Is it orthodox to do a partial orchiectomy (surgical removal of part of the testicle) with frozen section when there is suspicion of testicular neoplasm (tumor)?

Partial Orchiectomy with Frozen Section for Suspected Testicular Neoplasm

Partial orchiectomy with frozen section is only orthodox in specific clinical scenarios and should not be routinely performed for suspected testicular neoplasms. The standard of care remains radical orchiectomy for most cases of suspected testicular malignancy 1.

Appropriate Indications for Partial Orchiectomy

Partial orchiectomy with frozen section should be limited to the following specific scenarios:

• Patients with negative serum tumor markers and small tumors that are possibly benign 1
• Patients with synchronous bilateral testicular tumors 1
• Patients with metachronous contralateral (second) testicular tumors 1
• Patients with a tumor in a solitary testis with sufficient endocrine function 1
• Patients with a tumor and a contralateral atrophic testis 1

Requirements for Partial Orchiectomy

If partial orchiectomy is considered, several critical requirements must be met:

• The procedure should only be performed at centers with experience in managing these rare clinical situations 1
• Frozen section examination must be performed by expert pathologists 1
• Patients must be informed about the risk of completion orchiectomy if discordance exists between frozen section and final pathology 1
• Patients must understand that the spared testicular tissue almost always contains testicular intraepithelial neoplasia (TIN), which requires adjuvant radiotherapy 1

Post-Partial Orchiectomy Management

If partial orchiectomy is performed and TIN is histologically documented:

• Adjuvant radiotherapy (16-20 Gy) to the remaining testicular tissue is strongly recommended 1
• This can be delayed in patients who wish to father children, but only for as short a period as possible 1
• Patients should understand that radiotherapy will render the residual testicular tissue azoospermic but may retain some testosterone production 1

Standard Approach for Suspected Testicular Malignancy

For most cases of suspected testicular malignancy, the standard approach remains:

• Radical orchiectomy through an inguinal incision 1
• The tumor-bearing testicle is resected along with the spermatic cord at the level of the internal inguinal ring 1
• Any scrotal violation for biopsy or open surgery should be strongly avoided 1

Pitfalls and Caveats

• Partial orchiectomy outside the specific indications listed above is considered highly experimental and should be limited to clinical trials 1
• Testis-sparing surgery has a higher risk of local recurrence requiring close monitoring 2
• The testis may be a sanctuary site for germ cell malignancies during systemic treatment, emphasizing the importance of proper surgical management 3
• If frozen section analysis is equivocal, radical orchiectomy is required 4
• Fertility preservation through sperm banking should be offered to all patients before any surgical intervention 2

Conclusion

While partial orchiectomy with frozen section has a role in specific clinical scenarios, it should not be considered orthodox management for most cases of suspected testicular neoplasm. The gold standard remains radical orchiectomy, which provides both definitive diagnosis and treatment with the lowest risk of recurrence and highest chance of cure.