Testis-Sparing Surgery: Balancing Cancer Control with Fertility Preservation

  • Muhammad A. BulbulEmail author
  • Bassel G. Bachir


Testicular cancer remains the most commonly diagnosed malignancy in young men of reproductive age, with a peak incidence between the ages of 25 and 29. In patients with testicular cancer, the presence of the disease as well as the treatment itself may lead to significant morbidity, resulting in profound psychological, reproductive, and endocrinological damage to patients. Unfortunately, the incidence of testicular cancer has been steadily increasing in the Western world, bringing to the forefront the concept of testis-sparing surgery. Following the dogma of never-compromising cancer control, testis-sparing surgery (TSS) has the potential of reducing morbidity while preserving functionality. In this chapter, we discuss the evolving concept of TSS and its various indications and applications. Given the emerging evidence of the benign nature of most small, non-palpable testicular masses and the obvious benefits of organ preservation, the indications for TSS continue to expand. Initial evaluation includes history, physical examination, as well as review of pertinent imaging. Tumor markers and hormonal assessment are relevant, while baseline semen analysis is essential in patients who still desire fertility. TSS follows the same classic oncological principles of radical orchiectomy, including inguinal exploration and cord control. While various techniques can be utilized for tumor excision, frozen section examination is crucial for optimal treatment. When applied to select patients, TSS is a reality that must not be denied.


Testis-sparing surgery Non-palpable testes mass Organ preservation Fertility preservation Frozen section examination 


