Radical Orchiectomy and Testis-Sparing Surgery for Testicular Neoplasms

Eloka Okoye; Ahmad Hammoud; Stephen Leslie; Shady Saikali

Radical Orchiectomy and Testis-Sparing Surgery for Testicular Neoplasms

Author: Eloka Okoye Author: Ahmad Hammoud Author: Stephen W. Leslie Editor: Shady W. Saikali Updated: 9/14/2025 6:50:17 PM

Introduction

Orchiectomy is a surgical procedure that involves the removal of one or both testes. This procedure can take several forms:

A simple transscrotal orchiectomy for clearly benign disorders,
A radical inguinal orchiectomy for suspected testicular malignancies, or
An inguinal testis-sparing surgery with intraoperative frozen section analysis for smaller, benign-appearing testicular masses or nodules of indeterminate etiology in selected patients, particularly those with bilateral tumors or a solitary testis.[1][2][3][4][5][6][7][8][9][10][11][12]

Simple Orchiectomy

Simple orchiectomy is approached through the scrotum and is suitable for patients where there is no significant risk of testicular malignancy.[3] Historically, bilateral simple orchiectomies have been a popular means of permanent androgen deprivation therapy for the treatment of patients with locally advanced or metastatic prostate cancer.[13][14][15][16][17][18] This indication has, over time, largely been replaced by the less invasive hormonal medications such as gonadotropin-releasing hormone agonists or antagonists.[16][19][20][21][22]

The shift toward medical therapy as the initial hormonal treatment for prostate cancer has reduced the indications for simple orchiectomy to the removal of an atrophic or nonviable testicle due to trauma, torsion, intractable pain, abscess, or infection.[3][23][24][25][26]

Radical Orchiectomy

Radical orchiectomy uses an inguinal surgical approach that avoids potential contamination of the scrotal skin and lymphatic channels with malignant cells.[1][2][4][27] This procedure is the mainstay of diagnosing and treating known or suspected solid testicular malignancies.[1][2][[4][28][29][30][31]

Testis-Sparing Surgery

Testis-sparing surgery, also called a partial orchiectomy, is a newer approach for managing small solid scrotal masses that tries to salvage as much testicular function as possible without jeopardizing oncological control or outcomes.[1][2][3] This procedure involves an inguinal incision, externalization of the testicle and spermatic cord, vascular isolation of the cord with a tourniquet, resection of the tumor from the testis, and immediate intraoperative frozen section analysis of the resected lesion.[32] If the frozen section is negative for malignancy, in highly selected cases, the testis can be repaired and returned to the scrotum.[1][2][6][7][8][9][10][11][12][32] Otherwise, a radical orchiectomy is performed.[1][2][3][7][32][33][34][35] Testis-sparing surgery may be optimal for pediatric patients and adults with bilateral testicular tumors, psychological issues regarding loss of a testicle, male infertility, or a solitary testis.[1][2][3]

Testicular cancers are broadly classified into two main groups—germ cell tumors (e.g., seminomas and nonseminomatous germ cell malignancies) and the much less common non-germ cell tumors (e.g., testicular sex cord-stromal cancers, such as Leydig and Sertoli cell neoplasms).[28][36][37][38][39]

Germ cell neoplasms make up over 95% of testicular tumors, and over 50% are seminomas.[36][38][40][41]
In contrast, only 10% to 25% of seminomas are associated with a rise in beta-human chorionic gonadotropin (β-HCG) or lactate dehydrogenase (LDH), but no increase in alpha-fetoprotein (AFP).[38][41][42] Seminomas with elevated serum AFP are considered to have a nonseminomatous component, typically a yolk sac tumor or, less commonly, embryonal carcinoma.[36][43][44]
Nonseminomatous germ cell tumors comprise a heterogeneous group of neoplasms with different patterns that may include a combination of histologic types of seminomas and nonseminomas. Nonseminomatous germ cell tumors are frequently associated with elevated tumor markers, such as β-HCG, LDH, and AFP.[36]
Testicular sex cord-stromal tumors, including Leydig cell, Sertoli cell, granulosa cell, fibromas, and thecomas, are rarely malignant.[37][39]

Cryptorchidism and family history are risk factors traditionally associated with testicular cancer, but the relative rarity of the condition makes it hard to determine the underlying pathophysiology and to identify probable risk factors.[28][45][46]

Anatomy and Physiology

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Anatomy and Physiology

Testes are a pair of reproductive organs that are responsible for hormone and sperm production. These organs are smooth, ovoid-shaped structures located in the scrotum and separated by a fascial septum.[47] Testes are covered by a smooth, tough membrane called the tunica albuginea and are connected to the epididymis posterolaterally and to the internal scrotum through the gubernaculum.[47]

Embryologically, the testes develop from the genital ridge in the dorsal mesentery. These organs descend from the retroperitoneum through the inguinal canal to their final position in the scrotum, directed by a primordial structure called the gubernaculum. At birth, a majority of fetuses have their testes already descended into the scrotum.[48] As the testes descend, they acquire coverings from the anterior abdominal wall. These coverings of the testes include the tunica vaginalis, internal spermatic fascia, cremasteric fascia, external spermatic fascia, and the dartos muscle from deep to superficial layers. The tunica albuginea is the deepest covering of the testis, which represents the capsule of the testis and is not acquired from the abdominal wall.

