in testicular masses smaller than 1.5 cm. 7,8 In our study, the mean tumor size was 14.6 mm. Malign lesions were observed in 4 out of 13 patients (30.7%), while benign lesions were observed in 9 out of 13 patients (69.3%), which were compatible with the previous studies.…”

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

“…were able to save testis in 40% of patients presenting with lesions smaller than 15 mm, discovering benign lesions. 12 …”