Risks and Benefits of Organ-Sparing Surgery for Testicular Cancer
Considering testicular cancer tends to affect younger men, the potential medical, emotional and physical repercussions that could come with the full removal of a testicle cannot be overstated.
Clinicians know this, too, which is why they evaluate patients for a type of surgery that removes just the affected part of the testicle: testis-sparing surgery (TSS).
Understandably, some patients find this option preferable, but it's not always the best choice for treating the disease and making sure the cancer doesn't return. Every patient should know the basics when they consider their options for treatment.
What is testis-sparing surgery?
It's important to know the gold standard of care for testicular cancer is the full removal of the affected testicle—clinically called radical inguinal orchiectomy—which involves making an incision in the groin to remove the whole testicle from the scrotum. The goal of this surgery is to remove the cancerous mass and the surrounding tissue where cancer could conceivably come back.
"There have been studies that have shown that taking the whole testicle with the capsule around it can be therapeutic, basically, and takes care of the cancer," said Aydin Pooli, M.D., a urologic oncologist and an assistant professor in the Urology Department at UCLA Health.
TSS is a slightly different procedure because it leaves behind any portion of the affected testicle that does not contain cancer. Basically, the surgeon removes just the malignant mass, which means sometimes the patient can maintain fertility and the ability to produce testosterone. Plus, it can possibly make survivorship less emotionally traumatic.
Why isn't TSS used more frequently?
Organ-sparing surgery sounds like the kind of treatment that should be standard practice, but there are no guarantees it will work in the long term.
"If you would like to do organ-sparing surgery, if you want to take out part of the testicle with the mass and leave the rest behind, you have a higher risk of recurrence and subsequent metastasis, so it's not recommended," Pooli said.
In some cases, organ-sparing surgery could make testicular cancer worse.
"There is also concern about the possibility of inducing tumor spread at the time of surgery due to manipulation and the risk of short-term recurrence in the testicle, since many testis tumors have premalignant cells throughout the affected testicle," said Richard Matulewicz, M.D., an assistant professor in the surgery department in urology service at Memorial Sloan Kettering Cancer Center in New York.
Patients risk that a partial removal will result in abnormal sperm and testosterone function.
"If that is the case, then all of the benefits of the organ-sparing approach are diminished, and one is left with just the risk of disease recurrence," Matulewicz said.
Who is a good candidate?
TSS is only considered for a select number of patients, and decisions about which patients get the surgery are case-by-case, said Matulewicz, who added that these factors may make the procedure a possibility:
- Whether the tumor is less than 2 centimeters in size
- Whether diagnostic lab results—primarily blood tests—indicate that the mass may not be entirely cancerous
Sometimes, benign growths can form in the testes, Pooli explained.
A clinician may consider testis-sparing surgery if the patient has only one testicle due to congenital abnormalities or a previous traumatic injury. People with only one testicle can still function normally and lead a normal life, but a patient who develops cancer in their lone testicle is a different story.
"If you take out the whole testicle, the patient will lose the ability to produce a normal amount of testosterone. They may have infertility," Pooli said.
What can I expect from the surgery?
Testis-sparing surgery is pretty straightforward, according to Pooli. A surgeon makes an incision in the patient's groin, or lower belly, and operates on the testicle through the incision. Organ-sparing surgery is easier when the tumor is at the top or the bottom of the testicle—otherwise, the surgery becomes too complex and involves filleting the testicle to remove the tumor. More often than not, a patient in this circumstance is better off with full removal.
Patients will likely undergo an ultrasound beforehand to demarcate the margins of the tumor and ensure that all of the cancer is removed.
"You don't want to do a surgery and violate the tumor and remove some part of it and leave some part inside the body," Pooli said.
During the procedure, the surgeon sends tissue samples to an onsite lab immediately to check that the margins are clear and there is no tumor remaining before they suture the incision.
After surgery, a patient may have some bruising in the area, and it's recommended they rest and avoid heavy lifting and strenuous physical activity. Most men fully recover in three to six weeks.
What are short- and long-term side effects?
Unfortunately, men who opt for TSS over full removal may put themselves in a position of needing additional surgery at a later date if the cancer returns. This means a patient will have to endure frequent additional exams or ultrasounds to make sure they remain cancer-free.
A doctor may have to deliver additional radiation to the testicle to decrease a local recurrence. Radiation to the testes comes with its own side-effect risks, which include a disruption in sperm and testosterone production, and testicular atrophy, which could warrant additional surgery to remove the rest of the organ, Pooli said.
"If you radiate the testicle, you're not going to preserve sperm-producing cells," said James Wren, M.D., a urologist at Northwestern Medicine in Chicago. "You will be able to preserve some degree of testosterone-producing cells because radiation—the dosing that's used—is usually not enough to destroy Leydig cells that produce testosterone, but it does or is high enough to destroy all the sperm-producing cells."
What are my fertility options?
Regardless of the type of surgery a patient chooses, they should plan for potential infertility, because even a partial removal of a testicle doesn't guarantee sperm production will continue normally, especially with the addition of radiation. It's a good idea for men to speak with their medical care team about sperm banking.
Wren said patients also have another option for fertility known as onco-testicular sperm extraction.
"If somebody were to have only one testicle and they were looking to have children and they were found, before the testicles were removed, to have zero sperm in [ejaculate], which is known as azoospermia, then in those cases, you can undergo the onco-testicular sperm extraction," he said. "You remove the testicle, and once the testicle has been removed, you enucleate all of the tumor and process the healthy, unaffected testicular tissue under the microscope to search for viable sperm that can be used. They can be frozen and then later thawed for IVF [in vitro fertilization]."
Are there any cosmetic options?
While most clinicians agree that full removal of an affected testicle is likely to have a better outcome for a patient in terms of survival, men may feel unhappy about the physical outcome. If body image is of high concern to a patient, they can get a testicular prosthesis. Currently, Torosa by Coloplast is the only option approved by the Food and Drug Administration. A surgeon can add an artificial implant inside the empty scrotum after the cancerous testicle is removed. While it provides no physical function, it can bring peace of mind.