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Reoperation for cryptorchid testis in prepubertal child
REOPERATION FOR CRYPTORCHID IN PREPUBERTAL CHILD
TESTIS
TODD D. COHEN, M.D. ROBERT KAY,M.D. NANCY KNIPPER, R.N. From the Section of Pediatric Urology, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT-Twenty-two prepubertal patients with cryptorchid testes after having previous inguinal surgery were referred. These included 17 patients in whom orchidopexy had been unsuccessful. Five patients had prior surgery for hernia and/or hydrocele resulting in surgical entrapment of the testis. Five patients had bilateral disease. In 1 patient the testis was involved in Marlex mesh, 1 had had two prior orchidopexies, and 1 had prune belly syndrome. Postoperatively the testes were in good position in the scrotum in all 22 cases, with mean follow-up of 8.9 months. All testes were of normal size, and no atrophic testes ensued following the procedures. Principle factors for success in re-exploration included initial retrograde dissection of the testis and cord, intraperitoneal exposure, and subsequent dissection and adequate lengthening of the cord with protection of the spermatic vessels.
Inguinal surgery is commonly performed in the pre-pubescent male for a variety of different reasons.le9 Correction of maldescended testis, inguinal hernia, and hydrocele comprise the majority of these operations. The incidence for inguinal hernia and hydrocele is reported to be 4 and 6 percent, respectively2 The incidence of primary undescended testis in full-term infants is approximately 3.4 percent,2 making it one of the most common congenital anomalies. By the age of one year, most of these testes descend, and the incidence decreases to between 0.8 and 1 percent*-* and remains at this level. Between 20 and 30 percent of premature infants have undescended testis 2,4but this decreases with growth and development of the child to comparable levels for fullterm infants. Early orchidopexy, usually prior to the age of two, is recommended to limit histologic changes, improve fertility, improve detection of malignancy, and correct the noticeable anatomic defect.8,9 Although orchidopexy is usually a successful operation, it may be difficult in selected cases.
Submitted: April 13, 1993, accepted (with revisions): June 1.5, 1993
UROLOGY
/ OCTOBER1993 / VOLUME42, NUMBER4
Maizels et ~1.~and others1,5,7 have reported failure rates for primary orchidopexy to be between 7.5 and 13 percent. The testicle also may become “trapped” proximal to the scrotum in scar tissue following other inguinal procedures (i.e., herniorraphy and hydrocelectomy). This trapped testis phenomenon, or secondary undescended testis, creates a clinical and anatomic problem nearly identical to that of the failed orchidopexy. Herein, we report our series of 22 prepubertal patients with 27 cryptorchid testes who underwent secondary orchidopexy with 100 percent success. This series demonstrates that secondary orchidopexy is safe, feasible, and therefore is recommended instead of orchiectomy in the failed orchidopexy or trapped testis. MATERIAL AND METHODS The charts and operative records of 23 patients, all of whom were referred from outside institutions between 1981 and 1992, for undescended testis, were reviewed. These patients comprised all the referrals for failed orchidopexy in this period. One patient was noted to have an atrophic testis, and an orchidopexy was not attempted. This patient was excluded from the study 437
SURGICAL TECHNIQUE
All testes were approached via inguinal incisions. In nearly all cases the new incision was made on the site of the previous incision and extended when necessary. The initial approach was to identify the testis and sharply dissect and free it from the surrounding tissues. The cord was identified and mobilized from the surrounding fibrous tissue to the level of the internal inguinal ring when possible. If fibrous tissue encasement of the cord prohibited the safety of the dissection of the cord, the peritoneum was entered early The vas and vessels were identified within the peritoneal cavity and dissected free. With the proximal vessels dissected and the testis and distal cord identified, further dissection was easily carried out with careful protection of the vas and vessels by leaving a sleeve of external oblique aponeurosis intact over the cord to avoid injury Adequate length was achieved in all cases. Once adequate length was obtained, a subdartos pouch was constructed, and the testis was anchored within this pouch. RESULTS Twenty-two prepubertal boys with failed orchidopexy and/or surgically entrapped testis from prior inguinal surgery (total 27 testes) were referred. The mean age at presentation to our facility was 7.25 years (range 2-12 yrs). The mean age at the time of the initial surgery was 3.5 years (range 3 mos to 9 yrs). The mean time between initial surgery and reoperation was 4.7 years (range 13 mos to 12 yrs). Seventeen patients had failed orchidopexy for primary undescended testis. Ten testes occurred on the right, four on the left, and three were bilateral (total 20 testes). All of these patients had originally been surgically explored inguinally except 1 child with prune belly syndrome who had had a transabdominal repair. One patient had undergone two previous attempts at orchidopexy. Five of the boys had surgically trapped testes following inguinal hernia repair: 3 were on the right, and 2 were bilateral (total 7 testes). All of these were originally approached through the groin. In 1 patient Marlex mesh was used to surround the cord instead of a thin Silastic sheath as part of a planned two-stage orchidopexy. Extensive fibrosis surrounded the mesh and cord. The cord was able to be carefully dissected off the mesh, and the remainder of the procedure proceeded as described. The position of the testes found at exploration was noted in 20 instances. Of the failed orchi-
