Testicular nubbins and prosthesis insertion: is it all just in the timing?

Abstract

I was interested to read Emir et al’s [1] article on the histological evaluation of testicular nubbins in boys with an impalpable testis. At a mean age of 4.1 years 44 testicular nubbins were examined in 40 boys. Of these, only five were found to contain seminiferous tubules and none showed evidence of malignant degeneration. The authors then used this argument to propose that exploration for a testicular nubbin via an inguinal approach and its removal might therefore be postponed until the time of testicular prosthesis insertion, normally during late adolescence. But is it all simply in the timing of surgery? The authors’ contention raises a number of issues, not all of which they address in their article. First, deferring any inguino-scrotal surgery until completion of puberty potentially exposes the boy with a presumed single testis to some additional risk of loss of that testis through torsion. Whilst the risk is very low and ideal management controversial, many would advise prophylactic fixation of the contralateral remaining testis at the same time as excision of a testicular nubbin [2–4]. Secondly, the authors’ article implies that insertion of a testicular prosthesis represents routine practice and should therefore be another reason to safely defer exploration and removal of a testicular nubbin late in adolescence [1]. Insertion of such a prosthesis, however, would not represent standard practice at my institution. There remains considerable evidence from the literature to suggest potential long-term adverse consequences in a young adult, including local tissue reactions, particle migration, rupture and immunological sequelae [5–8]. These risks require careful evaluation by the surgeon, parent and patient on an individual basis prior to insertion, which should therefore never be regarded as ‘routine’.