Orchidopexy is a surgical procedure used to correct cryptorchidism, commonly known as undescended testes. Cryptorchidism is a condition whereby one or both testes do not relocate to the scrotum during fetal period or shortly after birth. Orchidopexy should attempt to relocate the undescended testicle(s) into the scrotum and fix them in place.
Indications
Cryptorchidism or undescended testicle:
Congenital Cryptorchidism: Cryptorchidism is the condition in which the testis that has not descended into the scrotum by the normal age, normally before the age of 6 months.
Ectopic Testis: The testis is in extra compartmental area, in the perineal, the thigh, or at the opposite side.
Retractile Testis: This condition may arise if the testis remains outside the scrotum, even after birth.
Testicular Torsion:
Fixed to the posterolateral aspect of the abdominal wall; it was used in the past to prevent future torsion of the contralateral (unaffected) testis.
May also be performed during the procedure if there is a chance for salvage of the affected testis.
Ascending Testis (Acquired Undescended Testis):
When a previously descended testis moves back up into the inguinal canal or higher.
Cosmetic and Psychological Reasons:
To ensure normal scrotal appearance, especially in adolescents.
Prevention of Long-term Complications:
Fertility Issues: Screening and early fixation of undescended testes are beneficial in improving future fertility.
Malignancy Risk: Reduces the incidence of a rare pathology, such as testicular cancer in connection with cryptorchidism.
Contraindications
Active Infection: The procedure is contraindicated in presences of a local or systemic infection, for example scrotal cellulitis or systemic sepsis.
Malignant Testicular Tumor: Orthidopexy must be avoided in cases of suspected malignant tumours or in case of a confirmed diagnosis of malignant tumours.
Inguinal or Abdominal Testis Not Viable: If the testis is atrophic or nonviable due to torsion, trauma or any cause, orchidopexy is contraindicated and, orchiectomy may be advised.
Severe Comorbidities: Patient with major cardiac, pulmonary or other significant systemic diseases that place them at high risk to receive anesthesia and surgery risk should be evaluated before.
Failed Previous Orchidopexy: Prior failed surgeries may complicate subsequent attempts, requiring alternative approaches or more complex procedures.
Testicular Ectopia: When the testis is at an ectopic site (such as perineum or femoral area), surgical possibility and strategy should also be weighed.
Medical History and Physical Exam:
Take birth history for prematurity and presence of perinatal problems
Look up the history of earlier surgeries, allergy, or hereditary factors for anesthesia problem.
Observe the palpability or non-palpability of the testis. Diagnostic Tests: Only if Indicated Ultrasound: For the non-palpable testis to locate testis. Hormonal Testing: This can be done particularly in the case of Bilateral to check testosterone/ Hormone level. Anesthesia Consultation:
Consultation with an anesthesiologist, especially if there are concerns about airway management or other comorbidities. Explanation of the Procedure:
Describe the surgical approach, either open or laparoscopic.
Discuss risks (bleeding, infection, testicular atrophy) and benefits (improved fertility, cancer risk reduction). Consent Form:
Obtain signed informed consent from parents or guardians.
Patient position:
Supine Position: The patient is positioned in a supine position that means the patient lies down on the back.
Hands may be reposed on arm boards.
Frog-Leg Position (variation):
Again, the patient is in the supine position while the legs are in a flexed and abducted position (frog leg position).
Sometimes it is needed to expose the scrotum better, in such situations this position is used.
Step 1-Preoperative Preparation:
Anesthesia: General anesthesia is administered.
Positioning: The patient is placed in a supine position with sterile preparation of the groin and scrotum.
Marking: The planned incision site is marked.
Step 2-Inguinal Incision:
A small transverse or oblique incision is made in the inguinal region.
The subcutaneous tissue and fascia are dissected to expose the inguinal canal.
Step 3-Mobilization of the Testis:
The spermatic cord structures are identified and carefully dissected to mobilize the testis.
The cremasteric fibers are divided to free the cord.
Care is taken to preserve the vas deferens and blood vessels (testicular artery and veins).
Step 4-High Ligation of the Processus Vaginalis (if needed):
If a patent processus vaginalis is present (as in a hernia), it is isolated and ligated at the internal ring to prevent herniation.
Step 5-Cord Length Assessment:
Adequate cord length is ensured by dissecting up to the internal ring and sometimes further retroperitoneally.