438
dopexies, 8 were located at or distal to the external inguinal ring, 9 in the inguinal canal, 1 in the retroperitoneum, and 1 at the internal ring. Of the trapped testes, 3 were at or distal to the external ring, and 4 were in the inguinal canal. No operative complications occurred. Eleven patients remained overnight following surgery for pain control, nausea, and vomiting. One patient was hospitalized for two days for the same indications. Each of these occurred in the earlier years of the study period with no hospitalizations during the past five years. Follow-up information was available on all 22 patients. The mean time to follow-up was 8.9 months (range 6-18 mos). All testes were noted to be viable by palpation and in good position in the scrotum. No patients required orchiectomy following reoperative orchidopexy. COMMENT The failure rate for primary orchidopexy previously has been reported to be approximately 10 percent.5-7 Adamsen and Borjesson’ closely examined their failed procedures and found several factors associated with a greater risk of surgical failure. These factors included tension on the spermatic cord, complicated simultaneous hemiorraphy, and simple dissection without anchoring of the testis in the scrotum. In our series, a total of 22 boys underwent reoperation for failed orchidopexy, surgically entrapped testis, and testicular repositioning. Each of these procedures was ultimately successful. The time from initial surgery to definitive correction varied greatly, between thirteen months and twelve years; however, this time differential had no effect on the final outcome. Despite the position of the testis, each was approached in a similar fashion. Careful dissection of the testis initially and lateral dissection of the cord superiorly to the internal inguinal ring affected a safe approach. Early entrance into the peritoneum further facilitated cord lengthening. This maneuver did not adversely affect the results or lead to any perceivable postoperative complications, and should be considered when attempting this surgery. After achieving adequate cord length, the testis could then be readily anchored in a subdartos pouch to further prevent retraction of the cord. In their report of 36 boys requiring re-orchidopexy for similar reasons, Maizels et ~1.~found it necessary to do retroperitoneal dissections; however, they did not describe entrance into the peritoneum. This is in distinct contrast to our technique where early entrance into the peritoneum
UROLOGY
I OCTOBER1993 /
VOLUME
42.
NL~MBER4
greatly facilitated cord lengthening and safe dissection of the spermatic vessels. The data in this series show that following failed orchidopexy or surgically entrapped testis, the testis can be successfully brought into the scrotum by careful dissection. There appears to be no need to leave the testis in the groin or to perform an orchiectomy in the normal-appearing testis. The indications for this surgery are the same for primary orchidopexy. These would include the ability to examine the testis, create an environment to allow for normal spermatogenesis, and create a natural cosmetic appearance. With careful attention to surgical techniques, nearly 100 percent of all testes may be salvaged. Robert Kay, M.D. Section
ofPediatric Urology
Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44195
UROLOGY
/ OCTOBER1993 / VOLUME42, NUMBER4
REFERENCES 1. Cartwright PC, Velagapudi S, Snyder HM, Keating MA, and Duckett JW: Successful redo orchiopexy (Abstr 260). J Ural 145: 277A, 1991. 2. Scorer CG, and Farrington GH: Congenital Deformities of the Testis and Epididymus, London, Butterworth & Co., 1971. 3. Cour-Palais IJ: Spontaneous descent of the testicle. Lancet 1: 1403-1406, 1966. 4. Cendron M, and Duckett JW Jr: The Maldescended Testicle, Baltimore, AUA Update Series, vol. 10, 1991, pages 28,218-223. 5. Livne PM, Savir A, and Servadio C: Re-orchidopexy: advantages and disadvantages. Eur Urol 18: 137-139, 1990. 6. Maizels M, Gomez F, and Firlit CF: Surgical correction of the failed orchidopexy. J Ural 130: 955-957, 1983. 7. Adamsen S, and Borjesson B: Factors affecting the outcome of orchiopexy for undescended testis. Acta Chir Stand 154: 529-533,1988. 8. Mengel W, Wronecki K, and Zimmerman FA: Comparison of the morphology of normal cryptorchid testes, in Fonkaslrud EW, and Mengel W, (Eds): The Undescended Testis, Chicago, Year Book Medical Pub, 1981, pp 71-73. 9. Hezmall HP, and Lipshultz LI: Cryptorchidism and infertility, Urol Clin North Am 9: 361-369, 1982.
