Radical removal of the testis (± silicone implant)

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

Key points

• Radical removal of the testicle is usually performed for suspected testicular cancer
• Taking small biopsies of a growth in a testicle may miss a cancer, whereas complete removal allows an accurate assessment of any suspicious area
• Removal of the testis may be all that is required if cancer is found, but chemotherapy or radiotherapy are sometimes needed
• Testicular cancer and its treatment can affect your fertility, so you should bank your sperm before treatment
• A testicular prosthesis (implant) can be put in at the time of your operation, if you wish

What does the procedure involve?

This involves removal of the testis via a groin incision for suspected testicular cancer. A testicular implant may be inserted at the same time if you wish.

What are the alternatives to this procedure?

In reality, there are often none but, occasionally, the surgeon may wish to discuss observation, biopsy or partial removal of the testis where a suspected tumour is present; these occasions, however, are very uncommon. The majority of testicular cancers can be detected by simple examination and ultrasound scanning together with blood tests (to measure tumour markers) and a CT (body) scan.

What should I expect before the procedure?

Having only one testis should not adversely affect your life. The remaining testis takes over the function of the removed one so your sex life and ability to father children should be unchanged. However, testicular cancer and its treatments (especially chemotherapy) can alter the amount of sperm produced.

You will, therefore, be given the opportunity to provide semen samples for storage. These can be used in the future for assisted conception if your fertility does not return after treatment.

If you are concerned about the cosmetic results of losing a testicle, a false testicle (prosthesis) can be inserted during the operation.

You will usually be admitted on the same day as your surgery. You will normally undergo pre assessment on the day of your clinic or an appointment for pre assessment will be made from clinic, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat for six hours but may drink clear fluids up to two hours before surgery. Immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

You will need to wear anti-thrombosis stockings during your hospital stay; these help prevent blood clots forming in the veins of your legs during and after surgery.

Please be sure to inform your urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel , ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you.

The testicle is normally removed through an incision in the groin (similar to that used for repair of a hernia) and local anaesthetic will placed in the wound. It may be necessary to take biopsies from the other (normal) testis; if this is needed, it will be discussed with you before the procedure.

The operation takes approximately 30 minutes.

What happens immediately after the procedure?

You may eat, drink and mobilise when you are fully recovered from the anaesthetic. You will be able to leave hospital as soon as you are comfortable, provided you have someone to collect you and to remain with you for the first 24 hours after discharge.

The average hospital stay is 12 hours.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

• Cancer, if found, may not be cured by removal of the testis alone
• Need for additional procedures or treatments such as surgery, radiation or chemotherapy
• Permission to biopsy the other testis if small, abnormal or history of maldescent

Occasional (between one in 10 and one in 50)

• Possibility that microscopic examination of the removed testicle may not give a conclusive result or may show no cancer
• Infection of the incision requiring further treatment (and possible removal of implant). Infection of the wound or scrotum is more common when a prosthesis is used and is more serious because it usually means that the prosthesis will need to be removed
• Bleeding requiring further surgery (and possible removal of implant)
• Loss of future fertility
• Injury to the nerve near the wound causing numbness, altered sensation, or pain in the groin and scrotum

Rare (less than one in 50)

• Pain, infection or leaking requiring removal of implant.
• Patient cosmetic expectations not always met by the implant
• Implant may lie higher in scrotum than normal testis
• Palpable stitch at one end of the implant which you may be able to feel
• Long term risks from use of silicone products unknown
• Anaesthetic or cardiovascular problems possible requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)

Hospital-acquired infection (overall risk for Addenbrooke’s)

• Colonisation with MRSA (0.01%, two in 15,500)
• Clostridium difficile bowel infection (0.02%; three in 15,500)
• MRSA bloodstream infection (0.00%; 0 in 15,000)

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation.

If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

The groin and scrotum may be uncomfortable for seven to 10 days. Simple painkillers will usually relieve this discomfort. It is common to notice some bruising in your groin and scrotal area. You may find it more comfortable to wear supportive pants (rather than boxer shorts).

