Orchiectomy: radical treatment for prostate cancer. Surgery to remove the testicles (orchiectomy): indications, performance, postoperative period Bilateral orchiectomy for prostate cancer

Orchiectomy is an operation performed on most patients with hormone-dependent prostate cancer. During the operation, the patient's testicles (one or both) are removed. Due to this, the level of testosterone in the blood significantly decreases.

Main indications

If prostate cancer is diagnosed, orchiectomy is performed as one of the treatment options.

The fact is that it is in the testicles that 90% of testosterone is produced - and it stimulates the development and growth of cancer cells. The operation is related to hormonal therapy and is indicated for patients with prostate cancer of any stage.

It is noteworthy that performing an orchiectomy on a patient with a metastatic form of cancer gives excellent results and increases survival to 5-7 years. Such patients experience a decrease in pain within 10-14 days after surgery, while it is extremely difficult to achieve such an effect using medication.

Advantages

As already mentioned, the main advantage of orchiectomy is a sharp slowdown in tumor growth. The effectiveness largely depends on the stage of the disease.

As a rule, orchiectomy performed for stages 1-2 prostate cancer significantly increases survival. In later stages, it helps reduce pain and slow tumor growth (in the last stages of the disease it grows much more rapidly than in the first).

Prostatitis will go away and potency will improve...

Frequent urge to urinate is the main symptom of PROSTATITIS. In 100% of cases, this disease leads to IMPOTENCE. In advanced cases, CANCER develops. It turns out (!) to protect yourself from cancer and completely get rid of prostatitis at home, it’s enough to drink a glass once a day...

It should also be noted that the operation is performed quite quickly, and the effect becomes noticeable within 10-1 hours after it.

Flaws

The disadvantages of the procedure include a significant number of rather unpleasant consequences:

The likelihood of bleeding or infection, the difficulty of undergoing anesthesia.
Erection problems, impotence, infertility.
Osteoporosis.
Increase in body weight (but at the same time the volume of muscle tissue decreases significantly).

Hot flashes, accompanied by mood swings, a feeling of intense heat, sweating, increased heart rate and arrhythmia.

Bilateral orchiectomy achieves greater clinical efficacy in 5-year survival than in patients treated with estrogen therapy. At the same time, the effectiveness of estrogen therapy in combination with orchiectomy was greater than the results of each of these treatment methods. However, the experience accumulated over the subsequent years in endocrine therapy for prostate cancer has significantly expanded the understanding of the mechanism of action of orchiectomy and estrogen therapy for prostate cancer, revealed the side effects of these treatment methods, their advantages and disadvantages, which gave reason to reconsider the indications for their use.

The purpose of orchiectomy in the treatment of prostate cancer is to turn off the function of the testicles, the main source of androgens in the male body. The advantage of orchiectomy is associated with a rapid decrease in the content of the free fraction of testosterone in the blood, which achieves a clinical effect a short time after this operation. After orchiectomy, in contrast to estrogen therapy, there is no increase in blood levels of prolactin. At the same time, the concentration of luteinizing hormones and follicle-stimulating hormones in the blood increases, which reflects a violation in the negative feedback mechanism in the testicular-adenohypophysis system. Bilateral total or subcapsular epididymorchiectomy is usually performed. Previously, it was believed that subcapsular orchiectomy does not effectively reduce the concentration of testosterone in the blood due to the preservation of Leydig-like cells in the tunica albuginea and its epididymis. At the same time, under the influence of human chorionic gonadotropin in patients undergoing subcapsular orchiectomy, there is no increase in testosterone in the blood, the levels of which decrease to the same extent with both methods of orchiectomy. A subcapsular orchiectomy, which does not remove the tunica albuginea and epididymis, is cosmetically more acceptable than a total orchiectomy. The advantage of orchiectomy for prostate cancer is the ability to reduce testosterone levels in the blood without the side effects associated with estrogens. At the same time, there are contradictions in the choice of the preferred form of treatment for prostate cancer - estrogen therapy or orchiectomy. This is due to the emergence of new drugs with estrogenic action, including the properties of cytostatics (estracite), a broader study of hormonal changes during estrogen therapy and orchiectomy, as well as the problem of the effectiveness of estrogen therapy after orchiectomy or orchiectomy in the treatment of estrogen-resistant forms of prostate cancer.