The histology of the testes shows 3 main types of cells as follows:

Germ cells make up the bulk of the seminiferous tubules and produce spermatozoa.[49][50][51][52]
Leydig cells are located in the interstitium between the seminiferous tubules. These cells produce testosterone when stimulated by luteinizing hormone (LH).[49][50][53][54]
Sertoli cells are also found in the seminiferous tubules, where they are the primary testicular cells that increase spermatogenesis in response to follicle-stimulating hormone.[49][50][55] The primary function of Sertoli cells is to support, nourish, stimulate, and protect spermatogenesis.[49][50][55][56] These cells also secrete Müllerian inhibiting factor, androgen-binding protein, activin, and inhibin B.[49][57][58][59][60] Structurally, Sertoli cells provide tight junctions to the seminiferous tubules, significantly contributing to the blood-testis barrier.[49][61][62]

The blood supply to the testes is robust and well collateralized.[47][63] The major arterial blood supply is via the testicular/gonadal artery, which is a direct branch of the abdominal aorta inferior to the superior mesenteric artery.[47][63] There are 2 primary collateral arteries supplying the testicle.[47][63]

The cremasteric artery (a branch of the inferior epigastric artery) anastomoses with the lower polar branch of the testicular artery in the testis.[47][63]
The vasal artery is another major collateral arterial supply to the testis, which originates from the inferior vesical artery and merges with branches of the testicular artery in the area of the mediastinum testis.[47][63]

The cremasteric and vasal arteries can ensure that the testicle receives adequate arterial blood even if the main testicular artery is ligated, cut, or compromised.[47][63] In various surgical procedures, the testicular artery sometimes requires ligation and division, but due to the substantial collateral blood supply, there is minimal concern for vascular compromise of the testis. This principle is the basis for the Fowler-Stephens, Shehata, and similar orchiopexy techniques, which involve division of the testicular artery to increase spermatic cord length.[46][64][65][66][67][68]

The venous drainage of the testes is through the pampiniform plexus of veins in the scrotum, which coalesce to form the testicular veins.[47] The right testicular vein drains into the inferior vena cava, whereas the left testicular vein drains into the left renal vein.[47]

The lymphatic drainage of the testes is along the testicular arteries to the para-aortic retroperitoneal lymph nodes, whereas the scrotum drains through a different lymphatic pathway to the inguinal lymph nodes.[69]

Indications

Clinical Presentation

Patients with testicular neoplasms most often present with a firm, painless, solid, unilateral, intra-scrotal mass or swelling arising from the testis.[28][36][37][38] Pain or discomfort in the testis, dull ache in the groin or lower abdomen, breast tenderness, or gynecomastia may also be presenting symptoms of a testicular neoplasm.[4][28][37] Late symptoms may include weight loss, low back pain, an abdominal mass, chest pain, cough, or hemoptysis due to retroperitoneal lymph node or lung metastases.[28][70] Testicular malignancies are prevalent in males aged 15 to 35.[28][36][37][38][71]

Physical Examination

Physical examination typically shows a painless, solid testicular mass, with larger neoplasms increasing the risk of a malignancy.[28][37][39][71] Testicular malignancies are prevalent in males aged 15 to 35.[28][36][37][38][71] Smaller testicular neoplasms (<2 cm) are more amenable to a testis-sparing surgical approach.[1][2][29][72][73]

Laboratory Investigations

Laboratory investigations include serum testicular tumor markers, such as AFP, LDH, and β-HCG.[28][36][38][71] Germ cell tumors, including seminomatous and nonseminomatous types, often present with elevated serum tumor markers; however, this finding is not definitive.[28][36][37][38][71] LH and testosterone levels should be assessed for patients being considered for testis-sparing surgery.[7]

Imaging

Ultrasonography: Ultrasonography is very sensitive in the early identification of testicular tumors, with over 95% of parenchymal lesions visible and over 90% sensitivity and specificity.[6][71][74][75] Typical findings include a well-defined, solid, vascular hypoechoic intratesticular mass, which is frequently homogeneous.[6][71][74][75][76][77][78][79][80][81][82] However, some tumors may have a heterogeneous appearance with necrotic, hemorrhagic, cystic, or calcified areas.[6][71][74][75][76][77][78][79][80][81][82] Keep in mind that ultrasonography tends to overestimate the diameter of the tumor and underestimate the size of the remaining residual testicular parenchyma due to the compression of normal tissue against the capsule of the neoplasm, creating a rim.[83]

Color Doppler and contrast-enhanced ultrasonography: Both these techniques often show increased vascular flow within the neoplasm and may indicate the presence of a feeder vessel.[6][78][80][81][82][84][85][86] Any vascularized testicular mass should be considered potentially cancerous, with up to 98% ultimately considered as malignant.[76][87] Elastography may also help differentiate benign from malignant testicular neoplasms.[88][89][90][91][92][93][94] Conversely, Leydig cell tumors, which are overwhelmingly (95%) benign, constitute about 22% of all impalpable testicular neoplasms detected on ultrasound.[37][95]

Magnetic resonance imaging: Magnetic resonance imaging (MRI) may also be selectively used in borderline or equivocal cases where findings could influence surgical decision-making, such as in patients being considered for possible testis-sparing surgery.[74][76][93][96][97][98][99][100][101][102][103][104][105][106][107][108] The minimum recommended criteria for an MRI of the testicle include axial T1-weighted imaging, axial and coronal T2-weighted imaging, axial diffusion-weighted imaging, and coronal subtracted dynamic contrast-enhanced imaging.[100][108] Testicular malignancies tend to show more heterogeneous enhancement and a lower apparent diffusion coefficient than benign lesions.[100][102][104][105][107][108][109] Computed tomography (CT) scans of the abdomen and pelvis are useful for preoperative staging but do not differentiate benign from malignant testicular neoplasms.[100][107][110]

A scrotal MRI is indicated in the evaluation of small testicular neoplasms in the following situations:[29][100][102][104][111]

When ultrasonography findings are ambiguous, equivocal, or inconclusive (benign versus malignant) in a patient who is a candidate for testis-sparing surgery.
For improved evaluation of possible tumor invasion of surrounding structures and the contralateral testis.
To help determine the staging and extent of the testicular mass in patients considered for testis-sparing surgery.
In patients being considered for testis-sparing surgery, impalpable neoplasms, or when ultrasonographic findings are inconclusive.
In cases of Suspected Leydig cell tumor, which is markedly hypointense on MRI and overwhelmingly benign.[95][112]
When MRI findings alter the planned surgical approach or treatment.

