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Bilateral subcapsular orchiectomyusing CO2 laser
BILATERAL SUBCAPSULAR ORCHIECTOMY USING CO2 LASER SAMUEL K. ROSEMBERG, M.D. From the Department of Surgery, Section of Urology, Sinai Hospital of Detroit, Michigan
In 1941 Huggins and co-workers documented regression of prostate cancer following castration, based on the assumption that malignant prostate cells are androgen-dependent. Bilateral orchiectomy appears to be the most reliable surgical means able to reduce testicular androgen production, with significant relief of bone pain, within hours of surgery. Nevertheless, many patients are reluctant to accept this surgical option due to its emasculating effects and severe psychologic trauma. With the availability of new hormonal strategies such as luteinizing hormone-releasing hormone (LHRH)agonists, androgen-blocking alone or in combination, surgical castration will probably be less attractive for patients and urologists alike. The indicators will then be reserved for those cases with an impending neurologic and/ or obstructive uropathy resulting in renal failure, in situations where rapid improvement is needed. If patients are presented with an alternative surgical option that will allow them to keep the "outer testes shell," and spermatic cords, by having only the "inside of the testes" removed, they usually agree to undergo this procedure.
FmURE 1. Longitudinal incision through tunica albuginea with handheld articulated arm.
Material and Methods From July 1988 to December 1989, we performed CO2 laser subcapsular orchiectomy on 10 patients with metastatic carcinoma, Stage D~. Diagnosis had been previously made by biopsy of prostate tissue, bone scan, serum prostate-specific antigen (PSA), and acid phosphatase. A 1060 Sharplan CO2 laser was used with an output power of 10 W, CW mode, delivered through an articulated light arm and a handheld piece. Rubber shods were applied to both spermatic cords, followed by a complete longi580
FIGURE2. Edges of tunica albuginea grasped with= ii ii!ii~!i Allis clamps exposing testicuIar tissue. tudinal incision through the tunica albuginea over the anterior testieular surface (Fig. 1 ) . ~ ! lis clamps were placed on the cut edges o f t h g tunica albuginea (Fig. 2), and with the help of a moist gauze, blunt dissection with ous vaporization of the inner asp tunica was accomplished by varyiI tance between the hand piece and ir UROLOGY
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JUNE 1991
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VOLUME XXXVII,
FIGURE 3. Inner aspect oJ tunica albugmea after subcapsular orchiectomy completed with vaporization o] inner sur]ace.
(Fig. 3). A "figure-eight" stitch was placed through the base of the tunica at the completion of the procedure, followed by release of the cord clamps and tunical closure (Fig. 4). Results Atl patients had an uneventful postoperative recovery, with a scrotal hematoma developing in only i patient. Serum PSA levels returned to normal in all patients, with mean postoperative serum testosterone values of.0.2. All were managed postoperatively with oral analgesics and, at three months, cords were palpable with 1.5 to 2.0-era size, nodular-feeling tunica albuginea. Comment Prostate cancer is the second most common malignancy in men, with 99,000 new cases and 20,000 deaths expected in 1989. 2 Two major hypotheses have been proposed to explain its etiology, one of them referring to the hormonal stimulation of the prostate by high levels of test0sterone, s,4 Bilateral orchiectomy causes a 95 percent reduction in serum testosterone levels and in some patients relief of bone pain within hours of surgery is usually seen, but the psychologic impact of surgical castration may lead to Patient refusal of this procedure. In addition, new evidence suggests ~,6 that combination ~erapy with gonadotropin-releasing hormone analogues plus oral androgen blockade has pro~aced a 25 percent extended median survival in ~tage D2 patients, which makes surgical castrati6n much less desirable. Subeapsular orchiectomy was first described by Riba in 1942, 7 and in 1988 Wishnow et al. 8 ased the CO2 laser to perform surgical subcap~JROLOGY /
JUNE 1991
/
VOLUME XXXVII, NUMBER 6
FIGURE 4.
