Review Article
Oncol Res Treat 2018;41:356–358 Received: April 10, 2018
DOI: 10.1159/000489346
Testis-Sparing Surgery in Patients with Germ Cell Cancer:
Indications and Clinical Outcome
David Pfister Pia Paffenholz Friederike Haidl
Department of Urology, University Hospital Cologne, Cologne, Germany
Keywords
Germ cell tumors · Seminoma · Testicular cancer
Summary
Testicular cancer affects mainly young men between 20
and 30 years of age. Due to the availability of effective
chemotherapy, the majority of patients are cured. De-
spite an increased risk of metachronous testicular can-
cer, it should be carefully considered whether immediate
orchiectomy is indicated. This mini review gives an ac-
count of the available literature on testis-sparing surgery
in patients with unilateral or bilateral synchronous or
metachronous testicular cancer.
© 2018 S. Karger GmbH, Freiburg
Germ cell cancer is the most common solid cancer in young
men. For the best outcome, a high concordance with guideline rec-
ommendations is mandatory. Large registry trials have shown a
lack of guideline-conformal treatment [1, 2]. In the case of under-
treatment, there is a worse oncologic control rate; in the case of
overtreatment, the patient does not benefit with regard to tumor
control but potentially suffers from negative side effects. Due to the
high cure rate and thus long life expectancy, quality of life should
be a major concern. This has already led to a less intensive systemic
treatment regimen being adopted, at least in clinical stage I disease
[3]. In both seminoma and non-seminomatous germ cell cancer
(NSGCC), active surveillance is the recommended treatment.
However, patients have an increased risk of developing metachro-
nous testicular cancer. In the past, as soon as a suspicious lesion
was found in the testis, an inguinal orchiectomy was performed.
Meanwhile, there are 2 constellations in which an organ-sparing
approach should be the first choice: In small primary lesions and in
metachronous testicular cancer in a solitary testicle, organ-sparing
surgery can be attempted (fig. 1, 2). For this procedure, close coop-
eration with the uropathologist is necessary. In the following re-
© 2018 S. Karger GmbH, Freiburg
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Accepted: April 18, 2018
Published online: May 16, 2018
view, we assess the indications for testis-sparing surgery as well as
outcome and specific difficulties facing the pathologist.
According to international guidelines, there are only limited in-
dications for testis-sparing surgery: The main indication is a soli-
tary testicle with a primary tumor or a metachronous tumor after
orchiectomy on the contralateral side. A testis-sparing approach in
the case of small lesions in 2 otherwise healthy testes is not or only
reluctantly recommended; however, these are patients that should
initially also be spared. In any case, the pathologist plays a major
role in this decision. To avoid secondary surgery, the urologist
needs to know the quality of the resected small tumor and the sur-
rounding tissue. In the case of a metachronous tumor, the inci-
dence of germ cell neoplasia in situ (GCNIS) is rather high [4] and
always requires adjuvant treatment.
In the case of metachronous relapse in a single testicle, the le-
sion size is usually significantly smaller compared to the primary
testicular cancer, allowing an initial organ-preserving approach.
This was shown in a retrospective analysis after introducing ultra-
sound into the follow-up schedule [5]. In a limited number of pa-
tients in whom the tumor was detected by palpation compared to a
patient cohort in whom ultrasound was implemented in the fol-
low-up, the mean tumor size was 1.2 (0.5–2.5) cm versus 2.68 (0.6–
5.5) cm (p = 0.031). This led to a possible testis-sparing procedure
in all patients in the ultrasound group compared to only 30% in the
control group (p < 0.001). In patients who are candidates for testis-
sparing surgery, the tumor size should not exceed 2  cm or more
than one third of the testicular volume. One reason for testis-spar-
ing surgery is maintenance of a physiological testosterone level.
Heidenreich et al. [4] did pioneer work in patients with metachro-
nous tumors. The authors evaluated the endocrine function of a
single testicle after organ-sparing surgery in 73 patients. In 62
(84.9%) and 11 (15.1%) patients, the tumor was enucleated under
cold and warm ischemia, respectively. In 62 patients, normal en-
dogenous testosterone levels were measured during a median fol-
low-up of 91 (3–191) months. In patients with hypogonadism after
surgery, a tumor diameter of more than 2  cm and/or warm is-
chemia were identified with poor endocrine function postopera-
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Prof. Dr. med. David Pfister
Department of Urology
University Hospital Cologne
Kerpener Str. 62, 50937 Cologne, Germany
david.pfister @ uk-koeln.de
Fig. 1. Ultrasound of pure seminoma and indication for tumor enucleation in
a single testis. Fig. 2. Situs after
tumor enucleation.

