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Transseptal Orchiopexy
THE JOURNAL OF UROLOGY
Vol. 81, No. 1, January 1959 Printed in U.S.A.
TRANSSEPTAL ORCHIOPEXY J. L. McCORMACK, A. W. KRETZ AND 0. A. NELSON There is as yet no agreement as to the ideal surgical procedure for undescended testis. A satisfactory orchiopexy requires freeing of the cord structures to allow the testis to be placed into the scrotum without tension and fixation to prevent retraction of the testis. In transseptal orchiopexy the scrotal septum buttoned over the mobilized testis exerts a constant physiologic traction to hold the testis in a scrotal pouch. The scrotal septum is formed by the fusion of the scrotolabial folds in the tenth week of development of the human embryo. At birth it is a fibrous sheath dividing the scrotum into two compartments, fusing with the dartos muscle at the free edges and being continuous with and fixed to Buck's fascia on the undersurface of the corpus spongiosum (fig. 1). The septum will hold the undescended testis in a scrotal compartment without the need for external fixation if the cord has been sufficiently lengthened. The Ombredonne technique, or transseptal orchiopexy, was first reported by Walter, Gersuny and Witzel1 in 1905. It was not until the Frenchman, Louis Ombredonne, 2 wrote his report in 1910 that serious consideration was given this method of orchiopexy. The earliest report of this method being used in this country was given by Ashhurst3 who reported two cases in 1928. Schutt4 described the method and reported several cases in 1945. Carney, Leuther and Marks (1946) employed this method of repair on soldiers and commented on the psychic improvement and short convalescence. 5 Although cryptorchism is found at birth in 4 per cent of mature infants and much higher Read at annual meeting of Western Section of American Urological Association, Inc., Palm . Springs, Cal., February 3-6, 1958. 1 Hinman, Frank: Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935, pp. 438-439. 2 Ombredonne, L.: Indication et technique de l'orchidopexe transcrotale. Presse med., 18: 745, 1910. 3
6 Scorer, C. G.: Descent of testicle in first year of life. Brit. J. Urol., 27: 374, 1955. 7 Cooper, E. R. A.: The ~istology of retain_ed testis in human subject at different ages, and its comparison with scrotal testis. J. Anat., 64: 5,
1929. 7 Robinson J. N. and Engle, E.T.: Some observations 01~ cryptorchid testis. J. Urol., 71:
726, 1954.
.
Schutt, J. P.: Ombredonne operat10ns for undescended testicle (cryptorchidism). Northwest Med., 44: 349, 1945. 5 Carney, T. B., Leuther, P.A. and Marks, M. M.: Transseptal orchipexy in adults. Am. J. Surg., 4
72: 715, 1946.
153
.
.
.
.
Hinman Frank: The 1mphcat10ns of testicular cytology in' treatment of cryptorchidism. Am. J. Surg., 90: 381, 1955. . ,o Gross, R. E. and JewE:tt, T. C.: Surgical experience from 1,222 operat10ns for undescended testis. J.A.M.A., 160: 634, 1956. 11 Snyder, W. H., Jr. and Chaffin, Lawrence: Inguinal hernia complicated by undescended testis. Am. J. Surg., 90: 325, 1955. 9
Ashhurst, A. P. C.: Ann. Surg., 88: 131-134,
1928.
