Surgical removal of the malignant testis is often carried out using an inguinal approach. The testis is not usually removed through a scrotal incision, because it is possible to spread tumor cells into the subcutaneous tissues of the scrotum, which has a different lymphatic drainage than the testis.
In the clinic
Interrupted descent of testis leads to an empty scrotal sac and abnormal location of the testis, which can lie anywhere along the usual route of descent. Most commonly the testis is present in the inguinal canal, where it can be palpated. This condition is usually diagnosed at birth or within the first year of life. A higher incidence of ectopic (undescended) testis occurs in premature births (30%) than in term births (3–5%). Normally, the ectopic testis can complete its descent within the first 3 months after a child is born; therefore watchful waiting is recommended for the first couple of months. A specialist referral is usually made at 6 months if the testis is still absent from the scrotal sac. It is crucial to make the diagnosis early so that an appropriate management plan can be initiated to avoid or reduce the risk of complications such as testicular malignancy, subfertility or infertility, testicular torsion, and inguinal hernia (due to patent processus vaginalis). If surgical correction is required, the ectopic testis is moved from the inguinal canal into the scrotum (orchiopexy). During mobilization of the testis, dissection of tissues must be performed carefully to avoid injuring the ilioinguinal nerve adjacent to the spermatic cord. At the time of orchiopexy, the patent processus vaginalis is closed and any inguinal hernia, if present, is repaired.
In the clinic
The ductus deferens transports spermatozoa from the tail of the epididymis in the scrotum to the ejaculatory duct in the pelvic cavity. Because it has a thick smooth muscle wall, it can be easily palpated in the spermatic cord between the testes and the superficial inguinal ring. Also, because it can be accessed through skin and superficial fascia, it is amenable to surgical dissection and surgical division. When this is carried out bilaterally (vasectomy), the patient is rendered sterile—this is a useful method for male contraception.
In the clinic
Prostate cancer is one of the most commonly diagnosed malignancies in men, and often the disease is advanced at diagnosis. Prostate cancer typically occurs in the peripheral zone of the prostate (see Fig. 5.48) and is relatively asymptomatic. In many cases, it is diagnosed by a digital rectal examination (DRE) (Fig. 5.49A) and by blood tests, which include serum acid phosphatase and serum prostate-specific antigen (PSA). In rectal exams, the tumorous prostate feels “rock” hard. The diagnosis is usually made by obtaining a number of biopsies of the prostate. Ultrasound is used during the biopsy procedure to image the prostate for the purpose of taking measurements and for needle placement. Ultrasound can also be used to aid planning radiotherapy by placing special metal markers, called fiducials, under direct ultrasound guidance, through the rectal wall into or near the tumor. This allows maximization of the radiation dose to the tumor while protecting healthy tissue.