Simple Orchiectomy
JONATHAN L. SILBERSTEIN
Simple orchiectomy involves the removal of one or both testes at the distal spermatic cord, usually through a transscrotal approach. Importantly, this is in direct contrast to a radical orchiectomy performed through an inguinal incision performed for a testicular mass with suspicion of malignancy. Radical orchiectomy is intended to remove the entire testis, epididymis, and distal spermatic cord up to the inguinal ring without violating the scrotum and disrupting the normal testicular lymphatic drainage. In contrast, a simple orchiectomy is used for the treatment of benign intrascrotal processes, such as epididymoorchitis unresponsive to antibiotics, or a devitalized testicle secondary to torsion or trauma. If the etiology of a testicular lesion is unclear and there is any possibility of malignancy, we favor an inguinal approach as it will not violate the scrotum and the added morbidity is minimal.
The testis account for 95% of circulating testosterone, and bilateral simple orchiectomy may be used as a method of surgical castration to rapidly deplete circulating androgens (1). Surgical castration may be used for palliation in men with metastatic prostate cancer and will result in normalization of prostate-specific antigen and objective tumor response in the vast majority of patients albeit at the cost of profound metabolic changes resulting in increased rates of cardiovascular disease, metabolic syndrome, fatigue, osteopenia/osteoporosis, depression, and loss of libido (2). Rarely, surgical castration via bilateral simple orchiectomy may be performed to reduce sexual recidivism among sexual predators (3). Importantly, regardless the intended rationale for surgical castration, medical castration may achieve the same desired effects without the burden of surgery and is the preferred option in many nations.
DIAGNOSIS
Diagnoses requiring simple orchiectomy depend on the condition being treated and vary greatly between benign intrascrotal processes and metastatic prostate cancer. For benign intrascrotal processes requiring simple orchiectomy, such as epididymoorchitis unresponsive to antibiotics, or devitalized tissues secondary to torsion or trauma, diagnosis is most commonly made through careful history and physical exam. Patients should be asked about the chronicity of the onset of their symptoms (acute, chronic), location (laterality, isolated to the scrotum), history of trauma or surgical intervention, lower urinary tract symptoms (urgency, frequency), or systemic symptoms (fever, rigors). The clinician should perform a thorough physical examination of the abdomen, inguinal region, spermatic cord, scrotal skin, testes, tunica vaginalis, epididymis, and rectal exam when indicated. Additionally, the cremasteric reflex should be assessed by stroking or gently pinching the skin of the upper thigh while observing the ipsilateral testis, absence of this reflex suggests testicular torsion, which may be a surgical emergency. If the etiology of a scrotal process is equivocal after history and physical examination, color Doppler ultrasonography is the diagnostic test of choice because it is inexpensive, noninvasive, and will provide information on vascularity as well as anatomic details (4). Radionuclide scintigraphy is an alternative imaging option and will provide information on testicular vascularity but without anatomic details of ultrasound. Importantly, acute processes potentially requiring simple orchiectomy may
be emergent, and if radiology is not available, suspicion is high, or the viability of the testis is in question, immediate exploration of the scrotum with intraoperative inspection and Doppler should be performed in lieu of delayed intervention following radiographic evaluation. For patients with chronic testicular pain, laboratory evaluation with urinalysis, urine culture, urine microscopy, semen culture, and urethral swab for sexually transmitted disease evaluation may be helpful in determining the diagnosis of a bacterial orchitis.
be emergent, and if radiology is not available, suspicion is high, or the viability of the testis is in question, immediate exploration of the scrotum with intraoperative inspection and Doppler should be performed in lieu of delayed intervention following radiographic evaluation. For patients with chronic testicular pain, laboratory evaluation with urinalysis, urine culture, urine microscopy, semen culture, and urethral swab for sexually transmitted disease evaluation may be helpful in determining the diagnosis of a bacterial orchitis.
The diagnosis of metastatic prostate cancer requiring castration may be made via digital rectal exam and prostate-specific antigen screening prompting transrectal ultrasound-guided biopsy and ultimately radiographic imaging demonstrating systemic disease. Alternatively, patients with previously treated local disease may be diagnosed with biochemical recurrence or progression prompting radiographic evaluation.
