Surgery for Testicular Cancer

Surgery is the first treatment for nearly all testicular cancers .

Radical inguinal orchiectomy

Surgery to remove a testicle with cancer is called a radical inguinal orchiectomy. An incision (cut) is made just above the pubic area, and the testicle is gently removed from the scrotum through the opening. The surgeon then removes the entire tumor along with the testicle and spermatic cord. The spermatic cord contains part of the vas deferens, as well as blood and lymph vessels that could act as pathways for testicular cancer to spread to the rest of the body. To lessen the chance of this, these vessels are tied off early in the operation.

All testicular cancers are typically treated with this surgery, even those that have spread.

Retroperitoneal lymph node dissection (RPLND)

Depending on the type and stage of your cancer, lymph nodes around the large blood vessels (the aorta and inferior vena cava) at the back of the abdomen (belly) may be removed at the same time as the orchiectomy or during a second operation. Not all people with testicular cancer need to have lymph nodes removed, so it’s important to discuss this (and options to it) with your doctor.

This is a complex and long operation. In most cases, a large incision (cut) is made down the middle of the abdomen to remove the lymph nodes. RPLND should be done by a surgeon who does this often. Experience counts.

Laparoscopic surgery

In some cases, the surgeon can remove lymph nodes through very small skin incisions in the abdomen by using a laparoscope and other long, thin surgical tools. A laparoscope is a narrow, lighted tube with a small camera on the end that lets doctors see inside the abdomen. The surgeon’s hands are not inside the patient’s body during this type of surgery.

In laparoscopic surgery, after being put to sleep, you're turned onto your side. Several small incisions are made on your abdomen. The laparoscope and surgical tools are put in through the incisions to remove the lymph nodes. The incisions are then closed and you're woken up.

Patients recover much more quickly from this operation than the standard open procedure and are walking soon after surgery. There's usually less pain and patients are eating sooner.

Laparoscopic surgery seems to be a lot easier for the patient, but doctors aren't sure if it’s as safe and effective as the standard “open” surgery in removing all of the lymph nodes that may contain cancer. Because of this uncertainty, doctors are more likely to recommend chemotherapy after laparoscopic surgery if cancer is found in the lymph nodes.

This procedure is most often used for patients with early-stage non-seminomas to see if the lymph nodes contain cancer. As with the standard open procedure, this is a complex operation that should only be done if the surgeon is very experienced.

Possible risks and side effects of surgery

The short-term risks of any type of surgery include reactions to anesthesia, excess bleeding, blood clots, and infections. Most men will have at least some pain after the operation, which can be helped with pain medicines, if needed.

Effects of orchiectomy

Losing one testicle usually has no effect on a man’s ability to get an erection and have sex. But if both testicles are removed, sperm cannot be made and a man becomes infertile. Also, without testicles, a man cannot make enough testosterone, which can decrease sex drive and affect his ability to have erections. Other effects could include fatigue, hot flashes, and loss of muscle mass. These side effects can be avoided by taking testosterone supplements, either in a gel, a patch, or a shot. Pills are generally not reliable sources of testosterone.

Usually men with testicular cancer are young and may be concerned about changes in how they look. They may be dating and worry about a partner’s reaction, or they may be athletic and feel embarrassed by the missing testicle when in locker rooms.

To restore a more natural look, a man can have a testicular prosthesis surgically implanted in his scrotum. The prosthesis approved for use in the United States is filled with saline (salt water) and comes in different sizes to match the remaining testicle. When in place, it can look like a normal testicle. There can be a scar after the operation, but it’s often partly hidden by pubic hair. Some men might want a prosthesis, while others might not. You should discuss your wishes with your surgeon before surgery. It could also help to talk with someone who has a testicular prosthesis, to hear what it has been like for them.

Effects of lymph node dissection

Surgery to remove retroperitoneal lymph nodes is a major operation. Serious complications are not common, but they can happen. About 5% to 10% of patients have short-term problems after surgery, such as infection or bowel obstruction (blockage). The standard approach for an RPLND requires a large incision in the abdomen, which will leave a scar and can take some time to heal. Your ability to get up and around after the operation will be limited for some time. This is less likely to be an issue if you have laparoscopic surgery, which uses smaller incisions.

This type of surgery does not cause impotence – a man can still have erections and sex. But it might damage some of the nerves that control ejaculation. If these nerves are damaged, when a man ejaculates, the semen doesn't come out through the urethra to exit the body but rather goes backwards into the bladder. This is called retrograde ejaculation, and it can make it hard to father children.

To save the normal ejaculation function, surgeons have developed a type of retroperitoneal lymph node surgery called nerve-sparing surgery that's very successful when done by experienced doctors. Testicular cancer often affects men at an age when they might be trying to have children. These men may wish to discuss nerve-sparing surgery with their doctors, as well as sperm banking (freezing and storing sperm cells obtained before treatment). Men with testicular cancer often have lower than normal sperm counts, which can sometimes make it hard to collect a good sperm sample. See Preserving Your Fertility When You Have Cancer (Men) for more about this.