The European Federation of Societies for Ultrasound in Medicine and Biology guidelines recommend contrast-enhanced ultrasonography for the differentiation of testicular neoplasms.[6][28][78][80][81][82][84][85][86] Contrast-enhanced ultrasonography can demonstrate increased microvascularization of testicular lesions, where hyperenhancement is an indicator of malignancy.[86][113][114][115] This technique can also be helpful to confirm the lack of increased or abnormal vascularity in complex benign lesions and epidermoid cysts.[6][28][78][80][81][82][84][85][86] Elastography and MRI may also be used selectively in equivocal cases where testis-sparing surgery is being considered, and serum tumor markers are negative.[100]

Differential Diagnosis of Intratesticular Masses

The differential diagnosis for intratesticular masses includes the following:[75][76][82]

Abscesses, granulomas, hematomas, infarcts, and scars (fibrosis), but these lesions appear avascular.[116][117]
Adrenal rests is only found in congenital adrenal hyperplasia.[118][119][120][121][122]
Chronic granulomatous orchitis, fibrous pseudotumors, lipomas, hamartomas, and sarcoidosis can mimic testicular neoplasms.[123][124][125]
Epidermoid cysts are easily differentiated due to their characteristic ultrasonographic features.[30][72][73][30][126][127]
Epididymo-orchitis tends to present more aggressively with pain, swelling, tenderness, and warmth than testicular cancer.[25][31][128] Other signs of infection may also be present.
Granulomatous, tuberculous, and BCG epididymo-orchitis can be difficult to differentiate from testicular malignancies.[129][130] The associated clinical history may provide clues to the correct diagnosis.
Hydroceles and spermatoceles have a markedly different appearance on ultrasound, with characteristic fluid-filled structures.[74][84][131][132][133][134][135]
Inguinal hernias can be diagnosed clinically with a focused physical examination.[136] On ultrasonography, they appear as structures with fat or bowel contents separated from the spermatic cord.[137][138]
Primary testicular lymphoma is a consideration, particularly in men older than 60 with bilateral testicular masses.[4][139]
- Chemoradiotherapy is used for systemic disease, based on lymphoma guidelines for extratesticular neoplasms.[4][139][140][141]
- Even if lymphoma is suspected, treatment is a radical orchiectomy, as chemotherapy is relatively ineffective due to the blood-testis barrier.[4][139][142]
- The contralateral testis is a common site of relapse.[4][139][143]

Testicular sex cord-stromal tumors.[37]
Testicular torsion has a different clinical presentation with significant acute pain and markedly decreased vascular flow on color Doppler ultrasonography.[26][144]

Indications for Radical Orchiectomy

Indications for a radical orchiectomy include both clinical and biochemical suspicion for any solid testicular neoplasm, as it remains the gold standard for managing testicular tumors of uncertain etiology.[1][2][4][29][145] This procedure provides tissue for a definitive histopathological diagnosis, aids in staging, and is curative for most patients (over 80% of men with clinical stage I testicular seminoma, 70% of men with nonseminomatous germ cell tumors, and more than 90% with sex cord-stromal tumors).[4][27][36][37][38]

Indications for Testis-Sparing Surgery (Partial Orchiectomy)

Indications for testis-sparing surgery (partial orchiectomy) are quite strict, as there is a risk of incomplete resection or a misdiagnosis resulting in the need for a subsequent salvage radical orchiectomy. In general, testis-sparing surgery is not recommended by guidelines for the vast majority of equivocal or suspected malignant testicular neoplasms. However, it may be considered a viable option for selected patients with small intrascrotal masses, particularly in cases where there may be psychological issues with losing a testicle, or preserving fertility and testicular hormonal function is a priority, such as patients with pre-existing infertility, hypogonadism, or Klinefelter syndrome.[1][2][29][126][127][146][147] These indications and criteria include the following:[1][2][7][29][126][127][146][147][148]

Bilateral testicular neoplasms.
High-quality intraoperative frozen section evaluations, by an experienced genitourinary pathologist, should be available.
Imaging is equivocal or benign appearing without malignant features (ultrasound and MRI).
Negative tumor markers for testicular germ-cell cancers (AFP and β-HCG).
Normal contralateral testis (except for bilateral synchronous tumors or a solitary testicle).
Normal preoperative LH and testosterone levels.
Prepubertal testicular masses.
Small testicular masses (<2 cm).
Solitary testicle (acquired, congenital, or functional).
Sperm banking and a possible testicular prosthesis implantation should be discussed with the patient and determined before surgery, even if a testis-sparing approach is planned.
The size of the testicular tumor is no more than 50% of the total testicular volume (<30% is optimal).[149]
The patient fully understands and accepts the following conditions:
- A radical orchiectomy is performed if the frozen section is suspicious or inconclusive for malignancy.
- Multiple biopsies of the remaining ipsilateral testicular parenchyma may be performed (recommended).
- If the final pathology is consistent with a testicular malignancy, a salvage radical inguinal orchiectomy should be performed.[146]
- There is a higher risk of a local recurrence in testicular malignancies, as high as 26%, and long-term data on the oncological effectiveness of testis-sparing surgery are limited.[148]
- Regular follow-up physical examinations and scrotal ultrasonography are necessary.
- There is still a risk of postoperative testicular atrophy, infertility, and the possible need for supplemental testosterone therapy, particularly in patients with preoperative subfertility, hypogonadism, or Klinefelter syndrome.

