Time for a change in the management of small testicular masses: Results of a large multicentric retrospective study on testis sparing surgery

ntroduction & Objectives: Radical Orchiectomy (RO) represents the standard treatment for patients (pts) with suspicious testicular masses and normal contralateral testis. Because a considerable amount of small testicular masses (STM) are benign lesions, this practice expose to a high risk of overtreatment. The aim of this study is to report results of testis sparing surgery (TSS) in the treatment of STM(< 2cm) and to identify an updated treatment strategy. Materials & Methods: We retrospectively reviewed clinical history of pts treated with TSS for STM<2cm in five tertiary referral centres. Clinical and pathological data were recorded and analysed. Results: Between Jan 2009 and Jan 2017, 147 pts have undergone TSS for STM<2 cm at diagnostic evaluation. Mean pts age was 33 (28-41) years. All diagnoses of STM were based on ultrasonographic evaluation pain in 25 pts, testicular mass in 20, varicocele in 15, infertility in 45 and other reasons in 42. No pts had elevated serum tumour markers. In all cases diagnosis of benign or malignant nature was achieved with frozen section examination(FSE) followed by definitive histology. Pts with benign lesions at FSE underwent TSS. Pts with malignant lesions at FSE underwent immediate RO. No grade II or higher complications according to the Clavien-Dindo classification were reported. 21 pts (14,3%) harboured malignant tumours while 126 (85,7%) benign lesions. In only two cases FSE was not confirmed by definitive pathological examination (leydigioma at FSE and mixed stromal tumour and seminoma at final pathology). FU has been scheduled according to EAU guidelines. Median FU of pts with malignant lesion was (24 months). No tumour recurrences or diffusion were reported. ROC analysis demonstrated that benign conditions were present in 92.6% of STM<1cm and in 73,1% of STM from 1 to 2 cm. Clinical and pathological features are reported in table 1. Conclusions: TSS for STM is a safe and feasible procedure. It allowed preservation of testis in the majority of pts and therefore should be considered the procedure of choice, particularly in nodules<1 cm. In pts with malignancies, during follow-up no recurrences or tumour spreading were observed when RO was preceded by TSS. At the best of our knowledge this is the largest cohort of pts and the biggest series of leydigioma treated with TSS. Guidelines on STM management should change accordingly.