Simple and Epididymal-Sparing Orchiectomy for Surgical Castration in Stage IV Prostate Cancer

Abstract

Background: Androgen deprivation therapy, the mainstay of treatment for patients with advanced prostate cancer, can be either medical or surgical. Surgery has cost benefits compared to medical treatment. In this study, we evaluated the use of simple and epididymal-sparing orchiectomy in 2 different practice settings for the treatment of metastatic prostate cancer. Methods: We reviewed patients who underwent surgical castration for metastatic prostate cancer between 2011 and 2022. The primary outcome was achieving castration-level total testosterone of <50 ng/dL. We also compared the characteristics of patients who were seen at a public academic teaching hospital vs those who were seen at a private community hospital (oncology group practice), and we evaluated the impact of orchiectomy approach (simple vs epididymal-sparing orchiectomy) on patient outcomes. Results: We analyzed 101 patients who underwent orchiectomy: 40 (39.6%) at a public academic teaching hospital and 61 (60.4%) at a private community hospital (oncology group practice). Of these patients, 81 (80.2%) underwent simple orchiectomy and 20 (19.8%) underwent epididymal-sparing orchiectomy. Forty-nine patients (48.5%) had previously received medical androgen deprivation therapy, 9 (18.4%) of whom had medication adherence issues. Patient age, race, and marital status differed significantly between hospital facilities. The overall surgical complication rate was 3.0%. Postoperative total testosterone levels were available for 81 patients, drawn a median of 57 days after surgery [IQR 30, 123]. All patients had castrate-level total testosterone (median 10 ng/dL [IQR 9, 19]) postoperatively, with no differences seen between surgery location (P = 0.84) or surgical technique (P = 0.90). Conclusion: Simple or epididymal-sparing orchiectomy is safe and effective for surgical castration and is an alternative to medical androgen deprivation therapy for patients diagnosed with metastatic prostate cancer regardless of the practice demographics.

Keywords: Castration; orchiectomy; prostate neoplasms.

Figure 1.

The testicle is delivered through a small scrotal incision.

Figure 2.

The parietal layer of the tunica vaginalis is peeled back.

Figure 3.

The head and tail of the epididymis with efferent ductules are dissected from the tunica albuginea using cautery.

Figure 4.

Perforating branches of the testicular artery are either suture tied or ligated with electrocautery.

Figure 5.

The testicular hilum is controlled with electrocautery.

Figure 6.

The tail of the epididymis is approximated to the head (shown) and then placed back inside the tunica vaginalis, which is sutured, and the incision is closed.