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Bilateral Simple Orchiectomy (Gender-Affirming)

Bilateral simple orchiectomy is a low-risk outpatient gender-affirming procedure for transgender women and gender-diverse individuals. It eliminates endogenous testicular testosterone production, allows reduction or discontinuation of antiandrogen therapy, and serves as either a standalone procedure or a bridge to future vaginoplasty.[1][2]

For the cohort-level decision framework and treatment database, see Feminizing Gender-Affirming Surgery. For the clinical-conditions overview, see Feminizing Procedures. When a future vaginoplasty is contemplated, scrotal-skin preservation is the main technical issue; see the Penile-Inversion Vaginoplasty technique page for donor-tissue assessment and prior-orchiectomy data.

Role in Gender-Affirming Care​

Bilateral orchiectomy is one of three genital gender-affirming options for transgender women (alongside vulvoplasty and full-depth vaginoplasty).[3] It is suited to regions with limited access to specialized GAS centers. Hehemann and Walsh describe gender-affirming orchiectomy as a generalizable procedure; Rahman and Ferrando describe a technique that draws on vaginal surgical skills for gynecologists and urogynecologists.[1][4] The 2015 U.S. Transgender Survey reported that 11% of transgender women had undergone orchiectomy and 47% wanted it some day; the ACOG opinion cited here gives different figures for that survey.[3][17]

Eligibility (WPATH SOC8 and Endocrine Society 2017)​

For gonadectomy, WPATH SOC8 suggests considering at least 6 months of hormone therapy when appropriate to the person’s gender goals, unless hormones are not clinically indicated (statement 5.6).[15] The Endocrine Society 2017 guideline advises at least 1 year of consistent hormone treatment before genital surgery, unless hormones are not desired or are medically contraindicated (ungraded good practice statement 5.2).[15][5] For hormone-treated transgender individuals, the Endocrine Society recommends referral for genital surgery when the patient has had a satisfactory social role change, is satisfied with the hormonal effects and desires definitive surgical change (recommendation 5.4, strong).[5] It suggests delaying gonadectomy, which includes bilateral orchiectomy, until the patient reaches the age of majority in their country (recommendation 5.5, weak).[5]

A mental-health assessment letter is commonly required for insurance authorization.[3] WPATH SOC8 (2022) revised the readiness criteria and is the current standard of care; insurer policies may still cite the earlier 12-month thresholds.[15]

Approach Selection​

When testicular malignancy is not suspected, gender-affirming orchiectomy commonly uses a scrotal approach.[1] A testicular mass suspicious for neoplasm calls for Doppler scrotal ultrasound ; a solid mass suspicious for malignancy also calls for AFP, hCG, and LDH measurement before treatment .[18] For a lesion suspicious for malignancy with a normal contralateral testis, the AUA recommends radical inguinal orchiectomy and discourages transscrotal orchiectomy .[18] For early standalone bridge orchiectomy, an inguinal approach has also been described as an alternative to the scrotal route; selection is based on patient preference and surgeon experience.[16]

IncisionNotes
Single midline rapheMost commonly used; both testes delivered sequentially; single well-concealed scar; preferred when future vaginoplasty is planned because it minimizes scrotal-skin loss[1][6]
Bilateral transverse hemiscrotalAlternative for additional exposure in selected cases

Anesthesia​

The procedure can be performed under local anesthesia alone (spermatic cord anesthesia block, SCAB), MAC, or general anesthesia.

  • A series of 132 bilateral simple orchiectomies under SCAB alone (Atlanta VA; mean age 75 years, none gender-affirming) reported a painless procedure (pain score = 0) in 77% of patients, with 92% rating satisfaction as "highly satisfactory."[7]
  • Typical block: equal-volume mixture of 1% lidocaine with epinephrine 1:100,000 and 0.25% bupivacaine, mean approximately 20 mL per case.[7]
  • Mean operative time excluding anesthesia was 33 minutes in the SCAB series and 37 minutes in the epididymal-sparing series, both in older men with prostate cancer.[7][6]

