Simple (Scrotal) Orchidectomy for Testicular Infarct

Indication: A non-viable testis secondary to prolonged ischemia (testicular torsion, segmental infarct from vasculitis, trauma) where salvage is impossible. Simple orchidectomy via a scrotal approach is the standard - not a radical inguinal approach, which is reserved for suspected malignancy.

Pre-operative

Consent: Include consent for unilateral orchidectomy and, if desired, simultaneous testicular prosthesis placement. Counsel the patient that the contralateral testis will also be explored and fixed (orchidopexy) if the cause was torsion.
Anesthesia: General, spinal, or regional (spermatic cord block with sedation). A full spermatic cord block alone is rarely sufficient for an acutely inflamed/infarcted testis.
Position: Supine, legs slightly abducted.
Prep: Shave and sterile prep the scrotum and perineum.

Step-by-Step Technique

Step 1 - Skin Incision

Make a transverse hemiscrotal incision within the scrotal rugae over the affected side, avoiding prominent scrotal blood vessels. Alternatively, a vertical midline incision along the median raphe gives access to both sides through a single skin incision - useful if bilateral exploration is planned (e.g., after torsion).

Transverse hemiscrotal incision - delivered testis with spermatic cord exposed

Fig. 116.1 - Transverse hemiscrotal incision (Hinman's Atlas)

Use diathermy on "cut" mode to incise, minimizing bleeding from scrotal skin vessels.

Step 2 - Layer-by-Layer Dissection and Testis Delivery

Carry the incision down through:

Scrotal skin
Dartos muscle/fascia
Tunica vaginalis (open sharply)

Deliver the testis into the wound. Inspect it - an infarcted testis is typically dark blue/black, firm, and non-pulsatile when the tunica albuginea is nicked. Apply gentle traction on the testis to expose the spermatic cord.

Step 3 - Assess Viability

If any doubt exists about viability, nick the tunica albuginea and look for bleeding. A frankly necrotic, non-bleeding testis with no arterial pulsation confirms non-viability - proceed to orchidectomy. If there is any uncertainty and the patient is young, an on-table urological consult or intraoperative Doppler is appropriate before committing to removal.

Step 4 - Separate and Ligate the Spermatic Cord

Separate the cord into two bundles:

Bundle 1 - Vas deferens:

Double-clamp proximally, single clamp distally
Divide sharply between the clamps
Place a 2-0 Vicryl (or silk) tie proximally, release the first clamp, then place a 2-0 Vicryl suture-ligature distally

Bundle 2 - Internal spermatic vessels (cremasteric vessels):

Identify and separate the cremasteric muscle from the internal spermatic vessels
Ligate each component separately with 2-0 silk sutures
Double-clamp proximal and single-clamp distal, divide, and suture-ligate

The spermatic cord separated into bundles with clamps applied - vas deferens (red) and vessels (blue) being controlled

Fig. 116.2 - Spermatic cord separated for ligation (Hinman's Atlas)

Step 5 - Remove the Testis

With both cord bundles ligated and divided, the testis and attached cord are free. Remove the specimen from the operative field and send it for histopathology (to exclude underlying tumour, which can present as infarction).

Step 6 - Haemostasis

Ensure meticulous haemostasis - inspect the cord stumps, the tunica vaginalis, and the dartos layer. Use electrocautery or additional ties as needed.

Step 7 - Optional Testicular Prosthesis

If the patient pre-operatively consented to a prosthesis, now is the time to insert it. Leave the gubernaculum and tunica vaginalis intact during the orchidectomy so the prosthesis can be placed inside the tunica vaginalis - this gives a natural position and appearance. The scrotal skin is inverted and the prosthesis is sutured to the dartos fascia internally to prevent high-riding.

Step 8 - Closure

Dartos muscle - reapproximate with interrupted 3-0 or 4-0 absorbable suture (Vicryl)
Local anaesthetic - inject wound with bupivacaine before skin closure
Skin - close in a running subcuticular fashion with 5-0 absorbable suture (Monocryl or Vicryl), using skin hooks at the apices to aid closure. Alternatively, interrupted 4-0 chromic sutures

Subcuticular skin closure with skin hooks at the apices of the scrotal incision

Fig. 116.3 - Skin hooks at apices during subcuticular closure (Hinman's Atlas)

Step 9 - Contralateral Exploration (if torsion was the cause)

If the infarct was caused by testicular torsion, explore the contralateral testis through the same midline skin incision (or a separate transverse incision). Perform a three-point orchidopexy to prevent metachronous torsion on the remaining side, even if it appears normal.

Step 10 - Wound Dressing

Dress with antibiotic ointment, dry fluffed gauze, and an athletic supporter (scrotal support) to reduce edema and provide comfort.

Post-operative Care

Item	Detail
Analgesia	Regular paracetamol + NSAID; opioids rarely needed
Scrotal support	Wear for 2-4 weeks
Activity	Avoid heavy lifting or straining for 2-3 weeks
Wound check	7-10 days
Histology	Follow up results to exclude malignancy
Hormone status	Single testis is sufficient for normal testosterone; check if bilateral

Key Decision Point: Simple vs Radical Orchiectomy

Approach	When
Simple scrotal orchidectomy	Confirmed infarct/torsion, no suspicion of malignancy
Radical inguinal orchidectomy	Any suspicion of testicular malignancy - to avoid disrupting scrotal lymphatic drainage

If there is any preoperative suspicion of tumour (solid mass, elevated AFP/beta-hCG, US findings), perform a radical inguinal approach instead. An infarcted testis can harbour an underlying germ cell tumour.

Sources: Hinman's Atlas of Urologic Surgery (Ch. 109, 116); Campbell-Walsh-Wein Urology (Ch. 83)

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