20 years of transcrotal orchidopexy for undescended testis: Results and outcomes

Journal of Pediatric Urology (2010) 6, 506e512

20 years of transcrotal orchidopexy for undescended testis: Results and outcomes Morris Gordon a, Raimondo M. Cervellione a,*, Antonino Morabito b, Adrian Bianchi a a b

Department of Paediatric Urology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK Department of Paediatric Surgery, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK

Received 16 September 2009; accepted 22 October 2009 Available online 26 November 2009

KEYWORDS Undescended testis; Palpable testis; Orchidopexy; Transcrotal orchidopexy; Paediatric; High scrotal orchidopexy; Single incision orchidopexy

Abstract Background: The role of the transcrotal approach to the undescended testis remains controversial despite its increasing popularity. The authors update their previous published series and review the literature on this subject, aiming to delineate the value of this technique. Methods: The authors performed a retrospective review of the transcrotal primary orchidopexy carried out to treat palpable undescended testis at Royal Manchester Children’s Hospital between 1993 and 2005. A structured review of literature published since the proposal of this technique was also performed. Results: 122 procedures were included. The transcrotal approach was successfully completed in 119 (97.5%). Additional groin incision was needed in three (2.5%) to further mobilize the spermatic cord. No immediate complications were recorded and 8.4% required a reoperative procedure. On review of the literature, a total of 16 articles were discovered spanning 1695 transcrotal procedures, including the previously published authors’ experience. On combining the data, the transcrotal approach required an additional groin incision in 4.4% of cases, 1.6% experienced immediate and/or early complications, and the overall recurrence rate was 2.0%. Conclusions: Transcrotal orchidopexy for the treatment of palpable undescended testes is a safe procedure with a long-term success rate comparable to the two-incision approach. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Introduction The majority of undescended testicles are palpable distal to the inguinal canal [1]. In 1989, Bianchi and Squire [2]

proposed that orchidopexy for the palpable undescended testis should commence with a scrotal incision, and that an additional groin incision be reserved for the few high testes that will not otherwise reach the scrotum, after maximal

* Corresponding author. Tel.: þ44 161 701 2177; fax: þ44 161 701 2928. E-mail address: [email protected] (R.M. Cervellione). 1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.10.016

20 years of transcrotal orchidopexy for undescended testis

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possible mobilization through the scrotum. The ‘Transcrotal Orchidopexy’ has the advantage of much less dissection, greater comfort for the patient, rapid healing, excellent cosmesis and a well maintained testicular position. In 1995, Bianchi and colleagues followed this up with a case series of 367 orchidopexies [3] that confirmed low complication rates and a success rate comparable to the two-incision procedure. This paper presents the results of a further case record review of transcrotal orchidopexies for the palpable undescended testes performed at the Royal Manchester Children’s Hospital from 1993 to 2005 by Bianchi and colleagues, which bring the published Manchester experience up to 489 procedures. The authors have also reviewed the literature published over the last 20 years relating to this surgical technique.

range at first operation was between 10 months and 8 years. Before operation, the position of the testes was the neck of the scrotum in 11 patients (9.0%), the external inguinal ring in 34 (27.9%), the inguinal canal in 25 (20.5%), near the internal inguinal ring in three (2.5%), ectopic position in one patient (0.8%), and 48 (39.3%) were not clearly specified but simply noted to be ‘palpable’. The transcrotal approach was completed in 119 orchidopexies (97.5%). An additional groin incision was needed on three occasions (2.5%) to further mobilize the spermatic cord. No short-term complications were recorded in any procedures. At follow up the testicular position was deemed unsatisfactory in 12 of 122 testes (9.8%) and it was elected that a redo procedure be performed. Of these 12 redo procedures, two were from the group of three transcrotal orchidopexies that were converted to a two-incision procedure. Therefore, the long-term recurrence rate for the group completed with a single transcrotal incision was 8.4% (10/119). The redo procedure was performed transcrotally on 10 occasions. One required a conventional two-incision procedure (groin and scrotum) and one a microvascular orchidopexy [4]. There were no immediate complications on reoperation and all testes at further follow up were recorded to be in the scrotum. No testes were recorded to have atrophied from any of the 122 orchidopexies. Including this report, a total of 489 transcrotal orchidopexies have been reviewed at the Royal Manchester Children’s Hospital from 1984 to 2005 [2,3]. Of these cases, 472 operations (96.5%) were completed transcrotally. Seventeen orchidopexies (3.5%) required an additional groin incision to mobilize further the spermatic cord in the retroperitoneum. Immediate or early complications, such as scrotal haematoma or infection, were experienced on seven occasions (1.4%). Testicular position was deemed unsatisfactory and a redo procedure performed in 23 of the 472 orchidopexies (4.9%) in which a transcrotal approach had been carried out. A total of three testes atrophied (0.6%). The review of the wider literature produced another 15 articles [5e19] reporting case series for the transcrotal orchidopexy. These papers report a further 1209 transcrotal procedures between 1996 and 2009. The rate of conversion to a conventional two-incision procedure at first operation is between 0% and 13%. Reported rates of immediate and early complications varied from 0% to 5.4%. Overall recurrence rate for the transcrotal cases varied from 0% to 5.4%. A summary of these studies and the Manchester experience is shown in Table 1. On combining data for the Royal Manchester Children’s Hospital with the data that is available from the other 15 case series to give an overall picture for the published data on the transcrotal approach in the last 20 years, 4.4% of procedures (75/1698) required an additional groin incision at first operation. Rates of immediate and early complications are reported for all but three of these studies [6,7,15] and when combined the total rate is 1.6% (23/1394). The overall recurrence rate for all cases in which a transcrotal approach was initially attempted was 2.0% (33/1665), although it must be noted that many papers did not specify if these recurrence figures excluded those who were converted to a two-incision approach.

