Unilateral and bilateral orchiectomy surgery

Orchiectomy is a surgical procedure in which the testicles (testicles) are removed from men. Removal of both testicles – bilateral orchiectomy – is a surgical castration.

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Indications for the procedure

First of all, indications for this operation include complicated purulent inflammation of the scrotum (scrotum) that has affected the fibrous membrane of the testicles; acute inflammation of the testicle itself (orchitis) with an abscess and necrosis (including as a result of its torsion); tuberculous tumor of the testicle; crushed or lacerated injuries of the groin area and genitals with destruction of the testicles.

Orchiectomy is performed in cryptorchidism - when even a two-stage orchiopexy cannot move the incorrectly positioned testicle into the scrotum (in most cases, if the form of cryptorchidism is abdominal), or it is completely atrophied. See - Testicular atrophy

The same method is used to solve the problem of unilateral testicular hypoplasia, as well as abnormal localization of the testicles in the extremely rare congenital Morris syndrome (or false male hermaphroditism), which is essentially the result of a mutation of the androgen receptor genes and is manifested by complete tissue insensitivity to testosterone.

Orchiectomy is performed for testicular cancer – testicular carcinoma, choriocarcinoma, seminoma, malignant embryonic cell tumor, etc.

To reduce the level of testosterone, which provokes the growth of malignant neoplasms of the prostate, and thereby stop or at least slow down the growth of the tumor, orchiectomy can be performed for prostate cancer (acinar, ductal, mucinous adenocarcinomas of disseminated form).

While the main surgical method for prostate cancer is its removal (prostatectomy), bilateral orchiectomy/bilateral orchiectomy is considered as a method of androgen deprivation – stopping the synthesis of the male sex hormone by removing the testicles that produce it (although drug therapy with antagonist hormones gives the same results, but not as quickly). In addition, after such an operation, the synthesis of an insignificant amount of androgen hormones continues by endocrinocytes of the reticular zone of the adrenal cortex.

It should be noted that in recent years, numerous scientific studies have shaken the established ideas about the exclusive role of testosterone in the growth of prostate tumors. In fact, the whole point may be in the increased influence of estrogen, if we take into account the process of natural reduction in the synthesis of androgenic steroids in men after 50-55 years - precisely at the age of the onset of andropause or male menopause, when problems with the prostate arise (in the form of prostatitis, adenoma and, of course, oncology).

It has also been established that a special form of metastatic prostate cancer, castration-resistant prostate cancer (CRPC), often develops after taking testosterone-suppressing hormones and reducing its level, as after orchiectomy. This is due to the fact that in response to low testosterone levels, the number of androgen receptors that tumor cells have increases, while their resistance to hormone therapy increases. According to clinical statistics, less than two years after drug-induced androgen deprivation, the tumor process progresses in almost half of patients.

Orchiectomy is never performed without medical indications: transgender men who insist on changing their gender to female undergo a comprehensive examination (including a psychiatric examination).

By the way, surgical castration – orchiectomy as a punishment for sexual abuse of minors – is a common sentence for pedophiles, handed down by courts in the Czech Republic (there were about a hundred such verdicts between 1998 and 2008) and Germany. In the US states of Florida, California, Illinois, Arkansas and Ohio, surgical castration is an alternative to long-term imprisonment. And in Texas and Louisiana, the offender is allowed to choose between subcapsular and radical orchiectomy.

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Preparation

If the operation is urgent – with injuries accompanied by bleeding and pain shock – the patient is immediately taken to the operating table. And preparation for a planned orchiectomy involves taking a general and biochemical blood test; a coagulogram; an analysis for urogenital infections, hepatitis and HIV.

The patient undergoes an ECG; Doppler ultrasonography of the scrotum; ultrasound of the groin, scrotum, prostate and abdominal cavity.

Of course, before deciding to perform this surgical intervention in cases of oncology, patients undergo a comprehensive examination. And the list of diagnostic procedures is more extensive, including biopsy, monitoring of testosterone levels in the blood serum and determining the PSA level. However, as experts from the American Cancer Society note, the prostate-specific antigen (PSA) produced by the prostate gland does not have absolute oncospecificity, and its level can be increased due to inflammation or benign hyperplasia of the prostate gland. Nevertheless, in most cases of prostate cancer, the PSA content in the blood is higher than age norms.

Patients should not eat or take any medications for six to eight hours prior to surgery, and drinking alcohol is strictly prohibited for at least a week prior to the scheduled orchiectomy.

Removal of the testicles during transgender transition is preceded by a fairly long-term therapy with testosterone antagonist hormones, which helps to avoid the development of the so-called post-castration syndrome.

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Technique orchiectomies

The technique chosen by the surgeon for performing an orchiectomy depends on the specific diagnosis and takes into account the extent of the necessary intervention: unilateral or bilateral orchiectomy.

