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Testicular atrophy after attempted pediatric orchidopexy for true undescended testis
Journal of Pediatric Surgery 49 (2014) 317–322
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Testicular atrophy after attempted pediatric orchidopexy for true undescended testis Sigmund H. Ein ⁎, Ahmed Nasr, Paul W. Wales, Arlene Ein Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Ontario, Canada, M5G 1X8
a r t i c l e
i n f o
Article history: Received 6 November 2013 Accepted 10 November 2013 Key words: Undescended testis Orchidopexy Risk factors Atrophic testis
a b s t r a c t Background/Purpose: A normal testis in the scrotum is the most important outcome of the attempted pediatric orchidopexy for a true undescended testis. The reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent to unclear. Our purpose in this study was to estimate the incidence of and associated risk factors for post-orchidopexy testicular atrophy. Methods: We performed a retrospective review of data from children who had an attempted orchidopexy for a true undescended testis from 1969 to 2003 inclusive. REB approval 1000011987. Results: There were 1400 attempted orchidopexies involving common (low) type (n = 1135), ectopic type (n = 174), and high type testes (n = 91). There were a total of 111/1400 (8%) atrophic testes, mostly rightsided. 66/111 (59%) were MADE atrophic, and 45 (41%) were FOUND atrophic. Of the 1135 common type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9%, respectively. The most significant risk factors associated with testes MADE atrophic were high testicle, vas problems, and pre-operative torsion. Conclusions: In this series, the incidence of post-operative testicular atrophy that was MADE was 5% in the common (low) type and 9% in the high type. These numbers and the above risk factors should be quoted to the caregiver during pre-operative informed consent. © 2014 Elsevier Inc. All rights reserved.
Today, orchidopexy is the fourth most common pediatric general surgical operation after appendectomy, circumcision and hernia repair [1]. The incidence of undescended testicle (UDT) is said to be between three and five percent at birth, but by one year of age 0.8% to 1.6% [2]. The most important aspect of the attempted pediatric orchidopexy for a true undescended testis is the end result of a normal testis in the scrotum [2]. However, reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent [1– 12] to unclear [13–23]. Our objectives in this study were to assess the risk factors associated with testicular atrophy after attempted orchidopexy. 1. Methods This was a retrospective cohort study from July 1969 to December 2003 inclusive of children treated at The Hospital for Sick Children (HSC), Toronto. The following variables were collected: age, weight, side or bilateral, hormone treatment, other medical problems, type of true undescended testis, pre-orchidopexy complications and problems, type of orchidopexy repair, intra-operative and post-operative complications, results (focusing on risk factors for atrophic testes). Follow-up of all the patients until their testicular problem was solved
⁎ Corresponding author. Tel.: +1 416 813 6405; fax: +1 905 576 1735. E-mail address: [email protected] (S.H. Ein). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.11.048
was carried out by the senior author with his surgical residents. This review received HSC Research Ethics Board approval (1000011987). We used the following definitions: testicular atrophy — decrease in size of the testicle by one-third or more compared to the contralateral testicle; low (common) UDT — testis found at the mid/lower inguinal canal (intra-canalicular) + complete indirect inguinal hernia; ectopic UDT — testis found at/outside external ring ± small indirect inguinal hernia; high undescended testis — testis found at high inguinal canal, at internal ring (peeping testis) or intra-abdominal + complete indirect inguinal hernia. All operations were done under general anesthesia along with either caudal analgesia or local nerve block. Unless there were other medical problems and/or emergencies, the majority of these procedures were done as elective outpatient operations. Data were compared using Chi square for categorical variables and student’s T test for continuous ones. A logistic regression model was made with an aim to predict variables associated with post-operative testicular atrophy. A P-value b 0.05 was considered significant. 2. Results There were 1400 [1368 (97.8%) unilateral and 32 (2.2%) bilateral] true UDTs who had an attempted orchidopexy; the 32 bilateral ones in 16 children were operated on at separate operations (Fig. 1). The mean age at operation was 5.4 years (range: 1 month to 18 years); the weight ranged between 1.9 and 113 kg. There were 55% rightsided, 44.5% left-sided and 0.5% bilateral.
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Fig. 1. Types of true undescended testes that underwent attempted orchidopexy.
From this group of 1400, there were 182 (13%) boys who had preorchidopexy complications and problems (excluding atrophic testes); the most common category was 64 (4.5% of 1400) secondary orchidopexies (recurrent or redo orchidopexy; [24–28] post-operative inguinal hernia repair) (Table 1). 2.1. Operative details There were 1400 attempted orchidopexies involving common (low) UDT (n = 1135, 81%), ectopic UDT (n = 174, 12.5%), and high UDT (91, 6.5%) (Fig. 1). There were 1348 standard (regular) repairs, for the three types of UDT (n = 1135 common (low), n = 174 ectopic and n = 39 high) (Table 2). Within the ectopic group were five with their testes located in the perineum (n = 2), groin (n = 2), and thigh (n = 1). The remaining 52 high undescended testes, felt to be too high to have a standard (regular) repair, received one of three different repairs: onestage open Fowler–Stephens [29] (n = 34), two-stage open Corkery [30] (Silon sheath) (n = 10) and Jones [31] (one-stage open retroperitoneal) (n = 8). Each testis was placed in a dartos (Koop, subcutaneous) scrotal pouch, with the entrance of the pouch narrowed by 1 or 2
sutures. No suture was placed through the testis to fix it in position within the pouch or scrotum [7,32]. Seventy-one (5%) had concomitant procedures (the commonest was circumcision 45%). Of the 43 (3.1%) boys in this series who had other medical problems and were operated on, 15 (33% of 43) were of the developmental delay variety, with almost all of the others having some kind of congenital anomaly. Six (0.4%) were abdominal wall and/or diaphragmatic defects (omphalocele n = 3, diaphragmatic hernia n = 2, gastroschisis n = 1), and all had delayed attempted orchidopexy with 50% success. There were 21 (1.5%) intra-operative orchidopexy complications and problems (including orchidectomy and considered an atrophic testis). The commonest was related to the vas. There were five orchidectomies (Table 3a). 2.2. Outcomes There were 36 (2.5%) post-operative orchidopexy complications, (excluding atrophic testis) the most common of which was wound infection (Table 3b).
