You are in: eMedicine Specialties > Urology > Cancer, Testicle Orchiectomy, RadicalArticle Last Updated: Jan 18, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Frank Papanikolaou, MD, Clinical Fellow, The Hospital for Sick Children, Department of Surgery, Division of Urology, University of Toronto, Canada Coauthor(s): Laurence Klotz, MD, Professor, Department of Surgery, University of Toronto School of Medicine, Canada Editors: Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Bradley Fields Schwartz, DO, FACS, Associate Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine Author and Editor Disclosure Synonyms and related keywords: radical orchidectomy, orchiectomy, orchidectomy, testicular cancer, cryptorchidism, intratubular germ cell neoplasia, contralateral testis cancer, testicular malignancy, diethylstilbestrol, testicular seminoma, testicular nonseminomatous germ cell tumors, testicular embryonal carcinoma, testicular teratocarcinoma, testicular teratoma, testicular pure choriocarcinoma, testicular choriocarcinoma, testicular carcinoma INTRODUCTIONSection 2 of 12
  Testicular cancer generally affects young men between puberty and age 35 years. Successful treatment incorporates a number of modalities, including radical orchiectomy, retroperitoneal lymph node dissection, chemotherapy, and radiation. FrequencyIn the For the last 30 years, the incidence of testicular cancer has been rising steadily at a rate of 2% per year in Western countries. The reasons for this are unclear. However, it may be due to improved detection. EtiologyCryptorchidism is associated with a relative risk of testicular cancer at a rate of 3-14 times the baseline risk. Approximately 9% of patients with testicular cancer have a history of cryptorchidism. Exogenous hormones (eg, diethylstilbestrol) and genetic predisposition may play a role. Other risk factors include intratubular germ cell neoplasia, a history of contralateral testis cancer, and race. ClinicalTesticular cancer occurs in males from 3 peak age groups—boys aged 0-10 years, men aged 20-40 years, and men older than 60 years (seminoma). Of all primary testicular malignancies, 90% are of the germ cell type. The distribution of subtypes is as follows:
The differential diagnoses of a mass in the body of the testis includes germ cell tumor, epidermoid cyst, adenomatoid tumor, carcinoid, Leydig cell tumor, Sertoli cell tumor, gonadoblastoma, and tuberculosis (rarely). Testicular tumors can cause both local and distant signs and symptoms. Local symptoms include scrotal swelling, acute pain, and scrotal heaviness. Distant signs and symptoms result from metastases. The clinical presentations with the corresponding metastatic locations are as follows:
In patients who present with a testicular mass, the physical examination involves inspecting the body of the testicle and epididymis and then assessing for the presence of a mass arising from the body of the testicle. Upon palpation, testicular tumors tend to be painless, firm, and irregular masses. They do not themselves transilluminate, but they can be associated with a hydrocele that does. Perform an abdominal examination to rule out nodal disease or visceral involvement. Check for supraclavicular lymph nodes and examine the chest to rule out gynecomastia. INDICATIONSSection 3 of 12
A radical orchiectomy is indicated in the management of a suspected testicular tumor. Suspect a testicular tumor in any patient with the physical findings of a painless, firm, and irregular mass arising from the testicle. Confirm this with Doppler ultrasonography of the scrotum. Most cases of testicular tumors demonstrate hypoechoic hypervascular intratesticular lesions. Elevated levels of alpha-fetoprotein (AFP) and/or human chorionic gonadotropin (hCG) should also suggest a testicular tumor (germ cell type). RELEVANT ANATOMYSection 4 of 12
Spermatic cord The spermatic cord suspends the testis in the scrotum and contains the following:
Testis The main functions or the testicles are to produce sperm and androgenic steroid hormones, particularly testosterone. Sperm form in convoluted seminiferous tubules that empty in 20-30 tubuli rectae. These join to form the rete testis. The efferent ductules then join the head of the epididymis and, eventually, form an epididymal duct, which continues to the body and tail of the epididymis and, ultimately, forms the vas deferens. The testicle is covered by a tunica albuginea and the visceral layer of the tunica vaginalis. The visceral layer does not cover the posterolateral layer of the testicle. The arterial supply to the testicle is from the testicular artery, which arises from the anterolateral surface of the aorta and is contributed to by the vasal and cremasteric arteries. The venous system draining the testicle is composed of both deep and superficial components. The deep component consists of the pampiniform plexus, testicular vein, deferential vein, and cremasteric veins. The superficial component consists of the scrotal veins. The testicular lymphatics from the right testicle drain to the nodes of the interaortocaval zone, the right paracaval, and right common iliac. The testicular lymphatics from the left testicle drain to the nodes of the left paraaortic and infrarenal hilar zones, the right paracaval, and the right iliac. CONTRAINDICATIONSSection 5 of 12
In some patients with a testicular mass, causes other than a testicular tumor need to be excluded before radical orchiectomy is performed. For example, if a patient presents with testicular enlargement but a history consistent with an orchitis, then, obviously, antibiotic therapy would be indicated prior to surgery. Similarly, if a patient with a history of congenital adrenal hyperplasia presents with bilateral multifocal testicular masses, a frozen section biopsy would be indicated at the time of the operation to confirm that the lesions are hyperplastic nodules of adrenal rests rather than multiple germ cell tumors. