Orchiectomy

Testes The testes (testicles) are male reproductive glands

found in a saccular extension of the anterior
abdominal wall called the scrotum.

They are in ovoid shape, average volume of the adult

testis is approximately 25 mL. Sized 3.5-5 cm in length
by 2.5-3 cm in both width by 3 cm in depth
(anteroposterior diameter).

Testes develop retroperitoneally on the

posterior abdominal wall and descend to
scrotum before birth.

The scrotum is often asymmetric, with one

testis extending further down than the
other.

After their descent, the testes remain connected

with the abdomen by spermatic cords, and
attached to the scrotum by the testicular ligament.
 ●
Testes in males are analogous
Analogous to the female ovaries.

They produce sex hormones called androgens (primarily

●

Product testosterone) in the process of steroidogenesis and are

the place of spermatogenesis, the production of sperm.

Controlled The function of the testes is controlled by the adenohypophysis

●

(anterior pituitary gland), where its luteinizing hormone (LH)

stimulates the production of testosterone, and follicle-

by stimulating hormone (FSH) stimulates sperm production.

Scrotum
• The scrotum is a cutaneous sac that contains the testes, or testicles, and the
lower parts of the spermatic cord.
• Importantly, the scrotum allows the testes to be positioned outside of the body.
• The scrotum layer from outside to inside
• Skin of scrotum
• Superficial (dartos fascia)
• External spermatic fascia
• Cremaster muscle and fascia
• Internal spermatic fascia
• Parietal layer of tunica vaginalis
• Visceral layer of tunica vaginalis
Netter FH. Atlas of Human Anatomy. Philadelphia: elsevier, 2019, p. 371
Netter FH. Atlas of Human Anatomy. Philadelphia: elsevier, 2019, p. 372
Vascularisation

Testes Scrotum
• Testicularis A. bracnh of aorta • Anterior scrotal A. terminal branch of
abdominalis external pudendal A.
• Deferentialis A. branch of Inferior • Posterior scrotal A. terminal branch of
vesicular A. internal pudendal A.
• Cremasterica A. branch of Inferior • Cremasteric A. branch of inferior
epigastric A. epigastric A.
• Vein drain  pampiniform venous • Scrotal veins ended at external pudendal
plexus veins
• Lymphatic drain  lymphatic nodes of • Lymphatic drain  inguinal lymph nodes
right and left aorta
Netter FH. Atlas of Human Anatomy. Philadelphia: elsevier, 2019, pp. 383. 385
Orchiectomy

Definition
• Removal of a testis

Type
• Inguinal
• Scrotal
Common indications
Contraindications

Manifest coagulation
disorders

If testicular cancer is
suspected, an inguinal
approach is mandatory
Complications

Bleeding with hematoma

Wound infection

Hypogonadism depending on the

contralateral testicular function
Simple orchiectomy

Definition
• Removal of both testes (usually bilateral) to halt the production of
testosterone in prostate cancer and as part of sex reassignment surgery from
male to female

Indication
• Unsalvageable testicular trauma
• Severe recurrent or chronic testicular pain
• Testicular infarction (e.g., following testicular torsion)
• Part of gender reassignment surgery
 Procedures
• Place the patient in the supine position
• Shave the scrotum and prepare the lower
abdomen, penis, and scrotum with aqueous
betadine or chlorhexidine. Drape accordingly
• Pull the testis down to relax the cremaster
• Grasp the scrotum and compress the testis
against the anterior scrotal wall to stretch the
skin over it

Hashim H, Abrams P, Dmochowski R. The handbook of office urological procedures. London: Springer; 2008. pp. 36.
 Procedures - incision

One of two incisions can be

made. They only need to be
approximately 3–5 cm:
●
Unilateral transverse incision within the
scrotal folds and between the scrotal vessels
●
Median raphe incision (preferred incision)
●
Allowing good accesst to both testis and
results in minimal bleeding with good
postoperative scar.

