What is the recommended operative approach and anatomical steps for performing a radical orchiectomy?

Radical Orchiectomy: Operative Approach and Anatomical Steps

Radical orchiectomy must be performed through an inguinal incision with early vascular control of the spermatic cord at the internal inguinal ring—any scrotal violation for biopsy or open surgery must be strictly avoided to prevent lymphatic spread of cancer cells. 1

Preoperative Considerations

Essential Preoperative Assessment

• Obtain tumor markers (AFP, HCG, LDH) before surgery and repeat 7 days postoperatively if elevated to determine half-life kinetics 1, 2
• Perform testicular ultrasound using a 7.5 MHz high-frequency transducer, noting contralateral testis size 1, 2
• Discuss fertility preservation with semen analysis and sperm banking offered before surgery or chemotherapy 1, 2
• Measure baseline hormones including total testosterone, LH, and FSH if fertility is a concern 1

Critical Timing Decision

• Surgery should be performed before any further treatment unless life-threatening metastatic disease with clear clinical diagnosis by marker elevation requires immediate chemotherapy 1

Surgical Technique: Step-by-Step

1. Incision and Approach

• Make an inguinal incision over the external inguinal ring 1, 2
• The standard inguinal approach is mandatory (Level II, Grade A evidence) 1
• For very large tumors, a single oblique inguinoscrotal incision may be used while maintaining inguinal delivery and early cord control 3

2. Early Vascular Control (Critical Step)

• Expose and mobilize the spermatic cord at the external inguinal ring 2
• Apply early vascular control by clamping the spermatic cord at the internal inguinal ring before any testicular manipulation 2, 4
• This prevents tumor dissemination through venous and lymphatic channels 5

3. Resection

• Resect the tumor-bearing testis along with the entire spermatic cord up to the level of the internal inguinal ring 1
• The cord must be divided at the internal inguinal ring to ensure adequate oncologic margins 1, 5

4. Frozen Section (When Indicated)

• Obtain frozen section in doubtful cases of small tumors before definitive surgery to allow consideration of organ-sparing surgery 1

Alternative Approaches and Special Situations

Organ-Preserving Surgery/Partial Orchiectomy

Radical orchiectomy may be replaced by organ-preserving surgery only in highly experienced centers and specific indications 1:

• Synchronous bilateral testicular tumors
• Metachronous contralateral testicular tumor
• Tumor in a solitary testis with sufficient endocrine function
• Contralateral atrophic testis

Important caveat: After partial resection, the spared testicular tissue always contains testicular intraepithelial neoplasia (TIN), requiring adjuvant radiotherapy (which should be delayed if fertility preservation is desired) 1

Subinguinal Approach (Emerging Technique)

• A subinguinal technique dividing the cord at the external inguinal ring (rather than internal ring) has shown acceptable oncological outcomes with potentially lower risk of neuropathic injury 6
• However, this deviates from guideline-recommended technique and requires further prospective validation 6

Contralateral Biopsy Considerations

Risk Assessment for TIN

• 3-5% of testicular cancer patients have TIN in the contralateral testis 1
• Highest risk (≥34%) occurs with testicular atrophy (volume <12 mL) and age <40 years 1
• If untreated, invasive tumor develops in 70% of TIN-positive testes within 7 years 1

Biopsy Timing and Patient Decision

• Offer contralateral biopsy at the time of orchiectomy, with high sensitivity and specificity from one random biopsy 1, 2
• Allow patients to decide between biopsy versus monitoring, given nearly 100% survival with either strategy 1
• Do not perform biopsy <2 years after chemotherapy 1

Critical Pitfalls to Avoid

Absolute Contraindications

• Never violate the scrotum for biopsy or open surgery—this alters lymphatic drainage patterns and increases risk of local recurrence 1, 4
• Never squeeze the testis through the external inguinal ring before vascular control, as this may cause tumor spread 7

Technical Errors

• Failing to achieve early vascular control before testicular manipulation increases risk of hematogenous spread 2, 5
• Inadequate cord resection (not reaching internal inguinal ring) may leave residual tumor 1, 5
• In patients with ≥2 prior hernia operations, explicitly warn about increased risk of ischemic orchitis and testicular atrophy 4

Postoperative Management

• Monitor tumor markers until normalization, even if initially normal 1
• Avoid strenuous activity and heavy lifting for 2-4 weeks 8
• Watch for signs of infection, excessive bleeding, or testicular atrophy in remaining testis 8, 4