After orchiectomy, there is a variable therapeutic response to subsequent estrogen therapy. The positive therapeutic effect of estrogen therapy after relapse due to orchiectomy is about 17%. The best way to determine the effectiveness of orchiectomy and the response to subsequent estrogen therapy due to recurrence of prostate cancer after orchiectomy is to monitor blood testosterone levels. As our studies have shown, the degree of decrease in testosterone levels in the blood after orchiectomy determines the further results of estrogen therapy carried out in connection with relapse of the disease after orchiectomy. Bilateral orchiectomy does not always succeed in reducing testosterone levels to castration levels (below 1 mcg/l). When trace levels of testosterone were reached in the blood, the duration of remission ranged from 3 to 24 months. At the same time, with an insufficiently deep drop in testosterone levels in the blood after orchiectomy (within 11.7 - 18.7 μg/l), the duration of remission was shorter (from 4 to 17 months). The nature of the decrease in testosterone in the blood after orchiectomy also determines the effectiveness of subsequent estrogen therapy carried out in connection with relapse after orchiectomy. The best clinical effect of estrogen therapy is observed when testosterone levels in the blood are maintained above castration values after orchiectomy. In these cases, the duration of remission is 20.8 months (range 1 to 60 months), as opposed to 4 months observed with trace levels of testosterone in the blood after orchiectomy. Thus, estrogen therapy is ineffective when low levels of testosterone in the blood persist after orchiectomy. The best results from estrogen therapy after orchiectomy can be expected with slightly elevated levels of testosterone in the blood. Against this background, treatment with small doses of estrogens (diethylstilbestrol at a dose of 1 or 3 mg/day) results in a decrease in testosterone in the blood to trace levels.

When treating disseminated prostate cancer with severe pain caused by bone metastases, it is necessary to achieve a rapid clinical effect. In such cases, alternative treatment methods are bilateral orchiectomy or intravenous administration of fosfestrol at a dose of 1000 mg/day for 3 to 5 days. Bilateral orchiectomy eliminates 90% of testosterone production. The half-life of the free fraction of testosterone in the blood is 10 - 20 minutes. In this regard, a decrease in the free fraction of testosterone after orchiectomy to castration levels is achieved on average 3 hours after completion of the operation (ranging from 2 to 6 hours). Intravenous administration of fosfestrol can reduce the initial values of free testosterone in the blood by 50% within 12 hours after infusion of the drug. Both treatment methods are quite effective in achieving rapid clinical effect. At the same time, massive intravenous estrogen therapy is accompanied by an increased risk of cardiovascular and thromboembolic complications, especially in individuals with severe vascular pathology, atherosclerosis, and liver dysfunction. Orchiectomy as the initial treatment method for patients with prostate cancer is the method of choice in patients with severe atherosclerosis, cardiovascular insufficiency, a history of thromboembolic episodes, intolerance to estrogen drugs, with elevated levels of testosterone and prolactin in the blood, in cases where it is necessary to achieve rapid regression diseases. Orchiectomy as an independent method of treating prostate cancer is clearly insufficient. A long-term decrease in testosterone levels in the blood, ensuring remission of the disease, should persist for about 2 years. The most common recurrence of prostate cancer after orchiectomy occurs in 80% of cases by one year after surgery. The pathogenesis of prostate cancer relapse is associated with an increase in the content of dihydrotestosterone in the tumor tissue. If after orchiectomy the content of dihydrotestosterone in prostate cancer tissue decreases below 2.4 ng/g (the values of dihydrotestosterone in prostate adenoma tissue and untreated prostate cancer are 5 and 4.9 ng/g, respectively), and testosterone in the blood is less than 1 μg /l, then during the period of relapse of the disease after orchiectomy, there is a dissociation in the content of testosterone in the blood and dihydrotestosterone in the prostate tissue. Against the background of stable values of testosterone in the blood, corresponding to the castration level, the content of dihydrotestosterone in prostate cancer tissue increases above 2.4 ng/g. This suggests that adrenocortical androgens are, under these conditions, a substrate for the formation of dihydrotestosterone. After orchiectomy, the only source of androgens is the adrenal cortex. Androstenedione and dehydroepiandrosterone are metabolized into dihydrotestosterone in prostate tissue.

