While radical orchiectomy remains the standard-of-care for the diagnosis and treatment of testis cancer, there are a couple of circumstances where testis-sparing surgery is advocated. The primary indications are in men with:
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
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
small, non-palpable, ultrasound detected testis mass with normal tumor markers approximately 80% likelihood of benign mass
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.
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. The tunica vaginalis should be opened vertically to expose the testicle and intraoperative ultrasound should be used to identify the mass, rule-out other masses and create a surgical plan. The testicle should be iced down for 10 minutes prior to placing a tourniquet or non-crushing clamp on the spermatic cord. Once the testicle has been iced, a clamp or tourniquet should be placed on the cord. The tunica albuginea (which houses the tubules of the testicle) should be opened horizontally above the mass. The mass can often be "shelled" out of the surrounding tubules with a margin of 3-5mm.
Surgical loupes or a microscope can be used to facilitate dissection with a clean margin. Bipolar forceps can be used to control any bleeding to prevent injury to the remaining tubules. The mass should then immediately 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 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.
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 2-4 weeks to prevent development of a hernia.
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.