Step-by-Step Technique​

  1. Incision and exposure. Vertical midline incision through skin and dartos along the median raphe; the testis is identified within the tunica vaginalis.[1][8]
  2. Delivery of the testis. Blunt and sharp dissection through the spermatic-cord coverings (external spermatic fascia, cremasteric muscle, internal spermatic fascia); the tunica vaginalis is opened to expose the testis and epididymis.[1]
  3. Cord identification and isolation. Vas deferens, testicular artery, pampiniform plexus, and cremasteric vessels are identified and isolated; the cord is clamped.[1][8]
  4. Ligation and transection. The cord is doubly suture-ligated and transected. Many surgeons ligate the vas deferens separately from the vascular pedicle for added security.[1][6] In a published gender-affirming technique, Francis and colleagues ligate close to the external ring with heavy silk and/or suture ligatures and remove maximal cord length to avoid a palpable remnant.[19]
  5. Hemostasis. Surgical bed inspected; electrocautery applied as needed.
  6. Contralateral side. Same steps, through the same midline raphe incision (preferred for scrotal-skin preservation) or a separate hemiscrotal incision.
  7. Closure. Dartos and skin closed in layers; scrotal support / compression applied.

Epididymal-sparing variant​

In the epididymal-sparing technique, the testis is dissected free from the epididymis and the epididymis is folded on itself (epididymoplasty) and left in the scrotum, preserving scrotal bulk and esthetic appearance. In a series of 91 epididymal-sparing orchiectomies for prostate cancer, follow-up was available for 26 of 52 patients who had previously received LH-RH agonist therapy; 96.2% were satisfied with the result and 84.6% preferred the procedure over medical castration. The series did not include transgender patients.[6]

Tissue Preservation for Future Vaginoplasty​

Scrotal-skin preservation at the time of orchiectomy is the main technical decision unique to gender-affirming orchiectomy, because the same tissue is used during penile-inversion vaginoplasty (PIV) to construct the labia majora and to supplement the vaginal canal.[1][9]

  • In a prospective cohort of 235 patients having PIV, prior orchiectomy was associated with 3 times greater odds of needing extragenital skin grafts, with less scrotal skin available. This is a preoperative counseling point.[10]
  • Stretched scrotal skin length > 10 cm was associated with a low risk of needing additional graft, and stretched penile skin length < 8 cm was associated with graft requirement.[10]
  • Duration of gender-affirming hormone exposure did not predict scrotal-skin availability (p = 0.8).[10]
  • Hair removal before later vaginoplasty. If a vaginal canal is planned, discuss permanent hair removal from penile-shaft and scrotal donor skin, and from any perineal skin selected for the lining, before vaginoplasty; hair-bearing neovaginal skin is a known complication that is difficult to revise. Standalone bridge orchiectomy can proceed while hair removal is incomplete.[3][21]
  • Incision design. A small midline raphe incision minimizes scrotal-skin loss. Excess scrotal skin is not excised at orchiectomy in patients who may pursue vaginoplasty.[1]

Outcomes and Safety​

DomainData
30-day complication rate3.7% in NSQIP 2010–2020 (n = 246 gender-affirming orchiectomies); not significantly different from orchiectomy for torsion (4.4%) or testicular pain (5.9%)[11]
Longer clinical follow-up (separate cohort)In a retrospective two-center cohort of 119 patients (median clinical follow-up 2.3 years), 102/119 (86%) had no recorded complication; 5/119 (4.2%) had hemorrhage requiring reoperation, 7/119 (5.8%) developed an abscess, and 2/119 (1.7%) had operative-site pain lasting >3 months.[22]
SettingSafely performed as outpatient across medically diverse patients[11]
Volume trendTransgender orchiectomy cases in NSQIP increased ~9.5 cases/year from 2015–2020[11]
Operative time33–37 minutes excluding anesthesia (older men, prostate cancer series)[7][6]
Anesthesia satisfaction (SCAB)77% painless, 92% highly satisfactory (n = 132, older men with prostate cancer)[7]

Fertility Considerations​

Bilateral orchiectomy irreversibly ends new sperm production, but sperm cryopreserved beforehand can preserve a route to genetic parenthood. Discuss sperm cryopreservation before surgery; estrogen or antiandrogen treatment may impair semen parameters, and spermatogenesis may recover after treatment cessation with variable timing. Fertility-preservation counseling was underdelivered in the cited 78-patient cohort.[12][16][20]

