OVERVIEW

Epidemiology & Etiology

Testicular cancer is the most common malignancy in men between the age of 15 to 35 years. Fortunately, it is one of the most curable cancers due to early diagnosis, new treatment such as cisplatin chemotherapy and a greater understanding of the nature of the disease.

There are approximately 8000 newly diagnosed cases of testicular cancer each year in the United States. The probability that an American white male will develop testicular cancer in his lifetime is approximately 0.2%. Most tumors occur in late adolescence or early adulthood.  However, occasionally tumors are seen in infancy and in patients over the age of 60 years. The incidence of testicular tumors in African Americans is dramatically less than that in American whites.

Types of Testicular Cancer

Seminoma
Non-seminoma
Embryonal carciroma
Choriocarcinoma
Yolk sac tumor
Teratoma

The cancer type determines its biological behavior, thus, distinguishing the type (seminoma vs. non-seminoma) is important in making treatment recommendations. It is not unusual to have multiple cell types in a given testicular cancer (i.e. embryonal carcinoma and teratoma together).

Some testicular tumors produce proteins which can be detected in the blood and can be used as tumor markers to detect and survey disease. The most common tumor markers produced by testicular cancer are alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH).  These tumor markers should normalize following successful treatment, and persistently elevated markers usually indicate presence of active disease.  Most testis cancers (70%) are diagnosed at an early stage (while still confined to the testicle).  However, nearly 20% of cases present with regional lymph node (retroperitoneal) involvement and approximately 10% present with distant metastasis.  In general, survival rates are excellent following treatment; 5-year survival for local, regional and distant disease is 99%, 96% and 71%, respectively.


Signs & Symptoms

Most patients notice a mass, pain or swelling in one testicle. In about 10% of patients, acute pain is a presenting symptom. In a very small percentage of patients, the first symptoms are from metastases, including neck mass, problems with breathing (cough or shortness of breath), difficulty eating, abdominal pain, back pain or pain in the bones.

Diagnosis

Typically the patient or a physician feels a mass within the testicle. It is not unusual to have small lumps in the epididymis, however, any unusual mass should be evaluated by a physician. Other diseases that can cause swelling or tenderness in the testicles include infection, fluid around testicles, hernia or testicular torsion. An ultrasound examination of the scrotum and testicle is the most reliable technique to evaluate the presence of a testicular tumor.

Early detection is important, so monthly self-examination is recommended. This is best performed in a warm shower.  Any suspicious areas should be examined by a physician.   If an intratesticular mass is present a radical orchiectomy – removal of affected testicle and spermatocord – should be performed.

Staging for testicular cancer 
Testicular tumors are staged using the TNM system. Tumors are staged based on the findings at the surgery to remove the testicle including; the microscopic examination, serum tumor markers, chest x-ray, CAT scan and other studies as indicated. Staging helps in assessing risk and in making treatment recommendations.

Testis tumors can spread by one of three routes. First and most commonly, they may spread through the lymph nodes in the back and abdomen.  Right-sided tumors tend to spread to the right side of the lymph nodes and left-sided lymph nodes in the back. Second, they may spread to adjacent tissue through the wall of the testicle into the blood supply or tubes that transport sperm.  Finally, testicular tumors can initially spread by the bloodstream to distant organs such as the lung, bone or brain.

Treatment

Where testicular cancer is probable, is best to treat it initially by removing the testicle through an incision in the groin.  Once the tumor is removed, any elevated tumor markers should return to the normal range. If they do not normalize, one should suspect that cancer is still present. Depending upon the examination, tumor markers, results of X-rays and type of tumor present on microscopic evaluation, a variety of different treatment options may be recommended.

In patients with low stage seminoma, removing the testicle and radiation to the back may be appropriate. With other types of tumors, initial chemotherapy or surgery to remove the lymph nodes in the back may be necessary.

Traditional surgery removes the retroperitoneal lymph nodes located in back of the abdomen.  For low stage disease, the lymph nodes can be observed, treated with a short course of chemotherapy, or treated with a lymph node dissection.  Most often, surgery is performed through an open incision to allow complete removal of all potentially involved lymph node tissue.  In some cases, laparoscopic surgery may be used to remove the lymph nodes.

OUR SURGEONS

At the University of Florida Department of Urology, radical orchiectomies/retroperitoneal lymph node dissections are performed by two experienced fellowship-trained surgeons: Dr. Chester Algood and Scott Gilbert.

