ORCHIOPEXY CRYPTORCHIDISM TESTICULAR TORSION
Category: Pediatric Surgery
Abstract :
Cryptorchidism The diagnosis of cryptorchidism is usually made when a pediatrician examines the newborn baby, although the condition can occur at any time before the boy reaches puberty. The first stage in diagnosis is an external physical examination of the child’s genitals. If either testicle does not appear to be in the scrotum, the doctor will palpate, or touch, the groin area and ab
Cryptorchidism
The diagnosis of cryptorchidism is usually made when a pediatrician examines the newborn baby, although the condition can occur at any time before the boy reaches puberty. The first stage in diagnosis is an external physical examination of the child’s genitals.
If either testicle does not appear to be in the scrotum, the doctor will palpate, or touch, the groin area and abdomen to determine whether a testicle can be felt in any of those locations. If the testicle can be felt, the doctor will decide on the basis of its location whether it is an undescended testicle, a so-called ectopic testicle, or a retractile testicle. An ectopic testicle is one that has developed in a location outside the normal path of development in the inguinal canal. Ectopic testicles are most often discovered along the inner part of the thigh near the groin, at the base of the penis, or below the scrotum in the perineum (the area between the scrotum and the rectum). A retractile testicle is one that is readily pulled back out of the scrotum by an overly sensitive reflex called the cremasteric reflex; it is not a genuinely undescended testicle. It is important for the doctor to distinguish a retractile testicle from genuine cryptorchidism because retractile testicles do not need surgical treatment. At this point in the diagnostic workup, a general pediatrician will often consult a specialist in pediatric urology.
In about 20% of male infants with cryptorchidism, the missing testicle cannot be felt at all. It is known as a non-palpable testicle. The child may be given a hormone challenge test to help determine whether the testicle is located in the abdomen or whether it has failed to develop fully. If the testosterone level in the blood rises in response to the test, the doctor knows that there is a testis present somewhere in the child’s body. In other cases, the testis has atrophied, or shriveled up due to an inadequate blood supply before birth. If neither testicle can be felt, the child should be examined further for evidence of inter-sexuality. The doctor may order an ultrasound to check for the presence of a uterus, particularly if the child’s external genitals are ambiguous in appearance.
Surgery is the next step in searching for a non-palpable testicle. The surgeon may perform either an open inguinal procedure or a laparoscopic approach. In an open inguinal exploration, the surgeon makes an incision in the child’s groin; if nothing is found, the incision may be extended into the lower abdomen. In a laparoscopic approach, the surgeon uses an instrument that looks like a small telescope with a light attached in order to see inside the groin or the abdominal cavity through a much smaller incision. If the surgeon is able to find the testicle, he or she may then proceed directly to perform an orchiopexy.
Testicular torsion
Testicular torsion is usually diagnosed in the emergency room. The doctor will usually suspect testicular torsion on the basis of sudden onset of severe pain on one side of the scrotum; it is unusual for pain to develop gradually in this disorder. The patient’s history often indicates recent hard physical work, vigorous exercise, or trauma to the genital area; however, testicular torsion can also occur without any apparent reason. Other symptoms may include swelling of the scrotum, blood in the semen, nausea and vomiting, pain in the abdomen, and fever. A few patients feel the need to urinate frequently. When the doctor examines the patient’s scrotum, the affected testicle is usually enlarged and is painful when the doctor touches it. It usually lies higher in the scrotum than the unaffected testicle and may be lying in a horizontal position. Since testicular torsion is a medical emergency, most doctors will not risk permanent damage to the testicle by taking the time to perform imaging studies. If the diagnosis is unclear, however, the doctor may order a radionuclide scan or a color Doppler ultrasound to determine whether the blood flow to the testicle has been cut off. The patient will be given a mild pain medication and referred to a urologist for surgery as soon as possible.
orchiopexy aftercare
Cryptorchidism
Aftercare in children depends partly on the complexity of the procedure. If the child has an uncomplicated orchiopexy, he can usually go home the same day. If the surgeon had to make an incision in the abdomen to find a non-palpable testicle before performing the orchiopexy, the child may remain in the hospital for two or three days. The doctor will usually prescribe a pain medication for the first few days after the procedure. After the child returns home, he should not bathe until the day after surgery. In addition, he should not ride a bicycle, climb trees, or do anything else that requires straddling for two or three weeks. An older boy should avoid sports or rough games that might result in injury to the genitals until he has a post-surgical checkup. Most surgeons will schedule the child for a checkup one or two weeks after the orchiopexy, with a second checkup three months later.
Testicular torsion
Aftercare is similar to that for orchiopexy in a child. The area around the incision should be washed very gently the next day and a clean dressing applied. Medication will be prescribed for postoperative pain. The patient is advised to rest at home for several days after surgery, to remain in bed as much as possible, to drink extra fluids, and to elevate the scrotum on a small pillow to ease the discomfort. Vigorous physical and sexual activity should be avoided until the pain and swelling go away.
orchiopexy risks
Cryptorchidism
The risks of orchiopexy in treating cryptorchidism include:
• infection of the incision
• bleeding
• damage to the blood vessels and other structures in the spermatic cord, leading to eventual loss of the testicle
• failure of the testicle to remain in the scrotum (This problem can be repaired by a second operation.)
• difficulty urinating for a few days after surgery
Testicular torsion
The risks of orchiopexy as a treatment for testicular torsion include:
• infection of the incision
• bleeding
• loss of blood circulation in the testicle leading to loss of the testicle
• reaction to anesthesia
orchiopexy Normal results
In a normal orchiopexy, the testicle remains in the scrotum without re-ascending. If the procedure has been successful, there is no damage to the blood vessels supplying the testicle, no loss of fertility, and no recurrence of torsion.
orchiopexy Morbidity and mortality rates
Cryptorchidism
Orchiopexy is most likely to be successful in children when the undescended testicle is relatively close to the scrotum. The rate of failure for orchiopexy performed as a treatment for cryptorchidism is 8% if the testicle lies just above the scrotum; 10–20% if the testicle is located in the inguinal canal; and 25% if the testicle lies within the abdomen.
Testicular torsion
The mortality rate for orchiopexy in adults is very low because almost all patients are young males in good health. The procedure has a 99% rate of success in saving the testicle when the diagnosis is made promptly and treated within six hours. After 12 hours, however, the rate of success in saving the testicle drops to 2%. The average rate of testicular atrophy following orchiopexy for testicular torsion is about 27%.
Alternatives
Cryptorchidism
Hormonal therapy using gonadotropins to stimulate the production of more testosterone is effective in some children in causing the testes to descend into the scrotum without surgery. This approach, however, is usually successful only with undescended testes that are already close to the scrotum; its rate of success ranges from 10–50%. Undescended testes that are located higher almost never respond to hormonal therapy. In addition, treatment with hormones has several undesirable side effects, including aggressive behavior. Some surgeons will, however, prescribe hormonal treatment before an orchiopexy in order to increase the size of the undescended testis and make it easier to identify during surgery.
Testicular torsion
Pain caused by testicular torsion can be relieved temporarily by manual detorsion. To perform this maneuver, the doctor stands at the patient’s feet and gently rotates the affected testicle toward the outside of the patient’s body in a sidewise direction. Manual detorsion is effective in relieving pain in 30–70% of patients; however, it is not considered an alternative to orchiopexy in preventing a recurrence of the torsion or loss of the testicle.
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