How is a radical inguinal orchiectomy performed for a suspected malignant testicular tumor in an adult male?

Radical Inguinal Orchiectomy Technique for Suspected Testicular Malignancy

Radical inguinal orchiectomy is performed through an inguinal incision with early vascular control of the spermatic cord at the internal inguinal ring, followed by en bloc resection of the tumor-bearing testis and entire spermatic cord up to the internal ring level. 1

Pre-operative Preparation

Mandatory Laboratory Assessment

• Obtain serum tumor markers (AFP, β-hCG, LDH) before surgery 2
• Repeat markers 7 days post-operatively if elevated to assess half-life kinetics 1, 2
• Perform high-frequency testicular ultrasound (7.5 MHz transducer) and document contralateral testis size 1, 2

Fertility Preservation Discussion

• Offer semen analysis and sperm banking prior to surgery 2
• Measure baseline hormonal profile (total testosterone, LH, FSH) when fertility is a concern 2

Surgical Technique: Step-by-Step

Incision and Approach

Make an inguinal incision over the external inguinal ring—scrotal violation for biopsy or open surgery must be strictly avoided to prevent altered lymphatic drainage and increased local recurrence risk. 1, 2

The inguinal approach is mandatory with Level II, Grade A evidence. 1 A transscrotal approach, while proposed by some, violates established oncologic principles and should not be used. 3

Early Vascular Control (Critical Step)

• Expose and mobilize the spermatic cord at the external inguinal ring 2
• Clamp the spermatic cord at the internal inguinal ring BEFORE any testicular manipulation 2
• This early vascular control prevents hematogenous tumor dissemination during subsequent manipulation 4

Resection

• Deliver the tumor-bearing testis through the inguinal incision 4
• Resect the testis en bloc with the entire spermatic cord 1
• Divide the spermatic cord at the level of the internal inguinal ring to obtain adequate oncologic margins 1, 2

Intra-operative Pathology

• Obtain frozen section in cases of small or doubtful tumors before definitive resection 1, 2
• This allows consideration of organ-sparing surgery if appropriate 1

Critical Pitfalls to Avoid

Scrotal Violation

Any scrotal approach—whether for biopsy or open surgery—must be strongly avoided. 1 Scrotal violation increases local recurrence risk from 0.0% to 2.5% (P < 0.001) and may leave residual tumor requiring subsequent scrotal scar excision in 9.3% of cases. 5 While short-term metastasis and survival may not be impacted, the increased local recurrence risk is unacceptable when proper technique eliminates this risk entirely. 5

Inadequate Cord Resection

Failure to divide the cord at the internal inguinal ring may leave residual tumor tissue. 2 The entire cord must be resected to this level. 1

Premature Testicular Manipulation

Manipulating or squeezing the testis before achieving vascular control may cause tumor dissemination through alternate venous routes. 3

Special Considerations

Organ-Preserving (Partial) Orchiectomy

Partial orchiectomy may be considered only in highly experienced centers for specific indications: 1, 2

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

Important caveat: Residual testicular tissue after partial resection invariably contains testicular intraepithelial neoplasia (TIN) requiring adjuvant radiotherapy. 1, 2 Radiotherapy can be delayed briefly for fertility preservation but should not be postponed indefinitely. 1

Contralateral Testis Biopsy

• Offer contralateral biopsy at the time of orchiectomy, as 3-5% of patients have contralateral TIN 1, 2
• Risk increases to ≥34% with testicular atrophy (volume <12 mL) and age <40 years 1, 2
• A single random biopsy provides high sensitivity and specificity 1
• Do not perform biopsy within 2 years after chemotherapy 1, 2
• Untreated TIN progresses to invasive cancer in 70% of cases within 7 years 1, 2

Timing Exceptions

Surgery should precede all other treatment unless life-threatening metastatic disease with markedly elevated markers requires immediate chemotherapy. 1, 2 In such cases, diagnosis may be based on clinical picture and marker elevation alone, with orchiectomy deferred. 1

Post-operative Management

• Monitor tumor markers until normalization, even if pre-operative levels were normal 1, 2
• Markers should be obtained after surgery in all cases 1