Table 1 Pre-orchidopexy complications and problems (excluding atrophic testes). COMPLICATION OR PROBLEM SECONDARY (recurrent/redo orchidopexy; post-operative inguinal hernia repair) INCARCERATION (Inguinal hernia with undescended testis) RETRACTILE (late ascent; small testis) TORSION (of true undescended testis) TOTAL
NUMBER (% of 1400)
MEAN AGE (yr)
MAJORITY SIDE
64 (4.5%)
6.5
R
61 (4.3%)
1.1
R
46 (3.2%)
5.4
R
11 (0.7%)
3.6
L
182 (13%)
4.1
R
S.H. Ein et al. / Journal of Pediatric Surgery 49 (2014) 317–322 Table 2 Results of attempted orchidopexy for type of true undescended testes (UDTs). Type of Orchidopexy
Standard (regular) Fowler–Stephens (1 stage, open) Corkery (2 stage, open, Silon) Jones (1 stage, open, retroperitoneal) Total Successful result
Common (Low) (n = 1135) Ectopic (n = 174)
Types of true UDTs High
Total (Types of Testes)
1309
39 34
1348 52
1309
Successful results %
93% 71%
10
100%
8
38%
91 74%
1400 92%
92%
There were a total of 111/1400 (8%) atrophic testes, mostly right-sided of which 66/111 (59%) were MADE atrophic and 45 (41%) were FOUND atrophic (Table 4). Of the 1135 common (low) type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9% respectively. The median age for testicular atrophy was 4.8 years: (range 7 days-18 years) at operation; all atrophic testicles were noted within three months postoperatively. Risk factors were compared between children who had had postoperative testicular atrophy and children who did not. In this univariate analysis (Table 5a), high position of the testicle, vas problems and pre-operative torsion were significantly associated with post-operative atrophy. This was further investigated using a logistic regression model with the outcome being post-operative atrophy (Table 5b). Variables identified in the univariate analysis were entered in the model and remained significant including high position of the testis, vas problems and pre-operative torsion. 3. Discussion This is the largest reported series of pediatric orchidopexies by one pediatric surgeon and covers a 35 year period. Other similarly large reports come from several pediatric centers, but it is not clear how many pediatric surgeons were involved in each review [9,10,19,21,33–37.] Although there were a total of 1881 boys initially evaluated in this series with a total of 2039 possible UDTs, not all of these were true undescended testes; this was also a similar observation in other series [3,4,11,21,38,39]. Only 1400 attempted orchidopexies for true UDTs were included in this series (Fig. 1) and 536 true UDTs were not operated on. The commonest reason was developmental delay (25%). Sixty-three boys with so-called vanishing scrotal testicles (from prenatal torsion of a descended testicle) and 40 post-testicular torsion orchidopexies in normally descended testes were also not counted as true UDT in this series. Some authors have included the latter two categories in their overall total of UDT and orchidopexies [16,20,21,24,29,33,35,37]. Although the optimum age recommended for orchidopexy was between nine and 12 years in the 1950 s [21], this has steadily decreased to one year or younger [24]. The mean age of the children in this series (as in some others [9]) was five years, although over the 35 years (1969 to 2003 inclusive) of the series, the mean age had Table 3a Intraoperative orchidopexy complications and problems (including atrophy *) [n = 21, 1.5% of total]. Vas Deferens n = 16 a) NO Vas n = 9 b) Not connected with testis n = 6 c) Cut n = 1 Orchidectomy * n = 5 d) Unable to bring testis down n = 4 e) Torsion of undescended testicular dermoid n = 1
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decreased from six years in the first half of this series to four years in the latter half. The lack of conformity of this series to the recommended age for orchidopexy is thought to be due to the local referral patterns. The accepted reason for the previous older age orchidopexy was that the infertility of these undescended testes was blamed on their congenital aspect; presently, the surgical treatment is done between one and two years before the germ cells disappear from the undescended testis [40–42]. Supporting this younger operative approach, Michikawa [13] showed that orchidopexy at less than two years of age prevented morphological changes in the repaired undescended testis [43]. Nonetheless, D’Agostino [44] has reported that “the timing of surgery and the anatomical position of the cryptorchid testes do not seem to affect the fertility rate”. More than half of the 1400 true undescended testes were on the right side, as in other series [21,33], but there were only 32 (2.2%) bilateral testes in 16 patients in our series compared with 20% in Gross’ series, [21] and 10% reported by Heiss [20]. There is no apparent explanation for this discrepancy. Bilateral UDTs were never repaired at the same time in this series and their operations were usually separated by at least three months until the final outcome of the first orchidopexy was determined [21]. If that outcome was not satisfactory, a second surgical opinion was obtained for the patient. Hormone treatment was never as popular in North America as it was in Europe during the 35 years of this series [22,24]. Moreover, human chorionic gonadotropin (hCG) has recently been replaced by luteinizing hormone-releasing hormone (LHRH) [24]. In this series, hCG was the only hormone used and only in 17 (1.2%) boys, 11 with bilateral UDT, with a 45% success. Other authors have reported success rates of 6%–66% in boys older than four years with bilateral undescended testes or retractile testes [10,22,24,45–47]. In unilateral UDT, only 14% of boys have successful hormonal treatment [24]. The definition of types of true UDT can be confusing in the literature (Fig. 1). There were attempted orchidopexies in 81% of our series involving the common (low) type of UDT often referred to elsewhere as intracanalicular [24] (Table 2). The second commonest UDT was ectopic (12.5%) [48]. Hutcheson has stated that the ectopic and common types of undescended testes are variants of the same congenital anomaly with the ectopic type reported as occurring in about 10% of all UDT [48]. “Whether testes in the superficial inguinal pouch should be labeled as ectopic is controversial.… Truly ectopic testes may be located in the perineum, femoral or pubopenile regions or contra-lateral hemiscrotum…” — as was seen in only five of ours [24]. The third commonest type of UDT in our series was the high type seen in only 6.5% of our series and consistent with the literature range of 5%–10% of cryptorchid boys [24]. The standard (regular) repair was tried in over 95% of UDTs from outside the external ring (ectopic type) up to the internal ring (common (low) type) and in some high types. It was invariably done through the usual pediatric inguinal hernia incision, with a lateral extension if needed (Table 2). The standard repair was inadequate in just over half of our high intra-abdominal UDT because of very short spermatic vessels, and one of three different repairs was tried (Table 1) [21]. A one-stage open Fowler–Stephens procedure was the commonest strategy (n = 34), in which the vessels were divided as far away as
Table 3b Post-operative wound-related complications (excluding atrophy) (n = 36, 2.5% of total). a) Infection n = 29 i) Inguinal incision n = 18 ii) Scrotal incision n = 11 b) Other scrotal incision complications n = 7 i) Dehiscence n = 4 ii) Bleeding n = 3
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Table 4 Atrophic* testes after attempted orchidopexy (all types true UDT). Type of UDT
Total attempted orchidopexies (% of 1400)
Mean Age (yr)
Majority side
Total atrophic ⁎ testes
FOUND Atrophic
MADE Atrophic
Common (low) Ectopic Sub-total
1135 (81%) 174 (12.5%) 1309 (93.5%)
5.4 8.6 7
R R R
83 4 87
High
91 (6.5%)
4.8
R
24
Total
1400
5.4
R
111 (8% of 1400)
27 2 29 (33% of 87) 16 (67% of 24) 45 (41% of 111)
56 2 58 (67% of 87) 8 (33% of 24) 66 (59% of 111)
⁎ ATROPHIC (absent, impalpable, missing, nonpalpable, not felt, no testis, nubbin, small, tiny, vanishing).
