Issues concerning contralateral testicular biopsy

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Contralateral testicular biopsy in patients with unilateral testis cancer at the time of orchiectomy for the primary tumor is a highly controversial subject. Biopsy patterns differ among countries as well as between high- and low-volume care centers. Contralateral testis biopsy at the time of orchiectomy for unilateral tumor is routinely performed in most large centers in Denmark, Germany, and Austria [32]. Among German urologists at high-volume centers (>20 cases/year), 95% of patients underwent contralateral testicular biopsy at the time of orchiectomy [29]. In contrast, urologists in the United Kingdom, United States, and the Netherlands do not routinely biopsy the contralateral testicle, while urologists in Norway only sample those patients considered high risk. Proponents of contralateral biopsy at the time of orchiectomy argue it is the best possible screening method for ITGCN, has minimal risk, and can offer valuable information if positive while providing reassurance if the biopsy is negative [33]. Additionally, they feel that if a patient has a negative biopsy, then follow-up can be limited to 5 years instead of 25 years or longer [30].

This viewpoint is highly debatable and many others do not advocate routine contralateral biopsy at the time of primary orchiectomy. Overall, contralateral ITGCN occurs in 2% to 5% of patients who have a history of TGCT and at least 50% will progress to a second testicular tumor [34]. Moreover, these patients are at a 25 to 50 fold increased risk for developing a contralateral

TGCT. However, routine biopsy remains controversial because of the low numbers of men who actually have ITGCN on biopsy, the potential for undesirable physical and emotional effects of a second orchiectomy, and an excellent prognosis if or when a second tumor develops [35]. In a recent review of the literature on screening of the contralateral testicle, three large studies reported the prevalence of ITGCN to be 4.9%, 5.7%, and 6.1%. On multivariate analysis the highest risk patients were those with testicular atrophy (<12 mL), history of an undescended testicle, and age younger than 30 [28].

Another high-risk group would be those men with abnormal calcifications on ultrasound. Holm and colleagues [23] has reported an association between contralateral testicular microlithiasis on testicular ultrasound and an increased risk of ITGCN (odds ratio 28.6, RR 21.6). These studies would suggest that the majority of men would not have a positive biopsy and would be placed at risk for complications from the procedure. Postsurgi-cal complications include hematoma, edema, and infection in approximately 3% of cases and 15% to 20% will experience pain for a period of time [4,36]. More importantly, exocrine and endocrine function of the remaining testis can be diminished. Trauma from the biopsy may have an adverse effect on spermatogenesis thereby further damaging the patient's fertility [37]. Serum testosterone has been shown to be decreased in men with atrophic testes who have undergone testicu-lar biopsy [38].

Based on these and other studies, most urologists in the United States have not recommended routine biopsy of the contralateral testicle. However, some urologists in the United States, United Kingdom and other countries favor selected biopsy for informed patients who are at high risk for ITGCN (cryptorchidism, testicular atrophy, age, gonadal dysgenesis, testicular microlithiasis). These criteria should limit the number of men who would be subjected to the additional risks of biopsy while selecting those most at risk for ITGCN [28].

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