1. Verify side of tumor - have imaging in the room
2. Make sure tumor markers have been drawn
3. Examine patient thoroughly prior to making incision -- this will help develop your testicular exam skills and verify side of tumor
*When performing testicular examination (in any setting), convince yourself that you are able to palpate (1) testicle proper, (2) epididymis, and (3) cord
4. A single dose of a second generation cephalosporin is appropriate prior to making incision.
1. In supine position, lower abdomen, genitalia, and perineum are shaved, prepped, and draped
2. Incision is made over the inguinal ligament similar to an inguinal herniorrhaphy. Landmarks are the anterior superior iliac spine and the pubic symphisis (marked on image below)
3. Electrocautery is used to divide the subcutaneous fat and expose the external oblique fascia
4. The fat is bluntly cleaned off the fascia for better exposure, typically using a sponge and/or retractors (spreading down to fascia with two band retractors works very well)
5. Using a scalpel, a small incision is made in the external oblique fascia in line with the muscle fibers
6. Metzenbaum scissors are used to extend the fascial incision all the way to the external ring as well as in the opposite direction (toward internal ring)
a. Care is taken to first spread open the scissors underneath the fascia to clear off the ilioinguinal nerve
b. The nerve can often now be identified and set aside by placing a hemostat on the lateral edge of the fascia with the nerve lateral to the hemostat
c. Some may find tagging the medial and lateral fascial edges with suture useful to expedite closure later
d. It is important to open the external ring completely, dividing all of the fascial fibers -- this will faciliate delivery of the testis later
7. Grasping the edges of the fascia, the cord is bluntly dissected free
8. The cord is then encircled, often first with a finger (tease the cord off the pubic symphisis with thumb and finger) and then a Penrose drain is pulled through to fully retract the cord.
9. The Penrose drain is then wrapped a second time around the cord and clamped to completely constrict the cord
a. The theoretical goal is to prevent hematogenous micrometastases from being sent into the circulation during tumor manipulation
10. The testis is then delivered into the wound by pulling on the cord and pushing on the testis (it you find this step difficult, you did not divide all the necessary fibers of the external ring). Fascial attachments preventing delivery of the testis into the wound may need to be freed. One must be very careful not to violate scrotal skin. Blunt dissection with a surgical sponge to peel off the testicle from scrotal skin is very useful here (image below).
11. The gubernaculums is then clamped, divided and ligated. Again be absolutely sure you are not button-holing the scrotal skin (note how the scrotal skin in inverted into the wound on the image below -- if you violate the scrotal skin, you upstage the tumor and may change post-operative management!)
12. Attention is then turned to the superior portion of the cord and vas, which are separately clamped and divided as high as possible above where the Penrose was placed.
a. Ligation is typically performed with 2-0 silk or proline free ties and a suture ligature. Leave one suture long, so you can find it at RPLND.
b. It is important to drop the cord into the internal ring/retroperitoneum in order to faciliate cord removal at RPLND.
c. Be sure your ligation is secure -- bleeding into the retroperitoneum from a poorly secured testicular artery can be life-threatening.
13. Electrocautery is used to obtain hemostasis, careful attention needs to be paid to the scrotum to prevent hematoma formation
14. The external oblique fascia is then closed followed by the subcutaneous fat and the skin
15. A sterile dressing as well as fluffs and a scrotal support are then typically applied.
1. Monitor patient for scrotal hematoma and retroperitoneal bleeding
2. Markers must be rechecked during a post-operative visit in ~ 4 weeks (remember T1/2 for AFP = ~5 days and for HCG = ~48 hours)
1) In supine position, lower abdomen, genitalia, and perineum are prepped and draped
2) If bilateral orchiectomy, median raphe incision is made. If unilateral, can perform either median raphe or transverse hemiscrotal incision.
a. Skin traction is important when making scrotal incisions due to tissue laxity
3) Electrocautery is used to dissect through the dartos muscle and cremasteric fibers in order to expose the tunica vaginalis
4) A sponge is used to push the fibers off of the tunica vaginalis and fully deliver the testis/tunica vaginalis through the wound
5) Continue to use a sponge to clean off the tunica vaginalis such that it is fully exposed
6) Incise the tunica and expose the testis
7) With traction on the testis to expose the cord, bluntly dissect the cord into 2 or 3 segments. The vas is typically isolated in its own segment. Clamp, cut, and ligate each segment, typically with 2-0 silk. A suture ligature is often used due to risk of bleeding from the cord and the fact that it will quickly retract up into the pelvis once it is released.
8) Irrigate the wound and liberally electrocoagulate possible bleeders due to risk of scrotal hematoma
9) Close the dartos in a running layer and then the skin.
10) The wound is typically dressed with bacitracin, fluffs, and scrotal support.