To assess the fertility outcomes of pathologist-guided ex vivo TESE of radical orchiectomy specimens, without involvement of reproductive urologist or microsurgical skills. Ex-vivo testicular sperm extraction (TESE) is a viable alternative for fertility preservation in patients with testicular cancer and concomitant azoospermia. While existing literature describes urologist-driven sperm retrieval, pathologist-driven extraction provides the opportunity to prioritize fertility outcomes in individuals while optimizing oncologic staging.

We performed a single-institution retrospective chart review of all patients who underwent radical orchiectomy for presumed testis cancer with concomitant ex-vivo TESE. Demographic, clinical, fertility, and oncologic information was extracted from the electronic medical record.

There were 11 patients who underwent concomitant orchiectomy and ex-vivo TESE between 2016 and 2025. Successful sperm retrieval and cryopreservation occurred in 8 individuals (73%) for an average of 3.8 vials (median 5.5, IQR 2.5-7). Preoperative semen analysis, serum tumor markers, and tumor stage, size, or histology did not correlate with the likelihood of successful ex-vivo TESE.

Pathologist-guided ex-vivo onco-TESE is a feasible and effective alternative to urologist-performed oncologic-TESE, achieving comparable or higher sperm retrieval rates without need for microsurgical expertise. This multidisciplinary model may expand access to fertility preservation while maintaining oncologic integrity.