Materials and methods The authors retrospectively reviewed the case records of all children who underwent orchidopexy from 1993 to 2005 at Royal Manchester Children’s Hospital. The children were under the care of Bianchi and colleagues who carry out the transcrotal approach [2] as the default procedure for all children with a palpable undescended testicle. All patients who underwent primary transcrotal orchidopexy for the treatment of palpable undescended testis were included. Position of the testes was confirmed while under anaesthetic. Cases in which conversion to a two-incision procedure took place were still included in the study. Attention was given to testicular position before and immediately after the procedure, complication rates, and overall outcome as documented at follow up. Follow ups initially took place between 6 months and 1 year after operation. Patients excluded from the study were those for whom case records were incomplete. Data were coded and entered into SPSS for Windows version 11.5 (SPSS Inc., Chicago, IL, USA) for descriptive analysis. It must be noted that paediatric surgery and paediatric urology have been performed in Manchester by Bianchi and colleagues at three different sites during the study period. For practical reasons, this review includes only the cases performed at Royal Manchester Children’s Hospital. A literature search was carried out using the search terms ‘transcrotal orchidopexy’ and all spelling derivatives, ‘single incision orchidopexy’, ‘single scrotal incision’, and ‘scrotal orchidopexy’ using the Medline database. Further articles were examined by searching for related articles on Medline and by reference searching. Articles that presented data from case series or trials looking at outcomes of the transcrotal orchidopexy were included.

Results A total of 126 orchidopexies were identified for case review within the study period. Exclusion criteria led to four procedures being removed from the study. The remaining group consisted of 118 patients, of whom four had bilateral procedures giving a total of 122 orchidopexies. The age

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Table 1

Review of the published literature regarding transcrotal orchidopexy. Year

No. of cases

Preoperative location (as described in each paper)

Inclusion criteria

Exclusion criteria

Conversion to a two-incision procedure

Immediate and early complication rate

No. of recurrences (%) [follow-up time]

Ref.

Bianchi A, Squire B

1989

120

Not specified

Not specified

5(4.2%)

3.3% 4 scrotal haematomas

0 [6 monthse3 years]

[2]

Iyer KR et al.

1995

247 new cases

IC Z 12(10.0%) EIR Z 36(30.0%) SIP Z 41(34.2%) NS Z 27(22.5%) E Z 4(2.5%) NK Z 247(100.0%)

Not specified

Not specified

9(3.6%)

13(5.3%) [1e8 years]

[3]

Lais A, Ferro F

1996

50

Not specified

Not specified

3(6%)

1(2%) [3e5 years]

[5]

Clarnette T et al.

1997

33

IC Z 7(14.0%) EIR Z 28(56.0%)) E Z 15(30.0% NK Z 33 (100%)

1.2% 2 wound infections 1 unexplained pyrexia 6% 3 scrotal haematomas

Not specified

0

Not specified

Not specified

[6]

Misra D et al.

1997

67

EIR Z 67(100.0%)

Not specified

9(13%) All with hernia sac were converted to a two-incision approach

Not specified

0 [1e5 years]

[7]

Jawad AJ

1997

106

Not specified

14(13%)

1.9% 2 wound infections

5(5.4%) [8e36 months]

[8]

Caruso AP et al.

2000

45

IC Z 18(17.0%) EIR Z 29(27.3%) SIP Z 35(33.0%) NS Z 21(19.8%) E Z 3(2.8%) EIR Z 45(100%)

Undescended testes that were recorded as normal in infancy Testes that could be manipulated into the scrotum with difficulty and on release of pressure, returned into the inguinal region All palpable testes

Redo procedures (15)

1(2.2%)

2.2% 1 scrotal haematoma

1(2.2%) [1 year]

[9]

Gokcora I, Yagmurlu A

2003

64

NK Z 64 (100%)

Acute scrotal infection and testicular torsion excluded, as well as having other surgery

0

0

0 [1-6 years]

[10]

All cases distal to the external ring Palpable undescended testes

M. Gordon et al.

Authors

2003

83

Rajimwale A, Brant WO et al.

