Year
Authors
Country
Number treated with TSS
Mean size of tumor mass US Dmax (range)
Histological findings (% on TSS procedures)
Outcome after TSS
2014
Leonhartsberger et al. [36]
Austria
33 in 30
14.8 mm (2–30 mm)
Stromal cell tumor: 19 (57.57%) Metachronous bilateral: GCT: 6 (18.18%)
Disease-free survival: 100%
Bilateral synchronous: Seminoma: 2 (6.06%)
Benign lesions: 6 (18.18%)
2015
Bojanic et al. [37]
Serbia
26
>20 mm
Seminoma: 16 (61.53%) nonseminoma: 9 (34.61%) Leydigoma: 1 (3.84%)
Local recurrence: 7 (26.92%)
Radical orchiectomy: 5 (19.23%)
Overall survival: 100%
2013
Bozzini et al. [38]
Italy
22
11.4 mm (5–31 mm)
Leydig cell tumur: 20 (90.90%)
Local recurrence or distant: 0 (0%)
Nonmalignant stromal: Tumor: 1 (4.54%)
Disease-free survival: 100%
B cell lymphoma: 1 (4.54%)
2011
Lawrentschuk et al. [39]
Canada
27
Benign 10 mm (5–28 mm) malignant 11 mm (6-27 mm)
Benign seminoma: 8 (36.3%) Nonseminomatous GCT: 2 (7.4%)
No perioperative complications
Malignant seminoma: 11 (40.7%) Nonseminomatous GCT: 3 (13.6%) mixed: 1 (4.54%) Teratoma: 2 (7.4%)
Observation in 12 of 17 cases (70.59%)
Local recurrence: 2 (11.76%)
Retroperitoneal lymph node dissection: 1 (5.88%)
2009
Suardi et al. [40]
Italy
28
13.3 mm
Leydig cell tumor: 28 (100%)
Patient died from the disease during the follow-up: 0 (0%)
Local or distant recurrence: 0 (0%)
2006
Heidenreich et al. [27]
Germany
100
15 mm (5–30 mm)
Seminoma: 57 (56.4%)
1 patient died
Embryonal carcinoma: 20 (19.8%)
100 patients are NED (99%)
Mature teratoma: 15 (14.8%)
Mixed/combined TGCT: 9 (8.9%)
The German testicular cancer study group compiled the largest case series and presented the updated results in 2006. A total of 101 men with seminomatous and nonseminomatous bilateral tumors or tumors in solitary testes were treated with TSS at eight centers. During surgery, multiple biopsies of the surgical bed were taken to disclose concomitant foci of TIN, and local adjuvant radiotherapy with an 18-Gy dose was offered to all patients with TIN. A total of 85 patients had TIN, and 80 underwent local radiotherapy. After a mean follow-up of 80 months, cancer-specific survival was excellent (100 of 101) and was coupled with low local recurrence rate (6 of 101) [27].
A uniform experience of all reports is that TSS for GCTs does require adjuvant radiotherapy to the remaining testis. Virtually all GCTs are associated with the presence of TIN in the adjacent parenchyma. Irradiation does eradicate TIN, thus preventing newly arising GCT, but it does also destroy all of the remaining germ cells causing permanent sterility. Nevertheless, in patients desiring to preserve fertility (or father), radiotherapy can safely be postponed provided that proper counselling is given and close monitoring is provided [34]. Leydig cells seem to be more resistant, yet many patients undergoing local radiotherapy experience some grade of endocrine function impairment. Optimal dose of local radiotherapy remains controversial. 20 Gy applied in 10 fractions within 2 weeks remains the standard scheme of adjuvant radiotherapy [11].
Dermoid cyst and mature teratoma represent true germ cell neoplasms. The presence of TIN in the accompanying parenchyma must be considered yet adjuvant radiation does not appear to be mandatory, as again these patients can be monitored closely with adequate counselling [41, 42].
Sex cord/gonadal stromal tumors account for 3–5% of all testis tumors, with Leydig cell tumors representing 75–80% of them. Less than 10% of all these tumors follow a malignant course. In contrast to GCTs, Leydig cell tumors may sometimes be suspected preoperatively because of typical heralding symptoms/signs (gynecomastia, infertility, endocrine abnormalities) or ultrasonographic features [43].
Functional Outcome
The loss of testis parenchyma has potential negative consequences on long-term exocrine and endocrine function [34]. The impact of unilateral orchidectomy has not been widely addressed in the literature so far. Some evidence indicates that the loss of one testis is associated with impaired spermatogenesis and altered endocrine function [44].
Consequently, it appears reasonable to preserve as much testicular parenchyma as possible by pursing TSS whenever possible, provided that cancer control is not jeopardized. These considerations hold particularly true for patients with malignant GCTs because a significant proportion of them have impaired spermatogenesis at the time of diagnosis [45]. In the largest TSS series reported so far with a mean follow-up of 80 months, 84 of 101 patients treated with TSS for GCTs had a normal postoperative testosterone [27].
In the series by Steiner et al. all patients had normal preoperative testosterone levels. Approximately 60 months after TSS, all patients but one had a normal testosterone level [7].
Conclusion
Organ-sparing surgery is a concept/reality that its time has come. Testicular sparing surgery should be embraced, in the appropriate patient, in the management of selected solid testicular masses replacing the dogmatic axiom of radical removal of the whole testicle. The psychological, hormonal, and fertility benefits are obvious. The utilization of intraoperative frozen section will guide and strengthen our indications. The indications are benign tumors, mass in a solitary testicle, bilateral tumors, and non-palpable ultrasound-detected small testicular mass .
References
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2.
3.
Ferreira U, Netto Junior NR, Esteves SC, Rivero MA, Schirren C. Comparative study of the fertility potential of men with only one testis. Scand J Urol Nephrol. 1991;25(4):255–9.CrossrefPubMed
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