Orchiectomy for Adult Undescended Testicle

Orchiectomy is surgical removal of a testicle.

When cryptorchidism persists beyond puberty, the affected testicle may have undergone substantial structural and functional deterioration.

Adult management therefore differs from childhood cryptorchidism.

Rather than automatically moving the testicle into the scrotum with orchidopexy, the specialist must determine whether preserving it offers meaningful:

• Fertility benefit

• Hormonal benefit

• Anatomical benefit

If those benefits are limited and the opposite testicle is healthy, removal may provide the more appropriate risk-benefit balance.

Why might an undescended testicle be removed?

A testicle that remains outside the scrotum for many years is exposed to a higher temperature than a normally descended testicle.

Long-term consequences may include:

• Germ-cell loss

• Impaired sperm production

• Testicular atrophy

• Fibrosis

• Abnormal histology

• Increased testicular cancer risk

By adulthood, some undescended testes are very small and provide little meaningful reproductive function.

In selected unilateral cases, orchiectomy may therefore be preferable to preserving a poorly functioning testicle.

When is orchiectomy preferred over orchidopexy?

The decision is individualized.

Orchiectomy becomes particularly relevant when:

• Cryptorchidism is unilateral

• The opposite testicle is healthy

• The undescended testicle is severely atrophic

• The testicle appears abnormal

• Meaningful spermatogenic function is unlikely

• Preservation provides little endocrine benefit

• Malignancy is suspected

Orchidopexy may instead be considered when preserving testicular tissue is clinically important.

What do European guidelines recommend?

Current European guidance distinguishes post-pubertal patients according to testicular and reproductive function.

In adult men with a unilateral undescended testicle and normal contralateral testicular function, orchiectomy may be offered.

Orchidopexy can remain appropriate in selected patients with bilateral disease, impaired spermatogenesis, hypogonadism or other reasons to preserve testicular tissue.

The decision should therefore not be based on age alone.

Why does cryptorchidism increase testicular cancer risk?

Testicular maldescent is associated with abnormal germ-cell development.

Men with a history of cryptorchidism have a higher risk of developing testicular germ-cell tumors than men whose testes descended normally.

Risk is influenced by factors including:

• Testicular location

• Unilateral versus bilateral disease

• Age at correction

• Underlying testicular abnormalities

Correction before puberty is associated with a lower malignancy risk than late correction.

Does orchidopexy eliminate cancer risk?

No.

Moving a post-pubertal testicle into the scrotum makes examination and surveillance easier but does not eliminate the increased malignancy risk associated with its history of cryptorchidism.

This is an important reason orchiectomy may be discussed when a unilateral adult cryptorchid testicle is severely atrophic and offers little functional benefit.

How is orchiectomy performed?

The approach depends on testicular location and whether malignancy is suspected.

Inguinal testicle

A palpable testicle in the groin can usually be approached through an inguinal incision.

The surgeon identifies:

• Testicle

• Spermatic cord

• Blood vessels

• Vas deferens

The relevant structures are controlled and the testicle is removed.

Intra-abdominal testicle

A testicle located inside the abdomen may be removed laparoscopically.

Small abdominal incisions allow the surgeon to identify the testicle and spermatic structures using a camera.

The testicle is detached and removed in a controlled manner.

What if testicular cancer is suspected?

The surgical strategy changes if a suspicious mass is present.

A potentially malignant testicular tumor should be managed according to testicular-cancer principles rather than treated as a routine benign orchiectomy.

This may require:

• Tumor markers

• Ultrasound

• Cross-sectional imaging

• Radical inguinal orchiectomy

• Histopathology

• Oncological staging

Patients with suspected malignancy should be managed through an appropriate urologic oncology pathway.

What happens to the removed testicle?

The specimen is generally sent for histopathological examination.

The pathologist examines the tissue for abnormalities including:

• Atrophy

• Fibrosis

• Germ-cell abnormalities

• Germ cell neoplasia in situ

• Testicular tumor

Histopathology is particularly important in long-standing adult cryptorchidism.

Will removing one testicle lower testosterone?

Usually not if the opposite testicle is healthy.

A normal contralateral testicle can generally produce sufficient testosterone to maintain:

• Libido

• Erections

• Muscle mass

• Bone health

• Male secondary sexual characteristics

Hormonal testing can be performed before surgery when there is concern about existing testicular dysfunction.

Will removing one testicle cause infertility?

Not necessarily.

A healthy opposite testicle can often produce enough sperm for natural fertility.

In fact, a severely atrophic undescended testicle may already contribute very little to sperm production.

However, fertility should be assessed before surgery when:

• Semen parameters are abnormal

• The opposite testicle is small or abnormal

• Previous testicular surgery occurred

• The patient has known infertility

• Future biological children are important

Should I have a semen analysis before surgery?

It can be valuable for men who want future fertility.

A semen analysis establishes baseline:

• Sperm concentration

• Motility

• Semen volume

If significant abnormalities exist, additional fertility evaluation may be appropriate before removing testicular tissue.

Should sperm be frozen before orchiectomy?

Routine sperm freezing is not necessary for every unilateral orchiectomy.

Sperm cryopreservation may be considered when:

• Semen quality is already reduced

• The opposite testicle is abnormal

• Bilateral testicular disease exists

• Future fertility is a major concern

• Additional gonadotoxic treatment may become necessary

What if both testicles are undescended?

Bilateral adult cryptorchidism requires a very different discussion.

Removing both testes causes permanent loss of natural testosterone production and eliminates any remaining sperm production.

Bilateral orchiectomy should therefore not be treated like routine unilateral removal.

Testis-preserving approaches, fertility evaluation and endocrine assessment become particularly important.

What if I only have one testicle?

If the undescended testicle is the patient's only testicle, removal has major endocrine and reproductive consequences.

Preservation should be considered whenever oncologically and technically safe.

If removal becomes necessary, the patient should receive counseling regarding:

• Testosterone replacement

• Fertility preservation

• Sperm retrieval when applicable

• Testicular prosthesis

What is a testicular prosthesis?

A testicular prosthesis is an implant placed inside the scrotum to reproduce the appearance and approximate feel of a testicle.

It does not:

• Produce testosterone

• Produce sperm

• Restore fertility

Its purpose is cosmetic.

Placement may occur during the same operation or at a later stage.

Is a testicular prosthesis necessary?

No.

Some men prefer a prosthesis for symmetry, while others are comfortable without one.

The decision is personal and should be discussed before surgery.

Can orchiectomy improve pain?

If an abnormal or atrophic undescended testicle is clearly responsible for pain, removal may relieve the source.

However, orchiectomy should not be promised as a universal cure for chronic groin or scrotal pain because pain may arise from nerves, hernia, pelvic structures or other causes.

Why surgeon experience matters

Adult cryptorchidism combines reproductive, endocrine and oncological considerations.

The treating specialist should be able to determine whether the best option is:

• Observation

• Orchidopexy

• Orchiectomy

• Fertility preservation

• Oncological investigation

For an international patient, this decision should ideally be made before travel whenever sufficient imaging and medical records are available.