Ex vivo microscopic testicular sperm extraction at the time of radical orchiectomy in men with nonobstructive azoospermia (NOA): a scoping review

Abstract

Testicular tumor is the most common solid malignancy in males under 40 years of age. This malignancy is known to have a negative impact on male fertility. Therefore, several techniques for sperm retrieval have been proposed, including microdissection testicular sperm extraction (mTESE). The objective of this study was to review the literature on the outcomes of oncological (Onco)-mTESE at the time of radical orchiectomy. We conducted a comprehensive literature search through PubMed, Scopus, and Cochrane Central Controlled Register of Trials. Only studies reporting ex vivo mTESE in patients with testicular tumor were considered. Twelve papers met the inclusion criteria and were included in this review. Tumor size was identified as the sole preoperative factor influencing spermatogenesis. The considered studies demonstrated a satisfactory success rate for Onco-mTESE, associated with a similarly valid percentage of live healthy births through assisted reproductive technology. Currently, no comparison has been made between Onco-mTESE and conventional Onco-TESE, hence further assessment is required. In cases where the tumor completely replaces the cancer-bearing testicle, a contralateral micro-TESE may be a viable alternative. However, the surgeon should evaluate associated risks and benefits preoperatively. In conclusion, Onco-mTESE at the time of radical orchiectomy appears to be a promising therapeutic option for young patients with testicular tumors. Nevertheless, additional studies are necessary to achieve a definitive conclusion.

INTRODUCTION

Testicular tumors (TTs) are a relatively uncommon form of cancer in males, accounting for approximately 1%–3% of all male malignancies.1 They are the most prevalent nonhematologic malignancy among males aged 15 years to 49 years. Globally, an estimated 74 500 cases of testicular tumors were reported in 2020.2 The majority of these tumors (approximately 95%) are germ cell tumors (GCTs). TTs have the potential to negatively impact fertility due to their harmful effects on the surrounding healthy tissue, leading to a significant reduction in sperm production. Several factors, such as bilateral TT, germ cell neoplasia in situ (GCNIS), advanced tumor stage, smaller testes, Sertoli cell-only (SCO) syndrome, and a history of undescended testicles (UDTs), can directly affect spermatogenesis.3 More than half of the patients with testicular cancer at diagnosis exhibit low sperm count (oligozoospermia), while up to 24% may experience the absence of sperm in the ejaculate (azoospermia).4 The inherent risk of reduced fertility, combined with the potential for treatment-induced infertility, which can be permanent, is a major concern. Testicular cancer patients experience an average decline of 30% in fertility.5 Consequently, there is a significant need to predict and effectively address the infertility issues faced by these individuals. Over time, this condition can progress to nonobstructive azoospermia (NOA), which is considered the most severe form of male infertility. However, individuals with NOA may still have viable sperm present in their testicles.6 Therefore, assisted reproductive techniques, including percutaneous and open surgical procedures, are available to retrieve sperm in cases of NOA.7 Intracytoplasmic sperm injection (ICSI) can be performed with the retrieved sperm to assist these men in becoming biological fathers. With advancements in sperm preparation, selection techniques, and assisted reproductive technology (ART), the use of testicular sperm instead of ejaculated sperm for ICSI has shown similar pregnancy rates in men with similar causes of male factor infertility.8 Testicular sperm samples from infertile men have a lower percentage of terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL)-positive cells, and a 50% success rate in achieving pregnancy and live birth has been observed among couples who previously failed one or more in vitro fertilization (IVF)–ICSI cycles with ejaculated sperm and underwent testicular sperm extraction (TESE) in ICSI.9 However, a recent systematic review highlighted significant inconsistencies in the reporting quality of outcomes related to microdissection testicular sperm extraction (micro-TESE), particularly in terms of the quantity and characteristics of retrieved spermatozoa, pregnancy and live birth outcomes, and fetal and neonatal outcomes.10

In an oncological context, it is recommended to perform TESE (oncological [Onco]-TESE) before any gonadotoxic treatments such as chemotherapy or radiotherapy. TESE involves extracting spermatozoa by removing a small portion of testicular tissue, and this surgical procedure can be performed simultaneously with radical surgery. Ogouma et al.11 reported that Onco-TESE is more commonly recommended for men diagnosed with testicular cancer before treatment, allowing for simultaneous tumor removal or orchiectomy. Modern advancements, such as the use of optical magnification through a surgical microscope, have significantly improved the accuracy of sperm retrieval in these procedures, obtaining the microsurgical Onco-TESE (Onco-mTESE).12

The aim of this comprehensive scoping review is to specifically examine the outcomes of Onco-mTESE performed concurrently with radical orchiectomy in patients with testicular tumors. The objective is to assess the success rate of this procedure and identify prognostic factors that might predict the success of Onco-mTESE.