2004

75

Handa R, Kale R et al. Bassel Y et al.

2006

35

EIR Z 35(100%)

2006

121

Dayanc M et al. Includes previous cases [19] Parsons J et al.

2007

204

E Z 10(8.3%) IC Z 14(11.6%) NS Z 17(14%) SIP Z 80(66.1%) DEIR Z 128(62.7%) IC Z 76(37.3%)

IC Z 13% EIR Z 20% NS Z 18% E Z 5%, SIP Z 44% Based on 85 cases (two excluded) IC Z 2(3%) SIP Z 42(56%) E Z 12(16%) G Z 19(25%)

71

DG Z 71(100%)

Samuel D, Izzidien A

2008

206

NK Z 206(100%)

Takahasi M et al.

2009

49

DEIR Z 49(100%)

Gordon M et al.

2009

119

IIR Z 3(2.5%) IC Z 25(20.5%) EIR Z 34(27.9%) NS Z 11(9.0%) E Z 1(0.8%) NK Z 48(39.3%)

Retractile testes, redo procedures (2)

1(1.2%)

2.4% 1 wound cellulitis 1 wound haematoma

1(1.2%) [1e36 months]

[11]

Testes that could be milked to the level of the midpubic tubercle or beyond under anaesthesia Distal to the external ring

Prior inguinal surgery, retractile testes

3(4.0%)

1.3% 1 scrotal haematoma

1(1.3%) [6 weekse 1 year]

[12]

Retractile, ectopic and redo patients

0

2.8% 1 wound infection

0 [2-6 months]

[13]

All palpable testes

Retractile testes

0

4 wound infections (3.3%)

0 [6 monthse 1 year]

[14]

Palpable testes that were non-retractile on exam under anaesthetic All cases of ectopic or ascending testes based on examination All testes that could be brought into the scrotum under manipulation with tension All palpable tested distal to Inguinal ring on exam under anaesthesia All palpable testes

Prior inguinal surgery

12(5.9%)

Not specified

Nil e Included five cases with prior surgery and three congenital abnormalities Retractile testis, ectopic testis previous inguinal surgery

14 (20%)

0

0 [1 weeke 3 months]

[16]

1(0.5%)

2 wound infections (1%)

0 [6 weekse2 years]

[17]

Prior surgery

0

0

1(2.7%)[12.1-68.8 months]

[18]

3(2.5%)

0

10(8.4%) [6 monthse2 years]

e

Inadequate note keeping (4)

[15] 0 [16-68 months] 25 children lost to follow up

(continued on next page)

509

2008

Testes that could be drawn close to or into the scrotum

20 years of transcrotal orchidopexy for undescended testis

Russinko PJ, Siddiq FM et al.

Total

Abbreviations: IIR Z internal inguinal ring, IC Z inguinal canal, EIR Z external inguinal ring, DEIC Z distal to external inguinal ring, DG Z distal groin, NS Z scrotal neck, SIP Z superficial inguinal pouch, E Z ectopic, G Z gliding, NK Z not known.

33/1665 (2.0%) [2 monthse 2 years] 23/1391(1.6%) Excluded three papers where complications not specified 75/1698 (4.4%) e

Exclusion criteria Inclusion criteria

e EIR Z 291 IIR Z 3 DEIR Z 177 SIP Z 235 DG Z 71 NS Z 91 E Z 49 IC Z 89 G Z 19 NK Z 673

Year

1989e2009

Authors

No. of cases

1698

No. of recurrences (%) [follow-up time] Immediate and early complication rate Conversion to a two-incision procedure Preoperative location (as described in each paper) Table 1 (continued).

e

M. Gordon et al. Ref.

510

Discussion Conventional orchidopexy today is still performed according to the concepts of Schuller [20] in 1881 and Bevan [21,22] in 1899 and 1903. The experiences of Bianchi and Squire [2] and Hazebroek et al. [23] confirmed that the testicular vessels and the vas in the majority of palpable undescended testicles, after dissection of the cremaster and the processus vaginalis (Fig. 1), are long enough to allow the testes to reach the scrotum without tension. Based on these observations, the approach was reversed and it was found that in most instances it was unnecessary to disrupt the inguinal canal, sufficient dissection being possible through the scrotal approach. The details of the surgical technique have been described previously [2], but some points have to be emphasized due to a few misinterpretations that can be found in the literature. Misra at al. [7] in 1997 illustrated a variation of the original technique described by Bianchi with a lower transverse scrotal incision. The authors believe that this does not help to find the testis and does not allow the creation of an adequate scrotal pouch. A curved, high, scrotal skin incision (Fig. 2) is, in our experience, the most convenient approach to the inguinal canal through the scrotum. In the article, Misra et al. [7] also state that the inguinal approach is needed in the case of a hernial sac discovered on scrotal exploration. In addition, the editorial on the article by Parsons et al. [16] states that the transcrotal approach may need to be converted to a two-incision approach if high ligation of the sac is needed. In the authors’ experience over the last 20 years of using the procedure, the processus vaginalis can be successfully dissected and tied from a scrotal incision in the vast majority of cases. Indeed, the scrotal approach is our preferred approach for the management of inguinal hernias and hydrocele [3].

