Rationale

While radical orchiectomy remains the standard of care for diagnosing and treating testis cancer, there are a couple of circumstances where testis-sparing surgery is advocated. The primary indications are in men with:

• Small, palpable testis masses and normal serum tumor markers.
• These men have a low, but significant risk of having a benign mass or non-germ cell cancer that does not require orchiectomy. If a testis cancer is confirmed, a radical orchiectomy is completed.
• A small, nonpalpable, ultrasound-detected testis mass with normal tumor markers has an approximately 80% likelihood of being a benign mass.
• Bilateral testis cancers, either synchronous (at the same time) or metachronous (that develop some time after the first testicle is removed).
• The standard of care would be to remove both testicles under suspicion of cancer, however the implications regarding fertility and testosterone replacement are well-established.

Some urologists advocate for testis-sparing surgery even for men with germ cell tumors of the testicle. While some evidence indicates that this can be done safely in some patients, it is not a proven or well-established technique. Before undergoing testis-sparing surgery, an extensive consultation should occur with the patient and their family regarding expectations and possible outcomes in the operating room.

Surgery

The beginning portion of a testis-sparing surgery is identical to a radical orchiectomy. Once the testicle is “delivered,” the testis-sparing portion should begin. Intraoperative ultrasound should be used to identify the mass, rule out other masses and create a surgical plan. The outer layer of the testicle (the tunica albuginea, which houses the tubules of the testicle) is opened and the mass is removed, often with a small margin of normal testicular tissue. The mass will go to pathology for frozen analysis — an expert genitourinary pathologist should evaluate the mass when possible.

If the patient has a normal contralateral testicle and cancer is confirmed in the mass, a completion radical orchiectomy should be performed.

If the patient has (or had) cancer in the contralateral testicle, the pathologist should confirm negative margins before leaving the remainder of the testicle. If there is any suspicion of residual cancer, the testicle should be removed. Once again, the standard of care is bilateral orchiectomy, and testosterone can easily be replaced.

Complications

The complications are the same for radical orchiectomy and testis-sparing surgery. In addition, even if testis-sparing surgery is performed, surgery can result in infertility or hypogonadism if the internal blood supply to the testicle is harmed or if the tubules are disrupted.

Inguinal hernia can occur if the external oblique fascia is not closed properly or if the closure breaks down. It is important to minimize strenuous activities for two to four weeks to prevent development of a hernia.

Testicular Prosthesis

Prostheses should be offered to all men undergoing orchiectomy. Not all men want a prosthesis — it is a personal decision. The prosthesis should be measured in the operating room with the patient asleep. The goal should be to match the remaining testicle in size, taking into account a cancerous testicle can be larger or smaller than normal, and the scrotal skin will make a prosthesis look larger once implanted.