Background Orchidectomy is the most cost-effective means of hormonal therapy for patients with locally advanced and metastatic prostate cancer (PCa). Bilateral simple orchidectomy (BSO) has been linked to negative psychometric deficits from the empty scrotum left behind. It is important that the pursuit of cost-effectiveness moves in tandem with the health-related quality of life (HRQoL). Aims This study aimed to compare the therapeutic efficacy of BSO with endogenous pseudotesticular techniques of bilateral subcapsular orchidectomy (BSCO) and bilateral-epididymal-sparing orchidectomy (BESO); and to determine which technique patients preferred. Research design It was a randomized experimental study. Consenting patients with locally advanced and metastatic PCa were distributed randomly into three surgical arms: one without pseudotesticles, BSO; and two with endogenous pseudotesticles, BSCO and BESO. Sociodemographic, disease-related and HRQoL questionnaires were administered before and three months after the orchidectomies. Serial serum testosterone and PSA measurements were taken. The pseudotesticular volumes and patient satisfaction were evaluated 3 months after the orchidectomy. Data analysis With the Statistical Package for Social Sciences Version 20 and STATA version 12, differences in clinical and biochemical parameters, pre- and post-operative testicular volumes, cosmetic appeal and HRQoL were compared between the three groups. Relevant tests of association were used. The level of statistical significance, p, used was ≤ 0.05. Result Sixty three patients were recruited (24 BSO, 21 BSCO, 18 BESO) with a median age of 71.5 years. They were predominantly low income earners. There was no significant difference between the PSA and testosterone nadirs achieved in the three respective groups over the three month follow-up period [11.3, 12.6, 15.2ng/ml (p=0.667) and 0.44, 0.64, 0.79 nmol/l (p=0.603) respectively]. The cost implication of performing each technique was similar (in terms of suture used, operating time, need for cautery or post-operative complications). Those in the BSCO arm had the highest HRQoL, sexual function and pseudotesticular volumes. The percentage satisfaction scores of patients in the three groups were 77.9 ± 22.8, 81 ± 13.9 and 81.9 ±22.5 respectively (p=0.858). Although the cosmetic appeal was similar between groups, those with pseudotesticles experienced a lower sense of emasculation (p=0.010). Conclusion The three techniques of orchidectomy resulted in similar declines in serum PSA and testosterone levels, cost implications and cosmetic appeal among patients with advanced PCa. Pseudotesticles significantly reduced the sense of emasculation experienced by the patients. BSCO produced the largest pseudotesticular volumes and the best post-operative HRQoL and sexual function. Principal exposure Type of orchidectomy Outcome variables Aesthetic scrotal appearance; Sense of emasculation; HRQoL; PSA response; Serum testosterone declines Word count: 399