possible from the testis, usually providing sufficient length for an orchidopexy [18,21,29,33,49]. Gross [21] first suggested in 1953 that a two-stage procedure may be of value by leaving the mobilized undescended testis at the lower most part of the canal or just outside the external ring for a year or two. This modified (Corkery) procedure [30] where a Silon sheath was placed surrounding the cord structures and testis in the lower inguinal canal until the second stage was used in 10 cases in this series. The third procedure was a small McBurneylike lower quadrant abdominal incision to explore the retroperitoneal area and, if possible, mobilize the intra-abdominal testis [31,35]. This Jones procedure was attempted in eight instances, but if the vessels required division, it was included under the Fowler–Stephens approach [29]. Four testes (0.2%) required removal because they could not be brought down close to the scrotum, even after the Fowler–Stephens [29] or Jones [31] procedures were tried; this did not occur using the Corkery [30] procedure. With these different operations used over many years, surgeons have achieved surprisingly different results from 1%–40% success [18,21,29-31,33,35,49]. Follow-up of all the patients was carried out by the senior author with his surgical residents and began at two weeks. It was our observation that the most serious post-operative complication (testis MADE atrophic) occurred within three months. For that reason alone, the minimum follow-up was at least three months. If there was a rare post-operative problem (e.g. wound infection), more frequent visits became necessary until the problem resolved. Very few children were lost to follow-up because of the perceived importance of the orchidopexy by the family. We believe that pre-operative, intra-operative and postoperative complications (excluding atrophic testes) have matched results reported in the literature. Without question success may be defined as a “viable testis positioned in the scrotum” [2]. We have arbitrarily added that the testis must be at least two-thirds the size of its contralateral fellow. Nonetheless, there is much confusion in the literature about what constitutes an atrophic testis, (nonpalpable [6,8,14,15,19,20,24,29,33,35,37,50–57], vanishing [6,15,16,20,37,57,58], nubbin [6,15,55,57]). We reviewed 33 papers and/or chapters on this topic written from 1953 to 2009 in which 12 different words (from atrophic to vanishing) were used by authors, with 15 (45%) using up to six different words for the same thing, 10 authors not mentioning testicular atrophy at all, and nine others being unclear in their definition. It is hard to tell whether a smaller than normal testis after orchidopexy was indeed considered atrophic as it was in our series (21%). Esposito [59] claimed “that
Table 5a Risk factors associated with postoperative testicular atrophy (univariate analysis). Risk factors
MADE atrophic (n = 66)
Non-atrophic (n = 1289)
P value (b0.05)
High testicle Vas problem Preoperative torsion
21.6% 3.6% 2.7%
5.1% 0.9% 0.6%
0.0001 0.007 0.01
greater than 83% of patients…had satisfactory results. The operated testis was always significantly smaller compared to the normal testis but was well vascularized”. We would have counted these “smaller” testes as atrophic. In the literature, the incidence of atrophy after an attempted orchidopexy for a true UDT ranges from 5% to 12% [17,34,36,49,60]. In our series, although 2/3 of the total 111 atrophic testes were MADE atrophic, the reverse was true in the high type. This suggests that the higher the undescended testis, the greater the chance that it will be FOUND atrophic. No other authors have reported this distinction. The literature certainly agrees with the overall fact that the higher the undescended testis, the greater the chance of testicular atrophy [2,49,60]. It was the policy for the patients in this series who had an impalpable testis (other than a proven true vanishing testicle from an intrauterine torsion) to be investigated with radiological imaging (e.g. ultrasonography (US)) to try and identify it without surgical intervention. The former approach was successful in about 50% of our cases and this has been similarly reported in the literature with success rates of 50%–75% [6,50,52,53]. A negative finding was unacceptable and magnetic resonance imaging (MRI) was then requested; this has been reported as having 65%–75% success by other authors [51]. Therefore, only if confirmation of the impalpable UDT was not made and/or was inconclusive, did the child undergo inguinal exploration [61]. The latter occurred during the first 20 years of this series, and after that laparoscopy with attempted orchidopexy was the procedure of choice [20,62]. There is controversy in the literature about whether a testicular “nubbin” carries a risk of malignancy and therefore requires excision [57,58]. In our series, we made no attempt to remove any residual testicular remnants and/or nubbins (unless for technical reasons) at the time of exploration. The largest published series that we could find was a 1995 review of 8425 orchidopexies for UDT which focused on “success rates”. In this, Docimo [49] reviewed 70 years (up to 1995) of more than 300 articles and book chapters. In his review, “success of orchidopexy (was) defined as scrotal position and absence of atrophy…”, but the results in his review were quite variable. We were satisfied with any position in the scrotum, and considered a one-third decrease in the normal size as atrophic. Some of the “successes” in the papers reviewed in Docimo’s publication were recorded as “testicular hypotrophy, decrease in testicular volume” [49]. He also classified “orchiectomy” for inability to achieve length as a failure, yet he excluded orchiectomy as an equivalent to testicular atrophy.
Table 5b Predictors for postoperative testicular atrophy (multivariate analysis).
