Operation of one-sided and bilateral orchiectomy

Orchiectomy - surgery, during which men remove testicles (testicles). Removal of both testicles - bilateral orchiectomy - is surgical castration.

[1], [2], [3], [4]

Indications for the procedure

First of all, the indications for this operation include a complicated, seized fibrous shell of the testicles, a purulent inflammation of the scrotum (scrotum); acute inflammation of the testis (orchitis) with abscess and necrosis (including as a result of its twisting); tuberculous testicular tumor; crushed or lacerated trauma of the inguinal region and genitals with the destruction of testicles.

An orchiectomy is performed with cryptorchidism - when even a two-stage orchiopexy can not move an abnormal testicle into the scrotum (in most cases, if the form of the  cryptorchidism is  abdominal), or it is completely atrophied. See -  Testicular Atrophy

In the same way, the problem of unilateral testicular hypoplasia as well as abnormal localization of testicles with an extremely rare congenital Morris syndrome (or false male hermaphroditism), which is essentially the result of a mutation of the androgen receptor genes, is manifested in the same way and manifests itself as complete insensitivity of the tissues to testosterone.

An orchiectomy is performed in testicular carcinoma, testicular carcinoma, chorion carcinoma, 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 the increase in the tumor, an orchiectomy can be performed in 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 producing it (although drug therapy with hormone antagonists gives the same results, but not so fast). In addition, after such an operation, the synthesis of a small amount of androgenic hormones is continued by the endocrine cells of the reticular cortex 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 cancer. In fact, the whole thing can be to increase the effect of estrogen, if we take into account the process of natural reduction of the synthesis of androgenic steroids in men after 50-55 years - precisely at the age of onset of andropause or  men's menopause, when there are problems with the prostate (in the form of prostatitis, adenomas and, of course, oncology).

Also, the fact of frequent development of a special form of metastatic prostate cancer - castrate-resistant prostate cancer (CRPC) - after taking testosterone-suppressing hormones and decreasing its level as after orchiectomy has been established. This is due to the fact that in response to a low level of testosterone, the number of androgen receptors that have tumor cells increases with simultaneous increase in their resistance to hormone therapy. According to clinical statistics, less than two years after drug-induced androgen deprivation, the tumor process progresses in almost half of the patients.

Never perform an orchiectomy without medical indications: a comprehensive examination (including psychiatric examination) is performed by transgender men who insist on  changing the sex  to female.

By the way, surgical castration - orchiectomy as a punishment for sexual abuse of minors - is a common sentence for pedophiles taken by the courts of the Czech Republic (in 1998-2008, there were about 100 such verdicts) and Germany. In the American states of Florida, California, Illinois, Arkansas and Ohio, surgical castration is an alternative to prolonged imprisonment. And in Texas and Louisiana, the criminal is allowed to choose between subcapsular and radical orchiectomy.

[5], [6], [7], [8], [9]

Preparation

If the operation is urgent - with injuries accompanied by bleeding and pain shock - the patient immediately gets on the operating table. A preparation for routine orchiectomy involves the surrender of a general and biochemical blood test; coagulograms; analysis for urogenital infections, hepatitis and HIV.

The patient is given an ECG; Doppler ultrasonography of the scrotum; Ultrasound of the groin, scrotum, prostate and abdominal cavity.

Of course, before the decision to perform this surgery in cases of oncology patients undergo a comprehensive examination. And the list of diagnostic procedures is more extensive, including biopsy, monitoring serum testosterone levels and determining the level of PSA. However, as noted by the experts of the American Cancer Society, there is no absolute oncospecificity in the prostate specific antigen (PSA) produced by the prostate gland, and its level can be increased because of inflammation or benign prostatic hyperplasia. However, in most cases of cancer of the prostate, the PSA content in the blood is higher than the age norms.

Six to eight hours before the operation, patients should not take food and any medications, and at least a week before the prescribed orchiectomy is strictly prohibited the use of alcoholic beverages.

Removal of testicles during a transgender transition is preceded by a sufficiently long therapy with testosterone hormone antagonists, which allows to avoid the development of the so-called Postastrational Syndrome.

