Orchiectomy

Orchiectomy in treatment of metastatic prostate cancer

Posted Sep 17 2008 1:54pm

Introduction

Certainly until the mid- and perhaps even the late 1980s there was no doubt whatsoever that orchiectomy was the gold standard for the hormonal treatment of metastatic prostate cancer.
By carrying out the surgical removal of a man’s testes, the physician was able to completely shut down the synthesis of testosterone, thus removing testosterone stimulation of prostate cancer growth and alleviating (for a while) the symptoms of progression of the disease, particularly bone pain. However, orchiectomy, like other forms of hormone therapy, was never shown to extend survival of men with metastatic prostate cancer evident on a bone scan.

What Are the Advantages of Orchiectomy?

First, it is a single, simple, surgical procedure with a very low risk of problems and 100 percent efficacy.
Second, it can be carried out in ways which are not physically evident. In other words, it is possible to carry out what is known as a subcapsular orchiectomy, in which the cores of the two testes are removed while the capsules remain in the scrotum. This means that the man still appears to be an “intact” male.

What are the Side Effects of Orchiectomy?

The side effects of orchiectomy are limited to those resulting from the absence of testosterone. These include:

• Loss of sexual desire (treatable with hormone injections or gel preparations)
• Impotence
• Hot flashes similar to those in menopausal women, controllable by medication
• Weight gain of 10–15 lb (4.5–6.8 kg)
• Mood swings and/or depression
• Gynecomastia — tenderness and swelling of the breasts and nipples (also treatable)
• Fatigue
• A loss of sensation in the groin or the genitals
• Osteoporosis (treatable with bisphosphonates and similar agents)

What Are the Other Disadvantages of Orchiectomy?

The major disadvantage appears to be the psychological one associated with “loss of manhood.” For many men this loss appears to be all but unbearable. Interestingly, the loss of “manhood” is not usually a problem for the partners of most prostate cancer patients when compared to the possibility of loss of life. However, the male association between his theoretical ability to be able to have sexual intercourse and his sense of self worth appears to be astonishingly strong, regardless of the truth about his actual level of sexual activity and/or capability.
The other disadvantage is that the procedure is not reversible. However, since cases of complete remission of advanced prostate cancer are almost completely unheard of and certainly not well documented, it would appear that the need for reversing this operation is about as close to zero as one can get!

Is Orchiectomy Becoming More Common Again?

During the 1990s and the first few years of the 21st Century here in America, the use of orchiectomy declined precipitously compared to the use of other forms of hormone therapy (most notably the use of the LHRH agonists). However, in the last couple of years, there seems to have been a gradual increase in the use of orchiectomy again.
A variety of suggestions have been made as to why this is the case. Frankly, most of the likely reasons seem to revolve around financial issues:

• In the 1990s, urologists were able to bill Medicare for administering LHRH agonists at costs significantly higher than the office acquisition cost. In other words, they were able to make a significant profit each time they gave an LHRH agonist injection. This may well have encouraged them to preferentially recommend LHRH agonist treatment to their patients as compared to orchiectomy.
• In 2005 this practice came to an end when Medicare set a flat reimbursement rate for the LHRH agonists that no longer made it possible for urologicts to profit in this way. And the use of orchiectomy started to rise again.
• In addition, legal cases were brought against some physicians and two major pharmaceutical companies for defrauding Medicare in the way that the LHRH agonists were marketed and the physicians sought Medicare reimbursement for clinical use of free drug “samples.”
• Finally, as we have noted above, orchiectomy is simply less expensive than LHRH therapy. For many patients today the co-pay required for treatment with an LHRH agonist for a year is simply not worth the cost compared to the simplicity of orchiectomy.

Some Things to Think About

If you are unfortunate enough to have advanced prostate cancer, we know that at present there is no cure for your disease. Orchiectomy (especially subcapsular orchiectomy, which allows the patient to retain the appearance of complete maleness) is still a very reasonable option. It is noticeably lower in cost over time than monthly or even quarterly injections of LHRH agonists, and the patient can avoid the necessity of regular visits for injections of LHRH agonists. However, presented with the choice, about seven out of 10 men will still select “medical castration” with LHRH therapy rather than orchiectomy.
It also needs to be understood that there is a very real difference between an orchiectomy and complete emasculation. After an orchiectomy (even an orchiectomy in which the testes are completely removed), the patient still retains full use of his penis, the scrotum is still present, and to all but the closest scrutiny a man still looks completely “male.”
Interestingly, there are rare but well documented cases of patients who retained sexual potency even after orchiectomy. This would appear to be impossible to explain. However, it introduces a fascinating series of possible speculations on the nature of male sexual function.