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Tissue expansion of underdeveloped scrotum to accommodate large testicular prosthesis
TISSUE EXPANSION OF UNDERDEVELOPED TO ACCOMMODATE
LARGE TESTICULAR
SCROTUM PROSTHESIS
A Technique JOHN K. LATTIMER, MICHAEL
M.D.,
D.Sc.
C. STALNECKER,
M.D.
From the Urologic and Plastic Surgical Services, Columbia-Presbyterian Medical Center, New York, New York
ABSTRACT-A contracted empty scrotum in a young man will not accept an artificial testis satisfactorily using any of the standard techniques. Previous operative scars, as from a failed orchiopexy, have often added to the difficulties. Greatly enlarging the scrotum by gradual distention of a tissue expander implanted in the contracted side has been successful in overcoming this problem, both cosmetically and functionally.
Underdevelopment of the scrotum is often seen in children who have no testis in one side of the sac. In the past, inserting a small prosthesis at an early age and replacing it periodically with progressively larger ones, has not proved satisfactory. Poor results have been reported in a large percentage of the patients.‘m3 Each larger replacement is painful for a while, and it often rides behind or in front of the good testis. Many of the prostheses are extruded through the incision. Consequently the children tend to resist submitting to the additional operations, so that the optimum time is missed and the program of keeping the scrotum stretched falls behind. The overall results have been poor. Moreover, the degree of compensatory hypertrophy tends to be greater in boys who lose a testis early in life, and even though a final prosthesis can be ordered in a “largerthan-normal” size, it may still not be large enough to match the good contralateral testis. Marshall’s3 review found that inadequate scrotal distention and wound dehiscence were the most common problems. The highest complication rates were seen in patients in whom inflammatory conditions had led to orchiec-
6
tomy, i.e., those with more scar tissue. Persistent pain was the next most frequent problem, and this too was more prevalent in patients with previous inflammatory conditions. The placement of successively larger implants is in itself a method of “staged” tissue expansion, but has never been satisfactory. We need a better method. The tissue expanders used so successfully by the plastic surgeons appeared to be a relevant and applicable solution to this problem, and this technique has proved to be highly satisfactory. We report our first case herein. Tissue expansion is a technique that is now in widespread use in plastic surgery.4*5 An empty silicone balloon with an attached filling port is inserted into the area to be expanded and gradually distended with normal saline solution. In general, overexpansion is desired, but the volume of each injection is adjusted according to patient discomfort and skin flap perfusion. The technique has been most beneficial in creating tissue laxity in scarred areas requiring reconstruction, most notably for breast reconstruction after mastectomy. In this application, tissue expansion allows placement of a breast
UROLOGY
/ JANUARY 1989
/ VOLUME
XXXIII,
NUMBER
1
FIGURE 2. (A) Tissue expander deflated; filling tube extends to left to attached metal-backed filling port, and (B) expanded to 153 cc; rated volume was 100 cc.
Right testis FIGURE 1. Preoperative appearance. absent; right scrotum underdeveloped and scarred on its lateral surface. Inguinal scar from childhood hernia and orchiopexy operation visible. Note remaining “good” left testis larger than normal due to compensatory hypertrophy and pushes across midline.
prosthesis under the skin and muscle that would otherwise not accomodate the added volume. We demonstrate the application of tissue expansion to testicular prosthesis placement. Case Report This seventeen-year-old patient was born with bilateral undescended testes and as a child underwent orchiopexy and hernia repair at another institution. Postoperatively the right testis atrophied, but he had no additional surgical treatment. The right scrotum shrivelled (Fig. 1). There was no palpable testis in the hypoplastic right scrotum, and the left testis was markedly enlarged due to compensatory hypertrophy (Fig. 1). Through the old right inguinal incision, the right scrotum was explored and an atrophic cord removed. A custommade, loo-cc spherical tissue expander was folded and placed in the right scrotum. The filling valve was placed under the pubic skin in the midline and 50 cc saline injected into the expander. Two weeks later, 10 cc were injected without difficulty, but the patient returned five days later with a partially deflated expander. Further attempts to expand the prosthesis were
UROLOGY
I
FIGURE 3. Scrotum with expander its final volume (153 cc).
