We evaluated 16 patients (pts) positive for STMs (lesion diameter <15 mm) to Ultrasound (US).

Scrotal US is performed with the use of high frequency broadband linear transducer (8-13 MHz) that can perform both power and spectral Doppler ultrasonography. Baseline gray scale and color Doppler sonographic examinations were performed using an MyLab™70 XVG system (Esaote, Genoa, Italy) with LA523 linear array contrast-enabled transducer.

The scrotum and its contents are evaluated in longitudinal and  trasverse plans.

All images were stored on an external hard disk for review. The lesions were reviewed for morphologic characteristics (including size and shape) and sonographic appearances (including echogenicity, the presence of calcification, cystic areas or concentric rings). The presence or absence of vascular signals at color Doppler was noted.

In all cases further US with intravenous infusion of second-generation contrast agent (Contrast Enhanced Ultrasound, CEUS) was performed. 

A low–mechanical index technique (Contrast tuned imaging, CnTI, Esaote) with mechanical index below 0.10 is applied. A bolus of 4.8 mL of sulfur hexafluoride microbubble contrast agent (SonoVue, Bracco SpA, Milan, Italy) is injected, followed by 10 mL of normal saline via an antecubital vein cannula. Split-screen technology is used and imaging is recorded on a cine loop for 180 seconds for later review.

On CEUS, note was made of if enhancement was present, and the pattern (hypo-, iso-, or hyper- enhancement) was noted.

The determination of the tumor markers such as alpha-fetoprotein (αFP), beta-human chorionic gonadotropion (βhCG) and lactate dehydrogenase (LDH) was assessed in all cases.

The patients underwent Testing sparing surgery (TSS) echoguided followed by eventual orchiectomy.

The selection criteria for TSS was the size of the mass (≤ 25 mm) and a safely distance of the mass from the rete testis, while advanced age of the patients was not considered an exclusion criteria.

All the patients underwent the exploration of the testis trough an inguinal access. After exteriorization of the testis, the small mass was identified by straight palpation of the testis or with intra operative ultrasonography (IUS), usually guided with a 30-g needle. In all patients we performed a cord clamping after the identification of the lesion in order to reduce the time of warm ischemia. After the excision of the mass, frozen section analysis (FSE) was performed in all cases associated with multiple biopsies of the surrounding tissue.