What is the management of a left testis with ectasia of the rete-testis and multiple intratesticular cysts, with the largest being 9mm?

Management of Rete Testis Ectasia and Intratesticular Cysts

Rete testis ectasia with multiple intratesticular cysts is a benign condition that requires no surgical intervention and can be safely managed with surveillance ultrasound.

Diagnostic Features and Classification

The ultrasound findings described in this case are characteristic of tubular ectasia of the rete testis (TERT) with associated intratesticular cysts:

• Left testis measuring 44mm × 26mm × 18mm (10.7cc)
• Homogeneous echotexture with normal vascularity
• Ectasia of the rete testis
• Multiple intratesticular cysts with largest measuring 9mm
• Normal left epididymis

These findings represent a benign condition that needs to be distinguished from testicular malignancy.

Management Approach

Initial Assessment

1. Confirm Benign Nature: The homogeneous echotexture with normal vascularity strongly suggests a benign condition 1.
2. Tumor Marker Evaluation: Obtain serum tumor markers (alpha-fetoprotein, beta-hCG, and LDH) to definitively rule out testicular malignancy 2.
3. Assess Risk Factors: Evaluate for risk factors for testicular cancer including:
   • History of cryptorchidism
   • Family history of testicular cancer
   • Personal history of testicular cancer
   • Testicular atrophy (volume <12 ml)
   • Age <40 years 2, 1

Recommended Management

For tubular ectasia of the rete testis with intratesticular cysts:

1. Conservative Management: This is a benign condition that requires no surgical intervention 3, 4.
2. Surveillance Ultrasound: Follow-up ultrasound in 6-12 months to ensure stability 5.
3. Patient Education: Instruct on testicular self-examination 1.

Clinical Considerations

Distinguishing Features from Malignancy

• TERT typically appears as multiple small anechoic structures located in the mediastinum testis 3, 6.
• Normal vascularity on Doppler examination (unlike most testicular tumors which show increased vascularity) 2.
• Stable appearance over time - no growth on follow-up imaging 3.

Associated Conditions

TERT is often associated with:

• Age >50 years
• History of vasectomy
• Epididymal cysts/spermatoceles
• Prior inguinal hernia repair
• Any condition causing epididymal or efferent duct obstruction 5

When to Consider Further Evaluation

Further evaluation should be considered if:

1. Serum tumor markers are elevated 2.
2. Ultrasound shows solid components within the cystic structures 1.
3. Follow-up imaging shows growth or changing characteristics 5.
4. Patient has known risk factors for testicular cancer 2, 1.

Common Pitfalls to Avoid

1. Unnecessary Surgery: Avoid radical orchiectomy for this benign condition 4.
2. Inadequate Follow-up: While the condition is benign, initial follow-up is important to confirm stability 5.
3. Misdiagnosis: Don't confuse TERT with cystic testicular tumors such as teratoma 6.
4. Ignoring Associated Conditions: Evaluate for underlying causes of obstruction 5.

In conclusion, tubular ectasia of the rete testis with multiple intratesticular cysts is a benign condition that can be confidently diagnosed based on its characteristic ultrasound appearance. Conservative management with surveillance ultrasound is the appropriate approach, avoiding unnecessary surgical intervention.