INDICATIONS FOR SURGERY
Indications for simple orchiectomy depend largely on the diagnosis; in cases of penetrating scrotal trauma or blunt scrotal trauma with suspicion rupture of the testis, immediate scrotal exploration and intraoperative assessment is required (5). Even with rupture of the testis, salvage is often still possible with debridement of necrotic and extruded seminiferous tubules followed by closure of the tunica albuginea, although complete rupture may require orchiectomy (6). For suspected orchitis or epididymitis resulting from probable urinary tract infection, treatment with antibiotics and supportive care will almost always obviate the need for scrotal exploration and orchiectomy. Even for patients with Fournier gangrene, necrotizing fasciitis around the male genitalia, requiring emergent surgical debridement, the need for orchiectomy is rare due to the independent blood supply to the testis. Simple orchiectomy may be performed for chronic orchalgia after exhaustive efforts have been made to resolve issue with nonsurgical intervention, although the preferred intervention is microsurgical denervation with transection of the branches of the genitofemoral nerve and preservation of the testis, vas, and testicular artery (7). In cases of testicular torsion at the time of scrotal exploration, the testis is detorsed and observed; if viable orchiopexy is performed and if not viable, then simple orchiectomy to remove ischemic tissue is necessary.
Malignant diseases of the testes, such as suspected germ cell tumor, should never be managed with simple orchiectomy through a transscrotal approach. Suboptimal approaches to testicular neoplasms, including scrotal orchiectomy and transscrotal biopsy, can alter the normal lymphatic drainage of the testis and increase the burden of therapy for the patient (8). A meta-analysis of 206 cases of scrotal violation reported a local recurrence rate of 2.9%, compared to 0.4% for patients treated with inguinal orchiectomy, but no difference in systemic relapse or survival were appreciated (8). Therefore, if there is any suspicion of testicular cancer, a radical orchiectomy through an inguinal incision should be performed.
The indications for surgical or chemical castration in the treatment of advanced prostate cancer are not altogether clear. Although it is clear that castration is beneficial for patients with symptomatic metastatic disease (9) and should be avoided in those with localized disease because it may result in decreased overall survival (10), for patients who do not fit into either of these categories, the timing of initiation of castration is controversial. Medical castration is an alternative to bilateral simple orchiectomy. Although surgical castration rapidly results in a decrease in circulating androgen (1), medical therapies can achieve a similar result either through inhibition of androgen synthesis, blockade of the androgen receptor, or inhibition of gonadotropin-releasing hormone (GnRH). The most commonly used modality of medical castration are GnRH agonist; analogues of GnRH that inhibit the pituitary gonadal axis, resulting in the downregulation of luteinizing hormone-releasing hormone receptors and subsequent decrease in gonadotropin secretion. Importantly, these cause a temporary increase, or flare, in the available androgen and may result in exacerbation of life-threatening symptoms and coadministration to block the flare with an antiandrogen is standard practice. For patients with impending spinal cord compression, surgical castration or medical castration with ketoconazole provides the most rapid declines in circulating androgen to prevent impending impingement. Although the psychological effects of surgical castration can be daunting for the patient, from an economic viewpoint, surgical castration is much more cost-effective than medical castration. One last consideration is that surgical castration is irreversible, whereas medical castration may be given intermittently, although to date, there is an ongoing debate whether intermittent androgen blockade has equivalent outcomes.
SURGICAL TECHNIQUE FOR SIMPLE ORCHIECTOMY
Orchiectomy when performed electively is a straightforward outpatient procedure that may be performed with local, regional, or general anesthesia. Local anesthetic sensory blockade is obtained by infiltrating the spermatic cord in the region of the vas deferens in the high scrotum just below the pubic tubercle with a 0.5% bupivacaine solution. Care must be taken to ensure that the block is not injected intravascularly by drawing back on the syringe prior to injecting the medication. The same solution is then injected subcutaneously at the site of the scrotal incisions. Sensory blockade should then be tested with pickups before the beginning of the procedure. For scrotal exploration in cases of blunt or penetrating trauma, general anesthesia may be preferable because the extent of the exploration may not be fully realized at the start of the procedure. If simple orchiectomy is performed for castration and no prosthesis is to be placed, antibiotic prophylaxis is not absolutely indicated; however, it is our preference that a first-generation cephalosporin should be given intravenously within 30 minutes of scrotal incision. Antibiotic prophylaxis is mandatory for trauma, possible infectious etiologies, or when placing a testicular prosthesis.