percentage in premature infants, after the first year of life less than 0.7 per cent of testes remain out of the scrotum. 6 About 10 per cent of these will descend spontaneously but the remaining require consideration as to their proper management. Histologic studies, as reported by Cooper,7 Robinson and Engle,8 and Hinman,9 show that the normal tubular growth and maturation of sperm cells do not occur if the testis remains undescended. Up to age five or six, the undescended testis is microscopically similar to its normally located mate, but after this time spermatogenesis lags even though Leydig cells appear normal. These studies imply that cryptorchism should be corrected between the fifth and eighth year if spermato11;enesis in an undescended testis is to be salvaged. Further support is the demonstration of fertility following successful orchiopexy in 75 per cent of men with bilateral cryptorchism as reported by Gross and Jewett. 10 This strongly suggests that some undescended testes must be capable of producing viable sperm when properly placed in a satisfactory environment. About 6 per cent of all inguinal hernias in children are accompanied by undescended testis.n There appears to be general agreement that this group and bilateral cryptorchids are best served by surgical intervention. There is less agreement regarding unilateral cryptorchism. Charny and Wolgin have studied 132 testicular biopsies obtained from patients who had undergone orchiopexy before puberty without demonstration
154
MCCORMACK, KRETZ AND NELSO"'
usually distraught but young boys are seldom aware of the absence of one or both testes. The psychic trauma may be greater in young men bathing in communal showers in the Army camp or locker rooms, and evidence of this may constitute an indication for orchiopexy. Discussing orchiopexy in adults, Carney, Leuther and Marks reported, "psychic improvement was noted in all cases. " 15 Cryptorchids, unilateral or bilateral, without hernia may be subjected to a short course of hormonal therapy (500 i.u. of chorionic gonadotrophin three times a week for two weeks) but not over 10 per cent respond by spontaneous descent. Those responding are probably the same group that would descend without treatment. Fm. 1. Schematic diagram shows relation of scrotal septum. Common locations of undescended testes. 1, Retroperitoneal; 2, abdominal; 3 inguinal ' canal; 4, external inguinal pouch. of adequate spermatogenesis in a single biopsy. 12 They doubt spermatogenic potential in a unilateral undescended testis and recommend no surgical therapy. Additional studies are needed to clarify this point. Besides improving fertility and correcting an associated inguinal hernia, the incidence of malignant change in an undescended testis and the psychologic value of numerically normal external genitalia have been proposed as indications for orchiopexy. Statistical data support the concept of higher incidence of neoplasia in an undescended testis. 13 Orchiopexy, per se, may not eliminate this hazard but places the organ in a location where changes in size and contour are more easily detected. However, surgery reputedly alters the lymphatic drainage so that the superficial inguinal lymph nodes are also involved in metastatic spread. 14 Thus, when treating an adult with a unilateral undescended testis, and probably no spermatogenic potential, Charny recommends orchiedomy, denying appreciable psychologic benefit of orchiopexy. 14 Admittedly, the psychologic value of orchiopexy is difficult to evaluate. Parents are 12 Charny, C. W. and Wolgin, William. Cryptorchidism. New York: Hoeber-Harper 1957 chapt. 4. ' ' 13 Dixon, F. J. and lVIoore, Robert: Tumors of the Male Sex Organs. Washington, D. C.: Armed Forces Institute of Pathology, 1952, p. 54. 14 Charny and Wolgin: Footnote 12, p. 90.
TECHNIQUE
Through either the usual inguinal incision or a transverse incision following the skin fold in a boy's groin, the inguinal canal is explored to determine the position of the testis and the presence of a hernia. After the hernial sac has been dissected, the spermatic cord is lengthened by lysis of the adhesions about the spermatic vessels and ductus deferens with division of the cremasteric muscle fibers in the inguinal canal (fig. 2, A). Retroperitoneal dissection of the spermatic vessels will provide additional length. Ligation of the inferior epigastric artery and reconstruction of the inguinal canal with the cord emerging at the external ring, as suggested by Prentiss16 and others, may be required to allow the testis to reach the scrotum. When adequate length of the cord has been obtained the hernial sac is ligated and the inguinal canal reconstructed. The index finger introduced through the scrotal neck tunnels to the scrotal septum. Next, a pouch is made for the testis in the contralateral scrotal compartment by blunt dissection through a small incision lateral to the scrotal septum (fig. 2, B). The septum is identified and an incision is made in this structure adequate to allow passage of the mobilized testis. A forceps introduced through the scrotal incision is used to grasp the tunica or gubernaculum of the cryptorchid (fig. 2, C). Holding the testicle at the lowest point it can be 15 Charny and Wolgin: Footnote 12. 16 Prentiss, R. J., Mullenix, R. B., Whisenand, J. M. and Feeney, M. J.: Medical and surgical treatment of cryptorchidism. A.M.A. Arch. Surg., 70: 283, 1955.