[10], [11]

Technique of the leave it

The surgical technique for performing an orchiectomy depends on the specific diagnosis and takes into account the amount of necessary intervention: one-sided or two-sided orchiectomy.

If the neoplasm in testicular cancer is localized within its shell, only the glandular tissue of the testicle parenchyma can be removed, that is, a subcapsular orchiectomy is performed - with access through the dissection of the scrotum. In many cases, such an operation is performed by a laparoscopic method: by special tools through small incisions, by twisting, under regional (epidural) anesthesia.

At detection of abnormal cells in the testicle shell and beyond, as well as in neoplasms in the prostate gland (and an insufficient decrease in testosterone by the medicamental method), a bilateral contralateral or radical orchiectomy is shown: 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 with 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 to stop the production of testosterone.

After the removal of the testicles, the corresponding treatment of the operating field is carried out, the tissues of the inguinal canal are strengthened with a special biocompatible mesh material, and the dissected tissues are layered together. The operation is completed by drainage of the wound (usually drainage costs no more than a day) and the application of a pressure bandage.

With any method of orchiectomy performed with regard to oncology, the removed tissues are subject to histomorphological examination.

Contraindications to the procedure

Orchiectomy is not used if the patient turns to a urologist or oncologist for an inoperable IV stage of prostate cancer with a common metastasis.

Also, the operation is not performed if there is a real chance to overcome the oncological pathology of the testicle at an early stage - by chemotherapy and irradiation.

Contraindications to orchiectomy are most often associated with the presence of active infectious diseases and severe somatic diseases (chronic cardiac or renal insufficiency, decompensated diabetes, thrombocytopenia).

In most cases, there are contraindications when applying for a transgender transition, when applicants for sex change do not meet clearly defined criteria for a sexual identity disorder, and psychiatric experts diagnose either a comorbid condition or a mental disorder.

[12], [13]

Consequences after the procedure

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

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

Tides of blood to the head, bouts of hyperhidrosis, rapidity of the pulse make itself felt vegetative consequences after the procedure of removing testicles.

If you rely on feedback from patients after this operation, then in the list of signs of reducing the impact on the male body of androgenic factors, you should add an externally unreasonable feeling of fatigue, an unstable mood with bouts of irritability, deterioration in sleep quality, and so on.

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

In the case of bilateral (bilateral) orchiectomy, an absolutely insufficient level of testosterone leads not only to a decrease in libido, but also to a complete loss of erectile function.

[14], [15], [16], [17], [18]

Complications after the procedure

The most frequent complications after the procedure of orchiectomy: pain and swelling in the groin and lower abdomen; inflammation in the seam area with reddening and the release of a turbid syphilis; fever. With the last two symptoms, a course of systemic antibiotics is prescribed.

It is not considered a complication, when for some time the scrotum after the orchiectomy is edematous and it hurts. With swelling, you can do cold compresses on the groin area, and if pain is severe, take painkillers.

[19], [20], [21], [22]

Care after the procedure

During the first days, care after the procedure of orchiectomy is carried out in a hospital. A day after the operation, patients can go up from the bed and walk: the movement helps to reduce edema and better trophic tissue. But any physical exertion should be avoided, so that the stitches (which are usually removed after a week) do not loosen or break.

Regular inspection of the operation area is carried out, as well as its antiseptic treatment with the change of dressing. Bath procedures are contraindicated (only not very hot shower), but personal hygiene in the genital area is mandatory. Doctors advise wearing loose clothing, a special inguinal bandage or medical knitted underwear.

Treatment after orchiectomy

It is necessary to determine PSA after orchiectomy for prostate cancer - to choose the right tactics for subsequent therapy.

Most patients with malignant tumors of the prostate gland follow further treatment after orchiectomy - radiation or chemotherapy.

And if the removal of the testicles was performed with cryptorchidism, orchitis, atrophy or trauma, then it is supposed to fill the testosterone deficiency with hormone replacement therapy - HRT after orchiectomy.

Similarly, transsexuals after orchiectomy in most cases continue to take medications containing estrogen, but, probably, in smaller doses.

[23], [24], [25], [26], [27]