Radical Orchiectomy (Testicular Cancer)
5453054520wRVU: 5.17 — Simple orchiectomy (including subcapsular; with or without prosthesis; scrotal or inguinal) — alternative primary for benign/hormonal indications (5.17 wRVU, 90-day global); use 54520-50 for bilateral54535wRVU: 12.86 — Radical orchiectomy with abdominal exploration — alternative primary for intra-abdominal/cryptorchid testis with tumor (12.86 wRVU, 90-day global); NOT an RPLND code54522wRVU: 9.99 — Orchiectomy, partial (testis-sparing) — for focal testicular lesion with intraoperative frozen section (9.99 wRVU, 90-day global); use for solitary testis or bilateral synchronous tumor54660wRVU: 5.6 — Insertion of testicular prosthesis (separate procedure) (5.60 wRVU, 90-day global); bundled into 54520; typically bundled with 54530 at same session — staged placement is cleanest separate-billing scenario
Right [left] testicular mass, [seminoma / non-seminomatous germ cell tumor / indeterminate], suspicious on ultrasound; [elevated AFP / beta-hCG / LDH / normal markers]
Same
Right [left] radical inguinal orchiectomy [with testicular prosthesis placement]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal [/ spinal]
The patient is a [age]-year-old male with a right [left] testicular mass, [X] cm, on scrotal ultrasound with [hypoechoic / heterogeneous] characteristics. Tumor markers: AFP [X], beta-hCG [X], LDH [X]. CT abdomen/pelvis demonstrated [no retroperitoneal adenopathy / [X]-cm retroperitoneal adenopathy]. Radical orchiectomy via an inguinal approach (no scrotal incision — preserves paraaortic lymphatic drainage) was planned for diagnosis and treatment. Risks including bleeding, infection, altered scrotal sensation (ilioinguinal nerve injury), retroperitoneal spread (if scrotal violation), and need for prosthesis discussed. Consent obtained.
A [X]-cm [firm / heterogeneous] mass was identified within the testis. The testis was delivered en bloc within its intact tunica vaginalis through the inguinal incision — the tunica vaginalis was NOT opened in the operative field. The spermatic cord was ligated at the internal inguinal ring. The specimen (testis + intact tunica vaginalis + cord) was excised en bloc and sent to pathology with the proximal cord margin marked. Intraoperative frozen section was [not performed / performed, confirming malignant germ cell tumor / benign].
The patient was positioned supine. The right [left] inguinal region was prepped and draped. A [5]-cm oblique inguinal incision was made in the right [left] inguinal crease. The external oblique aponeurosis was incised along its fibers to the external inguinal ring. The ilioinguinal nerve was identified and preserved.
The spermatic cord was identified at the external inguinal ring. A doubled Penrose drain was passed around the cord and clamped snugly just below the internal inguinal ring to serve as a vascular tourniquet, preventing hematogenous tumor dissemination during subsequent testicular manipulation. The cord was mobilized proximally to the internal inguinal ring with the tourniquet in place.
The testis was delivered through the inguinal incision by gentle traction on the cord. The gubernaculum was divided. The testis was delivered into the operative field entirely within its intact tunica vaginalis — the tunica vaginalis was NOT opened in the field (en bloc delivery preserves oncologic margins and prevents tumor spillage). [Intraoperative frozen section was sent / not sent given obvious malignancy on imaging and tumor markers.]
The Penrose tourniquet was maintained until the cord was ready for ligation. The spermatic cord was skeletonized at the internal inguinal ring. The vas deferens was ligated separately with [2-0 non-absorbable suture (Prolene)]. The testicular vessels were doubly ligated with [0 non-absorbable suture (Prolene)] and divided between clamps at the level of the internal inguinal ring, securing a maximum proximal cord margin. The Penrose tourniquet was released and removed.
The specimen (testis, intact tunica vaginalis, and spermatic cord) was excised en bloc. The proximal cord margin was marked with [a suture / ink] and sent to pathology for frozen and permanent section.
