Health After Orchidectomy for Testicular Cancer: Care Guide

What should be discussed before orchidectomy?

Testicular cancer is usually diagnosed between the ages of 18 and 40, so fertility and body image are part of the conversation before surgery. Before surgery, both testicles are examined with ultrasound and tumour markers are measured. The EAU testicular cancer guideline also makes a strong recommendation that sperm banking is discussed with all men before any treatment begins.

"Poor sperm quality is frequently found in TC patients, before and after treatment. Semen preservation is the most cost-effective strategy for fertility preservation." Source 1, p. 14

A testicular prosthesis should also be offered to every man having one or both testicles removed, another strong recommendation. The prosthesis can be placed at the time of orchidectomy or at a later operation, without adverse consequences, including infection. It restores the appearance of the scrotum but does not produce hormones or sperm.

What do tumour marker tests show after orchidectomy?

Tumour markers are blood tests for alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG) and lactate dehydrogenase (LDH). They are measured before orchidectomy and again afterwards. Raised levels can take several weeks to return to normal after surgery, because AFP has a half-life of five to seven days and hCG one to three days. Normal levels after surgery do not rule out spread of the cancer.

During follow-up, tumour markers are the least invasive test and, in a small proportion of patients, detect disease too small to see on scans. They can also give false positive results, so they are read alongside imaging or repeated.

How often are tumour markers checked during follow-up?

Follow-up schedules for testicular cancer depend on the tumour type, the stage and the treatment received. The guideline sets minimum schedules for three groups of men, based on a European consensus.

For seminoma stage I, tumour markers are checked twice a year in years one to three and once a year in years four and five. For non-seminoma stage I on active surveillance, they are checked four times a year in years one and two, twice in year three, and once or twice a year in years four and five. After adjuvant treatment, or after complete remission of advanced disease, they are checked four times a year in years one and two and twice a year in years three to five.

After five years, follow-up continues under a survivorship care plan.

What scans are used during follow-up?

Follow-up scans of the abdomen and pelvis use either MRI or CT, and some groups also have chest X-rays. MRI avoids ionising radiation but takes longer and is less widely available than CT.

Some studies have estimated that repeated CT follow-up alone carries a risk of up to 1 in 300 of a second cancer, although newer dose-saving protocols have reduced this. MRI of the abdomen is accepted as an alternative to contrast-enhanced CT in experienced centres.

Relapse after five years is rare, at about 0.5% of patients. Beyond five years, follow-up aims to detect late effects of treatment, and imaging is no longer routinely recommended. Most late relapses are found because of symptoms, so knowing the signs of relapse remains part of long-term care.

Why is the remaining testicle monitored?

Men who have had testicular cancer have a small risk of a new tumour in the other testicle. The rate of a later tumour is approximately 2.5%, and of GCNIS up to 9%, and the guideline describes both as low.

Men are encouraged to examine themselves and to tell their first-degree male relatives about the need for self-examination, which the guideline grades as a weak recommendation. Most members of the consensus panel behind the follow-up schedules did not support repeat ultrasound of the other testicle.

A biopsy of the other testicle is not routine. It is discussed with men at high risk, meaning those with a testicular volume under 12 mL or a history of undescended testicle, known as cryptorchidism. It is not necessary in men over 40 without these risk factors, and a later tumour can still occur after a negative biopsy.

How does treatment affect fertility and testosterone afterwards?

Testosterone is made mainly by the Leydig cells of the testicles, in response to luteinising hormone from the pituitary gland. After one testicle is removed, the other continues to produce it. The guideline does not give a rate of low testosterone after a standard orchidectomy, but it lists testosterone deficiency among the long-term risks screened for and treated during follow-up.

Testis-sparing surgery, where only the tumour is removed, is used in selected cases, such as a tumour in a single remaining testicle. After this operation, the risk of needing testosterone replacement is about 10%, so testosterone levels are checked every year.

Some later treatments affect fertility. When germ cell neoplasia in situ (GCNIS), a precancerous change, is found in a single remaining testicle, radiotherapy to that testicle is considered, and it results in infertility. Men who still wish to father children may defer this radiotherapy and be monitored with regular self-examination and repeat ultrasound instead. By contrast, two cycles of cisplatin-based chemotherapy given after surgery did not appear to harm fertility or sexual activity.

What long-term health effects are monitored?

Men with testicular cancer are usually diagnosed young and usually cured, so life after treatment extends over several decades. Follow-up screens for and treats high blood pressure, high cholesterol and testosterone deficiency. Long-term health problems are more common after chemotherapy than after surgery alone.

Modifiable risk factors contribute to several long-term problems, including high blood pressure, hearing loss after noise exposure, and poor circulation in the fingers, known as Raynaud phenomenon, in smokers. A healthy lifestyle is encouraged at follow-up visits.

The diagnosis and fear of recurrence can affect psychological well-being, and unemployment is higher among survivors than in the general male population. When specialist follow-up ends, a written survivorship plan covering late effects, lifestyle, recurrence risk and further follow-up may be helpful.