Organ-sparing approaches for testicular masses

Abstract

Organ-sparing approaches are currently practiced in urology for many malignancies. Partial orchiectomy of germ cell tumors (GCT) provides potential benefits over radical surgery by reducing the need for androgen substitution, lessening psychological stress, and preserving fertility, with a durable cure rate. Furthermore, many testicular lesions detected clinically or by ultrasonography will be benign, in which case radical orchiectomy represents overtreatment. Partial orchiectomy for benign lesions allows preservation of endocrine and exocrine function, and reduced risk of local recurrence. However, selection criteria are not clear and one must always be suspicious that a GCT might exist. Carcinoma in situ that remains in the salvaged testicle is a challenge to treat. Radiation therapy is an option, although there is a high chance that patients will subsequently require hormonal replacement. Partial orchiectomy should be undertaken only in selected patients--men with bilateral testicular cancer or GCT in a solitary testis--if the size and location of the mass are amenable to surgery. Informed patient consent discussing radical orchiectomy as the gold standard is mandatory, and discussion of the risks associated with CIS and its treatment, as well as the need for androgen supplementation are paramount. Alternative strategies of organ preservation, such as radiotherapy, HIFU and chemotherapy, might be appropriate treatment options in the future. However, the safety and efficacy of these procedures needs to be demonstrated in comparison with partial orchiectomy in larger and prospective studies with longer follow-up.