Continuing Education Activity

Radical orchidectomy is not only a diagnostic procedure but a therapeutic one in patients with suspected testicular malignancy. This procedure outlines the benefits of a radical orchidectomy and highlights the role of the Urologist in evaluating and treating patients who undergo a radical orchidectomy. This activity covers the indications, contraindications, complications, and management of the orchiectomy procedure.

Objectives:

• Identify the indications/contraindications of radical orchidectomy.
• Describe the equipment, personnel, preparation, and technique in regards to radical orchidectomy.
• Review the appropriate evaluation of the potential complications and clinical significance of radical orchidectomy.
• Discuss interprofessional team strategies for improving care coordination and communication to advance the care of patients undergoing radical orchidectomy and improve outcomes.

Introduction

Orchidectomy involves the surgical removal of the testes. It may be a radical or straightforward procedure. Simple orchidectomy is approached through the scrotum and historically has been a significant means of hormonal manipulation in the management of patients with locally advanced prostate cancer. This indication has, over time, been replaced by the less invasive hormonal medications such as gonadotropin-releasing hormone agonists or antagonists. This approach to therapy has limited the indications of simple orchidectomy to the removal of an atrophic testis and non-viable testis due to trauma, torsion, or infection. In contrast, radical orchidectomy uses a through the groin approach. It is the mainstay of diagnosis and treatment of testicular malignancies.

Testicular cancers fall into two main groups; germ cell tumors (GCTs) and non-germ cell tumors. GCTs make up over 95% of testicular tumors, and over 50% of GCTs are seminomas.[1] Non-seminomas comprise a heterogeneous group of tumors with different patterns that may include a combination of histologic types of seminomas and non-seminomas. Non-seminomatous GCTs are almost exclusively associated with elevated tumor markers, while only 10 to 25 percent of seminomas are associated with a rise in beta-human chorionic gonadotropin or lactate dehydrogenase, but no rise in alpha-fetoprotein.[2] Seminomas with elevated serum alpha-fetoprotein are considered to have a component of yolk sac tumors.

Anatomy and Physiology

The testes are a pair of reproductive organs that are responsible for hormone and sperm production. They are ovoid-shaped smooth structures located in the scrotum and separated by a fascial septum. 

Embryologically, the testes develop from the genital ridge in the dorsal mesentery. They descend from the retroperitoneum through the inguinal canal to their final position in the scrotum directed by a primordial structure called the gubernaculum. At birth, a majority of fetuses have their testes already descended in the scrotum.[3] As the testes descend, they acquire coverings from the anterior abdominal wall. These coverings of the testes are; tunica vaginalis, internal spermatic fascia, cremasteric fascia, external spermatic fascia, and the dartos muscle from deep to superficial layers. The deepest covering of the testis is the tunica albuginea, which represents the capsule of the testis and is not acquired from the abdominal wall.

The histology of the testes shows three main types of cells. 1. Germ cells that produce spermatozoa. 2. Sertoli cells that provide support. 3. Interstitial cells of Leydig that produce testosterone.

The blood supply to the testes is robust and well collateralized. The major arterial blood supply is supplied by the testicular/gonadal artery, which is a direct branch of the abdominal aorta inferior to the superior mesenteric artery (SMA). The collateral blood supply comes from the cremasteric artery (a branch of the inferior epigastric artery) and anastomoses with the testicular artery in the testis.

In non-testicular surgery, the gonadal artery sometimes requires ligation, but due to the collateral blood supply, there is low concern for vascular compromise. The venous drainage of the testes is through the pampiniform plexus of veins in the scrotum, which coalesce to form the testicular veins. The right testicular vein drains into the inferior vena cava while the left testicular vein drains into the left renal vein.

The lymphatic drainage of the testes is along the testicular arteries to the para-aortic group of lymph nodes. The scrotum is, in contrast, drained through a different lymphatic pathway to the inguinal lymph nodes.