  1. 1.
    La Vecchia C, Bosetti C, Lucchini F, Bertuccio P, Negri E, Boyle P, et al. Cancer mortality in Europe, 2000–2004, and an overview of trends since 1975. Ann Oncol. 2010;21(6):1323–60.CrossRefPubMedGoogle Scholar
  2. 2.
    Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, et al. EAU guidelines on testicular cancer: 2011 update. Eur Urol. 2011;60(2):304–19.CrossRefPubMedGoogle Scholar
  3. 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.CrossRefPubMedGoogle Scholar
  4. 4.
    Giannarini G, Dieckmann KP, Albers P, Heidenreich A, Pizzocaro G. Organ-sparing surgery for adult testicular tumours: a systematic review of the literature. Eur Urol. 2010;57(5):780–90.CrossRefPubMedGoogle Scholar
  5. 5.
    Hallak J, Cocuzza M, Sarkis AS, Athayde KS, Cerri GG, Srougi M. Organ-sparing microsurgical resection of incidental testicular tumors plus microdissection for sperm extraction and cryopreservation in azoospermic patients: surgical aspects and technical refinements. Urology. 2009;73(4):887–91. discussion 91–2CrossRefPubMedGoogle Scholar
  6. 6.
    Carmignani L, Gadda F, Gazzano G, Nerva F, Mancini M, Ferruti M, et al. High incidence of benign testicular neoplasms diagnosed by ultrasound. J Urol. 2003;170(5):1783–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Steiner H, Holtl L, Maneschg C, Berger AP, Rogatsch H, Bartsch G, et al. Frozen section analysis-guided organ-sparing approach in testicular tumors: technique, feasibility, and long-term results. Urology. 2003;62(3):508–13.CrossRefPubMedGoogle Scholar
  8. 8.
    Connolly SS, D’Arcy FT, Bredin HC, Callaghan J, Corcoran MO. Value of frozen section analysis with suspected testicular malignancy. Urology. 2006;67(1):162–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Bahadur G, Ozturk O, Muneer A, Wafa R, Ashraf A, Jaman N, et al. Semen quality before and after gonadotoxic treatment. Hum Reprod. 2005;20(3):774–81.CrossRefPubMedGoogle Scholar
  10. 10.
    Howell S, Shalet S. Gonadal damage from chemotherapy and radiotherapy. Endocrinol Metab Clin N Am. 1998;27(4):927–43.CrossRefGoogle Scholar
  11. 11.
    Krege S, Beyer J, Souchon R, Albers P, Albrecht W, Algaba F, et al. European consensus conference on diagnosis and treatment of germ cell cancer: a report of the second meeting of the European Germ Cell Cancer Consensus group (EGCCCG): part I. Eur Urol. 2008;53(3):478–96.CrossRefPubMedGoogle Scholar
  12. 12.
    Heidenreich A, Bonfig R, Derschum W, von Vietsch H, Wilbert DM. A conservative approach to bilateral testicular germ cell tumors. J Urol. 1995;153(1):10–3.CrossRefPubMedGoogle Scholar
  13. 13.
    Sheinfeld JMJ, Bosl GJ. Surgery of testicular tumors. In: Walsh PC, Vaughan ED, Wein AJ, editors. Campbells urology, vol. 4. 8th ed. Philadelphia: W.B. Saunders; 2002.Google Scholar
  14. 14.
    Goldstein M, Waterhouse K. When to use the Chevassu maneuver during exploration of intrascrotal masses. J Urol. 1983;130(6):1199–200.CrossRefPubMedGoogle Scholar
  15. 15.
    Giorgio Ivan Russo GR, Privitera S, Castelli T, Madonia M, Cimino S, Favilla V, Morgia G. Contemporary role of testis sparing surgery: a systematic review. Eur Med J Urol. 2015;3(1):34–40.Google Scholar
  16. 16.
    Giannarini G, Mogorovich A, Menchini Fabris F, Morelli G, De Maria M, Manassero F, et al. Long-term followup after elective testis sparing surgery for Leydig cell tumors: a single center experience. J Urol. 2007;178(3 Pt 1):872–6. quiz 1129CrossRefPubMedGoogle Scholar
  17. 17.
    Leonhartsberger N, Gozzi C, Akkad T, Springer-Stoehr B, Bartsch G, Steiner H. Organ-sparing surgery does not lead to greater antisperm antibody levels than orchidectomy. BJU Int. 2007;100(2):371–4.CrossRefPubMedGoogle Scholar
  18. 18.
    Maizlin ZV, Belenky A, Kunichezky M, Sandbank J, Strauss S. Leydig cell tumors of the testis: gray scale and color Doppler sonographic appearance. J Ultrasound Med. 2004;23(7):959–64.CrossRefPubMedGoogle Scholar
  19. 19.
    Carmignani L, Colombo R, Gadda F, Galasso G, Lania A, Palou J, et al. Conservative surgical therapy for leydig cell tumor. J Urol. 2007;178(2):507–11. discussion 11CrossRefPubMedGoogle Scholar
  20. 20.
    Wegner HE, Herbst H, Andresen R, Dieckmann KP. Leydig cell tumor recurrence after enucleation. J Urol. 1996;156(4):1443–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Haas GP, Shumaker BP, Cerny JC. The high incidence of benign testicular tumors. J Urol. 1986;136(6):1219–20.CrossRefPubMedGoogle Scholar
  22. 22.
    Kressel K, Schnell D, Thon WF, Heymer B, Hartmann M, Altwein JE. Benign testicular tumors: a case for testis preservation? Eur Urol. 1988;15(3–4):200–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Elert A, Olbert P, Hegele A, Barth P, Hofmann R, Heidenreich A. Accuracy of frozen section examination of testicular tumors of uncertain origin. Eur Urol. 2002;41(3):290–3.CrossRefPubMedGoogle Scholar
  24. 24.