EVIDENCE ACQUISITION

Literature search

In this study, we performed a scoping review evaluating the current evidence on the Onco-mTESE outcomes in the context of testicular malignant disease. Literature search was performed on June 22, 2023, using PubMed, Scopus, and Cochrane Central Controlled Register of Trials. The following terms and Boolean operators were used: (sperm extraction OR sperm retrieval OR TESE OR micro-TESE OR onco-TESE) AND (testicular cancer OR tumo* OR radical orchiectomy).

Selection criteria

Selection criteria were done according to the patient/population, intervention, comparison, outcome, and study design (PICOS) model.13 Only studies conducted on adult populations and published in English were included in this review. Specifically, we focused on studies that evaluated the outcomes of the Onco-mTESE procedure. Preclinical studies and those involving pediatric populations were excluded from consideration. In addition, studies examining alternative sperm retrieval techniques, including TESE, were not included. Reviews, letters to the editor, and meeting abstracts were also excluded from the analysis.

Study screening and selection

Only studies reporting the Onco-mTESE at the time of radical orchiectomy in patients with TT were considered. Our main objective was to evaluate the success rate of this procedure, with a secondary aim of assessing the predictive factors of failure. The PICOS model was used to frame and respond to the clinical question (P: adult men with testicular tumor, I: mTESE at the time of radical orchiectomy, C: TESE or none, O: mTESE success rate, and S: retrospective and prospective studies and case reports).

All the studies that were identified during the search were screened by two independent authors (CG and NHVP) using the Rayyan Intelligent Systematic Review tool (https://www.rayyan.ai/). Any discrepancies or disagreements between the authors were resolved through discussion with the third author (SC). The full text of the papers that were deemed relevant to the objective of this review was selected for further analysis. This review was registered on https://osf.io/registries/ (No. osf.io/hm438).

Data synthesis

To characterize the studies included in our analysis, we collected the following information: sample size, mean age of patients, tumor location, prior therapy received before the procedure, number of patients with azoospermia or oligospermia, cancer histologic type, success rate of Onco-mTESE, utilization of Onco-mTESE in the contralateral testis if sperm retrieval failed in the initial specimen, number of ART procedures performed using cryopreserved spermatozoa, and number of live births resulting from the insemination procedure. Data are available on request from the authors.

EVIDENCE SYNTHESIS

Literature screening

The literature search yielded a total of 712 papers. Among these, 73 duplicates were automatically removed, leaving 639 papers for screening based on their titles and abstracts. Out of these, 585 papers were deemed irrelevant to the objective of the present review and were subsequently excluded. The remaining 54 papers underwent a thorough assessment of their full texts for suitability, resulting in the exclusion of 42 papers. Ultimately, 12 papers met the inclusion criteria and were included in this review.14,15,16,17,18,19,20,21,22,23,24,25 The flow diagram illustrating the process of the literature search can be seen in Figure 1.

Figure 1.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 flow diagram.

Study characteristics

This review comprises 5 retrospective studies,16,17,22,23,25 7 case reports,14,15,18,19,20,21,24 and lacks a randomized trial, encompassing a total of 128 patients. In the context of a testicular tumor, all Onco-mTESE procedures were carried out concurrently with an orchiectomy. In all studies, the success rate of Onco-mTESE was reported, while only one22 showed sperm retrieval from the contralateral testis in case of failure of Onco-mTESE from testis specimens. Five articles reported the outcomes of ART and live birth.14,16,19,22,25 Table 1 shows the characteristics of the patients included in the studies.

Table 1.