Indications

Potential indications for radical orchidectomy include both clinical and biochemical suspicion of testicular tumors. Testicular cancers are common in males aged 15 to 35years. They present as a painless enlarging, usually unilateral intra-scrotal mass arising from the testis. Pain or discomfort in the testis, dull ache in the groin or lower abdomen, breast tenderness, or gynecomastia may also be presenting symptoms of testicular cancer. Late symptoms may include weight loss, low back pain, abdominal mass, chest pain, cough, or hemoptysis due to retroperitoneal lymph node metastases or lung metastases.[4]

Biochemical investigations include tumor markers, which are alpha-fetoprotein, beta-human chorionic gonadotropin, and lactate dehydrogenase. Ultrasonography reveals vascular hypoechoic testicular lesions. Ultrasonography is very sensitive in the early detection of testicular tumors, with over 95% of testicular parenchymal abnormalities identifiable on routine ultrasound scans. Computed tomography (CT) scans of the abdomen and pelvis help with the preoperative staging.[5] There is no real role for MRI in diagnosis and staging

Radical orchidectomy is both diagnostic and therapeutic in the management of suspected testicular cancer. This procedure is the mainstay for confirming the diagnosis of testicular cancer and achieving a cure. However, it is essential to exclude other conditions involving the testes and scrotum, which may mimic testicular neoplasms, including testicular torsion, epididymo-orchitis, hydrocoele, and inguinal hernias. Any other testicular pathology with no malignant suspicion is accessible via a scrotal incision with no concern over metastatic seeding to inguinal lymph nodes. However, these classify as simple orchidectomies rather than radical.

Clinical history and examination are vital in the assessment of testicular tumors.

Contraindications

Care is necessary for diagnosis, which should come from history and clinical examination. For instance, an adolescent male who presents with a sudden onset of severe testicular pain with progressive scrotal swelling over the previous few hours, who on examination demonstrates a tender and high lying testis most likely has testicular torsion and would benefit from emergency scrotal exploration and orchidopexy. This presentation compares to a patient with recent symptoms of urinary tract infection, fever, and subsequent scrotal swelling. They may likely have orchiepididimytis. It is, however, important to have a high index of suspicion in these cases as testicular tumors may sometimes precipitate torsions in these patients.

Equipment

The procedure takes place in the operating theatre, and standard equipment for abdominal surgery is needed. Bipolar diathermy may be more appropriate in controlling hemostasis in the inguinal canal as this reduces injuries to the ilioinguinal and/or genitofemoral nerves. A cord ring helps in separating the cord and its contents from other structures in the inguinal canal. 

Personnel

Radical orchidectomy requires a urological surgeon, at least one assistant, a scrub nurse or technician, and an anesthetist to administer the anesthesia. The theatre support staff are also needed, as is with other standard abdominal procedures.

Preparation

Preoperative preparation of the patients involves optimization and management of comorbidities, which may include cessation of medications such as anticoagulants or antiplatelets. A period of fasting is advisable, as appropriate. All patients undergoing orchidectomy should be offered testicular prosthesis and should have a discussion about this in the preoperative clinic.

Patients who are concerned about fertility should also be offered sperm banking, especially those who may require adjuvant care such as radiation or chemotherapy, which may affect the contralateral testis. A detailed written informed consent is obtained before surgery and is best obtained in the clinic before the day of surgery. On the day of surgery, the patient should have a re-examination, and the side marked clearly with a permanent marker.[6]

Technique or Treatment

It is an aseptic procedure and follows all the guidance as standard abdominal surgery. Once the patient arrives in the theatre, the WHO theatre checklist should be started and all the aspects completed for each step.  Anesthesia may be general or regional as appropriate and is administered in the induction room. 

On the operating table, the patient is positioned supine, routine cleaning is done with antiseptic solution from the nipple line to the mid-thighs and draped to isolate the sterile zone. A transverse groin skin crease incision yields the best cosmetic result post-op. Dissection is carried down through the layers of the anterior abdominal wall to the external oblique aponeurosis, which is opened along its fibers to gain access to the inguinal canal. Care is taken at this point to prevent injury to the ilioinguinal nerve just lying beneath the aponeurosis.

The cord contents are identified, and a Penrose drain wrapped and clamped tightly around the cord to prevent hematogenous micro-metastases. The testis is delivered along with its coverings from the scrotum through the inguinal wound. The distal gubernaculum is clamped and divided while the proximal cord is then clamped as close to the internal ring as possible, ligated preferably with a non-absorbable suture and divided.

