Partial Orchiectomy

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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 . [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]

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.

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.

In 2012, the American Cancer Society estimates that 8590 cases of testicular cancer will be diagnosed in men in the United States. [6] The annual incidence of testicular cancer ranges from 3-6 per 100,000 males.

The following are risk factors for testicular cancer:

Seven to ten percent of men who develop testicular cancer have a history of cryptorchidism. [2]

Gonadal dysgenesis is a risk factor.

Male factor infertility is a risk factor. [7]

Testicular cancer is 5 times more common in white males than in black males.

Age is a risk factor, with more than half of all testicular cancers being diagnosed between the ages of 20 and 34 years.

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.

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.

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. [8]

Newer indications for partial orchiectomy include small nodules in a solitary testicle or bilateral testicular nodules with a desire to the need for hormonal supplementation.

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.

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.

Rosenfield AT, Hammers LW. Imaging of the testicle: the painful scrotum and nonpalpable masses. Urol Radiol. 1992. 14:229. [Medline].

Richie JP, Steele GS. Neoplasms of the testis. Kavoussi LR, Novick AC, Partin AW, Peters CA, Wein AJ, eds. Campbells-Walsh Urology. 9th ed. Philadelphia, PA: Elsevier; 2007. Vol 1: 893-935.

Richie JP. Detection and treatment of testicular cancer. Cancer J Clin. 1993. 43:151. [Medline].

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 Feb. 185(2):508-13. [Medline].

Richie JP. Simultaneous bilateral testis tumors with unorthodox management. World J Urol. 1984. 2:74.

American Cancer Society. Cancer Facts and Figures 2012. Available at http://www.cancer.org/research/cancerfactsfigures/cancerfactsfigures/cancer-facts-figures-2012. Accessed: November 5, 2012.

Walsh TJ, Croughan MS, Schembri M, Chan JM, Turek PJ. Increased risk of testicular germ cell cancer among infertile men. Arch Intern Med. 2009 Feb 23. 169(4):351-6. [Medline].

Heidenreich A, Weissbach L, Höltl W, Albers P, Kliesch S, Köhrmann KU, et al. Organ sparing surgery for malignant germ cell tumor of the testis. J Urol. 2001 Dec. 166(6):2161-5. [Medline].

Peterson LJ, Catalona WJ, Koehler RE. Ultrasonic localization of a non-palpable testis tumor. Journal of Urology. 1983. 122:843. [Medline].

Bockrath JM, Schaeffer AJ, Kies MS, Neiman HL. Ultrasound identification of impalpable testicle tumor. J Urol. 1983. 130:355-6. [Medline].

Moudy PC, Makhija JS. Ultrasonic demonstration of a non-palpable testicular tumor. J Clin Ultrasound. 1983 Jan. 11(1):54-5. [Medline].

Powell TM, Tarter TH. Management of nonpalpable incidental testicular masses. J Urol. 2006. 176:96-8. [Medline].

Buckspan MB, Klotz PG, Goldfinger M, Stoll S, Fernandes B. Intraoperative ultrasound in the conservative resection of testicular neoplasms. J Urol. 1989. 141:326-7. [Medline].

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. 170:1783-6. [Medline].

Comiter CV, Carol JB, Capelouto CC, Kantoff P, Shulman L, Richie JP, et al. Nonpalpable intratesticular masses detected sonographically. J Urol. 1995. 154:1367-9. [Medline].

Corrie D, Mueller EJ, Thompson IM. Management of ultrasonically detected nonpalpable testis masses. Urology. 1991 Nov. 38(5):429-31. [Medline].

Csapo Z, Bornhof C, Giedl J. Impalpable testicular tumors diagnosed by scrotal ultrasonography. Urology. 1988. 32:549-52. [Medline].

Hopps CV, Goldstein M. Ultrasound guided needle localization and microsurgical exploration for incidental nonpalpable testicular tumors. J Urol. 2002. 168:1084-7. [Medline].

Horstman WG, Haluszka MM, Burkhard TK. Management of testicular masses incidentally discovered by ultrasound. J Urol. 1994. 151:1263-5. [Medline].

Bazzi WM, Raheem OA, Stroup SP, Kane CJ, Derweesh IH, Downs TM. Partial orchiectomy and testis intratubular germ cell neoplasia: World literature . Urol Ann. 2011 Sep. 3(3):115-8. [Medline]. [Full Text].

Samuel G Deem, DO Faculty, Department of Urology, Charleston Area Medical Center

Samuel G Deem, DO is a member of the following medical societies: American College of Surgeons, American Osteopathic Association, American Urological Association, Endourological Society, Society of Urologic Oncology, American Society of Clinical Oncology, American College of Osteopathic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus.

Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

Disclosure: Nothing to disclose.

Brandan A Kramer, MD Resident Physician, Division of Urology, Southern Illinois University

Brandan A Kramer, MD is a member of the following medical societies: American Association of Clinical Urologists, American Urological Association, and Endourological Society

Disclosure: Nothing to disclose.

Thomas H Tarter, MD, PhD Associate Professor, Department of Surgery, Division of Urology, Director of Urologic Oncology, Simmons Cooper Cancer Institute, Southern Illinois University School of Medicine

Thomas H Tarter, MD, PhD is a member of the following medical societies: American College of Surgeons Oncology Group, American Medical Association, American Urological Association, and Society of Urologic Oncology

Disclosure: Illinois Cryotherapy Enterprise Ownership interest Other

Partial Orchiectomy

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