BackTable / Urology / Article
Testicular Cancer and Fertility After Orchiectomy
Avery Wolfe • May 12, 2021 • 287 hits
The testes are responsible for both androgen and sperm production, so many patients have concerns about testicular cancer and fertility preservation after radical orchiectomy. AUA guidelines state that men with a normal contralateral testicle should undergo radical inguinal orchiectomy, as paternity rates are favorable following surgery. In patients with bilateral disease or a single testicle, partial orchiectomy is a viable option to balance oncologic control of testicular cancer and fertility preservation.
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The BackTable Urology Brief
• Paternity rates following radical inguinal orchiectomy approach 90% in patients with a normal contralateral testicle.
• Placing a prosthetic testicle at the time of orchiectomy is a good option, especially in young, single patients who may feel a greater sense of loss after radical orchiectomy.
• A preoperative semen analysis and testosterone level are useful tools to evaluate the likelihood of partial orchiectomy being successful for patients seeking to balance oncologic control of testicular cancer and fertility preservation.
Table of Contents
(1) Counseling Patients on Testicular Cancer and Fertility After Orchiectomy
(2) Radical Orchiectomy versus Partial Orchiectomy
(3) Optimal Timing For Offering Testicular Prosthesis
Counseling Patients on Testicular Cancer and Fertility After Orchiectomy
Dr. Bagrodia reviews his approach to counseling patients on testicular cancer and fertility prior to orchiectomy, explaining that the testicles are responsible for both sperm and androgen production. Though there is a baseline risk of oligospermia in men presenting with testis cancer, paternity rates after orchiectomy approach 90%. Dr. Bagrodia stresses the importance of examining the unaffected testicle, with a low threshold to consider semen analysis and cryopreservation before orchiectomy if it’s not completely normal.
...Is there something else [your patients are doing] in terms of sperm retrieval prior to the surgery? Any other labs? Like testosterone labs? Things like that?
Yeah. So excellent points. A couple of things. Starting out with the way I kind of counsel patients is say, "Hey, listen. The testes do two things. They make testosterone and they make sperm."
In terms of pre-orchiectomy testosterone levels, those are generally similar in men with testis cancer as healthy controls. Post-orchiectomy you will see hypogonadism in about 10% to 20% of patients. Now, whether that translates into clinical hypogonadism is patient-specific, but I definitely talk to them. In Texas that's actually a mandatory part of the consent.
The other aspect of this is, of course, sperm production. Now, you see some fertility or infertility with a baseline risk of oligospermia in about half of men presenting with testes cancer, and about 10% to 30% of men would have experienced infertility issues coming into it. Fortunately, post-orchiectomy paternity rates are about 90%, so generally they'll kind of even out.
Practically, I think it's important that you examine the contralateral testicle. You ask about any issues or problems with fertility. And if they're worried about it, if their contralateral testicle isn't normal, if they've got any type of syndromic type of features, then I would have a very low threshold to perform pre-orchiectomy semen analysis (i.e. count) and cryopreservation. A baseline testosterone, less inclined to obtain that just because I think it can be a source of anxiety in the absence of clinical hypogonadism, but certainly afterwards it's going to be something that I am counseling them about.
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Radical Orchiectomy versus Partial Orchiectomy
Dr. Bagrodia discusses his experience with partial orchiectomy for fertility preservation in patients with bilateral testis cancer or a single testicle, noting that per AUA guidelines a patient with a normal contralateral testicle should undergo radical inguinal orchiectomy instead. Dr. Bagrodia prefers to get a baseline semen analysis and testosterone level in these patients, as partial orchiectomy is unlikely to be successful in balancing oncologic control of testicular cancer and fertility preservation if the patient is already azoospermic at baseline.
Okay. So let's talk about other situations. Partial orchiectomies - is there a role? I mean, in Europe they're doing that for some cases. Are you doing some partial orchiectomies at your place?
Yeah. Yeah. So testis-sparing surgery does get a lot of attention, and per the AUA guidelines, if you've got a normal contralateral testicle, a radical inguinal orchiectomy should be performed. Now, of course, you're going to have patients - we see these not infrequently with bilateral tumors, or they've got a solitary testicle - and these are cases where absolutely you want to not just get it right but get it perfect.
So for starters, it's mandatory, in my opinion, to get a semen analysis and a baseline testosterone. If they're azoospermic, and they're hypogonadal, you're not really doing them any favors by doing a partial orchiectomy. Take it one step further. If they're azoospermic and hypogonadal, that's the case where you want to have your infertility specialist there to actually do a sperm extraction at the time of orchiectomy, and we've done that before.