	Chester B. Algood, MD, FACS Clinical Assistant Professor Medical Director, Urology Clinic
	Scott Gilbert, MD Assistant Professor of Urologic Oncology Medical Director, Urology Quality & Safety Program

APPOINTMENTS

To schedule an appointment with one of our surgeons, please contact the UF Shands Medical Plaza GU Oncology Clinic at 352-265-8282. For  more information, directions to the Medical Plaza and local accommodations please visit: http://www.urology.ufl.edu/urocare_patientinfo.php

TESTIS CANCER PRE-SURGERY

What to expect during you preoperative consultation

Prior to your initial consultation with your surgeon it is important that patients obtain all X-ray films (e.g. CT scan, MRI, sonogram) and reports pertaining to the diagnosis and bring them to the appointment.  In addition, our office may request pathology slides that confirm your diagnosis of testis cancer from your referring physician/hospital.  Your surgeon will then review your chart to determine the best course of action individualized to your particular situation.   

All alternatives and options for treatment including surgery, chemotherapy and radiation will be discussed with you at that time. A physical examination will also be performed and if deemed necessary, a surgery date will be determined with one of our Surgery Scheduling Coordinators.

What to expect prior to the surgery

Once your surgery date is secured by one of our Surgery Scheduling Coordinators, the items listed below will be ordered as necessary based upon your age, medical history and risk for surgery. These will be performed through a preoperative anesthesia consultation at the Presurgical Center at UF & Shands that will be arranged for you at your initial visit. During this consultation you will have the opportunity to speak to the anesthesia staff regarding the types of anesthesia available and the risks/benefits.

• Physical exam
• EKG (electrocardiogram)
• Chest X-ray
• CBC (complete blood count)
• PT / PTT (blood coagulation profile)
• Pulmonary Function Tests
• Comprehensive Metabolic Panel (blood chemistry profile)
• Urinalysis

Preparation for surgery

Medications to Avoid Prior to Surgery

The following is a list of medications to avoid at least 7-10 days prior to surgery.  Many of these medications can alter platelet function or your body’s ability to clot and therefore may contribute to unwanted bleeding during surgery. Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery. Do not stop any medication without contacting the prescribing doctor to get their approval.

Aspirin, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Vioxx, Plavix

A formal list of these medications and others will be provided to you by our Surgery Scheduling Coordinators.

Bowel Preparation and Clear Liquid Diet
Patients should adhere to a clear liquid diet 48 hours prior to surgery.  An example of a clear liquid diet is listed below.  In addition, bowel preparation with Fleets Phosphosoda or Magnesium Citrate the evening before surgery is often prescribed.  These can be purchased at your local pharmacy.  Do not eat or drink anything after midnight the night before the surgery.


Clear Liquid Diet
Remember not to eat or drink anything after midnight the evening before your surgery.
Clear liquids are liquids that you are able to see through.  Please follow the diet below.

• Water
• Clear Broths such as chicken or beef (no cream soups, meat, noodles etc.)
  
• Juices (no orange juice or tomato juice)
• Apple juice or apple cider
• Grape juice
• Cranberry juice
• Tang
• Hawaiian punch
• Lemonade
• Kool Aid
• Gator Aid
• Tea or coffee (you may add sweetener, but not cream or milk)
• Jello, popsicles, Italian ice (without fruit)

THE SURGERY

The Operation

Radical orchiectomy requires that patients undergo a general anesthesia. While operative time varies from one individual to another, the average operating time is approximately 1 hour. Your surgeon will make a four inch incision in the inguinal area, identify, dissect and remove the testicle with a mass.

Video Clips

The following is a series of video clips that demonstrate key steps of a retroperitoneal lymph node dissection for removal of a testis tumor.

Potential Risks and Complications

As with any major surgery, complications, although rare, may occur with Retroperitoneal Lymph Node Dissection (RPLND). Potential risks and complications with this operation include but are not limited to the following:

• Bleeding: RPLD requires dissection and removal of lymph nodes that reside around the large blood vessels traveling within the abdomen including the aorta and vena cava. Injury to these structures can result in substantial blood loss. If you are interested in autologous blood transfusion (donating your own blood) prior to your surgery, you must make your surgeon aware. This can be arranged locally in Gainesville, FL at the Civitan Regional Blood center or at your local Red Cross.  However, donation of blood in advance of your surgery is not required.

• Infection: Although patients are given broad spectrum intravenous antibiotics immediately prior to surgery, infections of the urinary tract and skin incisions may still occur but are rare. If you develop any signs or symptoms of infection after the surgery (fever, drainage from or redness around your incisions, urinary frequency/discomfort, pain) please contact us at once.

