Cryptorchidism:

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.

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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 cord-like 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 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

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 auto-transplantation. 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.

Diagnosis/Preparation

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.

Aftercare

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.

Risks

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

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.

Morbidity and mortality rates

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

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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