Overview of Orchiectomy
Orchidectomy is a procedure where the testicles are surgically removed. This procedure can either be a radical or straightforward. A simple orchidectomy, done through the scrotum, used to be a primary method of hormone control in patients with advanced prostate cancer. Over time, this method has been replaced by less invasive treatments such as hormone drugs, like gonadotropin-releasing hormone agonists or antagonists.
Nowadays, a simple orchidectomy is mainly used for removing a withered or non-functioning testicle due to injury, twisting, or infection. A radical orchidectomy, on the other hand, is performed through the groin. This procedure is mostly used for diagnosis and treatment of testicular cancers.
Testicular cancers are usually categorized into two groups: germ cell tumors (GCTs) and non-germ cell tumors. GCTs account for more than 95% of testicular cancers, and over half of them are seminomas. Seminomas and non-seminomas make up a diversified group of tumors that can combine different types.
Non-seminomatous GCTs are nearly always linked with increased tumor markers. Meanwhile, only 10% to 25% of seminomas are associated with a rise in certain compounds in the body such as beta-human chorionic gonadotropin or lactate dehydrogenase, but not alpha-fetoprotein. If a seminoma is accompanied by a rise in alpha-fetoprotein, it is thought to have a component of yolk sac tumors.
Anatomy and Physiology of Orchiectomy
The testes are a pair of oval-shaped reproductive organs that create hormones and produce sperm. They are found in the scrotum, a pouch of skin located below the male body, and each testis is on either side of a thin layer of tissue.
In the development stage within the mother’s womb, the testes originate from an area called the genital ridge. From this place, they gradually move downwards, through a path called the inguinal canal, to reach their final location in the scrotum. This movement is guided by a structure called the gubernaculum. When a baby boy is born, his testes are usually already in the scrotum.
As the testes move down, they get covered by different layers of tissue which come from the front of the abdominal wall. These layers, from deepest to the outermost, include the tunica vaginalis, internal spermatic fascia, cremasteric fascia, external spermatic fascia, and the dartos muscle. The tunica albuginea is the deepest layer that works as a protective casing of the testis, and unlike other layers, it does not come from the abdominal wall.
Under a microscope, we can see three main types of cells in the testes. Germ cells are the ones that produce sperm. Sertoli cells provide support to these germ cells. And interstitial cells of Leydig are responsible for the production of the male hormone, testosterone.
The blood flow to the testes is well-organized and has plenty of backups. The primary artery carrying blood to this region is the testicular or gonadal artery. This artery branches right off from the abdominal aorta, which is the main pipeline carrying oxygenated blood in our body, just below an artery called the superior mesenteric artery. The cremasteric artery is another artery that supplies blood to the testes and can step in if needed.
In some types of surgery not involving the testes, it might be needed to tie off the gonadal artery. But thanks to the backup blood supply, it doesn’t cause much worry. The testes return blood back to the heart via a network of veins called the pampiniform plexus, which eventually forms the testicular veins. These veins drain into different major veins depending on the side; the right testicular vein drains into the inferior vena cava, and the left testicular vein drains into the left renal vein.
Lastly, the lymph (a fluid that runs throughout the body and plays an essential role in our immune response) from the testes flows alongside the testicular arteries to reach a set of lymph nodes near the aorta, the largest artery in the body. Interestingly, the scrotum has a separate drainage system, draining to the lymph nodes in the groin area.
Why do People Need Orchiectomy
Testicular cancer is a condition often seen in men aged 15 to 35 years old. It develops when there’s an growth, typically painless and getting bigger, in one or both testicles. Sometimes, other symptoms like a mild ache in the lower stomach or groin, tenderness in the chest area, or development of breast tissues may signal the presence of testicular cancer. If the cancer has spread to other parts of the body, it might result in weight loss, lower back pain, lumps in the abdomen, chest pain, coughing, or coughing up blood.
To diagnose testicular cancer, doctors use special tests that measure the levels of certain substances, known as tumor markers, in the blood. These markers include alpha-fetoprotein, beta-human chorionic gonadotropin, and lactate dehydrogenase. An ultrasound is also carried out to look for any unusual changes in the testicles, like lumps or swelling. These ultrasounds can identify more than 95% of changes in the testicle tissue. Sometimes, computed tomography, or CT scans, of the patient’s abdomen and pelvis are conducted to help determine whether the cancer has spread. However, MRI scans aren’t typically used when diagnosing and working out the stage of the disease.