439
TESTIS
TODD D. COHEN, M.D. ROBERT KAY,M.D. NANCY KNIPPER, R.N. From the Section of Pediatric Urology, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT-Twenty-two prepubertal patients with cryptorchid testes after having previous inguinal surgery were referred. These included 17 patients in whom orchidopexy had been unsuccessful. Five patients had prior surgery for hernia and/or hydrocele resulting in surgical entrapment of the testis. Five patients had bilateral disease. In 1 patient the testis was involved in Marlex mesh, 1 had had two prior orchidopexies, and 1 had prune belly syndrome. Postoperatively the testes were in good position in the scrotum in all 22 cases, with mean follow-up of 8.9 months. All testes were of normal size, and no atrophic testes ensued following the procedures. Principle factors for success in re-exploration included initial retrograde dissection of the testis and cord, intraperitoneal exposure, and subsequent dissection and adequate lengthening of the cord with protection of the spermatic vessels.
Inguinal surgery is commonly performed in the pre-pubescent male for a variety of different reasons.le9 Correction of maldescended testis, inguinal hernia, and hydrocele comprise the majority of these operations. The incidence for inguinal hernia and hydrocele is reported to be 4 and 6 percent, respectively2 The incidence of primary undescended testis in full-term infants is approximately 3.4 percent,2 making it one of the most common congenital anomalies. By the age of one year, most of these testes descend, and the incidence decreases to between 0.8 and 1 percent*-* and remains at this level. Between 20 and 30 percent of premature infants have undescended testis 2,4but this decreases with growth and development of the child to comparable levels for fullterm infants. Early orchidopexy, usually prior to the age of two, is recommended to limit histologic changes, improve fertility, improve detection of malignancy, and correct the noticeable anatomic defect.8,9 Although orchidopexy is usually a successful operation, it may be difficult in selected cases.
Submitted: April 13, 1993, accepted (with revisions): June 1.5, 1993
UROLOGY
/ OCTOBER1993 / VOLUME42, NUMBER4
Maizels et ~1.~and others1,5,7 have reported failure rates for primary orchidopexy to be between 7.5 and 13 percent. The testicle also may become “trapped” proximal to the scrotum in scar tissue following other inguinal procedures (i.e., herniorraphy and hydrocelectomy). This trapped testis phenomenon, or secondary undescended testis, creates a clinical and anatomic problem nearly identical to that of the failed orchidopexy. Herein, we report our series of 22 prepubertal patients with 27 cryptorchid testes who underwent secondary orchidopexy with 100 percent success. This series demonstrates that secondary orchidopexy is safe, feasible, and therefore is recommended instead of orchiectomy in the failed orchidopexy or trapped testis. MATERIAL AND METHODS The charts and operative records of 23 patients, all of whom were referred from outside institutions between 1981 and 1992, for undescended testis, were reviewed. These patients comprised all the referrals for failed orchidopexy in this period. One patient was noted to have an atrophic testis, and an orchidopexy was not attempted. This patient was excluded from the study 437
SURGICAL TECHNIQUE
All testes were approached via inguinal incisions. In nearly all cases the new incision was made on the site of the previous incision and extended when necessary. The initial approach was to identify the testis and sharply dissect and free it from the surrounding tissues. The cord was identified and mobilized from the surrounding fibrous tissue to the level of the internal inguinal ring when possible. If fibrous tissue encasement of the cord prohibited the safety of the dissection of the cord, the peritoneum was entered early The vas and vessels were identified within the peritoneal cavity and dissected free. With the proximal vessels dissected and the testis and distal cord identified, further dissection was easily carried out with careful protection of the vas and vessels by leaving a sleeve of external oblique aponeurosis intact over the cord to avoid injury Adequate length was achieved in all cases. Once adequate length was obtained, a subdartos pouch was constructed, and the testis was anchored within this pouch. RESULTS Twenty-two prepubertal boys with failed orchidopexy and/or surgically entrapped testis from prior inguinal surgery (total 27 testes) were referred. The mean age at presentation to our facility was 7.25 years (range 2-12 yrs). The mean age at the time of the initial surgery was 3.5 years (range 3 mos to 9 yrs). The mean time between initial surgery and reoperation was 4.7 years (range 13 mos to 12 yrs). Seventeen patients had failed orchidopexy for primary undescended testis. Ten testes occurred on the right, four on the left, and three were bilateral (total 20 testes). All of these patients had originally been surgically explored inguinally except 1 child with prune belly syndrome who had had a transabdominal repair. One patient had undergone two previous attempts at orchidopexy. Five of the boys had surgically trapped testes following inguinal hernia repair: 3 were on the right, and 2 were bilateral (total 7 testes). All of these were originally approached through the groin. In 1 patient Marlex mesh was used to surround the cord instead of a thin Silastic sheath as part of a planned two-stage orchidopexy. Extensive fibrosis surrounded the mesh and cord. The cord was able to be carefully dissected off the mesh, and the remainder of the procedure proceeded as described. The position of the testes found at exploration was noted in 20 instances. Of the failed orchi-
