title: Testicular sparing surgery in small testis masses: A multinstitutional experience.
abstract: BACKGROUND
  The incidence of benign testicular tumors is increasing in particular in small lesion incidentally found at scrotal ultrasonography. Primary aim of this study was to perform radical surgery in malignant tumor. Secondary aim was to verify the efficacy of the diagnostic-therapeutic pathway recently adopted in management of small masses with testis sparing surgery in benign lesions.
  
  
  METHODS
  In this multicenter study, we reviewed all patients with single testis lesion less than 15 mm at ultrasound as main diameter. We applied the diagnostic-therapeutic pathway described by Sbrollini et al. (Arch Ital Urol Androl 2014; 86:397) which comprises: 1) testicular tumor markers, 2) repeated scrotal ultrasound at the tertiary center, 3) surgical exploration with inguinal approach, intraoperative ultrasound, and intraoperative pathological examination. Definitive histology was reviewed by a dedicated uro-pathologist.
  
  
  RESULTS
  Twenty-eight patients completed this clinical flowchart. The mean lesion size was 9.3 mm (range 2.5-15). Testicular tumor markers were normal except in a case. Intraoperative ultrasound was necessary in 8/28 cases. We treated 11/28 (39.3%) with immediate radical orchiectomy and 17/28 (60.7%) with testis-sparing surgery. Definitive pathological results were: malignant tumor in 6 cases (seminoma), benign tumor in 10 cases (5 Leydig tumors, 2 Sertoli tumors, 1 epidermoid cyst, 1 adenomatoid tumor, 1 angiofibroma), benign disease in 11 (8 inflammation with haemorragic infiltration, 2 tubular atrophy, 1 fibrosis), and normal parenchyma in 1 case. We observed a good concordance between frozen section examination and definitive histology. Any malignant tumor was treated conservatively. Any delayed orchiectomy was necessary based on definitive histology.
  
  
  CONCLUSIONS
  The incidence of benign lesions in 60% of small testis lesions with normal tumor markers makes orchiectomy an overtreatment. Testicular sparing surgery of single testicular nodules below 15 mm is a safe option, but requires a standardized pathway in diagnosis. Our pathway has shown good reliability and security profile to be applied in a multicenter management for small scrotal masses. Our study has shown the reliability of the diagnostic-therapeutic pathway in the management of single testicular masses. The higher incidence of benign lesions in 60% of patients makes often orchiectomy an overtreatment.
authors.affiliation: Clinica Urologica, Dipartimento Scienze Cliniche e Odontostomatologiche, Università Politecnica delle Marche, AO Ospedale Riuniti, Ancona. galosiab@yahoo.it.
authors.forename: Andrea B
authors.initials: AB
authors.lastname: Galosi
authors.forename: Paola
authors.initials: P
authors.lastname: Fulvi
authors.forename: Andrea
authors.initials: A
authors.lastname: Fabiani
authors.forename: Lucilla
authors.initials: L
authors.lastname: Servi
authors.forename: Alessandra
authors.initials: A
authors.lastname: Filosa
authors.forename: Luca
authors.initials: L
authors.lastname: Leone
authors.forename: Angelo
authors.initials: A
authors.lastname: Marronaro
authors.forename: Enrico
authors.initials: E
authors.lastname: Caraceni
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Montironi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003663:Decision Trees; D006801:Humans; D008297:Male; D008875:Middle Aged; D059351:Organ Sparing Treatments; D013733:Testicular Diseases / Q000473:pathology / Q000601:surgery*; D013736:Testicular Neoplasms / Q000473:pathology / Q000601:surgery*; D013737:Testis; D013521:Urologic Surgical Procedures, Male / Q000379:methods; D055815:Young Adult