In the presence of 17β-ol-dehydrogenase, androstenedione is metabolized into testosterone, which is subsequently metabolized into dihydrotestosterone under the influence of 5α-reductase. Thus, adrenal androgens may be precursors for significant amounts of dihydrotestosterone in prostate cancer tissue after orchiectomy, which stimulates tumor regrowth and recurrence. This serves as an indication for subsequent treatment aimed at suppressing the function of the adrenal cortex. It should also be taken into account that in some cases, estrogen therapy fails to achieve castration levels of testosterone in the blood, which determines the accumulation of dihydrotestosterone in prostate cancer tissue. If relapse of prostate cancer after initial estrogen therapy is accompanied by increased levels of testosterone in the blood, which gives reason to believe the accumulation of dihydrotestosterone in the tumor tissue, then this is an indication for orchiectomy. In contrast, estrogen therapy for recurrent prostate cancer after previous orchiectomy rarely produces a positive effect due to the development of hormonal resistance of the tumor.

In clinical practice, early diagnosis of estrogen resistance of a tumor is important to decide whether additional orchiectomy is necessary. The most sensitive methods for determining the hormonal resistance of prostate cancer are radionuclide bone scanning (on
scintigrams reveal metastases several months before their obvious clinical manifestations) and the determination of androgen and estrogen receptors in prostate cancer tissue obtained by puncture biopsy.

The question of the advisability of orchiectomy in cases of estrogen-resistant prostate cancer with metastases is quite controversial. Along with the improvement in the general condition of patients and regression of the disease, in other cases it is not possible to achieve clinical effectiveness, which gives reason to believe that a further decrease in free testosterone in the blood against the background of its castration level is unlikely. Orchiectomy in cases of estrogen-resistant prostate cancer with metastases is advisable in case of high levels of testosterone in the blood, followed by the administration of hormonal drugs with cytostatic properties, chemotherapy drugs, and prolactin inhibitors. In recent years, reports have appeared in the literature about good clinical results of orchiectomy with delayed (5-6 months after orchiectomy) radiation therapy to the pelvis and prostate gland. Combined treatment with orchiectomy followed by radiation therapy achieved 5-year survival in patients with stage C prostate cancer in 57% and stage D in 35% of cases.

I finally decided to write about all the events that happened to me in 2016. In September 2015, my treatment was canceled after. The PSA test at that time was 1.4 ng/ml. The doctor told me to come for a follow-up examination when PSA rises to 4 ng/ml.

I had tests done every three months and my PSA was slowly growing. 2.45-3.9-7.4-10.2 In mid-June it was 10.2 ng/ml. I collected all the required tests: blood and urine.

Orenburg Regional Clinical Oncological Dispensary

I went through an ultrasound and x-ray, took certificates from the therapist and the attending physician and went to the Orenburg Regional Clinical Oncology Dispensary (OOKOD).

The doctor, oncourologist Ilnur Damirovich Tukmanbetov, examined me. He told me that treatment needs to be resumed. I had severe symptoms, so I was given an order at my place of residence to undergo a 2-sided orchiectomy (removal of both testicles). In addition, he prescribed me to take one injection of Buserelin 3.75 monthly for three months. I provide a scan of the certificate that was given to me after the consultations. With the operation Tukmanbetov I.D. asked not to delay.

Bilateral orchiectomy after prostate cancer

At the end of July, I passed all the required tests and went to the hospital in the Tyulgan Republic of Belarus in the surgical department. On July 28 at 10 o'clock I was taken naked to the operating room on a gurney. There, surgeons Mirshat Ravkatovich Safarov and Olga Aleksandrovna Morozkina performed an operation on me to remove both testicles. I was given spinal anesthesia by making an injection between the vertebrae in the lumbar region. The body below the waist has completely lost sensation. I was conscious, but didn't feel anything. The operation lasted about an hour and a bit.

