The TCRC Orchiectomy Page

So, you've been diagnosed with testicular cancer...and if that's not bad enough, they want to cut your testicle off, and they want to do it NOW! Hopefully, this article will explain what they are going to do, and why they are going to do it.

First of all, if you've got a testicular tumor, you need this operation. We're sure you are thinking things like:

Well, these are all very good questions, and we'll try to answer them as best as we can.

Most urologists are going to strongly suspect testicular cancer simply by examining the affected testicle with their hands. A hard or irregular mass inside the testicle is very suspicious.

There are other tests they can use to confirm what they are feeling. They may try things like transillumination, shining a very bright light through the scrotum to help distinguish a fluid-filled cyst from a solid mass. In most modern settings, though, an ultrasound is going to be the most useful test. Ultrasound is very good at showing whether a mass is inside the testicle and whether it is solid or fluid-filled. If the ultrasound shows a solid mass inside the testicle, the testicle will most likely have to come out.

Before surgery, blood should also be drawn for the tumor markers AFP, beta-hCG and LDH. These numbers can be important later in determining the stage, deciding whether additional treatment is needed, and following the cancer after treatment. They are most useful if there is a baseline from before the tumor is removed.

Why does it have to come out? How do they know it's cancer and why can't they do a biopsy?

Well, they don't necessarily know that it is cancer before surgery, but a solid mass inside the testicle is very likely to be malignant. The only way to know exactly what the tumor is involves looking at the tissue under a microscope. Doctors normally do not biopsy a suspicious testicular mass through the scrotum, however, because the scrotal sac and the testicle belong to different lymphatic systems.

The testicle drains into lymph nodes in the retroperitoneum, the area toward the back of the abdomen near the kidneys, while the scrotal skin drains toward lymph nodes in the groin. If the scrotum is cut into and cancer cells contaminate that tissue, the normal pattern of spread can be altered. That can make both treatment and follow-up more complicated. That is why the standard operation approaches the testicle through the groin, not through the scrotum.

Usually, no. The standard operation for a suspicious tumor in one testicle, when the other testicle is normal, is to remove the entire affected testicle.

There is an operation called partial orchiectomy or testis-sparing surgery where only the tumor is removed, but it is uncommon and reserved for selected situations. These can include men with only one functioning testicle, tumors in both testicles, or certain small and unusual masses where preserving testicular function is particularly important. It is not the normal treatment for a typical testicular cancer.

Psychologically and/or socially, losing a testicle may bother some men quite a bit. Socially, though, it is unlikely that anyone will notice unless they are getting very up close and personal. Physically, one healthy testicle is usually enough to do everything you are used to doing. It should produce enough testosterone to maintain sex drive, erections and other male characteristics, and enough sperm to father children.

Be aware, though, that many men with testicular cancer already have fertility problems before the testicle is removed. Additional treatment such as chemotherapy, radiation or some types of surgery can affect fertility further. So if you might want biological children someday, sperm banking is worth discussing before treatment starts. A testicular prosthesis is also a viable option. It can often be placed during the orchiectomy or later, so if appearance or symmetry matters to you, discuss it with your urologist before surgery.

Tumor markers: AFP, beta-hCG and LDH should be measured before surgery, ideally as close to the orchiectomy as practical. If AFP or beta-hCG is elevated, the level should begin to fall after the tumor is removed. Knowing the value immediately before surgery gives the doctors the best starting point for determining whether the marker is falling at the expected rate.

Staging scans: At some point around the time of the orchiectomy, you will also need imaging to look for any evidence that the cancer has spread. Exactly which scans are used, and whether they are done before or after surgery, depends on local practice and your particular situation.

Testosterone: We also strongly encourage newly diagnosed men to ask about having their serum testosterone level checked before the orchiectomy. There may be no immediate treatment reason to do it, and one healthy remaining testicle normally makes enough testosterone, but having a baseline measurement can be useful later if symptoms of low testosterone ever develop.

Sperm banking: If future fertility matters to you, this is also the time to ask about sperm banking. Think of it as insurance. You may never need to use it, but if you do need it, you will be glad to have it.

