DR. VIVEK VENKAT

Testicular cancer is an abnormal malignant growth in the testicle. It has the potential to spread and be lethal to the patient.

Any abnormal growth or swelling in the testicle, should be examined by a urologist.

It is one of the commonest cancers affecting young men aged 20-45 years. The common risk factors are:

• An undescended testicle at birth which has not reached the scrotum.
• Genetic disorders like Klinefelter’s syndrome.
• Family history
• Infertility

Surgical removal of the testicle (orchidectomy) is an essential step in the diagnosis and treatment. It allows classification of the type of tumor and its local stage on pathological examination.

Surgical removal of the affected testis can achieve excellent cure in early stages.

In more advanced stages and high-grade tumors, the retroperitoneal lymph nodes are removed surgically. This allows better staging and may also be curative in some patients.

Doing this surgery robotically has reduced complications and allows for quicker recovery.

However, with highly effective chemotherapy available today this surgery is rarely needed.

Treatment depends on the stage of disease. Staging is based on the pathological findings after removal of the testicle, blood tumor marker levels (serum alpha fetoprotein, beta-HCG and LDH levels) and findings on the imaging (CT scan of the chest abdomen and pelvis).

If there is no spread anywhere and tumor markers are normal, orchidectomy alone may suffice.

In case there are adverse pathologic features on the orchidectomy, or tumor markers or imaging show spread of disease to the lymph nodes or other organs, chemotherapy is needed. Testicular cancer chemotherapy is very effective even in advanced cases.

Radical Orchidectomy

• Complete removal of the testis and adjacent spermatic cord is the first essential step in the treatment of testicular cancer.
• It provides the pathologic type of tumor and local stage.
• The testicle is removed through a small incision in the inguinal region with the spermatic cord.
• A biopsy of the testis through the scrotal skin should not be done because it can alter the route of spread of cancer.

Retroperitoneal lymph node dissection

• The retroperitoneal lymph nodes are the first site of spread from testicular cancer and carry important prognostic information about the disease.
• This is a very extensive surgery with risk of morbidity. All the lymph nodes from the kidney to pelvic nodes are removed (exact template depends on the side affected). These lymph nodes lie along the major blood vessels of the body (inferior vena cava and aorta).
• With very effective chemotherapy available today the need for this surgery has reduced, however it may be needed in those with persistent disease after chemotherapy.
• Doing these procedures by a robotic approach (robotic RPLND) reduces the risk of complications and allows for a quick recovery.

• Bleeding – A scrotal hematoma can occur and is usually managed conservatively. An RPLND can be associated with significant bleeding and blood transfusion.
• Infection – Most infections are mild and respond very well to antibiotics.
• Removal of adjacent organs – An RPLND may be associated with removal of adjacent organs because of involvement by the residual tumor. The kidney is the most common organ that can be affected.
• Ileus – Delay in recovery of intestinal function can be seen after RPLND.
• Ejaculatory difficulty – This can be seen after RPLND.

Robotic surgery provides significant benefits for both patient and surgeon.

• Basic investigations to assess your fitness for surgery.
• If a urinary infection is detected you will be placed on appropriate antibiotics.
• Blood thinners will need to stopped for about 5-7 days before the surgery and this should be discussed with your cardiologist.
• For RPLND special cardiac investigations may be needed.

• An orchidectomy is a simple day-care or 24-hour admission procedure. It is usually done under spinal or general anesthesia. Most patients are discharged quickly with minimal problems.
• An RPLND is major surgery needing general anesthesia. An epidural may be placed for pain relief as well.
• After an RPLND you will notice the urinary catheter which is a tube inserted into the bladder to drain the urine. It is generally left in place for 2-3 days.
• Some men may need to be shifted to ICU after an RPLND.
• You may have an abdominal drain after RPLND.
• Hospital stay after RPLND depends on the extent of the procedure and recovery of intestinal function and is usually 5-7 days

• Surgery has an excellent cure rate in early disease and men can remain on close surveillance if the pathologic features are favourable.
• Depending on the biopsy report and CT scan findings, chemotherapy may be required.
• In more advanced cases, the addition of lymph node dissection provides important information on prognosis and may be curative in some cases (especially after chemotherapy).