Overview
Definition:
Orchiectomy is the surgical removal of one or both testicles
For testicular tumors, it specifically refers to radical inguinal orchiectomy, which involves the removal of the entire testicle, its tunica, and the spermatic cord through an inguinal incision
This procedure serves both diagnostic and therapeutic purposes.
Epidemiology:
Testicular tumors are the most common solid malignancy in young men aged 15-35 years, with an incidence of about 5-10 per 100,000 males
Germ cell tumors (GCTs) account for over 90% of all testicular cancers, broadly classified into seminomas and non-seminomas
Orchidectomy is the primary diagnostic and therapeutic step for suspected testicular tumors.
Clinical Significance:
Orchiectomy is critical for the diagnosis, staging, and treatment of testicular tumors
It provides definitive histological diagnosis, allowing for appropriate risk stratification and subsequent management
It also serves as a crucial step in cancer control and can be curative for localized disease
Understanding the nuances of this surgery is vital for surgical residents preparing for DNB and NEET SS exams.
Indications
Suspicion Of Malignancy:
Any solid testicular mass detected on physical examination or imaging, especially if firm, non-tender, and irregular, is highly suspicious for malignancy.
Proved Testicular Tumor:
Following a suspicious ultrasound and elevated tumor markers (AFP, HCG, LDH), orchiectomy is indicated for definitive diagnosis and treatment.
Contralateral Testicular Lesion:
In cases of bilateral testicular masses or a contralateral testicular lesion after unilateral orchiectomy, a diagnostic orchiectomy of the suspicious contralateral testicle may be considered.
Testicular Torsion With Necrotic Mass:
If testicular torsion leads to testicular necrosis and a suspicious mass is identified, orchiectomy might be performed concurrently.
Preoperative Preparation
History And Physical Examination:
Thorough history including risk factors (undescended testes, family history, prior testicular issues) and physical exam focusing on testicular characteristics, size, consistency, and presence of pain
Assess for supraclavicular or inguinal lymphadenopathy.
Laboratory Investigations:
Complete blood count (CBC), renal function tests (RFTs), liver function tests (LFTs), serum tumor markers (alpha-fetoprotein [AFP], beta-human chorionic gonadotropin [β-hCG], lactate dehydrogenase [LDH]) preoperatively
Serial tumor markers are crucial for post-orchiectomy monitoring.
Imaging:
Scrotal ultrasound to characterize the mass (solid vs cystic, size, vascularity)
CT scan of the chest, abdomen, and pelvis is essential for staging after orchiectomy and biopsy confirmation of malignancy.
Informed Consent:
Detailed discussion with the patient regarding the procedure, risks (bleeding, infection, anesthetic risks, infertility, cosmetic concerns, hormonal replacement if bilateral), benefits, and alternatives
Sperm banking should be offered and discussed prior to surgery, especially for young men.
Anesthesia And Antibiotics:
General or spinal anesthesia is typically used
Prophylactic antibiotics are administered to reduce the risk of surgical site infection.
Surgical Procedure
Surgical Approach:
Radical inguinal orchiectomy is the standard
A scrotal incision is avoided to prevent tumor seeding into the scrotum and lymphatics, which would alter subsequent lymphatic drainage pathways.
Inguinal Incision:
A curvilinear incision is made in the inguinal region, similar to an inguinal hernia repair
The external oblique aponeurosis is opened, and the spermatic cord is identified and mobilized proximally.
Cord Ligation And Transection:
The spermatic cord is meticulously dissected free from surrounding tissues up to the internal inguinal ring
The cord is then double-ligated with non-absorbable sutures and transected
The testicle and cord are removed as a single specimen en bloc.
Tumor Marker Reassessment:
Post-orchiectomy tumor markers are drawn within 24 hours to establish a baseline and assess the immediate impact of tumor removal.
Staging Lymphadenectomy:
Inguinal lymph node dissection is generally NOT performed at the time of orchiectomy for suspected testicular cancer, as it does not improve survival and increases morbidity
Staging relies on imaging and subsequent treatment guided by histology and tumor markers.
Postoperative Care
Pain Management:
Adequate analgesia is provided, typically with opioid and non-opioid analgesics
Patients may experience post-orchiectomy pain for several days.
Wound Care:
The inguinal incision is dressed appropriately
Patients are advised to keep the wound clean and dry
Signs of infection should be monitored.
Mobility:
Early mobilization is encouraged to prevent deep vein thrombosis and pulmonary complications
However, strenuous activity and heavy lifting should be avoided for several weeks.
Hormone Replacement:
If bilateral orchiectomy is performed, lifelong testosterone replacement therapy will be necessary
For unilateral orchiectomy, testosterone levels should be monitored, and replacement therapy initiated if hypogonadism develops.
Psychological Support:
Emotional and psychological support is crucial, especially concerning body image, fertility, and sexual function
Referral to a counselor or support group may be beneficial.
Complications
Early Complications:
Bleeding and hematoma formation in the scrotum or inguinal region
surgical site infection
wound dehiscence
reactionary hydrocele.
Late Complications:
Chronic pain at the surgical site
nerve injury leading to groin pain or altered sensation
infertility (especially with bilateral orchiectomy or in the presence of pre-existing subfertility)
hormonal imbalance (hypogonadism) if residual testicular tissue is insufficient or if bilateral orchiectomy is performed
psychological distress.
Metastatic Disease:
Failure to remove all malignant tissue, leading to recurrence or metastasis, is a significant complication that necessitates further treatment.
Prognosis
Factors Affecting Prognosis:
Prognosis is primarily determined by the histological type of tumor (seminoma vs
non-seminoma), stage at diagnosis (presence of metastasis, tumor markers), and patient's overall health.
Outcomes:
With modern management, the cure rates for testicular cancer are very high, often exceeding 90% for localized disease
Radical inguinal orchiectomy is the first step towards cure.
Follow Up:
Long-term follow-up is essential, involving regular physical examinations, serial tumor marker monitoring, and periodic imaging (CT scans) to detect recurrence or metastasis
The surveillance protocol is tailored based on the tumor type and stage.
Key Points
Exam Focus:
Radical inguinal orchiectomy is the standard approach
Scrotal incision is avoided to prevent lymphatic spread
Post-orchiectomy tumor markers are vital for diagnosis confirmation and monitoring.
Clinical Pearls:
Always offer sperm banking before orchiectomy for suspected malignancy, as treatment can lead to infertility
Bilateral orchiectomy requires lifelong testosterone replacement
Consider RPLND for intermediate-risk non-seminomas, but it’s not typically done at the time of orchiectomy.
Common Mistakes:
Performing scrotal orchiectomy instead of inguinal
Delaying diagnosis due to patient or physician hesitation
Inadequate preoperative staging with CT scans
Failing to offer sperm banking
Not monitoring tumor markers postoperatively.