Version May 2024
INTRODUCTION — Testicular cancers, 95 percent of which are germ cell tumors, have become one of the most curable solid neoplasms because of remarkable treatment advances that began in the late 1970s. Prior to that time, testicular cancer accounted for 11 percent of all cancer deaths in men between the ages of 25 and 34, and the five-year survival rate was 64 percent [1]. Now, the five-year survival rate is over 95 percent for both seminoma and nonseminomatous germ cell tumors (table 1) [2], and testicular cancer only causes approximately 410 deaths annually in the United States [3].
These improvements in outcome are related to a better understanding of the natural history of testicular tumors, improved staging and surgical techniques, the use of tumor markers to guide patient management, and the introduction of effective platinum-based combination chemotherapy [1,4,5]. The consistently high cure rates in early-stage disease have resulted in a shift in focus toward reducing treatment-related effects on reproductive function as well as the toxicities associated with chemotherapy and radiation. (See "Treatment-related toxicity in testicular germ cell tumors".)
Radical orchiectomy for the diagnosis and treatment of men with suspected testicular cancer is discussed here. An overview of the management of testicular cancer is presented separately. (See "Initial risk-stratified treatment for advanced testicular germ cell tumors".)
SURGICAL TREATMENT OF THE TESTIS — The decision to proceed with operative intervention in a man with suspected testicular cancer is made after careful consideration of all available data, including clinical findings, imaging studies, and serum tumor markers. Although frequently used to support a clinical suspicion of testicular cancer, scrotal ultrasound of a testicular mass cannot replace surgical and histologic examination of the testis based upon radical inguinal orchiectomy. (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors".)
Radical inguinal orchiectomy — Radical inguinal orchiectomy with high ligation of the spermatic cord at the level of the internal ring is the procedure of choice for suspected testicular cancer.
There are two main benefits from this procedure:
●Removal of the testis establishes the histopathologic tumor type and T stage, both of which have an important effect on subsequent management.
●Radical inguinal orchiectomy provides definitive local tumor control and causes minimal morbidity. Rare exceptions to this rule occur in patients who have tumor spillage at the time of radical orchiectomy, who have a partial or incomplete orchiectomy, or who undergo surgery with an inappropriate incision (eg, transscrotal surgery or transscrotal biopsy). (See 'Scrotal violation' below.)
Technique — Radical inguinal orchiectomy can be performed under general, spinal, or local anesthesia, usually on an outpatient basis. The patient is placed in the supine position, and the lower abdomen and scrotum are prepped and draped in routine fashion. An oblique incision is made in the inguinal area parallel to the inguinal canal, beginning just lateral to the pubic tubercle for a distance of approximately 5 cm. Larger tumors may require a slightly larger incision, which is extended toward the neck of the scrotum.
The fascial layers of Camper and Scarpa are divided to the level of the external aponeurosis, which is then incised in the direction of its fibers to the level of the internal ring. The ilioinguinal nerve is identified, dissected free of the cord, and preserved. The spermatic cord is isolated and occluded at the level of the internal ring. The testis and its investing tunics are then delivered into the surgical field. Finally, the gubernacular attachments are divided, usually after they have been separated into two pedicles (vas deferens and spermatic vessels), and the spermatic cord is suture-ligated 1 to 2 cm inside the internal ring. The cord vessels are secured with silk ligatures, which can then be used to identify the spermatic cord stump if retroperitoneal lymphadenectomy is subsequently performed. (See "Retroperitoneal lymph node dissection for early-stage testicular germ cell tumors".)
A saline-filled testicular prosthesis may be inserted at the time of radical inguinal orchiectomy. We and others have been impressed by the excellent cosmetic results and patient satisfaction with this procedure, although this option is largely based upon patient preference [6,7]. As an example, 86 patients who received a testicular prosthesis at surgery were evaluated at a median of six years after surgery [8]. Overall satisfaction with the surgical outcome was rated as excellent in 28 percent and good in 45 percent. Nine men (10 percent) regretted having the prosthesis placed, and two subsequently had the prosthesis removed.
If a diagnostic biopsy or subtotal orchiectomy is planned, it should be undertaken after the testis is mobilized via the suprainguinal incision described above. Isolation of the rest of the surgical field from the testis is mandatory prior to incision into the testicular parenchyma to avoid scrotal violation. (See 'Scrotal violation' below.)