Figure 1 Dissection of the processus vaginalis from a single scrotal incision.

20 years of transcrotal orchidopexy for undescended testis

Figure 2 Curved, high, scrotal skin incision used for the treatment of the palpable undescended testis, shown in red.

But are the results of transcrotal orchidopexy comparable to those reported in the literature for the traditional two-incision procedure? In 1995, Docimo [24] reviewed the literature for conventional orchidopexy techniques. From 64 articles pertaining to 8425 testicles, a preoperative location was reported for 2491 testicles. Of these, 842 were intra-abdominal, leaving a total of 1649 palpable testes. The location for these 1649 testes was at the internal ring in 294 (17.8%), 681 were cannicular (41.3%) and 674 beyond the external ring (40.9%), most ectopically in the superficial inguinal pouch. The overall recurrence rate for procedures which had a 6-month follow up was 12.5% (176/1405). When the series was divided by date of publication and only those published after 1985 were included, the overall recurrence rate was 4.1% (15/371). Our own Manchester data combined with all the transcrotal data in the literature showed an overall recurrence rate of 2.0% (30/1665). If we look at the preoperative position of the testes, where it was recorded, there are no series that look at very proximal testes, near the internal inguinal ring. The majority of authors have excluded these high undescended testes from their transcrotal series; however, we have included all palpable testes as this is our routine practice. The general view from the Docimo [24] paper is that more proximal testes tend to have a poorer outcome on operation and this is widely accepted. In the authors’ view, transcrotal orchidopexy can be attempted for proximal undescended testes, bearing in mind that if the dissection of the cord is not enough to bring the testis into the scrotum, a second groin incision can be safely made. We would maintain that whether the procedure is eventually completed through a single- or two-incision approach, this will have no impact on the chance of recurrence. Comparing the calculated recurrence rate of 2.0% for all published transcrotal cases with 4.1% (15/364) from the Docimo [24] review for testes at or beyond the inguinal

511 canal in papers after 1985, the authors find that the transcrotal approach seems to offer at least comparable if not better results. There are very few further contemporary papers with results for the two-incision approach [25,26], and so a more appropriate, similarly sized control group is not available at this time. Prospective studies with appropriate control groups are still needed. Despite this paucity of contemporary comparative data, as the body of published evidence on the transcrotal approach increases, the merits of this technique are leading to its more widely accepted use within the urological community. A recent editorial by Canning [27] on the paper by Samuel et al. [17] stated that, given the large amount of favourable data on this technique, perhaps the time has come for paediatric urologists to consider it, the advantages of a single incision and rapid operative time providing an attractive alternative for this common surgical condition. The authors recognise the limitations of this study. This review only covered procedures performed at the Royal Manchester Children’s Hospital, one of three paediatric surgical sites within the region at the time where the authors would perform this procedure. Therefore, the number of procedures performed within the study period is less than with previous published data from Bianchi and colleagues [2,3], and the study group does contain a much wider age range than the previous Manchester experience, as older children will tend to be operated on at this site within the hospital trust. A number of testes did not have a specific preoperative position noted under anaesthetic. It is the author’s view that a number of proximal testes have been included in this group of 48 patients. As has already been noted, it is well recognised that this group of patients have significantly higher recurrence rates [24], and the authors feel this has contributed to a higher recurrence rate in this Manchester series than previously found. Further research to allow comparison of results specifically for proximal testes and a prospective study design to minimize these limitations are needed in the future.

Conclusions Published data from the last 20 years confirm that transcrotal orchidopexy is followed by uncomplicated healing and a well-placed scrotal testis. In comparison with the conventional two-incision operation, transcrotal orchidopexy offers the advantage of an aesthetic single scrotal crease incision, less dissection and greater comfort for the day-case child. Moreover, the literature suggests that the transcrotal orchidopexy offers at least a comparable recurrence rate to the two-incision approach for the treatment of the testes preoperatively located in the distal portion of the inguinal canal. Further studies are necessary to evaluate the role of transcrotal orchidopexy for the treatment of more proximal undescended testes in comparison to the two-incision approach.

Conflict of interests There are no conflicting interests for any of the authors.

512

Funding None.

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