Table 1. Trials investigating testis-sparing

Author [ref.] Year Patients, Follow-up, median NED, n (%)
surgery and oncologic outcome
n (range)

Heidenreich et al. [4] 1994–2000 73 91 (3–191) months 72 (98.6)

Steiner et al. [13] 1994–2002 30 46.3 months 30 (100)
Stefani et al. [15] 2004–2011 20 35 months 20 (100)
Gentile et al. [12] 2009–2013 15 19.2 months 15 (100)
Bojanic et al. [11] 1996–2013 24 51 (7–178) months 24 (100)
Bojanic et al. [14] 2010–2015 28 33 months 28 (100)
Lawrentschuk et al. [9] 1994–2009 30 5.7 (1.5–15.1) years 30 (100)

NED = No evidence of disease.

tively. In the majority of publications on organ-preserving surgery,
the procedure is described as having been carried out under cold
ischemia. Nowadays, we are aware that manipulation of the testis
during surgery does not increase the risk of metastasis. As a conse-
quence, this parameter as a direct influence on testosterone pro-
duction can be excluded. Leonhartsberger et al. [6] performed or-
gan-preserving procedures in 65 patients. The authors analyzed the
risk of developing metastasis if organ-sparing surgery was per-
formed without clamping the spermatic cord. In the case of malig-
nant tumor in the fresh frozen section and a normal contralateral
testis, an orchiectomy was performed (n = 35); in the case of a sin-
gle testis, organ-sparing surgery without ischemia was completed.
In the case of seminoma or NSGCC, further adjuvant treatment
was given. 28 patients received 2 cycles of carboplatin, 11 patients
were treated with laparoscopic retroperitoneal lymph node dissec-
tion (RPLND), 2 patients received polychemotherapy with bleo-
mycin and etoposide in addition to RPLND, and 1 patient received
local radiotherapy. During a mean follow-up of 50 (3–107) months,
no local or systemic relapses occurred.
Although safe if not exceeding 30  min [7, 8], clamping of the
spermatic cord can be omitted in organ-sparing surgery. Fresh fro-
zen section to determine whether the tumor is malignant necessi-
tates approximately 10-min clamping as described by Lawrents-
chuk et al. [9].
Table  1 lists studies including more than 10 patients treated
with an organ-sparing strategy. Three lessons can be learnt from
these trials: First there is a rather high rate of benign lesions in this
already selected patient cohort. Either tumor size or a metachro-
nous tumor history would be suspicious for malignancy. Never-
theless, there is a wide range of 8.7–100% for NSGCT and semi-
noma incidence among cases. In even smaller non-palpable tes-
ticular lesions diagnosed by chance via ultrasound, the likelihood
of a benign histology increases even more. This was shown in an
analysis by Giannarini et al. [10] reviewing the literature on testis-
sparing procedures, which showed that 74.8% of resected tumors
were of benign histology and would have been overtreated with
radical orchiectomy. In the case of a germ cell tumor pathology,
there is a high incidence of GCNIS (13.3–90.9%) [4, 9, 11–13].
GCNIS is associated with a significant risk of local recurrence.
Bojanovic et al. [11] analyzed their collective with regard to local
recurrence due to the presence of GCNIS. In patients without
GCNIS, 10-year recurrence-free survival was 82%. In testes har-
boring GCNIS, the median local progression-free survival was
roughly 40 months. This makes further treatment necessary and
needs to be taken into account. Nevertheless, in the available tri-
als, a more than acceptable risk of local recurrence is shown. Law-
rentschuk et al. [9] describes 2 local recurrences in 17 patients
with a malignant pathology and only 1 retroperitoneal metastatic
progression. Bojanovic et al. [14] showed local recurrence in 10%
(n = 1) of their cohort, whereas in a former analysis there was a
significantly higher rate of 7 local recurrences and 1 systemic pro-
gression among 24 patients [11].
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Testis-Sparing Surgery in Patients with Germ Cell Oncol Res Treat 2018;41:356–358 357
Cancer
 One major advantage of organ-sparing surgery, at least in pa-
tients with only a solitary testicle, is the possibility to maintain phys-
iological testosterone levels without the need for substitution. How-
ever, in this regard, there is a difference between patients undergo-
ing enucleation of a benign versus a malignant lesions. In larger se-
ries of patients with benign lesions, no hypogonadism requiring
testosterone replacement was observed [6, 15]. In the largest series
of organ-sparing tumor resection, Heidenreich et al. [4] showed
physiological testosterone levels in 85% of the patients; in 15%, sec-
ondary hypogonadism developed. The oncologic outcome was ex-
cellent with cancer-specific survival ranging between 98.6 and 100%.
One patient was non-compliant to further follow-up and treatment
and died of disease. Compliance is mandatory in this patient cohort
to avoid a negative influence on oncologic control rates.
There are strict guideline recommendations for testis-sparing
surgery: Only in the case of suspicious lesions in the testes of tumor
marker-negative patients and in single testes bearing a tumor not
exceeding one third of the testicular volume, an organ-preserving
strategy may be followed. According to the available literature,
even in the case of 2 otherwise healthy testes bearing suspicious
small lesions, primary organ-sparing surgery should be the first
choice. Close cooperation with a uropathologist is mandatory in
this setting, as is a highly reliable fresh frozen specimen.
Disclosure Statement
The authors have nothing to declare.

