Testis-preserving surgery in bilateral testicular germ cell tumours

To evaluate the indications, techniques and outcome of organ-preserving tumour enucleation in patients with bilateral testicular germ cell tumours (BTGCT) rather than standard bilateral radical orchidectomy which results in loss of fertility and a lifelong requirement for androgen replacement.

In 13 patients with BTGCT of 6-30 mm in diameter, the tumours were enucleated under cold ischaemia after inguinal testicular exploration, and biopsies of the tumour bed and the peripheral parenchyma were taken. Histology of the orchidectomy specimen revealed a seminoma in four cases, an embryonal carcinoma in three, a teratocarcinoma and a mixed-germ cell tumour in two each, and a mature teratoma in one. Histology of the enucleated tumours showed a seminoma in seven cases, an embryonal carcinoma in five and a mature teratoma in one. Six of the 13 patients underwent testicular radiation (20 Gy) for carcinoma in situ (CIS) and five patients had adjuvant local therapy. Six months postoperatively a testicular biopsy was taken to determine the success of therapy.

The median follow-up was 62 months (range 14-163) and the 13 patients are currently free of disease; one patient had local recurrence 9 months after tumour enucleation but after orchidectomy the patient is free of disease after a follow-up of 156 months. Serum concentrations of luteinizing hormone and testosterone were within the normal range in all patients and no androgen substitution was necessary. A testicular biopsy taken 6 months post-operatively revealed Sertoli cells only in all patients who had received radiation therapy.

These results suggest that organ-sparing surgery in patients with BTGCT represents a new therapeutic approach with endocrinological and psychological advantages. In our experience, enucleation resection of testicular tumours is possible with certain prerequisites, i.e. the tumour is organ-confined with no infiltration of the rete testis, multiple biopsies of the tumour bed and peripheral parenchyma should be taken, any associated CIS treated by radiation therapy, and patients must be followed closely.