Are testicular biopsies necessary for the diagnosis of testicular cancer?

Man sues over “botched” testicular surgery: Another frivolous lawsuit?
“A man is suing a hospital and one of its surgeons, claiming one of his testicles was wrongly removed during surgery.

Danny Curtis claims the surgeon at Kern Medical Center did not conduct a biopsy before arranging urgent surgery to remove a testicular tumor in July 2004, according to the lawsuit filed in Kern County Superior Court.”

I am not a urologist, so I did some reading into this. Are testicular biopsies necessary for the diagnosis of testicular cancer? The answer is no. Unfortunately, an orchiectomy (removal of the testicle) is the best way to diagnose testicular cancer. From UptoDate:

A radical inguinal orchiectomy should be performed to permit histologic evaluation of the primary tumor and to provide local tumor control. Neither scrotal ultrasound, as mentioned above, nor serum tumor markers are sufficiently accurate to replace radical inguinal orchiectomy. Scrotal violation at the time of surgery or an attempt to “biopsy” the testicle should be avoided because of concern for a poorer outcome.

In fact, studies show that those who had scrotal incisions for biopsy have a higher local recurrence rate as well as a higher relapse rate.

Thus, without knowing the details of the case, it seems that the physicians were doing the man a favor by not biopsying the testicle first. And their reward? A lawsuit.

Put yourself in the doctor’s shoes. You have a case of a suspicious testicular mass. You don’t know if it’s cancer or not. Biopsying the mass may lead to a worse outcome if it is cancer. However, there is a chance that it isn’t cancer. The only way to know for sure would be to take out the mass and look at it under a microscope. For the lawyers in the audience, what would you do? Such is the uncertainty inherent in medicine.

Our trial system unfortunately pounces on such uncertainty. The public has to understand that medicine is as much art as science – there are many cases where there are no “right” answers. Believe it or not, most doctors have the patients’ best interests at heart.

Update:
A urologist writes in the comments:

As a urologist, I can tell you that a testes should never be biopsied prior to removal if cancer is suspected. Why? It significantly increases the risk of tumor dissemination. Solid lesions in the testes are malignant >95% of the time. Therefore the patient needs to be counseled preop that there is a 2-4% chance that the testes will be removed and not have cancer. The risk of biospy exceeds the risk of removal of a non-cancerous testes. This is standard of care, and the only basis for suit is lack of informed consent.

Update 2:
Dr. Bob chimes in with an informed take from a urologist: Sued for proper care.

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