TRA :\:SSTI:P'l'AL OHCHIOPEXY
F10. 2. Trt1nsseptal orehiopexy. ,cl, lengthening cord, hernia repair. B, preparing pouch and n1ethod of placing te,stes through septum into prepared pouch. D, closure of inguinal canal, scrotum.
placed without tension, the scrotal septum is buttoned over the testis (fig. 2, D). In this maneuver the septum is brought to the testis, not vice Yerna. If needed, sutures may tighten a loose septa! opening to prevent the retraction of the testicle but care must be employed in placing these sutures not to embanass the circulation of the spcrmatic Yesscls. The inguinal incision is dosed by re-approximating external oblique fascia. ThE: usual closures of the skin and scrotum suffice. Drains are not needed. The reduced testis is relaxed in thci scmtum \\·itliin three or four weeks following surgery, and both testes ride one on each side of the midline. side When bilaternl ectopia is present, two similar procedures am advisable six to twelve weeks apart, placing one testis through the anterior portion of the septum. and the other through the posterior part of this fascia] sheath. In this manner the testes will not be crossed but the septum becomes S-slrnped. EXPERlEC'lCc;
The case records of 38 patients who had 4;3 orchiopexies in Swedish Hospital, Seattle, between 1948 through 1957, were reviewed. The statistical data are tabulated in tahle l. Separate surgical procedures were done on the bilateral cryptorchicls. The youngest patient in this series was fonr years old, the oldest 35. HoweYer, only ~ix boys were operated upon prior to their seventh
TA BLT, l. 1' ranssepial urr:hiopc:ry; 48 prncerl 11xcs on 88 patients, 1948-L95'l, Swedish H ospilal, Seattle, Wash. Cases
Side involved right .. left bilateral. Position of t.esl.is* abdominal. inguinal cairn!. external inguinal pouch. Associated hcrniu sac wit.Ii sa.c. ,vithout sac. Age groups, all less tha.n ll yrn. 11to14yrs .. over 1'1 ~'I'S. Bilaternl cryptorchicl less than 11 ,·rs. 11 lo I4 yrs .. over 14 yrs.
14 14 10 G
:m 27 Hi l7 1/J
7 4
2 4
* One perinea.] testis; locn1.ion of J not rnenrdc)d
birthday. Two patients had previous unsuccessful orchiopexies. Hernial sarn, with or without clrnical hernia, were present in 75 per cent of tlicsc patients, and two others had undergone pn,viuus herniorrhaphy without orchiopexy. i\ trnnsseptal ord1iopcxy was employed
156
MCCORMACK, KRETZ AcsD ?s"ELSON
each case. In the opinion of the operating surgeons, each surgical procedure was successful as far as placing the testis in the scrotum was concerned. The 19 patients who had orchiopexies done by members of our group had an average postoperative hospital stay of 2.2 days. We have no followup biopsies for evaluation of spermatogenesis. The four bilateral orchiopexies done on boys under eleven years of age are too recent to evaluate spermatogenesis by either semen examination or marital conceptions. DISCUSSION
This method of orchiopexy has the double advantage of requiring only a single surgical experience for the child and avoiding the encumbrance of external traction. In addition, there seems to be an added advantage in continuous traction exerted by the septum. We have observed testes located near the scrotal neck immediately following surgery which, as time passes,
come to lie near the bottom of the scrotum. This may represent only resolution of edema caused by the surgical trauma, but we believe that it is more likely an actual physiologic traction exerted by the septum. SUMMARY
The indications for orchiopexy, and conflicting opinions have been briefly considered. The technique of transseptal orchiopexy is described and the role of the scrotal septum in producing constant physiologic traction discussed. In the 43 cases reviewed, this procedure produced satisfactory results with a short, comfortable convalescence. We are grateful to Drs. A. C. Ohman, C. J. Pinard, and A. H. Bill, Jr., for 1Jermission to include their cases in this study.
