Surgery for testicular cancer

Surgery is typically the first treatment for all testicular cancers.

Radical inguinal orchiectomy

As described in the section “How is testicular cancer diagnosed?”, this type of surgery removes the testicle (or testicles) containing the cancer. An incision is made just above the pubic area, and the testicle is gently removed from the scrotum through the opening. A cut is made through the spermatic cord that attaches the testicle to the abdomen. The surgeon ties off the blood and lymph vessels in the spermatic cord early in the operation and takes other special precautions to avoid spreading cancer cells into the surgical wound or dislodging them from the tumor into the bloodstream.

All stages of testicular cancer are typically treated with this surgery.

Retroperitoneal lymph node dissection (RPLND)

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

This is a complex and long operation. A large incision is typically made down the middle of the abdomen to remove the lymph nodes. It 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 (a narrow, lighted tube with a small video camera on the end that lets doctors see inside the abdomen) and other long, thin surgical tools. The surgeon’s hands are not inside the patient’s body during this type of surgery.

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

In laparoscopic surgery, after being put to sleep, the patient is turned onto his side. Several small incisions are made on the abdomen. A laparoscope and long instruments are inserted through the incisions to remove the lymph nodes. The incisions are then closed and the patient is awakened.

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

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 usually be helped with pain medicines, if needed.

Effects of orchiectomy: Losing a testicle usually has no effect on a man’s ability to get an erection and have sex. But if both testicles are removed, sperm cells cannot be produced 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 the form of 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 that their appearance has changed. 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 to have a prosthesis, while others might not. You should discuss your wishes with your surgeon before considering this surgery. It could also help to talk with someone who has a testicular prosthesis, to see what their experience has been like.

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 temporary complications after surgery, such as bowel obstruction or wound infections. 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 sexual intercourse. But it might damage some of the nerves that control ejaculation. If these nerves are damaged, when a man ejaculates, the semen is not propelled forward through the urethra to exit the body but rather goes backwards into the bladder. This is known as 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 has a very high rate of success in experienced hands. Testicular cancer often affects men at an age when they may 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 our document Fertility and Men With Cancer to find out more about this.