Scrotal Approach for Palpable Undescended Testis
- 1. Department of Pediatric Surgery, Zagazig University, Egypt
Abstract
Undescended testis is one of the most common surgical disorders of childhood, with a rate of 3% among full-term infants and 30% in preterm infants. The traditional orchidopexy has been described by Schuller (1881) and Bevan (1899/1903). Which need two incisions, one inguinal incision to mobilize the cord structure and a second scrotal incision to fix the testes within the scrotum. Single scrotal incision orchidopexy (SSIO) was first described by Bianchi and Squire 1989.
Aim of the study: To evaluate the short term outcome of scrotal approach for palpable undescended testis.
Patients and methods: This is a prospective clinical study done at Zagazig University and international medical center Jeddah during the period from 2013 to 2015, all patients with palpable undescended testis have been included in the study, and all patients were operated by scrotal orchidopexy.
Results: This study includes 80 patients with 101 undescended testis underwent single scrotal incision orchidopexy, the mean age at operation was16 ± 7.2 months, the mean operative time was 30.8 ± 10.4 minutes, the mean follow-up was 4.7 ± 2.4 months, the incidence patent process vaginalais was 8 (7.9%) s, the success rate was 82.1%, conversion to traditional approach were in 18(17.8%), post-operative scrotal hematoma was found in 3 (3.75%), post (17.8%)operative wound infection was found in1 (1.25%). There was no cases of post-operative hernia, hydrocele or testicular ascend or atrophy.
Conclusion: Single incision transscrotal orchidopexy is safe and effective in up to 82.1% of cases of palpable undescended testis.
Keywords
• Undescended testis
• Scrotal orchidopexy
• Orchidopexy
Citation
Kasem H, Alshahat W, Alekrashi M (2018) Scrotal Approach for Palpable Undescended Testis. JSM Pediatr Surg 2(2): 1012.
ABBREVIATIONS
SSIO: Single Scrotal Incision Orchidopexy
INTRODUCTION
Undescended testis is one of the most common surgical disorders of childhood, with a rate of 3% among full-term infants and 30% in preterm infants [1]. Most of the undescended testis is lie distal to the inguinal canal close to the external inguinal ring [2].
The traditional orchidopexy has been described by Schuller (1881) and Bevan (1899/1903). This requires two incisions: one inguinal incision to mobilize the cord structure and a second scrotal incision to fix the testes within the scrotum [3]. Single scrotal incision orchidopexy (SSIO) was first described by Bianchi and Squire 1989 [4] Surgical intervention has been done during early infancy to avoid secondary degeneration of the testis, to improve fertility later, to help with the detection of malignancy, and to reduce the chance of testicular torsion [5,6].
PATIENTS AND METHODS
This is a retrospective study done at International Medical Center Jeddah and Zagazig University hospital during the period from 2013 to 2016, all patients with palpable undescended testis operated by single scrotal approach were included in this study, the operative indications for scrotal orchidopexy include all cases of undescended testis that lie distal to the external inguinal ring OR that can be pulled down to the scrotum under GA.
Children who have ectopic testis, retractile testis, or undescended testis related to ambiguous genitalia or intersex were excluded from the study
All of the following data were assessed, age, bilaterally, operative time, early post-operative complication (wound infection, scrotal hematoma), late post-operative complications (Testicular atrophy, testicular ascent), intraoperative finding of patent process vaginalais.
