Discussion :
Copper reported the first intraparenchymal testicular cyst in humans in
1845, though it was later determined to be a cystic teratoma. In 1966,
Schmidt reported the first case of a simple testicular cyst in a child
under
the age of 5 months. Tosi and Richardson reported the first adult case
of a
simple testicular cyst in 1975, involving a 58-year-old male. Less than
50
instances of simple testicular cysts were documented overall between
1966 and 2004. This indicates that a simple testicular cyst is a rare
condition. Small testicular cysts can develop at any age, although the
majority affect males over the age of 40. Güçer, Tanyel, and Calar
(2007)
found that 75% of patients with the infant type had a simple cyst in
the
left testis. Simple testicular cysts often have diameters between 0.2
and
2cm. Simple cysts seldom produce symptoms and are typically not
palpable if they are modest in size. A cyst may show as suspected
testicular torsion if there is spontaneous bleeding into the cyst
cavity.
Moreover, individuals may exhibit either painless or painful scrotal
enlargement, particularly if the cyst’s diameter is greater than 5 cm. 1
In
children, benign testicular masses including testicular teratomas,
epidermoid cysts, and tunica albuginea cysts are infrequently observed.
There have only been 48 cases of simple cysts in the testicular
parenchyma recorded in the literature, making them incredibly
uncommon. Eight of the patients in these situations were under the age
of
two.4 A one-year-old child was brought by his parents to the urology
department in our case with a right scrotal enlargement, which makes it
a
highly unusual case for the age and the location. Simple testicular cyst
etiology is still controversial, however in most cases, ectopic
epithelium
like that seen in the Wolffian duct is thought to be the cause. The
pathological findings of the cyst wall in this instance matched those of
the Wolffian duct. Testicular lymphoangiomas, dermoid and epidermoid
cysts, epididymal cysts, hydrocele, cyst of tunica albuginea, cystic
dysplasia, teratoma, and juvenile granulose cell tumor are among the
other possible diagnoses for a simple testicular cyst. This difference
is
pathologically conceivable. 1,4,5,6 In fact, the pathognomonic
ultrasonography characteristics described by Rifkin and Jacobs (1983)
enable the preoperative diagnosis of a simple testicular cyst. A simple
testicular cyst is distinguished on ultrasound by edge shadowing,
posterior wall enhancement, lack of internal echoes, and cleanly defined
walls. These preoperative ultrasonography requirements differentiate a
simple testicular cyst from other diseases. Epidermoid cysts look
uniformly solid. Lesions outside the testis are known as tunica
albuginea
cysts.5 The best way to identify a simple testicular cyst is through
pathology. The pathological requirements for a simple testicular cyst
are
as follows: When a cyst is considered to be normal, it meets the
following criteria: (a) it is located in the parenchyma of the testis,
(b) the
tunica albuginea is not involved, (c) it contains sperm-free clear fluid
and
is surrounded by a cyst wall lined entirely or partially by flat or
cuboidal
epithelial cells with a fibrous tissue wall, (d) it is free of
teratomatous
elements inside the cyst or testis , and (e) not having any fibrosis or
persistent inflammation outside of the cyst wall.1 Preoperative
ultrasonography was first introduced in 1988 by Alta-Donna et al, who
also promoted testis-sparing surgery. Following that study,
ultrasonography has been used to identify all cases of simple testicular
cysts, and the testes that were impacted have been saved.4 For simple
testicular cysts, inguinal or scrotal methods have been documented. Some
authors believe the inguinal method is unnecessary and the scrotal
approach is recommended if clinical, ultrasonographic, and serologic
criteria support a benign, entirely cystic mass.2 Clearly, individuals
with
asymptomatic cysts of both the infant and adult types should choose for
this ”watch and wait” approach.1 This is why we first chose to monitor
the lesion using follow-up ultrasonography. Surgery intervention is
still
necessary if any of the following conditions exist: (a) the cyst
undergoes
any change in ultrasonography while under surveillance; (b) the patient
fails to respond to the surveillance program; (c) the cyst is painful,
though it may not be the only cause of the pain; and (d) the cyst’s
diameter is greater than 3 cm for children or 5 cm for adults.1 Thus,
the
normal course of prepubertal testicular teratoma is very different from
that of adult testicular teratoma. Compared to approximately 90% of
cases in the latter, the former is virtually invariably benign and
seldom
exhibits concomitant intratubular germ cell neoplasia. Because of this,
metastatic assessment can be delayed until a histopathologic diagnosis
is
made. According to Shukla et al., therapy was based on testicular lesion
ultrasonographic and intraoperative visual appearance, as well as
preoperative AFP levels.They avoided frozen analysis and underwent
testis-sparing surgery in the
case of a prepubertal child who had a testicular tumor that was mostly
cystic and had AFP levels that were appropriate for the child’s age.
They
found that testicular cystic lesions, including epidermoid and dermoid
cysts as well as simple cysts and teratomas, were always benign.2 in our
case, Inguinal exploratory surgery was done. Radical orchiectomy was
performed after a frost section showed teratoma because the
non-malignant part did not exceed 5% of the entire testicle. The biopsy
confirmed the diagnosis of Mature Cystic teratoma 1 cm not invading
tunica albuginea because it revealed glandular forms beneath the
multilayered, keratinized epithelium that covered the cystic
formations.Even when ultrasonography shows a fully cystic lesion,
testicular
teratoma should be included in the differential diagnosis of testicular
transilluminating masses in infants. Ultrasonography and serum
indicators like AFP and HGC are first-level tests that guide the
following
treatment.