High testicle Vas problems Preoperative torsion
OR (CI)
P VALUE (b0.05)
2.8 (1.15 - 6.7) 1.6 (1.05 - 17.3) 3.1 (1.02 - 21.3)
0.002 0.01 0.03
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Table 6 Atrophic testes after attempted orchidopexy (True high UDT, n = 91). Operation
Total Orchidopexies
Mean Age (yr)
Majority side
⁎ Total atrophic testes
FOUND Atrophic
MADE Atrophic
Standard (regular) Non-Standard Fowler–Stephens Corkery Jones TOTAL
39 (43% of 91) 52 (57% of 91) 34 10 8 91 (6% of 1400)
5.4 4.8
R L R L R R
9 15 10 0 5 24 (26% of 91)
9 7 3 0 4 16 (67% of 24)
0 8 ⁎7 0 1 8 (33% of 24)
4.8
⁎ Includes 4 orchidectomies for testes unable to be brought down.
In Docimo’s large review series, the result rate for his “canalicular” type was 87% compared to our 93% common (low) type, and his “beyond the external ring” type was 92% to our ectopic 97%. His success rate for the high type was 78% compared to our 72% (Table 2) [49]. Docimo [49] also categorized his series’ results by the type of orchidopexy. He noted that “inguinal orchidopexy” was performed in 66% of his cases and was successful in 88%, whereas our similar 1348 standard (regular) repairs were 96.3% of our cases and had a success rate of 93% (Table 2). Their high 791 repairs that had five different repairs were 31% of their total cases (n = 2491) and had a success rate of 72%, but our 52 similar high cases that had three different repairs totaled only 3.7% of our 1400 cases and also had a success rate of 72% (Table 2). However, none of our patients had microvascular autotransplantation. Their Fowler–Stephens orchidopexies were done both in one stage (80%) and two stages (20%) with success rates of 66% and 76% respectively. The success rate in our small group of onestage Fowler–Stephens repairs was 71%. The Corkery two-stage orchidopexies with a Silon sheath were 72% successful in his review, 83% successful with both Steinhardt [63], and Ionkov [64] and 100% successful in our 10 cases. The one-stage Jones transabdominal retroperitoneal explorations were 81% successful in Docimo’s collective review as compared with our 38% success rate in just eight cases (Table 2) [49]. Since no attempt to categorize the atrophic testicle as FOUND or MADE was observed in the literature, we have some observations about these two types (Tables 4, 6). The FOUND atrophic true UDT, (as opposed to the vanishing scrotal testicle from the prenatal torsion of a descended testicle), is also assumed to be associated with a vascular problem and this vanishing testis (testicular regression syndrome, regressed testes) [16] almost always occurs in utero. There does not seem to be any way of predicting it, preventing it and/or treating it. This FOUND atrophic testis occurred in 3.2% of our orchidopexies for true UDT, 41% of our total atrophic testes and in 67% of the high ones (Table 4). The latter are also the ones with the poorest success rate throughout the literature [49]. Of more importance, 4.7% of orchidopexies for true UDT were MADE atrophic; this was 59% of our total atrophic testes and was surprisingly 67% of the lower, easier undescended testes to fix (Table 4). These are the atrophic results that are potentially preventable. In the literature, more than 25% of the abdominal testes become failures of orchidopexy, and if these high testes require division of their spermatic vessels, orchidopexy fails in about 30% [49]. Finally, after looking at all factors for post-operative atrophy, only the high testis, vas problems and pre-operative torsion seemed to be independent risk factors. References [1] Bonney T, Southwell B, Donnath S, et al. Orchidopexy trends in the paediatric population of Victoria, 1999–2006. J Pediatr Surg 2009;44:427–31. [2] Hutcheson JC, Cooper CS, Snyder III HM. The anatomical approach to inguinal orchiopexy. J Urol 2000;164:1702–4.
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[35] Gheiler EL, Barthold JS, González R. Benefits of laparoscopy and the Jones technique for the nonpalpable testis. J Urol 1997;158:1948–51. [36] Law GS, Pérez LM, Joseph DB. Two-stage Fowler–Stephens orchiopexy with laparoscopic clipping of the spermatic vessels. J Urol 1997;158:1205–7. [37] Bar-Maor JA, Groisman G, Lam M. Antenatal torsion of the testes: a cause of vanishing testis syndrome. Pediatr Surg Int 1993;8:236–8. [38] La Scala GC, Ein SH. Retractile testes: an outcome analysis on 150 patients. J Pediatr Surg 2004;39:1014–7. [39] Agarwal PK, Diaz M, Elder JS. Retractile testis — is it really a normal variant? J Urol 2006;175:1496–9. [40] Cortes D. Cryptorchidism — aspects of pathogenesis, histology and treatment. Scand J Urol Nephrol Suppl 1998;196:1–54. [41] Cortes D, Thorup JM, Visfeldt J, et al. Is infertility after surgery for cryptorchidism congenital or acquired? Pediatr Surg Int 1998;14:6–8. [42] Perrelli L, Pintus C, Manzoni C, et al. Cryptorchidism: a study of histological changes in undescended testis related to age. Pediatr Med Chir 1997;19:451–6. [43] Mengel W, Hienz HA, Sippe II WG, et al. Studies on cryptorchidism: a comparison of histological findings in the germinative epithelium before and after the second year of life. J Pediatr Surg 1974;9:445–50. [44] D’Agostino S, Zen F, Ioverno E, et al. Cryptorchidism and fertility: evaluation in adult age. Pediatr Med Chir 1996;18:37–40. [45] Aycan Z, Ustünsalih-Inan Y, Cetinkaya E, et al. Evaluation of low-dose hCG treatment for cryptorchidism. Turk J Pediatr 2006;48:228–31. [46] Giannopoulos MF, Vlachakis IG, Charissis GC. 13 years’ experience with the combined hormonal therapy of cryptorchidism. Horm Res 2001;55:33–7. [47] Demirbilek S, Atayurt HF, Celik N, et al. Does treatment with human chorionic gonadotropin induce reversible changes in undescended testes in boys? Pediatr Surg Int 1997;12:591–4. [48] Hutcheson JC, Snyder III HM, Zuñiaga ZU, et al. Ectopic and undescended testes: 2 variants of a single congenital anomaly? J Urol 2000;163:961–3. [49] Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995;154:1148–52.