Studies concerning the microscopic testicular sperm extraction at the time of radical orchiectomy

Study (year)	Country	Study type	Sample size (n)	Mean age (year)	Side of tumor: number	Pre-mTESE therapy	Patients underwent mTESE (n)	Azoospermia, n (%)	OAS, n (%)	Cancer type: number	Positive mTESE, n (%)	Positive contralateral TESE in case of failure, n (%)	ART (n)	Live birth (n)
Binsaleh et al.14 (2004)	Canada	Case report	2	29	Left: 2	None	2	2 (100)	-	LCT: 1 SCO pattern: 1	1 (50)	-	1	1
Carmignani et al.15 (2007)	Italy	Case report	4	-	Right: 3	None	3	3 (100)	-	Benign LCT: 2 Seminoma: 2	3 (100)	-	-	-
Hallak et al.16 (2009)	Brazil	Retrospective	5	36	Right: 2 Left: 2 Bilateral: 1	None	5	5 (100)	-	Benign LCT: 4 Sertoli cell tumor: 1 Seminoma: 1	4 (80)	-	1	1
Amano et al.17 (2013)	Japan	Retrospective	5	40	Bilateral: 5	CO and CHRT	1	1 (100)	-	Seminoma: 1	0	-	-	-
Haddad et al.18 (2014)	Canada	Case report	1	30	Right: 1	None	1	1 (100)	-	Seminoma: 1	1 (100)	-	-	-
Pindoria et al.19 (2016)	UK	Case report	1	43	Right: 1	None	1	1 (100)	-	Epididymal papillary cystadenocarcinoma: 1	1 (100)	-	1	1
Kuroda et al.20 (2018)	Japan	Case report	1	35	Right: 1	CO	1	1 (100)	-	Seminoma: 1	1 (100)	-	-	-
Liang et al.21 (2019)	China	Case report	1	28	Left: 1	None	1	1 (100)	-	Gonadal stromal tumor: 1	1 (100)	-	-	-
Blecher et al.22 (2022)	Australia	Retrospective	13	35	Right: 5 Left: 7 Bilateral: 1	None	13	12 (92.3)	1 (8)	GCT: 13 non-GCT: 4 Benign lesion: 2	7 (53.8)	3 (50)	6	5
Scott et al.23 (2021)	UK	Retrospective	61	34	-	None	9	9 (100)	-	-	7 (77.8)	-	-	-
Symeonidis et al.24 (2023)	Greece	Case report	1	20	Bilateral: 1	None	1	1 (100)	-	Seminoma and EC: 1 EC and IGCN unclassified: 1	1 (100)	-	-	-
Kaul et al.25 (2022)	UK	Retrospective	33	33	-	None	33	-	-	GCT: 25 Malignant LCT: 1 Benign LCT: 3 EpC: 2 CD: 1 SST: 1	13 (33.3)	-	3	2

SCO: Sertoli cell-only; ART: assisted reproductive technology; mTESE: microscopic testicular sperm extraction; OAS: oligoasthenospermia; GCT: germ cell tumor; CO: contralateral orchiectomy; CHRT: chemoradiotherapy; LCT: Leydig cell tumor; IGCN: intratubular germ cell neoplasia; EC: embryonal carcinoma; EpC: epidermoid cyst; CD: cystic dysplasia; SST: sclerosis of the seminiferous tubule; -: missing data

Sperm retrieval success rate

Among the five retrospective studies,16,12,22,23,25 the collective success of sperm retrieval using Onco-mTESE was observed in 31 cases out of 61, yielding a success rate of 50.8%. Two individual case series22,25 further categorized the outcomes based on the histological subtype of TT. In total, the sperm retrieval rate for malignant Leydig cell tumors and seminomas was 75.0% (3 out of 4 cases) and 47.1% (8 out of 17 cases), respectively. Notably, Onco-mTESE demonstrated a lower success rate in the context of nonseminomatous germ cell tumors, with a rate of 25.0% (3 out of 12 cases).

ART and live birth rate

Three articles provided information on the ARTs that were employed.16,22,25 In total, ten patients undertook attempts to achieve pregnancy through ART. Remarkably, eight live births were achieved in these cases, resulting in a commendable live birth rate of 80.0%.

DISCUSSION

The association between testicular pathology and male fertility

Testicular pathologies, such as TT, cryptorchidism, varicoceles, and infections, can disrupt the delicate process of spermatogenesis. In oncology patients, there tends to be an overall reduction in sperm quality, with approximately half of the patients experiencing subfertility and 20% facing azoospermia.26 The association between TT and male infertility may be linked to various factors, including testicular dysgenesis syndrome, testicular developmental disorders, systemic effects, endocrine effects, and immunity, all of which can potentially affect spermatogenesis.27

When examining radical orchiectomy specimens, regardless of the cancer type, there is a noticeable impairment of spermatogenesis that worsens as the tumor’s proximity increases in the remaining normal testicular tissue.28 On the other hand, infertile patients have a 20-fold higher incidence of testicular cancer compared to the general population.29 Moreover, men with testicular cancer may experience impaired spermatogenesis even before the disease becomes clinically apparent.