If the tumor in testicular cancer is localized within its membrane, only the glandular tissue of the testicular parenchyma can be removed, i.e. a subcapsular orchiectomy is performed - with access through dissection of the scrotum. In many cases, such an operation is performed laparoscopically: with special instruments through small incisions, by twisting, under regional (epidural) anesthesia.

If atypical cells are detected in the testicular membrane and beyond, as well as in the case of neoplasms in the prostate gland (and insufficient reduction of testosterone by the drug method), bilateral inguinal or radical orchiectomy is indicated: with access through incisions in the groin area, under general anesthesia, with complete removal of the testicle, spermatic cord, epididymis and inguinal lymph nodes. This operation for testicular tumors allows you to remove all damaged tissue and prevent the expansion of the pathological process. And in patients with prostate adenocarcinoma, as noted above, the main goal is achieved - to stop the production of testosterone.

After the testicles are removed, the surgical field is treated accordingly, the tissues of the inguinal canal are strengthened with a special biocompatible mesh material, and the dissected tissues are sutured layer by layer. The operation is completed by draining the wound (usually drainage lasts no more than a day) and applying a pressure bandage.

With any orchiectomy technique performed for oncology, the removed tissues are subject to histomorphological examination.

Contraindications to the procedure

Orchiectomy is not used if the patient consults a urologist or oncologist with inoperable stage IV prostate cancer with widespread metastasis.

Also, the operation is not performed if there is a real chance to overcome testicular cancer at an early stage – with chemotherapy and radiation.

Contraindications to orchiectomy are most often associated with the presence of active infectious diseases and severe somatic diseases (chronic heart or kidney failure, decompensated diabetes mellitus, thrombocytopenia).

In most cases, contraindications arise when applying for transgender transition when applicants for gender reassignment do not meet clearly established criteria for gender identity disorder, and psychiatric experts diagnose them with either a comorbid condition or a mental disorder.

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Consequences after the procedure

The main consequences of bilateral orchiectomy are caused by a decrease in testosterone levels and an increase in the influence of adrenal cortex estrogens and pituitary prolactin, which continue to be produced in the male body.

This is manifested by a violation of lipid metabolism and an increase in body weight due to adipose tissue (with a gradual reduction in muscle); a decrease in bone density with an increase in bone fragility; an increase in the size of the mammary glands and their sensitivity.

The vegetative-vascular consequences of the testicular removal procedure make themselves known by rushes of blood to the head, attacks of hyperhidrosis, and increased heart rate.

If we rely on patient feedback after this operation, then the list of signs of a reduction in the impact of androgenic factors on the male body should include an apparently unreasonable feeling of fatigue, unstable mood with bouts of irritability, deterioration in sleep quality, etc.

Sex after orchiectomy is possible if the operation was unilateral: the hormone-producing function of the remaining testicle is not affected. And if patients have problems, then – after a blood test for testosterone levels – hormone replacement therapy with androgenic steroids can be prescribed.

In the case of bilateral orchiectomy, absolutely insufficient testosterone levels lead not only to a decrease in libido, but also to a complete loss of erectile function.

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Complications after the procedure

The most common complications after an orchiectomy procedure are: pain and swelling in the groin and lower abdomen; inflammation in the suture area with redness and discharge of cloudy ichor; increased body temperature. For the last two symptoms, a course of systemic antibiotics is prescribed.

It is not considered a complication when the scrotum is swollen and painful for some time after orchiectomy. In case of swelling, cold compresses can be applied to the groin area, and if the pain is severe, painkillers can be taken.

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Care after the procedure

During the first days, care after the orchiectomy procedure is carried out in a hospital setting. A day after the operation, patients can get out of bed and walk: movement helps reduce swelling and improve tissue trophism. But any physical activity should be avoided so that the stitches (which are usually removed after a week) do not weaken or come apart.

The surgical area is regularly inspected, and antiseptically treated with a change of dressing. Bathing procedures are contraindicated (only a not very hot shower), but personal hygiene in the genital area is mandatory. Doctors advise wearing loose clothing, a special groin bandage or medical knitted underwear.

Treatment after orchiectomy

It is necessary to determine PSA after orchiectomy for prostate cancer in order to choose the correct tactics for subsequent therapy.

Most patients with prostate cancer undergo further treatment after orchiectomy, such as radiation or chemotherapy.

And if the testicle was removed due to cryptorchidism, orchitis, atrophy or trauma, then it is necessary to compensate for the lack of testosterone with hormone replacement therapy - HRT after orchiectomy.

Likewise, transsexuals after orchiectomy in most cases continue to take drugs containing estrogen, but perhaps in smaller doses.

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