CHAPTER 53 Orchidopexy

INTRODUCTION

Undescended testis (UDT) is one of the commonest abnormalities in male infants. In preterm
infants, the incidence may be 20% or more, as the final stage of descent from the groin to the
scrotum normally occurs at about 25–35 weeks of gestation. About 4–5% of males have
undescended testes at birth, but more than half of these will continue to descend in the first 12
weeks postnatally. By 3 months post-term, the incidence of congenital cryptorchidism is 1–2%.

There is considerable controversy about whether the subsequent testicular dysfunction is primary
or secondary. Some authors have proposed that germ cell loss postnatally is secondary to a
primary defect of the hypothalamic-pituitary-gonadal axis. Alternatively, there is strong evidence
that postnatally high temperature interferes with normal testicular function leading to germ cell
depletion and risk of cancer in adulthood. Consensus is building that the crucial step in postnatal
germ cell maturation is transformation of neonatal gonocytes into type A spermatogonia in the
second 6 months after birth; hence the current recommendation for orchidopexy is at 6 months of
age. Prevention of germ-cell loss is the aim of surgery, although this remains unproven so far.

The testis fails to remain in the scrotum in a significant number of older boys. They appear to have
acquired cryptorchidism, which has been called ascending testis, gliding testis or pathologically
retractable testis. The abnormality is likely secondary to failure of the spermatic cord to elongate
in proportion to the boy himself (the spermatic cord length doubles from 5 cm to 8–10 cm in the
first 10 years after birth).

At surgery the major finding is a fibrous remnant of the obliterated processus vaginalis, linking
acquired UDT with inguinal hernia. Occasionally the processus is still patent as a latent hernia. The
indication for surgery in this acquired group is failure of the testis to remain in the scrotum
without traction.

Figure 53.1

The patient is placed supine, with legs slightly apart, under full general anaesthesia (day surgery).
Skin preparation includes from the umbilicus to below the scrotum. For congenital cryptorchidism
a standard inguinal operation is preferred. A transverse skin crease incision is made over the
inguinal canal (one finger breadth above pubic tubercle) from level with the tubercle to the mid
inguinal point.

The incision is deepened through fat to expose the white fibrous layer of the superficial fascia (of
Scarpa), which is opened formally (diathermy or scissors). The superficial inferior epigastric vein is
swept aside or coagulated and divided formally.

Beneath Scarpa’s fascia the external oblique muscle is distinguished by the oblique orientation of
its fibres. Square retractors under Scarpa’s fascia reveal the lower edge of the muscle and the
inguinal ligament: sweeping movements with the closed scissors are effective to reveal the
spermatic cord where it emerges from the external inguinal ring.

Figure 53.2
The inguinal canal is opened either with a scalpel incision in external oblique aponeurosis parallel
to the inguinal ligament, or by opening the external inguinal ring with scissors and slitting the
aponeurosis laterally. Small artery forceps on the edges of external oblique control them and allow
easy identification at the end of the procedure. The ilioinguinal nerve is identified on the surface
of the cremaster fascia and avoided.

Figure 53.3

The spermatic cord is separated from the external oblique aponeurosis and the cord and testis
(usually just outside the external ring) are mobilized out of the wound by blunt dissection. The
distal gubernacular attachment is divided carefully (diathermy or scissors), avoiding any long-
looping vas deferens. A small clamp on the gubernaculum or distal tunica vaginalis allows traction
on the spermatic cord. The spermatic cord is dissected by first isolating and stripping off with blunt
forceps any cremaster muscle fibres. Occasionally the cremasteric artery (deep to the cord) needs
diathermy.

Figure 53.4

The remnant of the processus vaginalis is usually obvious in cryptorchidism as a shiny white,
translucent inelastic layer covering the vas deferens and testicular vessels. The hernial sac is
grasped with blunt forceps and the vas and vessels are carefully swept off its posterior surface en
masse. The vas deferens must be identified formally during this dissection, as it is closely adherent
to the posterior surface of peritoneum. The vas deferens and gonadal vessels are retracted away
from the sac, which then can be clamped and divided.

Figure 53.5

The hernial sac is pulled cranially, allowing the vas deferens and vessels to be separated bluntly
from the posterior surface right up to the internal inguinal ring.At this point the vas and vessels
begin to diverge and the peritoneum becomes more opaque.

