Treatment options

2. Surgery for testicular cancer:

The first treatment for testicular cancer is usually surgery to remove the affected testicle. You might also need another surgery to remove lymph nodes from the back of your abdomen.

Learn about the different types of surgery and what to expect both during your hospital stay and after your operation.

Types of surgery for testicular cancer:

There are different types of surgery for testicular cancer:

– Orchidectomy: This is the surgery to remove the affected testicle. It’s done both to diagnose and to treat testicular cancer.

– Retroperitoneal Lymph Node Dissection (RPLND): If needed, your doctor may perform surgery to remove some lymph nodes from the back of your abdomen.

– Lung Surgery: If the cancer has spread to your lung, you might have surgery to remove the cancer from the lung.

Removing a testicle (orchidectomy):

Removing the testicle is known as an orchidectomy or orchiectomy. In rare cases, if the tumor is very small, the surgeon may only remove a part of the testicle, which is called a partial orchidectomy.

During the surgery, the surgeon makes an incision in the groin and cuts the spermatic cord to remove the testicle.

Removing lymph nodes (retroperitoneal lymph node dissection):

Lymph nodes are found in many parts of the body and can become enlarged if cancer spreads to them.

Testicular cancer can spread to the lymph nodes located in the back of the abdomen, called the retroperitoneal lymph nodes, which are in front of the spine.

If this happens, you might need surgery to remove these lymph nodes. This surgery, known as a retroperitoneal lymph node dissection, is a major operation and is usually done at a specialized centre.

Image lymph nodes (cruk)

Removing secondary cancer in the lungs:

Testicular cancer can spread to the lungs, which is known as secondary cancer. If this happens, you might need surgery to remove the cancer from your lungs.

Your doctor might recommend this surgery if:

– There are still signs of cancer after chemotherapy.

– The cancer seems resistant to chemotherapy.

What to Expect

This is major surgery performed under general anaesthesia, so you will be asleep during the operation.

After you wake up, you’ll have:

– A drip (intravenous line) in your vein

– Tubes coming out from your wound

– A chest drain (a tube in your chest connected to a suction bottle) to help your lung expand again

The surgery will cause the lung to collapse temporarily, and the chest drain helps it re-inflate. Sometimes, the surgery may involve cutting through ribs, which can be painful while healing.

You might need this surgery more than once if the tumors come back, depending on your overall health and treatment preferences.

Removing lymph nodes for testicular cancer (retroperitoneal lymph node dissection):

You might need surgery to remove lymph nodes from your abdomen, known as the retroperitoneal lymph nodes. This surgery is called a retroperitoneal lymph node dissection.

It’s a major operation, and you may need to stay in the hospital for up to 5 days, depending on how the surgery goes.

What are retroperitoneal lymph nodes?:

Lymph nodes are a network of glands found throughout your body. Cancer can spread to these nodes and cause them to become enlarged.

Testicular cancer can spread to the lymph nodes in the back of your abdomen, known as the retroperitoneal lymph nodes, which are located in front of your spine.

Image of lymph nodes(cruk)

When do you have it:

Your doctor will discuss with you whether you need this surgery based on factors like the type and stage of your testicular cancer.

You might have this surgery if:

– Scans show your lymph nodes are still enlarged after chemotherapy.

– For stage 2A non-seminoma cancer, if chemotherapy isn’t an option and your tumor markers are normal.

– You cannot have chemotherapy or regular monitoring for some reason.

What happens:

This surgery is quite extensive and is done at a specialized centre. You might have a team of different surgeons, including a urologist and a vascular surgeon.

You will be under general anaesthesia, and the surgery can last between 3 and 7 hours.

Open Surgery:

– If you’re having this surgery after chemotherapy, it’s usually done as open surgery.

– The surgeon makes a long cut in your abdomen, from just below your rib cage to below your belly button.

Keyhole Surgery:

– If you haven’t had chemotherapy, you might have keyhole surgery, though it’s less common and usually done at specialized hospitals.

– Also known as laparoscopic surgery, this method involves several small cuts in your abdomen, with the help of a robotic system, rather than one large cut.