Guidelines and Considerations for Testis-Sparing Surgery

Testis-sparing surgery may be considered in selected patients with small testicular malignancies if the neoplasms are ≤2 cm in size and present as synchronous bilateral tumors or in a solitary testicle, according to the European Association of Urology guidelines.[29] The European Association of Urology guidelines do not recommend testis-sparing surgery for patients with a likely malignancy, even if ≤2 cm in size, if the contralateral testis is normal.[29]

Patients should be aware that radiation therapy may be required if biopsies of the residual testicular parenchyma show the presence of carcinoma in situ (CIS) (reported in 84% of such patients), which progresses to invasive disease without further treatment.[29] Radiation therapy should be performed if the histology from the biopsies shows evidence of CIS in the residual testicular parenchyma. However, adjunctive radiation therapy is recommended after testis-sparing surgery for germ cell malignancies regardless of the biopsy results.[29][150][151][152]

More than 80% of patients with germ cell testicular cancers who undergo testis-sparing surgery are found to have CIS in their remaining testicular parenchyma.[153] Patients should be informed of the effect of radiation therapy on spermatogenesis and testosterone production, as well as the possibility of testicular atrophy, hypogonadism, and infertility.[29][151][152]

According to the American Urological Association guidelines, testis-sparing surgery is not recommended for patients with small testicular malignancies if the contralateral testis is normal, as radical inguinal orchiectomy remains the standard of care.[1][2]

Pediatric Testicular Tumors and Surgical Approach

Pediatric testicular tumors may be treated selectively with testis-sparing surgery, particularly in prepubertal males.[154][155] Testicular tumors are rare in children and account for only 1% to 2% of all childhood neoplasms.[156] Most of these tumors in prepubertal boys are nonmalignant teratomas (50%), which are much more benign than in adults and not associated with CIS, so testis-sparing surgery is reasonable and recommended.[150][154][157] A yolk sac tumor (15%) is the most common prepubertal testicular malignancy, which almost always (95%-98%) presents with an elevated serum AFP.[150][158][159][160] Other common benign tumors include epidermoid cysts (15%) and sex cord-stromal tumors (10%).[150][158]

Young post-pubertal male individuals are substantially more likely to have a malignancy, so testis-sparing surgery is not routinely indicated, and they typically undergo a radical orchiectomy, which remains the gold standard.[155] However, patients with localized testicular neoplasms with negative tumor markers and imaging may be considered for testis-sparing surgery, as the majority of these lesions are benign, and the effects of an orchiectomy in such young patients should be considered. If testis-sparing surgery is performed, an intraoperative frozen section analysis is mandatory, along with long-term follow-up to monitor growth, sexual development, late recurrences, and psychological health.[150][154][161]

Unnecessary orchiectomies can be prevented in the pediatric age group with proper evaluation and management of testicular neoplasms.[150] Preoperative scrotal ultrasounds with selective color Doppler, contrast-enhanced ultrasonography, elastography, and MRI, along with serum tumor markers and intraoperative frozen sections, allow testis-sparing surgical procedures to be safely performed for smaller lesions, with adequate safety margins and the maximum preservation of testicular parenchyma to maintain hormonal levels and postoperative spermatogenesis.[154][158][162][163][164] The majority of solid testicular tumors in post-pubertal males are malignant; therefore, radical orchiectomy remains the standard of care, although testis-sparing surgery with intraoperative frozen sections may be considered in select cases.[150]

Contraindications

A simple transscrotal orchiectomy is not indicated for any intrascrotal surgery where there is any reasonable suspicion or possibility of a testicular malignancy.[1][2][3][29][126][127]

Such transscrotal surgeries are only performed for obvious and clearly benign conditions, such as an acute testicular torsion, hydrocele, spermatocele, varicocele, or traumatic injury. This limitation exists because transscrotal incisions can disrupt the natural lymphatic drainage pathways, exposing isolated scrotal tissue and its lymphatics to possible malignant cells released from surgical manipulation of the testicle and potentially increasing the risk of spreading the cancer and local recurrences.[1][2][4][27]

Testis-sparing surgery is not a good choice for patients who are not likely to be compliant with mandatory follow-up, especially for small testicular malignancies. This procedure should optimally be performed in high-volume centers where experienced genitourinary pathologists are available to perform the critical frozen section examinations. Testis-sparing surgery should not be performed without reliable frozen section pathological support.[32]

There are no specific contraindications to these surgeries except for an active infection, uncorrected coagulation disorders, and anesthesia considerations.

Equipment

The procedure is performed in the operating room, and standard equipment for abdominal surgery is needed. Bipolar diathermy may be more appropriate in controlling hemostasis in the inguinal canal, as this reduces injuries to the ilioinguinal and genitofemoral nerves. A cord ring or Penrose drain can help separate the cord and its contents from other structures in the inguinal canal.

Surgical loops or an operating microscope and intraoperative ultrasonography facilitate testis-sparing surgery, particularly for impalpable lesions.[165][166][167][168]

Personnel

Radical orchidectomy requires a urological surgeon, at least an assistant, a scrub nurse or technician, and an anesthetist to administer the anesthesia. As with other open surgical procedures, the standard operating room support staff is also needed.

