Microsurgical “testis-sparing” surgery for nonpalpable hypoechoic testicular lesions

Rolle, Luigi; Tamagnone, A.; Destefanis, Paolo; Bosio, Andrea; Timpano, M.; Fiori, Cristian; Ceruti, C.; Burlo, Paola; Fauciglietti, P; Fontana, Dario

doi:10.1016/j.urology.2006.02.028

Cited by 36 publications

(26 citation statements)

References 17 publications

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“…However, when the clinical picture of segmental infarction is unclear on account of inconclusive ultrasound findings and atypical morphology on MRI, a histological confirmation cannot be avoided. This can be obtained by using a micro‐invasive approach, such as micro‐TESE guided by ultrasound localization (Hopps & Goldstein, 2006; Rolle et al. , 2006).…”

Section: Discussionmentioning

confidence: 99%

Segmental testicular ischaemia: presentation, management and follow‐up

2009

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Segmental infarction of the testis is a rare event. Less than 40 cases have been reported in the literature and its aetiology remains largely unknown. The diagnosis is challenging and its identification crucial as partial ischaemia is frequently confused with testicular tumours and unnecessarily treated with orchiectomy. The objectives of this study are to: (i) raise awareness of this rare condition, (ii) provide the distinctive clinical and radiological features enabling pre-operative diagnosis, (iii) promote appropriate screening of causative factors and (iv) propose an alternative management approach to avoid surgery and preserve fertility. We describe three cases of partial testicular ischaemia in men presenting with reduced sperm quality. The cases demonstrate the ultrasound and magnetic resonance imaging appearance of testicular ischaemia. The surveillance strategy adopted for these lesions indicates that over 2 years of follow-up, marginal changes in the lesions can occur. Histology revealed that infiltration by stromal cells, leucocytes and macrophages is responsible for the remodelling of these lesions. Screening of risk factors for thromboembolism revealed that all patients carried a methylenetetrahydrofolate reductase 677C-->T (MTHFR) mutation in a gene involved in folate metabolism, and either borderline or elevated homocysteine levels. Distinctive features permit the pre-operative diagnosis of segmental testicular ischaemia. There are sufficient data to assert that a surveillance strategy is safe and feasible. We speculate that the defects in folate metabolism may pre-dispose individuals to the development of testicular infarction and infertility.

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Section: Discussionmentioning

confidence: 99%

Segmental testicular ischaemia: presentation, management and follow‐up

2009

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“…The key features of partial orchiectomy are the use of an inguinal approach and early vascular control before mobilization of the testis out of the scrotum, in order to avoid systemic tumor seeding. The mass is then excised with a core of normal parenchyma around it (Figure 2), 39 taking care not to violate the tumor capsule in situ. FSe is performed on tumor samples.…”

Section: Partial Orchiectomymentioning

confidence: 99%

“…In specific cases where small lesions are involved, intra operative ultrasonography has been used to locate lesions, 34 and microsurgical techniques have been developed. 34,39 warm or cold ischemia remains controversial, 40 but if performed, Steiner and colleagues 31 advocate immersion of the testis in crushed ice for 5 min before spermatic cord occlusion.…”

Section: Partial Orchiectomymentioning

confidence: 99%

“…7,39,[41][42][43][44][45] This has implications for the management of such masses, as the risk of overtreatment with radical orchiectomy is much greater than previously thought. Horstman et al 42 reported their experience of nine patients who were found to have incidental nonpalpable testicular lesions among approximately 1,600 scrotal ultrasonography scans performed for other indications.…”

Section: Management Of Benign Testicular Massesmentioning

confidence: 99%

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Organ-sparing approaches for testicular masses

2010

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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.

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“…The first description of the operative technique of ultrasound guided testicular nodule excision was made by Stoll et al (12) and progressively developed until 2002, when Hopps and Goldstein codified the procedure introducing the use of a magnificent system, with the aim of improving the identification and complete excision of small non palpable lesions (13). Rolle et al (14) described their experience on a series of 14 hypoechoic testicular lesions that underwent surgical exploration with the aid of the operating microscope. With a mean size of the nodules of 5.7 ± 4.6 mm, they reported the identification and the complete excision of lesions in all patients.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic ultrasound-guided excisional testicular biopsy for small (< 1 cm) incidental nodules. A single institution experience

Fabiani

Filosa

Fioretti

et al. 2014

Arch Ital Urol Androl

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Introduction and objectives:The widespread use of scrotal ultrasound (SUS) has led to a marked increase in the number of incidentally detected testicular lesions. A small incidental nodule (STN) has defined as a non palpable (< 10 mm), asymptomatic solid lesion with normal levels of oncological testicular markers. Nowadays the lack of agreement on the topic causes managing problems to andrologists. We present our experience consisting in 8 cases of STN discovered by SUS performed for different clinical indications. Matherial and methods: We retrieved from our ultrasonographic files the clinical information about 717 patients evaluated for andrological problems. Patients with STN underwent to a complete clinical history and physical examination as well as oncological testicular markers measurement and ormonal assessment and then received a diagnostic ultrasound guided excisional biopsy (DEB). Surgical approach was performed through an inguinal incision. Using the coordinates previously obtained from preoperative SUS, STN was localized by intraoperative SUS. The lesion was enucleated and sent to the Pathology department for frozen section examination (FSE). Biopsies of affected testis (TB) were also performed. Post-excision ultrasound has been used to confirm the complete removal of the nodule. Whether pathological findings were benign, testis sparing surgery (TSS) was performed. Immediate radical orchidectomy (IRO) was performed if FSE and TB findings suggested a malignant lesion. Results: STNs were discovered in 8 patients (1,1%). Very small lesions (< 5 mm) were detected in 50% of cases. We performed four IRO and four DEB with consequent TSS. In one case we performed a delayed radical orchidectomy (DRO). At FSE pathologist reported 3 Leydig cell tumor and 3 seminoma and an inflammatory regressive lesion in one case. FSE on TB reported intratesticular neoplasia (TIN) in three cases. In one case nodule wasn't sent to FSE. We observed a concordance between FSE and definitive pathologic report in six cases (75%). SummaryNo conflict of interest declared.

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Microsurgical “testis-sparing” surgery for nonpalpable hypoechoic testicular lesions

Cited by 36 publications

References 17 publications

Segmental testicular ischaemia: presentation, management and follow‐up

Segmental testicular ischaemia: presentation, management and follow‐up

Organ-sparing approaches for testicular masses

Diagnostic ultrasound-guided excisional testicular biopsy for small (< 1 cm) incidental nodules. A single institution experience

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