Continuing Education Activity

This activity reviews the indications for orchiopexy and describes multiple techniques based on the location of the aberrant testis. It also highlights the importance of the relationship between the pediatrician or primary care provider, the pediatric surgeon, the caretaker, and the patient in caring for infants and children with cryptorchidism.

Objectives:

• Identify the indications for performing an orchiopexy.
• Describe the different techniques in regards to orchiopexy and identify the appropriate technique based on physical exam and imaging findings.
• Review the potential complications and clinical significance of performing an orchiopexy
• Discuss interprofessional team strategies with primary care physicians and pediatric surgeons for improving care coordination and communication about orchiopexies to improve long term outcomes.

Introduction

Cryptorchidism is a relatively common condition, occurring in up to 9% in full-term infants and can occur in as many as 30% in premature neonates.[1] About 80% of undescended testes (UDT) migrate into the scrotum by 3 to 6 months of age.[2] UDT can be either unilateral or bilateral (10%).[3] Around 80% are palpable, and 90% of those are palpated in the inguinal canal. More than 90% of patients have a concomitant patent processus vaginalis. 

Multiple risk factors contribute to the development of UDT. These include twinning, low birth weight, a birth weight that does not correlate appropriately with gestational age, and prematurity. Of these, prematurity is the most significant. 

Types:

True undescended testis - The testis is located anywhere in the natural path of descent. 

• Retroperitoneal, intrabdominal, in the inguinal canal, at the superior aspect of the scrotum

Ectopic undescended testis - testis is not anywhere along the natural path of descent.

• In the femoral canal
• The opposite scrotum 
• Perineum
• In the femoral canal

Hypoplastic - underdeveloped testis

Dysgenetic - derangement of seminiferous tubules and function of testes 

Vanished - thought to be due to intrauterine testicular torsion in late gestation.

• It is important to note only 20 to 40% of non-palpable testes are truly absent at the time of surgery.

Ascent - a testis that was in the scrotum but has since returned to the inguinal canal

Retractile - A testis that moves in and out of the scrotum 

Acquired - failure of the spermatic cord to grow in proportion to body growth[4][5]

Anatomy and Physiology

The testicle migrates from the abdominal cavity through the inguinal canal into the scrotum via the gubernaculum. Migration can become arrested at any point along its descent. 

When viewing the internal ring of the inguinal canal during a laparoscopic approach, the vas deferens comes medially to join with the vasculature that comes in laterally. These then join to travel through the inguinal canal into the scrotum.[6]

Indications

• Failure of the testis to spontaneously descend by eight months of age
• Acute or intermittent testicular torsion

Contraindications

Atrophic testis - if the testis is atrophic, perform an orchiectomy instead.

Personnel

• Pediatric surgeon
• Anesthesiologist
• Scrub tech/nurse
• Circulating nurse

Technique or Treatment

Technique: 

A surgeon can perform an orchiopexy in several different manners. If the testis is not palpable, a laparoscopic approach is taken; this can be a one-stage or two-stage operation, depending on the laxity of the spermatic cord and testicular vasculature. If the testis is in the inguinal canal, an inguinal orchiopexy is performed. If the testis is retractile or at the top of the scrotum, a scrotal approach is the procedure of choice. Commonly, only one testis is fixated and then allowed to heal, so if blood supply is lost or infection develops, the patient has a remaining viable testis.[7][8][9]

Scrotal Approach

1. Make an incision in the ipsilateral hemiscrotum down to Dartos' fascia.
2. Dissect up through the soft tissue toward the internal inguinal ring until identifying the testis.
1. If the ilioinguinal nerve is encountered, it must be isolated and protected.
3. Bring the testis down into the operative field with gentle retraction.
4. Perform detorsion of the spermatic cord, if necessary.
5. Dissect out the gubernaculum and cremasteric muscles separate from the spermatic cord and tack to Dartos' fascia medially and laterally, allowing sufficient length of the spermatic cord for the testis to sit comfortably in the scrotum. 
1. If there is a hernia sac or patent processus vaginalis, it requires dissection out, with high ligation.
6. Place a tacking suture in the proximal Buck's fascia, such as a 4-0 vicryl, then run it in a pleating fashion toward the end of the fascia, then turn and bring suture back to the tacked suture in the same manner. Ensure that your bites do not go into the spermatic cord. 