Problems after surgery:

This surgery can sometimes damage nerves that control ejaculation, which might lead to:

– Difficulty ejaculating

– Sperm going into your bladder (retrograde ejaculation)

Even if this happens, you should still be able to get an erection and have an orgasm. However, with retrograde ejaculation, you won’t be able to father a child through sexual intercourse. Your doctor will discuss sperm banking with you before the surgery.

There’s a specialized technique called nerve-sparing lymph node dissection that aims to avoid this issue. This is a highly specialized procedure and might require traveling to a specialist hospital. It’s not always possible if the cancer is near the nerves, as leaving them could increase the risk of the cancer returning.

3. Problems after surgery for testicular cancer:

There’s always a chance of issues or complications after any surgery. While many of these issues are minor, some can be serious. It’s crucial to address any problems as quickly as possible.

The specific risks depend on the type of surgery you undergo.

General Risks:

Any major operation there is a risk of

Infection:

After surgery, there’s a chance you might get an infection. This can happen at the site of the wound, in your chest, or in your urinary tract. To lower the risk, you’ll be given antibiotics, but it’s important to let your doctor or nurse know if you notice any signs of infection.

Symptoms to watch for include:

– A high fever

– Shivering or chills

– Feeling hot and cold

– General unwellness

– Coughing

– Nausea

– Swelling, redness, or heat around your wound

– A bad smell or discharge from the wound

– Loss of appetite

In rare cases, if your wound gets infected, you might need another surgery to treat it.

Blood clots:

After surgery, there’s a chance of developing blood clots, known as deep vein thrombosis (DVT), because you might not be moving around as much as usual. These clots can block blood flow in your veins. If you notice any swelling, warmth, redness, or pain in your leg, let your doctor or nurse know right away.

There’s also a risk that a clot could break loose and travel to your lungs, causing a blockage called a pulmonary embolism. Symptoms of this include:

– Difficulty breathing

– Chest pain

– Coughing up blood

– Feeling faint or lightheaded

If you experience any of these symptoms, it’s important to seek medical attention immediately.

To help prevent blood clots after surgery, it’s crucial to do the leg exercises your nurse or physiotherapist showed you. Your nurse might also give you an injection under the skin to reduce the risk of clots while you’re in the hospital. Depending on the type of surgery, you might need to continue these injections for up to 4 weeks after you go home.

Before you leave the hospital, your nurse might teach you how to give yourself these injections, or a district nurse might visit your home to administer them. Additionally, if your doctor advises it, it’s important to keep wearing compression stockings to further reduce the risk of clots.

Bleeding:

After your surgery, there’s a chance you might experience some bleeding. The medical team will keep a close watch on you for any signs of bleeding, especially in the first few days, when the risk is highest. By the time 3 or 4 days have passed, the risk is much lower.

If bleeding occurs, the treatment you need will depend on how much blood you lose and what’s causing it. You might require a blood transfusion, and in rare cases, another surgery might be necessary to stop the bleeding.

Problems after surgery to remove one testicle:

Most men develop cancer in just one testicle, which is typically removed through surgery. It’s rare to require surgery on both testicles. After the operation, you may experience some discomfort and bruising for a couple of weeks.

Your sex life:

Removing one testicle doesn’t usually affect your ability to get an erection. The other testicle often compensates by producing more testosterone (the male hormone) and sperm.

However, after treatment, you might temporarily lose interest in sex due to fatigue, sickness, or other side effects.

Fertility and Having Children:

For most men, this surgery won’t impact your ability to father children. But in some cases, the remaining testicle may not function as effectively, which could reduce fertility.

Doctors may recommend sperm banking before starting treatment. This involves storing sperm for potential future use in fertility treatments.

Problems after surgery to remove both testicles:

It’s rare to have testicular cancer in both testicles. However, if it does occur, surgery is needed to remove both.

The testicles produce testosterone, and after their removal, the testosterone levels in your blood drop quickly. This can impact your sex drive and fertility, making these changes challenging to cope with. It might be helpful to talk to a close friend or a professional about your feelings.

Sex Life:

To maintain your sex drive and the ability to get an erection, you’ll need testosterone replacement therapy. This can be done through:

– Injections into the muscle of your arm or leg every 2 to 3 weeks

– Skin patches that continuously release a small dose through the skin

– Gel that you apply to your skin daily

Having Children (Fertility)

After both testicles are removed, you will no longer be able to have children naturally. Before the surgery, your doctor will discuss sperm banking as an option to preserve your ability to have children in the future.