438
dopexies, 8 were located at or distal to the external inguinal ring, 9 in the inguinal canal, 1 in the retroperitoneum, and 1 at the internal ring. Of the trapped testes, 3 were at or distal to the external ring, and 4 were in the inguinal canal. No operative complications occurred. Eleven patients remained overnight following surgery for pain control, nausea, and vomiting. One patient was hospitalized for two days for the same indications. Each of these occurred in the earlier years of the study period with no hospitalizations during the past five years. Follow-up information was available on all 22 patients. The mean time to follow-up was 8.9 months (range 6-18 mos). All testes were noted to be viable by palpation and in good position in the scrotum. No patients required orchiectomy following reoperative orchidopexy. COMMENT The failure rate for primary orchidopexy previously has been reported to be approximately 10 percent.5-7 Adamsen and Borjesson’ closely examined their failed procedures and found several factors associated with a greater risk of surgical failure. These factors included tension on the spermatic cord, complicated simultaneous hemiorraphy, and simple dissection without anchoring of the testis in the scrotum. In our series, a total of 22 boys underwent reoperation for failed orchidopexy, surgically entrapped testis, and testicular repositioning. Each of these procedures was ultimately successful. The time from initial surgery to definitive correction varied greatly, between thirteen months and twelve years; however, this time differential had no effect on the final outcome. Despite the position of the testis, each was approached in a similar fashion. Careful dissection of the testis initially and lateral dissection of the cord superiorly to the internal inguinal ring affected a safe approach. Early entrance into the peritoneum further facilitated cord lengthening. This maneuver did not adversely affect the results or lead to any perceivable postoperative complications, and should be considered when attempting this surgery. After achieving adequate cord length, the testis could then be readily anchored in a subdartos pouch to further prevent retraction of the cord. In their report of 36 boys requiring re-orchidopexy for similar reasons, Maizels et ~1.~found it necessary to do retroperitoneal dissections; however, they did not describe entrance into the peritoneum. This is in distinct contrast to our technique where early entrance into the peritoneum
UROLOGY
I OCTOBER1993 /
VOLUME
42.
NL~MBER4
greatly facilitated cord lengthening and safe dissection of the spermatic vessels. The data in this series show that following failed orchidopexy or surgically entrapped testis, the testis can be successfully brought into the scrotum by careful dissection. There appears to be no need to leave the testis in the groin or to perform an orchiectomy in the normal-appearing testis. The indications for this surgery are the same for primary orchidopexy. These would include the ability to examine the testis, create an environment to allow for normal spermatogenesis, and create a natural cosmetic appearance. With careful attention to surgical techniques, nearly 100 percent of all testes may be salvaged. Robert Kay, M.D. Section
ofPediatric Urology
Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44195
UROLOGY
/ OCTOBER1993 / VOLUME42, NUMBER4
REFERENCES 1. Cartwright PC, Velagapudi S, Snyder HM, Keating MA, and Duckett JW: Successful redo orchiopexy (Abstr 260). J Ural 145: 277A, 1991. 2. Scorer CG, and Farrington GH: Congenital Deformities of the Testis and Epididymus, London, Butterworth & Co., 1971. 3. Cour-Palais IJ: Spontaneous descent of the testicle. Lancet 1: 1403-1406, 1966. 4. Cendron M, and Duckett JW Jr: The Maldescended Testicle, Baltimore, AUA Update Series, vol. 10, 1991, pages 28,218-223. 5. Livne PM, Savir A, and Servadio C: Re-orchidopexy: advantages and disadvantages. Eur Urol 18: 137-139, 1990. 6. Maizels M, Gomez F, and Firlit CF: Surgical correction of the failed orchidopexy. J Ural 130: 955-957, 1983. 7. Adamsen S, and Borjesson B: Factors affecting the outcome of orchiopexy for undescended testis. Acta Chir Stand 154: 529-533,1988. 8. Mengel W, Wronecki K, and Zimmerman FA: Comparison of the morphology of normal cryptorchid testes, in Fonkaslrud EW, and Mengel W, (Eds): The Undescended Testis, Chicago, Year Book Medical Pub, 1981, pp 71-73. 9. Hezmall HP, and Lipshultz LI: Cryptorchidism and infertility, Urol Clin North Am 9: 361-369, 1982.
439