A Prentiss maneuver (medial cord displacement) may be performed if additional length is required.
Step 6-Scrotal Pouch Creation:
A separate small scrotal incision is made.
A pouch is created by blunt dissection in the scrotal subcutaneous tissue to accommodate the testis.
Step 7-Placement and Fixation of the Testis:
The mobilized testis is gently pulled into the scrotum.
The testis is secured in the scrotal pouch using a non-absorbable suture to prevent retraction.
Ensure there is no tension on the spermatic cord.
Step 8-Closure:
The inguinal incision is closed in layers using absorbable sutures for the fascia and subcutaneous tissue.
The skin is closed with absorbable or non-absorbable sutures or skin glue.
The scrotal incision is also closed in layers.
Step 9-Postoperative Care:
Sterile dressings are applied.
Pain management with appropriate analgesics.
Monitor for signs of infection, hematoma, or testicular ischemia.
Complications
Intraoperative Complications:
Injury to surrounding structures: Damage or injury to the vas deferens, the blood vessels like the spermatic cord, or any other structures around the vas deferens may occur.
Bleeding: Although uncommon, excessive bleeding during the procedure can happen.
Anesthetic complications: Like any procedure involving the use of anesthesia, there may be complications or reactions to anesthesia.
Early Postoperative Complications:
Wound infection: These are redness inflammation or pus like discharge at the area of surgery.
Hematoma or scrotal swelling: Swelling of the scrotum caused by blood or fluid.
Pain or discomfort: Mild to moderate pain should occur, which is controlled by using analgesics.
Testicular torsion: Occasionally the testis may twist, and this constitutes an acute emergency. This condition is referred as testicular torsion.
Late Postoperative Complications:
Testicular atrophy: Temporary decrease in blood circulation during the surgery may result in testicular atrophy or failure.
Recurrence of cryptorchidism: The testis may retract back, though this is uncommon with proper technique.
Infertility: A direct injury of the vas deferens and or testicular shrinkage could partly cause infertility.
Chronic pain: Chronic pain is pain that results from nerve damage or scarring.
Cosmetic concerns: Sometimes it may cause scarring or asymmetry of the scrotum.
Orchidopexy is a surgical procedure used to correct cryptorchidism, commonly known as undescended testes. Cryptorchidism is a condition whereby one or both testes do not relocate to the scrotum during fetal period or shortly after birth. Orchidopexy should attempt to relocate the undescended testicle(s) into the scrotum and fix them in place.
Cryptorchidism or undescended testicle:
Congenital Cryptorchidism: Cryptorchidism is the condition in which the testis that has not descended into the scrotum by the normal age, normally before the age of 6 months.
Ectopic Testis: The testis is in extra compartmental area, in the perineal, the thigh, or at the opposite side.
Retractile Testis: This condition may arise if the testis remains outside the scrotum, even after birth.
Testicular Torsion:
Fixed to the posterolateral aspect of the abdominal wall; it was used in the past to prevent future torsion of the contralateral (unaffected) testis.
May also be performed during the procedure if there is a chance for salvage of the affected testis.
Ascending Testis (Acquired Undescended Testis):
When a previously descended testis moves back up into the inguinal canal or higher.
Cosmetic and Psychological Reasons:
To ensure normal scrotal appearance, especially in adolescents.
Prevention of Long-term Complications:
Fertility Issues: Screening and early fixation of undescended testes are beneficial in improving future fertility.
Malignancy Risk: Reduces the incidence of a rare pathology, such as testicular cancer in connection with cryptorchidism.
Active Infection: The procedure is contraindicated in presences of a local or systemic infection, for example scrotal cellulitis or systemic sepsis.
Malignant Testicular Tumor: Orthidopexy must be avoided in cases of suspected malignant tumours or in case of a confirmed diagnosis of malignant tumours.
Inguinal or Abdominal Testis Not Viable: If the testis is atrophic or nonviable due to torsion, trauma or any cause, orchidopexy is contraindicated and, orchiectomy may be advised.
Severe Comorbidities: Patient with major cardiac, pulmonary or other significant systemic diseases that place them at high risk to receive anesthesia and surgery risk should be evaluated before.
Failed Previous Orchidopexy: Prior failed surgeries may complicate subsequent attempts, requiring alternative approaches or more complex procedures.
