Radical Orchiectomy (Testicular Cancer)
Right [left] testicular mass, [seminoma / non-seminomatous germ cell tumor / indeterminate], suspicious on ultrasound; [elevated AFP / beta-hCG / LDH / normal markers]
Same
Right [left] radical inguinal orchiectomy [with testicular prosthesis placement]
[***, MD/DO]
[Resident/PA name]
General endotracheal [/ spinal]
The patient is a [age]-year-old male with a right [left] testicular mass, [X] cm, on scrotal ultrasound with [hypoechoic / heterogeneous] characteristics. Tumor markers: AFP [X], beta-hCG [X], LDH [X]. CT abdomen/pelvis demonstrated [no retroperitoneal adenopathy / [X]-cm retroperitoneal adenopathy]. Radical orchiectomy via an inguinal approach (no scrotal incision — preserves paraaortic lymphatic drainage) was planned for diagnosis and treatment. Risks including bleeding, infection, altered scrotal sensation (ilioinguinal nerve injury), retroperitoneal spread (if scrotal violation), and need for prosthesis discussed. Consent obtained.
A [X]-cm [firm / heterogeneous] mass was identified within the testis. The testis was delivered en bloc within its intact tunica vaginalis through the inguinal incision — the tunica vaginalis was NOT opened in the operative field. The spermatic cord was ligated at the internal inguinal ring. The specimen (testis + intact tunica vaginalis + cord) was excised en bloc and sent to pathology with the proximal cord margin marked. Intraoperative frozen section was [not performed / performed, confirming malignant germ cell tumor / benign].
The patient was positioned supine. The right [left] inguinal region was prepped and draped. A [5]-cm oblique inguinal incision was made in the right [left] inguinal crease. The external oblique aponeurosis was incised along its fibers to the external inguinal ring. The ilioinguinal nerve was protected where encountered.
The spermatic cord was identified at the external inguinal ring. A doubled Penrose drain was passed around the cord and clamped snugly just below the internal inguinal ring to serve as a vascular tourniquet, preventing hematogenous tumor dissemination during subsequent testicular manipulation. The cord was mobilized proximally to the internal inguinal ring with the tourniquet in place.
The testis was delivered through the inguinal incision by gentle traction on the cord. The gubernaculum was divided. The testis was delivered into the operative field entirely within its intact tunica vaginalis — the tunica vaginalis was NOT opened in the field (en bloc delivery preserves oncologic margins and prevents tumor spillage). [Intraoperative frozen section was sent / not sent given obvious malignancy on imaging and tumor markers.]
The Penrose tourniquet was maintained until the cord was ready for ligation. The spermatic cord was skeletonized at the internal inguinal ring. The vas deferens was ligated separately with [2-0 non-absorbable suture (Prolene)]. The testicular vessels were doubly ligated with [0 non-absorbable suture (Prolene)] and divided between clamps at the level of the internal inguinal ring, securing a maximum proximal cord margin. The Penrose tourniquet was released and removed.
The specimen (testis, intact tunica vaginalis, and spermatic cord) was excised en bloc. The proximal cord margin was marked with [a suture / ink] and sent to pathology for frozen and permanent section.
[Testicular prosthesis: A [medium / large] saline-filled silicone testicular prosthesis was inserted into the scrotum through the inguinal wound, positioned in the dependent scrotum, and secured to the dartos muscle with [3-0 Vicryl]. Patient requested prosthesis placement and consent was obtained separately.]
The external oblique aponeurosis was closed with [2-0 Vicryl]. Skin was closed with [3-0 Monocryl].
None
Right [left] testis and spermatic cord: sent to pathology en bloc (tunica vaginalis intact), proximal cord margin marked with suture
Minimal
None
The patient was taken to the PACU in stable condition. Scrotal support was applied. Tumor markers (AFP, beta-hCG, LDH) to be repeated at [5-7 days] post-operatively for half-life assessment to guide staging and adjuvant therapy planning.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left testicular mass, *** suspicious for GCT
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left radical inguinal orchiectomy [+ prosthesis]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/spinal
INDICATIONS: .PTAGE-year-old male with *** cm testicular mass on US. AFP ***, hCG ***, LDH ***. CT: ***. Inguinal approach (no scrotal incision — preserves paraaortic lymphatics). Consent obtained.
FINDINGS: *** cm testicular mass. Testis delivered en bloc within intact tunica vaginalis — tunica NOT opened in field. Cord ligated at internal ring. Proximal cord margin marked and sent to pathology.
