Guideline of guidelines: management of small testicular masses

TL;DR

This paper compares international guidelines for managing small testicular masses, highlighting testis-sparing surgery as a viable option under certain conditions.

Contribution

The study provides a comprehensive comparison of the latest international guidelines and emphasizes the growing consensus on testis-sparing surgery for small testicular masses.

Findings

Testis-sparing surgery is supported by emerging evidence for managing small testicular masses with acceptable outcomes.

Shared indications for TSS include indeterminate masses with negative tumor markers, especially in cases of a solitary or bilateral testis.

Consensus among guidelines favors TSS when intra-operative analysis confirms a benign lesion, avoiding radical orchidectomy.

Abstract

To compare and summarise the most up to date international guidelines and major recommendations for the management of small testicular masses (STMs).

A systematic search was conducted in PubMed, EMBASE, Scopus, Google Scholar, and the Cochrane Library up to 1 November 2024. The latest editions of five international guidelines were included in the review: the European Association of Urology 2025; the National Comprehensive Cancer Network 2024; the American Urological Association 2023; the Canadian Urological Association 2022; and the European Society for Medical Oncology 2018. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was applied by two authors (M.T. and G.F.) to assess the quality of these guidelines.

Emerging evidence supports testis‐sparing surgery (TSS) as a viable option for managing STMs, showing acceptable oncological outcomes and preservation of gonadal function in select patients. The shared indications for TSS include indeterminate STMs identified on ultrasonography with negative tumour markers, particularly in the case of a solitary testis or of bilateral tumours. Where intra‐operative frozen section analysis is available, and confirms a benign lesion, a radical orchidectomy could be avoided.

Consensus across guidelines favours TSS in suitable cases, balancing oncological control with functional outcomes and informed patient decisions.