Testis-sparing surgery requires the availability of intraoperative frozen section procedure and an experienced genitourinary pathologist.

Preparation

Preoperative preparation involves optimization and management of comorbidities, which may include cessation of medications such as anticoagulants and antiplatelet drugs. A period of fasting is advisable, as appropriate.

Patients being considered for testis-sparing surgery should be thoroughly counseled about the risk of residual disease or positive margins, the limitation of frozen section examinations, conversion to a radical orchiectomy if the frozen section is equivocal or suspicious, the possible need for radiation therapy if CIS is discovered, and the necessity for long-term monitoring and follow-up examinations.[1][2][7][29][126][127][169]

All patients undergoing orchiectomy should have a thorough preoperative discussion about sperm banking (due to the potential for postoperative infertility) and the elective placement of a testicular prosthesis.[1][2][29] Patients with testicular prosthesis placement at the time of the orchidectomy have reported high satisfaction rates.[170][171][172][173][174][175][176]

Despite evidence of high patient satisfaction, safety, and low complication rates, only 53% of urologists report they always discuss the option of testicular prosthesis placement with the patient before surgical orchiectomy.[177]
The most commonly stated reasons for not discussing testicular prosthesis placement include possible delays in starting chemotherapy (41%), infection risk (33%), expected problems with cosmesis (17%), and lack of prosthesis availability (17%).[177]

All patients identified with a testicular tumor should have a full work-up in addition to the ultrasound scan, which includes tumor markers (AFP, LDH, and β-HCG), a baseline serum LH and testosterone, and a CT scan of the chest, abdomen, and pelvis.[178] Testis-sparing surgery may be considered in appropriately selected patients with small neoplasms, negative tumor markers, and no evidence of malignancy on imaging.[1][2][7][29][126][127] Contrast-enhanced ultrasonography, color Doppler imaging, elastrography, and MRI should be used preoperatively as necessary to help differentiate benign from malignant testicular neoplasms.[8][82][89][101][102][103][167][168][179][180]

A detailed, properly signed, and witnessed informed consent form should be obtained, preferably in the clinic, before the day of the procedure. On the day of surgery, the patient should have a physical re-examination, and the correct side should be clearly marked with a permanent surgical marker and verified by the patient as well as members of the surgical team.[181] Appropriate preoperative antibiotics should be administered.

Technique or Treatment

As a sterile aseptic procedure, preparations should follow all the rules and protocols for standard open surgeries. Once the patient arrives in the operating room, the standard preoperative checklist and time-out protocols should be completed. On the operating table, the patient is positioned supine and administered regional or general anesthesia. Regional anesthetic is not commonly used due to the expected length of the procedure and the possible reflex produced from significant intraoperative traction on the spermatic cord and testicle.[4]

Routine shaving, cleaning, and prep are done on the ipsilateral inguinal and lower abdominal areas with appropriate surgical scrub and antiseptic solutions. The surgical zone is isolated with a sterile drape, exposing the inguinal region and ipsilateral hemiscrotum, with the penis tucked under the drape and out of the field.[4] A scrotal approach has been deemed unacceptable because of the potential for spreading tumor cells to previously isolated, unexposed scrotal tissues and lymphatics, as well as the increased risk (2.5%) of local recurrence.[1][2][4][171][182][183][184]

Incision

The standard oblique inguinal incision starts just over the internal inguinal ring and extends to a point about 2 cm above and lateral to the pubic tubercle, following Langer's lines parallel to the inguinal ligament.[4][185] The use of a finger extended through the scrotum from the outside and up to the external ring can identify its exact anatomical location and assist in selecting the optimal location for the incision.

A transverse groin skin crease incision aligned with Langer's lines yields the best postoperative cosmetic results.[186][187][188] However, the traditional oblique incision should be considered for larger testicular masses, as it can easily be extended inferiorly towards the scrotum if necessary to avoid tearing of the skin, excessive traction on the spermatic cord, unnecessary manipulation of the testicle, spillage of tumor cells, and possible rupture of the testis.[4][185] The length of the incision varies between 3 and 10 cm, depending on the size of the testicular mass.[4][189][190] A subinguinal orchiectomy has been used in the last few years, allowing for a smaller incision, more rapid recovery, and fewer complications.[5]

Dissection

The fatty tissues overlying the inguinal canal can be bluntly dissected with Scarpa's fascia easily perforated with a Kelly clamp, and then dilated. The external oblique fascia is easily recognized due to its tough nature, white color, and oblique parallel fibers. The fascia should be bluntly cleaned of superficial fat sufficient to provide clear visualization of the area over the inguinal canal, which extends from the external ring and follows in the direction of the external oblique fascia's fibers to the internal ring; a length of about 4 cm.[4]

The iliolumbar and deep circumflex iliac veins are located close to the inguinal canal, with the deep circumflex iliac veins just 2 cm above the inguinal ligament.[189][191] Care should be taken to avoid injury to these vessels, which require ligation if damaged.

