Background
Partial orchiectomy is used as an alternative to radical orchiectomy when the latter could result in overtreatment, typically in the management of small nonpalpable testicular masses found incidentally on scrotal ultrasonography. [1] Most of these small masses are benign, meaning that radical orchiectomy may be an excessive treatment option in such cases. Partial orchiectomy may also be an option for the management of testicular malignancy in a select group of patients in whom radical orchiectomy is not desirable, including those with a solitary testicle, bilateral metachronous testicular malignancies, and/or a desire for fertility or being independent from androgen supplementation.
Testicular cancer is the most common malignancy in young men aged 15-35 years. [2] It usually presents as a palpable solid mass. [3] Although not considered the standard of care, partial orchiectomy is being used with increasing frequency for management of this disease. While preservation of viable testicular tissue can be helpful in avoiding the need for androgen supplementation, it may also lead to the need for further treatment, including chemotherapy or radiation. [4]
History of the Procedure
The first reported partial orchiectomy for testicular cancer was performed by Richie in the United States in 1984. [5] Since this time, multiple other reports have been made and have led to an increase in interest in this testis-sparing technique.
Problem
Testicular cancer treatment can lead to a multitude of medical morbidities, including infertility, disfigurement, and need for hormone replacement therapy. Partial orchiectomy can alleviate this burden in select cases.
Epidemiology
United States data
In 2020, the American Cancer Society estimates that about 9610 cases of testicular cancer will be diagnosed in men in the United States. [6] The annual incidence of testicular cancer is about 5.9 per 100,000 males. In 2017, an estimated 269,769 men were living with testicular cancer in the United States. [7]
Etiology
The following are risk factors for testicular cancer:
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Seven to ten percent of men who develop testicular cancer have a history of cryptorchidism. [2]
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Gonadal dysgenesis is a risk factor.
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Male factor infertility is a risk factor. [8]
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Testicular cancer is 5 times more common in white males than in black males.
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Age is a risk factor, with more than half of all testicular cancers being diagnosed between the ages of 20 and 34 years.
Pathophysiology
Genetic influences on the short arm of chromosome 12 appear to lead to the development of testicular cancer. This influence is hypothesized to induce abnormal cell division and malignant transformation of germ cells, leading to carcinoma. The exact mechanism of this development is yet to be determined.
Presentation
The most common presenting symptom of testicular carcinoma is a painless swelling or nodule of one or both testicles. A painful testicle or orchitis can rarely be a presentation of testicular cancer and this risk warrants investigation with ultrasound of the testicles after the inflammatory process has resolved. Metastatic testicular cancer may present with other symptoms related to the location of the metastasis and can include fever, lymphadenopathy, abdominal pain, nausea, wasting, neurologic deficits, cough, shortness of breath, or hemoptysis, among others.
Indications
Candidates for open excisional biopsy and partial orchiectomy include adult patients with nonpalpable, incidentally detected testicular neoplasms without a history of previous testicular cancer and serum marker levels within the reference range. Testicle-sparing surgery for larger lesions has been reported but is not currently the standard of care in the United States. [9]
Newer indications for partial orchiectomy include small nodules in a solitary testicle or bilateral testicular nodules with a desire to avoid the need for hormonal supplementation.
Relevant Anatomy
The testes are paired ovoid structures located in the pendulous scrotum of males. Blood supply to the testis is from the testicular artery and its drainage is via the pampiniform plexus of testicular veins. Covering the human testis is a thick, fibrous structure known as the tunica albuginea. Seminiferous tubules fill the testis, which are lined by a layer of germ cells. A ductal system through the rete testis connects the testis to the epididymis, which leaves the scrotum via the vas deferens as the primary conduit for sperm.
Contraindications
Patients with elevated serum marker levels, palpable testicular masses, gynecomastia, or retroperitoneal germ cell cancers are typically not candidates for partial orchiectomy with excisional biopsy. Instead, radical orchiectomy is usually necessary in these patients.
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Scrotal sonogram showing a 0.5-cm X 0.6-cm, hypoechoic, parenchymal mass in the left testis of a 24-year-old man with no palpable lesions. Findings of tumor marker studies and abdominal and pelvic CT scanning were negative. He was treated with an open ultrasound-guided excisional biopsy through an inguinal incision.
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Final pathology showing a sex cord stromal tumor. The testis was spared due to low malignant potential of the neoplasm.
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Scrotal sonogram showing a 0.5-cm X 0.4-cm hypoechoic parenchymal mass in the left testis of a 30-year-old man with a nonpalpable testicular mass. Tumor marker results were negative.
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Final pathology showing seminoma. Frozen section revealed a lymphocytic infiltrate with epithelioid cells consistent with granulomatous disease. Treatment was radical orchiectomy. No residual invasive seminoma was found in the orchiectomy specimen.