719 Summit Ave., Seattle 4, Wash.
Vol. 81, No. 1, January 1959 Printed in U.S.A.
TRANSSEPTAL ORCHIOPEXY J. L. McCORMACK, A. W. KRETZ AND 0. A. NELSON There is as yet no agreement as to the ideal surgical procedure for undescended testis. A satisfactory orchiopexy requires freeing of the cord structures to allow the testis to be placed into the scrotum without tension and fixation to prevent retraction of the testis. In transseptal orchiopexy the scrotal septum buttoned over the mobilized testis exerts a constant physiologic traction to hold the testis in a scrotal pouch. The scrotal septum is formed by the fusion of the scrotolabial folds in the tenth week of development of the human embryo. At birth it is a fibrous sheath dividing the scrotum into two compartments, fusing with the dartos muscle at the free edges and being continuous with and fixed to Buck's fascia on the undersurface of the corpus spongiosum (fig. 1). The septum will hold the undescended testis in a scrotal compartment without the need for external fixation if the cord has been sufficiently lengthened. The Ombredonne technique, or transseptal orchiopexy, was first reported by Walter, Gersuny and Witzel1 in 1905. It was not until the Frenchman, Louis Ombredonne, 2 wrote his report in 1910 that serious consideration was given this method of orchiopexy. The earliest report of this method being used in this country was given by Ashhurst3 who reported two cases in 1928. Schutt4 described the method and reported several cases in 1945. Carney, Leuther and Marks (1946) employed this method of repair on soldiers and commented on the psychic improvement and short convalescence. 5 Although cryptorchism is found at birth in 4 per cent of mature infants and much higher Read at annual meeting of Western Section of American Urological Association, Inc., Palm . Springs, Cal., February 3-6, 1958. 1 Hinman, Frank: Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935, pp. 438-439. 2 Ombredonne, L.: Indication et technique de l'orchidopexe transcrotale. Presse med., 18: 745, 1910. 3
6 Scorer, C. G.: Descent of testicle in first year of life. Brit. J. Urol., 27: 374, 1955. 7 Cooper, E. R. A.: The ~istology of retain_ed testis in human subject at different ages, and its comparison with scrotal testis. J. Anat., 64: 5,
1929. 7 Robinson J. N. and Engle, E.T.: Some observations 01~ cryptorchid testis. J. Urol., 71:
726, 1954.
.
Schutt, J. P.: Ombredonne operat10ns for undescended testicle (cryptorchidism). Northwest Med., 44: 349, 1945. 5 Carney, T. B., Leuther, P.A. and Marks, M. M.: Transseptal orchipexy in adults. Am. J. Surg., 4
72: 715, 1946.
153
.
.
.
.
Hinman Frank: The 1mphcat10ns of testicular cytology in' treatment of cryptorchidism. Am. J. Surg., 90: 381, 1955. . ,o Gross, R. E. and JewE:tt, T. C.: Surgical experience from 1,222 operat10ns for undescended testis. J.A.M.A., 160: 634, 1956. 11 Snyder, W. H., Jr. and Chaffin, Lawrence: Inguinal hernia complicated by undescended testis. Am. J. Surg., 90: 325, 1955. 9
Ashhurst, A. P. C.: Ann. Surg., 88: 131-134,
1928.
