Tumors that form in the testicles of men change over time depending on some factors. This is what happens testicular tumors It can be benign or malignant. As a result of urological examination and tests, it is determined that the tumor in the patient is benign or malignant. Depending on the course of the disease, it is decided whether surgical treatment will be applied or not. Factors such as swelling in the testicles, fluid formation, pain in the groin or lower abdomen testicular tumors may be an indicator. In this case, it is necessary to consult a Urologist.
Testicular Tumor Formation
It constitutes %1 of male malignant neoplasms. However, they are the most common solid tumors in men between the ages of 15-35, and there has been a significant increase in the incidence of the disease in the last 30 years. Pathologies such as cryptoorchidism, testicular atrophy, inguinal hernia and infertility constitute risk factors for testicular tumor development. testicular tumors Since it is seen especially in the young male population, possible delays or deficiencies in diagnosis and treatment lead to unnecessary morbidity and mortality. Today, the treatment of testicular tumors is surgical treatment, kemoterapi, radyoterapi gibi parametrelerin bir ya da birkaçını kombine olarak içerdiğinden tedavide multidisipliner yaklaşım gerekmektedir. Özellikle 1960’lı yıllarda tesis tümörlerinde %60-65 olan sağkalım oranının, 2000’li yıllara gelindiğinde %90’ların üzerine çıkması solid tümörlerde başarılı multidisipliner yaklaşımın önemini bir kez daha ortaya koymuştur. Günümüzde testis tümörlerinin cerrahi tedavisinde inguinal orşiyektomi (altın standart), testis korucu cerrahiler, retroperitoneal lenf nodu diseksiyonu (RPLND) gibi prosedürler uygulanmaktadır.
TestWork Tumors Inguinal Orchiectomy
The presence of an intrascrotal mass that cannot be localized anywhere other than the testicle is a sufficient indication for a surgical intervention performed through the inguinal approach. All masses detected within the testicle should be considered malignant until proven otherwise and should be treated surgically.
Radical orchiectomy combined with high ligation of the spermatic cord at the level of the internal inguinal ring constitutes the first step of treatment in patients with suspected testicular neoplasm. In this way, delay in diagnosis of the disease is prevented and local control is achieved with minimal morbidity, and appropriate treatment planning can be carried out by staging and categorizing the tumor.
Radical orchiectomy can be performed under local anesthesia, regional anesthesia such as spinal anesthesia, or under general anesthesia. The recommended method in cases without additional disease is surgery under general anesthesia. surgical treatment are applications. In this way, visceral pain that may develop due to manipulation of the spermatic cord is also controlled.
Delayed Inguinal Orchiectomy
There are different opinions about performing inguinal orchiectomy in advanced stage testicular tumors. While some researchers argue that inguinal orchiectomy should be performed as soon as a testicular tumor is detected, regardless of its stage, some authors argue that orchiectomy should be postponed so that chemotherapy can be started as soon as possible.
Orşiyektominin ertelenmesini savunan araştırmacıların temel dayanağı; orşiyektomi sonrası nadir de olsa gelişebilecek komplikasyonların kemoterapi başlanmasını geciktirebileceği düşüncesidir. Sistemik kemoterapi sonrası gecikmiş orşiyektomi yapılan 160 hastalık bir seride hastaların %25’inin testisinde anlamlı kanser ve %31’inde ise teratom saptanmıştır. Buna karşın orşiyektomi yapılmasını savunan arştırmacılar; kemoterapi esnasında testisin neoplazi kaynağı olmaya devam edeceği, kemoterapötik ajanların (özellikle bleomisin) pulmoner toksisiteye neden olarak anesteziye bağlı komorbiditeyi artırabileceği görüşünü ileri sürmektedirler.
Complications The most important complication in inguinal orchiectomy surgical treatment intrascrotal hematoma development. In order to prevent this complication from developing, bleeding control must be done carefully during the operation. Since the scrotum is an expandable structure, possible bleeding may not stop with the development of tamponade and may reach large sizes. The growth of the hematoma can be prevented by applying a compressive scrotal dressing, and the hematoma often resorbs spontaneously with conservative follow-up. If the sutures connecting the spermatic cord become loose, retroperitoneal hematoma may develop. These retroperitoneal hematomas may be confused with lymphadenopathy in tomography scans performed for postoperative staging.