Now let's say they've got some androgen production, and they've got some evidence of spermatogenesis. So of course you want to cryo-preserve. Then you really want to talk to the patient about what they prioritize here? Do they prioritize androgen production and fertility preservation? Or do they prioritize oncologic control? So, you have that conversation at the front, and you run through the various scenarios.
All right. So let's just say that they do want to consider a partial orchiectomy. So this is going to be important that the tumor is less than about two centimeters. If it's on one of the poles or superficial under the capsule, that makes it a lot easier. And then you want to make sure that your GU pathologist is on standby, not just any ‘Tom, Dick, and Harry’. So what I will do is, just like we initially talked about, deliver the testicle, make sure that the field is squared off. If you're concerned at all about being able to find the tumor, it's also not a bad idea to have your ultra-stenographer on deck. I'll make a tunical incision and, using loops, resect the mass, send it for frozen, and also take biopsies, and close up the testicle at that point. And then I'll put it on ice at that time as well.
So you really want to make sure that they don't have any germ cell neoplasia in situ, which can be a difficult intraoperative diagnosis, and then you also want to confirm that it's a testis cancer. So let's just say that it's a testis cancer with no GCNIS. Then you go ahead and proceed with your orchiopexy, your scrotal support, and so forth. Many times germ cell neoplasia in situ is difficult to diagnose from intraoperative sections. But if you've got negative margins and an absence of germ cell neoplasia in situ, then you just go on a surveillance program. Self-exams. I will typically get an ultrasound at three months, at six months, and then annually thereafter. That's not necessarily guideline-directed care.
If they do have germ cell neoplasia in situ, their risk of developing an invasive tumor is going to be right around 50%, So you can either give them adjuvant radiotherapy to mitigate that risk down to about 1% to 2%, or you can observe them, allow them to be... They have to know, "Hey. There's a real chance of developing a tumor," and if they're, for instance, trying to have a kid naturally, now would be the window to try to do it.
But the bottom line is, yes, you want to be familiar with this option. Doing a radical orchiectomy on a solitary tumor or doing bilateral orchiectomies is not a trivial decision. It's obviously an easier decision, but again, having the kind of clinical chops and the multi-disciplinary team to make those decisions is important.
I mean, and also partial orchiectomy is not easy, And you can have complications, you can have bleeding afterwards, and you can have other post orchiectomy problems that might end up causing maybe more problems to the patient, so definitely have that conversation with them, but you're trying to preserve function with the partial orchiectomy.
Optimal Timing For Offering Testicular Prosthesis
Dr. Bagrodia explains his preference to offer placement of a testicular prosthesis as part of preoperative counseling, so it can be placed at the time of radical orchiectomy. Studies show that placement of a prosthetic testicle may help reduce feelings of loss or shame after radical orchiectomy, especially in young, single patients.
...So in terms of the procedure, are you counseling them on testicular implants prior to the procedure? Do you offer them? I use Coloplast. I usually do it at the time of the surgery. Do you do it afterwards? What is a good timing to offer it, and if we're going to offer it, then do it?
Excellent point. As someone who sees patients that largely have had their orchiectomy, one of the things that we run across most frequently is that they were never offered a prosthesis. So, placement of a prosthesis is associated with better self-image, body image, profiles. There have been multiple studies to show that, and many of the feelings of loss, of uneasiness, and of shame can be mitigated by placing a prosthesis. And, unequivocally, it's going to be easier to place it at the time of orchiectomy. This myth of placing it at a different time is really just that...it's an old wives' tale.
So I also use a Coloplast. The majority of patients are going to use a large. It is something that oftentimes needs to be pre-arranged. Generally the prosthesis are not kept on the shelf at many hospitals, so you do want to know who your rep is and have them come in. Practically, that may not always be possible, but if you're not thinking about it at that initial consultation, you're going to miss the window. You're going to miss the opportunity.
Yeah. I found that usually the patients that are saying, "Yes," to the implants are younger patients in their 20's, single patients, and they still want to have that feeling of both testicles. Patients already married with kids, they probably don't care. They will say, "Don't worry about it. I don't care." Is that the same reaction to you in Texas?
Yeah. I would say generally it's kind of the same. And as you know, we can really impact that decision as well, and everybody's a little bit different, and if it's never offered and they don't know about it, they're not going to have an opinion. Typically, it is the young, single guys that are more interested in it and the older, married folks are less interested.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, April 17). Ep. 3 – Management of Testicular Cancer [Audio podcast]. Retrieved from https://www.backtable.com
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