Orchiectomy :
Definition
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.
Demographics
Cancer
Cancers in men vary widely in terms of both
the numbers of men affected and the age
groups most likely to be involved. Prostate
cancer is the single most common malignancy
affecting American men over the age of 50;
about 220,000 cases are reported each year.
According to the Centers for Disease Control
and Prevention (CDC), 31,000 men in the
United States die every year from prostate
cancer. African-American men are almost
70% more likely to develop prostate cancer
than either Caucasian or Asian-American
men; the reasons for this difference are
not yet known. Other factors that increase
a man's risk of developing prostate cancer
include a diet high in red meat, fat, and
dairy products, and a family history of
the disease. Men whose father or brother(s)
had prostate cancer are twice as likely
as other men to develop the disease themselves.
Today, however, there are still no genetic
tests available for prostate cancer.
Testicular
cancer, on the other hand, frequently occurs
in younger men; in fact, it is the most
common cancer diagnosed in males between
the ages of 15 and 34. The rate of new cases
in the United States each year is about
3.7 per 100,000 people. The incidence of
testicular cancer has been rising in the
developed countries at a rate of about 2%
per year since 1970. It is not yet known
whether this increase is a simple reflection
of improved diagnostic techniques or whether
there are other causes. There is some variation
among racial and ethnic groups, with men
of Scandinavian background having higher
than average rates of testicular cancer,
and African-American men having a lower
than average incidence. Testicular cancer
occurs most often in males in one of three
age groups: boys 10 years old or younger;
adult males between the ages of 20 and 40;
and men over 60.
Other risk
factors for testicular cancer include:
-
Cryptorchidism,
which is a condition in which a boy's
testicles do not move down from the
abdomen into the scrotum at the usual
point in fetal development. It is also
called undescended testicle(s). Ordinarily,
the testicles descend before the baby
is born; however, if the baby is born
prematurely, the scrotal sac may be
empty at the time of delivery. About
3–4% of full-term male infants are born
with undescended testicles. Men with
a history of childhood cryptorchidism
are three to 14 times more likely to
develop testicular cancer.
-
Family history of testicular cancer.
-
A mother who took diethylstilbestrol
(DES) during pregnancy. DES is a synthetic
hormone that was prescribed for many
women between 1938 and 1971 to prevent
miscarriage. It has since been found
to increase the risk of certain types
of cancer in the offspring of these
women.
-
Occupational
and environmental factors. Separate
groups of researchers in Germany and
New Zealand reported in 2003 that firefighters
have an elevated risk of testicular
cancer compared to control subjects.
The specific environmental trigger is
not yet known.
Gender reassignment
Statistics
for orchiectomies in connection with gender
reassignment surgery are difficult to establish
because most patients who have had this
type of surgery prefer to keep it confidential.
Persons undergoing the hormonal treatments
and periods of real-life experience as members
of the other sex that are required prior
to genital surgery frequently report social
rejection, job discrimination, and other
negative consequences of their decision.
Because of widespread social disapproval
of surgical gender reassignment, researchers
do not know the true prevalence of gender
identity disorders in the general population.
Early estimates were 1:37,000 males and
1:107,000 females. A recent study in the
Netherlands, however, maintains that a more
accurate estimation is 1:11,900 males and
1:30,400 females. In any case, the number
of surgical procedures is lower than the
number of patients diagnosed with gender
identity disorders.
Description
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/Preparation
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.
Long-term
aftercare for patients with testicular cancer
includes frequent checkups in addition to
radiation treatment or chemotherapy. Patients
with prostate cancer may be given various
hormonal therapies or radiation treatment.
Risks
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
-
weight gain of 10–15 lb (4.5–6.8 kg)
-
mood swings or depression
-
enlargement and tenderness in the breasts
-
fatigue
-
loss of sensation in the groin or the
genitals
-
osteoporosis (Men who are taking hormone
treatments for prostate cancer are at
greater risk of osteoporosis.)
-
An additional risk specific to cancer
patients is recurrence of the cancer.
Normal results
Cancer
Normal results depend on the location and
stage of the patient's cancer at the time
of surgery. Most prostate cancer patients,
however, report rapid relief from cancer
symptoms after an orchiectomy. Patients
with testicular cancer have a 95% survival
rate five years after surgery if the cancer
had not spread beyond the testicle. Metastatic
testicular cancer, however, has a poorer
prognosis.
Gender
reassignment
Normal results following orchiectomy as
part of a sex change from male to female
are a drop in testosterone levels with corresponding
decrease in sex drive and gradual reduction
of such masculine characteristics as beard
growth. The patient may choose to have further
operations at a later date.
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.
Alternatives
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:
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.
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