Surgery to remove the affected testicle called “radical orchidectomy” is both a way to confirm testicular cancer and treat it. This operation is considered a key step in curing testicular cancer. However, it’s crucial to rule out other conditions that might affect the testicles and scrotum and may look like testicular cancers. These can include conditions like a twisted testicle, an infection of the testicle or epididymis, a fluid-filled sac around a testicle, or a hernia in the groin area. In non-cancerous cases, a less extensive surgery, called a simple orchidectomy, can be performed to deal with these problems.
A full evaluation of a patient’s medical history and a thorough physical examination are vital steps in accurately assessing testicular tumors.
When a Person Should Avoid Orchiectomy
Doctors need to be very careful when making a diagnosis. They base their decision on the patient’s symptoms and a physical check-up. For example, if a teenage boy suddenly starts to feel intense pain in his testicles, and his scrotum swells up over a few hours, it’s highly likely that he has testicular torsion. This condition happens when the spermatic cord, which provides blood flow to the testicle, rotates and becomes twisted. This boy would need immediate surgery to untwist the spermatic cord and fix the testicle in place, a procedure called orchidopexy.
Now, this situation is different from a patient who recently had symptoms of a urinary tract infection and fever, followed by swelling of the scrotum. They might have orchiepididimytis, which is inflammation of the testicle and epididymis, a tube located at the back of the testicles. It’s often caused by an infection, including sexually transmitted infections.
In any case, doctors must be very observant because sometimes, testicular tumors can cause the spermatic cord to twist and lead to torsion. This is why it’s so important for healthcare professionals to be aware of all possibilities when patients come in with these symptoms.
Equipment used for Orchiectomy
The surgery happens in a special room just for operations and requires the usual tools used for belly surgeries. Use of something called bipolar diathermy might be better for controlling bleeding in the groin area as it helps avoid damage to certain nerves in that area (called the ilioinguinal and genitofemoral nerves). A device called a cord ring is used to help separate certain elements within the groin area from everything else. This makes the procedure more streamlined and reduces the risk of potential complications.
Who is needed to perform Orchiectomy?
A procedure called a radical orchidectomy, which is a surgery to remove a testicle, requires a team of medical professionals. This includes a urological surgeon, who is a doctor specialized in performing surgeries related to the urinary tract, at least one assistant to help with the procedure, a scrub nurse or technician to prepare and organize the tools and equipment used during the surgery, and an anesthetist. The anesthetist is a doctor or nurse who gives you the medicine that makes you sleep and not feel any pain during the surgery. Additionally, there are theatre support staff who help everything run smoothly in the operating room. This team setup is typical for many types of surgeries which happen in the abdomen, or belly area of the body.
Preparing for Orchiectomy
Before undergoing surgery, patients need to be fully prepared. This includes managing any existing health conditions and possibly stopping certain medications, such as blood thinners or drugs that prevent blood clotting. Doctors usually recommend that patients avoid eating or drinking for a certain period before the surgery.
In the case of orchidectomy, a surgery to remove one or both testicles, it’s important that patients are informed about the option of a testicular prosthesis – an artificial testicle that can be put in place of the removed one. Patients should discuss this option with their doctor well before the surgery date.
For patients worried about their ability to have children in the future, sperm banking can be offered. This is particularly important for those who may need additional treatments like radiation or chemotherapy after surgery, which can potentially harm the remaining testicle. Now, sperm banking is a method of preserving sperm cells by freezing them. This way, they could be used later if the patient decides to have children.
Lastly, a written consent is needed. It details what the surgery will involve and confirms that the patient understands and agrees to the procedure. It’s best to do this in the clinic before the surgery day. Then, on the day of the surgery, the patient will be examined again, and the side of the body where the surgery will take place will be clearly marked with a permanent marker. This rigorous process is to ensure the safety and well-being of the patient.
How is Orchiectomy performed
This is a clean surgery procedure, similar to a typical belly surgery. When the patient arrives in the operating room, they go through a safety checkpoint according to WHO guidelines. This ensures that all the necessary preparations are done.