• Tissue / Organ Injury: Although uncommon, adjacent organs and tissues may be injured as a result of your surgery. This includes the colon, bowel, vascular structures, nerves, muscles, lung, spleen, liver, pancreas, kidney and gallbladder. On rare occasions, further surgery may be required to address unexpected injuries to adjacent organs.

• Effects on Fertility: Testicular patients are generally young and therefore may have the interest in preserving their potential for future fertility. The treatments for testicular cancer can affect their fertility potential in several ways.
• Loss of Sperm Production: Testicular cancer patients who require chemotherapy should consider banking sperm prior to treatment, as chemotherapy may effect sperm production by the remaining testicle. Although sperm counts can improve following chemotherapy with time, there is a risk that the sperm quality may never return to normal levels and thus may be permanently affected by the necessary chemotherapy treatments.  Sperm banking can be performed at any major medical or local fertility center.
  
  
• Retrograde Ejaculation: Occasionally, the delicate nerves responsible for the control of ejaculation may be injured during RPLND surgery whether performed by open or laparoscopic surgery. This may result in a condition called retrograde ejaculation, where the sperm is expelled back into the bladder rather than forward and out of the penis. As a result, patients may notice a significant decline or complete absence in their ejaculate fluid.  Although retrograde ejaculation is not particularly harmful to your body, it will naturally adversely affect a man’s ability to father a child by intercourse. Nevertheless, assisted reproduction techniques such as in-vitro fertilization (IVF) can often be performed to achieve a successful pregnancy despite retrograde ejaculation.
• Lymphocele: Lymphatic fluid can rarely collect in the area where the lymph nodes were removed, which may require drainage of the fluid and further surgery.
  
  
• Respiratory Complication: Some chemotherapy agents such as bleomycin have potential toxicity to your lungs, therefore placing you at a higher risk of respiratory complications during and following surgery. However, in most cases, patients who have received such medications can still undergo successful surgery with greater attention paid to their respiratory status following surgery.

POST-SURGERY

Immediately after the surgery you will be taken to the intensive care unit (ICU) or the recovery room then transferred to your hospital room once you are fully awake and alert.

• Postoperative Pain: Pain at their incision sites is common, but is generally well controlled by use of intravenous pain medication, patient-controlled anesthesia pump, or oral pain medication provided by your nurse.

• Nausea: Nausea is common following any surgery especially related to general anesthesia. This is usually transient and controlled by medication which can be administered on an as needed basis by your nurse.

• Urinary Catheter: A urinary catheter (also called Foley catheter) is placed to drain your bladder at the time of surgery while you are asleep. This is in efforts to monitor your urine output over the first day or so following surgery. This is generally removed by your nurse once you are walking comfortably.

• Diet: Your diet will be advanced slowly following surgery from sips of water to liquids to solids as tolerated. It is often the case that your appetite will be poor for several weeks following surgery. In addition, your intestinal function is often sluggish due to the effects of surgery and general anesthesia. It is for these two reasons that we recommend taking only small amounts of liquids by mouth at any one time until you begin to pass flatus and your appetite returns. In the meantime, your intravenous catheter will provide the necessary hydration to your body as you oral intake improves.

• Fatigue: Fatigue is quite common following surgery and should subside in a few weeks following surgery.

• Incentive Spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections through using an incentive spirometry device (these exercises will be explained to you by the nursing staff during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.

• Ambulation: Usually the day after surgery you will begin to ambulate with the supervision of your nurse or family member.  Walking helps prevent pneumonia and prevents blood clots from forming in your legs. You can also expect to have SCD's (sequential compression devices) wrapped around your lower legs and calf area to prevent blood clots called deep vein thrombosis from forming in your legs. In the days that follow surgery, patients are advised to walk at least 4-6 separate times a day in the hallways. This serves to further reduce the change of deep vein thrombosis and speed the return of bowel function.

• Constipation/Gas Cramps: You may experience sluggish bowels for several days following surgery as a result of the anesthesia. Suppositories and stool softeners are usually given to help with this problem. Taking a teaspoon of mineral oil daily at home will also help to prevent constipation. Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.

• Hospital Stay: The length of hospital stay following radical orchiectomy is generally 1 day, whereas for retroperitoneal lymph node dissection is generally 7-10 days.

What to expect after discharge from the hospital

• Pain Control: For the majority of patients, one to two weeks of oral narcotic pain medication may be necessary after which Extra Strength Tylenol is usually sufficient to manage their pain.  Again, narcotics should be minimized to avoid constipation and over sedation.

