Monday, July 7, 2014

Surgery for Testicular Cancer: Orchiectomy

While scrotal ultrasound and serum tumor markers (beta-human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase) are the first steps in the diagnosis of a testis cancer, the diagnosis is not confirmed until an orchiectomy (surgical removal of the testicle) is performed.  The standard-of-care for the removal and treatment of testis cancer is a radical orchiectomy.  This is the most common operation performed for testis cancer worldwide. However, as our understanding of this disease and surgical technique has improved, testis-sparing surgery or partial orchiectomy has become an option for some patients.

This blog entry will briefly discuss important considerations for men undergoing orchiectomy for testis cancer.



This surgery involves removing the testicle and spermatic cord where it exits the body to identify and likely treat the majority of cancers localized to the testis.  As a male fetus develops, the testes develop near the fetal kidneys.  As the fetus grows, the testicles separate from the kidneys and, at about the eighth month of pregnancy, the testicles exit the body wall to rest in the scrotum (this is why premature infants have a higher likelihood of having undescended testicles).  Therefore the blood supply, lymphatic drainage and nerves to the testicle originate near the kidney on that side.  Once these structures exit the body through the internal inguinal ring they fuse with muscles of the body wall to form the spermatic cord.  To correctly stage and prevent any cancer from spreading, the spermatic cord must be taken as high toward or inside the body as possible -- hence the incision in the groin rather than the scrotum.

For men whose cancer has spread from the testicle and who have metastatic testis cancer (elsewhere in the body) or in the lymph nodes of the retroperitoneum, radical orchiectomy is an important first step in the diagnosis and management of disease.  Knowing the type of cancer may help guide chemotherapy or radiation treatments.


Adapted from Gottesman JE. In: Crawford ED, editor.
Current genitourinary cancer surgery.
Philadelphia: Lea & Febiger; 1990. p. 319.
The surgery can be performed under general or local anesthetic.  An approximately 5-10cm incision is made in the groin, just above the pubic tubercle (pubic bone) near the inguinal ligament.  This incision facilitates access to both the testicle and the proximal inguinal canal.  The skin incision is relatively painless, so a larger incision should be made to facilitate delivery of a large testicular tumor or to help with access to the spermatic cord.  The incision is carried down to the external oblique fascia (the outermost layer of the body wall).  The external oblique creates a tunnel through which the spermatic cord travels -- a hernia can form when there is weakness in these layers of the body wall.  Once the external oblique fascia is identified, the cord can then be identified exiting the external spermatic ring.  The cord should be isolated and the external fascia will need to be opened to gain access to the internal ring and to take the spermatic cord where it exits the body.  This can be done in either order.  Care should be taken to separate and preserve the ilioinguinal nerve which travels along the spermatic cord.  Once the cord is isolated, an occlusive, but non-crushing clamp or elastic drain can be used to stop blood supply to and from the testicle.  This prevents any "shedding" of tumor cells when the testicle is manipulated.  The testicle can then be "delivered" from the scrotum.  To deliver the testicle the scrotum can be inverted until the testicle is visible, facilitating dissection of the testicle from its scrotal contents.

Once the testicle and spermatic cord are entirely free from the inguinal canal, the testicle can be removed.  The spermatic cord should be ligated in two packets - one containing the gonadal artery and one containing the vas deferens (sperm duct) and its associated artery.  A large, non-absorbable suture should also be tied to the distal spermatic cord to facilitate easy identification in the case that a retroperitoneal lymph node dissection needs to be performed in the future.  Care should be taken to close the external oblique fascia to the level of the external ring to prevent future hernia.


The biggest risk of a radical orchiectomy is hematoma (or bleeding into the scrotum).  It is very common for the scrotum to be bruised, swollen and tender for 2-4 weeks after surgery.  However, a large, purple-appearing scrotum can indicate a hematoma.  Hematoma can be prevented with a compressive dressing, tight-fitting undergarments and/or ice packs.
Ilioinguinal nerve injury can occur if the nerve is damaged during dissection of the spermatic cord.  This is more common in men who underwent prior inguinal surgery (usually for an undescended testicle or hernia repair) and can occur during dissection or be inadvertently trapped in the closure of the external oblique fascia.  The deficit is often decreased sensation to the medial thigh, scrotum or base of the penis.  It is often transient, but can take several weeks or months to improve.
Inguinal hernia can occur if the external oblique fascia is not closed properly or if the closure breaks down.  It is important to minimize strenuous activities for 2-4 weeks to prevent development of a hernia.