The external oblique fascia is carefully opened just above the inguinal canal. Opening the external oblique fascia can be performed with a short, careful superficial incision using a scalpel in the middle of the canal or by starting at the external ring and sharply opening the fascia with scissors in the direction of its fibers. Care should be taken to angle the tip of the scissors upwards to avoid any possible injury to the spermatic cord or ilioinguinal nerve immediately beneath.[4][192] The nerve should be carefully and delicately dissected free of the spermatic cord and cremasteric fibers and either be divided or, preferably, sequestered laterally behind a hemostat on the edge of the fascia.[4][193] If the nerve is injured, it may cause altered sensation in the groin and inner thigh, chronic pain, or numbness.[192][194]

The spermatic cord may now be bluntly dissected free from the surrounding tissues inside the inguinal canal using fingers, 4 × 4 sponges, and surgical peanuts. Once passage is achieved underneath the cord, a Penrose drain may be passed for traction. Care should be taken to avoid inadvertent perforation through the floor of the inguinal canal, as it increases the risk of a direct hernia developing postoperatively.[4]

In a radical orchiectomy, when the spermatic cord is dissected free to the internal ring, the Penrose should be double wrapped around the cord close to the internal ring, tightened, and clamped to act as a tourniquet and prevent any possible inadvertent hematogenous spread of tumor cells if the testicular lesion proves to be malignant.[4] In testis-sparing surgery, the use of a tourniquet is optional, as some experts feel there is a risk of possible vascular injury to the testicle's blood supply. However, a Penrose can still be used for traction and help in delivering the testicle.[153][195]

Delivery

The testicle and its coverings can now be delivered from the scrotum through the inguinal incision. Traction on the spermatic cord, external pressure on the scrotum, and careful, methodical blunt dissection can free up all the remaining testicular attachments. However, the distal gubernaculum may need to be clamped and divided.[4] Care should be taken to avoid or perforate the scrotal skin, which gets tented upwards with traction on the cord.[4] One or two fingers pressing externally from outside the scrotum through the dimple and towards the inguinal canal can help in identifying the exact location of the scrotal skin, preventing inadvertent perforations when freeing up the testicle from the gubernaculum.

The freed testicle and spermatic cord are now fully delivered externally, and electrocautery is used for hemostasis. The surgical field can now be draped off with towels, leaving just the freed spermatic cord and testicle exposed.

At this stage, the 2 procedures differ in their technique and are described separately.

Radical Orchiectomy

Spermatic cord division, ligation, and prosthesis placement: The spermatic cord is then ligated and cut using a 3-clamp technique, with 2 clamps placed proximal to the Penrose tourniquet and 1 distal.[4] The proximal spermatic cord should be divided into 2 distinct corded structures—the vas deferens and the gonadal vessels—which are clamped or ligated individually. This approach not only makes the ligation less bulky and more secure but also facilitates the identification and removal of the spermatic cord stump if a retroperitoneal lymph node dissection is performed.[4][185]

Nonabsorbable suture ligatures are recommended to minimize the risk of a catastrophic ligature failure after the cord stump has retracted intraperitoneally, which requires a laparotomy to identify and tie off the bleeding vessels.[4]

If previously discussed and agreed upon, a testicular prosthesis may be inserted and anchored at this stage. Hemostasis should be meticulously achieved, and the wound irrigated thoroughly. Placing a Foley catheter in the most dependent part of the scrotum and blowing up the balloon is a common technique for estimating the volume of the testicular prosthesis to be used. The scrotal skin is then inverted, and the selected prosthesis can be sutured internally to the Dartos fascia, which permits a good cosmetic result while preventing inappropriate elevation (high-riding) of the prosthesis.[190]

In the event of inadvertent tumor spillage, copious rinsing of the wound with sterile water is required, followed by postoperative adjunctive therapy with chemotherapy or radiation.[4][185]

The wound is irrigated, hemostasis is verified, the ilioinguinal nerve is released and gently placed on the floor of the inguinal canal, and the incision is closed in layers, starting with the external oblique fascia.[196][197]

Testis-Sparing Surgery

Testis-sparing surgery can be challenging, especially for impalpable neoplasms. The goal is to remove all neoplastic tissue while preserving as much healthy testicular parenchyma as possible.[4][7] The remaining testis tissue needs to function normally without atrophy or fibrosis.[7][32] Achieving this requires skill, experience, careful planning, ideally the use of magnification loupes or a surgical microscope, and possibly intraoperative ultrasonography for impalpable lesions.[4][7]

Preparation of the testicle: Testis-sparing surgery should be performed using the same incision, spermatic cord exposure, and testicular delivery as for a radical orchiectomy to avoid any violation of the scrotum in the event the procedure needs to be converted to a radical orchidectomy.[1][2][4][169][171][182][183][184]

The delivered testicle should be moved away from the incision and placed on new sterile drapes to avoid any potential contamination if the neoplasm is determined to be malignant.[198]

Tourniquet and/or ice bath: The traditional approach is to use a tourniquet as in a radical orchiectomy, but there is a concern regarding ischemic damage or injury to critical testicular vasculature.[153][195] Some experts recommend cold ischemia (placing the testicle in a normal saline ice bath or slush for 5-10 minutes after application of the tourniquet), but others disagree, and these issues remain controversial.[166][153][197][199][200][201][202] Animal studies indicate that ice baths can help preserve germinal epithelium, but it is unclear if this is beneficial in humans if the tourniquet (ischemia) time is less than 1 hour.[199][203][204] If a tourniquet is used, it should optimally be limited to no more than 30 minutes, as changes to the Sertoli cells have been noted if the ischemia time is longer.[195]

Opening the tunica vaginalis: The tunica vaginalis is opened using an anterior transverse incision by scalpel over the neoplasm in an avascular plane.[166][169][205][206]

Intraoperative ultrasonography or surgical microscopy may now be used to identify and localize the neoplasm if it is not palpable.[4][153] Some experts recommend the routine use of intraoperative ultrasonography unless the lesion is clearly palpable.[199] Intraoperative, ultrasound-guided localization is described.[199][207][208][209] In general, this consists of placing a 30-gauge needle immediately adjacent or directly into the lesion to facilitate its identification, particularly for impalpable neoplasms.[199][207][208][209] A high-frequency (6-15 MHz) linear ultrasound probe is suggested. Dissection should then follow the needle directly to the neoplasm, minimizing unnecessary damage to the surrounding normal tissue.