[50] Cain MP, Garra B, Gibbons MD. Scrotal-inguinal ultrasonography: a technique for identifying the nonpalpable inguinal testis without laparoscopy. J Urol 1996;156:791–4. [51] Sarihan H, Sari A, Abes M, et al. Nonpalpable undescending testis. Value of magnetic resonance imaging. Minerva Urol Nefrol 1998;50:233–6. [52] Lam WW, Tam PK, Ai VH, et al. Using gadolinium-infusion MR venography to show the impalpable testis in pediatric patients. Am J Roentgenol 2001;176:1221–6. [53] Elder JS. Ultrasonagraphy is unnecessary in evaluating boys with a nonpalpable testis. Pediatrics 2002;110:748–51. [54] Efrati Y, Lotan G, Klin B, et al. Non-palpable testicle — the role of laparoscopy. Harefuah 2002;141:934–7. [55] Belman AB, Rushton HG. Is an empty left hemiscrotum and hypertrophied right descended testis predictive of perinatal torsion? J Urol 2003;170:1674–6. [56] Shah A, Shah A. Impalpable testes — is imaging really helpful? Indian Pediatr 2006;43:720–3. [57] Emir H, Ayik B, Elicevik M, et al. Histological evaluation of the testicular nubbins in patients with nonpalpable testis: assessment of etiology and surgical approach. Pediatr Surg Int 2007;23:41–4. [58] Grady RW, Mitchell ME, Carr MC. Laparoscopic and histologic evaluation of the inguinal vanishing testis. Urology 1998;52:866–9. [59] Esposito C, Vallone G, Savanelli A, et al. Long-term outcome of laparoscopic Fowler– Stephens orchiopexy in boys with intra-abdominal testis. J Urol 2009;181:1851–6. [60] Taran I, Elder JS. Results of orchiopexy for the undescended testis. World J Urol 2006;24:231–9. [61] Siemer S, Humke U, Uder M, et al. Diagnosis of nonpalpable testes in childhood: comparison of magnetic resonance imaging and laparoscopy in a prospective study. Eur J Pediatr Surg 2000;10:114–8. [62] Siemer S, Humke U, Uder M, et al. Diagnosis of non-palpable testis: value of a new miniaturized laparoscope. Langenbecks Arch Chir Suppl Kongressbd 1998;115:116–9. [63] Steinhardt GF, Kroovand RL, Perlmutter AD. Orchiopexy: planned 2-stage technique. J Urol 1985;133:434–5. [64] Ionkov A, Chatalbashev N. Two-stage orchidopexy — an alternative to orchiectomy in cryptorchidism. Khirurgiia (Sofiia) 2006:17–8.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Testicular atrophy after attempted pediatric orchidopexy for true undescended testis Sigmund H. Ein ⁎, Ahmed Nasr, Paul W. Wales, Arlene Ein Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Ontario, Canada, M5G 1X8
a r t i c l e
i n f o
Article history: Received 6 November 2013 Accepted 10 November 2013 Key words: Undescended testis Orchidopexy Risk factors Atrophic testis
a b s t r a c t Background/Purpose: A normal testis in the scrotum is the most important outcome of the attempted pediatric orchidopexy for a true undescended testis. The reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent to unclear. Our purpose in this study was to estimate the incidence of and associated risk factors for post-orchidopexy testicular atrophy. Methods: We performed a retrospective review of data from children who had an attempted orchidopexy for a true undescended testis from 1969 to 2003 inclusive. REB approval 1000011987. Results: There were 1400 attempted orchidopexies involving common (low) type (n = 1135), ectopic type (n = 174), and high type testes (n = 91). There were a total of 111/1400 (8%) atrophic testes, mostly rightsided. 66/111 (59%) were MADE atrophic, and 45 (41%) were FOUND atrophic. Of the 1135 common type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9%, respectively. The most significant risk factors associated with testes MADE atrophic were high testicle, vas problems, and pre-operative torsion. Conclusions: In this series, the incidence of post-operative testicular atrophy that was MADE was 5% in the common (low) type and 9% in the high type. These numbers and the above risk factors should be quoted to the caregiver during pre-operative informed consent. © 2014 Elsevier Inc. All rights reserved.
Today, orchidopexy is the fourth most common pediatric general surgical operation after appendectomy, circumcision and hernia repair [1]. The incidence of undescended testicle (UDT) is said to be between three and five percent at birth, but by one year of age 0.8% to 1.6% [2]. The most important aspect of the attempted pediatric orchidopexy for a true undescended testis is the end result of a normal testis in the scrotum [2]. However, reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent [1– 12] to unclear [13–23]. Our objectives in this study were to assess the risk factors associated with testicular atrophy after attempted orchidopexy. 1. Methods This was a retrospective cohort study from July 1969 to December 2003 inclusive of children treated at The Hospital for Sick Children (HSC), Toronto. The following variables were collected: age, weight, side or bilateral, hormone treatment, other medical problems, type of true undescended testis, pre-orchidopexy complications and problems, type of orchidopexy repair, intra-operative and post-operative complications, results (focusing on risk factors for atrophic testes). Follow-up of all the patients until their testicular problem was solved
⁎ Corresponding author. Tel.: +1 416 813 6405; fax: +1 905 576 1735. E-mail address: [email protected] (S.H. Ein). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.11.048
was carried out by the senior author with his surgical residents. This review received HSC Research Ethics Board approval (1000011987). We used the following definitions: testicular atrophy — decrease in size of the testicle by one-third or more compared to the contralateral testicle; low (common) UDT — testis found at the mid/lower inguinal canal (intra-canalicular) + complete indirect inguinal hernia; ectopic UDT — testis found at/outside external ring ± small indirect inguinal hernia; high undescended testis — testis found at high inguinal canal, at internal ring (peeping testis) or intra-abdominal + complete indirect inguinal hernia. All operations were done under general anesthesia along with either caudal analgesia or local nerve block. Unless there were other medical problems and/or emergencies, the majority of these procedures were done as elective outpatient operations. Data were compared using Chi square for categorical variables and student’s T test for continuous ones. A logistic regression model was made with an aim to predict variables associated with post-operative testicular atrophy. A P-value b 0.05 was considered significant. 2. Results There were 1400 [1368 (97.8%) unilateral and 32 (2.2%) bilateral] true UDTs who had an attempted orchidopexy; the 32 bilateral ones in 16 children were operated on at separate operations (Fig. 1). The mean age at operation was 5.4 years (range: 1 month to 18 years); the weight ranged between 1.9 and 113 kg. There were 55% rightsided, 44.5% left-sided and 0.5% bilateral.