The wound and scrotum are thoroughly irrigated, and hemostasis is secured. Surgical closure is usually performed in layers, followed by subcuticular skin closure and application of a compression dressing.
Complications — The most common complication of radical orchiectomy is postoperative wound hemorrhage, which may cause either a scrotal or retroperitoneal hematoma. Complications related to radical inguinal orchiectomy only rarely necessitate a delay in the initiation of chemotherapy for men who require further therapy. (See "Initial risk-stratified treatment for advanced testicular germ cell tumors".)
Delayed orchiectomy — For men who present with clinically advanced disease, we prefer to perform radical orchiectomy prior to chemotherapy whenever possible. In our experience, chemotherapy does not impair wound healing following radical orchiectomy. (See "Initial risk-stratified treatment for advanced testicular germ cell tumors".)
Despite this usual approach, there are some men who present with life-threatening advanced disease who undergo systemic chemotherapy prior to orchiectomy [9-15]. The rationale for late orchiectomy following chemotherapy is the presence of residual testicular disease in a significant percentage of patients that cannot be distinguished by testicular ultrasound from the scar tissue that is present in almost all patients.
The frequency of significant abnormalities in the orchiectomy specimen was illustrated in a series of 160 patients treated at Indiana University, in whom chemotherapy was given prior to surgery [9]. Residual carcinoma and pure teratoma were identified in 25 and 31 percent of cases, respectively, while necrosis or scar was present in the others.
Scrotal violation — Suboptimal approaches to testicular neoplasms, such as scrotal orchiectomy, transscrotal biopsy, or fine-needle aspiration, are performed in 4 to 17 percent of patients.
Some studies report a higher recurrence rate in patients with scrotal incisions [16,17]. Incisions in the scrotal wall change the lymphatic drainage, with possible spread to the inguinal nodes. This might necessitate groin dissection or adjunctive chemotherapy, which is totally unnecessary without scrotal violation and carries substantial morbidity.
The need for additional therapy in men in whom scrotal violation has occurred is unclear.
●In one series, there was no increase in the rate of local or distant recurrence in those receiving postorchiectomy chemotherapy among men who had scrotal orchiectomy compared with those undergoing inguinal orchiectomy [18]. The overall disease-free survival rate was 99 percent. These early findings led to a recommendation for chemotherapy rather than surveillance strategies in men who had scrotal violation.
●Other series suggest that men who have scrotal violation may have a small increase in the incidence of local recurrence, but this does not necessarily require further local or adjuvant systemic treatment [17,19,20]. A meta-analysis compared 206 men with testicular cancer in whom scrotal violation had occurred at the time of orchiectomy with 976 cases undergoing conventional inguinal orchiectomy without scrotal violation [17]. Although significant differences were noted in the local recurrence rate between the scrotal violation and inguinal orchiectomy groups, the overall local recurrence rates were small (2.9 versus 0.4 percent, respectively), and there were no significant differences in either distant recurrence or survival. Patients with scrotal violation who did not receive any local therapy (ie, radiation, scar excision) fared as well as those who did receive local therapy.
These data suggest that scrotal violation does not impart a significantly worse overall prognosis and that scrotal violation in men with stage I disease (table 1 and table 2A-B) should not necessarily disqualify them from surveillance protocols.
Although scrotal violation may not affect overall survival, we suggest the following in addition to spermatic cord excision, either before or after chemotherapy:
●Stage I nonseminomatous germ cell tumor – Scrotal scar excision.
●Stage I or II seminoma – Extension of radiation portals to include the ipsilateral groin and scrotum if patients are to receive radiation therapy.
●More advanced disease – We do not recommend additional local surgery in this subset of patients. These patients generally receive systemic therapy, and local relapse following systemic treatment is rare.
Partial orchiectomy — Partial orchiectomy is sometimes used to preserve future fertility.
A subset of carefully selected patients who have a solitary testicle, bilateral testicular tumors, or strong suspicion of a benign lesion may be candidates for "testis-sparing" surgery [21-23]. Simultaneous or sequential bilateral testicular germ cell tumors occur in 2 to 5 percent of affected men. Among those with second primary tumors, up to one-half present more than five years after the initial tumor [24-26]. (See "Epidemiology and risk factors for testicular cancer", section on 'Contralateral testicular cancer'.)
