Usually, the testis is exposed by an inguinal approach. In our clinical practice, ultrasound is performed before the funicular clamping to minimise the time of ischaemia and evaluate the testicular vasculature. At this point, the spermatic cord is clamped, the tunica albuginea is incised above the lesion, the lesion is enucleated with a small edge of the adjacent testicular parenchyma and sent immediately to the pathologist for frozen section analysis and the albuginea is closed (Fig. 44.3). Ultrasonography is then repeated to confirm the complete removal of the nodule. Tumour enucleation procedures should be performed under cold ischaemia with the testicle being placed in crushed ice while the frozen sections are analysed. Before removing the funicular clamp, the lesion is analysed to determine the type of tumour. If the analysis shows a malignant neoplasm, radical orchiectomy will be performed. Ideally, frozen ischaemia should last no more than 30 min, to minimise damage of the testicular parenchyma. This is the most critical step of the operation, because assessing the type of lesion on frozen sections may be difficult and time-consuming; the most important differential diagnosis between seminoma and Leydig cell tumour, in particular, may be problematic. In some centres, the surgeon prefers to remove the clamp before the results of the pathological analysis. Macroscopic findings during surgery may help the surgeon determine the possible nature of a testicular lesion. A golden-brown appearance and very well-defined margins are suggestive of a Leydig cell tumour, while whitish lesions are more suggestive of seminoma. It is important to repeat ultrasonographic investigation after the removal of the clamp and before placing again the testis inside the scrotum to rule out complications and to assess the testicular vascularisation (Fig. 44.4).

A definite benefit of testis-sparing surgery is that a significant proportion of patients do not have malignant tumours and are definitively treated with an organ-sparing approach. Despite excellent results reported in the literature, results are variable in the clinical practice. The procedure is potentially associated with recurrence, and clamping of the spermatic cord should be kept to minimum in order to grant viability of the operated testis. A trained multidisciplinary team is necessary.