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Transseptal Orchiopexy for Cryptorchism
VoL 9\ 0cc. Printed U.S._L
THE JOURNAL OF UROLOGY
Copyright © 1967 by The \Yilliarns & \'Vilkins Co,
TRA1'1SSEPTAL ORCHIOPEXY FOR CRYPTORCH1S~\I HARRY C. MILLER Prnm the Division of L'ro/ogy, Deparlment of Surgery, University of Rochester School of
111 edicine and Dentistry, Rochester, ,Y cw York
In an attempt to improve the hospital c:omsc of the patient undergoing c:ryptorchid repair and to shorten the postoperative morbidity of such patients, a series of patients was treated using the Ombredonne transseptal technique. The results in our small group of 13 consecutive patients have been gratifying; the procedure is herein described in detail. Paramount to the success of any cryptorchid repair is the complete and adequate mobilization of the testis. If this permits placement of the testis into the lmverrnost part of the scrotum, nearly any method of fixation in that position will be successful. If the testis cannot be brought into good position into the scroturn, the surgeon must clo the best he can and plan to reoperate later or pos:,;ibl)' to rern.ove the testis. Consequently, the description of this transseptal technique is appropriately begun after adequate mobilization of the testis has been accomplished (fig. 1). With the index finger, a tract is made into the ipsilateral scrotum reaching to the midline septum. This fibrous septum is to be the restraining structure which will prevent retraction of the testis back up to its cryptorchid position. The index finger is placed through the scrotal tract to the septum and the thumb is used to dra'A' the scrotal skin craniad, allowing deeper penetration of the index finger. The fingertip is elevated) lifting the septum to the scrotal skin and tensing the inferior and somewhat posterior scrotum. (fig. 2, A). A small incision is made over the fingertip and carried down through the dartos muscle but not to the level of the septum. The tunica vaginalis on the contralateral side poses no problem since it is very difficult to reach the tunica during this maneuver. A pouch, large enough to contain the testis, is made in the subcutaneous tissue by blunt dissection. The index finger again elevates the septum which now is seen as a pearly-white structure overlain with a small amount of fat. Accepted for publication December 30, 1966. Read at annual meeting of Northeastern Section, American Urological Association, Inc., Cooperstown, New York, September 15-18, 1965.
A small incision is now made in the ~epturn over the fingertip to allow passage of the mrn,,n through the opening (fig. 2, . Small Allis clamps are placed on the edges of this incision to identify them. As the index finger is withdrawn back up the tract an Allis clamp follows it, passing up through the scrotal and incisions to enierge at the inguinal incision (fig. 3, A). Grasping the gubernaculum or other co1. venient non-critical tissue, the Allis 1,; withdrawn, bringing the testis clown to the scrotum, through the septal opening and out the scrotal incision (fig. 3, B). Identifying the nM,
1 -·
:FIG,, L mobilized.
Operative
procedure:
testis
of the septum with the previously placed Allls clamps, it is an easy matter to close the opening around the spermatic cord with a 3-0 chromic catgut stitch. This stitch should not close the opening too tightly for fear of strangulating the cord; however, the opening should be closed tightly enough to prevent retraction of the testis (fig. 3, C). One stitch is all that ;,s needed. The testis is then gently placed into the subcutaneous pouch and the skin is closed over it (fig. 4, A). No drains are used. Hemostasis easily obtained and hematoma has proved no problem. The inguinal incision is closed in rem503
504
MILLER
tine fashion (fig. 4, B). Icebags can be used on the scrotum for 24 hours but have not been routine. The child is allowed out of bed the day after the operation and has been sent home in 3 or 4 days. The patient can return to school 2 weeks postoperatively and can resume full activity in about 6 weeks. The appearance of the scrotum rapidly approaches normal (fig. 5). There are several advantages to this procedure. There are no foreign bodies in or to the testis; this, therefore, reduces the chances of infection.
