From incidentaloma to actionable insight: a clinical-molecular-imaging framework for risk-stratified management of testicular microlithiasis

Objective: Testicular microlithiasis (TM) is common in infertile men, but its management is controversial due to an unclear link to testicular germ cell tumor (TGCT) risk. This scoping review synthesizes evidence to clarify the basis for personalized management of TM, focusing on infertile men. Methods: Following PRISMA-ScR guidelines, we systematically searched PubMed, Embase, and Web of Science (2015-2025) for studies on TM pathogenesis, imaging, molecular mechanisms, management, and TGCT association. Data were charted and narratively synthesized. Results: TM and TGCT share molecular pathways (e.g., KIT/KITLG, BMP7) within testicular dysgenesis syndrome. Isolated TM carries minimal risk, while coexisting with factors like cryptorchidism, infertility, or family history significantly elevates TGCT risk. Advanced imaging and liquid biopsy markers (e.g., miR-371a-3p) may refine risk assessment. Intermediate-risk patients (TM plus one established risk factor) may be considered for periodic ultrasound within shared decision-making; routine biomarker testing is not supported and should be individualized to selected high-risk contexts. Conclusion: The available evidence remains heterogeneous, and routine imaging surveillance for isolated testicular microlithiasis is not supported. We propose an evidence-informed, hypothesis-generating risk-stratification framework to support shared decision-making and highlight priorities for prospective validation.