in right side at
not successful. Therefore, one month after the initial operation the implant was replaced with a 30-1~ tissue expander. This could not be expanded above 40 cc because the filling port lost its self-sealing properties. Another loo-cc expander (Fig. 2) was inserted and expanded to 153 cc over seven weeks without difficulty (Fig. 3). It was then removed and replaced with a larger-than-normal testicular prosthesis which was fixed to the bottom of the scrotum using our standard technique.’ The right testicular prosthesis was still slightly smaller than the very hypertrophied left testis but was in good position next to the left testis, without overriding.
JANUARY 1989 / VOLUME XXXIII, NUMBER 1
7
FIGURE 4. (A and B) Appearance one month postoperatively; satisfactory result observed for twelve months and excellent result continues.
The scrotal skin could be draped naturally over the implant, with rugae that were normal in appearance (Fig. 4). Comment This case demonstrates to an extent even greater than intended, the advantages of tissue expansion in testicular prosthesis placement. Despite technical difficulties with the implanted expanders, a good result was obtained. Additional scarring from multiple procedures was overcome, to provide adequate scrotal soft tissue coverage. Another important advantage of this method is the ability to slowly distend the scrotal skin within the patient’s tolerance of pain. If an increased volume proves too uncomfortable, fluid can be withdrawn until tissue relaxation relieves the discomfort. Thus the occasional need to remove an implant due to persistent pain is avoided. Instead of placing successively larger implants, a much better result may by obtained by overexpanding the skin well beyond the size of the final implant. This can permit a more relaxed skin draping and decrease the tendency for the implant to override or underride the normal testis. The difficulties with the expanders in this patient were unusual, even for the custom prostheses used in this case. Occasional implant leakages have occurred in other tissue expansion applications. It is possible that there is a greater propensity for problems here, due to the mobil-
8
ity of the scrotum. Motion may cause the walls of a partially inflated prosthesis to rub against themselves causing a “fold failure.” Alternatively, movement between the filling tube and expander may cause increased stresses at their junction. In fact, the first prosthesis in this case failed at just that location. Actually, the relative looseness of the scrotal layers should make it a highly satisfactory site for the use of tissue expanders. It was noted that the contractility of the scrotal wall, in anticipation of ejaculation and in response to cold stimuli, was not impaired after the tissue expansion. The scrotum’s response to warmth (by letting the testes hang lower to avoid the heat of the body) was also unimpaired. We are encouraged by the results in this case and believe it offers substantial advantages over traditional methods. 1. Expansion could proceed at a rate that was comfortable for the patient. 2. Overexpansion increased the laxity of the scrotal soft tissue around the permanent prosthesis and overcame the tendency toward overriding. 3. Scarring from previous inflammation or surgical procedures caused fewer problems because it could be slowly expanded to accommodate a large prosthesis. 4. Scrotal function (expansion and contraction) was unimpaired. The following recommendations can be made from the experience gained in this case.
UROLOGY
/ JANUARY
1989 I VOLUME XxX111, NUMBER 1
1. Use a 75-100 cc expander rather than attempting marked overexpansion of a smaller bag. 2. Placement of the filling port suprapubically, in the midline, is well accepted and easily palpated. 3. Use an adjustable-length tube, with metal connector, to attach the filling port rather than a fixed-length tube (Fig. 2). 4. Consider having an even larger custom permanent implant available when the remaining (good) testis is hypertrophied to a size larger than usual.
UROLOGY
/
JANUARY
1989
I
VOLUME
XxX111, NUMBER
630 West 168 Street New York, New York 10032 (DR. LATTIMER) References 1. Lattimer JK, et al: A natural-feeling testicular prosthesis, J Urol 110: 81 (1973). 2. Rosen JS, and Benson RC: Testicular prostheses, Urology 11: 176 (1984). 3. Marshall S: Potential problems with testicular prostheses, Urology 28: 388 (1986). 4. Radovan C: Tissue expansion in soft-tissue reconstruction, Plast Reconstr Surg 74: 482 (1984). 5. Manders EK, et al: Soft tissue expansion: concepts and complications, Plast Reconstr Surg 74: 493 (1984).
