Partial Orchiectomy - A Non-radical Cancer Surgery

Introduction

Richie performed the first reported partial orchiectomy in the United States in 1984. Partial orchiectomy is performed in small nonpalpable testicular masses found on scrotal ultrasonography. When radical orchiectomy is considered an overtreatment for benign masses, partial orchiectomy is considered. In addition, partial orchiectomy may be considered in bilateral metachronous testicular malignancies, solitary testicles, restoring fertility, and being free from androgen supplements.

What Is Testicular Cancer?

The testis is located in the scrotum, a loose bag of skin below the penis. Testicular cancer is the most common cancer among men aged between 15 and 35. Testicular cancer presents as a solid, palpable mass. Therefore, partial orchiectomy may be ideal for the treatment of testicular cancer. In addition, partial orchiectomy may reduce the need for androgen supplements, but the individual may require chemotherapy or radiation.

What Are the Indications for Partial Orchiectomy?

The indications for partial orchiectomy involve:

Pre-pubertal Testis Tumors: Studies have shown a higher incidence between 48 to 74 percent of benign testicular lesions in pre-pubertal patients. The individuals show a teratoma with common histology. Therefore a testis-sparing approach becomes a necessity. Partial orchiectomy may be considered in pre-pubertal individuals with age-justified alpha-fetoprotein (a protein produced by the liver used to check for birth defects). Partial orchiectomy is considered when the histology of an intraoperative frozen section is benign. If malignancy is detected, then a radical orchiectomy is performed. Partial orchiectomy is a safe and effective procedure performed in cases of

• Teratoma.

• Epidermoid cyst.

• Sertoli cell tumor.

• Leydig cell tumor.

• Juvenile granulosa cell tumor.

• Simple intratesticular cyst.

• Tubular ectasia of the rete testis.

• Testicular adrenal rest tumors.

Post-pubertal Individuals: Malignant testicular tumors are commonly seen in post-pubertal individuals. Mixed germ cell tumor is the most common in young adults and adolescents, whereas 98 percent of prepubertal testis tumors are pure yolk sac tumors. Partial orchiectomy successfully manages epidermoid cysts, stromal tumors, and fibrous pseudotumors. Cases of small or incidentally detected testicular masses in adult cases are apt for partial orchiectomy procedures as they have a higher incidence of benign pathology. Small tumors involve masses less than two centimeters and have a 50 to 80 percent chance of being benign. Partial orchiectomy is considered only in cases where the mass in post-pubertal individuals is less than two centimeters and in normal tumor markers. Hence partial orchiectomy is done in benign masses, and radical orchiectomy is done in malignant masses. Partial orchiectomy is performed in adults with bilateral testis tumors or solitary tumor testis. In malignancy cases, in situ, individuals with a high incidence of germ cell neoplasia should undergo radiation therapy after partial orchiectomy. Post radiotherapy, the individual may require androgen replacement and have an increased risk of infertility. Counseling is given to the individuals before undergoing the procedure. The follow-up time for partial orchiectomy is 41 to 20 months.

What Operative Techniques are Used in Partial Orchiectomy?

Before the surgery, the individual may be evaluated under case and patient selection criteria and counseled about switching to radical orchiectomy. It must be highlighted that opting for testis sparing does not rule out the possibility of orchiectomy. The procedure is initiated with an incision of the inguinal and external oblique fascia and mobilization of the testis into the incision. A soft tourniquet is used for atraumatic occlusion of the spermatic cord. Clamping of the spermatic is avoided as it holds the risk of tumor spread. The testis is immersed in crushed ice after cold occlusion to attain cold ischemia. After the testis is delivered, it is draped in towels for tumor spillage, and the tunica vaginalis is later opened. The mass is localized by palpation, and scrotal ultrasound may help to locate deeper masses. The tumor is enucleated with a parenchyma rim and sent for frozen section examination. If the histology result is benign, the tunica albuginea is sutured and placed back into the scrotum. If malignancy is detected, then radical orchiectomy is performed. The frozen section is the principal component of partial orchiectomy. The frozen section has a high specificity and sensitivity in distinguishing benign and malignant tumors.

What Is the Presentation for Partial Orchiectomy?

The presentation is mainly associated with the symptoms of testicular cancer. They involve:

• Swelling or nodule in one or both testis.

• Painful testis or orchitis.

• Fever.

• Lymphadenopathy.

• Abdominal pain.

• Nausea.

• Neurologic deficits.

• Shortness of breath.

• Hemoptysis.

What Is the Etiology of Testicular Cancer?

The following are the etiologies of testicular cancer:

• Individuals with cryptorchidism have a seven to ten percent chance of having testicular cancer.

• Gonadal dysgenesis.

• Male factor infertility.

• Individuals aged between 20 to 34 years are at a higher risk of having testicular cancer.

What Are the Contraindications for Partial Orchiectomy?

The contraindications are:

• Individuals with elevated serum marker levels.

• Palpable testicular masses.

• Gynecomastia.

• Retroperitoneal germ cell cancers.

• Cases where an excisional biopsy cannot be performed.

In these cases, radical orchiectomy is preferred.

What Are the Functional Outcomes of Partial Orchiectomy?

Adults treated for malignant testicular tumors may have long-term effects from radiation, surgery, and chemotherapy. These procedures impact fertility, quality of life, and gonadal function. Studies have shown that losing a single testis may lead to a negative body image, decreased spermatogenesis, and insufficient androgen production. However, many individuals with germ cell tumors may have impaired fertility. Therefore, preservation of testis tissue through partial orchiectomy may be considered. Studies have shown that individuals who underwent partial orchiectomy for benign tumors preserved testicular parenchyma without atrophy and tumor recurrence after follow-up for 10 to 15 years. In addition, adults who underwent partial orchiectomy in solitary testis had sufficient postoperative testosterone levels.

Conclusion

Partial orchiectomy is a surgical procedure performed as an alternative to radical orchiectomy. Due to the predominance of benign testicular tumors, the need for testicular-sparing approaches has increased. Partial orchiectomy shows promising results in benign masses, as radical orchiectomy may be an overtreatment for such cases. However, radical orchiectomy is the standard for malignant tumors.