Testicular prosthesis: If you think you might want a prosthetic testicle, discuss it now rather than after the operation.

Frozen peas: Pick up a couple of bags before surgery. Wrapped in a thin towel, frozen peas make excellent flexible cold packs because they conform to the groin much better than a rigid ice pack. Keep something between the frozen bag and your skin and follow your surgeon's instructions about icing.

Clothing: Make sure you have loose sweatpants or shorts with an elastic waist. Anything tight across the groin incision can be pretty uncomfortable for the first several days.

Anesthesia: Most inguinal orchiectomies are done under general anesthesia. Spinal or epidural anesthesia can also be used in some situations, and some centers may use deep sedation combined with local or nerve-block anesthesia. What makes sense for you depends on your health, the anesthesiologist, the surgeon and the hospital.

We have created a list of questions that you might want to print out and take with you when you talk to the doctor about the operation. You can find these questions here.

The actual removal is done by making an incision along the groin, roughly near the "bikini line," on the affected side. They will NOT cut through the scrotal sac.

Once the incision has been made, the surgeon brings the testicle and spermatic cord up through the groin incision. The surgeon cuts the spermatic cord high in the groin and removes the testicle and cord together. The entire specimen then goes to the pathology laboratory for examination.

The operation itself is usually fairly quick. Most men in the United States go home the same day, although some may stay longer depending on their health, anesthesia, pain control or other circumstances.

They will probably get you up and walking fairly soon afterward. It will hurt, but moving around helps get everything working again and usually gets you back to normal sooner. You'll probably have a reasonable amount of pain and soreness around the incision, and there may also be some swelling or bruising.

There may also be numbness of the skin around the incision. That often improves over time, although a small numb area can sometimes remain for a long time. Different people react differently to the operation. Some will be up and about the next day; others will need more time.

Your doctor will probably restrict driving, heavy lifting and strenuous activity for a while, so be prepared to ask for help getting around. Developing a hernia because you tried to do too much too soon is no fun.

Following the operation, you get to experience what is arguably the most frustrating side of cancer: waiting for lab results! The pathology report may take several working days, and during that time it is very easy to spend a lot of time thinking, "what if, what if..."

We used this time to do a lot of our research so that we understood the possible paths ahead. Learning enough to understand what may come next can help, although there is no benefit in letting it completely consume you.

When you DO get the pathology results, be sure to get a copy. Use the TCRC Pathology Report page and the TCRC glossary to understand it. This report is one of the most important pieces of information you will receive. It will identify what type of tumor or other abnormality was found in the testicle and provide information that helps determine what treatment, if any, comes next.

If the tumor was mixed, the pathologist should identify the different types and usually estimate the percentage of each. The report should also say whether there was lymphovascular invasion, meaning cancer cells were seen inside small blood or lymphatic vessels. This information can be particularly important when deciding what to do after surgery.

Up to this point, you have probably been treated mainly by a urologist, and the urologist may be the person who gives you the pathology results. But once the orchiectomy is over, the question is no longer simply how to remove the testicular tumor. Now the pathology report, post-operative tumor markers and scans have to be put together to determine the stage and decide what comes next, whether that is surveillance or additional treatment.

If no additional treatment is necessary, you may simply begin surveillance. If chemotherapy is being considered, you should be seeing a medical oncologist, preferably one familiar with testicular cancer. If RPLND is being considered, the experience of the urologic surgeon becomes particularly important. Radiation may still be appropriate in selected seminoma cases.

If there is more than one reasonable option, get enough information to understand the advantages and disadvantages of each. A second medical opinion can be very useful when an important treatment decision is being made. You may also want a second opinion on the pathology itself, particularly if the tumor is unusual, the pathology does not fit the tumor markers or scans, or an important treatment decision depends on a particular pathology finding. The TCRC Pathology Report page explains when an expert pathology review may be worthwhile.

In any event, the orchiectomy is a fairly simple but extremely important first step in the testicular cancer experience. You should be back to normal fairly soon afterward. Listen to your doctor's post-op instructions, learn as much as you reasonably can, and stay involved in the management of your disease rather than simply becoming an unwilling passenger.

Testicular Cancer Treatments: The Inguinal Orchiectomy