Another complication that may develop in patients undergoing inguinal orchiectomy is scrotal injury. The risk of local recurrence is very low in scrotal injuries that occur without tumor contamination. In the past, when there was a scrotal injury, hemiscrotumectomy, inguinal lymphadenectomy or scrotal radiotherapy was recommended.
Organ Preserving Surgery
Organ-preserving surgery has become one of the treatment alternatives for many urological tumors and with this procedure; While providing a permanent cure, it is aimed to prevent unnecessary aggressive treatment in lesions that are likely to be benign and to preserve organ functions. In %1-5 cases with testicular tumor, a tumor also develops in the opposite testicle. Since gonads are not vital organs, they are bilateral. testicular tumors The main treatment should be bilateral orchiectomy.
However, bilateral orchiectomy; It has been shown that organ-sparing surgery may be a good option in well-selected cases, as it will bring about psychological problems such as infertility, lifelong androgen replacement, and castration at a young age. Organ-preserving surgery, or partial orchiectomy, in testicular tumors is generally performed in the presence of bilateral germ cell tumors, in the presence of tumor in cases with solitary testicles, in cases where the opposite testicle is severely atrophic, in the presence of benign lesions such as epidermoid cysts and simple cysts, in testicular masses detected in childhood (prepubertal). It is an exceptional method that is appropriate to perform (since the majority of tumors are benign).
The surgeon who will perform organ-sparing surgery must have sufficient experience in this field and know the vascular anatomy of the testicle well. In this way, complications such as testicular atrophy can be minimized. After the inguinal incision is made, the spermatic cord is accessed. Since Sertoli cells are damaged within 30 minutes in warm ischemia, the testicle is cooled by wrapping it with ice cubes for approximately 5 minutes before the spermatic cord is occluded with a penrous drain.
After the testicle is delivered to the operation field, the intratesticular mass is palpated, and with the help of intraoperative ultrasonography, both the localization of small-sized tumors and the detection of vascular structures can be achieved. Testicular Tumors After determining the location and wrapping ice around the cord and testicle, the tunica albuginea is incised at the point closest to the tumor under cold ischemia, then the area around the pseudocapsule of the tumor is dissected and enucleated to include 1-2 mm of normal parenchyma tissue. Bipolar electrocautery can be used to control bleeding. After enucleation, the specimen is immediately sent for frozen section and if the result is malignant, 4 biopsies are taken from the tumor bed and sent for frozen evaluation again. Surgical resection can be extended according to frozen results. Samples should be taken from the intact parenchyma and placed in Bouin's solution and sent for pathological examination to investigate the possible presence of TIN. At the end of the procedure, the tunica albuginea is closed continuously with 5/0 monocryl sutures.
Cancer Control, Fertility and Endocrine Function
Tüm kanser olgularında olduğu gibi testis kanserinde de öncelikle uzun sağkalım amaçlanmaktadır. Testis koruyucu cerrahide temel avantaj endokrin fonksiyonların korunuyor olmasıdır. Burada en önemli sorun tümöre komşu testis dokusunda % 85’lere varan oranlarda TİN görülmesi ve bu odakların 5 yıl içersinde %50’ye varan oranlarda invaziv kansere dönüşme riskinin bulunmasıdır.
Therefore, when TIN is detected in the ipsilateral intact testicular parenchyma, 18-20 Gy radiotherapy is recommended to prevent local recurrence. The local recurrence rate is reported as %5.4 by the German Working Group, and it is reported that all cases with local recurrence are due to the presence of TIN adjacent to the tumor and that radiotherapy cannot be applied for various reasons.
Leydig cell dysfunction and hypogonadism may develop in patients after radiotherapy. In addition, keeping the spermatic cord clamped for a long time during testicle-sparing surgery may lead to Leydig cell dysfunction by causing warm ischemia. For this reason, patients whose serum testosterone levels are observed to be normal at the 3rd month follow-up after testicle-sparing surgery should be informed that radiotherapy will inevitably result in infertility and should be sent for radiotherapy.
In patients who want to have children, radiotherapy can be postponed until plans are made regarding fertility. Despite all these harmful effects, testicle protective surgical treatment adjuvan radyoterapi alan hastaların %85’inde serum testosteron seviyelerinin normal olduğunu bildiren çalışmalar vardır. Bu bilgiler ışığında testis koruyucu cerrahi ile ilgili daha çok sayıda kontrollü çalışmalar yapılıncaya kadar bilateral testis tümörlü olgularda parsiyel orşiyektomiye temkinli bir şekilde yaklaşmak gerekmektedir.