  • In a retrospective cohort of 78 patients, 22% reported that reproductive options were not discussed before surgical consultation.[12]
  • Among patients with pathology data, 40% had some spermatogenesis in the testicular tissue.[12]
  • Of the 85% who were not interested in fertility preservation, the reasons were lack of interest in biological children (74%), unwillingness to delay transition (47%) and cost (36%).[12]

Pathology​

In a series of 45 orchiectomy specimens from 23 patients, only a subset showed changes of exogenous hormone therapy:[13]

  • Aspermatogenesis in 71% and hypospermatogenesis in 18%.[13]
  • Markedly reduced or absent Leydig cells in 85%.[13]
  • Nuclear cytomegaly in 25 of 45 specimens (56%) can mimic germ-cell neoplasia in situ (GCNIS); all 6 specimens tested for OCT4 were negative, a diagnostic pitfall for pathologists.[13]

The authors propose a grossing protocol of two sections including rete testis / epididymis plus a third section of cord margin, which identified the relevant pathology in this population.[13]

Postoperative Care and Hormonal Management​

General practice for outpatient scrotal surgery:

  • Ice and scrotal support for 24–48 hours
  • Activity restriction approximately 1–2 weeks
  • Wound check at 1–2 weeks
  • Antiandrogen therapy. Antiandrogens such as spironolactone can typically be discontinued or reduced after orchiectomy.[14]
  • Post-gonadectomy hormone plan. Coordinate sex-steroid management with the prescribing clinician before surgery, including for patients not taking hormones. Estradiol is typical after feminizing orchiectomy; SOC8 also discusses estrogen, testosterone, or both for nonbinary patients according to their goals. Monitor cardiovascular risk factors during hormone therapy and obtain bone-density testing when osteoporosis risk factors are present, particularly if sex steroids are stopped after gonadectomy.[5][14][15]
  • Submit specimens for histopathology; Cornejo and colleagues proposed a three-section grossing protocol based on 45 specimens from 23 patients.[13]

Key Principles​

  • Bilateral simple orchiectomy is a low-risk outpatient procedure (9/246 [3.7%] had 30-day complications in the NSQIP gender-affirming orchiectomy cohort) and has been performed by general urologists, general surgeons and urogynecologists.[11][4]
  • The scrotal approach is standard; the midline raphe incision is preferred when future vaginoplasty is contemplated.[1]
  • Scrotal-skin preservation is the main technical decision. Prior orchiectomy was associated with 3 times greater odds of needing extragenital skin grafts at later vaginoplasty.[10]
  • SCAB-only anesthesia is feasible and was well tolerated in older men with prostate cancer (77% painless).[7]
  • The procedure is irreversible; fertility-preservation counseling should precede surgery and is often not delivered.[12]
  • Antiandrogens such as spironolactone can usually be stopped after orchiectomy; arrange ongoing sex-steroid management according to the patient's goals and bone-density testing when osteoporosis risk factors are present.[5][14][15][16]
  • Nuclear cytomegaly in these specimens can mimic GCNIS; the cases in the pathology series were OCT4-negative.[13]

Videos​

Simple Orchiectomy Step-by-Step Technique
Omer Raheem MD (2021)
Gender-Affirming Orchiectomy
UCLA Health — Mark S. Litwin MD (2018)

References​

1. Hehemann MC, Walsh TJ. Orchiectomy as bridge or alternative to vaginoplasty. Urol Clin North Am. 2019;46(4):505-510. doi:10.1016/j.ucl.2019.07.005.

2. van der Sluis WB, Schäfer T, Nijhuis THJ, Bouman MB. Genital gender-affirming surgery for transgender women. Best Pract Res Clin Obstet Gynaecol. 2023;86:102297. doi:10.1016/j.bpobgyn.2022.102297.

3. Committee on Gynecologic Practice and Committee on Health Care for Underserved Women. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75-e88. doi:10.1097/AOG.0000000000004294.

4. Rahman S, Ferrando CA. Gender-affirming bilateral orchiectomy for the urogynecologist. Int Urogynecol J. 2026;37(4):1091-1094. doi:10.1007/s00192-025-06463-w.

5. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric / gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903. doi:10.1210/jc.2017-01658.

6. Issa MM, Lendvay TS, Bouet R, et al. Epididymal sparing bilateral simple orchiectomy with epididymoplasty: preservation of esthetics and body image. J Urol. 2005;174(3):893-7. doi:10.1097/01.ju.0000172567.09442.b0.

7. Issa MM, Hsiao K, Bassel YS, et al. Spermatic cord anesthesia block for scrotal procedures in outpatient clinic setting. J Urol. 2004;172(6 Pt 1):2358-61. doi:10.1097/01.ju.0000144544.43148.10.

8. Sharlip ID. Surgery of scrotal contents. Urol Clin North Am. 1987;14(1):145-8. doi:10.1016/s0094-0143(21)00827-2

9. Saylor L, Bernard S, Vinaja X, Loukas M, Schober J. Anatomy of genital reaffirmation surgery (male-to-female): vaginoplasty using penile skin graft with scrotal flaps. Clin Anat. 2018;31(2):140-144. doi:10.1002/ca.23015.

10. Sineath RC, Butler C, Dy GW, Dugi D. Genital hypoplasia in gender-affirming vaginoplasty: prior orchiectomy, penile length, and other factors to guide surgical planning. J Urol. 2022;208(6):1276-1287. doi:10.1097/JU.0000000000002900.

11. Saltman AJ, Dorante MI, Jonczyk MM, et al. Outcomes of orchiectomy for gender-affirming surgery: a National Surgical Quality Improvement Program study. Urology. 2023;180:98-104. doi:10.1016/j.urology.2023.07.003.

12. Craig Sineath R, Guerre M, Martin L, Chouhan JD. Interest in and prior receipt of counseling on fertility preservation in transgender patients presenting for gender-affirming orchiectomy. Urology. 2023;182:101-105. doi:10.1016/j.urology.2023.07.018.

13. Cornejo KM, Oliva E, Crotty R, et al. Clinicopathologic features and proposed grossing protocol of orchiectomy specimens performed for gender affirmation surgery. Hum Pathol. 2022;127:21-27. doi:10.1016/j.humpath.2022.05.017.

14. Jackson Q, Yedlinsky NT, Gray M. Lifelong care of patients after gender-affirming surgery. Am Fam Physician. 2024;109(6):560-565. PMID 38905554

15. Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. doi:10.1080/26895269.2022.2100644

16. Owyong M, Ramasamy R. Surgical anatomy: orchiectomy and fertility preservation options. In: Nikolavsky D, Blakely SA, eds. Urological Care for the Transgender Patient: A Comprehensive Guide. Springer; 2021:47-59. doi:10.1007/978-3-030-18533-6_5

17. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016. Figure 7.14, p. 102. Report.

18. American Urological Association. "Diagnosis and Treatment of Early-Stage Testicular Cancer: AUA Guideline (Published 2019; Amended 2023)." 2023. Guideline

19. Francis C, Grober E, Potter E, Blodgett N, Krakowsky Y. "A Simple Guide for Simple Orchiectomy in Transition-Related Surgeries." Sex Med Rev. 2020;8(3):492-496. doi:10.1016/j.sxmr.2019.11.004

20. De Roo C, Schneider F, Stolk THR, van Vugt WLJ, Stoop D, van Mello NM. "Fertility in transgender and gender diverse people: systematic review of the effects of gender-affirming hormones on reproductive organs and fertility." Hum Reprod Update. 2025;31(3):183-217. doi:10.1093/humupd/dmae036

21. Stelmar J, Victor R, Yuan N, et al. "Endocrine, gender dysphoria, and sexual function benefits of gender-affirming bilateral orchiectomy: patient outcomes and surgical technique." Sex Med. 2024;12(4):qfae048. doi:10.1093/sexmed/qfae048

22. van der Sluis WB, Smit JM, Schäfer T, Bouman MB. "Gender-affirming orchiectomy in transgender and non-binary individuals: A large cohort study with middle- to long-term follow-up." Int J Transgend Health. 2025;26(2):459-463. doi:10.1080/26895269.2024.2396939