[Testicular prosthesis: A [medium / large] saline-filled silicone testicular prosthesis was inserted into the scrotum through the inguinal wound, positioned in the dependent scrotum, and secured to the dartos muscle with [3-0 Vicryl]. Patient requested prosthesis placement and consent was obtained separately.]
The external oblique aponeurosis was closed with [2-0 Vicryl]. Skin was closed with [3-0 Monocryl].
None
Right [left] testis and spermatic cord: sent to pathology en bloc (tunica vaginalis intact), proximal cord margin marked with suture
Minimal
None
The patient was taken to the PACU in stable condition. Scrotal support was applied. Tumor markers (AFP, beta-hCG, LDH) to be repeated at [5-7 days] post-operatively for half-life assessment to guide staging and adjuvant therapy planning.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left testicular mass, *** suspicious for GCT
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left radical inguinal orchiectomy [+ prosthesis]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/spinal
INDICATIONS: .PTAGE-year-old male with *** cm testicular mass on US. AFP ***, hCG ***, LDH ***. CT: ***. Inguinal approach (no scrotal incision — preserves paraaortic lymphatics). Consent obtained.
FINDINGS: *** cm testicular mass. Testis delivered en bloc within intact tunica vaginalis — tunica NOT opened in field. Cord ligated at internal ring. Proximal cord margin marked and sent to pathology.
PROCEDURE:
Supine. Inguinal incision *** cm. External oblique incised to external ring. Ilioinguinal nerve identified and preserved. Cord encircled with doubled Penrose at internal ring — tourniquet applied before testis manipulation. Cord mobilized to internal ring. Testis delivered en bloc in intact tunica vaginalis. Gubernaculum divided. [Frozen section: ***.] Cord skeletonized at internal ring; vas ligated 2-0 Prolene; testicular vessels doubly ligated 0 Prolene and divided. Penrose tourniquet released. Specimen (testis + tunica + cord) excised en bloc; proximal cord margin marked with suture. [Prosthesis *** placed, secured to dartos.] External oblique 2-0 Vicryl. Skin 3-0 Monocryl.
EBL: Minimal
SPECIMENS: Testis + intact tunica vaginalis + cord to pathology; proximal cord margin marked
COMPLICATIONS: None
DISPOSITION: PACU. Scrotal support. Tumor markers + pathology at 5-7 days post-op.
Signed: .ME, .MYDEGREE
.TODAYVariants
Bilateral simple orchiectomy for androgen deprivation (CPT 54520-50)
Androgen deprivation for metastatic prostate cancer. Subcapsular technique: scrotal incision, tunica albuginea incised, seminiferous tubule contents expressed/removed, tunica albuginea closed or left open, epididymis and tunica left in situ for cosmesis. CPT 54520 with modifier -50 (bilateral) — not 54522. Bilateral subcapsular orchiectomy achieves castrate testosterone (<50 ng/dL) equivalent to LHRH agonist with no ongoing drug cost. Document bilateral technique and confirm castrate intent in indications.
Partial / testis-sparing orchiectomy (CPT 54522)
Indications: solitary testis, bilateral synchronous tumors, small lesion with normal markers and inconclusive ultrasound. CPT 54522 (9.99 wRVU). Inguinal approach — identical setup to radical orchiectomy. The tunica vaginalis is opened and the testicular lesion is excised with a margin of normal parenchyma. Intraoperative frozen section is mandatory — if malignant and the patient accepts the risk, convert to radical orchiectomy (54530). If benign, close the tunica over the remaining parenchyma. Document the decision to spare vs. convert, frozen results, and margin status.
Simple orchiectomy for trauma or torsion (CPT 54520)
Nonviable testis after trauma or failed torsion detorsion. Scrotal approach acceptable (no oncologic concern — scrotal incision does not affect lymphatics when the indication is benign). CPT 54520 (5.17 wRVU). Document preoperative Doppler absence of blood flow (torsion) or traumatic devascularization. Document the decision-point: detorsion was attempted / trauma was not compatible with viability. If prosthesis is placed at the same session it is included in 54520 (descriptor says 'with or without testicular prosthesis').
