Focal Surgery in Testis Cancer: Current State of the Art

Abstract

Radical orchiectomy is the standard treatment of testicular neoplasia causing androgen insufficiency, infertility and psychological stress. Focal surgery allows the preservation of fertility, endocrine function and integrity of the genital anatomy, with preservation of the image of the male body. The EAU guidelines suggest focal surgery in case of synchronous bilateral tumors, metachronous contralateral tumours, tumour in solitary testis with normal pre-operative testosterone levels, when the tumor volume less than 30% of the testicular volume. There are two focal surgical techniques: tumorectomy and polar resection, followed by biopsies and frozen section of the resection bed. In case of benign tumours, the treatment is often curative. In case of malignancy, carcinoma in situ is frequently found in the surrounding tissues. Adjuvant treatment with chemotherapy or radiotherapy is performed with a fair success rate. These adjuvant treatments reduce or delete the functional benefits achieved by conservative surgery. The evidence of the literature suggests that focal surgery is a valid option for all patients with testicular tumours that are not palpable and small sized, with the advantage of avoiding unnecessary radical orchiectomy in most cases. Therefore, the selection criteria for focal surgery are the mass size (less than 25 mm) and a safety distance of the tumor from the rete testis, in order to preserve testicular vascularization. A close follow-up with ultrasound, testicular markers and radiological examinations is mandatory in case of germ cell neoplasia treated conservatively in patients with indications for conservative surgery.