No external appliances are necessary to maintain tension. No tension is placed upon the testis tissue or tunica albuginea, eliminating the unpleasant complication of seminiferous tubule extrusion through the tunica, skin, or both. Operating time is not prolonged and may even be shortened compared to other procedures as one becomes familiar with this technique. Only 1 operation is required, assuming mobilization of the testis has been adequate. Ambulation, patient discharge and return to normal activity are
FIG. 2. Operative procedure. A, ipsilateral scrotal tract formed and contralateral scrotal skin being opened over fingertip. B, contralateral scrotal incision made, cutaneous pouch completed and mid-scrotal septum is being opened.
FIG. 3. Operative procedure. A, Allis clamp through tract, ready to bring cryptorchid down. B, cryptorchid descended and out contralateral incision. C, suture to close opening around spermatic cord.
TRAKSSEPTAL ORCHIOPEXY FOR CRYPTORCHISM
B
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FIG. 4. Operative procedure. A, testis placed in subcutaneous pouch, ready for skin closures. B, completion of procedure with sutures all in place. The one reservation about the 1,, that adequate mobilization of the testis must be accomplished. If the testis cannot be well down into the scrotum, it is testis is worth saving, to secure it as far d01Y11 the inguinal canal as possible and return at another time to advance it further. SUMMARY
The technique of the transseptal for cryptorchid repair is presented in brief note is 111;1de of the advantages of thi, pro-· cedure. It is enthusiastically recorn.menclccl for most cryptorchicl repairs. FIG. 5. Postoperative view of right orchiopexy done 46 days before. Scrotum is cosmetically normal.
REFERENCES L.: Indication et technique de l'orchidopcxie transscrotale. Presse med., 18:
0MBREDONNE,
all hastened. Tension on the testis to keep it in proper position is constant, steady and completely independent of the patient's activity or position. Within a few weeks the septum stretches sufficiently to allow the testis to shift so as to appear to reside on its customary side.
745, 1910. lYicCor-,~IACK, J. L.,
KRETZ,
A. W ..,Nn
NBLsoN,
0. A.: Transsept;1l orchiopexy. J. Urol., 81: 1.53, 1959.
ScH1.IT'r, J.P.: Ombredonne operations for 1.mdescenclecl testicle (cryptorchiclism). Northwest. J\Ied., 44: 349, 1945.
THE JOURNAL OF UROLOGY
Copyright © 1967 by The \Yilliarns & \'Vilkins Co,
TRA1'1SSEPTAL ORCHIOPEXY FOR CRYPTORCH1S~\I HARRY C. MILLER Prnm the Division of L'ro/ogy, Deparlment of Surgery, University of Rochester School of
111 edicine and Dentistry, Rochester, ,Y cw York
In an attempt to improve the hospital c:omsc of the patient undergoing c:ryptorchid repair and to shorten the postoperative morbidity of such patients, a series of patients was treated using the Ombredonne transseptal technique. The results in our small group of 13 consecutive patients have been gratifying; the procedure is herein described in detail. Paramount to the success of any cryptorchid repair is the complete and adequate mobilization of the testis. If this permits placement of the testis into the lmverrnost part of the scrotum, nearly any method of fixation in that position will be successful. If the testis cannot be brought into good position into the scroturn, the surgeon must clo the best he can and plan to reoperate later or pos:,;ibl)' to rern.ove the testis. Consequently, the description of this transseptal technique is appropriately begun after adequate mobilization of the testis has been accomplished (fig. 1). With the index finger, a tract is made into the ipsilateral scrotum reaching to the midline septum. This fibrous septum is to be the restraining structure which will prevent retraction of the testis back up to its cryptorchid position. The index finger is placed through the scrotal tract to the septum and the thumb is used to dra'A' the scrotal skin craniad, allowing deeper penetration of the index finger. The fingertip is elevated) lifting the septum to the scrotal skin and tensing the inferior and somewhat posterior scrotum. (fig. 2, A). A small incision is made over the fingertip and carried down through the dartos muscle but not to the level of the septum. The tunica vaginalis on the contralateral side poses no problem since it is very difficult to reach the tunica during this maneuver. A pouch, large enough to contain the testis, is made in the subcutaneous tissue by blunt dissection. The index finger again elevates the septum which now is seen as a pearly-white structure overlain with a small amount of fat. Accepted for publication December 30, 1966. Read at annual meeting of Northeastern Section, American Urological Association, Inc., Cooperstown, New York, September 15-18, 1965.
