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Orchidectomy (Orchiectomy) — Complete Surgical Reference

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1. Overview and Terminology

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2. Indications

Radical (Inguinal) Orchiectomy

• Suspected or confirmed testicular malignancy (germ cell tumor — seminoma, NSGCT)
• Provides histological diagnosis, T-staging, tumor markers, local control
• Curative in 80–85% of clinical stage I seminoma and 70–80% of CS I NSGCT
• Contraindicated scrotal approach — alters lymphatic drainage, risks inguinal/pelvic nodal seeding

Simple Orchiectomy

• Bilateral: Androgen deprivation for prostate cancer; gender-affirming surgery (transgender women)
• Unilateral: Infected testis (abscess) refractory to antibiotics; non-viable testis (torsion, trauma); chronic orchialgia (last resort)

Subcapsular Orchiectomy

• Alternative to simple orchiectomy for castration; preserves scrotal contour and body image

Epididymis-Sparing Orchiectomy

• Castration while preserving epididymis for palpable scrotal bulk

Partial (Testis-Sparing) Orchiectomy

• Polar tumor ≤2 cm with compromised/absent contralateral testis
• Synchronous bilateral tumors
• Suspected benign lesion (up to 80% of lesions <3 cm with >6 months symptoms are benign)

Delayed Orchiectomy

• Diffuse metastatic GCT requiring urgent chemotherapy first; orchiectomy recommended after regardless of systemic response

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3. Preoperative Assessment

• α-Fetoprotein (AFP)
• β-Human chorionic gonadotropin (β-hCG)
• Lactate dehydrogenase (LDH)

• General anesthesia (most common for radical)
• Spinal/regional anesthesia
• Spermatic cord block ± conscious sedation (for simple orchiectomy)

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4. Radical Inguinal Orchiectomy — Step-by-Step

Patient Positioning and Preparation

• Position: Supine on the operating table
• Skin prep: Abdomen to above the umbilicus, mid-thigh bilaterally, genitalia posteriorly to perineum
• Draping: Expose scrotum, ipsilateral ASIS, and pubic tubercle
• Examination under anaesthesia to locate the external inguinal ring

Step 1 — Skin Incision

• A 3–5 cm curvilinear/transverse incision is made 2 cm cephalad and lateral to the pubic tubercle, extending laterally along a Langer line for 5–7 cm
• The incision follows the inguinal crease overlying the inguinal canal
• For large tumours: extend obliquely toward the scrotum (hockey-stick or rotated orientation)

Step 2 — Superficial Dissection

• Incise through subcutaneous tissue (Camper and Scarpa fasciae are visible) using electrocautery
• Superficial inferior epigastric veins may be encountered laterally — carefully manage
• Expose the external abdominal oblique aponeurosis

Step 3 — Opening the External Oblique Aponeurosis

• Sharply incise the external oblique aponeurosis along the course of the inguinal canal, from the external inguinal ring medially to a point overlying the internal inguinal ring laterally (~4 cm)
• Weitlaner or Gelpi self-retaining retractors placed for exposure

Step 4 — Identify and Protect the Ilioinguinal Nerve

• The ilioinguinal nerve runs over the anterior aspect of the spermatic cord within the canal
• Identify it prospectively, dissect it free from its investing external spermatic fascia and cremasteric musculature, and retract it out of harm's way

Step 5 — Mobilise and Encircle the Spermatic Cord (Early Vascular Control)

• Blunt dissection at the pubic tubercle to circumscribe the spermatic cord and cremasteric musculature
• The surgeon's finger passes posterior to the cord along the floor of the inguinal canal
• Caution: Avoid dissecting through the floor of the canal (risk of postoperative direct inguinal hernia)
• Encircle the cord with a ½-inch Penrose drain passed twice around and clamped with a haemostat — this provides early vascular control before any tumour manipulation

Step 6 — Testis Delivery

• The assistant gently pushes the testis from the base of the prepped hemiscrotum toward the incision
• The surgeon applies gentle traction on the spermatic cord to aid delivery
• The external spermatic fascia and cremasteric fibres are divided
• The gubernaculum is divided
• The testis is delivered intact within the tunica vaginalis into the operative field
• Isolated from the wound with sterile towels

Step 7 — Intraoperative Frozen Section (If Indicated)

