Orchiectomy is the surgical removal of one or both testicles, or testes, in the human male. It is also called an orchidectomy, particularly in British publications. The
removal of both testicles is known as a bilateral orchiectomy, or castration, because the person is no longer able to reproduce. Emasculation is another word that is sometimes used for castration of a male. Castration in women is the surgical removal of both ovaries (bilateral oophorectomy).
Purpose
An orchiectomy is done to treat cancer or, for other reasons, to lower the level of testosterone, the primary male sex hormone, in the body. Surgical removal of a testicle is the usual treatment if a tumor is found within the gland itself, but an orchiectomy may also be performed to treat prostate cancer or cancer of the male breast, as testosterone causes these cancers to grow and metastasize (spread to other parts of the body). An orchiectomy is sometimes done to prevent cancer when an undescended testicle is found in a patient who is beyond the age of puberty.
A bilateral orchiectomy is commonly performed as one stage in male-to-female (MTF) gender reassignment surgery. It is done both to lower the levels of male hormones in the patient's body and to prepare the genital area for later operations to construct a vagina and external female genitalia.
Some European countries and four states in the United States (California, Florida, Montana, and Texas) allow convicted sex offenders to request surgical castration to help control their sexual urges. This option is considered controversial in some parts of the legal system. A small number of men with very strong sex drives request an orchiectomy for religious reasons; it should be noted, however, that official Roman Catholic teaching is opposed to the performance of castration for spiritual purity.
Cancer
There is no effective alternative to radical orchiectomy in the treatment of testicular cancer; radiation and chemotherapy are considered follow-up treatments rather than alternatives.
There are, however, several alternatives to orchiectomy in the treatment of prostate cancer:
watchful waiting
hormonal therapy (The drugs that are usually given for prostate cancer are either medications that oppose the action of male sex hormones [anti-androgens, usually flutamide or nilutamide] or medications that prevent the production of testosterone [goserelin or leuprolide acetate].)
radiation treatment
chemotherapy
Gender reassignment
The primary alternative to an orchiectomy for gender reassignment is hormonal therapy. Most patients seeking MTF gender reassignment begin taking female hormones (estrogens) for three to five months minimum before requesting genital surgery. Some persons postpone surgery for a longer period of time, often for financial reasons; others choose to continue on estrogen therapy indefinitely without surgery.
There are three basic types of orchiectomy: simple, subcapsular, and inguinal (or radical). The first two types are usually done under local or epidural anesthesia, and take about 30 minutes to perform. An inguinal orchiectomy is sometimes done under general anesthesia, and takes between 30 minutes and an hour to complete.
Simple orchiectomy
A simple orchiectomy is performed as part of gender reassignment surgery or as palliative treatment for advanced cancer of the prostate. The patient lies flat on an operating table with the penis taped against the abdomen. After the anesthetic has been given, the surgeon makes an incision in the midpoint of the scrotum and cuts through the underlying tissue. The surgeon removes the testicles and parts of the spermatic cord through the incision. The incision is closed with two layers of sutures and covered with a surgical dressing. If the patient desires, a prosthetic testicle can be inserted before the incision is closed to give the appearance of a normal scrotum from the outside.
Subcapsular orchiectomy
A subcapsular orchiectomy is also performed for treatment of prostate cancer. The operation is similar to a simple orchiectomy, with the exception that the glandular tissue is removed from the lining of each testicle rather than the entire gland being removed. This type of orchiectomy is done primarily to keep the appearance of a normal scrotum.
Inguinal orchiectomy
An inguinal orchiectomy, which is sometimes called a radical orchiectomy, is done when testicular cancer is suspected. It may be either unilateral, involving only one testicle, or bilateral. This procedure is called an inguinal orchiectomy because the surgeon makes the incision, which is about 3 in (7.6 cm) long, in the patient's groin area rather than directly into the scrotum. It is called a radical orchiectomy because the surgeon removes the entire spermatic cord as well as the testicle itself. The reason for this complete removal is that testicular cancers frequently spread from the spermatic cord into the lymph nodes near the kidneys. A long non-absorbable suture is left in the stump of the spermatic cord in case later surgery is necessary.
After the cord and testicle have been removed, the surgeon washes the area with saline solution and closes the various layers of tissues and skin with various types of sutures. The wound is then covered with sterile gauze and bandaged.
Diagnosis
CANCER. The doctor may suspect that a patient has prostate cancer from feeling a mass in the prostate in the course of a rectal examination, from the results of a transrectal ultrasound (TRUS), or from elevated levels of prostate-specific antigen (PSA) in the patient's blood. PSA is a tumor marker, or chemical, in the blood that can be used to detect cancer and monitor the results of therapy. A definite diagnosis of prostate cancer, however, requires a tissue biopsy. The tissue sample can usually be obtained with the needle technique. Testicular cancer is suspected when the doctor feels a mass in the patient's scrotum, which may or may not be painful. In order to perform a biopsy for definitive diagnosis, however, the doctor must remove the affected testicle by radical orchiectomy.
