Which arterial and venous structures must be identified and ligated during an orchiectomy?

Critical Vascular Structures in Orchiectomy

During radical inguinal orchiectomy, the spermatic cord must be ligated at the level of the internal inguinal ring, which contains the testicular artery (typically 1-3 branches), cremasteric artery, vasal artery, and the pampiniform plexus of veins. 1

Arterial Structures to Identify and Ligate

Testicular Artery (Internal Spermatic Artery)

• Multiple branches are frequently present at the proximal inguinal canal level, contrary to classical anatomical teaching 2
• 1-3 testicular arteries are typically found (mean of 2-2.4 arteries), with 69% having a single artery, 27% having two arteries, and 3% having three arteries 2, 3
• The testicular artery is consistently the largest caliber arterial vessel in the spermatic cord, with diameters ranging from 0.2-1.9 mm (mean 1.0 mm) 3
• In 57.5% of cases, the testicular artery diameter equals or exceeds the combined diameter of the vasal and cremasteric arteries 3

Cremasteric Artery

• 1-3 cremasteric arteries are present in the spermatic cord: single artery in 55%, two arteries in 31%, and three arteries in 4% of cases 3
• Diameter ranges from 0.1-1.5 mm (mean 0.5 mm) 3
• Located in the middle compartment of the spermatic cord alongside the testicular artery 4

Vasal Artery (Deferential Artery)

• A single vasal artery is present in 98% of cases 3
• Diameter ranges from 0.2-1.8 mm (mean 0.6 mm) 3
• Travels with the vas deferens in the dorsomedial compartment of the spermatic cord 4

Venous Structures to Identify and Ligate

Pampiniform Plexus

• The testicular veins are organized into two main groups forming two distinct venous plexuses 4
• One venous group forms a tight plexus around the testicular artery in the middle compartment 4
• The second venous group is located in the ventrolateral compartment with no topographic relation to the testicular artery, embedded in fatty tissue 4

Critical Surgical Technique

Level of Cord Division

• The spermatic cord must be divided at the internal inguinal ring during radical inguinal orchiectomy 1, 5
• This is the gold standard approach for testicular malignancies 5

Approach and Access

• Radical orchiectomy is performed through an inguinal incision 1
• Early spermatic cord control at the internal inguinal ring is mandatory before any testicular manipulation to prevent tumor spread 6
• Scrotal violation for biopsy or open surgery must be strongly avoided 1

Common Pitfalls to Avoid

Arterial Preservation Errors

• Do not assume only one testicular artery is present at the proximal inguinal canal—multiple branches exist in 31% of cases 2
• Surgeons performing varicocelectomy often mistakenly ligate all vascular structures after identifying one artery, risking inadvertent interruption of testicular arterial blood flow 2
• For orchiectomy, all arterial structures must be ligated, but awareness of multiple branches prevents incomplete ligation 2

Anatomical Compartment Awareness

• The spermatic cord has three distinct compartments: dorsomedial (vas deferens and vasal artery), middle (testicular artery and surrounding venous plexus), and ventrolateral (venous plexus in fatty tissue) 4
• Understanding this organization ensures complete vascular control 4

Collateral Circulation Considerations

• Anastomoses between testicular, cremasteric, and vasal arteries are extremely rare at the inguinal and scrotal cord levels 7
• A complex intersystemic junction exists near the epididymis-efferent duct connection, but this is not relevant at the level of cord division 7
• The testicular artery provides the majority of testicular blood flow, emphasizing the importance of complete ligation during orchiectomy 3