Problems after surgery to remove lymph nodes (retroperitoneal lymph node dissection):

You might need an operation to remove lymph nodes from the back of your abdomen. This surgery is called retroperitoneal lymph node dissection (RPLND) and is a significant procedure. It can affect the nerves that control how sperm is released, which might impact your sex life and future ability to have children.

Effects on Sex Life

After the operation, you should still be able to get an erection and have an orgasm. However, a common side effect is called “dry ejaculation,” where the semen goes backward into your bladder instead of coming out through your penis. This is known as retrograde ejaculation.

Effects on Fertility

With retrograde ejaculation, you won’t be able to get someone pregnant naturally. But there might be options to retrieve sperm directly from your testicles or from your urine after sex, which could then be used to fertilize your partner, possibly through in vitro fertilization (IVF).

Your doctor will discuss the possibility of storing your sperm before the surgery if needed.

Having Children (Fertility)

If you experience retrograde ejaculation, you won’t be able to get someone pregnant through regular sexual intercourse. However, doctors may be able to retrieve sperm directly from your testicles or from your urine after sex. A fertility specialist can then use your sperm to help fertilize your partner, either directly or through in vitro fertilization (IVF).

Your doctor will discuss the option of storing sperm before the surgery.

Damage to Other Organs in Your Abdomen

Because this is a major surgery, there’s a possibility that other organs in your abdomen, such as the small bowel, kidneys, or ureters (the tubes that carry urine), could be damaged. If any of these issues arise, the surgeon typically identifies and fixes them during the operation.

Leaks

Your abdomen contains lymphatic vessels, which are part of the lymphatic system and help drain fluid (called chyle) from the small bowel. Sometimes, these vessels can leak after surgery, causing chyle to accumulate in the abdomen—a condition known as chylous ascites.

If the leak is small, you might not need treatment. However, a larger leak can cause illness and may require the fluid to be drained through a tube placed in your abdomen for a few days. Additionally, you may need to follow a low-fat diet for about four weeks to reduce the amount of chyle your body produces.

4. Chemotherapy for testicular cancer:

Chemotherapy involves using anti-cancer (cytotoxic) drugs to kill cancer cells. These drugs travel throughout your body in the bloodstream.

You may need chemotherapy if there’s a higher chance of your cancer returning or if it has already spread. Typically, you’ll receive a combination of chemotherapy drugs.

The drugs are administered directly into your bloodstream, either by injection or through a drip (intravenously).

When you receive chemotherapy, it may be to:

– Help prevent the cancer from returning after surgery to remove a testicle (this is known as adjuvant chemotherapy).

– Treat cancer that has returned (relapsed) after the initial treatment.

– Treat cancer that has spread beyond the testicle.

How You Have Chemotherapy

Chemotherapy is typically given using a combination of drugs, administered directly into your bloodstream (intravenously).

Into Your Bloodstream

Chemotherapy is delivered through a thin, short tube (called a cannula) inserted into a vein in your arm each time you receive treatment.

Cycles

Chemotherapy is given in cycles, with each cycle being the period from the start of one treatment round to the start of the next. A typical cycle lasts 3 weeks (21 days). You receive chemotherapy on specific days within each cycle.

The number of cycles you need depends on:

– Whether your cancer has spread

– Where it has spread

– Your tumor marker blood test results

– How well your cancer responds to the treatment

Preventing Blood Clots

Chemotherapy can raise your chances of developing blood clots. How much your risk increases depend on your individual situation.

Your doctor may recommend taking medication to help reduce this risk. They will discuss your specific risk level with you and explain the pros and cons of taking these medications.

Where You Have Chemotherapy

Chemotherapy is usually given through your bloodstream at a cancer day clinic. You might sit in a chair for a few hours, so it’s a good idea to bring something to keep yourself occupied, like books, newspapers, or electronic devices. You can usually have a friend or family member with you for support.

Some chemotherapy treatments are given over several days. In these cases, you might be able to take some drugs home with you using a small portable pump.

For certain types of chemotherapy, you may need to stay in a hospital ward, either overnight or for a few days.

In some cases, certain chemotherapy treatments can be administered at home. Your doctor or nurse can provide more information about this option.

