ORCHIDECTOMY

Orchidectomy - Indications :
Two types radical orchidectomy and simple orchidectomy.

Radical (inguinal) orchidectomy
For excision of testicular cancer. This approach is used for 3 reasons:
- To allow ligation of the testicular lymphatics as high as possible as they pass in the spermatic cord and through the internal inguinal ring, thereby removing any cancer cells which might have started to metastasize along the cord.
- To allow cross clamping of the cord prior to manipulation of the testis which, theortetically at least, could promote dissemination of cancer cells along the lymphatics. (In reality, this probably doesn't occur.)
- To prevent the potential for dissemination of tumour cells into the lymphatics that drain the scrotal skin that could occur if a scrotal approach is used. These lympatics drain to inguinal nodes. Thus, direct spread of tumour to scrotal skin and  alfa˜violation alfa™ of another lymphatic field (the groin nodes) is avoided. Historically, this was important because the only adjuvant therapy for metastatic disease was radiotherapy. The morbidity of groin and scrotal irradiation was not inconsiderable (severe skin reactions to radiotherapy, irradiation of femoral artery and nerve).

Obtain serum markers before surgery (alfa-fetoprotein, beta-HCG, and lactic acid dehydrogenase  LDH) and get a CXR. Full staging CT scan wait till after surgery. If the contralateral testis has been removed or is small, offer sperm storage  there is usually time to do this. Warn the patient that, very occasionally, what appears clinically and on ultrasound to be a malignant testis tumour, turns out to be a benign tumour on subsequent histological examination.

Simple orchidectomy
For hormonal control of advanced prostate cancer. Done via a scrotal incision, with ligation and division of the cord and complete removal of the testis and epididymis. Alternatively, a subcapsular orchidectomy may be done, where the tunica of the testis is incised and the seminiferous tubules contained within are excised. There is the potential with this approach to leave a small number of Leydig cells which can continue to produce testosterone.

Anaesthesia
Local, regional, general. Few men will require or opt for local.

Post-operative care and common post-operative complications and their management
For both simple and radical orchidectomy: scrotal haematoma. Drain it if large or enlarging or if there are signs of infection (fever, discharge of pus from the wound).
For radical orchidectomy: damage to the ilioinguinal nerve leading to an area of loss of sensation overlying the scrotum.