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INTRODUCTION
Radical orchidectomy is the standard treatment for malignant testis tumours(1)(2). If the diagnosis is not clear, an inguinal exploration is recommended with exteriorisation of the testis within its tunics and a testicular biopsy should be taken for frozen histological examination(1).
Radical orchidectomy results in infertility, androgen deprivation and impaired psychological well-being, especially in synchronous bilateral tumours, metachronous contralateral tumours or tumour in a solitary testis.According to the European Association of Urology Guidelines, if pre-operative testosterone level is normal and the tumour volume is less than 30% of the testicular volume, organ preserving surgery can be performed(1).For nonpalpable tumours, organ-sparing surgery needs a precise intraoperative localization with high-frequency ultrasound (US) orwith a small-calibre needle placed adjacent to tumour and guided with US(3)(4)(5)(6) to guarantee complete excision in order to achieve correct oncological outcomes.
We report two cases of nonpalpable intratesticular tumours successfullylocalisedusing TC99mm nanocolloid injected with intraoperative USand detected with a γ-ray detection probe. Subsequent microsurgical excision was made to preserve the remainder of the affected testicle.
MATERIAL AND METHODS
Case 1
A 34-year-old patient with medical history of right orchidectomy two years ago because of a testicular seminoma (pT1N0M0S0, stage IA) presented at the urologic consultation. Contralateral testicle showed testicular microcalcifications at diagnosis.In routine follow-up, a nonpalpable 3,6 mm intratesticular massin the lower pole of the left testicle was detected with scrotal US and Doppler-colour was positive inside the lesion.Serum tumour markers (alpha-fetoprotein, human chorionic gonadotropin, lactate dehydrogenase) level for testis cancer were within normal parameters. Testosterone level was 425 ng/dL and seminogram was within normal limits. Semen cryopreservation was indicated before surgery.
At surgery, the testicle was delivered through inguinal incision and the tumour was localized with intraoperative US.With a 30-gauge needle the tumour was marked with TC99mm nanocolloid. Subsequently, the tunica albuginia was incised according to the radioactivity detected and the tumour was dissected along the γ-ray detection probe track. After complete tumour removal, intraoperative US and γ-ray detection search were repeated and neither residual mass nor radioactivity wasdetected.
Case 2
A 37- year-old man with personal history of pulmonary sarcoidosis presented at the urologic consultation because of incidental bilateral testicular tumours diagnosed by US after an episode of orchitis-epydidimitis. On physical examination masses were not palpable. Scrotal US showed multiple hypoecoic lesions in both testis.Tumourmarkers were within normal limits. Testosterone level was 281 ng/dL.
According to the scrotal US, left testicle was more accessible for the puncture. At surgery,the left testicle was exteriorized through an inguinal incision. With intraoperative US, we localised a representative tumour and with a 30-gauge needle TC99mm nanocolloid was injected into the mass. The tunica albuginea overlying the tumour was incised and the γ-ray detection probe correctly delimited the mass which was removed. No radioactivity was detected after excision.
RESULTS
In the case 1, the final pathology of the specimen revealed a 4mm classical seminoma with an intratubular germ cell neoplasm focus. The patient recovered after surgery without complication. Because of this intratubular neoplasm focus, the patient received 25 Gy of external radiotherapy as adjuvant treatment. Currently, 18 months after surgery, no recurrence has been notedwith scrotal US and testosterone levels maintain within normal parameters. Patient has not expressed desires for progeny.
In the case 2, the biopsy revealed a granulomatous inflammation compatible with testicular sarcoidosis. Patient recovered successfully after surgery without complication.
DISCUSSION
Intraoperative US has been successfully used to locate nonpalpable intratesticular masses. A needle placed directly within the mass guides the surgeon to perform a local excision in order to prevent from a radical orchiectomy. This method was first reported by Hopps and Goldstein (7) and other authors have reproduced it (5)(4).
In the two cases that we present, the testicle was delivered through an inguinal incision. By a high-frequency intraoperative US (12 MHz), the tumour was found and theTC99mm nanocolloid was injected into the mass with a 30-gauge needle. With the γ-ray detection probe, we localise the tumour and the tunica albuginea overlying is incised. Subsequently, the tumours are enucleated with microsurgical techniques. After enucleation, we confirmed the complete removal of the masses with the intraoperative US and γ-ray detection probe.
This is the first publication that reports a different technique instead of using a small-calibre needle to mark a non-palpable mass. In our opinion, using this technique, the main advantage is to guarantee the complete excision of the tumour because the γ-ray detection probe can detect the presence of radioactivity on surgical field, especially if the mass is poorly delimited. Futhermore, testicular biopsies could be better directed to the mass in comparison with an open biopsy only guided by intraoperative US.This method is easily reproducible and safe for the patient and no complications were developed in both cases.
CONCLUSION
Nonpalpable intratesticular tumours can be removed completely to guarantee correct oncological outcomes with the combination of intraoperative US and Tc99mm injection into the masses with γ-ray detection probe. This technique is especially interesting for synchronous bilateral tumours, metachronous contralateral tumours, tumour in a solitary testis or uncertain behaviour small tumours.
Bibliography
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