I was immediately taken to the general ward and for more than 4 hours I could not move my legs. Then slowly my legs began to move. I got back on my feet at night when I really wanted to go to the toilet. He was very weak and almost fell. But already in the morning he began to slowly walk along the corridor. I did not have any pain in the genital area. On the day of the operation and the next day, I was given IVs and painkilling injections.

Treatment after surgery to remove prostate cancer and bilateral orchiectomy

The postoperative period was without any problems. After two days I was left with only daily dressings. Then the drainage rubber bands were removed. On the 11th day, the stitches were removed and the next day he was discharged feeling well. Safarov M.R. advised me what I need to be careful of in the first 2 weeks: do not lift heavy objects or play sports, do not go to the sauna or take a bath. He also recommended that I wash myself every day with laundry soap. I strictly followed all his prohibitions and recommendations.

Packaging Buserelin-depot

Also, every month I was given an injection of Busarulin 3.75 mg. There were no painful sensations, except for the fact that after the first two injections in the first hours I felt very sleepy. I also became . But the doctors warned me about this in advance. In fact, this summer I underwent a double castration: surgical and chemical. In September, in Meleuz, I donated blood for a PSA test. It was 0.45 ng/ml.

Doctor OOKOD set the task: to return me to the state that was immediately after the operation to remove prostate cancer

And again I passed all the tests, ultrasound, x-rays, certificates from the therapist and surgeon about the progress of treatment.

PSA analysis after treatment

I post scans of all these documents here

Results of blood and urine tests

- Well, let's try to return you to the state that was immediately after the operation. How much was PSA?

“0.1 ng/ml,” I answered.

He prescribed me 3 more injections of Buserelin 3.75 mg. The next time I should come again when the PSA is more than 4. Every month I was given one injection and on December 16 I donated blood for PSA. It turned out to be 0.1 ng/ml, as predicted by Nikiforov V.O. I feel fine. A few touches to my current state. I can easily stand for three hours constantly standing on my feet. I bow down on my knees 25 times in a row. I clear snow near the garage for several hours without rest. It feels like my body is rejuvenating. At 45-55 years old, I felt much worse: I was out of breath, tired quickly, and sometimes dizzy. There is nothing like it now. I will have my next test in mid-March 2017. Let's see what it will be like.

Orchiectomy is a surgical measure that is prescribed to the vast majority of patients with hormone-dependent prostate cancer. During the operation, one testicle is removed or the organ is completely removed.

Thus, it is possible to reduce the level of hormones in the patient’s blood to acceptable levels. Reducing testosterone levels helps stop the further development of hormone-dependent forms of prostate cancer.

Two scenarios for fighting cancer

Testosterone “aggression” can be suppressed with the help of orchiectomy and estrogen therapy (the patient is prescribed female hormones in order to neutralize the negative effects of male hormonal levels). Even patients with metastatic advanced forms of prostate cancer demonstrate excellent results from the combination of these two treatment modalities.

However, when comparing orchiectomy and hormonal therapy, radical intervention for prostate cancer shows much better results. Let us consider the main features of this surgical technique.

Purposes of testicular removal and advantages of the operation performed

Orchiectomy for prostate cancer allows you to completely neutralize the functional power of the testicles, the main source of androgens in the male body. The main advantage of such a radical operation is that testosterone fractions begin to rapidly disappear immediately after the ectomy. In parallel with this, literally from the first days you can observe the clinical effect and extinction of symptoms of hormone-dependent prostate cancer.

Another important nuance: if during hormonal therapy in men a very unpleasant side effect is observed - an increase in prolactin, then with radical removal of the ovary such troubles do not occur. Orchiectomy allows you to quickly reduce androgen levels to the desired level, but does not put you in such a stressful state as estrogen therapy.

Tests are required before surgery

Before a scheduled ectomy, the patient should undergo the following diagnostic measures:

general blood analysis;
blood chemistry;
CT or MRI;
identification of cancer pathology using tumor markers;
TRUSY;
biopsy;
chest x-ray to detect possible sites of metastases;
Ultrasound of the abdominal cavity and scrotum (identification of secondary foci of the oncological process).