• If the diagnosis is uncertain, a frozen section biopsy may be performed at this point before definitive ligation
• For testis-sparing: tumour is excised with 2–5 mm margin and sent for frozen section

Step 8 — High Ligation of the Spermatic Cord

• The cord is dissected proximal to the internal inguinal ring
• Cremasteric muscle fibres and external spermatic fascia are incised with electrocautery at this level, skeletonising the cord
• A hand-held retractor elevates the internal abdominal oblique musculature forming the lateral edge of the internal ring, revealing retroperitoneal fat
• The cord is further dissected proximally to visualise:
  • Divergence of vas deferens from spermatic vessels
  • Reflection of peritoneum overlying the cord anteromedially

Step 9 — Separate Ligation and Division

• Vas deferens is ligated and divided separately with 2-0 permanent (non-absorbable) suture
• Gonadal vessels (spermatic cord proper) are doubly ligated and divided with 0 permanent suture
• Preferred ligation with non-absorbable sutures with 1–2 cm suture tails — these act as markers for identification during subsequent retroperitoneal lymph node dissection (RPLND)
• Some surgeons drop the ligated stump into the preperitoneal space deep to the internal ring to facilitate future RPLND

Step 10 — Wound Irrigation and Haemostasis

• Irrigate the surgical field
• Achieve meticulous haemostasis
• Ilioinguinal nerve repositioned safely in the bed of the inguinal canal

Step 11 — Closure

• Long-acting local anaesthetic (bupivacaine) injected before skin closure for postoperative analgesia
• Sterile dressings applied
• Scrotal support with fluff dressings added to reduce scrotal swelling and haematoma (especially useful for first 2–3 days)

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5. Simple Orchiectomy — Step-by-Step

Incision Options

1. Transverse hemiscrotal incision within scrotal rugae (avoiding prominent vessels) — preferred for unilateral
2. Longitudinal midline incision along the median raphe — for bilateral procedure (accesses both sides through one incision)

Steps

1. Shave and sterile prep the scrotum
2. Incise through dartos fibres and tunica vaginalis
3. Deliver the testis into the wound; apply gentle traction to expose the spermatic cord
4. Identify, ligate, and divide the vas deferens with 2-0 silk ligature
5. Separate cremasteric muscle from the internal spermatic vessels
6. Ligate each bundle separately with 2-0 silk sutures (vas deferens and remaining cord)
7. Testicular prosthesis (if desired): leave gubernaculum and tunica vaginalis intact; place prosthesis inside the tunica vaginalis for natural position
8. Meticulous haemostasis
9. Dartos reapproximation: interrupted 3-0 or 4-0 absorbable suture
10. Skin closure: inject with bupivacaine; running subcuticular 5-0 absorbable suture with skin hooks at apices
11. Wound dressing: antibiotic ointment, fluffed gauze, athletic supporter

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6. Subcapsular Orchiectomy

Steps

1. Approach via scrotal incision as described for simple orchiectomy; deliver testis
2. Incise the tunica albuginea
3. Remove all testicular parenchyma (seminiferous tubules, Leydig cells) using blunt and sharp dissection
4. Leave the tunica albuginea and epididymis intact — the tunica serves as a natural prosthesis
5. Achieve haemostasis
6. Close the tunica albuginea with absorbable suture
7. Return within the tunica vaginalis; close the wound as for simple orchiectomy

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7. Epididymis-Sparing Orchiectomy

1. Deliver testis as for simple orchiectomy
2. Bring operating microscope into the field
3. Sharply dissect epididymis off the testis
4. Clamp and ligate the three major groups of epididymal vessels — superior, middle, caudal — with 2-0 silk
5. Approximate caput and cauda of the epididymis with 3-0 absorbable suture → creates ellipsoid structure
6. Insert a drain through a dependent stab wound (this is a bloodier operation than simple orchiectomy)
7. Return epididymis to tunica vaginalis; close tunica vaginalis with 5-0 Vicryl
8. Complete dartos and skin closure as for simple orchiectomy

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8. Partial (Testis-Sparing) Orchiectomy

Indications (Highly Selective)

• Polar tumour ≤2 cm, contralateral testis compromised or absent
• Synchronous bilateral tumours
• Suspected benign lesion; infertility concerns
• Contraindicated when a normal contralateral testis is present

