Partial Orchiectomy 

Updated: Dec 11, 2020
Author: Samuel G Deem, DO; Chief Editor: Bradley Fields Schwartz, DO, FACS 

Overview

Background

Partial orchiectomy is used as an alternative to radical orchiectomy when the latter could result in overtreatment, typically in the management of small nonpalpable testicular masses found incidentally on scrotal ultrasonography.[1] Most of these small masses are benign, meaning that radical orchiectomy may be an excessive treatment option in such cases. Partial orchiectomy may also be an option for the management of testicular malignancy in a select group of patients in whom radical orchiectomy is not desirable, including those with a solitary testicle, bilateral metachronous testicular malignancies, and/or a desire for fertility or being independent from androgen supplementation.

Testicular cancer is the most common malignancy in young men aged 15-35 years.[2] It usually presents as a palpable solid mass.[3] Although not considered the standard of care, partial orchiectomy is being used with increasing frequency for management of this disease. While preservation of viable testicular tissue can be helpful in avoiding the need for androgen supplementation, it may also lead to the need for further treatment, including chemotherapy or radiation.[4]

History of the Procedure

The first reported partial orchiectomy for testicular cancer was performed by Richie in the United States in 1984.[5] Since this time, multiple other reports have been made and have led to an increase in interest in this testis-sparing technique.

Problem

Testicular cancer treatment can lead to a multitude of medical morbidities, including infertility, disfigurement, and need for hormone replacement therapy. Partial orchiectomy can alleviate this burden in select cases.

Epidemiology

United States data

In 2020, the American Cancer Society estimates that about 9610 cases of testicular cancer will be diagnosed in men in the United States.[6]  The annual incidence of testicular cancer is about 5.9 per 100,000 males. In 2017, an estimated 269,769 men were living with testicular cancer in the United States.[7]

Etiology

The following are risk factors for testicular cancer:

  • Seven to ten percent of men who develop testicular cancer have a history of cryptorchidism.[2]

  • Gonadal dysgenesis is a risk factor.

  • Male factor infertility is a risk factor.[8]

  • Testicular cancer is 5 times more common in white males than in black males.

  • Age is a risk factor, with more than half of all testicular cancers being diagnosed between the ages of 20 and 34 years.

Pathophysiology

Genetic influences on the short arm of chromosome 12 appear to lead to the development of testicular cancer. This influence is hypothesized to induce abnormal cell division and malignant transformation of germ cells, leading to carcinoma. The exact mechanism of this development is yet to be determined.

Presentation

The most common presenting symptom of testicular carcinoma is a painless swelling or nodule of one or both testicles. A painful testicle or orchitis can rarely be a presentation of testicular cancer and this risk warrants investigation with ultrasound of the testicles after the inflammatory process has resolved. Metastatic testicular cancer may present with other symptoms related to the location of the metastasis and can include fever, lymphadenopathy, abdominal pain, nausea, wasting, neurologic deficits, cough, shortness of breath, or hemoptysis, among others.

Indications

Candidates for open excisional biopsy and partial orchiectomy include adult patients with nonpalpable, incidentally detected testicular neoplasms without a history of previous testicular cancer and serum marker levels within the reference range. Testicle-sparing surgery for larger lesions has been reported but is not currently the standard of care in the United States.[9]

Newer indications for partial orchiectomy include small nodules in a solitary testicle or bilateral testicular nodules with a desire to avoid the need for hormonal supplementation.

Relevant Anatomy

The testes are paired ovoid structures located in the pendulous scrotum of males. Blood supply to the testis is from the testicular artery and its drainage is via the pampiniform plexus of testicular veins. Covering the human testis is a thick, fibrous structure known as the tunica albuginea. Seminiferous tubules fill the testis, which are lined by a layer of germ cells. A ductal system through the rete testis connects the testis to the epididymis, which leaves the scrotum via the vas deferens as the primary conduit for sperm.

Contraindications

Patients with elevated serum marker levels, palpable testicular masses, gynecomastia, or retroperitoneal germ cell cancers are typically not candidates for partial orchiectomy with excisional biopsy. Instead, radical orchiectomy is usually necessary in these patients.

 

Workup

Laboratory Studies

An evaluation of serum tumor markers (alpha-fetoprotein [AFP], beta-human chorionic gonadotropin [bHCG], lactate dehydrogenase [LDH], testosterone) is mandatory in the assessment of any testicular mass. If the marker levels are elevated, testicle-sparing surgery is not an option; the appropriate management is radical orchiectomy. When the marker levels are within the reference range in patients with nonpalpable testicular masses detected incidentally, open excisional biopsy can be offered.

Imaging Studies

The frequency of testicular ultrasonography performed for reasons other than evaluating a testicular mass has been increasing. Other indications for testicular ultrasonography include orchalgia, epididymitis, hydrocele, varicocele, and testicular trauma, among many other conditions. A hypoechoic area within the confines of the tunica albuginea is suspicious for testicular cancer.[10, 11] If this mass is nonpalpable, partial orchiectomy can be considered as a treatment option.[12] See the images below.

Scrotal sonogram showing a 0.5-cm X 0.6-cm, hypoec Scrotal sonogram showing a 0.5-cm X 0.6-cm, hypoechoic, parenchymal mass in the left testis of a 24-year-old man with no palpable lesions. Findings of tumor marker studies and abdominal and pelvic CT scanning were negative. He was treated with an open ultrasound-guided excisional biopsy through an inguinal incision.
Scrotal sonogram showing a 0.5-cm X 0.4-cm hypoech Scrotal sonogram showing a 0.5-cm X 0.4-cm hypoechoic parenchymal mass in the left testis of a 30-year-old man with a nonpalpable testicular mass. Tumor marker results were negative.