PROCEDURE:
Supine. Inguinal incision *** cm. External oblique incised to external ring. Ilioinguinal nerve protected where encountered. Cord encircled with doubled Penrose at internal ring — tourniquet applied before testis manipulation. Cord mobilized to internal ring. Testis delivered en bloc in intact tunica vaginalis. Gubernaculum divided. [Frozen section: ***.] Cord skeletonized at internal ring; vas ligated 2-0 Prolene; testicular vessels doubly ligated 0 Prolene and divided. Penrose tourniquet released. Specimen (testis + tunica + cord) excised en bloc; proximal cord margin marked with suture. [Prosthesis *** placed, secured to dartos.] External oblique 2-0 Vicryl. Skin 3-0 Monocryl.
EBL: Minimal
SPECIMENS: Testis + intact tunica vaginalis + cord to pathology; proximal cord margin marked
COMPLICATIONS: None
DISPOSITION: PACU. Scrotal support. Tumor markers + pathology at 5-7 days post-op.
Signed: .ME, .MYDEGREE
.TODAYVariants
Bilateral simple orchiectomy for androgen deprivation
Androgen deprivation for metastatic prostate cancer. Subcapsular technique: scrotal incision, tunica albuginea incised, seminiferous tubule contents expressed/removed, tunica albuginea closed or left open, epididymis and tunica left in situ for cosmesis. Bilateral subcapsular orchiectomy achieves castrate testosterone (<50 ng/dL) equivalent to LHRH agonist with no ongoing drug cost. Document bilateral technique and confirm castrate intent in indications.
Partial / testis-sparing orchiectomy
Indications: solitary testis, bilateral synchronous tumors, small lesion with normal markers and inconclusive ultrasound. Inguinal approach — identical setup to radical orchiectomy. The tunica vaginalis is opened and the testicular lesion is excised with a margin of normal parenchyma. If benign, close the tunica over the remaining parenchyma. Document the decision to spare vs. convert, frozen results, and margin status.
Simple orchiectomy for trauma or torsion
Nonviable testis after trauma or failed torsion detorsion. Scrotal approach acceptable (no oncologic concern — scrotal incision does not affect lymphatics when the indication is benign). Document preoperative Doppler absence of blood flow (torsion) or traumatic devascularization. Document the decision-point: detorsion was attempted / trauma was not compatible with viability.
Charting Tips
- Document inguinal approach explicitly and confirm no scrotal violation. Transcrotal orchiectomy changes lymphatic drainage from paraaortic to inguinal nodes, potentially upstaging the patient and altering surveillance/adjuvant treatment. Document: 'radical inguinal orchiectomy performed; no scrotal incision was made.' If prior scrotal surgery exists, document it and note that inguinal surveillance may be needed.
- Document that the Penrose cord tourniquet was applied at the internal ring BEFORE testicular delivery and manipulation. This prevents hematogenous tumor dissemination. Document: 'a doubled Penrose drain was applied as a vascular tourniquet at the internal inguinal ring prior to testicular delivery.'
- Document en bloc delivery with intact tunica vaginalis. The testis must be delivered without opening the tunica vaginalis in the operative field. Document: 'the testis was delivered en bloc within its intact tunica vaginalis — the tunica vaginalis was not opened in the operative field.'
- Document cord ligation at the internal inguinal ring and suture type. Non-absorbable synthetic suture (Prolene) is standard — not silk, which loses tensile strength over time and risks ligature slippage. Document: 'spermatic cord ligated at the level of the internal inguinal ring with non-absorbable suture; proximal cord margin marked and sent to pathology.'
Documentation & Reimbursement Considerations
- Report Radical Orchiectomy (Testicular Cancer) as the primary service when it is the definitive operation performed.
- The operation removes the testis and tunica vaginalis en bloc with the spermatic cord divided at the internal inguinal ring.
- A testicular prosthesis may be inserted during the same operation. Common indications include trauma or torsion with a nonviable testis and androgen deprivation.
- It does not represent retroperitoneal lymph node dissection (RPLND).
- Indications include a solitary testis, bilateral synchronous tumors, or a small lesion with negative or normal tumor markers. It is not a bilateral orchiectomy code.
- Verify bilateral modifier rules with specific payer (some require two line items with right- or left-side reporting instead of one line with bilateral-procedure reporting).
- Testicular prosthesis reporting options (5.60 wRVU, 90-day global): prosthesis placement is already accounted for under the related service and cannot be separately billed during the same session. With the primary service, reporting options is also typically bundled when the prosthesis is placed through the same incision during the same session. Delayed placement during a separate operation is the most defensible separately billable scenario.
- Global period is 90 days. Tumor marker surveillance (AFP, beta-hCG, LDH) and post-op imaging are not bundled — they generate separate laboratory and radiology billing. Recurrence requiring reoperation within 90 days uses related unplanned return-to-the-operating-room reporting.