I am curious about Kimmel and his apparent problems with some patients. It appears to me that surgery in the scrotal area is fraught with problems even in the best of circumstances. If it was done by your local guy you would be back in his office for a checkup at the first sign of trouble. In most of his patient cases they will have returned home and that support is not available. Going to your local urologist is almost automatically going to attract a critical response because of the unusual nature of an elective orchiectomy.
Issues that I wonder about are:
1. The area is prone to infectious agents if not kept meticulously clean. It is adjacent to the anus and the penis can aslo be a source. Plus it is normally sweaty and damp. From the various reports here that I have seen, it doesn't seem that there is any unexpectedly high rate of nfection that would have resulted from improper practice.
2. The problems seem to be typically extended drainage, slow healing, and stiching failures.
I think extended drainage is to be expected in most scrotal orchiectomies. I noted at least one surgical proceedure text book description that referred to leaving a drain in place in the scrotum to allow drainage to escape freely essentially leaving the bottom of the scrotum open until the drainage had ceased. From my various experiments in small scrotal incisions they do not heal quickly and the healing process appears quite different to a small cut elsewhare in the body. May have to do with the moavements ofvarious tiny muscles that cause the scrotum to tighten and loosen. Similarly swelling can be expected and it doesn't surprise me that there will be problems with some of the stitching. If stitching is set too loosely the skin won't be closed up properly and wont heal quickly. If it is set too tightly obviously it will pull loose if swelling occurs.
3. Most orchiectomies these days are done through dual incisions into the inguinal canals above/alongside the penis. I think the reason is that it is then more or less conventional surgery and moves the incision well away from the areas of danger of infection and will avoid the swelling etc that is related to injuring the scrotum and associated. I think that this technique recovers the testicles without invilving the tunica vaginalis(internal pouches that cover each testicle. My guess is that it is damage to this structure that causes much of the problem. Anyone who has had abdominal surgery will know that the skin heals quicky and the stitches can be removed in a few days with out problem.
4. The inguinal approach also allows the cords to be tied off higher up avoiding problems some have had with adhesions and subsequent cord pain.
So I wonder how much of the problem is really Dr Kimmel's practices (clearly from some descriptions there are some issues related to his office and gear there) and how much is the nature of the scrotal orchiectomy beast in the first place. If anyone out there has any experience with a scrotal orchiectomy done in hospital conditions etc it would be interesting to hear how they fared in comparision. My gut feel is that even with the best castration techniques the scrotal approach is likely to have much the same array of problems no matter who does them.
Is there anyone out there who would do an elective inguinal orchiectomy??