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LARGE TESTICULAR
SCROTUM PROSTHESIS
A Technique JOHN K. LATTIMER, MICHAEL
M.D.,
D.Sc.
C. STALNECKER,
M.D.
From the Urologic and Plastic Surgical Services, Columbia-Presbyterian Medical Center, New York, New York
ABSTRACT-A contracted empty scrotum in a young man will not accept an artificial testis satisfactorily using any of the standard techniques. Previous operative scars, as from a failed orchiopexy, have often added to the difficulties. Greatly enlarging the scrotum by gradual distention of a tissue expander implanted in the contracted side has been successful in overcoming this problem, both cosmetically and functionally.
Underdevelopment of the scrotum is often seen in children who have no testis in one side of the sac. In the past, inserting a small prosthesis at an early age and replacing it periodically with progressively larger ones, has not proved satisfactory. Poor results have been reported in a large percentage of the patients.‘m3 Each larger replacement is painful for a while, and it often rides behind or in front of the good testis. Many of the prostheses are extruded through the incision. Consequently the children tend to resist submitting to the additional operations, so that the optimum time is missed and the program of keeping the scrotum stretched falls behind. The overall results have been poor. Moreover, the degree of compensatory hypertrophy tends to be greater in boys who lose a testis early in life, and even though a final prosthesis can be ordered in a “largerthan-normal” size, it may still not be large enough to match the good contralateral testis. Marshall’s3 review found that inadequate scrotal distention and wound dehiscence were the most common problems. The highest complication rates were seen in patients in whom inflammatory conditions had led to orchiec-
6
tomy, i.e., those with more scar tissue. Persistent pain was the next most frequent problem, and this too was more prevalent in patients with previous inflammatory conditions. The placement of successively larger implants is in itself a method of “staged” tissue expansion, but has never been satisfactory. We need a better method. The tissue expanders used so successfully by the plastic surgeons appeared to be a relevant and applicable solution to this problem, and this technique has proved to be highly satisfactory. We report our first case herein. Tissue expansion is a technique that is now in widespread use in plastic surgery.4*5 An empty silicone balloon with an attached filling port is inserted into the area to be expanded and gradually distended with normal saline solution. In general, overexpansion is desired, but the volume of each injection is adjusted according to patient discomfort and skin flap perfusion. The technique has been most beneficial in creating tissue laxity in scarred areas requiring reconstruction, most notably for breast reconstruction after mastectomy. In this application, tissue expansion allows placement of a breast
UROLOGY
/ JANUARY 1989
/ VOLUME
XXXIII,
NUMBER
1
FIGURE 2. (A) Tissue expander deflated; filling tube extends to left to attached metal-backed filling port, and (B) expanded to 153 cc; rated volume was 100 cc.
Right testis FIGURE 1. Preoperative appearance. absent; right scrotum underdeveloped and scarred on its lateral surface. Inguinal scar from childhood hernia and orchiopexy operation visible. Note remaining “good” left testis larger than normal due to compensatory hypertrophy and pushes across midline.
prosthesis under the skin and muscle that would otherwise not accomodate the added volume. We demonstrate the application of tissue expansion to testicular prosthesis placement. Case Report This seventeen-year-old patient was born with bilateral undescended testes and as a child underwent orchiopexy and hernia repair at another institution. Postoperatively the right testis atrophied, but he had no additional surgical treatment. The right scrotum shrivelled (Fig. 1). There was no palpable testis in the hypoplastic right scrotum, and the left testis was markedly enlarged due to compensatory hypertrophy (Fig. 1). Through the old right inguinal incision, the right scrotum was explored and an atrophic cord removed. A custommade, loo-cc spherical tissue expander was folded and placed in the right scrotum. The filling valve was placed under the pubic skin in the midline and 50 cc saline injected into the expander. Two weeks later, 10 cc were injected without difficulty, but the patient returned five days later with a partially deflated expander. Further attempts to expand the prosthesis were
UROLOGY
I
FIGURE 3. Scrotum with expander its final volume (153 cc).
in right side at
not successful. Therefore, one month after the initial operation the implant was replaced with a 30-1~ tissue expander. This could not be expanded above 40 cc because the filling port lost its self-sealing properties. Another loo-cc expander (Fig. 2) was inserted and expanded to 153 cc over seven weeks without difficulty (Fig. 3). It was then removed and replaced with a larger-than-normal testicular prosthesis which was fixed to the bottom of the scrotum using our standard technique.’ The right testicular prosthesis was still slightly smaller than the very hypertrophied left testis but was in good position next to the left testis, without overriding.
