Bilateral Orchiectomy Results in Decreased Prostate Glandular Volume
The correct answer is B: Decreased prostate glandular volume. Bilateral orchiectomy eliminates the primary source of testosterone production, resulting in profound hypogonadism that causes atrophy of androgen-dependent tissues, particularly the glandular component of the prostate.
Physiologic Consequences of Bilateral Orchiectomy
Testosterone Deficiency and Its Effects
Following bilateral orchiectomy, this patient will develop complete androgen deficiency, as the testes produce approximately 95% of circulating testosterone. This hormonal change drives predictable physiologic alterations:
Prostate Changes (Answer B - Correct)
- The glandular epithelium of the prostate is highly androgen-dependent and undergoes atrophy in the absence of testosterone
- Decreased prostate glandular volume is the expected outcome of surgical castration
- This effect is so reliable that bilateral orchiectomy was historically used as treatment for advanced prostate cancer
Body Composition Changes
- Decreased lean body mass (not increased as in option C) occurs with testosterone deficiency
- Increased subcutaneous fat (not decreased as in option A) develops due to altered metabolism and reduced anabolic effects
- These changes represent the opposite of what testosterone normally promotes
Bone Density Changes
- Decreased trabecular bone density (not increased as in option D) results from testosterone deficiency
- Testosterone is essential for maintaining bone mineral density in men
- Hypogonadal men have significantly increased fracture risk
Stromal vs. Glandular Prostate Tissue
- Option E (increased prostate stroma) is incorrect
- While relative stromal proportion may increase as glandular tissue atrophies, absolute stromal volume does not increase
- The dominant change is glandular atrophy, not stromal proliferation
Clinical Context: Bilateral Testicular Cancer
This patient's history of bilateral cryptorchidism placed him at 3.6-7.4 times higher risk of testicular cancer compared to the general population, with a 2-6% absolute lifetime risk 1, 2. The development of bilateral testicular germ cell tumors, while rare (occurring in 2.8-5.3% of testicular cancer patients), necessitated bilateral orchiectomy 3, 4.
Critical Management Considerations
Testosterone Replacement Therapy
- Mandatory for patients undergoing bilateral orchiectomy to address testosterone deficiency 5
- Should be initiated to prevent the adverse metabolic, cardiovascular, and bone health consequences of hypogonadism
- Monitoring should include complete blood count, PSA, and digital rectal examination 3-6 weeks after initiation 5
Fertility Preservation
- Sperm banking should have been performed before orchiectomy 5
- Men with bilateral cryptorchidism have significantly reduced fertility (62% paternity rate vs. 94% in controls), representing a six-fold increased infertility risk 6
Long-term Survivorship
- Five-year survival rates for testicular germ cell tumors are excellent: 99% for stage I, 92% for stage II, and 85% for stage III 7
- Treatment decisions must balance oncologic control with survivorship concerns including body image, fertility, hypogonadism, mental health, cardiovascular disease risk, and secondary malignancies 7
Common Pitfall
The most critical error would be failing to initiate testosterone replacement therapy promptly after bilateral orchiectomy. Without testosterone replacement, patients experience progressive deterioration in quality of life, including decreased muscle mass, increased fat mass, decreased bone density with fracture risk, sexual dysfunction, fatigue, depression, and increased cardiovascular risk. These consequences are entirely preventable with appropriate hormone replacement 5.