Simple Orchiectomy
Simple orchiectomy provides an effective means of achieving castrate levels of testosterone for patients with prostate cancer or for surgical castration of transgender patients who identify as female and wish to undergo hormonal transition. Occasionally, simple orchiectomy may be used for treatment of epididymoorchitis with abscess formation that is refractory to antibiotic treatment, particularly in older or immunocompromised patients. More rarely, simple orchiectomy may be considered for treatment of chronic orchialgia. Anesthetic options include regional anesthesia via spermatic cord block, sedation, spinal anesthesia, or general anesthesia.
After shaving and sterile preparation of the scrotum, a transverse hemiscrotal incision is made within the scrotal rugae, with caution taken to avoid any prominent scrotal blood vessels ( Fig. 116.1 ). If performing bilateral simple orchiectomies, a longitudinal incision along the median raphe may be performed to readily access the left and right sides of the scrotum through one skin incision. Carry the incision through the dartos fibers and tunica vaginalis and deliver the testis into the wound. Provide gentle traction on the testis to expose the spermatic cord.
Identify, ligate, and divide the vas deferens using a 2-0 silk ligature. Separate the cremasteric muscle from the internal spermatic vessels and ligate each separately using 2-0 silk sutures ( Fig. 116.2 ). If a testicular prosthesis is desired after simple orchiectomy, the gubernaculum and tunica vaginalis are left intact, and the prosthesis is placed inside the tunica vaginalis. This allows for a natural position and appearance of the prosthesis.
Ensure meticulous hemostasis. The dartos muscle should be reapproximated in an interrupted fashion using 3-0 or 4-0 self-absorbing suture. Inject the wound with bupivacaine then close the skin edges in a running subcuticular fashion with 5-0 absorbable suture using two skin hooks at the apices to aid in closure ( Fig. 116.3 ).
An identical operation is carried out on the contralateral side if indicated through a separate incision (or through the same skin incision if access was obtained through the median raphe). At the completion of the procedure, the wound is dressed with antibiotic ointment, dry fluffed gauze, and an athletic supporter.
Epididymis-Sparing Orchiectomy
This procedure leaves a palpable mass within the scrotum; however, it is a bloodier operation than simple orchiectomy. Use of the operating microscope facilitates dissection.
After delivery of the testis as described for simple orchiectomy, bring the operating microscope into the field. Sharply dissect the epididymis off of the testis. Clamp and ligate the three major groups of epididymal vessels—superior, middle, and caudal—using 2-0 silk ( Fig. 116.4 ).
Approximate the caput and cauda of the epididymis using 3-0 absorbable suture to create an ellipsoid structure ( Fig. 116.5 ). Given the bloodier nature of this procedure, a drain should be placed through a dependent stab wound before initiating closure. Reduce the epididymis within the tunica vaginalis and close the tunica vaginalis with a 4-0 or 5-0 self-absorbing suture. Completion of dartos and skin closure may be carried out as described for simple orchiectomy.
