You may occasionally need to remove a patient's testes. If he has a seminoma or a teratoma, remove one of them (32.34a). This is much safer than biopsying it, which may spread his tumour. If he has a carcinoma of his prostate, and you decide not to treat him with oestrogens, you can remove both of them, either by doing a total orchidectomy or a subcapsular one. If you do the latter, you can tell him that you are only removing ''the part of the testicle which produces the hormones', which may be more acceptable to him. The remnant is small but is easily palpable. Even so, you will probably find that subcapsular orchidectomy is more unpopular than stilboestrol (32.32).
Fig. 23-32 SUBCAPSULAR ORCHIDECTOMY FOR CARCINOMA OF THE PROSTATE. A, make a longitudinal incision in the patient's scrotum. B, evaginate his testis. C, incise his tunica albuginea. D, separate the substance of his testis from the inner surface of his tunica albuginea. ]]D, close his tunica, E, close his skin. After Rob C and Smith R ''Operative Surgery': Urology', pp. 667 and 668 (Butterworth). With the kind permission of Hugh Dudley.
ORCHIDECTOMY Don't mistake mumps orchitis for a tumour. This causes rapid enlargement, and some pain (minimal in the case of a tumour). Mumps orchitis may cause little pain, so if you are in doubt, wait for a few days rather than remove his testis.
You will have to exert some traction on the cord, but beware of its upper end slipping out of the clamp and retracting out of sight. Take great care to secure haemostasis, before you close the wound. If possible, apply diathermy to the smaller bleeding vessels, and tie off the larger ones. Close the patient's skin with continuous horizontal mattress sutures of catgut.
SUBCAPSULAR ORCHIDECTOMY [s7]FOR CARCINOMA OF THE PROSTATE Raise his scrotum, and incise his stretched skin and dartos muscle, to expose both his testes (A, Fig. 23-32). Evaginate each testis with its coverings, and incise its tunica vaginalis vertically to expose his testis and epididymis (B). Incise his visceral tunica vertically over the globe of his testis. Use sharp and blunt dissection, to separate the substance of his testis from the inner surface of his tunica albuginea (C). Control bleeding carefully at the upper pole. Remove all testicular tissue, and close his tunica with continuous 3/0 plain catgut sutures (D). Close his scrotum in 2 layers with continuous 3/0 chromic catgut, without inserting a drain. After a few weeks, blood clot in his tunica will become organized to form a small palpable nodule, like a small testis.
ORCHIDECTOMY [s7]FOR A TESTICULAR TUMOUR You will need to remove his cord with his testis, so open up his inguinal canal as for a hernia with an inguino-scrotal incision (14-4). Pick up his cord within its covering of cremaster. Apply a soft bowel clamp to it, before you do anything else. Deliver his testis from his scrotum by pushing it up from below. If his tumour is large, you will have to extend the incision further into his scrotum.
If you feel a hard irregular mass, which is not chronic epididymo-orchitis, doubly transfix and tie his cord proximal to the clamp as near his internal ring as you can, and excise his testis. If he has a seminoma, he should have radiotherapy to his retroperitoneal nodes.
ORCHIDECTOMY [s7]FOR CHRONIC INFECTION (rare) If you do not suspect malignancy, and there is an overlying skin lesion on his scrotum, arange your incision so as to excise this, and remove it attached to the structures under it. Enter his scrotum away from any diseased area. Deliver his testis and any skin which is attached to it. Pull gently on his testis, to free about 6 cm of his cord; divide it between two clamps, and tie it twice with strong catgut. Divide it between them. If it is very thick, separate its structures and tie them separately. Leave the wound in his scrotum unsutured to drain freely, dress it loosely, and close it by delayed primary suture.
Fig. 23-33 TOTAL ORCHIDECTOMY FOR A TUMOUR. A, apply a soft bowel clamp to the patient's cord before you do anything else. B, ]]make an inguino-scrotal incision and remove his cord with his testis. After Blandy J, ''Operative Urology'', (1978), Figs. 15.37 and 15.40. Blackwell Scientific Publications, with kind permission.