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Fig. 1. Types of true undescended testes that underwent attempted orchidopexy.
From this group of 1400, there were 182 (13%) boys who had preorchidopexy complications and problems (excluding atrophic testes); the most common category was 64 (4.5% of 1400) secondary orchidopexies (recurrent or redo orchidopexy; [24–28] post-operative inguinal hernia repair) (Table 1). 2.1. Operative details There were 1400 attempted orchidopexies involving common (low) UDT (n = 1135, 81%), ectopic UDT (n = 174, 12.5%), and high UDT (91, 6.5%) (Fig. 1). There were 1348 standard (regular) repairs, for the three types of UDT (n = 1135 common (low), n = 174 ectopic and n = 39 high) (Table 2). Within the ectopic group were five with their testes located in the perineum (n = 2), groin (n = 2), and thigh (n = 1). The remaining 52 high undescended testes, felt to be too high to have a standard (regular) repair, received one of three different repairs: onestage open Fowler–Stephens [29] (n = 34), two-stage open Corkery [30] (Silon sheath) (n = 10) and Jones [31] (one-stage open retroperitoneal) (n = 8). Each testis was placed in a dartos (Koop, subcutaneous) scrotal pouch, with the entrance of the pouch narrowed by 1 or 2
sutures. No suture was placed through the testis to fix it in position within the pouch or scrotum [7,32]. Seventy-one (5%) had concomitant procedures (the commonest was circumcision 45%). Of the 43 (3.1%) boys in this series who had other medical problems and were operated on, 15 (33% of 43) were of the developmental delay variety, with almost all of the others having some kind of congenital anomaly. Six (0.4%) were abdominal wall and/or diaphragmatic defects (omphalocele n = 3, diaphragmatic hernia n = 2, gastroschisis n = 1), and all had delayed attempted orchidopexy with 50% success. There were 21 (1.5%) intra-operative orchidopexy complications and problems (including orchidectomy and considered an atrophic testis). The commonest was related to the vas. There were five orchidectomies (Table 3a). 2.2. Outcomes There were 36 (2.5%) post-operative orchidopexy complications, (excluding atrophic testis) the most common of which was wound infection (Table 3b).
Table 1 Pre-orchidopexy complications and problems (excluding atrophic testes). COMPLICATION OR PROBLEM SECONDARY (recurrent/redo orchidopexy; post-operative inguinal hernia repair) INCARCERATION (Inguinal hernia with undescended testis) RETRACTILE (late ascent; small testis) TORSION (of true undescended testis) TOTAL
NUMBER (% of 1400)
MEAN AGE (yr)
MAJORITY SIDE
64 (4.5%)
6.5
R
61 (4.3%)
1.1
R
46 (3.2%)
5.4
R
11 (0.7%)
3.6
L
182 (13%)
4.1
R
S.H. Ein et al. / Journal of Pediatric Surgery 49 (2014) 317–322 Table 2 Results of attempted orchidopexy for type of true undescended testes (UDTs). Type of Orchidopexy
Standard (regular) Fowler–Stephens (1 stage, open) Corkery (2 stage, open, Silon) Jones (1 stage, open, retroperitoneal) Total Successful result
Common (Low) (n = 1135) Ectopic (n = 174)
Types of true UDTs High
Total (Types of Testes)
1309
39 34
1348 52
1309
Successful results %
93% 71%
10
100%
8
38%
91 74%
1400 92%
92%
There were a total of 111/1400 (8%) atrophic testes, mostly right-sided of which 66/111 (59%) were MADE atrophic and 45 (41%) were FOUND atrophic (Table 4). Of the 1135 common (low) type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9% respectively. The median age for testicular atrophy was 4.8 years: (range 7 days-18 years) at operation; all atrophic testicles were noted within three months postoperatively. Risk factors were compared between children who had had postoperative testicular atrophy and children who did not. In this univariate analysis (Table 5a), high position of the testicle, vas problems and pre-operative torsion were significantly associated with post-operative atrophy. This was further investigated using a logistic regression model with the outcome being post-operative atrophy (Table 5b). Variables identified in the univariate analysis were entered in the model and remained significant including high position of the testis, vas problems and pre-operative torsion. 3. Discussion This is the largest reported series of pediatric orchidopexies by one pediatric surgeon and covers a 35 year period. Other similarly large reports come from several pediatric centers, but it is not clear how many pediatric surgeons were involved in each review [9,10,19,21,33–37.] Although there were a total of 1881 boys initially evaluated in this series with a total of 2039 possible UDTs, not all of these were true undescended testes; this was also a similar observation in other series [3,4,11,21,38,39]. Only 1400 attempted orchidopexies for true UDTs were included in this series (Fig. 1) and 536 true UDTs were not operated on. The commonest reason was developmental delay (25%). Sixty-three boys with so-called vanishing scrotal testicles (from prenatal torsion of a descended testicle) and 40 post-testicular torsion orchidopexies in normally descended testes were also not counted as true UDT in this series. Some authors have included the latter two categories in their overall total of UDT and orchidopexies [16,20,21,24,29,33,35,37]. Although the optimum age recommended for orchidopexy was between nine and 12 years in the 1950 s [21], this has steadily decreased to one year or younger [24]. The mean age of the children in this series (as in some others [9]) was five years, although over the 35 years (1969 to 2003 inclusive) of the series, the mean age had Table 3a Intraoperative orchidopexy complications and problems (including atrophy *) [n = 21, 1.5% of total]. Vas Deferens n = 16 a) NO Vas n = 9 b) Not connected with testis n = 6 c) Cut n = 1 Orchidectomy * n = 5 d) Unable to bring testis down n = 4 e) Torsion of undescended testicular dermoid n = 1
