Orchiectomy

Radical Orchiectomy

• See Video
• Position: supine
• Preparation: abdomen above the umbilicus cranially, the bilateral mid-to-lower thigh caudally, and the external genitalia through to the perineum posteriorly
• Draping: exposure of the ipsilateral anterior superior iliac spine, pubic tubercle, and scrotum is required.
• Incision:
  • Transverse, overlying the inguinal canal, following lines of Langer (use the hair follicles as a guide), typically 3-5 cm in length
    • Use finger to invaginate scrotum and identify approximate location of the external inguinal ring.
      • The medial extent of the incision should be a few mm superior to this.
    • The internal ring will be midway between the anterior superior iliac spine and pubic tubercle, and approximately 4cm lateral to the external inguinal ring.
  • In circumstances in which a mass is too large to be delivered through the standard incision, the incision can be extended down along the anterior scrotum in a hockey-stick fashion.
• Step by step
  • General anesthesia and insertion of lines.
  • Patient positioning, antiseptic preparation, draping.
    • After induction of general anesthesia...
    • Trim hair overlying operative site, if needed.
    • Prepare surgical area and drape to expose the ipsilateral anterior superior iliac spine, pubic tubercle, and scrotum.
  • Skin incision. Use marking pen to denote external inguinal ring and a 3-5cm transverse line extending laterally from this point, overlying the inguinal canal. Make an incision with scalpel/cautery.
  • Dissect down to external oblique fascia and expose external inguinal ring. Dissect down through fat and Scarpa's fascia to expose the external oblique fascia overlying the inguinal canal. Tug on the testicle to facilitate identification of the inguinal canal. Continue to expose the external oblique fascia distally towards the external inguinal ring.
    • Recall that anterior wall and floor (inferior wall) of the inguinal canal are formed by the external oblique fascia, the roof (superior wall) by the internal oblique and transversus abdominis, and the posterior wall by the transversalis fascia.
  • Open the inguinal canal and identify ilioinguinal nerve. Use a knife to create a stab incision in the external oblique fascia in the area of the proximal cord. To release the ilioinguinal nerve, use metzenbaum scissors with closed tips pointed anteriorly to pass under the external oblique fascia from the knife incision to the external ring, staying as close to the underside of the fascia. Spread scissors when tips through external ring. Use metzenbaum scissors to extend fascial incision towards the external inguinal ring, small cuts at a time, taking care to identify and preserve the ilioinguinal nerve. Place mosquito clamp on lateral edge of external oblique fascia.
    • Mobilize nerve, if identified. The ilioinguinal nerve courses parallel to spermatic cord, typically along the cephalad aspect of its anterior surface. Dissect the nerve using Debakey forceps and metzenbaum scissors. After the nerve has been adequately dissected, replace a mosquito clamp so that nerve is protected behind the clamp.
    • Recall, ilioinguinal nerve (L1) provides sensation to anterior scrotum (or mons pubis and labium majus), root of penis, and upper medial thigh
  • Mobolize spermatic cord. When the nerve is safely displaced, use a pledget to displace the external spermatic fascia and cremasteric fibers that surround the spermatic cord. Divide these fibers as needed. If needed, place Babcock clamp around the cord to facilitate dissection. When the spermatic cord is adequately mobilized anteriorly and laterally, pass finger under cord and use sponge in contralateral hand to peel tissue medially and eventually the finger will go through. This method helps ensure that all cord structures are taken. Use a lauer to encircle the spermatic cord with a Penrose drain, wrapped twice around the proximal cord, and then apply a Kelly clamp to cut of the blood supply to the spermatic cord.
  • Deliver testicle. Divide any remaining external spermatic fascia and cremasteric fiber attachments of the spermatic cord. Use finger to develop space in the scrotum around cord and testicle. Deliver the testicle with gentle traction in the cephalad direction to draw the testicle toward the incision. Delivery of the testicle can be facilitated by applying external pressure to the ipsilateral hemiscrotum. If unable to deliver testicle, increase length of incision. Excessive force could rupture the tumour and increase the risk of local recurrence.
