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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 cycle (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:

Inguinal incision and approach to the inguinal canal. Starting from the superficial inguinal ring, split the aponeurosis of the external oblique muscle along the inguinal canal 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 transsect 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:

The spermatic cord is mobilized to the deep inguinal ring, cremasteric muscle is incised to open the spermatic cord. Identify the peritoneal sac. The testicular vessels are separated from the vas deferens, both structures are transected separately between overholt clamps. The vas deferens is ligated with 2-0 and the testicular vessels are double ligated 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 is done to expose the tunica albuginea. A 5 mm incision of the tunica at the upper pole of the testis is sufficient, the protruding testicular tissue is best sent in Stieve or Bouin solution for histological examination. Close the tunica with a 3-0 suture. The testis is now moved in the scrotal compartment and a testicular biopsy is repeated at the lower pole.

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, nerve injury 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