References
1 Schrader M, Weissbach L, Hartmann M, et al.: Burden
or relief: do second-opinion centers influence the qual-
ity of care delivered to patients with testicular germ
cell cancer? Eur Urol 2010; 57: 867–872.
2 Zengerling F, Hartmann M, Heidenreich A, et al.: Ger-
man second-opinion network for testicular cancer:
sealing the leaky pipe between evidence and clinical
practice. Oncol Rep 2014; 31: 2477–2481.
3 Albers P, Albrecht W, Algaba F, et al.: Guidelines on
testicular cancer: 2015 update. Eur Urol 2015;68:1054–
1068.
4 Heidenreich A, Weissbach L, Holtl W, et al.: Organ
sparing surgery for malignant germ cell tumor of the
testis. J Urol 2001; 166: 2161–2165.
5 Stoehr B, Zangerl F, Steiner E, et al.: Routine scrotal
ultrasonography during the follow-up of patients with
testicular cancer leads to earlier detection of asynchro-
nous tumours and a high rate of organ preservation.
BJU Int 2010; 105: 1118–1120.
6 Leonhartsberger N, Pichler R, Stoehr B, Horninger W,
Steiner H: Organ preservation technique without is-
chemia in patients with testicular tumor. Urology
2014; 83: 1107–1111.
7 Miller DC, Peron SE, Keck RW, Kropp KA: Effects of
hypothermia on testicular ischemia. J Urol 1990; 143:
1046–1048.
8 Cummings JM, Boullier JA, Sekhon D, Bose K: Adult
testicular torsion. J Urol 2002; 167: 2109–2110.
9 Lawrentschuk N, Zuniga A, Grabowksi AC, Rendon
RA, Jewett MA: Partial orchiectomy for presumed ma-
lignancy in patients with a solitary testis due to a prior
germ cell tumor: a large North American experience.
J Urol 2011; 185: 508–513.
10 Giannarini G, Mogorovich A, Bardelli I, Manassero F,
Selli C: Testis-sparing surgery for benign and malig-
nant tumors: a critical analysis of the literature. Indian
J Urol 2008; 24: 467–474.
11 Bojanic N, Bumbasirevic U, Vukovic I, et al.: Testis
sparing surgery in the treatment of bilateral testicular
germ cell tumors and solitary testicle tumors: a single
institution experience. J Surg Oncol 2015; 111:226–230.
12 Gentile G, Brunocilla E, Franceschelli A, et al.: Can
testis-sparing surgery for small testicular masses be
considered a valid alternative to radical orchiectomy?
A prospective single-center study. Clin Genitourin
Cancer 2013; 11: 522–526.
13 Steiner H, Holtl L, Maneschg C, et al.: Frozen section
analysis-guided organ-sparing approach in testicular
tumors: technique, feasibility, and long-term results.
Urology 2003; 62: 508–513.
14 Bojanic N, Bumbasirevic U, Bojanic G, Vukovic I, Mi-
lojevic B, Pekmezovic T: Testis sparing surgery for
treatment of small testicular lesions: is it feasible even
in germ cell tumors? J Surg Oncol 2017; 115: 287–290.
15 De Stefani S, Isgro G, Varca V, et al.: Microsurgical
testis-sparing surgery in small testicular masses: seven
years retrospective management and results. Urology
2012; 79: 858–862.

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358 Oncol Res Treat 2018;41:356–358 Pfister/Paffenholz/Haidl