Final reconstruction of testicle beyore return to scrotal cavity.
sular castration stating that the procedure was simple and safe, with patients experiencing minimal postoperative pain and swelling. Our observations are in agreement with those made in the past; since the procedure, indeed, is simple, safe, produces minimal postoperative pain, and reduces serum testosterone to castration levels. The technique provides a reasonable alternative for those patients with impending neurologic damage and bilateral ureteral obstruction due to m e t a s t a t i c prostate cancer, who otherwise would have refused bilateral orchiectomy by being more agreeable to having "only the insides of the testes" removed. 17100 W. Twelve Mile Road Southfield, Michigan 48076 References 1. Huggins C, and Hodges CV: Studies on prostatic cancer; effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate, Cancer Res 1:293 (1941). 2. Silverberg E, and Lubera JA: Cancer statistics, 1988, CA 38:5 (1988). 3. Catalona WJ, and Scott WW: Carcinoma of the prostate, in Walsh PC, Gittes RF, Perlmutter AD, and Stamey TA (Eds): Campbell's Urology, ed 5, Philadelphia, WB Saunders Co., 1966, pp 1463-1534. 4. Ross R K , Paganini-Hill A, and Henderson BE: Epidemiology of prostatic cancer, in Skinner DG, and Heskawsky G (Eds): Diagnosis and Mangement of Genitourinary Cancer, Philadelphia, WB Saunders Co., 1988, pp 40-45. 5. Crawford ED, et ah Treatment of newly diagnosed Stage D2 prostate cancer with leuprolide and flutamide, or leuprolide alone, Phase III Intergroup Study 0036, Proc ASCO 7:19 (1988). 6. Labrie F, et ah New hormonal therapy in prostatic carcinoma: combined treatment with an LH-RH agonist and an anti-androgen, Clin Invest Med 5:267 (1982). 7. Riba L: Subcapstdar castration for carcinoma of the prostate, J Urol 48:384 (1942). 8. Wishnow KI, et ah Subcapsular orchiectomy using the CO2 laser: a new technique, Laser Surg Med 8:604 (1988).
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In 1941 Huggins and co-workers documented regression of prostate cancer following castration, based on the assumption that malignant prostate cells are androgen-dependent. Bilateral orchiectomy appears to be the most reliable surgical means able to reduce testicular androgen production, with significant relief of bone pain, within hours of surgery. Nevertheless, many patients are reluctant to accept this surgical option due to its emasculating effects and severe psychologic trauma. With the availability of new hormonal strategies such as luteinizing hormone-releasing hormone (LHRH)agonists, androgen-blocking alone or in combination, surgical castration will probably be less attractive for patients and urologists alike. The indicators will then be reserved for those cases with an impending neurologic and/ or obstructive uropathy resulting in renal failure, in situations where rapid improvement is needed. If patients are presented with an alternative surgical option that will allow them to keep the "outer testes shell," and spermatic cords, by having only the "inside of the testes" removed, they usually agree to undergo this procedure.
FmURE 1. Longitudinal incision through tunica albuginea with handheld articulated arm.
Material and Methods From July 1988 to December 1989, we performed CO2 laser subcapsular orchiectomy on 10 patients with metastatic carcinoma, Stage D~. Diagnosis had been previously made by biopsy of prostate tissue, bone scan, serum prostate-specific antigen (PSA), and acid phosphatase. A 1060 Sharplan CO2 laser was used with an output power of 10 W, CW mode, delivered through an articulated light arm and a handheld piece. Rubber shods were applied to both spermatic cords, followed by a complete longi580
FIGURE2. Edges of tunica albuginea grasped with= ii ii!ii~!i Allis clamps exposing testicuIar tissue. tudinal incision through the tunica albuginea over the anterior testieular surface (Fig. 1 ) . ~ ! lis clamps were placed on the cut edges o f t h g tunica albuginea (Fig. 2), and with the help of a moist gauze, blunt dissection with ous vaporization of the inner asp tunica was accomplished by varyiI tance between the hand piece and ir UROLOGY
/
JUNE 1991
/
VOLUME XXXVII,
FIGURE 3. Inner aspect oJ tunica albugmea after subcapsular orchiectomy completed with vaporization o] inner sur]ace.
