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.

RADICAL ORCHIECTOMY

Rationale

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.

Surgery

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.

Complications

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.

TESTIS-SPARING SURGERY (PARTIAL ORCHIECTOMY)

Rationale

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.

Surgery

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.

Complications

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.

Summary

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.

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