ORCHIECTOMY

Indra Tresnanda
NPM 131821150004

DEPARTEMEN UROLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS PADJADJARAN
RUMAH SAKIT DR. HASAN SADIKIN BANDUNG
2020
DEFINISI

 Tindakan pengangkatan jaringan testis yang bersifat permanen.

 Orchiectomy dapat dilakukan melalui pendekatan skrotum dan inguinal (simple or
radical).
SIMPLE ORCHIECTOMY
ORCHIECTOMY
SIMPLE

 Teknik pengangkatan testis dan epididimis dengan langsung melakukan ligasi

funikulus spermatika (scrotal or subinguinal approach).
 Indikasi :
• Jaringan testis yang tidak viable pada torsio testis.
• Kerusakan testis yang berat akibat trauma.
• Infected testicle refractory to conservative treatment.
• Prosedur surgical castration pada kanker prostat (achieving castrate levels of
testosterone) → bilateral orchiectomy.
• Chronic orchialgia.
SIMPLE ORCHIECTOMY
TEKNIK OPERASI

 Anesthetic options: regional anesthesia via

spermatic cord block, conscious sedation, spinal
anesthesia, or general anesthesia.
 Shave and prep the scrotum.
 Use single vertical midline incision in median raphe
or transverse scrotal incision over the cord just
above testicle.
 Transverse incision is made within the scrotal rugae
(avoid any prominent scrotal blood vessels).
 Carry the incision down through dartos fibers and
tunica vaginalis.
 Deliver testis into the wound.
SIMPLE ORCHIECTOMY
TEKNIK OPERASI
Approach for simple (A), epididymis-
 sparing (B),
Gentle traction on testis to expose spermatic cord.
and subcapsular orchiectomy (C).
• At this point, options include ligation of spermatic cord,
epididymis-sparing orchiectomy, or subcapsular orchiectomy.
 Separate the cord into two bundles.
 Identify, ligate, and divide the vas deferens using a 2-0 silk ligature.
 Separate cremasteric muscle from internal spermatic vessels and
ligate each separately using 2-0 silk sutures.
 Double clamp proximally and single distally.
 Divide sharply.
 Place a 2-0 Vicryl tie proximally.
 Release the first clamp prior to placing 2-0 Vicryl suture ligature
distally.
 Repeat on the remaining bundle.
 Ensure meticulous hemostasis. (A) Isolation of the vas deferens. (B)
Ligation of the vas deferens.
SIMPLE ORCHIECTOMY
TEKNIK OPERASI

 Dartos muscle is re-approximated with

interrupted 3-0 or 4-0 Vicryl suture.
 Inject the wound with bupivacaine.
 Close the skin edges with interrupted 4-0
chromic or Monocryl sutures or running
subcuticular fashion with 5-0 absorbable suture
using two skin hooks at the apices to aid in
closure.
 Identical operation is carried out on the
contralateral side if indicated.
 The wound is dressed with antibiotic ointment,
dry fluffed gauze, and scrotal support.
ORCHIECTOMY
SUBCAPSULAR/ EPIDIDYMIS-SPARING
ORCHIECTOMY
 Jaringan yang diangkat hanya jaringan testisnya saja → tunika vaginalis dan
epididimis dipertahankan.
 Dilakukan pada surgical castration pasien kanker prostat.
 This procedure leaves a palpable mass within the scrotum → efek psikologis yang
lebih baik karena pasien masih merasa seperti memiliki testis.
 Potentially bloodier operation → ↑ epididymitis.
SUBCAPSULAR ORCHIECTOMY
TEKNIK OPERASI
Dissection of epididymis off of
testis under magnification with
 ligation of vessels.
Use of the operating microscope facilitates dissection.
 After delivery of testis, bring the operating
microscope into the field.
 Sharply dissect the epididymis off of the testis.
 Clamp and ligate the three major groups of
epididymal vessels (superior, middle, and caudal)
using 2-0 silk.
 Approximate the caput and cauda of epididymis using
3-0 absorbable suture → create an ellipsoid structure.
 Bloodier nature → drain should be placed through a
dependent stab wound before closing.
Approximation of
 Return the epididymis to tunica vaginalis and close epididymal ends.
tunica vaginalis with 5-0 Vicryl.
RADICAL ORCHIECTOMY
RADICAL ORCHIECTOMY

 Inguinal approach → orchiectomy ligasi tinggi.

 Provides staging information in testicular tumor.
 Local tumor control.
 Curative in patients with low-stage disease.
RADICAL ORCHIECTOMY
TEKNIK OPERASI

 Anatomic landmarks (patient in supine position)

• Penis and scrotum.
• Pubic tubercle medially.
• Anterior superior iliac spine laterally and
cephalad.
• Inguinal ligament caudad (may be palpable in
thin men).
 Curvilinear incision is made beginning
approximately 2 cm cephalad and lateral to pubic
tubercle, extending laterally along a Langer line for
5-7 cm.

Curvilinear incision for radical orchiectomy.

RADICAL ORCHIECTOMY
TEKNIK OPERASI

 Incision through subcutaneous tissue onto external

abdominal oblique aponeurosis with electrocautery →
Camper and Scarpa fasciae are visible.
 Subcutaneous superficial inferior epigastric veins are
frequently encountered laterally.
 External abdominal oblique aponeurosis is sharply opened
over the inguinal canal, extending medially to external
inguinal ring and laterally to a point overlying the level of
the internal inguinal ring.
 Retraction of the ilioinguinal nerve.
Ilioinguinal nerve on top of spermatic cord is identified and
dissected from external spermatic fascia and cremasteric
musculature and retracted out.
RADICAL ORCHIECTOMY
TEKNIK OPERASI

 Blunt dissection at pubic tubercle. Dissection at the

level of the pubic
 Circumscribing spermatic cord and cremasteric tubercle.
musculature.
 Avoid dissection through the floor of inguinal canal
(avoiding risk of postoperative direct inguinal
hernia).
 The cord secured with 14-inch Penrose drain
passed twice around and clamped with hemostat →
early vascular control.

Securing of the
spermatic cord.
RADICAL ORCHIECTOMY
TEKNIK OPERASI

 The assistant surgeon push the testicle from the base of

hemiscrotum toward the incision → delivery of intact testicle
within tunica vaginalis.
 Apply gentle traction to the spermatic cord to aid this
maneuver.
 Further blunt or electrocautery dissection → to free tunica
vaginalis from fascial layers.
 Gubernaculum is incised with electrocautery.
Traction of the spermatic cord.
RADICAL ORCHIECTOMY
TEKNIK OPERASI

 The cord is dissected proximal to internal

inguinal ring.
 Cremasteric muscle fibers and external
spermatic fascia are incised with electrocautery
at this level → skeletonizing the cord → clear
visibility of the cord vasculature and vas
deferens.
 Elevate internal abdominal oblique
musculature (lateral edge of internal ring) →
revealing retroperitoneal fat. Procedural diagram showing retraction of the
abdominal musculature and secured spermatic
cord.
RADICAL ORCHIECTOMY
TEKNIK OPERASI

 Ligate and divide vas deferens separately from the cord with 2-0 permanent suture.
 The cord proper is doubly ligated and divided with 0 permanent suture.
 The surgical field is irrigated, and meticulous hemostasis is obtained.
 External abdominal oblique aponeurosis is approximated with running 2-0
absorbable suture (not include the ilioinguinal nerve).
 Subcutaneous fascial tissue layers are approximated with running 3-0 absorbable
suture.
 Subcuticular closure for skin with running 4-0 absorbable suture.
TERIMA KASIH