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decreased from six years in the first half of this series to four years in the latter half. The lack of conformity of this series to the recommended age for orchidopexy is thought to be due to the local referral patterns. The accepted reason for the previous older age orchidopexy was that the infertility of these undescended testes was blamed on their congenital aspect; presently, the surgical treatment is done between one and two years before the germ cells disappear from the undescended testis [40–42]. Supporting this younger operative approach, Michikawa [13] showed that orchidopexy at less than two years of age prevented morphological changes in the repaired undescended testis [43]. Nonetheless, D’Agostino [44] has reported that “the timing of surgery and the anatomical position of the cryptorchid testes do not seem to affect the fertility rate”. More than half of the 1400 true undescended testes were on the right side, as in other series [21,33], but there were only 32 (2.2%) bilateral testes in 16 patients in our series compared with 20% in Gross’ series, [21] and 10% reported by Heiss [20]. There is no apparent explanation for this discrepancy. Bilateral UDTs were never repaired at the same time in this series and their operations were usually separated by at least three months until the final outcome of the first orchidopexy was determined [21]. If that outcome was not satisfactory, a second surgical opinion was obtained for the patient. Hormone treatment was never as popular in North America as it was in Europe during the 35 years of this series [22,24]. Moreover, human chorionic gonadotropin (hCG) has recently been replaced by luteinizing hormone-releasing hormone (LHRH) [24]. In this series, hCG was the only hormone used and only in 17 (1.2%) boys, 11 with bilateral UDT, with a 45% success. Other authors have reported success rates of 6%–66% in boys older than four years with bilateral undescended testes or retractile testes [10,22,24,45–47]. In unilateral UDT, only 14% of boys have successful hormonal treatment [24]. The definition of types of true UDT can be confusing in the literature (Fig. 1). There were attempted orchidopexies in 81% of our series involving the common (low) type of UDT often referred to elsewhere as intracanalicular [24] (Table 2). The second commonest UDT was ectopic (12.5%) [48]. Hutcheson has stated that the ectopic and common types of undescended testes are variants of the same congenital anomaly with the ectopic type reported as occurring in about 10% of all UDT [48]. “Whether testes in the superficial inguinal pouch should be labeled as ectopic is controversial.… Truly ectopic testes may be located in the perineum, femoral or pubopenile regions or contra-lateral hemiscrotum…” — as was seen in only five of ours [24]. The third commonest type of UDT in our series was the high type seen in only 6.5% of our series and consistent with the literature range of 5%–10% of cryptorchid boys [24]. The standard (regular) repair was tried in over 95% of UDTs from outside the external ring (ectopic type) up to the internal ring (common (low) type) and in some high types. It was invariably done through the usual pediatric inguinal hernia incision, with a lateral extension if needed (Table 2). The standard repair was inadequate in just over half of our high intra-abdominal UDT because of very short spermatic vessels, and one of three different repairs was tried (Table 1) [21]. A one-stage open Fowler–Stephens procedure was the commonest strategy (n = 34), in which the vessels were divided as far away as
Table 3b Post-operative wound-related complications (excluding atrophy) (n = 36, 2.5% of total). a) Infection n = 29 i) Inguinal incision n = 18 ii) Scrotal incision n = 11 b) Other scrotal incision complications n = 7 i) Dehiscence n = 4 ii) Bleeding n = 3
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Table 4 Atrophic* testes after attempted orchidopexy (all types true UDT). Type of UDT
Total attempted orchidopexies (% of 1400)
Mean Age (yr)
Majority side
Total atrophic ⁎ testes
FOUND Atrophic
MADE Atrophic
Common (low) Ectopic Sub-total
1135 (81%) 174 (12.5%) 1309 (93.5%)
5.4 8.6 7
R R R
83 4 87
High
91 (6.5%)
4.8
R
24
Total
1400
5.4
R
111 (8% of 1400)
27 2 29 (33% of 87) 16 (67% of 24) 45 (41% of 111)
56 2 58 (67% of 87) 8 (33% of 24) 66 (59% of 111)
⁎ ATROPHIC (absent, impalpable, missing, nonpalpable, not felt, no testis, nubbin, small, tiny, vanishing).
possible from the testis, usually providing sufficient length for an orchidopexy [18,21,29,33,49]. Gross [21] first suggested in 1953 that a two-stage procedure may be of value by leaving the mobilized undescended testis at the lower most part of the canal or just outside the external ring for a year or two. This modified (Corkery) procedure [30] where a Silon sheath was placed surrounding the cord structures and testis in the lower inguinal canal until the second stage was used in 10 cases in this series. The third procedure was a small McBurneylike lower quadrant abdominal incision to explore the retroperitoneal area and, if possible, mobilize the intra-abdominal testis [31,35]. This Jones procedure was attempted in eight instances, but if the vessels required division, it was included under the Fowler–Stephens approach [29]. Four testes (0.2%) required removal because they could not be brought down close to the scrotum, even after the Fowler–Stephens [29] or Jones [31] procedures were tried; this did not occur using the Corkery [30] procedure. With these different operations used over many years, surgeons have achieved surprisingly different results from 1%–40% success [18,21,29-31,33,35,49]. Follow-up of all the patients was carried out by the senior author with his surgical residents and began at two weeks. It was our observation that the most serious post-operative complication (testis MADE atrophic) occurred within three months. For that reason alone, the minimum follow-up was at least three months. If there was a rare post-operative problem (e.g. wound infection), more frequent visits became necessary until the problem resolved. Very few children were lost to follow-up because of the perceived importance of the orchidopexy by the family. We believe that pre-operative, intra-operative and postoperative complications (excluding atrophic testes) have matched results reported in the literature. Without question success may be defined as a “viable testis positioned in the scrotum” [2]. We have arbitrarily added that the testis must be at least two-thirds the size of its contralateral fellow. Nonetheless, there is much confusion in the literature about what constitutes an atrophic testis, (nonpalpable [6,8,14,15,19,20,24,29,33,35,37,50–57], vanishing [6,15,16,20,37,57,58], nubbin [6,15,55,57]). We reviewed 33 papers and/or chapters on this topic written from 1953 to 2009 in which 12 different words (from atrophic to vanishing) were used by authors, with 15 (45%) using up to six different words for the same thing, 10 authors not mentioning testicular atrophy at all, and nine others being unclear in their definition. It is hard to tell whether a smaller than normal testis after orchidopexy was indeed considered atrophic as it was in our series (21%). Esposito [59] claimed “that
Table 5a Risk factors associated with postoperative testicular atrophy (univariate analysis). Risk factors
MADE atrophic (n = 66)
Non-atrophic (n = 1289)
P value (b0.05)
High testicle Vas problem Preoperative torsion
21.6% 3.6% 2.7%
5.1% 0.9% 0.6%
0.0001 0.007 0.01