Before You Start Chemotherapy

Before beginning chemotherapy, you’ll need to have blood tests to ensure it’s safe to proceed. These tests are typically done a few days before or on the day you start treatment. You’ll have blood tests before each round or cycle of chemotherapy.

It’s important for your blood cells to recover from the previous treatment before you receive more chemotherapy. If your blood counts are too low, your doctor may delay your next treatment. They’ll let you know when to have the blood test repeated and when it’s safe to continue with the treatment.

Side Effects

Common side effects of chemotherapy may include:

– Nausea

– Loss of appetite

– Weight loss

– Extreme tiredness

– Higher risk of infections

– Easy bruising and bleeding

– Diarrhea or constipation

– Hair loss

Side effects vary based on:

– The specific drugs you are taking

– The dosage of each drug

– Your individual reaction to the drugs

Let your treatment team know about any side affects your experience.

Most side effects are temporary and usually last only a few days. Your treatment team can assist in managing any side affects your encounter.

5. Radiotherapy for testicular cancer

Radiotherapy uses high-energy X-rays to kill cancer cells. Typically, you’ll have external radiotherapy, where a machine directs the radiation at the cancer.

This treatment might be used for seminoma cancer that has spread to the lymph nodes in your abdomen.

When you might have it

You might receive radiotherapy if you have seminoma testicular cancer that has spread to the lymph nodes in your abdomen.

Doctors will carefully plan the treatment area, which is typically a strip down the middle of your abdomen, known as the midline strip.

Radiotherapy is given in short sessions, called fractions, at the hospital’s radiotherapy department. You’ll have treatment on weekdays, from Monday to Friday, and not on weekends.

The entire course usually lasts between 3 and 4 weeks.

The Radiotherapy Room

Radiotherapy machines are large and might seem intimidating at first. They could be stationary or move around you to deliver treatment from various angles. However, the machine does not make physical contact with you.

Before your first treatment, your radiographers will explain what to expect and what you’ll see and hear. In some departments, you can plug in your music player to listen to your own music during the treatment.

Image of a Radiotherapy room 

During the Treatment

You need to lie very still during the treatment. Your radiographers might take x-rays or scans beforehand to ensure you’re positioned correctly. The machine will make whirring and beeping noises, but you won’t feel anything during the treatment.

Your radiographers will monitor you via a CCTV screen from another room. They can communicate with you through an intercom and might ask you to hold your breath or breathe lightly at times. You can also use the intercom or raise your hand if you need to stop or if you feel uncomfortable.

You Won’t Be Radioactive

This type of radiotherapy doesn’t make you radioactive. It’s safe to be around other people, including pregnant women and children.

Side effects of Radiotherapy for testicular cancer

Side effects typically start a few days after radiotherapy begins and may get worse as treatment continues. They might also continue to worsen for a short time after treatment ends, but usually, they begin to improve within 1 or 2 weeks.

Everyone experiences side effects differently, and you might not have all of the effects mentioned.

Side effects can include:

Tiredness and weakness

Radiotherapy can make you feel tired. This tiredness usually begins during the treatment and can last for about a week after it ends, gradually improving over time.

You might also feel weak and low on energy. Staying active, as much as you’re able, can help.

Sore skin

Sometimes, the skin in the treatment area can become red and sore, similar to mild sunburn.

For radiotherapy used to treat testicular cancer, this is usually not severe, especially if the treatment lasts for about 2 weeks.

Sickness

When you receive radiotherapy to your abdomen for testicular cancer, it can sometimes cause mild nausea, though you might not experience it at all.

If you do feel sick, let your doctor, radiographer, or radiotherapy nurse know. They can provide anti-nausea tablets to take before your treatment.

If the tablets don’t help, inform them so you can try a different type. Some anti-nausea medications work better for different people.

If you have trouble eating, consider trying a high-calorie food supplement drink, available at most chemists or prescribed by your doctor.

For dietary issues, you can also ask to see a dietitian at the hospital.

Diarrhea

When receiving radiotherapy to your abdomen for testicular cancer, you might experience mild diarrhea, though some people don’t have this side effect at all.

If you do have diarrhea, medication to slow down your bowel can help. Ask your healthcare team if this is necessary for you.