Hashim H, Abrams P, Dmochowski R. The handbook of office urological procedures. London: Springer; 2008. pp. 36.
Procedures
• Keep testis under compression and incises dartos muscle and
cremasteric layers one by one from one edge of the wound to the
other. Stop when you reach the bluish tunica vaginalis.
• Push all the scrotal layers away from the testis using a swab. The testis
can at this stage be delivered with the tunica vaginalis and then the
tunica vaginalis incised.
• Gently pull the testis down to expose the epididymis and cord.
 Spermatic cord separation

• Gently and bluntly, using tissue

scissors, separate the
spermatic vessels from the vas
deferens. The vas normally lies
anterior and the vessels
posterior to it.

Hashim H, Abrams P, Dmochowski R. The handbook of office urological procedures. London: Springer; 2008. pp. 350.
Procedures
• Place two clamps proximally (cranially), one above the other with
approximately 1 cm between them on the vas, and one distal
approximately 2 cm from the lower of the two proximal clamps.
• Divide the vas between the distal and proximal clamps using tissue
scissors. Ligate the vas below the distal clamp and remove the clamp.
Then ligate the vas above the lower proximal clamp and remove it,
and then ligate above the top proximal clamp and remove the clamp.
3/0 synthetic absorbable sutures can be used for ligation.
Procedures - closing
• Ensure that hemostasis is achieved before closure.
• At this stage a prosthesis can be inserted.
• Close the dartos muscle with undyed 3/0 absorbable suture in a
continuous fashion.
• Close the skin with interrupted undyed 4/0 synthetic absorbable
suture to avoid staining of the skin. Alternatively, you can use surgical
glue or use a subcuticular monofi lament continuous suture.
• Cover the wound with a non-stick dressing.
Subcapsular orchiectomy

Definition
• Variation of simple orchiectomy
• Capsule of the testes is left behind to maintain scrotum shape

Indication
• Management of prostatic carcinoma
• Treatment of hormone-dependent prostate cancer
Procedures
• Same delivering of testis procedures as simple orchiectomy
• Incises the tunica albuginea of the testis along its length
• Clamp the sides of the tunica albuginea with two or three clamps on
each side and evert the edges.
• Using a gauze swab, use the index fi nger to swipe off all the tubules
from the inner layer of the tunica albuginea. This tends to bleed and
you will need to electrocauterize the bleeding vessels as they appear.
 Procedures
• The tubules will be attached to the hilum
inside the tunica albuginea. Clamp, ligate,
and divide the hilus and electrocauterize it
to stop any bleeding.
• Electrocauterize all the internal surface of
the tunica albuginea to destroy any
residual cells that may produce
testosterone.
• Suture the edges of the tunica albuginea
with a continuous 3/0 synthetic
absorbable suture.

Hashim H, Abrams P, Dmochowski R. The handbook of office urological procedures. London: Springer; 2008. pp. 56.
Procedures – contralateral testis
• Replace the testis back into the scrotum.
• Ensure that hemostasis is achieved before closure.
• Close the dartos muscle with undyed 3/0 absorbable suture in a
continuous fashion.
• Open the contralateral hemiscrotum through the same midline
incision and deliver the testis as before. Follow the previous steps.
Procedures - closing
• Close the skin with interrupted undyed 4/0 synthetic absorbable
suture to avoid staining of the skin. Alternatively, you can use surgical
glue or use a subcuticular monofi lament continuous suture.
• Cover the wound with a non-stick dressing.
Radical orchiectomy

Definition
• Removal of testis and spermatic cord
• Done through groin incision

Indication
• Radical orchiectomy is typically the first step in any
multidisciplinary approach to the management of men with
testicular germ cell neoplasia.
Procedures
• Patient in the supine position
• A curvilinear incision is made
beginning approximately 2 cm
cephalad and lateral to the pubic
tubercle, extending laterally along a
Langer’s line for 5 to 7 cm.
• The incision can be oriented more
obliquely and extend toward, or
onto, the scrotum to facilitate
delivery of a large testicular tumor.

