Testis-Sparing Surgery in Children. Ten-Year Experience

Patients and Methods: we here present a series of 10 pediatric patients ranging from 9 to 15 years (mean age 11.9yrs) referred to our Institution for mono lateral testicular lesion accidentally detected at US or for indefinite testicular pain and submitted to TSS. The lesions measured from 6 to 20mm (mean 13.1 mm). Histological diagnosis showed 2 residues of adrenocortical tissue,1 epidermoid cyst,3 Large cell calcifying Sertoli cell tumor, 2 Leydig cell tumors; 1 Leydig cell hypertrophia; 1 gonadoblastoma. Surgery was performed through an inguinal approach by cold ischemia and with organ-sparing surgery.

.  Urological follow-up was then scheduled every 6 months for two years, as well as annual chest X-ray if clinically indicated.

Results
No significant intraoperative bleeding was observed. Neither

Discussion
Testicular tumors are rare in childhood, and they are benign in 25% of cases [4]. In light of their uncommon occurrence at a young age, the initial data regarding testis-sparing surgery have been obtained from adult patients. Generally, testicular tumors with a size <25 mm in diameter are defined as small testicular masses, and masses with a diameter <20 mm can be considered good candidates for TSS because nearly 80% of these lesions are benign. Our caseseries shows a large array of pathologies confirming the crucial role of FSE to safely perform TSS [5]. Indeed, none of the preoperative tests can clarify the exact diagnosis. For this reason, all testicular masses should be assumed to be malignant, until proven otherwise.
This is particularly true in pediatric cases, and informed consent should always include the possibility of an orchid funiculectomy.
There is usually a dissection plane between healthy tissue and the tumor mass. Preoperative and sometimes intraoperative ultrasonography is extremely helpful and enables the surgical team to perform enucleation.
Once the frozen-section has confirmed that the tumor is benign and that the surgical borders are tumor-free, vascular occlusion should be terminated immediately and orchiopexy performed. In both of our cases, the results of frozen section and pathological examinations of paraffin blocks were identical. Some Authors have described warm ischemia conditions lasting less than 30 mins during the occlusion of vascular supply [6], and no testicular atrophy was reported in these cases. This is probably due to relatively shorter periods of ischemia. The development of late testicular atrophy has been reported in an experimental study, and some authors strongly recommend cold ischemia conditions [7,8]. In our opinion, cold ischemia is very useful for ensuring a wider safety margin for both the surgeon and the pathologist, for a possible deepening or to increase the resection margins. Testicular US was performed in all our cases, demonstrating high sensitivity, although MRI can be an efficient diagnostic tool for uncertain cases [9]. At present, a combination of preoperative evaluation and intraoperative biopsy could help urologists to distinguish testicular benign tumors and malignant tumors effectively.
In fact, it was feasible and reliable in this study as well as in recent reports, and no recurrence or atrophy was recorded. patients with Leydig cell tumors [14][15][16][17]. Interestingly, our Series includes 3 cases of LCCSCT. This is an exceptionally rare neoplasm originating from sperm cord cells [18]. The lesions may occur in an isolated form (approximately 60% of the cases) or in the context of a more complex genetic syndrome (approximately 40% of the cases) including Peutz-Jeghers syndrome and Carney complex [18].
For these reasons, after the diagnosis, a careful clinical evaluation of the patient is necessary to exclude a tumor with syndromic manifestation.

Conclusion
TSS represents a modern, safe and effective way to treat benign testicular lesions in children and adolescents with potential longterm psychological, cosmetic, and functional benefits. TSS should be used in pediatric patients with testicular masses in which the healthy testicular tissue appears to be salvageable based on US and FSE. Further prospective investigation is warranted to determine the oncologic outcomes of TSS for both pubertal and post pubertal patients.