Complexities of technology, basic surgical techniques and types of interventions

Subcapsular orchiectomy allows preserving the tunica albuginea and the epididymis itself in case of prostate cancer. Aesthetically, the procedure is considered more justified than the total removal of male testicles. However, most experts consider this surgical method to be incomplete.

Usually, andrologists and oncologists, when developing a treatment plan for prostate cancer, debate for a long time regarding the advisability of hormonal techniques and radical removal of the testicles. The reason is quite simple. The pharmacological market is developing faster than new surgical developments and techniques are appearing.

Patients often fear operations of any kind, especially those involving total organ removal. Instead, it is considered a more acceptable way to try new drugs that combine the qualities of advanced cytostatics and hormonal drugs.

Special categories of cancer

The disseminated form of cancer is almost always accompanied by extremely severe intense pain, since metastases in bone structures begin their active growth, deforming the nerve tissue and the structure of the osteophytes themselves. In this case, it is most effective to perform a bilateral testicularectomy. This will reduce the level of androgens by at least 85%, without exposing the body to additional stress.

Orchiectomy in most cases makes it possible to achieve high-quality remission of the oncological process in the structure of the prostate gland for an average of 1.5 - 2 years. Then the beneficial therapeutic effect of the operation will be reinforced with the help of estrogen therapy.

Doctors try to begin hormonal effects on the body as late as possible, taking into account the complexity of the side effects caused by the forced introduction of estrogens into the male body. Patients exhausted by a long fight against the cancerous process in the structure of the prostate gland may also encounter cardiovascular pathologies, thromboembolic phenomena, and dysfunctional manifestations of hepatocytes. Men begin to be bothered by “purely feminine” symptoms, and their appearance suffers.

Relapses of oncological processes in the prostate: main aspects of the problem

It is believed that the re-development of oncological processes in the structure of the glandular organ is predetermined by the content of dihydrotestosterone. Testosterone levels can be quite stable and meet the criteria for normal castration levels, however, androgens of the adrenocortical type can become the basis for the formation of new testosterone fractions of a dihedral nature.

The source of “harmful” hormones after surgery is the adrenal cortex. In this case, drug therapy is carried out to suppress their activity.

Patients suffering from prostate cancer resistant to hormone therapy undergo testicularectomy only in exceptional cases. The operation is indicated for very high levels of androgens in the blood of patients. Immediately after surgery, patients are prescribed powerful cytostatics and hormonal drugs.

In recent years, orchiectomy has been used in combination with radiation therapy. Moreover, irradiation is carried out only 4–6 months after surgery. Similar therapeutic regimens in oncology can extend the life of patients by 4–6 years, even at stages C and D.

The main disadvantages of testicular removal surgery

Any medical procedure can always cause a number of side effects or provoke the development of secondary concomitant pathologies.

Removing one or more testicles can lead to the following problems:

Bleeding during anectomy or in the early postoperative period.
Infection of prostate tissue or nearby structures when medical personnel do not comply with all appropriate standards of asepsis and antisepsis.
Development of serious sexual dysfunction in later stages.
Impotence.
Infertility.
Osteoporosis.
Body weight increases (at the same time, the patient loses muscle reserves, but suffers from an excess of fat deposits).
Tides.
Mood swings.
Intense heat that suddenly covers the entire body.
Arrhythmia.

When a man is diagnosed with prostate cancer, especially the metastatic type, in most cases a bilateral orchiectomy is prescribed. Popularly this operation is called castration. As a result of surgery, the growth of malignant tumors is slowed down by blocking the production of the hormone testosterone in a man’s body.

The surgical technique for prostate cancer is carried out in many countries and has positive dynamics after its implementation. Patients experience a significant improvement in their general condition, with the chances of recovery increasing in 85-90% of men who have stage 1 or 2 cancer. In later stages, remission of the disease is observed for 5 years.

What is orchiectomy?

