Is there a Role for Bilateral Orchidectomy as a Preliminary Procedure Prior to Full Genitoplasty in MtF Patients?
Mr. Tim Terry
Consultant Surgeon. Urology. University Hospital Leicester
Summary by Alice Purnell RGN, BSc, PGDC
Gendys Conference, 2002
There seem to be benefits in psychological and hormonal changes after this operation, as well as anatomical, there being a slight reduction of the scrotal bulge. There is no change to the voice, but male pattern baldness may reduce, and in time body hair may reduce. Distribution of muscle and body fat will be similar to that of a eunuch.
This surgery is irreversible. After it a patient will of course be infertile and since 95% of testosterone is produced by the testes so the patient will probably entirely lose erections.
In the agonadal there is a result similar to Androgen Deficiency Syndrome with several effects a patient should be aware of prior to surgery. Muscle bulk will reduce over the years, anaemia can be a problem, uptake of Calcium can occur resulting in reduced bone density (increased risk of Osteoporosis) together with changes in fat distribution and skin quality.
There are pluses and minuses to consider. There is also the cost to the NHS or the patient of an extra surgical procedure. The cost of an extra procedure should be weighed against that of replacing the use of antiandrogens to reduce testosterone and there may besome morbidity (haematoma or pain). However this is sometimes useful to a patient who cannot wait for the full surgery, wishes to reduce male pattern baldness, or the regrowth of facial hair if undergoing electrolysis or who is elderly and does not perhaps have concerns about sexual activity.
Young patients may need to consider storing sperm prior to this surgery. Feminizing hormones reduce the amount of scrotal tissue available for genitoplasty. It is a myth that orchidectomy alone will do this. Bilateral Orchidectomy is performed as a day case, using a vertical scrotal incision. There should be at least a 6 month wait prior to GRS if this is the plan.
There are costs and risks and side effects reported for all medications, these need to be considered prior to informed consent from the patient commencing them, as well as prior to any surgery - a realistic informed decision needs to be obtained from all patients. To reduce Testosterone, synthetic anti-androgens (Cyprotone Acetate = Androcur) is usually used, or a 5 alpha reductase inhibitor (Finasteride) can be used. Androcur can in some cases affect liver function, or cause depression, or other effects. Flutamide, a hormone antagonist, causes acute diarrhoea in some twenty percent of patients. LHRH Analogues over-stimulate the pituitary, switching off production of testosterone. These can be given as 3 monthly injections (which cost £350). Orchidectomy costs about £600.
Those opting for Orchidectomy, having been assessed and fully informed are treated as day cases, under local anaesthetic, with no need for starving prior to surgery, no need for general anaesthetic in almost all cases. They may be anxious, so might need Diazepam. It is a good idea if a friend collects them after the surgery. They go home after 2 hours. There will be an i/v line during surgery. The patient will be discharged with absorbable sutures, a small dressing and pain control.
It is a very straight forward procedure. There is a very low morbidity. There is a case for this as a staging procedure, replacing use of drugs to reduce testosterone levels and as a means of an alternative to waiting a very long time for GRS.It is sometimes hard for a clinician to put himself entirely in the shoes of a patient, so it is important to listen and to be flexible. Physical and psychological aspects must not be underestimated. Fully informed patients choose what they want pragmatically taking personal responsibility for this. A good result is a patient who understands that things can go wrong, but you have to deal with it. Realism is vital.
Mr Terry was asked to perform this procedure on a man who had to continue to appear male at work who requested orchidectomy but with insertion of prosthetic testes as a means of stopping testosterone. We need much more research and training both for endocrinologists and the prescribing psychiatrists.
Citation:Terry, T., (Summary by Purnell, P.,) (2002),Is there a Role for Bilateral Orchidectomy as a Preliminary Procedure Prior to Full Genitoplasty in MtF Patients? GENDYS 2002, The Seventh International Gender Dysphoria Conference, Manchester England.
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