Guidelines for Radical Orchiectomy in Testicular Cancer

Pre‑operative Assessment

Obtain serum tumor markers (AFP, β‑hCG, LDH) before surgery and repeat 7 days post‑operatively if elevated to assess half‑life kinetics. 1, 2
Perform a high‑frequency (≈7.5 MHz) testicular ultrasound and record the size of the contralateral testis. 3
Discuss fertility preservation with the patient; offer semen analysis and sperm banking prior to surgery or chemotherapy. 1, 4
Measure baseline hormonal profile (total testosterone, LH, FSH) when fertility is a concern. 4

Proceed with radical orchiectomy before any additional therapy unless the patient has life‑threatening metastatic disease confirmed by markedly elevated markers, in which case immediate chemotherapy is justified. 1, 2, 5

Perform the operation through an inguinal incision over the external inguinal ring; scrotal violation for biopsy or open surgery must be avoided to prevent lymphatic tumor spread. 1, 2
The standard inguinal approach is mandatory (Level II, Grade A evidence). 1, 2

Early vascular control is achieved by clamping the spermatic cord at the internal inguinal ring before any testicular manipulation.
Resect the tumor‑bearing testis together with the entire spermatic cord up to the internal inguinal ring to obtain adequate oncologic margins; the cord must be divided at this level. 1, 2, 5

Obtain a frozen‑section specimen in cases of doubtful small tumors to allow consideration of organ‑preserving surgery. 1, 2, 5

Partial orchiectomy may be offered only in highly experienced centers and only for specific indications:
- Synchronous bilateral testicular tumors,
- Metachronous contralateral tumor,
- Tumor in a solitary testis with sufficient endocrine function,
- Contralateral atrophic testis. 1, 2, 5, 3
Residual testicular tissue after partial resection invariably contains testicular intra‑epithelial neoplasia (TIN) and therefore requires adjuvant radiotherapy; radiotherapy can be delayed if fertility preservation is a priority. 1, 2, 3

Approximately 3–5 % of patients with testicular cancer have TIN in the contralateral testis. 1, 2, 5
The highest risk of contralateral TIN (≥34 %) occurs in patients with testicular atrophy (volume < 12 mL) and age < 40 years. 1, 2, 3
If left untreated, invasive cancer develops in about 70 % of TIN‑positive testes within 7 years. 1, 5
Offer a contralateral biopsy at the time of orchiectomy; a single random biopsy provides high sensitivity and specificity. 1, 2
Patients may choose biopsy or active surveillance; both strategies yield near‑100 % disease‑specific survival. 1, 2
Do not perform a contralateral biopsy within 2 years after chemotherapy. 1, 2, 5

Never violate the scrotum for biopsy or open surgery, as this alters lymphatic drainage and increases the risk of local recurrence. 1, 2
Inadequate cord resection that does not reach the internal inguinal ring may leave residual tumor tissue. 1

Monitor serum tumor markers until they return to normal, even when pre‑operative levels were within normal limits. 1, 2

The European Society for Medical Oncology recommends radical orchidectomy as the standard procedure for testicular cancer, involving complete removal of the testicle along with the spermatic cord up to the internal inguinal ring 6, 7
Radical orchidectomy should be performed through an inguinal incision to prevent lymphatic spread of cancer cells 6, 7, 8
The American Society of Clinical Oncology indicates that partial/orchidectomy is an alternative to radical orchidectomy in specific situations, such as synchronous bilateral testicular tumors, metachronous contralateral tumors, tumors in a solitary testicle with normal testosterone levels, and contralateral atrophic testis 6, 8, 9
Simple bilateral orchidectomy is used primarily for androgen deprivation therapy in prostate cancer, causing rapid reduction in testosterone to castrate levels (<10 ng/mL) 10, 11

Preoperative assessment for radical orchidectomy should include obtaining tumor markers (e.g. generic tumor markers) before surgery and performing testicular ultrasound with a high-frequency transducer 6, 7, 8
The surgical approach for radical orchidectomy involves making an inguinal incision over the external ring, exposing and mobilizing the spermatic cord at the external inguinal ring, and applying early vascular control of the spermatic cord at the internal inguinal ring 6, 7
For bilateral orchidectomy in prostate cancer, preoperative assessment should confirm indication for androgen deprivation therapy and discuss potential side effects with the patient 10, 11

The European Association of Urology recommends that contralateral biopsy for testicular intraepithelial neoplasia (TIN) should be performed preferably at the time of orchiectomy, as 5% of testicular cancer patients have TIN in the contralateral testicle 6, 12
Sperm banking should be offered before bilateral orchidectomy to preserve fertility 13
Bilateral orchidectomy for prostate cancer results in rapid reduction in testosterone levels, eliminates issues with medication compliance, and may achieve lower castrate levels of testosterone than medical castration 10, 11
Potential complications of bilateral orchidectomy include surgical complications, psychological impact, hypotestosteronemia effects, and long-term effects such as osteopenia and hypercholesterolemia 11