Made by Coloplast

Testicular Prosthesis

Prostheses should be offered to all men undergoing orchiectomy.  Not all men want a prosthesis -- it is a personal decision.  The prosthesis should be measured in the operating room with the patient asleep.  The goal should be to match the remaining testicle in size taking into account a cancerous testicle can be larger or smaller than normal, and the scrotal skin will make a prosthesis look larger once implanted.



While radical orchiectomy remains the standard-of-care for the diagnosis and treatment of testis cancer, there are a couple of circumstances where testis-sparing surgery is advocated.  The primary indications are in men with:

  • bilateral testis cancers (either synchronous, at the same time; or metachronous, that develop some time after the first testicle is removed)
    • the standard-of-care would be to remove both testicles under suspicion of cancer, however the implications regarding fertility and testosterone replacement are well-established
  • small, palpable testis masses and normal serum tumor markers
    • these men have a low, but significant risk of having a benign mass or non-germ cell cancer that does not require orchiectomy
    • if a testis cancer is confirmed, a radical orchiectomy is completed
  • small, non-palpable, ultrasound detected testis mass with normal tumor markers
    • approximately 80% likelihood of benign mass [1] 
Some urologists advocate for testis-sparing surgery even for men with germ cell tumors of the testicle.  While some evidence indicates that this can be done safely in some patients, it is not a proven or well-established technique.[2,3]  Before undergoing testis-sparing surgery, an extensive consultation should occur with the patient and their family regarding expectations and possible outcomes in the operating room.


Tumor being identified with
intra-operative ultrasound.
The beginning portion of a testis-sparing surgery is identical to a radical orchiectomy.  Once the testicle is "delivered," the testis-sparing portion should begin.  The tunica vaginalis should be opened vertically to expose the testicle and intraoperative ultrasound should be used to identify the mass, rule-out other masses and create a surgical plan.  The testicle should be iced down for 10 minutes prior to placing a tourniquet or non-crushing clamp on the spermatic cord.  Once the testicle has been iced, a clamp or tourniquet should be placed on the cord.  The tunica albuginea (which houses the tubules of the testicle) should be opened horizontally above the mass.  The mass can often be "shelled" out of the surrounding tubules with a margin of 3-5mm.  Surgical loupes or a microscope can be used to facilitate dissection with a clean margin.  Bipolar forceps can be used to control any bleeding to prevent injury to the remaining tubules.  The mass should then immediately go to pathology for frozen analysis - an expert genitourinary pathologist should evaluate the mass when possible.

If the patient has a normal contralateral testicle and cancer is confirmed in the mass, a completion radical orchiectomy should be performed.

Tumor (in clamp) being dissected from normal testis.
If the patient has (or had) cancer in the contralateral testicle, the pathologist should confirm negative margins before leaving the remainder of the testicle.  If any suspicion of residual cancer, the testicle should be removed.  Once again, the standard-of-care is bilateral orchiectomy and testosterone can easily be replaced.


The complications are the same for radical orchiectomy and testis-sparing surgery.  In addition, even if testis-sparing surgery is performed, surgery can result in infertility or hypogonadism if the internal blood supply to the testicle is harmed or if the tubules are disrupted.


Radical orchiectomy is the standard-of-care for men with suspicion of testis cancer and is therefore the most common operation done for testicular cancer.  Testis-sparing surgery (or partial orchiectomy) is a novel approach suitable for some patients.

Phillip M. Pierorazio, MD is the Director of the Division of Testicular Cancer at the Brady Urological Institute at Johns Hopkins.  

[1] Giannarini G, Dieckmann KP, Albers P, Heidenreich A, Pizzocaro G.  Organ-sparing surgery for adult testicular tumours: a systematic review of the literature.Eur Urol. 2010 May;57(5):780-90. doi: 10.1016/j.eururo.2010.01.014. Epub 2010 Jan 20.
[2] Brunocilla E, Gentile G, Schiavina R, Borghesi M, Franceschelli A, Pultrone CV, Chessa F, Romagnoli D, Ghanem SM, Gacci M, Martorana G, Colombo F.  Testis-sparing surgery for the conservative management of small testicular masses: an update.  Anticancer Res. 2013 Nov;33(11):5205-10.
[3] Leonhartsberger N, Pichler R, Stoehr B, Horninger W, Steiner H.  Organ preservation technique without ischemia in patients with testicular tumor.  Urology. 2014 May;83(5):1107-11. doi: 10.1016/j.urology.2013.12.021. Epub 2014 Feb 21.

