What are the considerations and management strategies for partial orchidectomy (partial removal of a testicle) in children?

Partial Orchidectomy in Children

Primary Recommendation

Partial orchidectomy (testis-sparing surgery) is a safe and appropriate alternative to radical orchidectomy in carefully selected prepubertal children with testicular tumors, particularly when preoperative ultrasound demonstrates adequate healthy testicular parenchyma and tumor markers are negative. 1, 2, 3

Specific Indications for Partial Orchidectomy in Children

Partial orchidectomy should be considered in the following clinical scenarios:

• Prepubertal boys with small, localized testicular masses and negative serum tumor markers (AFP, β-HCG, LDH) 1, 2, 3
• Synchronous bilateral testicular tumors where preservation of testicular tissue is essential for future hormonal function 4, 2
• Solitary functioning testis with sufficient endocrine function, where radical orchidectomy would necessitate lifelong testosterone replacement 4, 2
• Contralateral atrophic testis where preserving any functional testicular tissue is paramount 4, 2
• Tumors occupying ≤30% of testicular volume with adequate spared healthy parenchyma visible on imaging 5, 6

Critical Age-Based Distinction

Postpubertal adolescents should NOT routinely undergo partial orchidectomy due to significantly higher risk of testicular intraepithelial neoplasia (TIN) and must be treated according to adult protocols, not pediatric protocols. 1, 2 The residual testicular tissue in postpubertal patients almost always contains TIN after local resection, requiring adjuvant radiotherapy that compromises the fertility-preservation benefit. 4

Mandatory Preoperative Requirements

Before proceeding with partial orchidectomy:

• Obtain serum tumor markers (AFP, β-HCG, LDH) before any surgical intervention—these must be negative or age-appropriate for benign lesions 1, 2
• High-resolution scrotal ultrasound (7.5 MHz transducer) to assess tumor size, location, and quantity of healthy parenchyma that can be preserved 4, 2
• Discuss and offer sperm banking in postpubertal boys before any testicular surgery, even if partial orchidectomy is planned 1, 2
• Measure baseline testosterone, LH, and FSH to document endocrine function 4

Surgical Technique Requirements

The surgical approach is non-negotiable:

• Always use an inguinal incision with early spermatic cord control at the internal inguinal ring before manipulating the testis 4, 2
• Never perform scrotal biopsy or scrotal incision for suspected malignancy—scrotal violation increases local recurrence risk 1, 2
• Obtain intraoperative frozen section before completing the partial orchidectomy to confirm adequate margins and guide decision-making 4, 2
• Resect the tumor-bearing testis with the spermatic cord at the level of the internal inguinal ring if frozen section reveals malignancy requiring radical approach 4

Expected Outcomes in Pediatric Populations

Evidence from pediatric series demonstrates excellent outcomes:

• Recurrence rate of only 1.1% in prepubertal children undergoing testis-sparing surgery, with most tumors being mature teratomas (62%) 3
• Testicular atrophy occurs in <1% of cases when proper technique is used 3
• Normal sexual maturation (appropriate Tanner staging) documented in long-term follow-up of prepubertal patients 3
• Approximately one-third of small testicular masses are benign, making organ preservation particularly valuable in avoiding overtreatment 6

Postoperative Management

After partial orchidectomy:

• Repeat tumor markers after surgery until normalization, allowing adequate time for marker half-lives (HCG: 24-36 hours; AFP: 5-7 days) 1
• Long-term surveillance is mandatory to monitor testicular growth, pubertal development, and psychological health 3
• Consider salvage radical orchidectomy if positive margins are identified, though notably, no patients with positive margins in one series developed recurrence 6
• Monitor for radiologically or clinically detected recurrence, which occurs in approximately 20% requiring salvage orchidectomy 6

Facility and Expertise Requirements

Partial orchidectomy should only be performed in highly experienced centers with multidisciplinary teams including pediatric urology, medical oncology, pathology, and radiology expertise. 4, 1 The procedure requires:

• Availability of immediate frozen section pathology 4, 2
• Expertise in testis-sparing surgical techniques 4
• Established protocols for long-term surveillance 3

Critical Pitfalls to Avoid

• Never use a scrotal approach—only inguinal incision with early cord control is acceptable 1, 2
• Never proceed without preoperative tumor markers—this information is essential for appropriate patient selection 1, 2
• Never apply pediatric protocols to postpubertal adolescents—they require adult treatment algorithms due to different tumor biology 1
• Never skip frozen section analysis—completing partial orchidectomy without pathologic confirmation risks leaving malignant tissue 2
• Never fail to discuss fertility preservation before any testicular surgery in postpubertal boys 1, 2