  • Divide gubernacular attachments. After delivering testicle, use sponge to sweep away as much gubernaculum as possible. Then, divide gubernaculum with cautery, taking care not to buttonhole the scrotum. Be liberal with hemostasis to reduce risk of scrotal hematoma.
  • Mobilize spermatic cord to the level of the internal inguinal ring. After division of the gubernaculum, mobilize the spermatic cord to the level of the internal inguinal ring until the peritoneal reflection is visualized.
  • Dissect out and vas and gonadal vessels and ligate them separately. At the level of the internal inguinal ring, use a lauer to dissect the vas deferens and gonadal vessels. Ligate and divide them separately to ensure a hemostatic tie on the vascular structures.
    • Use non-absorbable suture such as silk
    • First, tie and divide the vas deferens.
    • For ligation of the gonadal vessels, first use a heavy silk. Then use a 2-0 silk to suture ligate the cord in the area as proximal as possible in between the transected vas deferens. Pass the needle through the middle of the cord. Tie once. Bring suture around cord and tie. Leave a 1- to 2-cm suture tail on the stump of the gonadal vessels to facilitate identification at RPLND. Return this stay stump to the internal ring.
    • Individually ligating the vas deferens from the remainder of the spermatic cord facilitates retrieval of the distal spermatic cord stump during subsequent RPLND because the vas deferens is not taken as part of this specimen.
  • Divide spermatic cord. Bring towel under cord to avoid blood and tumour cell spillage. Put top end of Debakey forceps under cord. Use knife to divide cord. Take slow cuts to ensure no bleeding.
  • Deliver specimen.
  • Obtain hemostasis. Invaginate scrotum and ensure no bleeding.
  • Insert prosthesis, if needed. With clean gloves, prepare the prosthesis. Insert butterfly needle into prosthesis and fill with appropriate amount of fluid. Remove air, insert fluid, and repeat until as much air a possible is evacuated. This may require manipulating the butterfly needle, take care not to hit wall of prosthesis with needle. When prosthesis ready, deliver it into the dependent scrotum, taking care not to touch skin.
  • Closure. Reposition the ilioinguinal nerve into inguinal canal. Reapproximate external oblique fascia from internal inguinal ring to external inguinal ring using 2-0 vicryl in a running manner, taking care not to include the ilioinguinal nerve. Take small bites on fascia to prevent fascia from rolling on itself. Reapproximate subcutaneous tissue using a 3-0 vicryl in a running manner. Subcuticular closure with 4-0 biosyn/monocryl. Apply dressings.
  • Post-operative management
    • In general, scrotal support and fluff dressings are helpful to avoid unnecessary scrotal swelling and hematoma formation for the first 48 to 72 hours

Testis-sparing Surgery (Partial Orchiectomy)

• Approach is identical to the approach of a radical inguinal orchiectomy.
• Intraoperative ultrasonography can be used to facilitate localization of the mass.
• When the mass is identified, a scalpel can be used to incise the tunica albuginea overlying the mass.
  • When the approach is from the ventral midline, a vertical incision along the long axis of the testis is preferred. Otherwise, incisions localized medial or lateral to the ventral midline should be oriented horizontally to follow the course of the segmental arteries beneath the tunica albuginea.
• Once identified, the tumor is enucleated preferably with a small rim of surrounding seminiferous tubules insulating the mass. A fresh-sample is sent to pathology.
• If radical orchiectomy is not performed, the tunica is closed with absorbable suture, and the testis is placed back into the dependent portion of the scrotal compartment and secured at three points of internal fixation to the gubernaculum or medial septum of the scrotum.

Complications

Intra-operative

1. Injury to inguinal nerve

Early post-operative

1. Wound infection
2. Scrotal hematoma

Late post-operative

1. Sensory numbness over incision

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 35