Additional References/Resources:
Joel Sheinfeld MD and George J. Bosl MD.  Surgery of Testicular Tumors in Campbell-Walsh Urology, Tenth Edition. 2012,  871-892.

Donald A. Elmajian and Dennis D. Venable.  Radical orchiectomy in Hinman's Atlas of Urologic Surgery, Third Edition.  2012. 353-356.


  1. Top 10 Hospitals in India believe in quality and have the inclusive assortment of nursing and sympathetic medical care like pediatric, orthopedic-an, heart, trauma, transplantation, airway, lymph, node, breast, thoracic, endocrine, head & neck and hernias.

  2. Very informative and impressive post you have written, this is quite interesting and i have went through it completely, an upgraded information is shared, keep sharing such valuable information. Hospitals in Dombivli || Physiotherapy in Dombivli || Hospital in Dombivli

  3. i was just read your blog that was really superb got much pleasure to read that post. please keep sharing post like that.thanks for share with us for this post. Critical Care in Dombivali || Plastic Surgeon in dombivli || Orthopedic Hospital in Dombivli

  4. I like the valuable information you provide in your blog. I will bookmark your blog and check again here frequently. I'm quite certain I will learn many new stuff right here! Best of luck for the next! Cancer Surgeon in Dombivli || Urology Center in dombivli || Orthopedic Surgeon in Dombivli

  5. I would be very thankful if you continue with quality what you are serving right now with your blog. I really enjoyed it. and i really appreciate to you for this. Multi Speciality in Dombivali || Physician and Neurosurgeon in Dombivali || Multispeciality Hospitals in Dombivli

  6. Most prostate cancers are adenocarcinomas, cancers that arise in glandular cells of the prostate’s epithelial tissue. Prostate cancers usually progress slowly and produce no symptoms in the initial stages. Eventually, the tumor may enlarge like mine use too, the prostate gland, pressing on the urethra and causing painful or frequent urination and blood in the urine. So I was so uncomfortable with this prostate cancer diseases then I decided to do online search on how to cure cancer because I well have read a lot about herbal medicine,I came across a lot of testimony how Dr Itua cure HIV/herpes then Cancer was listed below the comment.with courage I contacted Dr Itua and he sent me his herbal medicine through Courier service then I was asked to pick it up at my post office which i quickly did. I contacted Dr Itua that i have received my herbal medicine so he instructs me on how to drink it for three weeks and that is how Dr Itua Herbal Medicine cure my prostate Cancer, The treatment takes three weeks and I was cured completely. Dr Itua is a god sent and I thank him every day of my life. Contact him now Whatsapp:+2348149277967.
    He listed to that he can as well cure the following diseases below.... Cerebral Amides. Lung Cancer, Alzheimer's disease, Adrenocortical carcinoma. Alma, Uterine Cancer, Breast Cancer, Allergic diseases. Kidney cancer, Love Spell, Glaucoma., Cataracts,Macular degeneration,Cardiovascular disease,Lung disease.Enlarged prostate,Osteoporosis.Alzheimer's disease,
    Dementia.Colo rectal cancer, Lottery Spell, Bladder Cancer, Skin Cancer,Ovarian Cancer,Pancreatic Cancer, HIV /Aids, Herpes, Non-Hodgkin lymphoma, Inflammatory bowel disease, Copd, Diabetes, Hepatitis

  7. WHAT A GREAT MIRACLE THAT I HAVE EVER SEE IN MY LIFE. My names are Clara David I’m a citizen of USA, My younger sister was sicking of
    breast cancer and her name is Sandra David I and my family have taking her
    to all kind of hospital in USA still yet no good result. I decided to go to
    the internet and search for cancer cure so that was how I find a lady
    called peter Lizzy she was testifies to the world about the goodness of a
    herbal man who has the roots and herbs to cure all kind of disease and the
    herbal man email was there. So I decided to contact the herbal man @herbalist_sakura for my younger sister help to cure her breast cancer. I contacted him and told him
    my problem he told me that I should not worry that my sister cancer will be
    cure, he told me that there is a medicine that he is going to give me that
    I will cook it and give it to my sister to drink for one week, so I ask how
    can I receive the cure that I am in USA, he told me
    That I will pay for the delivery service. The courier service can
    transport it to me so he told me the amount I will pay, so my dad paid for
    the delivery fee. two days later I receive the cure from the courier
    service so I used it as the herbal man instructed me to, before the week
    complete my sister cancer was healed and it was like a dream to me not
    knowing that it was physical I and my family were very happy about the
    miracle of Doctor so my dad wanted to pay him 5 million us dollars the
    herbal man did not accept the offer from my dad, but I don't know why he
    didn't accept the offer, he only say that I should tell the world about him
    and his miracle he perform so am now here to tell the world about him if
    you or your relative is having any kind of disease that you can't get from
    the hospital please contact or whats app him
    +2348110114739  you can follow him up on Instagram @herbalist_sakura for the cure, he will help you out with the
    problem. And if you need more information about the doctor you can mail me 