• Showering: Patients can shower immediately upon discharge from the hospital allowing their incisions to get wet. Once out of the shower, pad your incision sites dry and avoid any heavy creams or lotions. Tub baths or hot tubs in the first 2 weeks are discouraged as this will allow for prolonged soaking of your incisions and increase the risk of infection. In patients who have undergone an orchiectomy, internal sutures are used to keep the wound together.  The internal suture will dissolve on their own.  In patients who have undergone a retroperitoneal lymph node dissection, staples are used to keep the wound together. The staples from your wound will be removed 1-2 weeks after surgery.  Then adhesive tapes across is applied to the incision, called Steri-strips which can be removed in another 1-2 weeks.

• Activity: Walking 4-6 times a day for the first two weeks after surgery on a level surface is strongly encouraged as prolong sitting or lying can increase your risk of pneumonia and deep vein thrombosis. It is permissible to climb stairs. No heavy lifting or exertion for up to 4 weeks following surgery.  Patients may begin driving once they are off of narcotic pain medication and have full range of motion at their waist (around 4 weeks after surgery). Most patients can return to full activity including work on an average 4-8 weeks after surgery.

• Diet:  Generally, there are no dietary restrictions once you return home from your hospitalization. You should, however, drink plenty of fluids.

• Follow-up Appointment: Patients should make a follow-up appointment with their surgeon by contacting the Shands Medical Plaza Urology Clinic at 352-265-8240. Your surgeon will let you know the timing and schedule of clinic visits following surgery.

• Pathology Results: The pathology results from your surgery are usually available in 2-4 weeks following surgery. This will provide information as to the presence of cancer, location and size within the testis or lymph nodes, and extent of growth. Your results will be discussed with you in the office during a follow-up clinic appointment. At this time, the significance and prognosis of your diagnosis will be discussed.

• Long Term Follow-up: Based on the pathology report of your testis or retroperitoneal lymph nodes, you may need additional treatment such as radiation therapy or chemotherapy. You will need a CT scan, chest x-ray and blood work including Alpha-fetoprotein (AFP), Lactic Dehydrogenase (LDH) and human Chorionic Gonadotropin (HCG) periodically. The frequency of this testing can vary from patient to patient.

WHEN TO CALL YOUR DOCTOR

Serious adverse events are rare following orchiectomy or retroperitoneal lymph node dissection, it is important for patients to recognize these events and know when to contact their surgeon. You should contact your surgeon or primary care doctor immediately if any of the following occur:

• Worsening pain over the ensuing days following your surgery despite the use of oral pain medication/.
• Fevers >101o F may indicate a serious infection within the urinary tract. 
  
• Nausea and vomiting
• Chest pain or difficulty breathing

Frequently Asked Questions (FAQs)

Will I need radiation therapy or chemotherapy after my orchiectomy?
Depending on the type of cancer or extent of cancer, patients may benefit from radiation therapy or chemotherapy after orchiectomy with the purpose of eradicating other possible sites of tumor spread. Duration of radiation therapy may range from 1-2 weeks.  Radiation therapy is administered under the advisement of a radiation oncologist. Administration of chemotherapy may range from 2-4 months.  Chemotherapy would be administrated under advisement of a medical oncologist. Upon completion of radiation therapy or chemotherapy, further blood work and X-rays will be performed to confirm response to radiation therapy or chemotherapy.

Will I need further treatment such as radiation or chemotherapy following surgery?
The need for further adjuvant therapy such as chemotherapy after retroperitoneal lymph node dissection will depend largely upon the stage of your testicular cancer. This will be discussed thoroughly with you in conjunction with a medical if needed.

How will my ejaculate return following surgery?
The ability to have antegrade (or forward) ejaculation depends on the presence of sympathetic nerves traveling in and around the retroperitoneal lymph nodes. If these nerves can be spared safely, then your ability to have antegrade ejaculation should be excellent.  However, as with any nerve, transient injury due to traction or manipulation during surgery may delay return of antegrade ejaculation for several months following surgery.

Will my erections be affected by RPLND?
No. The ability to have erections are governed by a separate set of nerves that arise from lower in your spinal cord that travel in your pelvis. These nerves will not be disturbed during RPLND surgery.

What is the overall success rate of surgery for testis cancer?
Prognosis of cancer-free survival is based upon the grade and stage of your particular cancer and will be discussed with you by your surgeon. However, cancer-free survival rates for testis cancer are extremely favorable.