Use of an operating microscope is recommended if the equipment is available and the surgeon is experienced in its use.[7] Magnification between ×10 and ×25 is typically used.[7][206] Although most useful for impalpable testis neoplasms, microscopy offers several other advantages.[7][165][166][208][210] Microsurgery is the best modality for identifying blood vessels, minimizing bleeding, and preserving the maximum amount of normal testicular tissue in testis-sparing surgery.[208][210] This surgical technique also facilitates the complete removal of all neoplastic tissue.[7][208][210] Overall, it tends to reduce the risk of postoperative atrophy, hypogonadism, and infertility.[165][166][206] Therefore, using an operating microscope is recommended for testis-sparing procedures when possible, as it facilitates complete removal of the tumor and avoids unnecessary injury to the vascular supply.[165][166][205][206][208][211]

Removing the neoplasm: The lesion is typically separated easily from the surrounding testicular tissue by enucleation due to the frequent presence of a pseudocapsule.[4][7][150][212] If this is not possible, it may be sharply excised.[150] Difficulty in extracting the neoplasm suggests a malignancy with possible involvement of adjacent structures.[7][213] Multiple biopsies (at least 4) from the surrounding normal testicular tissue should also be taken to identify any in situ germ cell neoplasia or CIS.[1][2][29][212][213][214] In addition to enucleation or resection of the primary neoplasm, a 2 to 5 mm tissue margin surrounding the lesion should also be resected, scraped away, or removed.[4][153] A biopsy of the tumor bed is also recommended.[215][216]

The gross appearance of the lesion after removal is sometimes helpful. If the neoplasm has well-demarcated margins and a golden-brown color, a Leydig cell tumor is likely, while a whitish colored neoplasm suggests seminoma.[4][37][38]

Frozen section: The neoplasm, additional biopsies from the tumor bed, and the marginal tissue should be sent for frozen section examination to identify any suspicious histology, CIS, and involvement of the surgical margins.[4][7][213] Fortunately, intraoperative frozen section analysis is highly reliable, with a positive predictive value of 98% to 100% and <1% of malignant tumors being initially misread as benign.[4][33][217][218]

If the frozen section histology indicates a benign lesion with negative margins, the testis is salvageable and can be safely returned to the scrotum.[2][146] A repeat examination of the testis using an ultrasound or microscopy is recommended before closure of the tunica to ensure that all neoplastic tissue has been successfully removed.[199] Bleeding should be controlled through meticulous hemostasis using cautery; the incision in the testis should be irrigated, the defect in the tunica albuginea closed with a small running absorbable suture, the tourniquet released (if present), and the testicle carefully replaced in the scrotum, taking care to avoid twisting of the cord.[4][7][219] The wound is then repaired in the same manner as the radical orchiectomy procedure described previously.

If the frozen section is positive, suspicious, or even indeterminate, a radical orchiectomy should generally be performed. When agreed upon preoperatively, a testicular prosthesis may be inserted. Patients should be thoroughly counseled and prepared for both possibilities.

Complications

The complication rate for radical inguinal orchiectomy is low, with an overall incidence of 2.6%.[4][220][221] Bleeding and hematoma formation may occur in 2% to 5% of patients, deep vein thrombosis in <1%, infection in about 1% to 2%, and ilioinguinal nerve injury in <1%.[4][220][221] These complications are generally mild and easily managed with appropriate treatment.[4]

Complications specifically associated with testis-sparing surgery may partly reflect poor patient selection and improper surgical technique in inexperienced centers.[178] The overall complication rate for testis-sparing surgery is described as low, with reported rates of 1% to 6%.[7][153][222] The most frequently reported complications include bleeding, hematoma formation, infections, and testicular atrophy.[7][153][222]

Commonly reported complications include the following:[4][7][153][185][222][223]

Bleeding and hematoma formation.
CIS is frequently (>80%) found in patients with malignant testicular tumors who undergo testis-sparing surgery. Postoperative radiation therapy is required, which can cause testicular atrophy, Leydig cell dysfunction, hypogonadism, and infertility, especially in a solitary testis.
Damage to the ilioinguinal nerve can cause paraesthesia or numbness on the patch of skin on the medial part of the upper thigh and the anterior part of the scrotum, or predispose the patient to a direct inguinal hernia (<1%) due to weakness of the posterior inguinal wall muscles.
Deep vein thrombosis.
Early, vigorous handling of the tumor or late application of the spermatic cord tourniquet can increase the risk for local recurrence and metastatic spread.
Excessive primary hemorrhaging may occur intraoperatively due to injury to the inferior epigastric vessels, which lie medial to the internal ring. Fortunately, this is quite rare.
Final pathology indicates a malignancy in a patient who received testis-sparing surgery. These patients need a salvage radical orchiectomy. Fortunately, frozen sections are quite excellent at identifying malignancies, so this is quite rare.
Hypogonadism is an uncommon postoperative complication, occurring in approximately 0.5% of patients within one year following surgery.[219]
Infertility or subfertility may develop in 20% of patients who become oligospermic and 5% azoospermic.
- This may partly be due to excessive handling of the vas deferens, which can cause vasitis and vasal obstruction, contributing to infertility.[195]