Maintaining a healthy, balanced diet is important. Eating small, frequent meals and snacks can be helpful. If needed, consult your team about any dietary adjustments. Some people find it beneficial to avoid high-fiber foods like beans, nuts, seeds, dried fruit, bran, and raw vegetables.

Make sure to drink plenty of fluids to replace what you lose. Aim for 8 to 10 glasses of water each day.

Temporary sperm damage

 During radiotherapy for testicular cancer, treatment typically targets the lymph nodes in the abdomen. The radiographer directs the radiation beams:

– At an area down the middle of your abdomen.

– Sometimes towards the groin area.

A lead shield is used to protect the remaining testicle from the radiation beams. However, there is a small chance that the remaining testicle might receive some radiation.

Doctors recommend that men avoid trying to father a child during radiotherapy and for up to a year afterward. After this period, the risk of birth abnormalities is not increased.

6. Follow up after testicular cancer treatment:

After your treatment, you’ll have regular check-ups at the hospital. These visits will include tests such as blood tests, x-rays, and scans. As time goes on, these appointments will become less frequent.

Why You Have Follow-Up Appointments

After surgery to remove your testicle, your doctor will closely monitor you during follow-up appointments. These visits are important to detect any early signs of the cancer returning, allowing for prompt treatment if needed. This process is known as surveillance. If there are any indications that the cancer has come back, your doctor will start treatment right away.

You’ll also have regular follow-up appointments and tests after chemotherapy or radiotherapy. These check-ups help your doctor monitor your recovery, address any issues or concerns you might have, and watch for any signs of the cancer returning. These appointments are also a good opportunity for you to discuss any worries or questions about your progress.

How often you have appointments with your specialist depends on several factors, including:

– The type and stage of your testicular cancer

– Your risk of the cancer returning or spreading

– The treatment you’ve received

Typically, you might see your doctor 2 to 4 times a year, and you may need to have some scans before these visits. As time goes on and the risk of the cancer returning decreases, your appointments will become less frequent.

During your appointment, your doctor will examine you and check your other testicle. They will also ask how you’re feeling, giving you a chance to discuss:

– Any new or ongoing symptoms

– Emotional or sexual issues related to the cancer or its treatment

This helps your doctor provide the best care and support for you.

You’ll likely have some tests during these appointments, though not necessarily all at once. These tests might include:

– Blood tests to check your tumor marker levels

– Chest x-rays

– CT scans

7. If your testicular cancer comes back:

When testicular cancer returns, it’s called a relapse or recurrence. The goal of treatment in this case is still to cure the cancer, and treatment is often successful even if the cancer has spread to another part of your body.

If your cancer does come back, it’s most likely to happen within 2 years of completing your treatment.

A late relapse is when the cancer comes back more than 2 years after treatment. This is quite rare, occurring in only about 2 to 3 out of every 100 people (2-3%) with testicular cancer.

Deciding on Treatment

A group of specialist doctors will review your case and decide on the best treatment plan for you. They will consider several factors, including:

– The type of testicular cancer you have

– Where the cancer is located in your body

– Your tumor marker levels

– How long it’s been since your last treatment

– The type of treatment you had before and how effective it was

– Your overall health and fitness

Your doctor will go over the treatment options with you, explaining the possible side effects and what each treatment involves. This includes how long the treatment will last and how often you’ll need to visit the hospital.

What Treatment Will I Have If My Cancer Comes Back?

If your cancer returns, you’ll usually undergo further treatment, known as second-line treatment.

Chemotherapy is a common choice for treating recurrent testicular cancer. Depending on your situation, you might also need surgery.

Chemotherapy involves using anti-cancer drugs that travel through your bloodstream to destroy cancer cells. You might receive a different combination of chemotherapy drugs than you did in your initial treatment. Common second-line chemotherapy options include:

Coping with Relapse

Learning that your cancer has returned can be overwhelming. Facing treatment again might bring up many emotions like shock, frustration, and fear.

You might need more tests to understand exactly where the cancer is, which will help your doctors determine the best treatment options for you.

Your specialist doctor and nurse will discuss your test results with you, explaining the available treatment options and what they involve. They’ll also talk to you about the goals of the treatment and help you make informed decisions.

Everyone needs different kinds of support during this time. It’s important to find what works best for you. Many people find it helpful to talk to family and friends. There are also specialist nurses, counselors, and support groups available to provide additional help and guidance.