(Fig. 3). A "figure-eight" stitch was placed through the base of the tunica at the completion of the procedure, followed by release of the cord clamps and tunical closure (Fig. 4). Results Atl patients had an uneventful postoperative recovery, with a scrotal hematoma developing in only i patient. Serum PSA levels returned to normal in all patients, with mean postoperative serum testosterone values of.0.2. All were managed postoperatively with oral analgesics and, at three months, cords were palpable with 1.5 to 2.0-era size, nodular-feeling tunica albuginea. Comment Prostate cancer is the second most common malignancy in men, with 99,000 new cases and 20,000 deaths expected in 1989. 2 Two major hypotheses have been proposed to explain its etiology, one of them referring to the hormonal stimulation of the prostate by high levels of test0sterone, s,4 Bilateral orchiectomy causes a 95 percent reduction in serum testosterone levels and in some patients relief of bone pain within hours of surgery is usually seen, but the psychologic impact of surgical castration may lead to Patient refusal of this procedure. In addition, new evidence suggests ~,6 that combination ~erapy with gonadotropin-releasing hormone analogues plus oral androgen blockade has pro~aced a 25 percent extended median survival in ~tage D2 patients, which makes surgical castrati6n much less desirable. Subeapsular orchiectomy was first described by Riba in 1942, 7 and in 1988 Wishnow et al. 8 ased the CO2 laser to perform surgical subcap~JROLOGY /
JUNE 1991
/
VOLUME XXXVII, NUMBER 6
FIGURE 4.
Final reconstruction of testicle beyore return to scrotal cavity.
sular castration stating that the procedure was simple and safe, with patients experiencing minimal postoperative pain and swelling. Our observations are in agreement with those made in the past; since the procedure, indeed, is simple, safe, produces minimal postoperative pain, and reduces serum testosterone to castration levels. The technique provides a reasonable alternative for those patients with impending neurologic damage and bilateral ureteral obstruction due to m e t a s t a t i c prostate cancer, who otherwise would have refused bilateral orchiectomy by being more agreeable to having "only the insides of the testes" removed. 17100 W. Twelve Mile Road Southfield, Michigan 48076 References 1. Huggins C, and Hodges CV: Studies on prostatic cancer; effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate, Cancer Res 1:293 (1941). 2. Silverberg E, and Lubera JA: Cancer statistics, 1988, CA 38:5 (1988). 3. Catalona WJ, and Scott WW: Carcinoma of the prostate, in Walsh PC, Gittes RF, Perlmutter AD, and Stamey TA (Eds): Campbell's Urology, ed 5, Philadelphia, WB Saunders Co., 1966, pp 1463-1534. 4. Ross R K , Paganini-Hill A, and Henderson BE: Epidemiology of prostatic cancer, in Skinner DG, and Heskawsky G (Eds): Diagnosis and Mangement of Genitourinary Cancer, Philadelphia, WB Saunders Co., 1988, pp 40-45. 5. Crawford ED, et ah Treatment of newly diagnosed Stage D2 prostate cancer with leuprolide and flutamide, or leuprolide alone, Phase III Intergroup Study 0036, Proc ASCO 7:19 (1988). 6. Labrie F, et ah New hormonal therapy in prostatic carcinoma: combined treatment with an LH-RH agonist and an anti-androgen, Clin Invest Med 5:267 (1982). 7. Riba L: Subcapstdar castration for carcinoma of the prostate, J Urol 48:384 (1942). 8. Wishnow KI, et ah Subcapsular orchiectomy using the CO2 laser: a new technique, Laser Surg Med 8:604 (1988).
581