Radical orchidectomy requires a urological surgeon, at least one assistant, a scrub nurse or technician, and an anesthetist to administer the anesthesia. The theatre support staff are also needed, as is with other standard abdominal procedures.

Preoperative preparation of the patients involves optimization and management of comorbidities, which may include cessation of medications such as anticoagulants or antiplatelets. A period of fasting is advisable, as appropriate. All patients undergoing orchidectomy should be offered testicular prosthesis and should have a discussion about this in the preoperative clinic.

Patients who are concerned about fertility should also be offered sperm banking, especially those who may require adjuvant care such as radiation or chemotherapy, which may affect the contralateral testis. A detailed written informed consent is obtained before surgery and is best obtained in the clinic before the day of surgery. On the day of surgery, the patient should have a re-examination, and the side marked clearly with a permanent marker.[6]

It is an aseptic procedure and follows all the guidance as standard abdominal surgery. Once the patient arrives in the theatre, the WHO theatre checklist should be started and all the aspects completed for each step.  Anesthesia may be general or regional as appropriate and is administered in the induction room. 

On the operating table, the patient is positioned supine, routine cleaning is done with antiseptic solution from the nipple line to the mid-thighs and draped to isolate the sterile zone. A transverse groin skin crease incision yields the best cosmetic result post-op. Dissection is carried down through the layers of the anterior abdominal wall to the external oblique aponeurosis, which is opened along its fibers to gain access to the inguinal canal. Care is taken at this point to prevent injury to the ilioinguinal nerve just lying beneath the aponeurosis.

The cord contents are identified, and a Penrose drain wrapped and clamped tightly around the cord to prevent hematogenous micro-metastases. The testis is delivered along with its coverings from the scrotum through the inguinal wound. The distal gubernaculum is clamped and divided while the proximal cord is then clamped as close to the internal ring as possible, ligated preferably with a non-absorbable suture and divided.

Ligating the testicular vessels in continuity will prevent potentially life-threatening retroperitoneal bleeding from a slipped ligature. It is essential throughout the procedure to avoid any breach of the scrotal skin, as this may alter the lymphatic drainage of the tumor. To achieve this, gentle blunt dissection to free the testes from the scrotal skin is helpful. Hemostasis is achieved with the use of bipolar electrocautery. A testicular prosthesis is then inserted and anchored at this point if agreed earlier. The wound is then closed in layers and dressed with a sterile dressing.[7]

Excessive primary hemorrhage may occur intraoperatively due to injury to the inferior epigastric vessels, which lie medial to the internal ring. Damage to the ilioinguinal nerve can cause paraesthesia or numbness on the patch of skin on the medial part of the upper thigh and the anterior part of the scrotum, or predispose the patient to direct inguinal hernia due to weakness of the posterior inguinal wall muscles. Wound complications may include wound infection, extensive bruising, seroma, or hematoma.

Most wound complications resolve spontaneously with few requiring aspiration or re-exploration for evacuation. Scrotal edema or hematoma may occur following extensive scrotal dissection in delivering large tumors and may require management with scrotal support, analgesia and anti-inflammatories. Rarely, large hematomas will require surgical exploration and evacuation. Early handling of the tumor or late clamping of the cord may cause micro-metastases or increase the risk for local recurrence. 

Long term psychological or social complications due to the absence of the testis may be improved with the use of testicular prosthesis. A testicular prosthesis may be associated with complications such as rupture, scarring, retraction, contracture, or implant infection.[8]

Testicular cancers are rare malignancies accounting for about 1% of all malignancies in the male population. It is, however, the most common solid organ malignancy in young males aged 15 to 35 years.[9] Early diagnosis significantly improves cure rates. Lymphatic drainage of testicular cancer follows the testicular arteries to the para-aortic, interaortocaval, and infrarenal groups of lymph nodes, while drainage of the scrotum is to the inguinal lymph nodes. This disparity in the drainage of these very closely related structures influences the importance of an entirely inguinal approach to delivering testicular cancers to prevent breaching the scrotum and interfering with the lymphatic drainages and upstaging the tumor. Trans-scrotal testicular biopsies are therefore absolutely contraindicated for the same reason.[10]

Once the general practitioner suspects testicular cancer, a referral is made under the suspected cancer pathway for an appointment within two weeks with a urologist. The patients can be seen in one-stop clinics with direct access to testicular ultrasound scanning. A large cohort study involving 1757 patients who attended a one-stop testicular clinic in a University hospital in the UK showed that the median waiting time to be seen was nine days compared to 13 days for general patients. The time from clinic to orchidectomy was five days with the benefits of discovery of subclinical cancers, timely diagnosis, treatment, and on-time reassurance of patients with benign results.[11]

All patients with a strong suspicion of or confirmed case of testicular cancer merit discussion in the local multidisciplinary meeting (MDT) of the hospital. All aspects of a patient’s management are discussed and agreed at the MDT meeting. These include staging investigations, plan for adjuvant radiotherapy, chemotherapy or hormonal therapy, social, psychological care, and follow-up.

The members of the urology cancer MDT include:

• Urologist/lead clinician
• Macmillan clinical nurse specialists
• Radiologist
• Histopathologist
• Palliative care medicine
• Oncologist
• MDT coordinator

Clinical specialist nurses are very experienced in the care of patients with cancers. Macmillan nurses are involved early in the management of testicular cancers, and they provide early guidance, optimal follow-up, and advice when required. They offer a strong link between the surgeon, the oncologist, and the palliative care physicians.

The clinical nurse specialists have dedicated clinics that follow up patients who have had orchidectomies and provide close patient health worker relationships and surveillance needed for patients who are post adjuvant care or those who required no further treatment following their surgical procedure.