What are the types and steps involved in a bilateral orchidectomy?

Types and Steps of Bilateral Orchidectomy

Bilateral orchidectomy is a surgical procedure involving the removal of both testicles, primarily performed for testicular cancer or as androgen deprivation therapy for prostate cancer. The procedure has specific types and steps that vary based on the clinical indication.

Types of Orchidectomy

1. Radical Orchidectomy

• Standard procedure for testicular cancer, involving complete removal of the testicle along with the spermatic cord up to the internal inguinal ring 1
• Performed through an inguinal incision to prevent lymphatic spread of cancer cells 1
• Any scrotal violation for biopsy or open surgery should be strictly avoided to prevent cancer spread 1

2. Partial/Organ-Preserving Orchidectomy

• Alternative to radical orchidectomy in specific situations 1
• Indicated for:
  • Synchronous bilateral testicular tumors 1
  • Metachronous contralateral tumors 1
  • Tumors in a solitary testicle with normal testosterone levels 1
  • Contralateral atrophic testis 1, 2
• Should only be performed at centers with experience in managing these rare clinical situations 1
• Remaining testicular tissue typically contains testicular intraepithelial neoplasia (TIN), requiring adjuvant radiotherapy 1

3. Simple Bilateral Orchidectomy

• Used primarily for androgen deprivation therapy in prostate cancer 1
• Causes rapid reduction in testosterone to castrate levels (<10 ng/mL) 1
• May be performed through scrotal or inguinal approach 3

Surgical Steps for Bilateral Orchidectomy

For Radical Orchidectomy (Testicular Cancer)

1. Preoperative Assessment

   • Obtain tumor markers (AFP, β-HCG, LDH) before surgery 1
   • Perform testicular ultrasound with 7.5 MHz transducer 1

2. Surgical Approach

   • Position patient supine under appropriate anesthesia 1
   • Make an inguinal incision over the external ring 1
   • Expose and mobilize the spermatic cord at the external inguinal ring 1

3. Cord Control and Delivery

   • Apply early vascular control of the spermatic cord at the internal inguinal ring 1
   • Deliver the testicle from the scrotum into the wound 1

4. Resection

   • Resect the testicle along with the spermatic cord at the level of the internal inguinal ring 1
   • In cases of small tumors with negative markers, consider frozen section before definitive orchidectomy 1

5. Closure

   • Achieve hemostasis 4
   • Close the wound in layers 4
   • Consider testicular prosthesis placement if desired by the patient 4

For Bilateral Orchidectomy (Prostate Cancer)

1. Preoperative Assessment

   • Confirm indication for androgen deprivation therapy 1
   • Discuss potential side effects with patient 1

2. Surgical Approach

   • Position patient supine under appropriate anesthesia 1
   • Make bilateral inguinal or scrotal incisions 1, 3

3. Resection

   • Identify and isolate both testicles 1
   • Ligate and divide the spermatic cords 1
   • Remove both testicles 1, 3

4. Closure

   • Achieve hemostasis 3
   • Close the incisions in layers 3

Special Considerations

Contralateral Biopsy for TIN

• 5% of testicular cancer patients have TIN in the contralateral testicle 1
• Higher risk (≥34%) in patients with testicular atrophy (volume <12 ml) and age <30 years 1
• If untreated, invasive testicular tumor develops in 70% of TIN-positive testes within 7 years 1
• Biopsy should be performed preferably at the time of orchiectomy 1
• Biopsies must be preserved in Stieve's or Bouin's solution, not formalin 1

Fertility Preservation

• Sperm banking should be offered before bilateral orchidectomy 2, 4
• In cases requiring bilateral orchidectomy for cancer, consider testosterone replacement therapy to maintain sexual function 5, 6

Timing of Surgery

• Orchidectomy should be timely scheduled; emergency surgery is not necessary 1
• In patients with life-threatening metastatic disease and elevated tumor markers, chemotherapy should be given first and orchidectomy postponed until after chemotherapy completion 1

Outcomes and Complications

Benefits of Bilateral Orchidectomy for Prostate Cancer

• Rapid reduction in testosterone levels 1
• Eliminates issues with medication compliance 1
• Lower cost compared to medical castration 1
• May achieve lower castrate levels of testosterone than LHRH antagonists 3

Potential Complications

• Surgical complications: wound infection, hematoma, pain 1
• Psychological impact due to body image changes 1
• Hypotestosteronemia effects: hot flushes, weight gain, mood changes, gynecomastia, fatigue, loss of libido 1, 7
• Long-term effects: osteopenia, hypercholesterolemia 1

Common Pitfalls to Avoid

• Failing to consider fertility preservation before bilateral orchidectomy 2, 4
• Performing scrotal approach for testicular cancer (increases risk of cancer spread) 1
• Inadequate patient counseling about psychological effects and hormone replacement needs 5, 6
• Suboptimal testosterone replacement scheduling in bilateral orchidectomy patients (intervals ≥3 weeks lead to fluctuating hormone levels) 5, 6