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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 that eliminates endogenous testosterone production, allows reduction or discontinuation of antiandrogen therapy, and serves as either a standalone procedure or a bridge to future vaginoplasty.[1][2]

This is the dedicated atlas page for the scrotal-approach gender-affirming orchiectomy. 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 central technical issue — see the Penile-Inversion Vaginoplasty database row for downstream tissue-availability 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 particularly valuable in regions with limited access to specialized GAS centers because the operative steps are generalizable to urologists, general surgeons, and gynecologists / urogynecologists with minimal additional training — the dissection planes parallel those of vaginal gynecologic surgery.[4][1] The 2015 U.S. Transgender Survey found 25% of transfeminine respondents had undergone orchiectomy and 61% desired it in the future.[3]

Eligibility (Endocrine Society 2017)​

The Endocrine Society Clinical Practice Guideline lists the following criteria for fertility-affecting GAS, including orchiectomy:[5]

  1. Persistent, well-documented gender dysphoria
  2. Legal age of majority (in the country of surgery)
  3. 12 months of continuous gender-affirming hormone therapy (unless medically contraindicated)
  4. 12 months of continuous full-time living in the desired gender role
  5. Significant medical and mental-health conditions well controlled
  6. Demonstrable knowledge of practical aspects of surgery (cost, complications, rehabilitation)

A mental-health assessment letter is commonly required for insurance authorization.[3] Eligibility may be modified by WPATH SOC v8 (2022), which removed the rigid 12-month duration thresholds in favor of an individualized readiness assessment.

Approach Selection​

The scrotal approach is used for gender-affirming orchiectomy — distinct from the inguinal approach used for oncologic indications.[1]

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 132-patient series of bilateral simple orchiectomies under SCAB alone reported a completely 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 + 0.25% bupivacaine, mean ~20 mL per case.[7]
  • Mean operative time (excluding anesthesia): 33–37 minutes.[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; the cord stump is allowed to retract into the scrotum.[1][6]
  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 91-case series, 96% of patients were satisfied with the cosmetic result and 85% preferred epididymal-sparing orchiectomy over medical castration.[6]

Tissue Preservation for Future Vaginoplasty​

Scrotal-skin preservation at the time of orchiectomy is the most consequential 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][10]

  • In a 235-patient PIV cohort, prior orchiectomy was associated with 3× greater odds of needing extragenital skin grafts because of reduced scrotal-skin availability — a critical preoperative counseling point.[11]
  • Scrotal skin length > 10 cm was protective against need for additional graft, while stretched penile length < 10 cm independently predicted graft requirement.[11]
  • Length of time on gender-affirming hormones did not predict scrotal-skin availability (p = 0.8) — the relationship is anatomic, not hormonal.[11]
  • Preoperative scrotal / perineal electrolysis should be discussed if future vaginoplasty is planned — hair-bearing skin in the neovagina is a known and difficult-to-revise complication.[3]
  • Incision design should minimize scrotal-skin loss: a small midline raphe incision is preferred, and excess scrotal skin is never excised at orchiectomy in patients who may pursue vaginoplasty.[1]

Outcomes and Safety​

DomainData
Overall complication rate3.7% in NSQIP 2010–2020 (n = 246 transgender orchiectomies); not significantly different from cisgender non-oncologic orchiectomy[12]
SettingSafely performed as outpatient across medically diverse patients[12]
Volume trendTransgender orchiectomy cases in NSQIP increased ~9.5 cases/year from 2015–2020[12]
Operative time33–37 minutes (excluding anesthesia)[7][6]
Anesthesia satisfaction (SCAB)77% completely painless, 92% highly satisfactory (n = 132)[7]

Fertility Considerations​

Bilateral orchiectomy is irreversible with permanent loss of fertility. Fertility-preservation counseling is recommended but underutilized.[13]

  • In one cohort, 22% of patients reported reproductive options were never discussed prior to surgical consultation.
  • Despite prolonged hormone therapy, 40% of orchiectomy specimens still showed some level of spermatogenesis.
  • Reasons patients declined fertility preservation: lack of interest in biological children (74%), unwillingness to delay transition (47%), and cost (36%).[13]

Pathology​

Most specimens show effects of exogenous estrogen therapy:[14]

  • Aspermatogenesis 71%; hypospermatogenesis 18%
  • Markedly reduced or absent Leydig cells in 85%
  • Nuclear cytomegaly can mimic germ-cell neoplasia in situ (GCNIS) but is typically OCT4-negative — an important diagnostic pitfall for pathologists[14]

A grossing protocol of two sections including rete testis / epididymis plus a cord-margin section is sufficient to identify relevant pathology in this population.[14]

Postoperative Care and Hormonal Management​

  • Ice and scrotal support for 24–48 hours
  • Activity restriction ~1–2 weeks
  • Wound check at 1–2 weeks
  • Antiandrogen therapy (e.g., spironolactone) can typically be discontinued or markedly reduced after orchiectomy.[15]
  • Estrogen therapy is continued to prevent hypogonadal complications including osteoporosis; ongoing endocrine monitoring of bone health and metabolic parameters remains important given absent gonadal hormone production.[15]
  • Specimens are sent for histopathology with the Cornejo grossing protocol.[14]

Key Principles​

  • Bilateral simple orchiectomy is a low-risk outpatient procedure (3.7% NSQIP complication rate) and can be performed by general urologists, general surgeons, or urogynecologists.[12][4]
  • The scrotal approach is standard; the midline raphe incision is preferred when future vaginoplasty is contemplated.[1]
  • Scrotal-skin preservation is the most consequential technical decision — prior orchiectomy triples the odds of needing extragenital skin grafts at later vaginoplasty.[11]
  • SCAB-only anesthesia is feasible and well tolerated (77% completely painless).[7]
  • Procedure is irreversible; fertility-preservation counseling is mandatory and currently underdelivered.[13]
  • Antiandrogens can be stopped; estrogen continues with standard endocrine surveillance.[15]
  • Histopathology requires awareness of estrogen-driven changes that can mimic GCNIS — OCT4 staining distinguishes them.[14]

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.

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. National Comprehensive Cancer Network. Testicular Cancer (NCCN Guidelines). Updated 2025-10-15.

11. 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.

12. 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.

13. 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.

14. 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.

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