Testis Removal Surgery Name

[Gauthier Zitnik]

Asimple orchiectomy is commonly performed as part of gender-affirming surgery for transgender women, or as palliative treatment for advanced cases of prostate cancer. A simple orchiectomy may also be required in the event of testicular torsion.[5]

For the procedure, the person lies flat on an operating table with the penis taped against the abdomen. The nurse shaves a small area for the incision. After anesthetic has been administered, the surgeon makes an incision in the midpoint of the scrotum and cuts through the underlying tissue. The surgeon removes the testicles and parts of the spermatic cord through the incision. The incision is closed with two layers of sutures and is covered with a surgical dressing. If desired, prosthetic testicles can be inserted before the incision is closed to present an outward appearance of a pre-surgical scrotum.[6]

A subcapsular orchiectomy is also commonly performed for treatment of prostate cancer. The operation is similar to that of a simple orchiectomy, with the exception that the glandular tissue that surrounds each testicle is removed rather than the entire testis itself. This type of orchiectomy is performed to remove testosterone-producing glandular tissue while maintaining the appearance of an ordinary scrotum.[6][4]

Inguinal orchiectomy (named from the Latin inguen for "groin", and also called radical orchiectomy) is performed when an onset of testicular cancer is suspected, in order to prevent a possible spread of cancer from the spermatic cord into the lymph nodes near the kidneys.[6]

An inguinal orchiectomy can be either unilateral (one testicle) or bilateral (both testicles). The surgeon makes an incision in the groin area (in contrast to an incision in the scrotum, as is done in both simple and subcapsular orchiectomies). The entire spermatic cord is removed, as well as the testicle(s). A long, non-absorbable suture may be left in the stump of the spermatic cord in case later surgery is deemed necessary.[6] After the cord and testicle(s) have been removed, the surgeon washes the area with saline solution and closes the layers of tissues and skin with sutures. The wound is then covered with sterile gauze and bandaged.[6]

Partial orchiectomy is an option for individuals with testicular masses that want to preserve their testes and their function. During surgery, the testis is exposed in a similar way to inguinal orchiectomy. Once the testis is exposed and the spermatic cord is clamped, there is a current debate as to whether surgeons should deliver cold ischaemia which means submitting the organ, in this case the testis, into a cold/freezing environment. Whether or not it is submerged and frozen, the next step is to cut the tunica vaginalis and an ultrasound is used to find the tumor. After, the tumor is scraped away from the testis in a process called enucleation. Following enucleation, biopsies are taken of the tissues surrounding the testicle where the mass once was. Afterwards, each layer or tunica of the testis is sutured up and the testis is placed back in the scrotum. The skin layers are also closed up with sutures.[7]

Guidelines state that fertility counseling should be offered to all patients undergoing inguinal orchiectomy, as there is a risk of reduced fertility or infertility. Testicular germ cell tumors (TGCT) accounts for 95% of cases of testicular cancer in young men.[7] TGCT is associated with abnormal semen parameters.[8] Because testicular cancer is commonly diagnosed in young, fertile men, it is critical that these individuals be educated on preserving their semen through freezing (cryopreservation) and complete a fertility assessment prior to surgery. In addition, testicular prosthesis placement counseling and education is encouraged to be given before an individual undergoes orchiectomy or before inguinal exploration with possibility of orchiectomy. This is an elective surgery which can be done at the time of orchiectomy. Testicular prosthesic placement has known psychological benefits (see below). Although risks for complications with prosthesis is low, individuals should also be informed of the possibility of infection, rotation, and replacement of prosthesis.[7]

Following orchiectomy, those who have undergone the procedure are advised to avoid bathing, swimming, and heavy lifting for at least one month. If an individual had previously been taking hormone and/or hormone-blocking medications, modifications to their medication would be needed after the procedure. Any androgen-blocking medications, such as spironolactone or cyproterone, are stopped, and estrogen hormones can be resumed at the doctor's discretion. Post-operative pain management includes icing the surgical site, wearing supportive underwear, and the use of pain relief medications (analgesics) such as acetaminophen or ibuprofen; for more severe pain, narcotic analgesics may be needed. A follow-up appointment to monitor recovery and healing is routine.[1]

Risks and complications should be discussed with an individual pre-operatively. Risks and complications for inguinal orchiectomy include scrotal hematoma (accumulation of blood in the scrotum), infection, post-operative pain (60% initially, 1.8% one year after), phantom testis syndrome (pain in the kidney as a result from trauma from the testicle), reduced fertility, and with the more rare complications being inguinal hernia, ilioinguinal nerve injury, tumor spillage, and hypogonadism.[7]

