ORCHIOPEXY ORCHIDOPEXY UNDESCENDED TESTICLE
Category: Pediatric Surgery
Abstract :
Orchiopexy Definition : Orchiopexy is a procedure in which a surgeon fastens an undescended testicle inside the scrotum, usually with absorbable sutures. It is done most often in male infants or very young children to correct cryptorchidism, which is the medical term for undescended testicles. Orchiopexy is also occasionally performed in adolescents or adults, and may involve one or both testi
Orchiopexy
Definition : Orchiopexy is a procedure in which a surgeon fastens an undescended testicle inside the scrotum, usually with absorbable sutures. It is done most often in male infants or very young children to correct cryptorchidism, which is the medical term for undescended testicles. Orchiopexy is also occasionally performed in adolescents or adults, and may involve one or both testicles.
In adults, orchiopexy is most often done to treat testicular torsion, which is a urologic emergency resulting from the testicle’s twisting around the spermatic cord and losing its blood supply.
Other names for orchiopexy include orchidopexy, inguinal orchiopexy, repair of undescended testicle, cryptorchidism repair, and testicular torsion repair.
Purpose
To understand the reasons for performing an orchiopexy in children, it is helpful to have an outline of the normal pattern of development of the testes in a male infant. The gubernaculum is an embryonic cordlike ligament that attaches the testes within the inguinal (groin) region of a male fetus up through the seventh month of pregnancy. Between the 28th and the 35th week of pregnancy, the gubernaculum migrates into the scrotum and creates space for the testes to descend.
In normal development, the testes have followed the gubernaculum downward into the scrotum by the time the baby is born. The normal pattern may be interrupted by several possible factors, including inadequate androgen (male sex hormone) secretion, structural abnormalities in the boy’s genitals, and defective nerves in the genital region.
Orchiopexy is performed in children for several reasons:
• To minimize the risk of infertility. Adult males with cryptorchidism typically have lower sperm counts and produce sperm of poorer quality than men with normal testicles. The risk of infertility rises with increasing age at the time of orchiopexy and whether both testicles are affected. Men with one undescended testicle have a 40% chance of being infertile; this figure rises to 70% in men with bilateral cryptorchidism.
• To lower the risk of testicular cancer. The incidence of malignant tumors in undescended testes has been estimated to be 48 times the incidence in normal testes. Men with cryptorchidism have a 10% chance of eventually developing testicular cancer.
• To lower the risk of traumatic injury to the testicle. Undescended testicles that remain in the patient’s groin area are vulnerable to sports injuries and pressure from car seat belts.
• To prevent the development of an inguinal hernia. An inguinal hernia is a disorder that occurs when a portion of the contents of the abdomen pushes through an abnormal opening in the abdominal wall. It is likely to occur in a male infant with cryptorchidism because a sac known as the processus vaginalis, which connects the scrotum and the abdominal cavity, remains open after birth. In normal development, the processus vaginalis closes shortly after the testes descend into the scrotum. If the sac remains open, a section of the child’s intestine can extend into the sac. It may become trapped (incarcerated) in the sac, forming what is called a strangulated hernia. The portion of the intestine that is trapped in the sac may die, which is a medical emergency.
• To prevent testicular torsion in adolescence.
• To maintain the appearance of a normal scrotum. Orchiopexy is considered a necessary procedure for psychological reasons, as boys with only one visible testicle are frequently subjected to teasing and ridicule after they start school.
The primary reason for performing an orchiopexy in an adolescent or adult male is treatment of testicular torsion, rather than cryptorchidism. Testicles that have not descended by the time a boy reaches puberty are usually removed by a complete orchiectomy.
Demographics
Cryptorchidism
Cryptorchidism is the most common abnormality of the male genital tract, affecting 3–5% of full-term male infants and 30–32% of premature male infants. In most cases, the condition resolves during the first few months after delivery; only 0.8% of infants over three months of age still have undescended testicles. Because of the potentially serious consequences of cryptorchidism, however, doctors do not advise watchful waiting once the child is over six months old. Undescended testicles rarely come down into the scrotum of their own accord after that age.
Cryptorchidism is a frequent occurrence in prune belly syndrome (PBS) and a few other genetic disorders characterized by structural abnormalities of the genitourinary tract.
No variation in the incidence of cryptorchidism among different racial and ethnic groups has been reported.
Testicular torsion
Most American males suffering from testicular torsion are below age 30, with the majority between the ages of 12 and 18. The peak ages for an acute episode of testicular torsion are the first year of life and age 14. Testicular torsion occurs on the left side of the body slightly more often than on the right side, about 52% versus 48% of cases.
Description
Cryptorchidism
Some orchiopexies in children are relatively simple procedures; however, others are complicated by the location of the undescended testicle. In general, an orchiopexy for an undescended testicle that lies in front of the scrotum or just above it is a less complicated operation than one done to treat a non-palpable testicle. The procedure is usually done under general anesthesia.
If the undescended testis is in the groin area, the surgeon will make a small incision in the groin and a second small incision in the scrotum. The testis is moved downward from the groin without complete separation from the gubernaculum. It is then placed inside a small pouch created by the surgeon between the skin of the scrotum and a layer of muscle in the scrotum called the dartos muscle. The testicle is held in place with sutures that are eventually absorbed by the body.
The Fowler-Stephens technique is often used when the undescended testicle is located high above the scrotum or in the abdomen. It may be done in two stages scheduled several months apart. In the first stage, the surgeon moves the testicle downward and attaches it temporarily to the inside of the thigh. In the second stage, the testicle is transferred into the scrotum itself and sutured into place.
A third type of orchiopexy is called testicular autotransplantation. The surgeon removes the undescended testicle completely from its present location and re-implants it in the scrotum by reattaching its surrounding tissues and blood vessels to nearby blood vessels. This technique minimizes the risk of an inadequate blood supply to the re-implanted testicle.
Testicular torsion
An orchiopexy done to treat testicular torsion is usually done under general or epidural anesthesia. The surgeon makes an incision in the patient’s scrotum and untwists the spermatic cord. The affected testicle is inspected for signs of necrosis, or tissue death. If too much tissue has died due to loss of blood supply, the surgeon will remove the entire testicle. If the tissue appears to be healthy, the surgeon sutures the testicle to the wall of the scrotum and then closes the incision. In most cases, the surgeon will also attach the unaffected testicle to the scrotal wall as a preventive measure.
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