Overview
Definition:
Inguinal orchidectomy is the surgical removal of a testis through an incision in the inguinal canal
It is the definitive surgical treatment for suspected testicular malignancy, aiming for complete tumor extirpation with wide margins and lymph node assessment
This approach is crucial to prevent tumor spillage into the scrotum and to facilitate subsequent staging and adjuvant therapy.
Epidemiology:
Testicular cancer is the most common cancer in young men aged 15-35 years, with an incidence of approximately 5-10 per 100,000 worldwide
In India, while less common than globally, it represents a significant oncological challenge
Early diagnosis and treatment are associated with excellent cure rates.
Clinical Significance:
Inguinal orchidectomy is a cornerstone in the management of testicular germ cell tumors and other testicular neoplasms
Proper technique is vital to ensure oncological safety, prevent recurrence, and guide further treatment decisions, impacting patient survival and quality of life
Understanding the procedure is essential for all surgical residents preparing for DNB and NEET SS examinations.
Indications
Absolute Indications:
Palpable testicular mass suggestive of malignancy
Non-palpable testicular lesion identified on imaging (e.g., ultrasound) with high suspicion of malignancy
Testicular torsion with a non-salvageable testis and suspicion of malignancy
Previous history of contralateral testicular germ cell tumor with new suspicious lesion.
Relative Indications:
Testicular atrophy with suspicion of malignancy
Trauma to the testis with persistent pain and suspicion of underlying neoplasm
Follow-up of individuals with genetic predisposition or cryptorchidism who develop a suspicious lesion.
Contraindications:
Absolute contraindications are rare
however, extensive local invasion or distant metastases may alter the primary management strategy, potentially involving neoadjuvant chemotherapy before definitive surgery or palliative measures
The patient's overall medical condition must also be considered.
Diagnostic Approach
History Taking:
Detailed history of scrotal swelling or mass (painless or painful)
Duration and progression of symptoms
History of trauma, cryptorchidism, or previous testicular malignancy
Family history of testicular cancer
Presence of systemic symptoms (e.g., back pain, cough, gynecomastia).
Physical Examination:
Careful palpation of the testis and epididymis to differentiate between testicular mass and other scrotal pathology
Assessment for firmness, irregularity, and pain
Examination of the inguinal region for lymphadenopathy
Examination for gynecomastia
Assess for signs of metastatic disease (e.g., supraclavicular lymph nodes, abdominal masses).
Investigations:
Serum tumor markers: Alpha-fetoprotein (AFP), Beta-human chorionic gonadotropin (β-hCG), Lactate dehydrogenase (LDH) are crucial for diagnosis, staging, and monitoring response to treatment
Ultrasound of the scrotum: High-resolution ultrasound is the initial imaging modality of choice to differentiate testicular masses from extratesticular lesions and hydroceles
characteristic features of malignancy include hypoechogenicity, irregular borders, and vascularity
CT scan of the abdomen and pelvis: Essential for staging to detect retroperitoneal lymphadenopathy and distant metastases
Chest X-ray or CT chest: To assess for pulmonary metastases
MRI: May be used in select cases for better local staging or assessing invasion.
Differential Diagnosis:
Testicular torsion
Epididymitis/orchitis
Hydrocele
Spermatocele
Varicocele
Inguinal hernia
Metastasis to the testis from other primary tumors
Lymphoma of the testis (more common in older men).
Surgical Management
Procedure Steps:
Radical inguinal orchidectomy is performed via an inguinal incision, not a scrotal one, to prevent tumor seeding
The spermatic cord is identified, ligated, and divided as proximally as possible within the inguinal canal
The testis and cord are then delivered out of the inguinal canal
Tumor markers and imaging should guide the extent of lymph node dissection if indicated
Biopsy is generally avoided in the primary setting due to risk of tumor seeding
The specimen is sent for histopathological analysis.
Anesthesia And Timing:
General anesthesia is typically used
The procedure should ideally be performed within 2-4 weeks of diagnosis of a suspicious lesion, or as soon as possible after confirmation
For suspected torsion with malignancy, emergent orchidectomy may be necessary.
Lymphadenectomy:
Template lymph node dissection (inguinal or retroperitoneal) may be performed at the time of orchidectomy or later based on the stage and histology of the tumor
Retroperitoneal lymph node dissection (RPLND) is a major procedure indicated for specific tumor types and stages, often performed by experienced oncologic surgeons.
Postoperative Care
Pain Management:
Adequate analgesia, typically with opioid and non-opioid analgesics
Monitor for wound pain and incisional tenderness
Early mobilization is encouraged.
Wound Care:
Keep the incision clean and dry
Monitor for signs of infection (redness, swelling, discharge, fever)
Suture removal as per protocol
Scrotal support may be provided.
Monitoring:
Monitor vital signs and urine output
Assess for complications like hematoma or infection
Review histopathology reports and tumor markers to guide further management
Discuss fertility preservation options if not already addressed.
Adjuvant Therapy:
Based on histopathology and staging, adjuvant chemotherapy (e.g., platinum-based regimens like BEP) or radiotherapy may be recommended
Discuss options for prosthesis if the patient desires cosmetic reconstruction.
Complications
Early Complications:
Hemorrhage or hematoma formation
Wound infection
Orchitis or epididymitis
Testicular phantom pain
Injury to surrounding structures (e.g., vas deferens, nerves).
Late Complications:
Incisional hernia
Lymphocele formation after lymphadenectomy
Testicular atrophy (if contralateral testis is affected)
Infertility
Psychological distress related to loss of testis and body image
Recurrence of malignancy.
Prevention Strategies:
Meticulous surgical technique to control bleeding and avoid injury to structures
Strict aseptic precautions to prevent infection
Performing orchidectomy through the inguinal canal to prevent scrotal seeding
Adequate perioperative antibiotic prophylaxis
Thorough preoperative assessment and patient counseling regarding potential complications and fertility preservation.
Prognosis
Factors Affecting Prognosis:
Stage of the disease at diagnosis
Histological subtype of the tumor
Presence of vascular or lymphatic invasion
Serum tumor marker levels
Response to adjuvant therapy
Overall health status of the patient.
Outcomes:
With timely diagnosis and appropriate treatment, testicular cancer has an excellent prognosis, with overall survival rates exceeding 90%
Early-stage disease has particularly favorable outcomes
Long-term surveillance is crucial to detect recurrence or secondary malignancies.
Follow Up:
Regular clinical examinations, serum tumor marker monitoring, and imaging (CT scans) are essential for follow-up
The frequency and duration of follow-up depend on the stage and histology of the initial tumor
This is a critical aspect to emphasize for DNB and NEET SS candidates who will manage these patients.
Key Points
Exam Focus:
Radical inguinal orchidectomy is the standard surgical approach for suspected testicular malignancy to prevent scrotal seeding
Serum tumor markers (AFP, β-hCG, LDH) are critical for diagnosis, staging, and follow-up
Ultrasound is the initial imaging modality
CT abdomen/pelvis is essential for staging
Avoid testicular biopsy in the primary setting.
Clinical Pearls:
Always perform inguinal, not scrotal, incision for suspected testicular malignancy
Ligate and divide the spermatic cord as high as possible in the inguinal canal
Consider fertility preservation options before treatment
Recognize the importance of multidisciplinary team approach involving urologists, oncologists, and radiologists.
Common Mistakes:
Performing a scrotal incision which can lead to tumor seeding
Delaying definitive treatment due to fear of infertility or cosmetic concerns
Inadequate staging investigations
Incorrect interpretation of tumor markers
Not considering or offering fertility preservation options to young patients.