OR

1. Pexy the testicle in place by placing four cardinal prolene sutures in Dartos' fascia and then into the testicular capsule. 
2. Place the testicle in the pouch and reapproximate the scrotum with interrupted chromic sutures. This process should leave about 0.5 cm between bites. Cover the incision with collodian. 

Inguinal Approach - most common approach:

1. Make an incision over the inguinal canal, much like an open inguinal hernia repair. Dissect through the subcutaneous tissue to expose the inguinal canal and external ring. 
2. Open the external oblique fascia. If the ilioinguinal nerve is identified, isolate the nerve and preserve it.
3. Identify the undescended testis and spermatic cord. 
4. Identify and dissect the processus vaginalis off of the spermatic cord, which is generally on the anteromedial aspect of the spermatic cord, perform high suture ligation of the sac to provide adequate length so that the testis will reach the scrotum without tension. 
5. Ensure that the spermatic vessels lay anterior to the vas deferens. 
6. Develop the Dartos' pouch by making an incision in the ipsilateral hemiscrotum, pass a nontraumatic grasper through the incision up into the inguinal canal and gently pull the testis down into the pouch.
7. Tack the testis down to Dartos' fascia using absorbable suture. Close the dartos' muscle and incision in the scrotum. 
8. Close the inguinal incision in multiple layers, including the inguinal canal and Scarpa's fascia, before closing the skin. 

Laparoscopic Approach 

1. Enter the abdomen in a controlled manner, place two additional ports under direct supervision, triangulating with the appropriate inguinal canal. 
2. Identify the testicle location, viability, and vasculature.
3. Release gubernacular attachments carefully and mobilize the cord structure from the abdominal wall.
4. Mobilize the blood vessels by dissecting proximally. 
5. Develop Dartos' pouch in the scrotum by making an incision in the ipsilateral hemiscrotum, placing a port under direct supervision, and then passing an instrument through the inguinal canal into the peritoneal cavity, grasping the testicle and pulling it down into Dartos' pouch.
6. Fix the testis to the Dartos' fascia using absorbable sutures as described above.

If the testis cannot be mobilized sufficiently to pass through the inguinal canal into the scrotum without tension, a two-stage Fowler-Stephens approach is an option. There are several considerations when deciding between a one-stage and two-stage procedure; these include the distance from the testis to the internal ring (two-stage if > 2.5 cm), mobility of the vasculature (two-stage if excessive tension), and age of the patient (> 5 years old, consider two-stage).[10]

In the first step, the testis is identified laparoscopically; then, the vascular supply is ligated with minimal dissection of the spermatic cord. After several months, the patient undergoes a second laparoscopic surgery, the testis is identified, and viability assessed. If viable, the peritoneal attachments are taken down, providing sufficient length for the testis to sit in the scrotal pouch without tension.[8]

Complications

Along with the complications that accompany any procedure (i.e., infection, bleeding, scarring), there are several severe complications related directly to orchiopexy. These include: 

• Testicular atrophy - the most devastating complication that can occur and is generally due to over-skeletonization during dissection
• Damage to or ligation of the vas deferens - the vas deferens can be devascularized during dissection, it can also be unintentionally ligated or transected.
• The ascent of the testis - this can occur if the testis has become fixed in the scrotum under excessive tension, usually due to not freeing up the connective tissue around the spermatic cord appropriately.
• Infection - risks of infection include infection of both testes with bilateral orchiopexy, resulting in loss of both testes; for this reason, if the patient has bilateral UDT, each procedure is performed separately and several months apart.[11]

Clinical Significance

Patients with UDT are at increased risk of infertility, testicular cancer in both testes, and testicular torsion. There is a 40 times increased risk of testicular cancer in the UDT, and the contralateral testis, even if located in the scrotum, has about a 20% increased cancer risk compared to the general population.[12] 

Seminoma is the most common malignant tumor associated with undescended testicles. Orchiopexy should be performed after six months and before 18 months of age to reduce the risks of infertility and development of cancer.[13][14] Furthermore, patients with UDT are at increased risk of testicular torsion; this can also result in loss of the testis and increased risk of infertility. 

Enhancing Healthcare Team Outcomes

 Key points for multi-disciplinary care of pediatric patients with UDT: 

• The patient's pediatrician should perform regular testicular exams to ensure the testes are in the scrotum.
• The pediatrician should refer the patient to a pediatric surgeon by six months of age if testicles have not descended yet.
• Patients with a history of UDT must learn how to perform regular self-exams as they have a significantly higher risk of developing testicular cancer.[15]