Testicular Cancer

Surgery

Nearly all men with testicular cancer begin treatment with surgery to remove the cancerous testicle. This procedure is called a radical inguinal orchiectomy.

Seminoma. For early stage seminoma testicular cancer, no more surgery is done after orchiectomy. Instead, radiation or watchful waiting are likely to be your treatment options. (For this type of cancer, chemotherapy is a newer treatment choice, though it is mostly used in Europe.¹⁰)

Nonseminoma. For some cases of nonseminoma testicular cancer, orchiectomy is followed by a retroperitoneal lymph node dissection (RPLND). This is the surgical removal of lymph nodes in the pelvis and lower back. Sometimes, chemotherapy is used before or after RPLND.

If you have nonseminoma that was diagnosed at an early stage, and tests suggest that it hasn't spread beyond the testes, you may choose to follow orchiectomy with a watchful waiting program rather than RPLND. Watchful waiting, or surveillance, is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment.

In more advanced cases of testicular cancer, chemotherapy with additional surgery and sometimes radiation may be necessary to treat cancer that has spread beyond the lymph nodes in the lower abdomen. Other areas of the body that may be affected include the lungs, brain, liver, and bones.

More about RPLND

RPLND removes lymph nodes in the pelvis and lower back that are common sites of spread (metastasis) for testicular cancers. Although this lowers the chance that your cancer will reappear, some men with stage I cancers are cured without this procedure. In addition, RPLND is related to several complications, including:¹

• Retrograde ejaculation, a condition in which the semen flows from the prostate gland into the bladder rather than through the penis and outside the body, resulting in infertility. Men who suffer from retrograde ejaculation typically do not have erection problems or difficulty enjoying sex.
• Postoperative pain.
• Chylous ascites, a condition in which digestive fluids collect inside the abdominal cavity. This may lead to abdominal pain and difficulty breathing.
• Lymphedema, which is a collection of fluid that causes swelling (edema) in the arms and legs. This type of edema occurs when the amount of lymph fluid in a person's arm or leg exceeds the body's ability to remove it, and the fluid then collects in the tissues of the limb. For more information, see:

  Lymphedema: Managing lymphedema.

• Excessive bleeding (hemorrhage).
• Pulmonary embolism, which is the sudden blockage of blood flow within the lung.

Surgery Choices

Radical inguinal orchiectomy

Retroperitoneal lymph node dissection (RPLND)

What To Think About

Fertility and testicle surgery. In most cases, surgery to remove a cancerous testicle does not cause infertility unless both testicles are removed. But there is a small chance that surgery could harm your ability to conceive a child. Unless you are sure you won't want to father a child in the future, talk to your doctor about sperm banking before any treatment for testicular cancer.

If you have both testicles removed, it will be necessary for you to undergo hormone replacement therapy to replace testosterone, the male hormone produced by the testes. However, in most cases when just one testicle is removed, fertility and hormone levels remain normal.

Modern laparoscopic and other "nerve-sparing" surgical techniques have reduced the number of men who suffer from retrograde ejaculation after RPLND. Even though about 95% of men remain fertile after nerve-sparing RPLND, most health professionals recommend sperm banking before surgery.⁵ Nerve-sparing RPLND surgery may not be possible for men who previously have had chemotherapy treatment for cancer.

An increasing number of RPLNDs are done using laparoscopic surgery. For laparoscopy, a lighted viewing instrument (laparoscope) and other surgical instruments are inserted into the lower abdomen through small incisions, usually made below the navel. Though not yet commonly available, laparoscopic RPLND is much less invasive and carries less risk than standard RPLND surgery.

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Author:	Kathe Gallagher, MSW	Last Updated: February 5, 2007
Medical Review:	Martin Gabica, MD - Family Medicine Kathleen Romito, MD - Family Medicine Christopher G. Wood, MD, FACS - Urology/Oncology
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