    Lange PH. A gallery of unusual cases. World J Urol. 1984;2:73–86.CrossRefGoogle Scholar
  25. 25.
    Yossepowitch O, Baniel J. Role of organ-sparing surgery in germ cell tumors of the testis. Urology. 2004;63(3):421–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Weissbach L. Organ preserving surgery of malignant germ cell tumors. J Urol. 1995;153(1):90–3.CrossRefPubMedGoogle Scholar
  27. 27.
    Heidenreich A, Albers P, Krege S. Management of bilateral testicular germ cell tumours––experience of the German Testicular Cancer Study Group (GTCSG). Eur Urol Suppl. 2006;5(2):97.CrossRefGoogle Scholar
  28. 28.
    Albers P. Management of stage I testis cancer. Eur Urol. 2007;51(1):34–43. discussion 43−4CrossRefPubMedGoogle Scholar
  29. 29.
    Hopps CV, Goldstein M. Ultrasound guided needle localization and microsurgical exploration for incidental nonpalpable testicular tumors. J Urol. 2002;168(3):1084–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Leroy X, Rigot JM, Aubert S, Ballereau C, Gosselin B. Value of frozen section examination for the management of nonpalpable incidental testicular tumors. Eur Urol. 2003;44(4):458–60.CrossRefPubMedGoogle Scholar
  31. 31.
    Powell TM, Tarter TH. Management of nonpalpable incidental testicular masses. J Urol. 2006;176(1):96–8. discussion 99CrossRefPubMedGoogle Scholar
  32. 32.
    Carmignani L, Gadda F, Mancini M, Gazzano G, Nerva F, Rocco F, et al. Detection of testicular ultrasonographic lesions in severe male infertility. J Urol. 2004;172(3):1045–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Carmignani L, Morabito A, Gadda F, Bozzini G, Rocco F, Colpi GM. Prognostic parameters in adult impalpable ultrasonographic lesions of the testicle. J Urol. 2005;174(3):1035–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Heidenreich A, Weissbach L, Holtl W, Albers P, Kliesch S, Kohrmann KU, et al. Organ sparing surgery for malignant germ cell tumor of the testis. J Urol. 2001;166(6):2161–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Seppelt U. Enukleation eines sukzessiven Zweittumors im Resthoden. Therapiewoche. 1982;32:560–3.Google Scholar
  36. 36.
    Leonhartsberger N, Pichler R, Stoehr B, Horninger W, Steiner H. Organ preservation technique without ischemia in patients with testicular tumor. Urology. 2014;83(5):1107–11.CrossRefPubMedGoogle Scholar
  37. 37.
    Bojanic N, Bumbasirevic U, Vukovic I, Bojanic G, Milojevic B, Nale D, et al. Testis sparing surgery in the treatment of bilateral testicular germ cell tumors and solitary testicle tumors: a single institution experience. J Surg Oncol. 2015;111(2):226–30.CrossRefPubMedGoogle Scholar
  38. 38.
    Bozzini G, Picozzi S, Gadda F, Colombo R, Decobelli O, Palou J, et al. Long-term follow-up using testicle-sparing surgery for Leydig cell tumor. Clin Genitourin Cancer. 2013;11(3):321–4.CrossRefPubMedGoogle Scholar
  39. 39.
    Lawrentschuk N, Zuniga A, Grabowksi AC, Rendon RA, Jewett MA. Partial orchiectomy for presumed malignancy in patients with a solitary testis due to a prior germ cell tumor: a large North American experience. J Urol. 2011;185(2):508–13.CrossRefPubMedGoogle Scholar
  40. 40.
    Suardi N, Strada E, Colombo R, Freschi M, Salonia A, Lania C, et al. Leydig cell tumour of the testis: presentation, therapy, long-term follow-up and the role of organ-sparing surgery in a single-institution experience. BJU Int. 2009;103(2):197–200.CrossRefPubMedGoogle Scholar
  41. 41.
    Vigano P, Picozzi SC, Manganini V, Casu M, Giuberti A, Mazza L, et al. A 7-year history of an intratesticular mass: patient description and review of the literature about dermoid cysts of the testis. Urol Int. 2006;77(3):281–3.CrossRefPubMedGoogle Scholar
  42. 42.
    Davidov MI, Malkov AD. Dermoid cyst of the testis. Urologiia. 2003;2(2):52–5.Google Scholar
  43. 43.
    Acar C, Gurocak S, Sozen S. Current treatment of testicular sex cord-stromal tumors: critical review. Urology. 2009;73(6):1165–71.CrossRefPubMedGoogle Scholar
  44. 44.
    Nord C, Bjoro T, Ellingsen D, Mykletun A, Dahl O, Klepp O, et al. Gonadal hormones in long-term survivors 10 years after treatment for unilateral testicular cancer. Eur Urol. 2003;44(3):322–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Dieckmann KP, Linke J, Pichlmeier U, Kulejewski M, Loy V, German Testicular Cancer Study G. Spermatogenesis in the contralateral testis of patients with testicular germ cell cancer: histological evaluation of testicular biopsies and a comparison with healthy males. BJU Int. 2007;99(5):1079–85.CrossRefPubMedGoogle Scholar
  46. 46.
    Huyghe E, Soulie M, Escourrou G, Mieusset R, Plante P, Thonneau P. Conservative management of small testicular tumors relative to carcinoma in situ prevalence. J Urol. 2005;173(3):820–3.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Division of Urology, Department of SurgeryAmerican University of BeirutBeirutLebanon

Personalised recommendations