An orchiectomy procedure is a surgical procedure in the scrotum that removes a testicle. Removal can be unilateral or bilateral, where one or both testicles are removed, depending on the medical indication. If there is a tumor in the prostate gland or a nearby area, additional removal of it is performed.
To understand what orchiectomy is and why it is needed, you need to familiarize yourself with the process of testosterone synthesis in the male body. After all, it is precisely such radical measures that make it possible to control its production and maintain prolactin levels at the required level. This, in turn, leads to a positive clinical effect in a fairly short period of time.

Orchiectomy - surgical technique

When diagnosing prostate cancer, the doctor chooses the most effective treatment methods, most often surgical ones. In most cases, orchiectomy for prostate cancer is carried out to disable the main function of the testicles, that is, the production of a source of androgens that contribute to the development of a malignant disease.

The surgical technique for prostate cancer is carried out in several ways, that is:

Radical inguinal surgery;
Local through the scrotum.

Regardless of the prescribed method, the operation is performed under general anesthesia for 1-3 hours. With the inguinal method, the surgeon makes a 6-7 cm incision in the lower abdomen. After this, the regional lymph nodes affected by metastases are removed and the seminal canal is excised. Finally, one or two testicles are removed. With a simple local method, the spermatic cord is twisted.

The surgical technique used means that the desired result will be achieved after just a few hours, unlike hormonal therapy, and the doctor will be able to continue further treatment of the prostate. In this case, the postoperative period takes no more than two to three weeks. A stable result lasts for about a year, so the risk of relapse occurs approximately after this time.

Orchiectomy for prostate cancer

Like any operation, orchiectomy has advantages in the form of a rapid therapeutic effect and minimal risk of complications, and disadvantages, such as:

Decreased sexual desire;
Gradual increase in body weight;
Disturbance of calcium metabolism in the body;
Development of anemia or diabetes;
Depressive state;
Attacks of hot flashes.

However, despite the unpleasant list of symptoms that will accompany a man after the operation, this cannot be compared with the ability to continue living. After all, all of these symptoms are easily suppressed by drug treatment in the form of taking hormonal drugs.

Where can I have an orchiectomy?

Orchiectomy surgery to remove the testicles is performed only on an inpatient basis. Before the procedure, the doctor prescribes the patient to undergo the following diagnostic measures:

Taking urine and blood tests;
Ultrasound examination of the prostate, scrotum and pelvic organs;
If necessary, undergo a tomography;
Biopsy of the formation.

Based on the diagnosis, the surgeon chooses the most effective method of removing the testicle, namely through the scrotum or peritoneal cavity. It should be understood that the local method of removal through the scrotum is used in more advanced stages of cancer, when the process of metastasis has begun. As a result, chemotherapy or radiation is added to the main treatment.

Orchiectomy and its consequences

The technique of surgery for prostate cancer frightens many patients, as there is a high risk of loss of desire. However, there are frequent cases when sexual function is gradually restored, the main thing is to choose the right postoperative treatment. To give the male genitalia an aesthetically pleasing appearance, many patients resort to implantation. In this case, the genital organ does not suffer during surgical manipulations and the fertilization function is preserved.
The consequences of the surgical technique for prostate cancer are incommensurate with the ability to live even with advanced forms of cancer, especially for men over the age of 60, when only after surgery the growth of cancer cells is significantly reduced.

Treatment of hot flashes after orchiectomy

The selected surgical technique for prostate cancer is the only correct decision, since it is the high level of testosterone that contributes to the rapid growth of the tumor. Despite the possible consequences after the procedure, it is used at different stages of prostate cancer and has a positive prognosis.

Many men experience hot flashes, rapid heartbeat, and irritability after an orchiectomy as the endocrine system is disrupted. If signs appear, symptomatic treatment with hormonal drugs is prescribed, which give good results within a few days. The most commonly used drugs are Sustan, Testenate, Methyltestosterone, Testobromlecite.

It should be taken into account that hormonal treatment for prostate cancer is extremely dangerous and can cause relapse, so the necessary drugs to eliminate symptoms can only be selected by a qualified doctor who monitors the patient. If you select medications on your own, the consequences can be much worse.

Despite the unpleasant technique of the surgical procedure for men, if you already have a serious prostate diagnosis, you should not despair and set yourself up for a long road to recovery from a terrible illness.