percentage in premature infants, after the first year of life less than 0.7 per cent of testes remain out of the scrotum. 6 About 10 per cent of these will descend spontaneously but the remaining require consideration as to their proper management. Histologic studies, as reported by Cooper,7 Robinson and Engle,8 and Hinman,9 show that the normal tubular growth and maturation of sperm cells do not occur if the testis remains undescended. Up to age five or six, the undescended testis is microscopically similar to its normally located mate, but after this time spermatogenesis lags even though Leydig cells appear normal. These studies imply that cryptorchism should be corrected between the fifth and eighth year if spermato11;enesis in an undescended testis is to be salvaged. Further support is the demonstration of fertility following successful orchiopexy in 75 per cent of men with bilateral cryptorchism as reported by Gross and Jewett. 10 This strongly suggests that some undescended testes must be capable of producing viable sperm when properly placed in a satisfactory environment. About 6 per cent of all inguinal hernias in children are accompanied by undescended testis.n There appears to be general agreement that this group and bilateral cryptorchids are best served by surgical intervention. There is less agreement regarding unilateral cryptorchism. Charny and Wolgin have studied 132 testicular biopsies obtained from patients who had undergone orchiopexy before puberty without demonstration
154
MCCORMACK, KRETZ AND NELSO"'
usually distraught but young boys are seldom aware of the absence of one or both testes. The psychic trauma may be greater in young men bathing in communal showers in the Army camp or locker rooms, and evidence of this may constitute an indication for orchiopexy. Discussing orchiopexy in adults, Carney, Leuther and Marks reported, "psychic improvement was noted in all cases. " 15 Cryptorchids, unilateral or bilateral, without hernia may be subjected to a short course of hormonal therapy (500 i.u. of chorionic gonadotrophin three times a week for two weeks) but not over 10 per cent respond by spontaneous descent. Those responding are probably the same group that would descend without treatment. Fm. 1. Schematic diagram shows relation of scrotal septum. Common locations of undescended testes. 1, Retroperitoneal; 2, abdominal; 3 inguinal ' canal; 4, external inguinal pouch. of adequate spermatogenesis in a single biopsy. 12 They doubt spermatogenic potential in a unilateral undescended testis and recommend no surgical therapy. Additional studies are needed to clarify this point. Besides improving fertility and correcting an associated inguinal hernia, the incidence of malignant change in an undescended testis and the psychologic value of numerically normal external genitalia have been proposed as indications for orchiopexy. Statistical data support the concept of higher incidence of neoplasia in an undescended testis. 13 Orchiopexy, per se, may not eliminate this hazard but places the organ in a location where changes in size and contour are more easily detected. However, surgery reputedly alters the lymphatic drainage so that the superficial inguinal lymph nodes are also involved in metastatic spread. 14 Thus, when treating an adult with a unilateral undescended testis, and probably no spermatogenic potential, Charny recommends orchiedomy, denying appreciable psychologic benefit of orchiopexy. 14 Admittedly, the psychologic value of orchiopexy is difficult to evaluate. Parents are 12 Charny, C. W. and Wolgin, William. Cryptorchidism. New York: Hoeber-Harper 1957 chapt. 4. ' ' 13 Dixon, F. J. and lVIoore, Robert: Tumors of the Male Sex Organs. Washington, D. C.: Armed Forces Institute of Pathology, 1952, p. 54. 14 Charny and Wolgin: Footnote 12, p. 90.
TECHNIQUE
Through either the usual inguinal incision or a transverse incision following the skin fold in a boy's groin, the inguinal canal is explored to determine the position of the testis and the presence of a hernia. After the hernial sac has been dissected, the spermatic cord is lengthened by lysis of the adhesions about the spermatic vessels and ductus deferens with division of the cremasteric muscle fibers in the inguinal canal (fig. 2, A). Retroperitoneal dissection of the spermatic vessels will provide additional length. Ligation of the inferior epigastric artery and reconstruction of the inguinal canal with the cord emerging at the external ring, as suggested by Prentiss16 and others, may be required to allow the testis to reach the scrotum. When adequate length of the cord has been obtained the hernial sac is ligated and the inguinal canal reconstructed. The index finger introduced through the scrotal neck tunnels to the scrotal septum. Next, a pouch is made for the testis in the contralateral scrotal compartment by blunt dissection through a small incision lateral to the scrotal septum (fig. 2, B). The septum is identified and an incision is made in this structure adequate to allow passage of the mobilized testis. A forceps introduced through the scrotal incision is used to grasp the tunica or gubernaculum of the cryptorchid (fig. 2, C). Holding the testicle at the lowest point it can be 15 Charny and Wolgin: Footnote 12. 16 Prentiss, R. J., Mullenix, R. B., Whisenand, J. M. and Feeney, M. J.: Medical and surgical treatment of cryptorchidism. A.M.A. Arch. Surg., 70: 283, 1955.