You may shower or bath 24 hours after the procedure but ensure that your wound is thoroughly dried by gently dabbing the area. You should be able to return to work after two weeks but it is sensible to avoid heavy lifting and strenuous exercise for a month. You are advised not to drive for two weeks and, before driving, to check with your motor insurance company; do not drive if you still have pain.

Sexual activity can be resumed after two weeks although, for some men, the strain of surgery may reduce your sex drive temporarily. Testicular cancer cannot be passed to your partner during sex.

Absorbable stitches are normally used but these may take up to 90 days to disappear completely.

What else should I look out for?

If you develop a temperature, increased redness, throbbing or drainage at the site of the operation, increasing abdominal pain or dizziness, please contact your GP or the urology ward (Ward M5, 01223 254850). Any other post-operative problems should also be reported to your GP, especially if they involve chest symptoms.

Are there any other important points?

It will normally take 14 to 21 days for the pathology results to become available. It is normal practice for the results of all biopsies to be discussed in detail at a multidisciplinary meeting before any further treatment decisions are made. You and your GP will be informed of the results after this discussion.

Further treatment will usually be carried out under the supervision of the oncology department and this will probably require follow up for life. An appointment for the oncology clinic will usually be arranged for you before you leave hospital.

In the unlikely event that the pathology results show you do not have cancer, you will be seen in the urology outpatient clinic or asked to visit your GP for further follow up.

If you need further information about testicular cancer, please contact the oncology centre, 01223 216552. Cancer BACUP produces a free, detailed booklet "Understanding Testicular Cancer". For a free copy, telephone Freephone 0800 181199 or log in to the Cancer BACUP website (www.cancerbacup.org.uk)

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and / or specialist one to one care is required

Hair removal before operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Is there any research being carried out in this field at CUH?

Yes. As part of your operation, various specimens of tissue will be sent to the pathology department so that we can find out details of the disease and whether it has affected other areas. This information sheet has already described to you what tissue will be removed.

We would also like your agreement to carry out research on that tissue which will be left over when the pathologist has finished making a full diagnosis. Normally, this tissue is disposed of or simply stored. What we would like to do is to store samples of the tissue, both frozen and after it has been processed. Please note that we are not asking you to provide any tissue apart from that which would normally be removed during the operation.

We are carrying out a series of research projects which involve studying the genes and proteins produced by normal and diseased tissues. The reason for doing this is to try to discover differences between diseased and normal tissue to help develop new tests or treatments that might benefit future generations. This research is being carried out here in Cambridge but we sometimes work with other universities or with industry to move our research forwards more quickly than it would if we did everything here.

The consent form you will sign from the hospital allows you to indicate whether you are prepared to provide this tissue. If you would like any further information, please ask the ward to contact your consultant.

Who can I contact for more help or information?

Oncology nurses

• Uro-oncology nurse specialist: 01223 586748
• Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG): 01223 274608
• Prostate cancer nurse practitioner: 01223 274608 or 01223 216897
• Surgical care practitioner: 01223 348590 or 01223 256157

Non-oncology nurses

• Urology nurse practitioner (incontinence, urodynamics, catheter patients): 01223 274608 or 01223 586748
• Urology nurse practitioner (stoma care): 01223 349800
• Urology nurse practitioner (stone disease): 01223 349800

Patient Advice and Liaison Centre (PALS): 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail:

PALS
Box No 53
Cambridge University Hospitals NHS Foundation Trust
Hills Road
Cambridge
CB2 2QQ

Chaplaincy and multi faith community: 01223 217769
Email chaplaincy

Mail:

The Chaplaincy
Box No 105
Addenbrooke's Hospital
Hills Road
Cambridge
CB2 2QQ

MINICOM System ("type" system for the hard of hearing): 01223 217589

Access office (travel, parking and security information): 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know.

If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

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