Pre-operatively:
- Tumour markers mandatory prior to orchidectomy
- Assess fertility and offer sperm banking
- Identify factors which may make procedure difficult – previous inguinal hernia repair, cryptorchidism surgery, concurrent hernia, obesity
- Offer testicular prosthesis with placement at time of orchidectomy
Procedure:
- Transverse incision
- Deep ring landmark – 2 – 4 cm above midpoint of inguinal ligament
- External ring – 1.5 cm superior / lateral to pubic tubercle (or invaginate scrotum)
- Dissection through superficial fat – 2 x superficial veins usually identified and controlled
- Exposure of EOA down to superficial ring
- Incise EOA sharply in line of fibres. Identify and protect ilioinguinal nerve deep to EOA.
- Mobilise cord circumferentially off EOA, cremasteric fibres and external spermatic fascia down to level of pubic tubercle. Early clamping of proximal cord to avoid theoretical seeding of tumour cells.
- Deliver testis and divide gubernacular fibres, careful not to button-hole scrotal skin.
- Division of cord in one or two parts, with ligation of proximal cord – transfixion suture 0-vicryl (ease n squeeze) followed by 2-0 prolene tag.
- Haemostasis of cremasteric and gubernacular fibres. Place prosthesis if doing so. Closure of EOA with 3-0 vicryl avoiding II nerve.
Complications
- Infection – rare.
- Ilioinguinal nerve injury or entrapment – may present with pain (immediate or delayed), or hypoesthesia or hyperesthesia (anterior scrotum / upper thigh)
- Post-operative retroperitoneal bleed
- Consider observation if haemodynamically stable / Hb stable, or embolisation
- Re-open inguinal incision with proximal extension, may need to extend into retroperitoneum to find bleeding stump
- Scrotal violation – need to surveil inguinal nodes also