Orchiectomy Step-by-Step Procedure
Radical orchiectomy is performed through an inguinal incision with early vascular control of the spermatic cord at the internal inguinal ring, followed by complete removal of the testis and cord up to that level. 1
Preoperative Preparation
Obtain tumor markers (AFP, β-hCG, LDH) before any surgical intervention, as these values are critical for staging and risk stratification. 1 The markers must be drawn before orchiectomy and repeated minimum 7 days post-surgery to determine half-life kinetics. 1
Offer sperm banking to all patients before orchiectomy, particularly those of reproductive age, as this is the most cost-effective fertility preservation strategy. 1, 2 This should ideally occur before the procedure when possible. 1
Perform testicular ultrasound with high-frequency (7.5 MHz) transducer to confirm the diagnosis and assess the contralateral testis. 1, 2 Standard preoperative assessment should include complete blood count, creatinine, electrolytes, and liver enzymes. 1
Surgical Technique
Incision and Exposure
Make an inguinal incision over the external inguinal ring - never use a scrotal approach, as scrotal violation for biopsy or surgery must be avoided to prevent altered lymphatic drainage and potential tumor spread. 1, 2
Expose and mobilize the spermatic cord at the external inguinal ring level. 2
Vascular Control
Apply early vascular control of the spermatic cord at the internal inguinal ring before manipulating the testis. 2 This critical step prevents potential hematogenous spread during tumor manipulation.
Clamp the spermatic cord at the level of the internal inguinal ring. 1
Resection
Resect the tumor-bearing testis with the entire spermatic cord up to the internal inguinal ring level. 1 The complete cord must be removed to ensure adequate margins.
Special Considerations for Testis-Sparing Surgery
In highly experienced centers only, partial orchiectomy may be considered for: synchronous bilateral testicular tumors, metachronous contralateral tumors, tumor in a solitary testis with sufficient endocrine function, or contralateral atrophic testis. 1, 2
Frozen section examination is mandatory before definitive testis-sparing surgery to confirm the diagnosis and guide the extent of resection. 1 Patients must be counseled about the risk of completion orchiectomy if frozen section and final pathology are discordant. 1
If germ cell tumor is confirmed on testis-sparing surgery, post-resection testicular radiotherapy or completion orchiectomy is mandatory due to high risk of germ cell neoplasia in situ (GCNIS) in remaining tissue. 1
Contralateral Biopsy Consideration
Contralateral biopsy for GCNIS should be performed at the time of orchiectomy in high-risk patients: those with testicular atrophy (volume <12 mL), age <40 years, or extragonadal germ cell tumor. 1, 2 The risk of contralateral GCNIS is 3-5% overall but reaches 34% in patients with testicular atrophy. 1
One random biopsy has very high sensitivity and specificity for detecting GCNIS. 1 However, patients should be informed and allowed to decide between biopsy versus surveillance, as survival approaches 100% with either strategy. 1
Critical Pitfalls to Avoid
Never perform scrotal biopsy or scrotal incision for suspected testicular malignancy - only the inguinal approach is appropriate to avoid altering lymphatic drainage patterns. 1, 3
Do not delay surgery for imaging if life-threatening metastatic disease requires immediate chemotherapy in patients with clear clinical diagnosis and elevated tumor markers. 1 In these rare cases, orchiectomy can be performed after chemotherapy.
Ensure frozen section is available before attempting testis-sparing surgery, and only perform this in experienced centers. 1
Postoperative Management
Repeat tumor markers 7 days after surgery if initially elevated, then monitor until normalization to confirm adequate half-life kinetics. 1 Continue monitoring even if markers were initially normal. 1
Radiotherapy should start within 7 weeks after orchiectomy if indicated for adjuvant treatment. 1
Post-orchiectomy management and staging should only be carried out by highly experienced clinicians. 1