    Hola a todos, estoy aquí para dar mi testimonio sobre un herbolario llamado Dr. imoloa. Fui infectado con el virus del herpes simple 2 en 2013, fui a muchos hospitales para curarme pero no había solución, así que estaba pensando en cómo puedo encontrar una solución para que mi cuerpo pueda estar bien. un día estaba en el lado de la piscina navegando y pensando en dónde puedo encontrar una solución. Visito muchos sitios web donde vi tantos testimonios sobre el Dr. Imoloa sobre cómo los curó. No lo creía pero decidí intentarlo, lo contacté y él me preparó el herpes que recibí a través del servicio de mensajería de DHL. Lo tomé durante dos semanas después, luego me indicó que fuera a hacerme un chequeo, después de la prueba me confirmaron que tenía herpes negativo. Soy tan libre y feliz. por lo tanto, si tiene un problema o está infectado con alguna enfermedad, comuníquese con él por correo electrónico o / whatssapp - + 2347081986098.
    Este testimonio sirve como una expresión de mi gratitud. él también tiene

  9. All thanks to this great herbal doctor who cured me from (LUPUS DISEASE) his name is dr imoloa.  I suffered lupus disease for over 8 years with pains like: joints, Skin rash,  Pain in the chest,  swollen joints and many more.  The anti-inflammatory drugs couldn’t cure me, until I read about his recommendation. 2 months ago, I contacted him through his email address. . and he sent me the herbal treatment through DHL courier service and he instructed me on how to drink it for good two weeks. after then,  And I was confirmed cured and free at the hospital after taken his powerful herbal medications You too can be cured with it if interested, he also uses his powerful herbal healing medicine to cure disease like: parkison disease, vaginal cancer, epilepsy,  Anxiety Disorders, Autoimmune Disease,  Back Pain,  Back Sprain,   Bipolar Disorder,  Brain Tumour,  Malignant,  Bruxism, Bulimia,  Cervical Disk Disease, cardiovascular disease, Neoplasms,  chronic respiratory disease,  mental and behavioural disorder,  Cystic  Fibrosis,  Hypertension, Diabetes, asthma,  Inflammatory autoimmune-mediated arthritis.  chronic kidney disease, inflammatory joint disease, back pain,  impotence,  feta  alcohol spectrum,  Dysthymic Disorder,   Eczema, skin cancer,  tuberculosis,  Chronic Fatigue Syndrome, constipation, inflammatory bowel  disease, bone cancer, lungs cancer,  mouth ulcer,  mouth cancer, body pain, fever, hepatitis A.B.C.,   syphilis,  diarrhea,  HIV/AIDS,  Huntington's Disease,  back acne,  Chronic renal failure,   addison disease,  Chronic Pain,   Crohn's  Disease,  Cystic Fibrosis,  Fibromyalgia,   Inflammatory Bowel Disease,  fungal  nail disease, Lyme Disease, Celia disease, Lymphoma, Major  Depression,  Malignant Melanoma,   Mania,  Melorheostosis,   Meniere's  Disease,  Mucopolysaccharidosis , Multiple Sclerosis,  Muscular  Dystrophy,  Rheumatoid Arthritis, Alzheimer's Disease, bring back relationship spell.      Contact him today  and get a permanent cure. contact him via... email-  /whatssapp-+2347081986098.

  10. I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the
    liver already present. I started on antiviral medications which
    reduced the viral load initially. After a couple of years the virus
    became resistant. I started on HEPATITIS B Herbal treatment from
    ULTIMATE LIFE CLINIC ( in March, 2020. Their
    treatment totally reversed the virus. I did another blood test after
    the 6 months long treatment and tested negative to the virus. Amazing
    treatment! This treatment is a breakthrough for all HBV carriers.