Large hematomas may rarely require surgical investigation and clot evacuation.
Postoperative pain is reported in up to 60% of patients initially, with about 1.8% continuing to experience pain 1 year later.
Phantom testicle syndrome may begin 2 months after surgery and is chronic in about 25% of patients.
Psychological issues related to the loss of a testicle can be mitigated by the early use of a testicular prosthesis.
Residual tumor (positive margins) may be left behind on final pathological review.
Testicle viability may be an issue after testis-sparing surgery, with atrophy reported in 3% to 5% of patients.[219]
Testicular prostheses are sometimes associated with contractures, infection, malposition, patient dissatisfaction, prosthesis relocation, retraction, rupture, or scarring.[4][224]
Scrotal edema or hematoma may occur following extensive scrotal dissection in delivering large tumors and may require management with scrotal support, analgesia, and anti-inflammatories.
Wound complications may include infection (1%), extensive bruising, seromas, or a scrotal hematoma (1%-2%). Most resolve without any intervention, but very few may require surgical exploration, aspiration, evacuation, or other treatment.

Clinical Significance

Testicular cancer is a rare malignancy, accounting for about 1% of all malignancies in the male population. However, it remains the most common solid organ malignancy in young males aged 15 to 35.[225] Early diagnosis significantly improves cure rates.[45]

Testis-sparing surgery preserves testicular hormonal function in about 80% to 90% of patients, and about 50% can achieve paternity.[7] The low reported recurrence and complication rates indicate that testis-sparing surgery is safe, effective, and produces satisfactory oncological control.[7]

Lymphatic drainage of testicular cancer follows the gonadal arteries to the para-aortic, interaortocaval, and infrarenal groups of retroperitoneal lymph nodes. In contrast, drainage of the scrotum is to the inguinal lymph nodes.[69][226][227]

This disparity in the drainage of these very closely related structures influences the importance of an entirely inguinal approach to delivering testicular cancers to prevent surgically violating the scrotum, interfering with the normal lymphatic drainage patterns, increasing local recurrence rates, and risking upstaging of the tumor.[1][2][4][27] Transscrotal testicular biopsies are absolutely contraindicated for the same reason.[228] Small indeterminate testicular masses without risk factors can sometimes be followed by active surveillance using scrotal ultrasound, although exact timing intervals have not been determined.[6]

Histological reports indicate that about two-thirds of patients with solid testicular masses ≤2.5 cm and negative serum tumor markers have benign lesions.[8] These findings suggest that testis-sparing surgery can be performed more frequently to avoid many unnecessary orchiectomies.

Despite clear and growing indications as well as recommendations in published American Urological Association and European Association of Urology guidelines, testis-sparing surgery is still performed infrequently. Factors limiting its widespread use include inadequate training and experience with the technique among most practicing urologists, lack of confidence in intraoperative frozen section analysis, unavailability of an experienced and trusted genitourinary pathologist, a recommendation that these complex procedures be performed in high-volume tertiary care centers of excellence, and the requirement for intraoperative ultrasonography and surgical microscopy skills for impalpable lesions.[4][7][223][229]

Large-scale prospective studies with long-term follow-up are required to verify the effectiveness, durability, and oncological safety of testis-sparing surgery, as well as to update the patient selection criteria for the procedure.[206] Until then, inguinal radical orchiectomy remains the gold standard of care for most patients with testicular neoplasms.

Testis-sparing surgery is a reasonable option for males with small, solid testicular neoplasms, as frozen section procedure is highly reliable in detecting malignancies intraoperatively, conversion to a radical orchiectomy does not appear to negatively affect oncological outcomes, and appropriate adjuvant treatment (radiotherapy) provides excellent control if germ cell CIS is detected in the residual parenchymal biopsies.[195][206]

Enhancing Healthcare Team Outcomes

Once a primary care physician or pediatrician suspects testicular cancer or identifies a suspicious solid testicular mass, the patient should be referred to a urologist. In some cases, patients can undergo evaluation at one-stop clinics offering direct access to a testicular ultrasound. A testicular ultrasound should optimally be performed prior to the urology visit, if possible. A large cohort study involving 1757 patients who attended a one-stop testicular clinic in a University hospital in the United Kingdom showed that the median waiting time to be seen was 9 days compared to 13 days for general patients. The time from clinic to orchiectomy was 5 days, with the benefits of the discovery of subclinical cancers, timely diagnosis, early treatment, reduced patient anxiety, and rapid reassurance of patients with benign results.[230]

All patients with a strong suspicion of or confirmed case of testicular cancer should be discussed at a hospital multidisciplinary tumor board. At these meetings, all aspects of a patient's management, including staging investigations, a plan for adjuvant radiotherapy, chemotherapy, and/or hormonal therapy, social and psychological care, and follow-up, are discussed.

The multidisciplinary healthcare team includes primary care physicians, radiologists, pathologists, pediatricians, oncologists, urologists, and clinical nurse specialists. Effective collaboration, communication, and coordination among these specialists help ensure optimal treatment and improved patient outcomes.

Nursing, Allied Health, and Interprofessional Team Interventions

Clinical oncology nurse specialists are highly experienced in the care of patients with cancer. These specialists should be involved early in the management of testicular cancers, as they provide early guidance, monitor follow-up visits, coordinate care and communication among members of the healthcare team, and provide patient counseling. Clinical oncology nurse specialists serve as a strong link between the urologist, primary care, oncologist, and palliative care physicians.

Nursing, Allied Health, and Interprofessional Team Monitoring

Some clinical oncology nurse specialists have dedicated clinics to follow up with patients who have had orchiectomies. These clinics provide the close patient-health worker relationships and surveillance needed for patients who are post-adjuvant care or those who require no further treatment following their surgical procedure.

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