Testicular Ectopia: When the testis is at an ectopic site (such as perineum or femoral area), surgical possibility and strategy should also be weighed.
Medical History and Physical Exam:
Take birth history for prematurity and presence of perinatal problems
Look up the history of earlier surgeries, allergy, or hereditary factors for anesthesia problem.
Observe the palpability or non-palpability of the testis. Diagnostic Tests: Only if Indicated Ultrasound: For the non-palpable testis to locate testis. Hormonal Testing: This can be done particularly in the case of Bilateral to check testosterone/ Hormone level. Anesthesia Consultation:
Consultation with an anesthesiologist, especially if there are concerns about airway management or other comorbidities. Explanation of the Procedure:
Describe the surgical approach, either open or laparoscopic.
Discuss risks (bleeding, infection, testicular atrophy) and benefits (improved fertility, cancer risk reduction). Consent Form:
Obtain signed informed consent from parents or guardians.
Patient position:
Supine Position: The patient is positioned in a supine position that means the patient lies down on the back.
Hands may be reposed on arm boards.
Frog-Leg Position (variation):
Again, the patient is in the supine position while the legs are in a flexed and abducted position (frog leg position).
Sometimes it is needed to expose the scrotum better, in such situations this position is used.
Step 1-Preoperative Preparation:
Anesthesia: General anesthesia is administered.
Positioning: The patient is placed in a supine position with sterile preparation of the groin and scrotum.
Marking: The planned incision site is marked.
Step 2-Inguinal Incision:
A small transverse or oblique incision is made in the inguinal region.
The subcutaneous tissue and fascia are dissected to expose the inguinal canal.
Step 3-Mobilization of the Testis:
The spermatic cord structures are identified and carefully dissected to mobilize the testis.
The cremasteric fibers are divided to free the cord.
Care is taken to preserve the vas deferens and blood vessels (testicular artery and veins).
Step 4-High Ligation of the Processus Vaginalis (if needed):
If a patent processus vaginalis is present (as in a hernia), it is isolated and ligated at the internal ring to prevent herniation.
Step 5-Cord Length Assessment:
Adequate cord length is ensured by dissecting up to the internal ring and sometimes further retroperitoneally.
A Prentiss maneuver (medial cord displacement) may be performed if additional length is required.
Step 6-Scrotal Pouch Creation:
A separate small scrotal incision is made.
A pouch is created by blunt dissection in the scrotal subcutaneous tissue to accommodate the testis.
Step 7-Placement and Fixation of the Testis:
The mobilized testis is gently pulled into the scrotum.
The testis is secured in the scrotal pouch using a non-absorbable suture to prevent retraction.
Ensure there is no tension on the spermatic cord.
Step 8-Closure:
The inguinal incision is closed in layers using absorbable sutures for the fascia and subcutaneous tissue.
The skin is closed with absorbable or non-absorbable sutures or skin glue.
The scrotal incision is also closed in layers.
Step 9-Postoperative Care:
Sterile dressings are applied.
Pain management with appropriate analgesics.
Monitor for signs of infection, hematoma, or testicular ischemia.
Complications
Intraoperative Complications:
Injury to surrounding structures: Damage or injury to the vas deferens, the blood vessels like the spermatic cord, or any other structures around the vas deferens may occur.
Bleeding: Although uncommon, excessive bleeding during the procedure can happen.
Anesthetic complications: Like any procedure involving the use of anesthesia, there may be complications or reactions to anesthesia.
Early Postoperative Complications:
Wound infection: These are redness inflammation or pus like discharge at the area of surgery.
Hematoma or scrotal swelling: Swelling of the scrotum caused by blood or fluid.
Pain or discomfort: Mild to moderate pain should occur, which is controlled by using analgesics.
Testicular torsion: Occasionally the testis may twist, and this constitutes an acute emergency. This condition is referred as testicular torsion.
Late Postoperative Complications:
Testicular atrophy: Temporary decrease in blood circulation during the surgery may result in testicular atrophy or failure.
Recurrence of cryptorchidism: The testis may retract back, though this is uncommon with proper technique.
Infertility: A direct injury of the vas deferens and or testicular shrinkage could partly cause infertility.
Chronic pain: Chronic pain is pain that results from nerve damage or scarring.
Cosmetic concerns: Sometimes it may cause scarring or asymmetry of the scrotum.
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