Surgical: Rosenmerkel
performed the first orchiopexy in 1820. Orchiopexy nowadays is a frequently
performed operation done on outpatient basis and sometimes under local
anesthesia (1,5,18). Several different techniques have been described
for different clinical situations (2,15). They are:
-Simple
Dartos pouch technique: is usually performed for testes in the
superficial inguinal pouch. In this technique, the gubernaculum is
divided and the testis is dissected from its retroperitoneal attachments
and brought down to the scrotum where it is placed in a pouch created
between the scrotal skin and Dartos facsia.
-Multistage
technique: is similar to the simple technique but requires at
least two operative interventions separated by six months. It is performed
in cases where the length of the testicular vessels or cord is not
enough.
-Fowler
Stephens technique: performed for high undescended and abdominal
testes. It requires the division of the main testicular pedicle and
reliance on the collateral circulation from the vasal and cremasteric
vessels. Because of a significant rate of atrophy associated with
this technique, a variation was developed, which is a two stage procedure
with initial complete ligation or laparoscopic clipping of the testicular
pedicle and subsequent scrotal transfer after six months.
-Microvascular
technique: immediately returns a full blood supply to the testis
by anastomosis of the main testicular vessels to the inferior epigastric
vessels. This procedure, if carried by an experienced surgeon, is
associated with a 92% testicular survival rate and growth at puberty.
-Refluo
technique: came following the observation that testicular loss
following Fowler-Stephens approach was largely due to testicular congestion
from inadequate venous drainage through the vasal collaterals. The
Refluo technique relies on the arterial inflow from the vasal vessels,
but provides venous drainage by microvascular anastomosis of the testicular
veins to the inferior epigastric veins. This technique has acceptable
testicular survival rates and limited spermatogenic injury.
The
success rates of orchiopexy as reported by Docimo in a meta analysis
are: 74% for abdominal testes, 82% for testes |
palpated at the internal
inguinal ring, 87% for testes located in the inguinal canal and
92% for testes located distal to the external inguinal ring (18).
The parents should be reassured that the outlook for fertility in
unilateral undescended testes is approximately the same as normal.
In bilaterally undescended testes that are in the superficial inguinal
pouch, outlook for fertility is normal after orchiopexy. It is when
both testes are impalpable that the subject of fertility should
be approached cautiously. In bilateral maldescent, there is at least
a 10% chance that the testes are agenic or dysgenic (5).
For
the nonpalpable testes, surgery is both diagnostic and therapeutic.
Here, there are two approaches: the laparoscopic approach and the
open inguinal approach. In the open inguinal approach, the groin
is explored. If cord structures or testicular remnants are found,
they are removed and the procedure is terminated. If the groin exploration
is negative the incision is extended to enter the peritoneum and
search for an intraabdominal testicle. If found, orchidopexy is
done, utilizing any of the above mentioned techniques. In the laparoscopic
approach, the inguinal rings are examined and the status of the
processus vaginalis is assessed . The presence of blind ending spermatic
vessels confirms an absent testis and the procedure is terminated.
If vessels are seen exiting the internal ring, then open groin exploration
is carried out. If the testis is identified intraabdominally, orchiopexy
is done (10,11,18).
For
retractile testes, there is overwhelming evidence that as they enlarge
to a normal size they will come into the scrotum at puberty and
function normallly. Therefore, surgical intervention is not indicated.
For
ascending testes, it is controversial whether or not surgery is
required. Many surgeons, however, will elect to operate once these
testes become completely out of the scrotum.
Complications
of orchiopexy are hematoma, wound sepsis, testicular atrophy, failure
of the testes to reach the scrotum, retraction of the testes out
of the scrotum and occlusion of the vas deferens (1,15).
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