Initial findings by Choy et al.30 indicated a correlation between tumor size and spermatogenesis in patients with testicular tumors. They reported that 86%, 81%, and 57% of cases with tumor sizes of 1 cm, 2 cm, and 5 cm, respectively, exhibited spermatogenesis. These results were later confirmed through multiple regression analysis, which demonstrated that tumor diameter negatively affected spermatogenesis (regression coefficient = −0.437, P < 0.001), while age and cancer type had no significant impact.31 At multivariate analysis, Shoshany et al.32 evaluated a 4-cm threshold for the TT, with percentages of 83% and 49% of sperm cells when it is below or above that value, respectively.

As a result, many patients with TT are infertile, and some may produce semen samples inadequate for cryopreservation. Therefore, it is crucial to consider Onco-TESE and sperm preservation after surgery.23,24

The impact of testicular pathology on male fertility varies and depends essentially on the extent of the TT. In certain cases, sperm production may only be mildly affected, allowing for the possibility of natural conception or ARTs with minimal intervention. However, severe testicular pathologies can result in a complete absence of sperm production, significantly compromising a man’s fertility and his chances of conceiving a child naturally.

Prognostic factors for the success of micro-TESE at the time of radical orchiectomy

Onco-mTESE has become widely accepted as a standard and frequently used technique for patients with NOA. Its widespread popularity can be ascribed to its technical simplicity, as substantiated by prior research,33 albeit its effectiveness may be affected by antecedent pathological conditions, such as cryptorchidism.34 One of the key advantages of micro-TESE is its ability to target specific tubules for biopsy, resulting in the removal of less tissue and reducing testicular damage. This procedure allows the surgeon to harvest a broader expanse of healthy testicular tissue, thereby substantially enhancing the likelihood of identifying viable sperm, especially in cases of radical orchiectomy. Several cases have evaluated the outcomes of Onco-mTESE.

Carmignani et al.15 examined four cases, consisting of two Leydig cell tumors and two seminomas. Three of these cases underwent Onco-mTESE, and remarkably, all three achieved a 100% successful sperm retrieval rate.

In a retrospective study conducted by Hallak et al.,16 five azoospermic patients, with a mean age of 36 years, were analyzed, including one with a Sertoli cell tumor and one with seminomas. Among them, four individuals underwent Onco-mTESE, and all of them achieved successful sperm retrieval. Only one ART procedure was performed, resulting in a successful term pregnancy. However, Amano et al.17 retrospectively reviewed five cases of Onco-mTESE at the time of radical orchiectomy. All of them had already undergone chemoradiotherapy and contralateral surgery for malignancy. No Onco-mTESE procedure successfully retrieved sperm. The authors concluded that these patients might require a more aggressive therapy for preserving male fertility, considering that testosterone injections can effectively and safely relieve several symptoms, but do not restore fertility.

Finally, Blecher et al.22 conducted a retrospective study involving 13 cases of germ cell tumors, most of which had azoospermia. They reported a 54% success rate in sperm retrieval through Onco-mTESE on the ipsilateral side. When evaluating only germ cell tumors, sperm retrieval occurred in only three out of seven patients. Nonetheless, ART was performed in four patients, resulting in six pregnancies, with five healthy live births and one miscarriage. Therefore, while these findings suggest Onco-mTESE as a viable option in germ cell tumors, the success rate was moderate.

The success of Onco-mTESE can be attributed to several factors. In the previous paragraph, we discussed how the presence of malignancy itself has a negative predictive value on the presence of sperm cells in the tubules. Two studies evaluated perioperative prognostic factors.

In the retrospective study by Scott et al.,23 61 cases were examined, and 9 patients underwent mTESE, achieving a remarkable 78% success rate in sperm retrieval. Univariate analysis identified serum lactate dehydrogenase (LDH) levels as a predictor of azoospermia (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.00–1.02, P < 0.01). Multivariate analysis confirmed this association (OR: 1.03, 95% CI: 1.01–1.05, P < 0.01). Interestingly, tumor histology did not predict the success of cryopreservation. LDH levels appear to serve as a potential prognostic factor for azoospermia, while tumor histology alone does not determine the success outcome.

