What are the indications for testicular sparing surgery in children?

Indications for Testicular Sparing Surgery in Children

Testicular sparing surgery (TSS) is indicated in prepubertal children (<12 years) with small testicular masses, negative tumor markers (AFP, β-HCG), and ultrasound evidence of adequate healthy testicular parenchyma, particularly for benign germ cell tumors and sex cord-stromal tumors. 1, 2

Primary Indications

Tumor-Specific Criteria

• Benign germ cell tumors (mature teratomas, epidermoid cysts) in prepubertal patients with normal AFP and β-HCG levels are ideal candidates for TSS 2, 3
• Sex cord-stromal tumors (Leydig cell tumors, Sertoli cell tumors) in prepubertal children can be safely managed with TSS 2
• Small tumor size (<2 cm) with preservation of adequate normal testicular parenchyma on preoperative ultrasound supports TSS 4

Patient-Specific Criteria

• Prepubertal age (<12 years) is the most critical patient factor, as 94% of successful TSS cases occur in this population 1, 2
• Synchronous bilateral testicular tumors where preservation of testicular tissue is essential for hormonal function 5, 6
• Solitary testis with sufficient endocrine function where radical orchiectomy would necessitate lifelong testosterone replacement 5
• Contralateral atrophic testis where preserving any functional testicular tissue is paramount 5, 7

Preoperative Requirements

Mandatory Assessments

• Tumor markers (AFP, β-HCG, LDH) must be within normal limits for age; elevated markers mandate radical orchiectomy 1, 4
• High-resolution testicular ultrasound (7.5 MHz transducer) to assess tumor size, location, and amount of spared healthy parenchyma 5, 8
• Inguinal surgical approach with early spermatic cord control at the internal inguinal ring before testicular manipulation 5

Intraoperative Protocol

• Frozen section examination is mandatory before completing TSS to confirm benign histology; discordance with final pathology may require completion orchiectomy 5, 9
• Surgery should only be performed in experienced centers with expert pathologists capable of reliable frozen section interpretation 5, 1

Contraindications

Absolute Contraindications

• Elevated tumor markers (AFP or β-HCG above age-appropriate norms) indicate malignant germ cell tumor requiring radical orchiectomy 1, 4
• Malignant germ cell tumors (yolk sac tumor, embryonal carcinoma, choriocarcinoma) where only 0.4% received TSS with poor outcomes 2
• Postpubertal patients where risk of testicular intraepithelial neoplasia (TIN) is significantly higher 5

Relative Contraindications

• Large tumors (>2 cm) with insufficient remaining healthy parenchyma 4
• Inability to achieve negative surgical margins during tumor enucleation 3

Outcomes and Follow-Up

Expected Results

• Recurrence rates are extremely low: 1.1% across 269 pediatric patients, with only 3 recurrences (2 Leydig cell tumors, 1 teratoma) 1
• Testicular atrophy occurs in only 0.37% of cases when TSS is performed appropriately 1, 2
• Normal sexual maturation and age-appropriate Tanner staging are achieved in properly selected patients 1

Surveillance Protocol

• Long-term follow-up is essential with serial physical examinations and scrotal ultrasound to monitor testicular growth and detect recurrence 1, 9
• Hormone monitoring (testosterone, LH, FSH) to assess testicular function and pubertal development 5
• Median follow-up of 4-7 years demonstrates safety and efficacy of TSS in appropriate candidates 1, 2

Critical Pitfalls to Avoid

• Scrotal violation for biopsy or surgery must be avoided; always use inguinal approach with early cord control 5
• Failure to obtain frozen section before completing TSS risks leaving malignant tissue 5, 9
• Attempting TSS in postpubertal patients without considering high TIN risk (34% with testicular atrophy) 5
• Not discussing fertility preservation (sperm banking) before any testicular surgery, even in prepubertal patients for future consideration 5, 6