The patient might receive general or local anesthesia. This gets done in a specific room, known as the induction room.
Once the patient is on the operation table, they’re laid flat on their back. The surgical team follows cleanliness routines using an antiseptic solution. This cleaning procedure typically covers the chest area down to the middle of the thighs. After cleaning, a special sheet is used to mark the clean (or “sterile”) area.
The surgeon’s first cut is made along a crease in the groin. Making the incision in this area usually results in a better cosmetic outcome after surgery. The surgeon then carefully cuts down through the layers of the belly wall until they reach a tough layer called the “external oblique aponeurosis.” The surgeon carefully opens this layer to enter the inguinal canal, being especially careful to avoid damaging the nearby ilioinguinal nerve.
Next, they identify the contents of the “cord,” an important structure in this area of the body. They then carefully wrap and tighten a special drain around the cord to prevent any tiny cancer cells from spreading through the blood. The testicle is then gently moved from the scrotum through the surgical wound. The surgeon clamps and cuts the “gubernaculum,” a structure associated with the testicle. They then move to the upper part of the cord, clamping it as close as possible to the internal ring (a landmark in this area), tying it off with a strong, non-dissolving stitch, and cutting it.
This step of tying off the testicular blood vessels is extremely important because missing it can lead to serious bleeding from a structure known as the retroperitoneal space. During the whole process, the surgical team takes extra care to avoid touching or otherwise disturbing the scrotal skin, because this could interfere with the normal draining of any tumor cells. Going slowly and using a gentle technique to free the testicle from the scrotal skin can be very beneficial. To stop any bleeding, they use a tool that delivers a small electric current (bipolar electrocautery).
If agreed upon before the surgery, a prosthetic testicle is then inserted and secured at this point. Finally, the surgeon closes the wound in layers and applies a sterile dressing.
Possible Complications of Orchiectomy
During surgery, there may be a risk of heavy bleeding if blood vessels located near the internal ring get injured. This could also damage a nerve that could cause a tingling sensation or numbness on a portion of skin on the inside of the upper thigh and the front part of the scrotum. The damage could also weaken the muscles in the back wall of the inguinal canal, leading to a type of hernia known as a direct inguinal hernia. Other complications that could happen include infection at the site of the wound, extensive bruising, fluid-filled swelling, or a blood-filled swelling.
Thankfully, most of the time these issues with the wound get better on their own. Sometimes, though, we might have to drain the fluid or blood, or in rare cases, perform another operation to remove it. If you have a large tumor, and we have to perform extensive surgery in the scrotal area, you may end up with swelling or a blood-filled swelling in the scrotum. In these instances, we can manage it with support for the scrotum, pain relief, and anti-inflammatory drugs. In rare cases, if these swellings get really large, we may need to remove them surgically.
Handling the tumor early or clamping the cord late during surgery might cause tiny sites of spread of cancer or a higher risk of the cancer coming back.
In the long run, the absence of a testicle could lead to psychological or social issues. An artificial testicle, or a testicular prosthesis, can help with this. Be aware though, even this solution could come with its complications like rupture, scarring, contraction, or infection.
What Else Should I Know About Orchiectomy?
Testicular cancer is relatively rare, making up about 1% of all cancers found in males. However, it’s the most common type of cancer in males aged 15 to 35. The earlier it’s found, the higher the chances of successful treatment.
When it comes to the “drainage” (or the movement of fluid away from an area), testicular cancer follows a specific pattern. The fluid can move towards the para-aortic, interaortocaval, and infrarenal groups of lymph nodes. Lymph nodes are small, bean-shaped structures that produce cells which fight infection. The fluid from the scrotum (the sack that contains the testicles), on the other hand, usually drains to the lymph nodes in the groin.
Because the fluid from the testicles and the scrotum drain to different areas, it’s important to avoid interference between them when treating testicular cancer. This is why doctors prefer to use an “inguinal approach”, which avoids the scrotum altogether. This means using an opening in the groin area to remove the cancer, helping to prevent the cancer from spreading.
It’s also why taking a biopsy (a small tissue sample) directly from the testicles through the scrotum is a big no-no—it can inadvertently contribute to the spread of the cancer. Therefore, this kind of biopsy is strictly avoided.