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Simple Orchiectomy via a Scrotal Approach: Surgical Technique and Complications

Indications for Simple Orchiectomy

• Bilateral orchiectomy as an anti-androgenic therapy in advanced or metastatic prostate cancer
• Testicular abscess, e.g., due to progressive epididymitis
• After testicular trauma with completely infarcted or shattered testis
• Missed testicular torsion with complete necrosis

Contraindications of Scrotal Orchiectomy

• Bleeding disorders
• If testicular cancer is suspected, an inguinal approach is mandatory.
• The other contraindications depend on the surgical risk due to the patient's comorbidity, and the surgical procedure's impact on the patient's quality of life.

Surgical Technique of Scrotal Orchiectomy

Preoperative Patient Preparation:

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

Scrotal Approach:

Scrotal skin incision along the raphe testis, both testicles can be reached with the same incision. Alternatively, a transverse incision between the scrotal skin vessels is possible for a unilateral approach.

Subcapsular (Bilateral) Orchiectomy:

The subcapsular orchiectomy (Riba's technique) is indicated for advanced prostate carcinoma and avoids the feeling of an empty scrotum after orchiectomy. After the skin incision and incision of the tunica vaginalis parietalis, the testis is delivered into the wound. The tunica albuginea is incised from the upper to the lower pole. The protruding testicular tissue is detached from the tunica albuginea until the parenchyma is only fixed to the hilus. The hilar vessels are secured with a clamp, and the testicular tissue is dissected and removed. A figure-of-eight suture closes the hilar vessels. Careful cautery is done to control remaining bleeding. The tunica albuginea is closed with a running suture (e.g., vicryl 3-0). The next running suture adapts the tunica vaginalis parietalis and subcutis. The contralateral testis is reached via the same incision. The skin is closed with a fast absorbable (monofilament) suture 4-0.

Scrotal Orchidoepididymectomy:

Compete orchidoepididymectomy is indicated for infection, testicular trauma or after missed testicular torsion (see above). After the skin incision, the testis is mobilized with intact tunica vaginalis parietalis. Tension on the testis enables mobilization of the spermatic cord up to the superficial inguinal ring. The spermatic cord is opened, and the vas and the testicular vessels are dissected separately between overholt clamps and suture ligations. Careful cautery is done to control the remaining bleeding. Place a Redon suction drain if orchiectomy was done for severe infection. A running or interrupted suture closes the subcutis. The skin closed with fast absorbable (monofilament) suture 4-0.

Complications of Orchiectomy

• Bleeding with hematoma
• Wound infection
• Hypogonadism depending on the contralateral testicular function

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: Skrotale Orchiektomie