All patients were seen in the outpatient department one week postoperative to evaluate for any complications as wound infection or scrotal hematoma and then at 3 months, 6 months and 12 months to evaluate for success rate or late complications as testicular atrophy or testicular ascent
The success rate was archived by no conversion to the traditional technique and the presence of the testis in intra scrotal position without atrophy or ascent. Atrophy was defined with decrease of the size of the testis by 50% of the contra -lateral testis in unilateral cases of unilateral undescended testis or of that of expected age in bilateral cases
Surgical technique
After induction of anesthesia, preoperative examination to assess the site of the testis and the testicular mobility, high scrotal transverse incision , creation of sub dartos pouch to later fix the testis in it, blunt dissection of the subcutaneous tissue till we find the testis , mobilization of the testis by dividing the cremasteric muscle and spermatic fascia and ligation of the process vaginalais if present (Figure 1),
Figure 1 Mobilization of the testis.
if more length is required another inguinal incision was done , the testis was then placed in the subdartos pouch and fixed by suture between the tunica and the edge of the dartos fascia (Figure 2),
Figure 2 Fixation of the testis in subdartos pouch.
scrotal skin closed by interrupted absorbable suture.
RESULTS
A total of 80 cases with 101 undescended testis underwent single scrotal incision orchidopexy have been included in this study, Most of the undescended testis were located in superficial inguinal pouch in (29), in the inguinal canal near the external ring in (33), intracanalicular in (7), at the neck of the scrotum in (12) Table (2).
Table 2 : Position of the testis at surgery
|
7 (6.9%) |
intracanalicular |
|
33 (32.6%) |
External inguinal ring |
|
29 (28.7%) |
Superficial inguinal pouch |
|
12 (11.8 %) |
Neck of the scrotum |
Mean operative time was 30.8 ± 10.4 minutes; mean hospital stay was 16.7 ± 8.5 hours
In 18(17.8%) cases dissection of the cord was not enough to gain adequate length of the cord to place the test is in the scrotum, and another inguinal incision was done, and the overall success rate was 82.1% Table (1).
Table 1: Patient’s characteristics and intraoperative findings.
| Variable | |
| No. of testis (n) | 101 |
| Laterality(n) Unilateral bilateral |
59 21 |
| Mean age (months ) | 16±7.2 m |
| Mean follow up (months ) | 4.7±2.4 m |
| Hospital stay(h) | 16.7±8.5 h |
| Operative time(m) | 30.8±10.4 m |
| Conversion to traditional orchidopexy | 18 (17.8%) |
| Patent process vaginalais | 8 (7.9%) |
| Success rate | 82.1% |
| Abbreviations: n: Number; m: Month; h: Hour; m: Minute | |
Post-operative wound infection was found in 1 (0.9%) and scrotal hematoma in 3 (2.9%) Table (3).
Table 3: Post operative complications.
| Variable | |
| Wound infection | 1 (0.9%) |
| Scrotal hematoma | 3 (2.9%) |
The median follow up was 5 months range from 0 to 40 months8 cases missed the follow-up at 3 months and 20 cases escaped the follow-up at 12 months, on follow-up all testis were located in the scrotum in a good position, there has been no inguinal hernia or hydrocele formation post-operative, No testis has become atrophied.
DISCUSSION
The traditional approach for orchidopexy is still widely used by many pediatric surgeons it offers wide access to the inguinal canal and high ligation of the process vaginalais but it involve 2 incision one groin and one scrotal incision (3)
Bianchi was first do scrotal approach for the palpable undescended testis he concluded that most of the palpable undescended testis could be corrected by single scrotal approach due to most of the testis are in the superficial inguinal pouch, the inguinal canal is short in pediatric, short distance between the inguinal canal and the scrotum, elasticity of the scrotal and inguinal skin (4).
In his series Bianchi did an oblique incision along the superior border of the scrotum [7], use a transverse scrotal incision and its advantage lies on that if we need further mobilization of the testis or to do high ligation of the process vaginalais a second inguinal incision can be done as the original approach [8], used a longitudinal incision at the median raphe and stated that it has good cosmoses especially in the bilateral undescended testis In our study we use transverse inguinal incision in all cases of palpable undescended testis with good results [9], described transscrotal orchidopexy through transverse incision in the mid of the scrotum and fixation of the testis to the prescrotal fat.