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Surgical therapyDefinitive treatment of testicular cancer entails a radical orchiectomy. Preoperative detailsMeasure the serum tumor markers AFP, beta-hCG, and LDH. The serum half-lives of AFP and beta–hCG are 5-7 days and 24-36 hours, respectively; these values are clinically useful in determining when the tumor marker levels can be expected to normalize after treatment. Perform chest radiography. Abdominal and pelvic CT scanning is indicated once the diagnosis is confirmed. Administer cefazolin intravenously at a dose of 1 g 30-60 minutes prior to incising the skin if placement of a testicular prosthesis is being considered. Administer general anesthetic. Intraoperative detailsPlace the patient in the supine position. Shave the lower abdomen and scrotum. Prepare and drape the penis, scrotum, and lower abdomen. Make an incision in the skin 2 cm superior and parallel to the inguinal ligament, following the line connecting the internal and external rings (see Image 1). If the testicular mass is too large to be delivered through this incision, then the incision can be extended toward the scrotum. Continue the incision through the subcutaneous fat and the Camper and Scarpa fasciae. Identify the external oblique fibers and external inguinal ring. Incise along the direction of the fibers from the external inguinal ring. Identify and mobilize the ilioinguinal nerve and separate it so as not to resect it during the radical orchiectomy. Take the 2 leaves of the external oblique fascia with snaps and lift them anteriorly in order to dissect free the spermatic cord along its length. Isolate the spermatic cord at the pubic tubercle. Wrap a Penrose drain tightly around it and secure it with a snap to form a tourniquet. Stretch the point of entry of the cord into the scrotum with a finger and deliver the testicle into the operative site. Identify the gubernaculum and then clamp, divide, and ligate. Confirm the diagnosis with inspection. A frozen section is rarely necessary. Occasionally, the diagnosis is unclear, even when the testicle has been delivered. In cases of uncertainty, remove the testicle because the risks of replacing a testis tumor outweigh the impact of losing one testicle. Take the spermatic cord in 2 portions (a vascular portion and the vas deferens) by doubly clamping, dividing, and ligating above the tourniquet. The cord must be ligated as close as possible to the internal ring to facilitate complete removal of cord tissue in case a later retroperitoneal lymph node dissection (RPLND) is required. Leave long silk sutures on the cord to allow identification of the cord stump. Remove the testicle from the operative field and send it for pathology. Inspect the wound and, especially, the scrotum for adequate hemostasis. At this point, a testicular prosthesis may be placed into the hemiscrotum. Close the external oblique fascia and external ring in a running fashion, appose Scarpa fascia in an interrupted fashion, and close the skin. Postoperative detailsPostoperatively, the authors recommend bedrest for 24 hours, scrotal fluffs or a jock strap for 2-3 days, and resumption of routine activities after 2-3 weeks. Follow-upFollow-up depends on the type of tumor and the treatment used. Common scenarios include the following:
For excellent patient education resources, visit eMedicine's Men's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Cancer of the Testicle and Testicular Self-Exam. COMPLICATIONSSection 8 of 12
Complications associated with this procedure include the following:
OUTCOME AND PROGNOSISSection 9 of 12
Seminoma After treatment with radical orchiectomy and external-beam radiation therapy, the 5-year disease-free survival rate is 98% for stage I tumors and 92-94% for stage IIA tumors. For higher-stage disease that has been treated with radical orchiectomy followed by chemotherapy, the 5-year disease-free survival rate is 35-75%. Nonseminomatous germ cell tumors For stage I tumors, which are treated with radical orchiectomy and RPLND, the 5-year survival rate is 96-100%. For low-volume stage II disease, which is treated with radical orchiectomy and chemotherapy, the 5-year disease-free survival rate is 90%. For bulky stage II disease, which is treated with radical orchiectomy followed by chemotherapy and RPLND, the 5-year disease-free survival rate is 55-80%. FUTURE AND CONTROVERSIESSection 10 of 12
Scrotal violation Inguinal orchiectomy is the standard treatment for suspected testicular carcinoma. Scrotal violations that occur during scrotal orchiectomy, open testicular biopsy, and fine-needle aspiration may compromise the patient’s prognosis. Thus, patients with a scrotal violation often are subjected to potentially morbid local therapies. In addition, surveillance protocols usually exclude patients with scrotal violations. Much of the current bias in managing scrotal violation stems from a 1925 article by Dean, who reported a 24% local recurrence rate after simple orchiectomy.1 However, the validity of this report has been questioned, and numerous articles have suggested that scrotal violation may not necessarily confer a worse prognosis. In particular, 2 articles have addressed this issue. In 1995, Capelouto et al reviewed all published series of patients with testicular cancer in whom scrotal violation occurred.2 They then performed a meta-analysis to choose a subset on the effect of scrotal violation on patient prognosis for critical analysis. Although the local recurrence rates among the scrotal violation studies contained statistically significant differences, the overall local recurrence rates were minimal (2.9% vs 0.4%, respectively). In all groups analyzed, the rates of distant recurrence and survival were statistically similar. In 1995, Leibovitch et al published a retrospective review of 78 of 1,708 patients (4.6%) with nonseminomatous testis cancer who presented to Indiana University School of Medicine following scrotal violation.3 The overall relapse rate among patients with pathological stage A disease associated with scrotal violation was increased. The finding was exclusively attributed to local recurrences in 7.7% of cases following scrotal violation, compared with no local recurrences in patients who underwent standard radical orchiectomy. However, the overall patient survival rate was comparable to that in patients without scrotal violation. Inguinal orchiectomy and high spermatic cord ligation remain the standard of care for diagnosis and initial management of testicular cancer. Scrotal violation alone, without tumor contamination, does not impart a worse prognosis in patients with testicular cancer. In the absence of gross tumor spillage, close observation alone may be adequate management for scrotal violation. Therefore, consider local or systemic therapies only upon evidence of a local recurrence. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Jan 18, 2008 | |||||||
