Radical Orchiectomy

Radical inguinal orchiectomy is usually the first step in managing a testicular germ-cell tumour: it removes the testicle and spermatic cord to the internal inguinal ring, yielding histologic diagnosis, staging information, and local tumour control, and may be curative in low-stage disease managed by observation. The management context (indications, timing, testis-sparing criteria, adjuvant therapy) is covered in the Testicular Cancer topic; this page is the operative reference.

Preoperative Workup

• Serum tumour markers — AFP, β-hCG, and LDH (plus a urine pregnancy test). Markers support the diagnosis but must not decide whether to operate (normal AFP/hCG do not exclude a GCT) and must not be used for clinical staging; after surgery they should normalise over 4 half-lives (AFP ~20–28 days).
• Imaging — scrotal ultrasound with Doppler (a firm intratesticular mass is malignant until proven otherwise), and CT of the chest, abdomen, and pelvis for staging (a chest x-ray may substitute for the chest CT). The retroperitoneal (abdomen/pelvis) CT is not mandatory before orchiectomy and can be obtained post-operatively; some prefer it pre-operatively so that a post-orchiectomy haematoma does not confound the CT stage.

Key Principles

• Inguinal approach only. The trans-scrotal approach is contraindicated because scrotal violation alters lymphatic drainage and adds an inguinal nodal route to local/pelvic recurrence.
• 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.

Operative Setup

• Antibiotics: 2 g cefazolin (900 mg clindamycin if penicillin-allergic).
• Sutures: 0 and 2-0 permanent (silk) for cord and vas 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

1. Position and prep. Supine under general anaesthesia. Prep from above the umbilicus to the mid-thighs, including the external genitalia and perineum. Drape to expose the ipsilateral anterior superior iliac spine (ASIS), pubic tubercle, and scrotum.
2. Mark the incision. Plan a curvilinear incision beginning ~2 cm cephalad and lateral to the pubic tubercle, extending 5–7 cm laterally over the inguinal canal along a line 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.
3. Skin incision. Incise with scalpel/cautery. For a mass too large to deliver, orient the incision more obliquely and extend it onto the anterior scrotum in a hockey-stick fashion.
4. Expose the external oblique fascia. Dissect through fat and Scarpa's fascia to the external oblique aponeurosis and external ring (superficial inferior epigastric veins are often met laterally). Recall the canal: anterior wall/floor = external oblique; roof = internal oblique + transversus abdominis; posterior wall = transversalis fascia.
5. Open the canal and protect the ilioinguinal nerve. Open the external oblique fascia toward the external ring, identifying and preserving the ilioinguinal nerve lying on the anterior surface of the cord; dissect it free of the external spermatic fascia/cremaster and retract it out of harm's way. (The ilioinguinal nerve [L1] supplies the anterior scrotum, penile root, and upper medial thigh.)
6. Mobilise and occlude the cord. With blunt dissection at the pubic tubercle, circumscribe the cord so a finger passes easily posterior to it along the canal floor — avoid dissecting through the floor (risk of a direct inguinal hernia). Encircle the proximal cord twice with a ¼-inch Penrose drain and clamp it, achieving early vascular control before any tumour manipulation.
7. Deliver the testicle. The assistant pushes the testis up from the hemiscrotum while the surgeon applies gentle cephalad cord traction; free the tunica vaginalis from its fascial layers. If it will not deliver, extend the incision — excessive force risks tumour rupture and local recurrence.
8. Divide the gubernaculum. The delivered hemiscrotum is invaginated by the gubernaculum, which is divided with cautery (avoid buttonholing the scrotum); be liberal with haemostasis to prevent a scrotal haematoma.
9. High ligation — skeletonise the cord. Dissect the cord proximal to the internal ring, incising the cremaster and external spermatic fascia to skeletonise it; elevate the internal oblique with a retractor to reveal retroperitoneal fat, and follow the cord until the vas diverges from the spermatic vessels and the peritoneal reflection is seen anteromedially.
10. Ligate the vas and vessels separately. Ligate and divide the vas deferens first with 2-0 permanent suture, then doubly ligate the cord (gonadal vessels) with 0 permanent suture as proximally as possible. Leave long suture tails on the cord stump to aid identification at a future RPLND, and return the stump to the internal ring; ligating the vas separately keeps it out of the cord specimen.
11. Deliver the specimen. Place a towel beneath the cord to avoid blood/tumour spillage, divide the cord, deliver the specimen, and confirm haemostasis. (If a biopsy is ever indicated, take it at this point.)
12. Prosthesis (optional). Fill and de-air the prosthesis and deliver it into the dependent scrotum without touching the skin.
13. Closure. Reposition the ilioinguinal nerve into the canal. Approximate the external oblique aponeurosis with running 2-0 absorbable suture (avoiding the nerve), the subcutaneous layer with 3-0 absorbable, and skin subcuticularly with 4-0 absorbable; instil long-acting local anaesthetic for postoperative pain if desired.

Testis-Sparing (Partial) Orchiectomy

The exposure is identical to a radical orchiectomy. Use intraoperative ultrasonography to localise the mass, then incise the tunica albuginea over it (a vertical incision along the long axis from the ventral midline, or a horizontal one following the segmental arteries if the lesion is medial/lateral). Enucleate the tumour with a small rim of surrounding 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 fixation to the gubernaculum or medial septum.

Post-operative Care

Scrotal support and fluff dressings help avoid scrotal swelling and haematoma during the first 48–72 hours.

Complications

• Intra-operative: ilioinguinal nerve injury.
• Early post-operative: wound infection, scrotal haematoma.
• Late: sensory numbness over the incision; a direct inguinal hernia if the canal floor was breached.