greater than 83% of patients…had satisfactory results. The operated testis was always significantly smaller compared to the normal testis but was well vascularized”. We would have counted these “smaller” testes as atrophic. In the literature, the incidence of atrophy after an attempted orchidopexy for a true UDT ranges from 5% to 12% [17,34,36,49,60]. In our series, although 2/3 of the total 111 atrophic testes were MADE atrophic, the reverse was true in the high type. This suggests that the higher the undescended testis, the greater the chance that it will be FOUND atrophic. No other authors have reported this distinction. The literature certainly agrees with the overall fact that the higher the undescended testis, the greater the chance of testicular atrophy [2,49,60]. It was the policy for the patients in this series who had an impalpable testis (other than a proven true vanishing testicle from an intrauterine torsion) to be investigated with radiological imaging (e.g. ultrasonography (US)) to try and identify it without surgical intervention. The former approach was successful in about 50% of our cases and this has been similarly reported in the literature with success rates of 50%–75% [6,50,52,53]. A negative finding was unacceptable and magnetic resonance imaging (MRI) was then requested; this has been reported as having 65%–75% success by other authors [51]. Therefore, only if confirmation of the impalpable UDT was not made and/or was inconclusive, did the child undergo inguinal exploration [61]. The latter occurred during the first 20 years of this series, and after that laparoscopy with attempted orchidopexy was the procedure of choice [20,62]. There is controversy in the literature about whether a testicular “nubbin” carries a risk of malignancy and therefore requires excision [57,58]. In our series, we made no attempt to remove any residual testicular remnants and/or nubbins (unless for technical reasons) at the time of exploration. The largest published series that we could find was a 1995 review of 8425 orchidopexies for UDT which focused on “success rates”. In this, Docimo [49] reviewed 70 years (up to 1995) of more than 300 articles and book chapters. In his review, “success of orchidopexy (was) defined as scrotal position and absence of atrophy…”, but the results in his review were quite variable. We were satisfied with any position in the scrotum, and considered a one-third decrease in the normal size as atrophic. Some of the “successes” in the papers reviewed in Docimo’s publication were recorded as “testicular hypotrophy, decrease in testicular volume” [49]. He also classified “orchiectomy” for inability to achieve length as a failure, yet he excluded orchiectomy as an equivalent to testicular atrophy.
Table 5b Predictors for postoperative testicular atrophy (multivariate analysis).
High testicle Vas problems Preoperative torsion
OR (CI)
P VALUE (b0.05)
2.8 (1.15 - 6.7) 1.6 (1.05 - 17.3) 3.1 (1.02 - 21.3)
0.002 0.01 0.03
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Table 6 Atrophic testes after attempted orchidopexy (True high UDT, n = 91). Operation
Total Orchidopexies
Mean Age (yr)
Majority side
⁎ Total atrophic testes
FOUND Atrophic
MADE Atrophic
Standard (regular) Non-Standard Fowler–Stephens Corkery Jones TOTAL
39 (43% of 91) 52 (57% of 91) 34 10 8 91 (6% of 1400)
5.4 4.8
R L R L R R
9 15 10 0 5 24 (26% of 91)
9 7 3 0 4 16 (67% of 24)
0 8 ⁎7 0 1 8 (33% of 24)
4.8
⁎ Includes 4 orchidectomies for testes unable to be brought down.
In Docimo’s large review series, the result rate for his “canalicular” type was 87% compared to our 93% common (low) type, and his “beyond the external ring” type was 92% to our ectopic 97%. His success rate for the high type was 78% compared to our 72% (Table 2) [49]. Docimo [49] also categorized his series’ results by the type of orchidopexy. He noted that “inguinal orchidopexy” was performed in 66% of his cases and was successful in 88%, whereas our similar 1348 standard (regular) repairs were 96.3% of our cases and had a success rate of 93% (Table 2). Their high 791 repairs that had five different repairs were 31% of their total cases (n = 2491) and had a success rate of 72%, but our 52 similar high cases that had three different repairs totaled only 3.7% of our 1400 cases and also had a success rate of 72% (Table 2). However, none of our patients had microvascular autotransplantation. Their Fowler–Stephens orchidopexies were done both in one stage (80%) and two stages (20%) with success rates of 66% and 76% respectively. The success rate in our small group of onestage Fowler–Stephens repairs was 71%. The Corkery two-stage orchidopexies with a Silon sheath were 72% successful in his review, 83% successful with both Steinhardt [63], and Ionkov [64] and 100% successful in our 10 cases. The one-stage Jones transabdominal retroperitoneal explorations were 81% successful in Docimo’s collective review as compared with our 38% success rate in just eight cases (Table 2) [49]. Since no attempt to categorize the atrophic testicle as FOUND or MADE was observed in the literature, we have some observations about these two types (Tables 4, 6). The FOUND atrophic true UDT, (as opposed to the vanishing scrotal testicle from the prenatal torsion of a descended testicle), is also assumed to be associated with a vascular problem and this vanishing testis (testicular regression syndrome, regressed testes) [16] almost always occurs in utero. There does not seem to be any way of predicting it, preventing it and/or treating it. This FOUND atrophic testis occurred in 3.2% of our orchidopexies for true UDT, 41% of our total atrophic testes and in 67% of the high ones (Table 4). The latter are also the ones with the poorest success rate throughout the literature [49]. Of more importance, 4.7% of orchidopexies for true UDT were MADE atrophic; this was 59% of our total atrophic testes and was surprisingly 67% of the lower, easier undescended testes to fix (Table 4). These are the atrophic results that are potentially preventable. In the literature, more than 25% of the abdominal testes become failures of orchidopexy, and if these high testes require division of their spermatic vessels, orchidopexy fails in about 30% [49]. Finally, after looking at all factors for post-operative atrophy, only the high testis, vas problems and pre-operative torsion seemed to be independent risk factors. References [1] Bonney T, Southwell B, Donnath S, et al. Orchidopexy trends in the paediatric population of Victoria, 1999–2006. J Pediatr Surg 2009;44:427–31. [2] Hutcheson JC, Cooper CS, Snyder III HM. The anatomical approach to inguinal orchiopexy. J Urol 2000;164:1702–4.
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