Charting Tips
- Document inguinal approach explicitly and confirm no scrotal violation. Transcrotal orchiectomy changes lymphatic drainage from paraaortic to inguinal nodes, potentially upstaging the patient and altering surveillance/adjuvant treatment. Document: 'radical inguinal orchiectomy performed; no scrotal incision was made.' If prior scrotal surgery exists, document it and note that inguinal surveillance may be needed.
- Document that the Penrose cord tourniquet was applied at the internal ring BEFORE testicular delivery and manipulation. This prevents hematogenous tumor dissemination. Document: 'a doubled Penrose drain was applied as a vascular tourniquet at the internal inguinal ring prior to testicular delivery.'
- Document en bloc delivery with intact tunica vaginalis. The testis must be delivered without opening the tunica vaginalis in the operative field. Opening the tunica in the field is the technique for testis-sparing surgery (54522) and is not appropriate for radical orchiectomy. Document: 'the testis was delivered en bloc within its intact tunica vaginalis — the tunica vaginalis was not opened in the operative field.'
- Document cord ligation at the internal inguinal ring and suture type. Non-absorbable synthetic suture (Prolene) is standard — not silk, which loses tensile strength over time and risks ligature slippage. Document: 'spermatic cord ligated at the level of the internal inguinal ring with non-absorbable suture; proximal cord margin marked and sent to pathology.'
Billing Tips
- 54530 (radical orchiectomy, inguinal approach, for tumor, 8.25 wRVU, 90-day global) is the standard code for testicular cancer. It covers inguinal approach with en bloc removal of the testis, tunica vaginalis, and spermatic cord to the internal inguinal ring.
- 54520 (orchiectomy, simple, including subcapsular, with or without testicular prosthesis, scrotal or inguinal approach, 5.17 wRVU, 90-day global) is for non-oncologic orchiectomy — trauma with nonviable testis, torsion with nonviable testis, or simple orchiectomy for androgen deprivation. Never use 54520 for testicular cancer (lymphatic drainage implications; see documentation tip).
- 54535 (orchiectomy, radical, with abdominal exploration, 12.86 wRVU, 90-day global) covers an inguinal radical orchiectomy that requires extension into the abdominal cavity to explore for gross disease — for example, an intra-abdominal or cryptorchid testis with tumor requiring abdominal exploration. It does NOT represent retroperitoneal lymph node dissection (RPLND). Formal RPLND is a distinct operation billed as CPT 38780 (17.26 wRVU, 90-day global) and is almost never performed at the same session as initial orchiectomy in modern practice (staging is completed first).
- 54522 (orchiectomy, partial, 9.99 wRVU, 90-day global) is for testis-sparing (partial) orchiectomy — excision of a focal testicular lesion with preservation of the remaining testis and intraoperative frozen section. Indications include solitary testis, bilateral synchronous tumors, small lesion with negative or normal tumor markers. It is NOT a bilateral orchiectomy code.
- Bilateral simple orchiectomy for androgen deprivation (prostate cancer): bill 54520 with modifier -50 (bilateral). There is no separate CPT code for bilateral orchiectomy — bilateral is conveyed by modifier -50 applied to 54520. Verify bilateral modifier rules with specific payer (some require two line items with -RT/-LT instead of one line with -50).
- Testicular prosthesis (54660, 5.60 wRVU, 90-day global): CPT 54520's full descriptor includes 'with or without testicular prosthesis,' meaning prosthesis placement is bundled into 54520 and cannot be separately billed when performed at the same session. For 54530 (radical), 54660 is a '(separate procedure)' code and is typically considered bundled when performed through the same incision at the same session. Staged prosthesis insertion (delayed, separate session) is the most defensible separately billable scenario. Document patient request and consent regardless; confirm with payer before billing 54660 concurrently.
- Global period is 90 days. Tumor marker surveillance (AFP, beta-hCG, LDH) and post-op imaging are not bundled — they generate separate laboratory and radiology billing. Recurrence requiring reoperation within 90 days uses modifier -78.
General coding reference. Verify with your institution’s billing department before submitting claims.