Radical Inguinal Orchiectomy
DANIEL J. LEE
DOUGLAS S. SCHERR
Testicular tumors are an uncommon and clinically heterogeneous group of tumors, accounting for approximately 8,000 new cases and 370 deaths in 2013 (1) and an incidence of 5 per 100,000 men. Ninety-five percent of testicular tumors are germ cell tumors (GCTs), with the remainder consisting of gonadal stroma and secondary tumors of the testis. Approximately 90% of the GCTs arise in the testis, with 2% to 5% appearing in extragonadal regions such as the retroperitoneum and mediastinum. The survival rates for testicular cancer have improved remarkably over the past 50 years with the development of cisplatin-based chemotherapy and multidisciplinary collaboration, from 60% to 65% in the 1960s to more than 90% currently. The improvements are especially noticeable in advanced and metastatic GCT, with survival rates improving from 5% to 10% to 80% to 90% before and after the use of cisplatin-based chemotherapy. Although testicular cancer is highly curable, inappropriate management can have drastic consequences on the long-term survival and morbidity. Surgical management remains an integral part in the management of testicular cancer, although the development of improved chemotherapy options, clinical staging, and imaging modalities has changed its role. In this chapter, we will review the indications, common surgical techniques, and their associated complications for radical inguinal orchiectomy.
DIAGNOSIS
Most testicular tumors present as a painless testicular mass. Until proven otherwise, a firm intratesticular mass should be considered suspicious for cancer and worked up accordingly. The differential diagnosis of a testicular mass includes tumor, epididymitis, epididymoorchitis, torsion, and, less frequently, hernia, hydrocele, spermatocele, varicocele, hematoma, and hematocele. Acute testicular pain is less common and can be caused by rapid expansion of the testis from an intratumor hemorrhage or infarction caused by rapid tumor growth. Pain is more commonly associated with nonseminomatous GCT (NSGCT) because these
tumors tend to have rapid growth and high vascularity. A significant proportion of GCT will present with metastatic disease at diagnosis, with 67% NSGCT and 15% of seminomas. However, only 10% to 20% of those with metastatic disease will be symptomatic from their metastases, with symptoms such as abdominal pain, palpable neck mass indicating supraclavicular metastasis, flank pain from ureteral obstruction, lower extremity edema from compression of the inferior vena cava, back pain from involvement of nerve roots, or dyspnea and hemoptysis from pulmonary metastasis. Approximately 2% of men will present with gynecomastia, most commonly seen in Leydig cell tumors, from elevated levels of human chorionic gonadotropin (hCG), increased estrogen, or decreased androgen production. Two-thirds of men with GCT will have decreased fertility.
tumors tend to have rapid growth and high vascularity. A significant proportion of GCT will present with metastatic disease at diagnosis, with 67% NSGCT and 15% of seminomas. However, only 10% to 20% of those with metastatic disease will be symptomatic from their metastases, with symptoms such as abdominal pain, palpable neck mass indicating supraclavicular metastasis, flank pain from ureteral obstruction, lower extremity edema from compression of the inferior vena cava, back pain from involvement of nerve roots, or dyspnea and hemoptysis from pulmonary metastasis. Approximately 2% of men will present with gynecomastia, most commonly seen in Leydig cell tumors, from elevated levels of human chorionic gonadotropin (hCG), increased estrogen, or decreased androgen production. Two-thirds of men with GCT will have decreased fertility.
Delays in Diagnosis
Delays in diagnosis of testicular cancer remain a significant problem and can have significant impact on outcomes, especially in the population of young adult males. Up to one-third of testicular cancers were found to be initially misdiagnosed as an epididymitis or hydrocele, with a median delay of 75, 101, and 134 days for stage I, II, and III, respectively (2). Even patients with metastatic disease may undergo inappropriate treatment and unnecessary surgery, as Stephenson et al. (3) reported on 40 patients who underwent an unnecessary laparotomy prior to diagnosis of a testicular mass. In a review of the literature of 4,948 testicular cancer patients, Moul (4) reported a mean duration of symptoms of 26 weeks before diagnosis.
Scrotal Ultrasound
In men with a solid testicular mass, or unexplained scrotal signs or symptoms, a scrotal ultrasound should be performed especially because it is widely available, rapid, sensitive, noninvasive, and inexpensive. Intratesticular lesions, as small as a few millimeters, can be detected with high-frequency transducers (5 to 10 Hz) with a clear delineation of anatomy. GCTs are often hypoechoic on ultrasound, with NSGCT normally with a heterogeneous echotexture, whereas seminomas tend to have a more homogenous echotexture. The incidence of bilateral GCTs is approximately 2%, so both testicles should be evaluated at each scrotal ultrasound. Testicular microlithiasis does not have a clear association with GCTs and in isolation should not prompt further evaluation (5).
Tumor Markers
Tumor markers are essential in the diagnosis, prognosis, treatment, and surveillance of testicular cancer. Testicular tumor markers, including lactate dehydrogenase, α-fetoprotein, and hCG, should be obtained at diagnosis and after orchiectomy to monitor for response to chemotherapy and to monitor for signs of recurrence.
ALTERNATIVE THERAPY
Radical inguinal orchiectomy is the standard therapy for a solid intratesticular lesion; however, partial orchiectomy may be appropriate in certain specific situations. Patients with a solitary testis or bilateral testicular masses or those with a possibility of an epidermoid cyst or benign testicular tumor may be considered for a testis-sparing procedure. The selection criteria, technique, and outcomes of testis-sparing surgery are presented elsewhere.
Sperm Cryopreservation
Sperm cryopreservation should be recommended prior to orchiectomy for all men where future fertility is a potential concern, even if the contralateral testis appears to be normal (6).
Radical Inguinal Orchiectomy
Patients suspected of having a testicular neoplasm should undergo a radical inguinal orchiectomy with removal of the tumor-bearing testis and spermatic cord up to the level of the internal inguinal ring. This procedure allows histopathologic diagnosis, tumor staging, and can provide local control of the tumor with minimal morbidity if performed appropriately.
The procedure can be performed under general, spinal, or local anesthesia on an outpatient basis. With the patient in a supine position, the lower abdominal wall, penis, and scrotum are prepped in the sterile surgical field. An oblique skin incision is made in the inguinal area along Langerhans skin lines approximately 2 cm above the pubic tubercle, extending approximately 5 to 7 cm laterally from just above the pubic tubercle (Fig. 59.1). This incision can be extended onto the upper scrotum to facilitate removal of large tumors. Camper and Scarpa fascia are incised with electrocautery to the level of the external oblique aponeurosis. A scalpel is used to make a small incision in the external oblique aponeurosis halfway between the internal and external inguinal rings. Metzenbaum scissors are then inserted into the incision with the tips closed and are pushed upward against the aponeurosis toward the external inguinal ring and then laterally toward the internal ring, so that the external oblique fascia is tented over the
length of the inguinal canal to help ensure that the ilioinguinal nerve is not injured (Fig. 59.2). The opening is then incised in the direction of its fibers to the level of the inguinal ring. The ilioinguinal nerve is then identified, dissected free of the cord, and can then be retracted out of the surgical field.
length of the inguinal canal to help ensure that the ilioinguinal nerve is not injured (Fig. 59.2). The opening is then incised in the direction of its fibers to the level of the inguinal ring. The ilioinguinal nerve is then identified, dissected free of the cord, and can then be retracted out of the surgical field.
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