What is an orchiectomy?

What is an Orchiectomy?

Orchiectomy is the surgical removal of one or both testicles, performed through an inguinal or scrotal approach, primarily indicated for testicular cancer, advanced prostate cancer requiring androgen deprivation, severe testicular trauma, or gender-affirming care. 1, 2, 3

Surgical Procedure

The standard technique involves:

• Inguinal approach (preferred for cancer): Division of the spermatic cord at the internal inguinal ring to prevent tumor seeding 2
• Scrotal approach (trans-scrotal): Used for benign conditions like advanced prostate cancer, though associated with higher local recurrence rates if malignancy is present 2, 3
• Can be performed as unilateral (removal of one testis) or bilateral (removal of both testes) 3

Primary Clinical Indications

Testicular Cancer

• Radical inguinal orchiectomy is the initial definitive treatment for suspected testicular germ cell tumors 2, 4
• A scrotal approach must be avoided in cancer cases due to altered lymphatic drainage patterns 2
• Sperm banking should be offered before surgery when feasible 2, 4

Advanced Prostate Cancer

• Bilateral orchiectomy achieves surgical castration by rapidly reducing testosterone to castrate levels (<10 ng/mL) within days 1
• Provides quick palliation with disease progression reduced from 62% to 32% at 10 years compared to placebo 1
• Eliminates compliance issues with medical therapy and is cost-effective 1
• Three surgical variants exist: total, subcapsular (removes testosterone-producing tissue while preserving tunica albuginea), and sub-epididymal 3

Severe Testicular Trauma

• Indicated when the testicle is extensively damaged and irreparable with compromised blood supply 5
• Performed as a last resort when tissue preservation is not viable 5

Gender-Affirming Care

• Bilateral orchiectomy eliminates endogenous testosterone production, allowing reduced hormonal supplementation 6, 7
• Can serve as a bridge to or alternative for vaginoplasty 6

Physiologic Effects

After bilateral orchiectomy, patients experience:

• Immediate hormonal changes: Testosterone drops to castrate levels, eliminating 90-95% of circulating testosterone (the testes produce most testosterone in response to luteinizing hormone) 1
• Metabolic consequences: Osteopenia, hypercholesterolemia, weight gain 1
• Vasomotor symptoms: Hot flashes, mood lability 1
• Sexual effects: Loss of libido, erectile dysfunction, gynecomastia 1, 8
• Cognitive changes: Fatigue, lassitude, potential cognitive impairment 1

Surgical Complications and Outcomes

Immediate surgical risks are minimal and include:

• Wound infection (most common at 10%) 3
• Hematoma formation 1
• Postoperative pain 1

The procedure has a 28.7% overall complication rate in large series, predominantly minor complications 3. Most procedures can be performed under regional anesthesia (56.3% of cases) 3.

Psychological Impact

The emotional burden is often greater than physical complications, particularly for prostate cancer patients where most men choose medical castration over surgery when given the option 1. Recent evidence shows orchiectomy is associated with:

• Diminished genital self-image 8
• Increased rates of depression and anxiety 9
• Greater sexual dissatisfaction 8
• Body image concerns requiring psychological support 9

Critical Clinical Considerations

For unilateral orchiectomy: The remaining testicle typically compensates for hormonal and fertility functions 5

For bilateral orchiectomy: The procedure is irreversible and permanently eliminates natural testosterone production and fertility 1, 6

Pre-operative counseling should address testosterone replacement therapy options, fertility preservation through sperm banking, and psychological support resources including cognitive behavioral therapy 9, 2, 4

Fertility preservation is time-sensitive and should ideally occur before orchiectomy, particularly in cancer cases where additional treatments may follow [2, @20@]