A radical orchiectomy is one aspect of the definitive treatment of testicular cancer.
Testicular cancer generally affects young men between puberty and age 35 years. Successful treatment incorporates a number of modalities, including radical orchiectomy, retroperitoneal lymph node dissection, chemotherapy, and radiation.
A radical orchiectomy is indicated in the management of a suspected testicular tumor. A testicular tumor should be suspected in any patient with the physical findings of a painless, firm, and irregular mass arising from the testicle. Confirm this with Doppler ultrasonography of the scrotum.
Most cases of testicular tumors demonstrate hypoechoic hypervascular intratesticular lesions. Elevated levels of alpha-fetoprotein and/or human chorionic gonadotropin should also suggest a testicular tumor (germ cell type).
In some patients with a testicular mass, causes other than a testicular tumor need to be excluded before radical orchiectomy is performed. For example, if a patient presents with testicular enlargement but a history consistent with an orchitis, then antibiotic therapy would be indicated prior to surgery.
Similarly, if a patient with a history of congenital adrenal hyperplasia presents with bilateral multifocal testicular masses, a frozen section biopsy would be indicated at the time of the operation to confirm that the lesions are hyperplastic nodules of adrenal rests rather than multiple germ cell tumors.
A study that assessed the clinical outcome of testicular sex cord stromal tumors (TSCST) according to management and stage reported that testis-sparing surgery may be feasible and effective in case of small tumors.
Another study concluded that testis-sparing surgery performed for small testicular masses may represent a safe procedure with optimal results in terms of functional and oncologic end points.
After treatment with radical orchiectomy and external-beam radiation therapy, the 5-year disease-free survival rate is 98% for stage I tumors and 92-94% for stage IIA tumors. For higher-stage disease that has been treated with radical orchiectomy followed by chemotherapy, the 5-year disease-free survival rate is 35-75%.
Nonseminomatous Germ Cell Tumors
For stage I tumors, which are treated with radical orchiectomy and retroperitoneal lymph node dissection, the 5-year survival rate is 96-100%.
For low-volume stage II disease, which is treated with radical orchiectomy and chemotherapy, the 5-year disease-free survival rate is 90%. For bulky stage II disease, which is treated with radical orchiectomy followed by chemotherapy and retroperitoneal lymph node dissection, the 5-year disease-free survival rate is 55-80%.
Inguinal orchiectomy is the standard treatment for suspected testicular carcinoma. Scrotal violations that occur during scrotal orchiectomy, open testicular biopsy, and fine-needle aspiration may compromise the patient’s prognosis. Thus, patients with a scrotal violation often are subjected to potentially morbid local therapies. In addition, surveillance protocols usually exclude patients with scrotal violations.
Much of the current bias in managing scrotal violation stems from a 1925 article by Dean, who reported a 24% local recurrence rate after simple orchiectomy.
However, the validity of this report has been questioned, and numerous articles have suggested that scrotal violation may not necessarily confer a worse prognosis.
In particular, 2 articles have addressed this issue. In 1995, Capelouto et al reviewed all published series of patients with testicular cancer in whom scrotal violation occurred.
They then performed a meta-analysis to choose a subset on the effect of scrotal violation on patient prognosis for critical analysis. Although the local recurrence rates among the scrotal violation studies contained statistically significant differences, the overall local recurrence rates were minimal (2.9% vs 0.4%, respectively). In all groups analyzed, the rates of distant recurrence and survival were statistically similar.
In 1995, Leibovitch et al published a retrospective review of 78 of 1,708 patients (4.6%) with nonseminomatous testis cancer who presented to Indiana University School of Medicine following scrotal violation.
The overall relapse rate among patients with pathological stage A disease associated with scrotal violation was increased. The finding was exclusively attributed to local recurrences in 7.7% of cases following scrotal violation, compared with no local recurrences in patients who underwent standard radical orchiectomy. However, the overall patient survival rate was comparable to that in patients without scrotal violation.
Inguinal orchiectomy and high spermatic cord ligation remain the standard of care for diagnosis and initial management of testicular cancer. Scrotal violation alone, without tumor contamination, does not impart a worse prognosis in patients with testicular cancer. In the absence of gross tumor spillage, close observation alone may be adequate management for scrotal violation. Therefore, consider local or systemic therapies only upon evidence of a local recurrence.