JANUARY 1989 / VOLUME XXXIII, NUMBER 1
7
FIGURE 4. (A and B) Appearance one month postoperatively; satisfactory result observed for twelve months and excellent result continues.
The scrotal skin could be draped naturally over the implant, with rugae that were normal in appearance (Fig. 4). Comment This case demonstrates to an extent even greater than intended, the advantages of tissue expansion in testicular prosthesis placement. Despite technical difficulties with the implanted expanders, a good result was obtained. Additional scarring from multiple procedures was overcome, to provide adequate scrotal soft tissue coverage. Another important advantage of this method is the ability to slowly distend the scrotal skin within the patient’s tolerance of pain. If an increased volume proves too uncomfortable, fluid can be withdrawn until tissue relaxation relieves the discomfort. Thus the occasional need to remove an implant due to persistent pain is avoided. Instead of placing successively larger implants, a much better result may by obtained by overexpanding the skin well beyond the size of the final implant. This can permit a more relaxed skin draping and decrease the tendency for the implant to override or underride the normal testis. The difficulties with the expanders in this patient were unusual, even for the custom prostheses used in this case. Occasional implant leakages have occurred in other tissue expansion applications. It is possible that there is a greater propensity for problems here, due to the mobil-
8
ity of the scrotum. Motion may cause the walls of a partially inflated prosthesis to rub against themselves causing a “fold failure.” Alternatively, movement between the filling tube and expander may cause increased stresses at their junction. In fact, the first prosthesis in this case failed at just that location. Actually, the relative looseness of the scrotal layers should make it a highly satisfactory site for the use of tissue expanders. It was noted that the contractility of the scrotal wall, in anticipation of ejaculation and in response to cold stimuli, was not impaired after the tissue expansion. The scrotum’s response to warmth (by letting the testes hang lower to avoid the heat of the body) was also unimpaired. We are encouraged by the results in this case and believe it offers substantial advantages over traditional methods. 1. Expansion could proceed at a rate that was comfortable for the patient. 2. Overexpansion increased the laxity of the scrotal soft tissue around the permanent prosthesis and overcame the tendency toward overriding. 3. Scarring from previous inflammation or surgical procedures caused fewer problems because it could be slowly expanded to accommodate a large prosthesis. 4. Scrotal function (expansion and contraction) was unimpaired. The following recommendations can be made from the experience gained in this case.
UROLOGY
/ JANUARY
1989 I VOLUME XxX111, NUMBER 1
1. Use a 75-100 cc expander rather than attempting marked overexpansion of a smaller bag. 2. Placement of the filling port suprapubically, in the midline, is well accepted and easily palpated. 3. Use an adjustable-length tube, with metal connector, to attach the filling port rather than a fixed-length tube (Fig. 2). 4. Consider having an even larger custom permanent implant available when the remaining (good) testis is hypertrophied to a size larger than usual.
UROLOGY
/
JANUARY
1989
I
VOLUME
XxX111, NUMBER
630 West 168 Street New York, New York 10032 (DR. LATTIMER) References 1. Lattimer JK, et al: A natural-feeling testicular prosthesis, J Urol 110: 81 (1973). 2. Rosen JS, and Benson RC: Testicular prostheses, Urology 11: 176 (1984). 3. Marshall S: Potential problems with testicular prostheses, Urology 28: 388 (1986). 4. Radovan C: Tissue expansion in soft-tissue reconstruction, Plast Reconstr Surg 74: 482 (1984). 5. Manders EK, et al: Soft tissue expansion: concepts and complications, Plast Reconstr Surg 74: 493 (1984).
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