Organ-Preserving Surgery in Testicular Tumors

AXEL HEIDENREICH

Testicular germ cell tumors (TGCTs) are the most common neoplasms in young men, with bilateral simultaneous and sequential tumors arising in 2% to 3% of patients. Bilateral orchiectomy is still recommended as the gold standard treatment; it results in infertility, lifelong dependency on androgen substitution, and psychological distress due to castration at a young age. Because most testicular cancer patients are going to be longtime survivors with modern therapeutic approaches, long-term morbidity should be omitted whenever possible; cure of cancer might only be achieved if quality of life following therapy can be restored to pretreatment levels. Considering these quality-of-life issues, organ-sparing surgical approaches have been developed in patients with bilateral testicular cancer or in selected patients with a germ cell tumor arising in a solitary testicle. In addition, any patient with a testicular tumor of unknown origin should be offered organ preservation (1) even in the presence of a normal contralateral testis if testicular ultrasonography is typical for benign tumors such as simple testicular cysts (Fig. 60.1) or epidermoid cysts (Fig. 60.2).

DIAGNOSIS

The diagnosis of testicular cancer is usually made by the appearance of a mass in the testicle that on ultrasonography appears solid or appears to have some cystic components (2). Scrotal magnetic resonance imaging appears only to be necessary if there is more than one lesion suspected or if there is a very high suspicion for a benign testicular tumor (Fig. 60.3). Serum markers, including β-human chorionic gonadotropin and α-fetoprotein, are routinely drawn prior to surgery.

FIGURE 60.1 Ultrasound of simple testicular cysts.

FIGURE 60.2 Ultrasound of epidermoid testicular cysts.

INDICATIONS FOR SURGERY

Patients in whom preservation surgery is contemplated should have enough testicular parenchyma for maintaining physiologic testosterone synthesis, which requires that the diameter of the tumor should not exceed 2 cm (3,4). Preoperative serum testosterone and serum luteinizing hormone (LH) levels should be in the normal range. Elevated LH levels in the presence of normal testosterone levels indicate compensated Leydig cell insufficiency. These patients bear a high risk to develop hypogonadism with the need for androgen substitution following surgery. In addition, a semen analysis should be obtained to assess fertility and to discuss the option of cryopreservation (3,5). Also, testicular ultrasonography must be performed preoperatively because this usually represents the imaging modality of choice to assess the intratesticular location and diameter of the tumor. Scrotal magnetic resonance imaging appears only to be necessary if there is more than tumor suspected or if there is a very high suspicion for a benign testicular lesion (6).

ALTERNATIVE THERAPY

The alternative to testicular-sparing surgery is bilateral orchiectomy, which will require lifelong hormonal replacement. Other problems associated with bilateral orchiectomy include
infertility and the psychological impact of the procedure on the patient, who is usually a young male.

FIGURE 60.3 A and B: Scrotal magnetic resonance imaging only for very high suspicion for a benign testicular tumor.

SURGICAL TECHNIQUE

An inguinal approach is chosen (4) with the skin incision being made about two fingerbreadths above and parallel to the inguinal ligament (Fig. 60.4). The incision extends from the external inguinal ring cephalad for about 5 cm and is carried down to the external oblique fascia (Fig. 60.5). Care is taken not to injure the ilioinguinal nerve, which runs laterally just underneath the fascia.

The spermatic cord is identified and isolated at the level of the pubic tubercle (Fig. 60.6), secured with a half-inch Penrose drain, and mobilized back to the internal inguinal ring (Fig. 60.7). As in the case of radical orchiectomy, the spermatic cord might be cross-clamped with a rubbershod clamp prior to delivering the testicle in the operating field. In this scenario, all following manipulations should be performed under cold ischemia by placing the testicle in crushed ice (1,7).

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