What is the appropriate management for a patient with a 14cm scrotal cystic lesion?

Management of a 14cm Scrotal Cystic Lesion

A 14cm scrotal cystic lesion requires immediate scrotal ultrasound with Doppler imaging to characterize the lesion and determine if it is intratesticular versus extratesticular, followed by surgical excision given its massive size, which poses significant risk for complications and may harbor underlying malignancy.

Initial Diagnostic Workup

Scrotal ultrasound with Doppler is the mandatory first imaging study for any scrotal abnormality, as recommended by the American College of Radiology 1. This imaging is nearly 100% sensitive for detecting intrascrotal masses and 98-100% accurate for distinguishing intratesticular from extratesticular processes 1.

Critical Imaging Components

• Grayscale ultrasound must assess the lesion's location (intratesticular vs extratesticular), internal architecture (simple cystic vs complex), wall characteristics, and relationship to surrounding structures 2, 3
• Color and Power Doppler evaluation is essential to assess vascularity within the lesion and testicular perfusion, as virtually all testicular tumors display vascularization except for cystic components and necrotic regions 1
• Both testes must be evaluated since the contralateral testis has increased malignancy risk in patients with cryptorchidism or other risk factors 1

Key Diagnostic Considerations

The ultrasound findings will determine the urgency and type of intervention needed:

If the lesion is intratesticular:

• Any solid or mixed cystic-solid intratesticular mass requires surgical exploration, as ultrasound cannot reliably differentiate benign from malignant testicular lesions 1
• Even purely cystic intratesticular lesions of this size warrant surgical removal given the inability to exclude cystic malignancies (nonseminomatous germ cell tumors can appear cystic due to necrosis) 1

If the lesion is extratesticular:

• Most extratesticular cystic lesions are benign (epididymal cysts, spermatoceles, hydroceles, cystic lymphangiomas) 4, 5, 6
• However, a 14cm lesion is extraordinarily large and requires surgical management regardless of benign appearance 6

Management Algorithm

For Intratesticular Lesions

Immediate urological referral for radical inguinal orchiectomy is indicated for any suspicious intratesticular mass, as this is both diagnostic and therapeutic 1. The consensus is that sonographic detection of a solid or mixed cystic lesion requires surgical exploration 1.

• Intraoperative frozen section should be performed if there is any possibility of a benign process to allow testis-sparing surgery 6
• Testis-sparing procedures are only appropriate when a benign lesion is definitively recognized intraoperatively 6

For Extratesticular Lesions

Surgical excision is strongly recommended for a 14cm extratesticular cystic lesion due to:

• The massive size causing significant morbidity (discomfort, functional impairment, cosmetic concerns)
• Risk of infection, rupture, or hemorrhage into such a large cystic structure
• Inability to completely exclude malignancy without histopathological examination 7
• Potential for rare entities like cystic lymphangioma that require complete excision to prevent recurrence 8

Additional Imaging Considerations

MRI of the pelvis/scrotum may be appropriate when the ultrasound is limited by the massive size of the lesion or when differentiating intratesticular from extratesticular pathology remains unclear 2.

CT or MRI of abdomen/pelvis should be obtained if there is concern for underlying malignancy, pelvic lymphadenopathy, or retroperitoneal pathology that could cause secondary lymphatic obstruction 2.

Critical Pitfalls to Avoid

• Do not assume a purely cystic appearance on ultrasound excludes malignancy, as nonseminomatous germ cell tumors can appear cystic due to necrosis and calcification 1
• Chronic massive lesions may mask underlying testicular pathology, so careful assessment of testicular parenchyma is essential despite overlying fluid 2
• Complete surgical excision is crucial for cystic lesions like lymphangiomas, as incomplete excision leads to recurrence 8
• Inflamed cysts are difficult to excise completely, so if there are signs of acute inflammation, treat with warm compresses and possibly antibiotics first, then perform definitive excision after inflammation subsides 7

Surgical Planning

Given the 14cm size, surgical planning should include:

• Urological consultation for operative planning and patient counseling about potential outcomes 1
• Histopathological examination is mandatory for any excised tissue, particularly given the size and to exclude unusual features or malignancy 7
• Patient counseling about the possibility of orchiectomy if an intratesticular malignancy is discovered, versus testis-preserving surgery if a benign process is confirmed 6