What are the recommendations for a testicular biopsy using the trucut (transcutaneous) method?

Testicular Trucut Biopsy: Clinical Recommendations

Primary Recommendation

Trucut (percutaneous) testicular biopsy should be avoided in the primary diagnosis of suspected testicular cancer, as radical inguinal orchiectomy is the standard of care; however, trucut biopsy may be considered in highly selected cases including retroperitoneal/mediastinal primaries, small indeterminate lesions in a solitary testis, or for sperm retrieval in azoospermia. 1

---

When Trucut Biopsy is Acceptable

Extragonadal Presentations

• Trucut biopsy is appropriate for patients presenting with retroperitoneal or mediastinal primary tumors where tissue diagnosis is needed before initiating treatment 1
• Mediastinoscopy-guided biopsy can be used for mediastinal masses 1

Small or Indeterminate Testicular Lesions

• Trucut biopsy may be considered for small testicular masses with negative tumor markers and a normal contralateral testis, particularly when testis-sparing surgery is being contemplated 1
• This approach is only appropriate in highly experienced centers with immediate frozen section capability 1
• The lesion should ideally be <2 cm, located at the lower pole, in a patient with excellent compliance 1

Non-Cancer Indications

• Percutaneous needle biopsy is well-established for sperm retrieval in azoospermic men undergoing assisted reproduction 2, 3, 4, 5
• Both 14-gauge and 16-gauge cutting needles provide adequate tissue for histopathological assessment and sperm retrieval 5

---

Critical Contraindications and Pitfalls

Absolute Contraindications

• Any scrotal violation for biopsy or open surgery must be strongly avoided in suspected testicular cancer, as this is associated with higher local recurrence rates 1
• Trucut biopsy should never replace radical inguinal orchiectomy as the primary diagnostic approach for suspected testicular malignancy 1

Technical Requirements When Biopsy is Performed

• If testis-sparing surgery is considered based on biopsy results, at least two additional testicular biopsies from the remaining testicle must be taken to exclude germ cell neoplasia in situ (GCNIS) 1
• Frozen section analysis is mandatory in doubtful cases before definitive surgery 1

Timing Considerations

• Contralateral testicular biopsy should not be performed <2 years after chemotherapy due to the potential for chemotherapy to eradicate testicular intraepithelial neoplasia 1

---

Specific Clinical Scenarios

High-Risk Patients for Contralateral GCNIS

• Patients with testicular volume <12 mL and/or history of cryptorchidism have up to 34% risk of contralateral GCNIS and should be counseled about contralateral biopsy 1
• Contralateral biopsy is not indicated in patients aged >40 years without risk factors 1
• The sensitivity and specificity of one random biopsy for detecting testicular intraepithelial neoplasia is very high 1

Fertility Preservation Context

• Sperm cryopreservation should be offered before any testicular intervention, ideally before orchiectomy 1
• Percutaneous testicular biopsy for sperm retrieval is well-tolerated with minimal complications (minor pain and local swelling) 2, 5

---

Technical Considerations

Needle Size and Adequacy

• Both 14-gauge and 16-gauge cutting needles with 19 mm notch provide sufficient tissue for histopathological assessment 5
• One needle biopsy may not be representative of the entire testis, particularly in non-obstructive azoospermia 5
• Three-quarters of retrieved tissue should be used for histopathology and one-quarter for direct microscopy 5

Complications

• Minor complications include small hematomas and moderate hemorrhage between tunica vaginalis layers 6
• The procedure is generally safe and well-tolerated under local anesthesia 2, 5

---

Key Clinical Algorithm

For suspected testicular cancer:

1. Perform radical inguinal orchiectomy (not trucut biopsy) 1
2. Exception: Retroperitoneal/mediastinal primary requiring tissue diagnosis 1

For small indeterminate lesions in solitary testis:

1. Ensure tumor markers are negative 1
2. Perform trucut biopsy only in experienced centers with frozen section capability 1
3. If testis-sparing surgery proceeds, obtain at least two additional biopsies to exclude GCNIS 1

For azoospermia/infertility:

1. Percutaneous needle biopsy is appropriate for sperm retrieval 2, 3, 4, 5
2. Use 14-gauge or 16-gauge cutting needle 5