Further workup for a testicular mass includes an abdominal CT scanning and chest radiography.

Diagnostic Procedures

Intraoperative ultrasonography with needle localization is used at the time of surgery. Preoperative biopsy is usually not offered in order to prevent altering lymphatic drainage and patterns of lymphatic spread by creating a tract through the scrotum.

Histologic Findings

In some cases, frozen-section analysis at the time of surgery yields false-negative results. Final pathology can reveal testicular carcinoma.

In a study by Powell and Tarter (2006), 50% of patients undergoing open excisional biopsy for a nonpalpable, incidentally detected testicular mass required delayed radical orchiectomy.[13]

In a review of 8 published studies on nonpalpable, incidentally detected testicular masses, cancer was present in 32% (14 of 44) cases.[13, 14, 15, 16, 17, 18, 19, 20] All neoplasms were seminoma except one mature teratoma. This is an important finding in counseling patients, as up to 50% of final pathology specimens can reveal testicular cancer, necessitating radical orchiectomy. See the images below.

Final pathology showing a sex cord stromal tumor. Final pathology showing a sex cord stromal tumor. The testis was spared due to low malignant potential of the neoplasm.
Final pathology showing seminoma. Frozen section r Final pathology showing seminoma. Frozen section revealed a lymphocytic infiltrate with epithelioid cells consistent with granulomatous disease. Treatment was radical orchiectomy. No residual invasive seminoma was found in the orchiectomy specimen.

Staging

The following is the tumor, node, and metastases (TNM) staging system for testicular cancer, developed by the American Joint Committee on Cancer (AJCC):

Primary tumor (T)

See the list below:

  • pTX - Primary tumor cannot be assessed

  • pT0 - No evidence of primary tumor

  • pTis - Intratubular germ cell neoplasia[21]

  • pT1 - Tumor limited to the testis and epididymis and no vascular/lymphatic invasion

  • pT2 - Tumor limited to the testis and epididymis with vascular/lymphatic invasion or tumor extending through the tunica albuginea with involvement of tunica vaginalis

  • pT3 - Tumor invades the spermatic cord with or without vascular/lymphatic invasion

  • pT4 - Tumor invades the scrotum with or without vascular/lymphatic invasion

Pathologic regional lymph nodes (N)

See the list below:

  • pN0 - No regional lymph node metastasis

  • pN1 - Lymph node mass, 2 cm or less in greatest dimension and 6 or fewer positive nodes, none larger than 2 cm in greatest dimension

  • pN2 - Lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension; more than 5 nodes positive, none larger than 5 cm; evidence of extranodal extension of tumor

  • pN3 - Lymph node mass more than 5 cm in greatest dimension

Distant metastases (M)

See the list below:

  • M0 - No evidence of distant metastases

  • M1 - Nonregional nodal or pulmonary metastases

  • M2 - Nonpulmonary visceral masses

 

Treatment

Medical Therapy

Primary therapy for any testicular mass includes radical or partial orchiectomy. This is followed by complete metastatic workup including CT of the abdomen and pelvis and chest radiography with serum levels of tumor markers. No further testing is necessary in routine cases.

Surgical Therapy

Surgical therapy consists of partial orchiectomy (excisional biopsy) under ultrasound and needle guidance. Frozen-section analysis results dictate whether radical or partial orchiectomy is indicated.

Preoperative Details

Candidates for partial orchiectomy must have negative findings on serum marker studies, abdominal CT scanning, and chest radiography. The patient must be counseled that a negative frozen-section result followed by a positive pathology result on final pathologic diagnosis would require delayed radical orchiectomy. In addition, sperm banking must be offered, if applicable. Testicular sperm extraction at the time of partial orchiectomy can also be offered to patients with azoospermia.

Intraoperative Details

Open excisional biopsy is similar to radical inguinal orchiectomy in many ways. The authors' treatment algorithm is as follows:

  1. An inguinal incision is made to deliver the testis and spermatic cord.

  2. Towels are placed over the incision.

  3. The testis is manipulated on a towel away from the incision.

  4. Intraoperative ultrasonography is used to locate the mass.

  5. A needle can be passed into the mass for localization if desired.

  6. The mass is excised with a margin of normal parenchyma. Cold ischemia can be used.

  7. Postexcisional ultrasonography is performed to evaluate for a hypoechoic lesion.

  8. The specimen is sent for frozen-section pathological analysis.

  9. If the frozen analysis result is benign, the testis is placed into the scrotum and the wound is closed.

  10. If the frozen analysis result shows viable tumor, radical orchiectomy should be considered.

Postoperative Details

A scrotal support is applied, and the patient is instructed to avoid strenuous activity for 2-3 weeks postoperatively.

Follow-up

Follow-up ultrasonography 1-2 months after surgery is recommended to ensure the patient has no residual mass. Routine follow-up of the testicular cancer is performed based on pathologic staging.

Complications

Complications of partial orchiectomy include the following:

  • False-negative frozen-section analysis result

  • Tumor spillage

  • Incomplete incision of the tumor mass

  • Bleeding

  • Infection

  • Testicular infarction

  • Infertility

Outcome and Prognosis

Outcomes and prognosis following partial orchiectomy are typically favorable, with at least half of the patients in some small series without evidence of tumor on final pathology. Most cancerous testicular masses are composed of pure seminoma, which carries a favorable prognosis and is highly radiosensitive.