Ligating the testicular vessels in continuity will prevent potentially life-threatening retroperitoneal bleeding from a slipped ligature. It is essential throughout the procedure to avoid any breach of the scrotal skin, as this may alter the lymphatic drainage of the tumor. To achieve this, gentle blunt dissection to free the testes from the scrotal skin is helpful. Hemostasis is achieved with the use of bipolar electrocautery. A testicular prosthesis is then inserted and anchored at this point if agreed earlier. The wound is then closed in layers and dressed with a sterile dressing.[7]

Complications

Excessive primary hemorrhage may occur intraoperatively due to injury to the inferior epigastric vessels, which lie medial to the internal ring. Damage to the ilioinguinal nerve can cause paraesthesia or numbness on the patch of skin on the medial part of the upper thigh and the anterior part of the scrotum, or predispose the patient to direct inguinal hernia due to weakness of the posterior inguinal wall muscles. Wound complications may include wound infection, extensive bruising, seroma, or hematoma.

Most wound complications resolve spontaneously with few requiring aspiration or re-exploration for evacuation. Scrotal edema or hematoma may occur following extensive scrotal dissection in delivering large tumors and may require management with scrotal support, analgesia and anti-inflammatories. Rarely, large hematomas will require surgical exploration and evacuation. Early handling of the tumor or late clamping of the cord may cause micro-metastases or increase the risk for local recurrence. 

Long term psychological or social complications due to the absence of the testis may be improved with the use of testicular prosthesis. A testicular prosthesis may be associated with complications such as rupture, scarring, retraction, contracture, or implant infection.[8]

Clinical Significance

Testicular cancers are rare malignancies accounting for about 1% of all malignancies in the male population. It is, however, the most common solid organ malignancy in young males aged 15 to 35 years.[9] Early diagnosis significantly improves cure rates. Lymphatic drainage of testicular cancer follows the testicular arteries to the para-aortic, interaortocaval, and infrarenal groups of lymph nodes, while drainage of the scrotum is to the inguinal lymph nodes. This disparity in the drainage of these very closely related structures influences the importance of an entirely inguinal approach to delivering testicular cancers to prevent breaching the scrotum and interfering with the lymphatic drainages and upstaging the tumor. Trans-scrotal testicular biopsies are therefore absolutely contraindicated for the same reason.[10]

Enhancing Healthcare Team Outcomes

Once the general practitioner suspects testicular cancer, a referral is made under the suspected cancer pathway for an appointment within two weeks with a urologist. The patients can be seen in one-stop clinics with direct access to testicular ultrasound scanning. A large cohort study involving 1757 patients who attended a one-stop testicular clinic in a University hospital in the UK showed that the median waiting time to be seen was nine days compared to 13 days for general patients. The time from clinic to orchidectomy was five days with the benefits of discovery of subclinical cancers, timely diagnosis, treatment, and on-time reassurance of patients with benign results.[11]

All patients with a strong suspicion of or confirmed case of testicular cancer merit discussion in the local multidisciplinary meeting (MDT) of the hospital. All aspects of a patient’s management are discussed and agreed at the MDT meeting. These include staging investigations, plan for adjuvant radiotherapy, chemotherapy or hormonal therapy, social, psychological care, and follow-up.

The members of the urology cancer MDT include:

• Urologist/lead clinician
• Macmillan clinical nurse specialists
• Radiologist
• Histopathologist
• Palliative care medicine
• Oncologist
• MDT coordinator

Nursing, Allied Health, and Interprofessional Team Interventions

Clinical specialist nurses are very experienced in the care of patients with cancers. Macmillan nurses are involved early in the management of testicular cancers, and they provide early guidance, optimal follow-up, and advice when required. They offer a strong link between the surgeon, the oncologist, and the palliative care physicians.

Nursing, Allied Health, and Interprofessional Team Monitoring

The clinical nurse specialists have dedicated clinics that follow up patients who have had orchidectomies and provide close patient health worker relationships and surveillance needed for patients who are post adjuvant care or those who required no further treatment following their surgical procedure.