Radical orchiectomy is typically the first step in any multidisciplinary approach to the management of men with testicular germ cell neoplasia. It yields histologic confirmation of the diagnosis, provides important staging information that guides additional management, accomplishes local tumor control, and may be curative in patients with low-stage disease who opt for an observation protocol.
Adjuncts to physical examination in the preoperative setting may include serum α-fetoprotein; serum β-human chorionic gonadotropin; urine pregnancy test; serum lactate dehydrogenase; testicular ultrasonography; and computed tomography (CT) of the chest, abdomen, and pelvis. One may opt to forgo chest CT in lieu of chest x-ray study. We prefer CT of the retroperitoneum preoperatively rather than postoperatively to obviate the possibility of postoperative retroperitoneal hematoma after radical orchiectomy influencing the CT stage.
The technique of radical orchiectomy is timeless. The anatomic landmarks readily visible with the patient in the supine position include the penis and scrotum; the pubic tubercle medially; the anterior superior iliac spine laterally and cephalad; and the inguinal ligament caudad, which may be palpable in thin men. A curvilinear incision is made beginning approximately 2 cm cephalad and lateral to the pubic tubercle, extending laterally along a Langer line for 5 to 7 cm ( Fig. 117.1 ). The incision can be oriented more obliquely and extend toward, or onto, the scrotum to facilitate delivery of a large testicular tumor.
The incision is carried through the subcutaneous tissue onto the external abdominal oblique aponeurosis with electrocautery. Camper and Scarpa fasciae are often readily visible. Subcutaneous superficial inferior epigastric veins are frequently encountered laterally. One may opt to further dissect the subcutaneous tissue off the external abdominal oblique aponeurosis to clearly identify the inguinal ligament and aid with closure. The external abdominal oblique aponeurosis is sharply opened over the inguinal canal, extending medially to the external inguinal ring and laterally to a point overlying the level of the internal inguinal ring. The ilioinguinal nerve lying on top of the spermatic cord is identified and dissected free from its investing external spermatic fascia and cremasteric musculature and retracted out of harm’s way ( Fig. 117.2 ).
Gentle blunt dissection at the level of the pubic tubercle with the aim of circumscribing the spermatic cord and cremasteric musculature is next accomplished ( Fig. 117.3 ). The surgeon’s finger should subsequently easily pass posterior to the cord along the floor of the inguinal canal. Care should be taken to avoid dissection through the floor of the inguinal canal, avoiding risk of the development of a postoperative direct inguinal hernia. The cord should be secured with a -inch Penrose drain passed twice around and clamped with a hemostat, providing early vascular control before any tumor manipulation is done ( Fig. 117.4 ).