A major concern when sparing part of a tumor-bearing testis is the high prevalence of adjacent foci of germ cell neoplasia in situ, which is present in as many as 85 percent of cases [27]. Biopsy with frozen section analysis may be helpful [28]. (See "Testicular germ cell neoplasia in situ".)
A report from the German Testicular Cancer Study Group described 73 men who underwent partial orchiectomy [29]. At a median follow-up of 91 months, only four had developed a local recurrence. All occurred in the setting of untreated germ cell neoplasia in situ, and all were successfully salvaged by inguinal orchiectomy. In 85 percent of these men, normal serum testosterone concentrations were maintained.
In another report of 24 patients undergoing partial orchiectomies for bilateral or solitary small (<2 cm) testicular tumors, seven developed a local recurrence: five with testicular intraepithelial neoplasia (TIN) were salvaged with radical orchiectomy; two underwent redo partial orchiectomy [30]. After a median follow-up of 51 months, all patients survived and had normal testosterone levels; four patients achieved conception. Another study from the same clinic reported that among nine patients who underwent partial orchiectomy and were diagnosed with germ cell tumor, only one developed a local recurrence after a median follow-up of 45 months [31].
The optimal management of men who have undergone partial orchiectomy is controversial. Some advocates of organ-preserving surgery in testicular cancer recommend that all patients be treated with adjuvant radiation therapy (18 to 20 Gy) to the retained testicular parenchyma because of the risk of recurrence, regardless of whether the testicular tumor histology is seminoma or nonseminoma [22,29]. However, such treatment invariably results in arrest of spermatogenesis and infertility, and it has not become the standard of care [30]. Others recommend it only when germ cell neoplasia in situ is documented [23].
In our view, partial orchiectomy should be considered only for carefully selected men with testicular cancer and a solitary testicle in whom preservation of fertility is an important consideration. Negative postresection biopsies of the tumor bed and absence of germ cell neoplasia in situ in the remaining testicular parenchyma should be a sine qua non of this procedure, which should be carefully performed under conditions of cold ischemia to avoid tumor spillage or contamination. In addition, patient compliance for rigorous follow-up must be assured.
FOLLOW-UP AFTER RADICAL ORCHIECTOMY — The need for further treatment following radical inguinal orchiectomy is dictated by the results of the staging evaluation, the histologic type of malignancy, and the postoperative serum tumor marker status. (See "Initial risk-stratified treatment for advanced testicular germ cell tumors".)
Serum tumor markers — Elevated serum concentrations of tumor markers, particularly the beta subunit of human chorionic gonadotropin (beta-hCG) and alpha-fetoprotein (AFP), are common in patients with nonseminomatous germ cell tumors and, infrequently, in those with pure seminoma. In men with stage I disease who have elevated serum tumor markers prior to radical orchiectomy, follow-up values should be obtained on a weekly basis to document the postorchiectomy decline. Rapid normalization of or a 10-fold reduction in serum beta-hCG within two weeks and serum AFP within 25 to 30 days suggest elimination of the tumor, while persistent elevation of tumor markers after the period during which normalization is expected to occur may be the only evidence of persistent occult disease. (See "Serum tumor markers in testicular germ cell tumors".)
Following successful initial treatment, periodic surveillance of serum beta-hCG and AFP is the most sensitive means of detecting early relapse. Recommended schedules for monitoring tumor markers and other follow-up studies are discussed elsewhere. (See "Posttreatment follow-up for testicular germ cell tumors".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Testicular cancer".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Testicular cancer (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Radical inguinal orchiectomy – For men with suspected primary testicular cancer, we recommend orchiectomy to establish the histologic diagnosis and to provide definitive treatment of the primary tumor (Grade 1A). The standard approach for orchiectomy is radical inguinal orchiectomy. Such men should not undergo a lesser procedure involving a scrotal violation, because of the risk of local recurrence. (See 'Radical inguinal orchiectomy' above and 'Scrotal violation' above.)
●Partial orchiectomy – Partial orchiectomy is an alternative for men with a solitary testicle in whom preservation of fertility is an important consideration. Other options to preserve fertility, such as sperm cryopreservation, should also be considered. (See 'Partial orchiectomy' above and "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors", section on 'Cryopreservation of sperm'.)
●Follow-up after surgery – Following orchiectomy, serum tumor markers should be monitored closely to ensure that orchiectomy removed all disease and to provide early evidence of any recurrence. (See 'Serum tumor markers' above and "Posttreatment follow-up for testicular germ cell tumors".)
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