Radical inguinal orchiectomy is the diagnostic and primary therapeutic procedure for a testicular mass suspicious for malignancy — it removes the testicle and spermatic cord to the level of the internal inguinal ring. The management context (indications, timing, testis-sparing criteria) is covered in the Testicular Cancer topic; this page is the operative reference.
Key Principles
- Inguinal approach only. The trans-scrotal approach is contraindicated because scrotal violation alters lymphatic drainage and increases the risk of local recurrence and pelvic/inguinal nodal spread.
- Control the cord before manipulating the tumour to prevent vascular and lymphatic seeding; avoid excessive traction that could rupture the tumour.
- Discuss a testicular prosthesis with the patient beforehand.
Pre-operative Preparation
- Antibiotics: 2 g cefazolin (900 mg clindamycin if penicillin-allergic).
- Sutures: 0 silk and 2-0 silk for cord ligation; 2-0 and 3-0 Vicryl and 4-0 biosyn/monocryl for closure.
- Instruments: Adson and DeBakey forceps; right-angle, Babcock, Kelly, and hemostat clamps; self-retaining Weitlaner, Langenbeck, Army-Navy, and Senn retractors.
Steps — Radical Inguinal Orchiectomy
- Position and prep. Supine under general anesthesia. Prep from above the umbilicus cranially to the mid-to-lower thighs caudally, including the external genitalia to the perineum. Drape to expose the ipsilateral anterior superior iliac spine (ASIS), pubic tubercle, and scrotum.
- Mark the incision. Invaginate the scrotum with a finger to locate the external inguinal ring. Plan a 3–5 cm transverse incision extending laterally over the inguinal canal along the lines of Langer, ideally below the underwear line. The internal ring lies midway between the ASIS and pubic tubercle, ~4 cm lateral to the external ring.
- Skin incision. Incise with scalpel/cautery. For a mass too large to deliver, extend the incision onto the anterior scrotum in a hockey-stick fashion.
- Expose the external oblique fascia. Dissect through fat and Scarpa's fascia to the external oblique aponeurosis and external ring. (Recall the inguinal canal: anterior wall and floor = external oblique; roof = internal oblique + transversus abdominis; posterior wall = transversalis fascia.)
- Open the canal and protect the ilioinguinal nerve. Make a stab in the external oblique fascia and extend it toward the external ring with Metzenbaum scissors, identifying and preserving the ilioinguinal nerve, which runs parallel to the cord along the cephalad aspect of its anterior surface. (The ilioinguinal nerve [L1] supplies the anterior scrotum, root of the penis, and upper medial thigh.) Displace the nerve behind a protective clamp.
- Mobilize and occlude the cord. Divide the external spermatic fascia and cremasteric fibers, encircle the proximal cord with a Penrose drain (wrapped twice), and apply a Kelly clamp to occlude the cord's blood supply early.
- Deliver the testicle. Divide remaining attachments, develop the scrotal space, and deliver the testis with gentle cephalad traction and external scrotal pressure. If it will not deliver, extend the incision — excessive force risks tumour rupture and local recurrence.
- Divide the gubernaculum. Sweep and divide gubernacular attachments with cautery, avoiding buttonholing the scrotum; be liberal with hemostasis to prevent scrotal hematoma.
- Mobilize to the internal ring. Continue to the internal inguinal ring until the peritoneal reflection is seen.
- Ligate vas and vessels separately. Using non-absorbable (silk) suture, tie and divide the vas deferens first, then suture-ligate the gonadal vessels as proximally as possible. Leave a 1–2 cm suture tail on the gonadal vessel stump to aid identification at a future RPLND, and return the stump to the internal ring. Ligating the vas separately leaves it out of the cord specimen, easing retrieval of the distal cord stump at RPLND.
- Divide the cord and deliver the specimen. Place a towel beneath the cord to avoid blood/tumour spillage, divide the cord, deliver the specimen, and confirm hemostasis.
- Prosthesis (optional). Fill the prosthesis, evacuate air, and deliver it into the dependent scrotum without touching the skin.
- Closure. Reposition the ilioinguinal nerve into the canal. Reapproximate the external oblique fascia from internal to external ring with running 2-0 Vicryl (avoiding the nerve), close subcutaneous tissue with running 3-0 Vicryl, and close skin subcuticularly with 4-0 biosyn/monocryl.
Testis-Sparing (Partial) Orchiectomy
The approach is identical to radical inguinal orchiectomy. Use intraoperative ultrasonography to localize the mass, then incise the tunica albuginea over it — a vertical incision along the testis long axis from the ventral midline, or a horizontal incision (following the segmental arteries) if medial/lateral to the midline. Enucleate the tumour with a small rim of surrounding seminiferous tubules and send a fresh sample to pathology. If radical orchiectomy is not required, close the tunica with absorbable suture and return the testis to the dependent scrotum, securing it at three points of internal fixation to the gubernaculum or medial scrotal septum.
Post-operative Care
Scrotal support and fluff dressings help avoid scrotal swelling and hematoma during the first 48–72 hours.
Complications
- Intra-operative: ilioinguinal nerve injury.
- Early post-operative: wound infection, scrotal hematoma.
- Late: sensory numbness over the incision.