Undescended Testes/Orchiopexy James C.Y. Dunn, MD, PhD, 1 Akemi L. Kawaguchi, MD, 2 and Eric W. Fonkalsrud, MD 1 Surgical management of the undescended testis is performed to prevent the potential complications of cryptorchidism. When feasible, surgical correction should be performed at 1 to 2 years of age because later repair commonly results in increasingly more severe impairment of seminiferous tubular development and reduced spermatogenesis. Although orchiopexy increases the potential for fertility, it does not restore the spermatogenesis to normal levels and does not abolish the increased risk of developing testicular cancer. 1 Orchiopexy, however, does allow for earlier detection of neoplasms by From the 1 Department of Pediatric Surgery, UCLA School of Medicine, Los Angeles, CA; and 2 Department of Surgery, Massachusetts General Hospital, Boston, MA. Address reprint requests to Eric W. Fonkalsrud, MD, Professor, Department of Surgery, Emeritus Chief of Pediatric Surgery, UCLA School of Medicine, 10833 Le Conte Avenue, Room 72-126, Los Angeles, CA 90095. 2005 Elsevier Inc. All rights reserved. 1524-153X/04/0604-0005$30.00/0 doi:10.1053/j.optechgensurg.2004.10.005 self-examination of the testicles. Other problems associated with cryptorchidism include inguinal hernia and, occasionally, testicular torsion. The success of treatment depends on the position of the testis at diagnosis with much better results being achieved with testes located in the low inguinal canal. Laparoscopic approaches to diagnosis and repair may hold the promise of improved outcomes for high positioned testes. 2,3 The most significant complication of orchiopexy is testicular atrophy. Injury to the spermatic vessels, or extensive downward traction during repair, can cause postoperative venous congestion or ischemia with resultant testicular atrophy. Although this is a rare complication of routine orchiopexy, published reports indicate an 8% failure rate of orchiopexy, even in the distally situated undescended testis, and failure of more than 25% for intraabdominal testes. Other infrequent complications include ascent of the testis requiring a second orchiopexy, infection, and bleeding. Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 269-280 269
270 Dunn et al INGUINAL ORCHIOPEXY: SURGICAL TECHNIQUE 1 For undescended testes that are palpable, orchiopexy is performed through an inguinal incision slightly longer than that used for inguinal herniorrhaphy. Because the length of the spermatic vessels is shorter than normal, the descent of the testis is limited. The objective of the repair is to change the course of the spermatic vessels such that they extend from their origin near the renal vascular pedicle to the scrotum, instead of the triangular course through the internal inguinal ring and the inguinal canal.
Undescended Testes/Orchiopexy 271 2 With the patient lying in the supine position, an oblique skin incision is made through the lowermost abdominal skin crease over the inguinal ligament.
272 Dunn et al 3 The undescended testis is usually positioned at or near the external ring and may extend through the ring into the superficial inguinal pouch. The external oblique fascia is exposed and incised from the external ring along the direction of the fibers to the internal ring. The testis and its tunica vaginalis are mobilized from the gubernaculum and attachments to the pubis up to the internal inguinal ring.
Undescended Testes/Orchiopexy 273 4 The cremaster muscle is dissected from the spermatic vessels and the vas deferens is mobilized to the level of the internal ring. The internal oblique is divided just lateral to the internal ring, and the transversalis fascia is opened widely to expose the retroperitoneum. The inferior epigastric vessels are ligated and divided. The accompanying indirect inguinal hernia sac is separated from the spermatic vessels and the vas. This maneuver may be facilitated by injecting a small amount of saline through a 26-gauge needle between the hernia sac and the cord structures.
274 Dunn et al 5 A high ligation of the sac is performed with a transfixion suture. The testicle and epididymis are carefully examined for any abnormalities. The remaining tunica is closed loosely over the testis. The mobilization is continued into the retroperitoneal space by elevating the peritoneum using blunt dissection. The lateral spermatic fascia is divided, and the spermatic vessels are mobilized up near their origin high in the retroperitoneal space.
Undescended Testes/Orchiopexy 275 6 The scrotum is stretched by inserting a blunt clamp, and then a finger through the wound into the lowest portion of the scrotum. A small incision is made through a scrotal skin crease in the most dependent position, and a space between the dartos muscle and the scrotal skin is developed to accommodate the testis. An opening is then made in the dartos layer to allow the passage of the untwisted spermatic cord and testis into the newly created space. The upper edge of the tunica is anchored to the dartos fascia in a circumferential manner with interrupted nonabsorbable sutures to minimize the risk of retraction or torsion. The scrotal skin is closed with fine absorbable sutures. The transversalis fascia is closed, leaving a small opening adjacent to the pubis to serve as both the internal and external inguinal rings, and to allow the passage of the spermatic cord. The internal and external oblique muscles are re-approximated in layers in the same manner as used for inguinal herniorrhaphy.
276 Dunn et al LAPAROSCOPIC ORCHIOPEXY: SURGICAL TECHNIQUE 7 For a nonpalpable testis, laparoscopy is useful for both diagnosis and treatment. Laparoscopy can be utilized to locate the testis as well as to facilitate orchiopexy or ligation of vessels. If the nonpalpable testis is not located in the abdomen, it is likely that the testis has vanished secondary to prenatal torsion. With the patient lying in the supine position, an umbilical port is inserted to allow insufflation of the abdomen. The testis is usually found within 1 cm of the internal ring. If the testis is absent and the vas and vessels approach the internal ring, then the testis has atrophied. If neither the vas nor vessels are seen, then additional ports should be placed to locate the testis higher up in the abdomen. If the testis is deemed too high to be brought down in a single stage procedure, then the spermatic vessels may be ligated to allow for neovascularization of the testis in the next 6 months in preparation for the second stage of a Fowler-Stephens orchiopexy. After locating the testis with the laparoscope, two additional ports are placed at the level of the umbilicus along the mid-clavicular line.
Undescended Testes/Orchiopexy 277 8 The gubernacular attachment is grasped and transected to begin mobilization of the testis. The dissection is carried medially to the bladder, incising the peritoneum well above the vas, and laterally the peritoneum is incised along the pelvic wall along the spermatic vessels.
278 Dunn et al 9 This peritoneal release provides additional length for the testis to reach the scrotum and leaves a broad strip of peritoneum in case the division of spermatic vessels is needed. An incision is then made in the scrotum to develop a space over the dartos muscles. A scrotal port that goes from the dartos pouch to the abdominal wall near the pubic tubercle, medial to the median umbilical ligament, is used to bring the mobilized testis down to the scrotum.
Undescended Testes/Orchiopexy 279 10 The internal ring is usually small and will close spontaneously. The testis is anchored to the dartos fascia with interrupted sutures circumferentially. The scrotal skin is approximated with fine sutures.
280 Dunn et al REFERENCES 1. Jordan GH, Winslow BH: Laparoscopic single stage and staged orchiopexy. J Urol 152:1249-1252, 1994 2. Hadziselimovic F: Cryptorchism, its impact on male fertility. Eur Urol 41:121-123, 2002 3. Holcomb GW III: Diagnostic laparoscopy for contralateral patent processus vaginalis and nonpalpable testes. Semin Pediatr Surg 7:232-238, 1998