PO is usually performed under general anesthesia with the patient in the supine position. In the usual sterile manner including prepping the scrotum, a 4–5 cm incision is made along the Langerhans skin line about 2 cm above and parallel to the inguinal ligament. The initial steps are the same as radical orchiectomy. The subcutaneous fat is dissected to expose Scarpa’s fascia which is incised to the level of the external oblique aponeurosis which in turn is incised towards the internal inguinal ring. The ileoinguinal nerve is identified, dissected free of the cord and preserved after identification. The cord is clamped with a rubber-shod clamp or Penrose tourniquet at the level of internal ring and the testicle is delivered from the scrotum into the wound, taking care to control small vessels. The gubernaculum attachments are divided with electrocautery or ligated. Before opening tunica vaginalis, the lesion is located in the testicle by palpation or with the help of the intraoperative US [75] (Fig. 9.2). Warm or cold ischemia remains controversial but if performed, Steiner and colleagues advocate immersion of the testis in crushed ice or slush for 5 min before spermatic cord occlusion [78, 81]. If FSE is planned, the wound should be covered before opening the tunica vaginalis and incising the parenchyma. An operating microscope with 6–25× magnification can be used to help identification of testis and tumor blood supply [75]. The tumor is enucleated with an attempt to preserve surrounding normal parenchyma. There are possible two scenarios after the result of the FSE. If the lesion appears to be benign, the vessels are unclamped and after ensuring hemostasis, the tunica albuginea is closed with running 4-0 or 5-0 absorbable suture. When the FSE is positive for malignancy and a decision is made to proceed with PO, some authors recommended multiple biopsies of the remaining tumor bed to rule out other possible malignant lesions or CIS [33]. Testicle is placed back in the scrotum without twisting or tension. After returning the testis to the scrotum, the external oblique aponeurosis is closed in a running fashion with absorbable sutures after thorough hemostasis. Scarpas’ fascia is also closed with absorbable sutures. Skin is closed with 4-0 subcuticular sutures. Compressive scrotal support can minimize wound edema. The patient usually goes home the same day or may stay overnight.

The well-known radiosensitivity of semonimas prompted several studies of treatment of primary GCT with radiation without PO [82, 83]. However, the required dose of radiation can affect hormone production and replacement therapy may be necessary. Previous studies showed that 33 Gy decrease testosterone levels in 50% of men [84]. At lower doses for CIS, there is a decline in testosterone production and 40% of men require required testosterone replacement [84, 85]. The high risk of testosterone replacement supports a surgical approach, but in selected cases radiation can be successfully used [82, 83]. Further dose-fractionation studies needed to optimize protocol of tumor eradication with acceptable hormone function preservation.

There is only one report of chemotherapy alone in the organ-sparing treatment of testicular cancer. Tomita et al. reported bilateral GCT where the unilateral testis was preserved by three courses of BEP chemotherapy [86]. Patients showed no recurrence and testicular preservation between 24 and 82 months after treatment. On the other hand the effect of chemotherapy in eradicating CIS is very controversial, so further studies with larger number of patients and longer follow-up needed to recommend chemotherapy as safe organ-sparing approach.

HIFU is a minimally invasive technique to achieve coagulation necrosis of the tumor (90–100 °C). It has been successfully used in other applications in oncology, particularly for treatment of patients with rectal, prostate, breast, liver, and pancreatic tumors [87–93]. Therapeutic goal for HIFU in GCT is similar to that of local tumor excision in patients selected for organ-preservation strategy. The group from Germany have published their experience with GCT in seven patients with a solitary testis and mean follow-up of 42 months [94]. Transscrotal HIFU under general anesthesia with mean operative time of 31 min, followed 6 weeks later by prophylactic testicular irradiation (18–20 Gy). One patient received two cycles of chemotherapy for a single suspicious retroperitoneal lymph node diagnosed 6 months after HIFU. Other six patients remained tumor free at the mean follow-up of 42 (3–93) months. One patient who refused adjuvant radiation developed a recurrent tumor within 6 months was treated with radical orchiectomy. HIFU is a very promising treatment, producing necrosis without surgical trauma to the vascular anatomy and allows to preserve more gonadal function. But the downside of this would be lack of histological examination of the lesion.