Radical orchiectomy: specialists & information

In a radical orchiectomy, the paired testicles are removed either on one side (unilateral) or on both sides (bilateral).

This surgical form of castration leads to permanent infertility (also known as "irreversible infertility"). However, the person affected can have sperm frozen beforehand(cryopreservation). This allows them to fulfill their desire to have children at a later date by means of artificial insemination.

The germinal tissue of the testicles produces most of the sex hormone testosterone. After a radical orchiectomy, the testosterone level is therefore reduced by up to 90 percent to values below 50ng/dl in the serum. In the case of bilateral orchiectomy, the patient must therefore undergo permanent testosterone replacement therapy .

The surgically removed testicle can be replaced by an implant if necessary.

When is an orchiectomy performed?

An orchiectomy is usually performed in the following cases

• for testicular cancer (radical tumor surgery for testicular germ cell carcinoma),
• as hormone deprivation therapy for advanced prostate cancer (so-called androgen ablative treatment of advanced prostate cancer),
• in the case of irreversible, i.e. irreversible impairment of testicular function,
• in men of advanced age as a last resort for regularly recurring inguinal hernias.

An orchiectomy involves the complete or partial removal of the testicles © Henrie / Fotolia

What types of orchiectomy are there?

There are generally three types of orchiectomy available. The doctor selects the surgical technique based on the individual treatment case. In detail, the orchiectomy procedures differ in their surgical approach to the testicular tissue and the extent of the tissue removed:

• the simple orchiectomy,
• subcapsular orchiectomy and
• inguinal orchiectomy.

The simple orchiectomy

Theprerequisites for a simple orchiectomy are

• a non-reversible (irreversible) disease of the testicle, but
• no malignant (malignant) cause such as cancer.

These include in particular

• a significant reduction in the size of one or both testicles as a result of torsion of the testicle (so-called testicular atrophy due to testicular torsion),
• inflammation of the testicles with accumulation of pus in the tissue (abscessing orchitis) and
• a testicle located in the inguinal canal whose position has not normalized by adulthood (so-called persistent inguinal testicle).

In a simple orchiectomy, the surgeon makes a small incision in the middle of thescrotum. He cuts through the underlying testicular sheaths layer by layer. He then removes the testicles and part of the spermatic cord before suturing the scrotum and access again.

If desired, testicular implants can be inserted during the operation. This allows the scrotum to retain the appearance of existing testicles.

The subcapsular orchiectomy

Subcapsular orchiectomy(hormone deprivation therapy) is mainly performed for prostate cancer. It serves as an alternative to drug treatment.

In almost all cases of prostate cancer, the cancer cells require male sex hormones for their growth. These are so-called androgens such as testosterone. If these sex hormones are missing as a result of treatment, the tumor can no longer grow as quickly. This slows down the progression of the cancer.

This is achieved either

• with medication known as antiandrogens or
• by removing the hormone-producing parts of the testicles as part of a subcapsular orchiectomy.

A subcapsular orchiectomy is similar to a simple orchiectomy. However, only the glandular tissue surrounding each testicle is removed rather than the entire testicle. This has the advantage that

• the testicular sheath and capsule(tunica albuginea),
• the epididymis and
• the spermatic cord

remain intact. This method does not significantly change the appearance or feel of the testicles. The patient therefore does not require an implant.

The procedure can generally be performed on an outpatient basis . First, a small incision is made in the scrotum(scrotal incision) and the testicular sheaths are opened. The surgeon then carefully removes the testicular parenchyma (germinal tissue) from the inside of the testicular capsule using a small swab or finger. He then separates the germinal tissue that is still attached to the midline using the electrocautery.

Finally, the surgeon carefully stops the bleeding and sutures the testicular capsule and scrotum.

Testicle removal by means of an inguinal incision (inguinal orchiectomy). This involves cutting the spermatic cord and removing the testicle © Cancer Research UK / Wikimedia Commons

The inguinal orchiectomy

Inguinal orchiectomy is used for testicular cancer and involves the removal of the testicles via the groin (lat. inguinal). This approach allows the testicular lymphatic and blood vessels to be checked at an early stage, while at the same time avoiding injury to the scrotum. A testicular prosthesis can also be inserted comparatively easily and with few complications via the inguinal approach.

Testicular cancer usually affects young men between the ages of 20 and 40. Those affected often make a suspected diagnosis by feeling an enlarged testicle. This can be confirmed by further medical examinations . These may include ultrasound or an analysis of blood markers, for example.

If the findings are suspicious of cancer, the testicle is surgically exposed via the groin. After a rapid histological examination, it is treated accordingly.

With this surgical technique, the surgeon first makes an incision in the groin. This exposes the blood vessels supplying the testicles and the spermatic cord and cuts them off.

In the next step, the testicle is removed from the scrotum and the suspected tumor tissue is removed while preserving the organ . The tissue is then sent to a pathologist for a histological examination(frozen section diagnosis).

If the findings are benign, the testicle is placed back in the scrotum(reduction of the testicle). If a malignant tumor is present, the affected testicle is surgically removed(radical orchiectomy).