Steps

1. Initial approach identical to radical orchiectomy (inguinal incision, early cord control with Penrose drain)
2. Deliver testis; isolate from wound with sterile towels
3. Intraoperative ultrasonography for non-palpable lesions — needle localisation before tunica incision
4. Cool testis with ice slush for 10 minutes to reduce warm ischaemia (some centres omit if resection <30 min)
5. Occlude spermatic cord with two rubber-shod vascular clamps (cord and gubernaculum)
6. Incise tunica albuginea in an avascular region under 10× magnification using a 15-degree microknife
7. Blunt dissection through seminiferous tubules with microneedle holder until mass visualised
8. Excise the mass with 2–5 mm margin of normal parenchyma using bipolar microforceps
9. Frozen-section analysis — expert pathology input required
   • Benign → preserve remainder
   • Malignant + normal contralateral testis → proceed to radical orchiectomy
   • Malignant + indication for organ-sparing → multiple random biopsies; preserve if negative margins and no intratubular germ cell neoplasia (GCNIS)
10. If preserved: clamps released; haemostasis with bipolar cautery; tunica albuginea closed with running 5-0 absorbable suture; testis returned to tunica vaginalis (closed 4-0/5-0 absorbable)
11. Wound closure: external oblique with 3-0 absorbable (running); Scarpa fascia 3-0 absorbable (interrupted); Camper fascia 3-0 absorbable (interrupted); subcutaneous 4-0 horizontal mattress; skin 5-0 subcuticular
12. Adjuvant radiation (18–20 Gy) to remnant testis historically recommended for confirmed GCT; select patients can now be observed

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9. Delayed Orchiectomy

• Diagnosis may be made via biopsy of a metastatic site or presumptively on clinical/serological grounds
• Radical orchiectomy is still recommended after chemotherapy regardless of systemic response — discordant response rates exist between the testis and other metastatic sites
• For presumed extragonadal primary: GCNIS found in up to 42% of ipsilateral testis biopsies; 5% develop metachronous testicular cancer on observation

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10. Postoperative Management

Immediate

• Scrotal support/athletic supporter for 2–3 days (reduces swelling and haematoma)
• Antibiotic ointment and gauze dressing
• Bupivacaine wound infiltration for analgesia
• Scrotal elevation

Staging After Radical Orchiectomy

• Repeat serum tumor markers (AFP, β-hCG, LDH) — trend in values guides management
• CT chest/abdomen/pelvis with IV contrast
• Note: PET and lymphangiography do not play a major role in initial staging

Pathological Examination of Specimen

• Histological tumour type and subtypes with percentages (for mixed GCT)
• Tumour size and multifocality
• Local invasion: rete testis, tunica albuginea, tunica vaginalis, epididymis, spermatic cord, scrotum
• Primary T stage (AJCC/UICC TNM)
• Lymphovascular invasion (LVI)
• Germ cell neoplasia in situ (GCNIS)
• Surgical margin status

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11. Complications

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12. Special Considerations

Testicular Prosthesis

• Can be placed at the time of radical orchiectomy (audit of 904 men confirms safety)
• For simple orchiectomy: place inside the intact tunica vaginalis with gubernaculum preserved for natural positioning

Bilateral Simple Orchiectomy

• Used for medical castration in prostate cancer — achieves castrate testosterone levels (<50 ng/dL) reliably and permanently
• Alternative to LHRH agonists; avoids injection-site reactions and compliance issues
• Consider subcapsular technique or epididymis-sparing for improved body image

Scrotal Violation (Oncological Principle)

• Leaves the inguinal portion of spermatic cord intact
• Alters testicular lymphatic drainage
• Increases risk of local recurrence and pelvic/inguinal nodal metastasis

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References (Standard Textbooks)

1. Hinman's Atlas of Urologic Surgery, 4th Edition — Elmajian DA (Ch. 117: Radical Orchiectomy); Tanrikut C, Goldstein M (Ch. 116: Simple Orchiectomy, Epididymis-Sparing Orchiectomy, Testis-Sparing Surgery); Ch. 109
2. Campbell-Walsh-Wein Urology, 12th Edition — Chs. 77 (Testicular Cancer Management, Radical/Partial/Delayed Orchiectomy), 43, 28 (Orchiectomy for Chronic Scrotal Pain)
3. Smith & Tanagho's General Urology, 19th Edition — Bilateral Orchiectomy