In a retrospective study, Kaul et al.25 reviewed 33 patients, including various types of testicular tumors. Among these cases, GCT accounted for 25 cases, one was a malignant Leydig cell tumor (LCT), three were benign LCT, two were epidermoid cysts (EpCs), one was Leydig cell tumor with calcification (CD), and one was a Sertoli stromal tumor (SST). The study reported a success rate of 39% in sperm retrieval through Onco-mTESE. Nonetheless, upon conducting a subanalysis regarding sperm retrieval based on histological tumor type, it becomes evident that seminoma exhibits a higher success rate compared to nonseminomatous tumors (40% vs 29%, respectively). This observation underscores the influence of tumor type on the likelihood of procedural success. Out of the 13 patients who cryopreserved their sperm, only 3 proceeded with ART, resulting in 2 live births. Consequently, the live birth rate amounted to 66.7% (2 out of 3).

In conclusion, Onco-mTESE shows promise as a valuable technique for sperm retrieval in various testicular tumor types. However, the observed success rate is relatively moderate, warranting further research to investigate potential prognostic factors that might influence the outcomes of Onco-mTESE in different types of testicular tumors. Larger sample sizes and prospective studies will offer more accurate and comprehensive insights into the success rates and predictive factors of mTESE in this patient population.

A comparison of micro-TESE and TESE in the presence of testicular cancer

In patients with NOA, obtaining adequate sperm retrieval with conventional TESE may be challenging due to reduced spermatogenesis and decreased density of mature sperm cells. Various techniques have been proposed to increase success rates, such as performing a single large biopsy, multiple small biopsies, or excising a larger volume of testicular tissue to ensure an adequate sample.35 The micro-TESE technique minimizes the amount of testicular tissue required by selectively extracting seminiferous tubules containing spermatogenic cells only. In a prospective comparative study, the micro-TESE approach resulted in less testicular tissue extraction, yet a higher percentage of cases showed the presence of spermatozoa compared to conventional TESE (50.8% vs 33.7%, P < 0.001), indicating an improvement in sperm retrieval for men with NOA using the former method.36 Corona et al.37 conducted a comprehensive analysis of 21 404 patients across 117 studies, demonstrating comparable success rates between conventional TESE and micro-TESE procedures in individuals with NOA. However, the studies exhibited significant heterogeneity (89%), indicating the necessity for further studies to establish definitive conclusions.37

The standardized methodology establishment for Onco-mTESE in testicular cancer patients remains elusive. Its concept was introduced in 2003, involving the extraction of testicular sperm during orchidectomy.38 Performing Onco-mTESE in such cases is difficult due to the need for extracting samples from noncancerous tissue separate from cancerous tissue. Insufficient evidence exists regarding sperm use from noncancerous tissue in cancerous testes. However, Onco-mTESE is crucial, particularly when the affected testis with the tumor is the only functioning one, offering the sole opportunity for fertility preservation. A hemi-equatorial incision is made on the testicle for the Onco-mTESE technique, followed by microscopic identification. Subsequently, seminiferous tubules are extracted from regions of the testis, unaffected by tumors, and examined using a benchtop microscope.22 Hence, Onco-mTESE provides azoospermic men diagnosed with testicular cancer the opportunity to undergo simultaneous surgical sperm retrieval during orchiectomy.

Currently, there are no comparative studies between conventional TESE and Onco-mTESE at the time of radical orchidectomy in patients with testicular cancer. Ideally, the surgical microscope should offer significant benefits in identifying healthy seminiferous tubules free from tumor cells compared to conventional TESE. However, a recent systematic review evaluating both techniques in patients with TT found no evidence to support the superiority of Onco-mTESE over the conventional procedure.11

Fate of the contralateral testis in case TESE fails on the affected testis from cancer

Men with testicular cancer have the highest sperm counts before undergoing orchiectomy, indicating that the optimal opportunity for sperm retrieval in individuals with testicular cancer and NOA is during radical orchiectomy, particularly when adjuvant chemotherapy is anticipated.39

However, it is worth noting that contemporary testicular cancer diagnoses often occur during infertility assessments or ultrasound examinations, and infertile patients with testicular cancer frequently have small-sized contralateral testis. Therefore, the compromised functional potential of the atrophic contralateral testis poses a challenge in managing these cases,19 and there may be a limited benefit to performing a contralateral micro-TESE procedure when initial sperm retrieval from the testis has failed. Furthermore, the contralateral micro-TESE procedure significantly prolongs operative time and incurs higher financial costs. A recent study involving 900 men with NOA (excluding those with testicular cancer) revealed that out of 506 individuals who underwent bilateral micro-TESE, only 40 (8%) had sperm found in the contralateral side after an unsuccessful procedure in the initial testis.40 However, in cases where the cancer-bearing testicle is entirely replaced by a tumor, a contralateral micro-TESE may be a viable option.25 Kaul et al.25 also reported that a successful contralateral micro-TESE was performed after the initial micro-TESE procedure had failed in two cases. Sperm retrieval was successfully achieved from both testes in the five patients who underwent bilateral micro-TESE.