Smith J, Howards S, Preminger G. Hinman's atlas of urologic surgery. 3rd ed. Philadelpia: Elsevier; 2012. pp. 353.
Procedures
• The incision is carried through the
subcutaneous tissue onto the external
abdominal oblique aponeurosis with
electrocautery.
• The external abdominal oblique aponeurosis
is sharply opened over the inguinal canal
extending medially to the external inguinal
ring and laterally to a point overlying the
level of the internal inguinal ring.
• The ilioinguinal nerve lying on top of the
spermatic cord is identified and dissected
free from its investing external spermatic
fascia and cremasteric musculature, and
retracted laterally out of harm’s way.
Smith J, Howards S, Preminger G. Hinman's atlas of urologic surgery. 3rd ed. Philadelpia: Elsevier; 2012. pp. 354.
Procedures
• Gentle blunt dissection at the level of
the pubic tubercle with the aim of
circumscribing the spermatic cord and
cremasteric musculature is next
accomplished (Fig. 59-3).
• The surgeon’s finger should
subsequently easily pass posterior to the
cord along the floor of the inguinal canal.
• Care should be taken to avoid dissection
through the floor of the inguinal canal,
avoiding the risk of the development of a
postoperative direct inguinal hernia.

Smith J, Howards S, Preminger G. Hinman's atlas of urologic surgery. 3rd ed. Philadelpia: Elsevier; 2012. pp. 354.
Procedures
• The cord should be secured with
a 1⁄4-inch Penrose drain passed
twice around and clamped with
a hemostat, providing early
vascular control before any
tumor manipulation is done.

Smith J, Howards S, Preminger G. Hinman's atlas of urologic surgery. 3rd ed. Philadelpia: Elsevier; 2012. pp. 354.
Procedures
• The assistant surgeon should
gently push the testicle from
the base of the prepped
hemiscrotum toward the
incision to facilitate delivery of
the intact testicle within the
tunica vaginalis.
• The surgeon should apply gentle
traction to the spermatic cord
to aid this mane

Smith J, Howards S, Preminger G. Hinman's atlas of urologic surgery. 3rd ed. Philadelpia: Elsevier; 2012. pp. 354.
Procedures
• Subsequent to delivery of the testicle, the hemiscrotum will be
invaginated at the level of the incision by the gubernaculum, which
should be incised by electrocautery.
• The delivered testicle within the tunica vaginalis is then free and
attached only by the spermatic cord. In the rare instance that biopsy
is indicated, it should be performed at this time.
• To facilitate removal of the abdominal portion of the spermatic cord
during retroperitoneal lymphadenectomy, we prefer high ligation of
the spermatic cord.
• The cord is dissected proximal to the internal inguinal ring.
Procedures
• Cremasteric muscle fibers are
incised with electrocautery at this
level, thus skeletonizing the cord
and allowing clear visibility of the
cord vasculature and vas deferens.
• A handheld retractor can be used
to elevate the internal abdominal
oblique musculature that forms
the lateral edge of the internal
ring, revealing retroperitoneal fat

Smith J, Howards S, Preminger G. Hinman's atlas of urologic surgery. 3rd ed. Philadelpia: Elsevier; 2012. pp. 355.
Procedures
• Ligate and divide the vas deferens separately from the cord at this level
with 2-0 permanent suture.
• The cord proper is doubly ligated and divided at this level with 0
permanent suture.
• The surgical field is irrigated and meticulous hemostasis is obtained.
• The external abdominal oblique aponeurosis is approximated with running
2-0 absorbable suture, taking care to not include the ilioinguinal nerve.
• The subcutaneous fascial tissue layers are approximated with running 3-0
absorbable suture. The skin is closed in a routine fashion.
• A subcuticular closure with running 4-0 absorbable suture is preferred.
Thank you
Bibliography
• Hashim H, Abrams P, Dmochowski R. The handbook of office
urological procedures. London: Springer; 2008. pp. 51-8.
• Netter FH. Atlas of Human Anatomy. Philadelphia: elsevier, 2019, p.
371, 372, 383, 385
• Smith J, Howards S, Preminger G. Hinman's atlas of urologic surgery.
3rd ed. Philadelpia: Elsevier; 2012. pp. 353-5.
• Partin A, Dmochowski R, Kavoussi L, Peters C. Campbell-Walsh-Wein
urology. 12th ed. Philadelphia: Elsevier; 2018. pp. 7969-83.