Testicular Incision Biopsy in Children: Indications
Incision (open) testicular biopsy in children is NOT routinely indicated and should be reserved for highly specific clinical scenarios, primarily in postpubertal boys with cryptorchidism when orchiectomy is being considered, or for experimental fertility preservation before gonadotoxic therapy.
Primary Indication: Postpubertal Cryptorchidism
In postpubertal children with undescended testes, consideration should be given to performing either orchiectomy or biopsy, particularly when the contralateral testis is normal. 1 This recommendation reflects the significantly elevated cancer risk (2.75-8 fold increase) and limited fertility benefit of orchidopexy after puberty. 1
Key Decision Points:
- Status of contralateral testis: If normal, orchiectomy is generally preferred over biopsy for postpubertal undescended testes 1
- Associated medical conditions and anesthetic risk must be carefully weighed 1
- Hormonal function: In adults with biochemical hypogonadism, orchidopexy may be offered if technically feasible, making biopsy for tissue diagnosis less relevant 2
Secondary Indication: Fertility Preservation Before Gonadotoxic Therapy
Testicular biopsy for fertility preservation is an emerging experimental indication in prepubertal boys facing gonadotoxic chemotherapy or hematopoietic stem cell transplantation. 3, 4 This involves cryopreservation of testicular tissue, though methods to use this tissue remain experimental.
Evidence Supporting Safety:
- Postoperative complications (hematoma, infection) occur in only 1-3.8% of cases 4, 5
- Testicular growth is not impeded by biopsy - biopsied testes show equivalent growth to contralateral non-biopsied testes up to 12 months post-procedure 5
- Mean testicular volumes remain comparable between biopsied and non-biopsied testes over one year of follow-up 5
Contraindicated Scenarios
Prepubertal Cryptorchidism
Routine testicular biopsy is NOT indicated in prepubertal boys with cryptorchidism. 1 The standard of care is orchidopexy by 18 months of age, which should be performed without biopsy. 1, 6, 7
Critical pitfall to avoid: Performing biopsy instead of proceeding directly to orchidopexy in prepubertal boys delays definitive treatment and provides no therapeutic benefit. 6, 7
Diagnostic Purposes in Routine Cases
Scrotal violation for biopsy should be strongly avoided in suspected testicular tumors - radical inguinal orchiectomy is the standard approach. 1 Frozen section may be used intraoperatively in doubtful cases of small tumors to allow organ-sparing surgery, but this is not an "incision biopsy" in the traditional sense. 1
Special Consideration: Contralateral Biopsy for TIN Detection
Contralateral testicular biopsy to detect testicular intraepithelial neoplasia (TIN) may be offered in high-risk adult patients, particularly those with testicular atrophy (volume <12 ml) and age <40 years, or extragonadal germ cell tumors. 1 However, this is primarily an adult indication and patient preference plays a significant role, as surveillance is an acceptable alternative with near 100% survival regardless of strategy chosen. 1
Technical Considerations When Biopsy IS Performed
- Open biopsy is preferred over needle biopsy for adequate tissue sampling, though needle biopsy can be safe when performed carefully 8
- Tissue must be preserved in Stieve's or Bouin's solution (NOT formalin) for proper TIN detection 1
- Immunohistochemical markers (OCT3/4, TSPY, Kit ligand, ALPP) facilitate detection of germ cell tumor precursors 3
Bottom Line Algorithm
- Prepubertal cryptorchidism: Orchidopexy by 18 months - NO biopsy 1, 6, 7
- Postpubertal cryptorchidism with normal contralateral testis: Consider orchiectomy OR biopsy based on individual factors 1, 2
- Prepubertal boys facing gonadotoxic therapy: Experimental testicular biopsy for fertility preservation may be offered 3, 4, 5
- Suspected testicular tumor: Radical inguinal orchiectomy (NOT scrotal biopsy) 1