GENDER REASSIGNMENT. Patients requesting gender reassignment surgery must undergo a lengthy process of physical and psychological evaluation before receiving approval for surgery. The Harry Benjamin International Gender Dysphoria Association (HBIGDA), which is presently the largest worldwide professional association dealing with the treatment of gender identity disorders, has published standards of care that are followed by most surgeons who perform genital surgery for gender reassignment. HBIGDA stipulates that a patient must meet the diagnostic criteria for gender identity disorders as defined by either the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) or the International Classification of Diseases–10 (ICD-10).
Preparation
All patients preparing for an orchiectomy will have standard blood and urine tests before the procedure. They are asked to discontinue aspirin-based medications for a week before surgery and all non-steroidal anti-inflammatory drugs (NSAIDs) two days before the procedure. Patients should not eat or drink anything for the eight hours before the scheduled time of surgery.
Most surgeons ask patients to shower or bathe on the morning of surgery using a special antibacterial soap. They should take extra time to lather, scrub, and rinse their genitals and groin area.
Patients who are anxious or nervous before the procedure are usually given a sedative to help them relax.
CANCER. Patients who are having an orchiectomy as treatment for testicular cancer should consider banking sperm if they plan to have children following surgery. Although it is possible to father a child if only one testicle is removed, some surgeons recommend banking sperm as a precaution in case the other testicle should develop a tumor at a later date.
GENDER REASSIGNMENT. Most males who have requested an orchiectomy as part of male-to-female gender reassignment have been taking hormones for a period of several months to several years prior to surgery, and have had some real-life experience dressing and functioning as women. The surgery is not performed as an immediate response to the patient's request.
Because the standards of care for gender reassignment require a psychiatric diagnosis as well as a physical examination, the surgeon who is performing the orchiectomy should receive two letters of evaluation and recommendation by mental health professionals, preferably one from a psychiatrist and one from a clinical psychologist.
Aftercare
Patients who are having an orchiectomy in an ambulatory surgery center or other outpatient facility must have a friend or family member to drive them home after the procedure. Most patients can go to work the following day, although some may need an additional day of rest at home. Even though it is normal for patients to feel nauseated after the anesthetic wears off, they should start eating regularly when they get home. Some pain and swelling is also normal; the doctor will usually prescribe a pain-killing medication to be taken for a few days.
Other recommendations for aftercare include:
Drinking extra fluids for the next several days, except for caffeinated and alcoholic beverages.
Avoiding sexual activity, heavy lifting, and vigorous exercise until the follow-up appointment with the doctor.
Taking a shower rather than a tub bath for a week following surgery to minimize the risk of absorbable stitches dissolving prematurely.
Applying an ice pack to the groin area for the first 24–48 hours.
Wearing a jock strap or snug briefs to support the scrotum for two weeks after surgery.
Some patients may require psychological counseling following an orchiectomy as part of their long-term aftercare. Many men have very strong feelings about any procedure involving their genitals, and may feel depressed or anxious about their bodies or their relationships after genital surgery. In addition to individual psychotherapy, support groups are often helpful. There are active networks of prostate cancer support groups in Canada and the United States as well as support groups for men's issues in general.
Some of the risks for an orchiectomy done under general anesthesia are the same as for other procedures. They include deep venous thrombosis, heart or breathing problems, bleeding, infection, or reaction to the anesthesia. If the patient is having epidural anesthesia, the risks include bleeding into the spinal canal, nerve damage, or a spinal headache.
Specific risks associated with an orchiectomy include:
loss of sexual desire (This side effect can be treated with hormone injections or gel preparations.)
impotence
hot flashes similar to those in menopausal women, controllable by medication
An additional risk specific to cancer patients is recurrence of the cancer.
Morbidity and mortality rates
Orchiectomy by itself has a very low rate of morbidity and mortality. Patients who are having an orchiectomy as part of cancer therapy have a higher risk of dying from the cancer than from testicular surgery.
The morbidity and mortality rates for persons having an orchiectomy as part of gender reassignment surgery are about the same as those for any procedure involving general or epidural anesthesia.
BOOKS
"Breast Disorders: Breast Cancer in Men." Section 18, Chapter 242 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
"Congenital Anomalies: Renal and Genitourinary Defects." Section 19, Chapter 261 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Morris, Jan. Conundrum. New York: Harcourt Brace Jovanovich, Inc., 1974.
"Principles of Cancer Therapy: Other Modalities." Section 11, Chapter 144 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
"Sexual and Gender Identity Disorders." In Diagnostic andStatistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.