A small incision is now made in the ~epturn over the fingertip to allow passage of the mrn,,n through the opening (fig. 2, . Small Allis clamps are placed on the edges of this incision to identify them. As the index finger is withdrawn back up the tract an Allis clamp follows it, passing up through the scrotal and incisions to enierge at the inguinal incision (fig. 3, A). Grasping the gubernaculum or other co1. venient non-critical tissue, the Allis 1,; withdrawn, bringing the testis clown to the scrotum, through the septal opening and out the scrotal incision (fig. 3, B). Identifying the nM,
1 -·
:FIG,, L mobilized.
Operative
procedure:
testis
of the septum with the previously placed Allls clamps, it is an easy matter to close the opening around the spermatic cord with a 3-0 chromic catgut stitch. This stitch should not close the opening too tightly for fear of strangulating the cord; however, the opening should be closed tightly enough to prevent retraction of the testis (fig. 3, C). One stitch is all that ;,s needed. The testis is then gently placed into the subcutaneous pouch and the skin is closed over it (fig. 4, A). No drains are used. Hemostasis easily obtained and hematoma has proved no problem. The inguinal incision is closed in rem503
504
MILLER
tine fashion (fig. 4, B). Icebags can be used on the scrotum for 24 hours but have not been routine. The child is allowed out of bed the day after the operation and has been sent home in 3 or 4 days. The patient can return to school 2 weeks postoperatively and can resume full activity in about 6 weeks. The appearance of the scrotum rapidly approaches normal (fig. 5). There are several advantages to this procedure. There are no foreign bodies in or to the testis; this, therefore, reduces the chances of infection.
No external appliances are necessary to maintain tension. No tension is placed upon the testis tissue or tunica albuginea, eliminating the unpleasant complication of seminiferous tubule extrusion through the tunica, skin, or both. Operating time is not prolonged and may even be shortened compared to other procedures as one becomes familiar with this technique. Only 1 operation is required, assuming mobilization of the testis has been adequate. Ambulation, patient discharge and return to normal activity are
FIG. 2. Operative procedure. A, ipsilateral scrotal tract formed and contralateral scrotal skin being opened over fingertip. B, contralateral scrotal incision made, cutaneous pouch completed and mid-scrotal septum is being opened.
FIG. 3. Operative procedure. A, Allis clamp through tract, ready to bring cryptorchid down. B, cryptorchid descended and out contralateral incision. C, suture to close opening around spermatic cord.
TRAKSSEPTAL ORCHIOPEXY FOR CRYPTORCHISM
B
'\
~
JI,.
\
1,11
)
FIG. 4. Operative procedure. A, testis placed in subcutaneous pouch, ready for skin closures. B, completion of procedure with sutures all in place. The one reservation about the 1,, that adequate mobilization of the testis must be accomplished. If the testis cannot be well down into the scrotum, it is testis is worth saving, to secure it as far d01Y11 the inguinal canal as possible and return at another time to advance it further. SUMMARY
The technique of the transseptal for cryptorchid repair is presented in brief note is 111;1de of the advantages of thi, pro-· cedure. It is enthusiastically recorn.menclccl for most cryptorchicl repairs. FIG. 5. Postoperative view of right orchiopexy done 46 days before. Scrotum is cosmetically normal.
REFERENCES L.: Indication et technique de l'orchidopcxie transscrotale. Presse med., 18:
0MBREDONNE,
all hastened. Tension on the testis to keep it in proper position is constant, steady and completely independent of the patient's activity or position. Within a few weeks the septum stretches sufficiently to allow the testis to shift so as to appear to reside on its customary side.
745, 1910. lYicCor-,~IACK, J. L.,
KRETZ,
A. W ..,Nn
NBLsoN,
0. A.: Transsept;1l orchiopexy. J. Urol., 81: 1.53, 1959.
ScH1.IT'r, J.P.: Ombredonne operations for 1.mdescenclecl testicle (cryptorchiclism). Northwest. J\Ied., 44: 349, 1945.