TRA :\:SSTI:P'l'AL OHCHIOPEXY
F10. 2. Trt1nsseptal orehiopexy. ,cl, lengthening cord, hernia repair. B, preparing pouch and n1ethod of placing te,stes through septum into prepared pouch. D, closure of inguinal canal, scrotum.
placed without tension, the scrotal septum is buttoned over the testis (fig. 2, D). In this maneuver the septum is brought to the testis, not vice Yerna. If needed, sutures may tighten a loose septa! opening to prevent the retraction of the testicle but care must be employed in placing these sutures not to embanass the circulation of the spcrmatic Yesscls. The inguinal incision is dosed by re-approximating external oblique fascia. ThE: usual closures of the skin and scrotum suffice. Drains are not needed. The reduced testis is relaxed in thci scmtum \\·itliin three or four weeks following surgery, and both testes ride one on each side of the midline. side When bilaternl ectopia is present, two similar procedures am advisable six to twelve weeks apart, placing one testis through the anterior portion of the septum. and the other through the posterior part of this fascia] sheath. In this manner the testes will not be crossed but the septum becomes S-slrnped. EXPERlEC'lCc;
The case records of 38 patients who had 4;3 orchiopexies in Swedish Hospital, Seattle, between 1948 through 1957, were reviewed. The statistical data are tabulated in tahle l. Separate surgical procedures were done on the bilateral cryptorchicls. The youngest patient in this series was fonr years old, the oldest 35. HoweYer, only ~ix boys were operated upon prior to their seventh
TA BLT, l. 1' ranssepial urr:hiopc:ry; 48 prncerl 11xcs on 88 patients, 1948-L95'l, Swedish H ospilal, Seattle, Wash. Cases
Side involved right .. left bilateral. Position of t.esl.is* abdominal. inguinal cairn!. external inguinal pouch. Associated hcrniu sac wit.Ii sa.c. ,vithout sac. Age groups, all less tha.n ll yrn. 11to14yrs .. over 1'1 ~'I'S. Bilaternl cryptorchicl less than 11 ,·rs. 11 lo I4 yrs .. over 14 yrs.
14 14 10 G
:m 27 Hi l7 1/J
7 4
2 4
* One perinea.] testis; locn1.ion of J not rnenrdc)d
birthday. Two patients had previous unsuccessful orchiopexies. Hernial sarn, with or without clrnical hernia, were present in 75 per cent of tlicsc patients, and two others had undergone pn,viuus herniorrhaphy without orchiopexy. i\ trnnsseptal ord1iopcxy was employed
156
MCCORMACK, KRETZ AcsD ?s"ELSON
each case. In the opinion of the operating surgeons, each surgical procedure was successful as far as placing the testis in the scrotum was concerned. The 19 patients who had orchiopexies done by members of our group had an average postoperative hospital stay of 2.2 days. We have no followup biopsies for evaluation of spermatogenesis. The four bilateral orchiopexies done on boys under eleven years of age are too recent to evaluate spermatogenesis by either semen examination or marital conceptions. DISCUSSION
This method of orchiopexy has the double advantage of requiring only a single surgical experience for the child and avoiding the encumbrance of external traction. In addition, there seems to be an added advantage in continuous traction exerted by the septum. We have observed testes located near the scrotal neck immediately following surgery which, as time passes,
come to lie near the bottom of the scrotum. This may represent only resolution of edema caused by the surgical trauma, but we believe that it is more likely an actual physiologic traction exerted by the septum. SUMMARY
The indications for orchiopexy, and conflicting opinions have been briefly considered. The technique of transseptal orchiopexy is described and the role of the scrotal septum in producing constant physiologic traction discussed. In the 43 cases reviewed, this procedure produced satisfactory results with a short, comfortable convalescence. We are grateful to Drs. A. C. Ohman, C. J. Pinard, and A. H. Bill, Jr., for 1Jermission to include their cases in this study.
719 Summit Ave., Seattle 4, Wash.