Figure 53.6

The vas deferens hooks medially around the edge of the transversalis fascia and adjacent inferior
epigastric vessels, whereas the spermatic vessels pass laterally and cranially into the
retroperitoneal space. A small Langenbeck retractor is placed behind the peritoneum and the
retroperitoneal space is opened with blunt dissection. Any lateral fibrous attachments to the
vessels are identified by traction and then divided. This should provide adequate length to allow
the testis to reach the scrotum. If there is inadequate length of the vas deferens, the inferior
epigastric vessels can be isolated and a hole made in the posterior wall of the inguinal canal medial
to the vessels. Once the vas deferens has been mobilized carefully, the testis is redirected medial
to the vessels: further traction on the testis will identify any remaining fibrous strands that need
division. The processus vaginalis is twisted to exclude intraperitoneal contents and transfixed and
ligated with absorbable suture.

Figure 53.7, 53.8

A finger is introduced through the wound and bluntly pushed down to the scrotum. The scrotal
skin is immobilized between the internal finger and the thumb and then a skin incision is made
(either horizontal or vertical in the midline). A subcutaneous pouch is developed with scissors or
small artery forceps with the finger still in place. Bleeding is managed by meticulous diathermy to
avoid subsequent scrotal haematoma.

Figure 53.9

A small artery forceps is passed into the pouch and pressed against the deep fascia stretched over
the finger tip, which then guides the forceps back out through the inguinal incision. The
gubernaculum or tunica vaginalis is grasped by the forceps and the testis is gently drawn down to
the scrotum and out through the lower incision. At this point the tunica can be opened and
everted and any testicular appendages are excised. The testis can be held in the scrotal pouch by a
small suture through the lower septum and the tunica albuginea. Alternatively, the neck of the
scrotum can be tightened with a suture around the spermatic cord. Sometimes the button-hole in
the tissues at the neck of the scrotum is small enough to hold the testis without any suture.

Figure 53.10

The testis is nestled into its new subcutaneous pouch and the scrotum closed with subcuticular
suture. The inguinal incision is closed with a running suture in the external oblique aponeurosis
(the artery forceps placed on the edges at the start make identification easy). Scarpa’s fascia is
closed with one or two sutures and the skin closed with subcuticular suture. A waterproof dressing
is applied to both wounds.

Figure 53.11

Diagnostic laparoscopy is the first step in the management of a nonpalpable testis. The three likely
findings at laparoscopy are:

Blind ending vas and vessels (vanishing testis): viable testicular remnants have been noted in 6% to
20% of vanishing testes. It has been suggested that inguinal exploration should be carried out in
these patients to remove testicular “nubbins” to prevent future risk of malignancy. Contralateral
fixation orchidopexy may be indicated.

Cord structures entering the internal ring: inguinal exploration is carried out, and if a viable testis
is found the testis is relocated to the scrotum. If remnant “nubbin” is found it is excised in toto to
remove the nidus of germ cells to prevent the occurrence of malignancy later.

A viable intra-abdominal testis: the limiting factor to relocate the intra-abdominal testis to the
scotum is the length of the gonadal vessels. Testis is supplied by three arteries – the main
testicular, the vassal and the cremasteric arteries. The decision to perform Fowler-Stephens or one
of its modifications must be made before any extensive inguinal exploration that disrupts the
collaterals. The viable intra-abdominal testis is treated by laparoscopic clip ligation of the main
spermatic vessels and by orchidopexy based upon vassal vessels and the collateral is performed at
a later stage. placed on the edges at the start make identification easy). Scarpa’s fascia is closed
with one or two sutures and the skin closed with subcuticular suture. A waterproof dressing is
applied to both wounds.

CONCLUSION
Post-operative recovery from all orchidopexy procedures is rapid, with return to full activity within
a few days. Sports may need to be restricted for 1–2 weeks and the boy is reviewed again at 6–12
months to ensure atrophy has not occurred. Boys with primary maldescent (especially bilateral)
and those with impalpable testes would be advised to return at 14 years of age for review of
pubertal development and discussion about prognosis for cancer and fertility.

Complications that are most frequent are wound infection or haematoma, both of which can be
avoided by meticulous haemostasis at operation and leaving the waterproof dressing in place for
at least a week. The risk of testicular atrophy should be less than 5% and in most series it is 1–2%.
Depending on the method used to fix the testis in the scrotum, there is a small risk of retraction of
the testis back into the groin, requiring secondary orchidopexy.

The estimated risk of testicular cancer (between 15 and 40 years) is approximately 5–10 times
higher than in a normal testis, although most pediatric surgeons anticipate the orchidopexy in
early infancy (<1 year of age) may avoid this.

The estimated risk of infertility is about 30% for bilateral undescended testes and lower (but not
normal) for unilateral cases. Whether these risks will disappear with early surgery remains
unknown at this time. Because epididymal anomalies are commonly associated with
cryptorchidism, it is likely that a small number of boys may be infertile subsequently because of
epididymal-testicular dissociation, even if germ cell maturation is normal.