Scrotal Approach
Scrotal approach to the simple orchiectomy may be through a single midline incision or two separate lateral incisions over the upper portion of the scrotal cord. Two incisions may decrease the need for mobilization and potentially reduce the risk for postoperative hematoma but may increase morbidity. Regardless of how many incisions are made, the first step is to shave the anterior scrotal wall to remove existing hair;
the scrotum and genitalia are then prepared in a sterile manner. A 2.5- to 3.0-cm midline incision is made just through the skin within the median raphe in the anterior scrotal wall using a no. 15 blade scalpel while the assistant pushes a testicle toward the incision between his or her thumb and index finger so that the testicle lies directly under the incision (Fig. 58.1). By electrocautery, the incision is then carried down through the dartos and cremasteric layers until the parietal portion of the tunica vaginalis is incised directly over the testis. This is usually evidence by a gush of fluid from the peritesticular space. The incision in the tunica vaginalis is lengthened in both directions, enough to allow exposure of the entire testicle through the wound. The surrounding tunics are freed from the spermatic cord by a combination of blunt and sharp dissection. Meticulous hemostasis may be obtained in each layer as it is entered with electrocautery. Once the spermatic cord is isolated, the vas deferens is separated, doubly clamped, divided, and ligated with 2-0 Vicryl or 2-0 silk ties (Fig. 58.2). The remainder of the cord structures may be divided into one or more bundles and are doubly clamped on the proximal side and singly clamped on the distal side. Once divided, the proximal portion of the cord is ligated with a 0 Vicryl or silk free tie behind the most proximal clamp, which is then removed, and a 0 Vicryl suture ligature is placed just distal to the free tie (see Fig. 58.2). Before the cord is released to retract proximally, the tunics, dartos, and subcutaneous areas are again inspected for hemostasis. Once this is felt to be adequate, the cord is allowed to retract and attention is turned to the opposite testicle. It is then removed through the same midline or a separate transverse scrotal skin fold incision in the same manner. This leaves two openings in the tunica vaginalis and dartos layers, which are separated by a median septum. These deep layers are then closed in one layer using a 3-0 Vicryl running suture. Allis clamps are placed at either end of the median septum to facilitate the exposure (Fig. 58.3). The skin is then closed with interrupted 3-0 chromic sutures or a continuous subcuticular
absorbable closure and a gauze dressing is applied. Drains are not required but can be considered if there is doubt about hemostasis. Compression or turban dressings may also be used if there is concern over postoperative hemostasis or edema.
the scrotum and genitalia are then prepared in a sterile manner. A 2.5- to 3.0-cm midline incision is made just through the skin within the median raphe in the anterior scrotal wall using a no. 15 blade scalpel while the assistant pushes a testicle toward the incision between his or her thumb and index finger so that the testicle lies directly under the incision (Fig. 58.1). By electrocautery, the incision is then carried down through the dartos and cremasteric layers until the parietal portion of the tunica vaginalis is incised directly over the testis. This is usually evidence by a gush of fluid from the peritesticular space. The incision in the tunica vaginalis is lengthened in both directions, enough to allow exposure of the entire testicle through the wound. The surrounding tunics are freed from the spermatic cord by a combination of blunt and sharp dissection. Meticulous hemostasis may be obtained in each layer as it is entered with electrocautery. Once the spermatic cord is isolated, the vas deferens is separated, doubly clamped, divided, and ligated with 2-0 Vicryl or 2-0 silk ties (Fig. 58.2). The remainder of the cord structures may be divided into one or more bundles and are doubly clamped on the proximal side and singly clamped on the distal side. Once divided, the proximal portion of the cord is ligated with a 0 Vicryl or silk free tie behind the most proximal clamp, which is then removed, and a 0 Vicryl suture ligature is placed just distal to the free tie (see Fig. 58.2). Before the cord is released to retract proximally, the tunics, dartos, and subcutaneous areas are again inspected for hemostasis. Once this is felt to be adequate, the cord is allowed to retract and attention is turned to the opposite testicle. It is then removed through the same midline or a separate transverse scrotal skin fold incision in the same manner. This leaves two openings in the tunica vaginalis and dartos layers, which are separated by a median septum. These deep layers are then closed in one layer using a 3-0 Vicryl running suture. Allis clamps are placed at either end of the median septum to facilitate the exposure (Fig. 58.3). The skin is then closed with interrupted 3-0 chromic sutures or a continuous subcuticular
absorbable closure and a gauze dressing is applied. Drains are not required but can be considered if there is doubt about hemostasis. Compression or turban dressings may also be used if there is concern over postoperative hemostasis or edema.
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