Radical orchiectomy has long been the standard treatment for testicular tumors. However, with the increasing use of ultrasound, more small non-palpable testicular masses are being detected, raising concerns about overtreatment with radical orchiectomy for benign lesions.

Case 1: A 16-year-old male presented with a painless left testicular lump for four months. Physical examination revealed a small, firm mass over left testis. Serum tumor markers were within normal limits. Ultrasound and MRI both showed a well-circumscribed 1.6 cm mass with strong enhancement. The left testis was approached via an inguinal incision, revealing a reddish-brown nodule attached to the upper pole. The lesion was excised entirely without damage to the testis. Frozen section exam proved well-encapsulated lymphoid tissue with hyperplastic follicles, consistent with splenic tissue. The final pathological diagnosis was splenogonadal fusion, a benign congenital malformation. Case 2: A 24-year-old male presented with a painless left testicular mass for three days. Ultrasound showed a 2 cm heterogeneous mass, and tumor markers were within normal limits. CT and MRI revealed a well-defined nodule, with no evidence of lymphadenopathy. Left orchiectomy was performed via an inguinal incision, and intraoperative frozen section exam ruled out malignancy, allowing for partial orchiectomy. The final pathology confirmed an epidermal cyst. Case 3: A 52-year-old male presented with a progressively enlarging left scrotal mass over three years, associated with itching and pain recently. Ultrasound revealed a non-tender left scrotal mass and bilateral testicular atrophy. MRI showed a 7.3 cm non-enhancing mass in the left scrotal region, suspected to be a cystic tumor or lymph node. Given the low suspicion of malignancy, the tumor was excised completely via a scrotal approach. Intraoperatively, the mass contained pus-like necrotic soft tissue. Culture identified Escherichia coli, and final pathology confirmed an epidermal cyst.

Testis-sparing surgery (TSS), such as partial orchiectomy, can be considered in select patients with a testicular mass. TSS has been proposed for patients with bilateral tumors or with a single testicle in order to preserve testicular function. Partial orchidectomy has been shown to be effective and safe from an oncological standpoint in terms of survival and recurrence. Thanks to frozen section exam, patients with small testicular masses could avoid unnecessary orchiectomy. Small testicular messes, especially < 2cm in prepubertal males, are often benign. The inherent psychological and endocrine implications of orchiectomy have resulted in a shift in the management of testicular masses from radical orchiectomy to a testis-preserving approach.

Radical inguinal orchiectomy is the gold standard for the management of malignant testis tumors. In prepubertal patients with small testis masses and normal tumor markers, partial orchiectomy is appropriate. Frozen section exam with confirmation of benign histology is a key component of partial orchiectomy.