Reply to Julian Chavarriaga and Robert Hamilton's Letter to the Editor re: Manolis Pratsinis, Christian Fankhauser, Katerina Pratsinis, et al. Metastatic Potential of Small Testicular Germ Cell Tumors: Implications for Surveillance of Small Testicular Masses. Eur Urol Open Sci 2022;40:16-8. Should We Be Afraid of Surveillance? Clinically Meaningful Reasons Why Offering Surveillance for Incidentally Detected Small Testicular Masses Remains a Safe Approach.

The low proportion of malignant tumors among small testicular masses (STMs) [1], [2], [3] has led to an ongoing debate regarding the choice between surveillance and surgical exploration, even among the major urological guidelines [4], [5].

This debate is caused by the limited and therefore unconvincing data on the trade-offs between histological clarification and ongoing surveillance. On the one hand, testis-sparing surgery with frozen section analysis poses a high risk of overtreatment and a low risk of pain or complications leading to subsequent orchiectomy, hypogonadism, infertility, and absence from work, among other side effects. On the other hand, surveillance requires repeated appointments for blood measurements and ultrasound, and may have a negative psychological impact on many men who do not require any follow-up at all. Our study [6] adds some evidence suggesting that there is indeed limited metastatic potential in men with STMs. This means that curative treatment with orchiectomy alone may be withheld and patients may later require systemic chemotherapy with its associated long-term toxicity. We believe that the evidence generated by this study is important to consider when discussing the trade-off between surveillance and surgical exploration for STMs.

We would like to thank Julian Chavarriaga and Robert Hamilton for their letter contributing to this important debate and would appreciate a discussion on potential prospective follow-up protocols for men with STMs. Such protocols should not only define the frequency of current tests, including ultrasound and traditional serum tumor markers, but should also consider the role of newer diagnostics such as microRNA 371 [7] and magnetic resonance imaging, as well as invasive methods including fine needle aspiration, core needle biopsies, ablative local treatment, and surgical exploration.

: The authors have nothing to disclose.