PERIODICALS
Berruti, A., et al. "Background to and Management of Treatment-Related Bone Loss in Prostate Cancer." Drugs and Aging, 19 (2002): 899–910.
Dawson, C. "Testicular Cancer: Seek Advice Early." Journal ofFamily Health Care, 12 (2002): 3.
Elert, A., K. Jahn, A. Heidenreich, and R. Hofmann. "The Familial Undescended Testis." [in German] Klinische Padiatrie, 215 (January–February 2003): 40–45.
Geldart, T. R., P. D. Simmonds, and G. M. Mead. "Orchidectomy after Chemotherapy for Patients with Metastatic Testicular Germ Cell Cancer." BJU International, 90 (September 2002): 451–455.
Incrocci, L., W. C. Hop, A. Wijnmaalen, and A. K. Slob. "Treatment Outcome, Body Image, and Sexual Functioning After Orchiectomy and Radiotherapy for Stage I-II Testicular Seminoma." International Journal of Radiation Oncology, Biology, Physics, 53 (August 1, 2002): 1165–1173.
Landen, M., et al. "Done Is Done—and Gone Is Gone. Sex Reassignment is Presently the Best Cure for Transsexuals." [in Swedish] Lakartidningen, 98 (July 25, 2001): 3322–3326.
Papanikolaou, Frank, and Laurence Klotz. "Orchiectomy, Radical." eMedicine,, October 3, 2001 [March 30, 2003]. <http://www.emedicine.com/med/topic3063.htm>.
Roberts, L. W., M. Hollifield, and T. McCarty. "Psychiatric Evaluation of a 'Monk' Requesting Castration: A Patient's Fable, with Morals." American Journal of Psychiatry, 155 (March 1998): 415–420.
Smith, M. R. "Osteoporosis and Other Adverse Body Composition Changes During Androgen Deprivation Therapy for Prostate Cancer." Cancer and Metastasis Reviews, 21 (2002): 159–166.
Stang, A., K. H. Jockel, C. Baumgardt-Elms, and W. Ahrens. "Firefighting and Risk of Testicular Cancer: Results from a German Population-Based Case-Control Study." American Journal of Industrial Medicine, 43 (March 2003): 291–294.
Stone, T. H., W. J. Winslade, and C. M. Klugman. "Sex Offenders, Sentencing Laws and Pharmaceutical Treatment: A Prescription for Failure." Behavioral Sciences and the Law, 18 (2000): 83–110.
Volm, M. D. "Male Breast Cancer." Current Treatment Options in Oncology, 4 (April 2003): 159–164.
ORGANIZATIONS
American Board of Urology (ABU). 2216 Ivy Road, Suite 210, Charlottesville, VA 22903. (434) 979-0059. <http://www.abu.org>.
American Prostate Society. P. O. Box 870, Hanover, MD 21076. (800) 308-1106. <http://www.ameripros.org>.
Canadian Prostate Cancer Network. P. O. Box 1253, Lakefield, ON K0L 2H0 Canada. (705) 652-9200. <http://www.cpcn.org>.
Centers for Disease Control and Prevention (CDC) Cancer Prevention and Control Program. 4770 Buford Highway, NE, MS K64, Atlanta, GA 30341. (888) 842-6355. <http://www.cdc.gov/cancer/comments.htm>.
Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA). 1300 South Second Street, Suite 180, Minneapolis, MN 55454. (612) 625-1500. <http://www.hbigda.org>.
National Cancer Institute (NCI). NCI Public Inquiries Office. Suite 3036A, 6116 Executive Boulevard, MSC8332, Bethesda, MD 20892-8322. (800) 4-CANCER or (800) 332-8615 (TTY). <http://www.nci.nih.gov>.
OTHER
Harry Benjamin International Gender Dysphoria Association (HBIGDA). Standards of Care for Gender Identity Disorders, 6th version, February, 2001 [April 1, 2003]. <http://www.hbigda.org/socv6.html>.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Orchiectomy performed as part of cancer therapy may be done in a hospital under general anesthesia, but is most often done as an outpatient procedure in a urology clinic or similar facility. Most surgeons who perform orchiectomies to treat cancer are board-certified urologists or general surgeons.
Orchiectomies performed as part of gender reassignment surgery are usually done in clinics that specialize in genital surgery. The standards of care defined by the Harry Benjamin International Gender Dysphoria Association stipulate that the surgeon should be a board-certified urologist, gynecologist, plastic surgeon, or general surgeon, and that he or she must have undergone supervised training in genital reconstruction.
QUESTIONS TO ASK THE DOCTOR
How effective is an orchiectomy in preventing a recurrence of my cancer?
What side effects of this procedure am I most likely to experience?
How many orchiectomies have you performed?
Can you recommend a local men's network or support group?
