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Difficulty: EasyUrologic Surgery

A 27-year-old graphic designer schedules a clinic appointment after discovering a firm, painless lump in his left testicle while showering. He denies any recent scrotal trauma, dysuria, urethral discharge, or fever. He is otherwise healthy and takes no medications. On physical examination, vital signs are within normal limits. Scrotal examination reveals a 3-cm, hard, non-tender mass within the left testicle that does not transilluminate. The right testicle is normal to palpation, and there is no inguinal lymphadenopathy. A scrotal ultrasound confirms the presence of a solid, hypervascular intratesticular lesion. Serum laboratory testing shows significantly elevated levels of β\beta-human chorionic gonadotropin (β\beta-hCG) and α\alpha-fetoprotein (AFP). What is the most appropriate next step in the management of this patient?

  1. Radical inguinal orchiectomyAnswer
  2. B
    Transscrotal biopsy of the testicular mass
  3. C
    Administration of empiric oral antibiotics and observation
  4. D
    Initiation of systemic induction chemotherapy
  5. E
    Routine follow-up scrotal ultrasound in 3 to 6 months

Answer

The correct approach is to perform a radical inguinal orchiectomy.
The correct intervention is radical inguinal orchiectomy. In a young male presenting with a painless, solid intratesticular mass and elevated serum tumor markers (AFP and β\beta-hCG), the diagnosis is a testicular germ cell tumor until proven otherwise. The definitive initial management is surgical removal of the affected testicle along with the spermatic cord up to the internal inguinal ring. This provides a definitive histologic diagnosis, achieves local tumor control, and prevents lymphatic seeding that could occur with a transscrotal approach.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and diagnostic findings.
The patient has a painless, solid intratesticular mass that does not transilluminate, accompanied by elevated tumor markers (β\beta-hCG and AFP).
Identifying the nature of the mass is crucial for determining the likelihood of malignancy.
2
Formulate the most likely diagnosis based on the evidence.
The findings are highly diagnostic of testicular cancer, specifically a non-seminomatous germ cell tumor given the elevated AFP.
Testicular cancer is the most common solid malignancy in young adult males and presents exactly in this manner.
3
Determine the standard of care for initial surgical intervention.
The standard diagnostic and therapeutic approach is a radical inguinal orchiectomy.
This procedure safely removes the primary tumor while providing tissue for histologic diagnosis without violating the scrotal lymphatic drainage, which would risk spreading the cancer to inguinal lymph nodes.

Key Concept

The primary management of a highly suspicious testicular mass is radical inguinal orchiectomy, strictly avoiding transscrotal procedures to prevent tumor seeding.
Estimated Time:1m 0s
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Topics

Urologic Surgery

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