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Radical Inguinal Orchiectomy: Technique and Complications

Indications for Radical Orchiectomy

Malignant testicular tumor, e.g., germ cell tumors. Any tumor-suspicious finding is treated with an inguinal approach and treated accordingly after a frozen section diagnosis.

Contraindications

Bleeding disorders. Advanced germ cell tumors with life-threatening complications of metastases: patients require immediate chemotherapy first. Radical orchiectomy can be performed between the second and third chemotherapy cycles (depending on remission).

Surgical Technique of Radical Orchiectomy

Preoperative Patient Preparation:

Supine positioning, spinal or general anesthesia. Perioperative antibiotic prophylaxis if risk factors for surgical site infections are present.

Inguinal approach:

Start with an Inguinal incision for the approach to the inguinal canal. The aponeurosis of the external oblique muscle is split along the inguinal canal from the superficial inguinal ring to the level of the deep inguinal ring. Identify and protect the ilioinguinal nerve. Mobilize the spermatic cord up to the deep inguinal ring. Deliver the testis from the scrotum into the wound, coagulate and transect the gubernaculum testis. If there is no doubt about a malignant testicular tumor, proceed with radical orchiectomy (see below).

Organ-preserving tumor excision:

An organ-preserving approach is indicated in uncertain cases: small, well-demarcated testicular tumors without elevation of testicular tumor markers. Protect the wound with sterile towels. Incise the tunica vaginalis parietalis. Incise the tunica albuginea above the tumor; intraoperative ultrasound is helpful for small nonpalpable tumors. Perform an organ-preserving tumor resection with a small safety margin and send the specimen for frozen section diagnosis. After hemostasis, close the tunica albuginea and tunica vaginalis and await the frozen section diagnosis. If benign, the testis is repositioned into the scrotum.

Radical orchiectomy:

Mobilize the spermatic cord to the deep inguinal ring. Incise the cremasteric muscle to open the spermatic cord. Identify the peritoneal sac. Separate the testicular vessels from the vas deferens; transect both structures separately between overholt clamps. Ligate the vas deferens with 2-0 and the testicular vessels with 0 sutures.

Contralateral testicular biopsy:

A contralateral testicular biopsy is performed together with orchiectomy. For the indication of contralateral testicular biopsy see section surgical therapy of testicular cancer.

The testis is fixed by the assistant in the scrotal compartment with stretched skin. A small skin incision through all scrotal layers exposes the tunica albuginea. A 5 mm incision of the tunica at the upper pole of the testis is sufficient, and the protruding testicular tissue is sent for histological examination in Stieve or Bouin solution. Close the tunica with a 3-0 suture. The testis is repositioned in the scrotal compartment, and a testicular biopsy is repeated at the lower pole using the same skin incision.

Wound closure:

A Bassini suture can be used to reinforce a weak dorsal wall of the inguinal canal. Close the external abdominal oblique aponeurosis with a running suture 2-0 without including the ilioinguinal nerve. Infiltrate the wound edges and the external aponeurosis with a long-acting local anesthetic. Subcutaneous sutures. Skin suture. Drainage is usually unnecessary.

Complications

Bleeding, hematoma, wound infection, injury to the ilioinguinal nerve with hypesthesia or persistent pain, inguinal hernia.

References

J. A. Smith, S. S. Howards, G. M. Preminger, and R. R. Dmochowski, Hinman’s Atlas of Urologic Surgery Revised Reprint. Elsevier, 2019.

  Deutsche Version: Inguinale radikale Orchiektomie