Unilateral orchiectomy results in decreased sperm count but does not reduce testosterone levels.[9][4] Bilateral orchiectomy causes infertility and greatly reduced testosterone levels. This can lead to side effects including loss of sexual interest, erectile dysfunction, hot flashes, breast enlargement (gynecomastia), weight gain, loss of muscle mass, and osteoporosis.[4] It has been discovered that some individuals with a history of prostate cancer who had bilateral orchiectomy had effects on their new bone production, resulting in increased risk of bone fractures due to testosterone deficiency after the procedure.[10]

Bilateral orchiectomy also reduces the use of exogenous medications for transgender women; the reduction in testosterone eliminates the need for testosterone-blocking medications and can contribute to feminizing features such as breast enlargement.[1][11][12]

The loss of one or both testicles from orchiectomy can have severe implications in a male's identity and self-image surrounding masculinity, such that it can lead to an individual having thoughts of hopelessness, inadequacy, and loss. Among testicular cancer survivors who have lost a testicle, there are feelings of shame and loss, which are more evident in young and single men than older and non-single men.[13] As many as one third of individuals who will undergo orchiectomy are not offered the option of having a testicular prosthesis. Data shows that simply offering testicular prosthesis to individuals undergoing orchioectomy is psychologically beneficial. While some individuals do not mind losing a testicle, studies have shown that there is a change in body image in testicular cancer survivors who have undergone orchiectomy and an improvement in body image in 50-60% of individuals who undergo testicular prosthesis placement. One year after testicular prosthesis placement, there are reports of increase in self-esteem and psychological well-being during sexual activity in a study that followed up on post-orchiectomy individuals including adolescents.[14] On the other hand, there is a current debate whether children undergoing orchiectomy should be offered testicular prosthesis to be inserted at the time of orchiectomy procedure.[5][15]

Bilateral simple orchiectomy is one option of gender-affirming surgery for transgender women.[1] It may be performed as a standalone procedure or at the same time as a vaginoplasty.[1] Bilateral orchiectomy is considered first before undergoing vaginoplasty. Vaginoplasty can still be administered after undergoing bilateral orchiectomy, as the orchiectomy preserves the penoscrotal skin that can later be transformed into a skin flap. Additionally, it is an option for those who are unable to undergo vaginoplasty due to the risk of complications.[11]

In addition to alleviating gender dysphoria, the procedure allows trans women to stop taking testosterone-blocking medications, which may cause unwanted side effects.[1] Some common testosterone-blocking medications that most use before undergoing orchiectomy are spironolactone and cyproterone. Common side effects caused by spironolactone are drowsiness, confusion, headache, fatigue, nausea/vomiting, gastritis, polyuria, polydipsia, and electrolyte imbalance (hyperkalemia). Cyproterone can cause side effects such as fatigue, low mood, and fulminant hepatitis. Orchiectomy allows individuals to stop taking these medications and avoid these adverse effects.[1] It is also an alternative for trans women who have contraindications to antiandrogens and is a minimally invasive procedure to eliminate testosterone levels.[11]

Criteria from the World Professional Association for Transgender Health (WPATH) are used as a framework to guide health care professionals in approving or denying an orchiectomy. When a transgender individual wants to complete an orchiectomy, they are in a state of gender incongruence and they must meet the criteria before having the procedure done. The criteria are as follows:[1]

Additionally, persons wishing to go through with the procedure are required to obtain referrals from two independent qualified mental health professionals. This referral should include "the individual's demographic information, psychosocial assessment results, duration of the therapeutic relationship, type of evaluation and therapy performed, if the criteria for surgery have been met and if informed consent has been obtained from the patient."[1]

An individual seeking to undergo orchiectomy is evaluated by a healthcare provider to ensure that the procedure is safe. Many candidates for orchiectomy are on estrogen therapy before the operation, which increases risk of intraoperative venous thromboembolism (VTE); thus, the provider must take this risk into account and determine whether prophylaxis (prevention) is necessary.[11] Current smokers, individuals with limited mobility, individuals older than the age of 40, and individuals who have a medical history of thrombolytic disorder are at higher risk of developing VTE. For these high-risk populations, the use of sequential compression devices during the operation is recommended to prevent VTE complications.[11]

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