Scrotal approach for orchidopexy was first used for the low palpable undescended testis however [10], suggested that this approach even can be used in more difficult cases with impalpable testis provided that patent process vaginalais also [11], reported that more proximal testis tend to have a poor outcome however [12], reported that trans-scrotal orchidopexy can be used in more proximal testis in our study we used it in all palpable undescended testis beyond the external inguinal canal and could be mobilized to the scrotum on examination under anesthesia.
The advantages of SSO include short operative time, less pain, good cosmoses this has been showed by many studies [10], our study also shows a significant short operative time between the scrotal orchidopexy and the traditional approach [13]. Evaluate bianchi technique for orchidopexy in undescended testis distal to the external ring and reported that this technique is safe.
The incidence of PPV in undescended testis is range from 20% to 70% and it is more common in intracanalicular and less in low laying. Ligation of the process vaginalais in undescended testis is still controversy [14], in his series reported that an inguinal incision was necessary for ligation of the PPV but some other studied on SSIO found that the process vaginalais could be ligated successfully through the scrotal incision [2,10,15,16] reported that the long term outcome of non-ligation of the process vaginalis were not associated with postoperative hernia or hydrocele formation also [17], showed that ligation of the process vaginalais is time consuming and lead to more complications In our study PPV was found in 18 cases (17.8%) and in 11 cases we were able to do high ligation of the PV and in 7 cases ligation could not be done and converted to the traditional approach .
The rate of conversion from transscrotal orchidopexy to inguinal approach is variable in the literature ranging from 0 to 13% and most of the failure in intracanalicular testis’s [15], reported complete success rate in 14 cases of intracanalicular testis by scrotal orchidopexy also [18], in his study 37 cases of intracanalicular testis have been brought successfully in the scrotum by scrotal approach. In the series of bianchi only 5 cases require another groin incision for proper mobilization of the cord and ligation of the PPV. In our study only 7 cases need another inguinal approach due to short cord and we need to do Prentiss maneuver and retroperitoneal dissection to get more cord length in those cases the testis were present intracanalicular.
It has been is reported that preoperative Gn RH therapy is useful to increase trophism and testicular mobility and may reduce the surgical difficulties that occur when scrotum is not well developed, small testis or short vessels [19].
However, it has some disadvantages as cost and its side effects, as accelerated secondary sexual characteristic, premature epiphyseal closure and an aggressive behavior of the child during the treatment (that usually recedes after cessation of therapy).
The possible complication of transscrotal orchidopexy include missing hernia sac, inadequate mobilization of the cord, damage to vas and vessels, scrotal hematoma, wound infection In the series of Gordon et al [12] other inguinal incision was done in 4.4%, early post-operative complications occur in 1.5%, reoperation in 4.9%, and testicular atrophy in 0.6% and the overall complication rate was 3.5 % was comparable with that reported before [15,20] investigate early outcome of Trans scrotal orchidopexy and have demonstrated no testicular atrophy or ascending testis also in our study we didn’t have any case of testicular atrophy or testicular ascent
The results of our study show no post-operative hernia, at follow up, there were no cases of testicular atrophy or injury to vas and vessels and the occurrence of scrotal hematoma was 3 (2,9%) and wound infection was 1 (0.9%)
In the series of Bianchi only 5 case from 120 case required conversion to the traditional inguinal approach a study done by [21] there were 5 cases of recurence,2 cases of testicular atrophy , 16 scrotal hematoma, 2 cases of scrotal wound infection. In the original study done by [4] the success rate was 96.2% [20], also publish series with a success rate 94.4% and no complications in long- term follow-up. Other studies have reported high success rates with scrotal orchidopexy [11,12]. In our study the success rate was comparable with most of the published studies (91.2%).
CONCLUSION
Our study show that transscrotal orchidopexy is effective, safe, and with a success rate of 82.1% and no major complications such as testicular atrophy or recurrence equal to classical inguinal approach.