Performing micro-TESE on the contralateral testis ensures a success rate even in the other studies. In a case report involving a 32-year-old man with only two motile sperm retrieved from the testis affected by TT, Binsaleh et al.14 applied ICSI using the sperm from the other testis on four oocytes from his partner, resulting in four viable embryos, of which two were transferred, leading to a clinical pregnancy.

In a multicenter retrospective analysis of 89 patients treated for TT and 9 who underwent radical orchiectomy and Onco-mTESE, Scott et al.23 achieved successful sperm retrieval (from either the affected testis or, if unsuccessful, the contralateral testis) in 78% of cases.

Moreover, Blecher et al.22 published the only study where micro-TESE was performed on a healthy testis in cases of Onco-mTESE failure from the affected one. The study reported a successful sperm retrieval rate of 54% in testes with cancer. Among the remaining cases, micro-TESE on the contralateral testis was effective in 50%, resulting in an overall success rate of 77%. Among the six ARTs, five live births occurred. The authors concluded that the concurrent Onco-TESE and Onco-mTESE (on the healthy testis) use demonstrated feasible sperm retrieval rates with acceptable live birth rates following ART. Nevertheless, conducting micro-TESE in the opposite testis carries the potential risk of postoperative hypogonadism. It entails dangers such as vascular injury, scarring within the testicle, and testicular atrophy, which can further diminish sperm production and endocrine function.31 No significant postoperative complications were reported in the contralateral testis in the previously examined studies.14,22,23,25

In summary, a comprehensive preoperative assessment is imperative to comprehensively weigh the associated risks and benefits pertaining to sperm retrieval from the contralateral testis. However, due to the limited number of articles available, further research is required to clarify this issue.

Limitations

This scoping review has several limitations. Most of the included studies were case reports and retrospective studies with small sample sizes, resulting in low-quality evidence. Therefore, it is crucial to conduct more extensive and higher-quality investigations in the future. Another limitation is the variability in surgeon expertise across the included studies, which may have influenced the chosen approach and potentially impacted the outcomes. In addition, the significant differences in interventions among the studies hindered a comprehensive analysis of overall oncological and functional outcomes. Future investigations on Onco-mTESE should incorporate larger sample sizes and prospective study designs. These studies should also consider additional factors such as tumor markers, genetic abnormalities, hormonal profiles, and genetic counseling to identify potential markers for successful sperm retrieval.

CONCLUSIONS

The cumulative findings from the reviewed studies and case reports highlight the effectiveness of Onco-mTESE as a valuable technique for sperm retrieval in cases of testicular cancer. However, the success rates of Onco-mTESE varied across studies, emphasizing the need for further research and exploration of prognostic factors.

A comprehensive assessment of preoperative fertility markers and patient desires for future parenthood is crucial for tailored fertility planning and preservation strategies. Furthermore, collaboration among multidisciplinary teams, including urologists, oncologists, and reproductive specialists, is imperative to ensure comprehensive preoperative evaluations and optimize patient outcomes. By advancing our understanding of the predictive factors and success rates of Onco-mTESE, we can improve fertility planning, provide individualized counseling, and optimize reproductive outcomes for men with testicular cancer. Overall, Onco-mTESE holds promise as a valuable approach for sperm retrieval in men with testicular cancer. However, further research is warranted to elucidate the complex interplay of factors influencing sperm retrieval success, refine prognostic models, and guide personalized fertility preservation strategies for this patient population.

AUTHOR CONTRIBUTIONS

CG contributed to the conceptualization, project administration, original draft preparation, investigation, methodology and review and editing the manuscript. NHVP contributed to the investigation and original draft preparation. SC supervised the study and manuscript. All authors read and approved the final manuscript.

COMPETING INTERESTS

All authors declare no competing interests.