Treatment of undescended testicle

TREATMENT WITH PARTICULAR

OF UNDESCENDED TESTICLE*

REFERENCE

TO ENDOCRINE OPERATION

FRANKLIN I. HARRIS, SAN

M.D.,

THERAPY

AND THE TOREK

F.A.C.S.

FRANCISCO

T

HE desirability of placing the undescended testicIe in the scrotum is generaIIy recognized and accepted by ah. Experimenta and cIinica1 evidences prove that norma testicuIar deveIopment and spermatogenesis do not take pIace after puberty if the testis is outside the scrotum. The increased danger of malignancy or torsion of the cord are further arguments in favor of a normaIIy situated testis, as we11 as the psychic effect on the individua1. It is not my intention in this paper to discuss these phases of the subject nor the etioIogy and pathoIogy; a11 of these have been we11 covered in the exceIIent papers by Wangenstein,l Herbert WiIIy Meyer,2 and Higgins and WeIty.3 There are, however, some perplexing questions reIative to the *probIem of the undescended testis which the surgeon must be prepared to answer to his medica and pediatric coIIeagues : I. Does the preadoIescent undescended testis aIways necessitate surgica1 intervention for its correction? 2. If surgery is indicated, at what age shouJd it be undertaken? 3. Is there a surgica1 procedure, which can guarantee satisfactory end resuIts in the correction of this condition? Bevan, with whose name this subject is indeIibIy associated advocates surgica1 intervention in practicahy a11 cases of undescent seen before puberty and advises operation at a very earIy age, preferabIy before the age of five. Cabot5 likewise recommends surgery in a11 cases before the age of nine. The majority of surgeons

writing on this subject give the impression that an undescended testicIe seen any time before puberty shouId aIways be operated on. Recent deveIopments and further study on this subject make necessary, at this time, a change in attitude on our part, toward the advisabiIity of surgica1 intervention in every case of undescended and testis. We must cIearIy recognize differentiate two groups of cases: I. Those in which no operative procedure is necessary to obtain descent of the ectopic testis. 2. Those in which surgery offers the onIy hope of bringing the testicIe into its norma scrota1 position. In the non-surgica1 group of cases are (a) norma boys without demonstrabIe genera1 endocrine disturbances whose undescended testis wiI1 spontaneousIy descend sometime before or at puberty; (b) norma boys treated by a specific gIanduIar therapy which wiI1 produce descent of the testis into the scrotum; (c) cases of dispituitarism, known as FrijhIich’s syndrome, with biIatera1 undescent and genera1 obesity in which surgery is never of any vaIue. Spontaneous descent of the preadoIescent ectopic testis is a phenomenon that many pediatricians have observed in their practice, but which heretofore has not been sufficientIy emphasized. Bevan emphaticaIIy denies that it ever occurs. He states that there is IittIe Iikelihood, if the organs are not in their normal position at birth, of their descent in the period from birth to puberty and that he has never seen in his

* Read before the Genera1 Surgery Section, California MedicaI Association at 63d annual session, Riverside, CaIifornia. From the SurgicaI Service of the Mount Zion Hospital, San Francisco. 147

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Iarge experience a definite exampIe of this kind. On the other hand, a recent study by Drake6 who sent a questionnaire to the

i

FIG. I. Usual incision made pIasty. Incisions in thigh be described are indicated.

as for an inguinaI and in scrotum

herniolatre to

physicians of various boys’ schooIs, concIuded from it and his own experience with tweIve cases that, “the uniIatera1 undescended testis does not present any majority surgica1 probIem, as the greater of such cases wiI1 descend spontaneousIy by the age of fourteen and wiI1 become normal in size and eventuaIIy Iie Iow in the scrota1 sac.” I cannot agree with this writer when he states that the greater majority wiI1 descend, because United States statistics of the Army during the draft period, showed an incidence of 3 in IOOO recruits with undescended testes. In my persona1 experience during the 1 have witnessed years 1926 through 1933, spontaneous descent in eIeven boys, the age of descent varying from three to eIeven years. Five of these cases were biIatera1 and six were uniIatera1 cases of true undescent, uncompIicated by any picture of genera1 gIanduIar dystrophy. The treatment of undescended testis by an apparent specific form of gIanduIar therapy is based on the recent experimenta work of Enge17 of New York, who worked

TesticIe

1933 hlARCH,

upon the macacus monkeys, in which the testes at birth are in the upper end of the inguina1 cana and do not normaIIy descend for a few years. Injections of the anterior pituitary hormone, isoIated from the urine of pregnant women, produced a series of spectacuIar phenomena. Within a few days there was seen a remarkable deveIopment and eIongation of the immature scrotum and by the end of the month both testes had descended into a fuIIy deveIoped scrota1 sac. On the basis of this work and in conjunction with Dr. SamueI Cohn, of the Pediatric Department of the Mount Zion HospitaI, I have had the opportunity in the Iast year to study 7 cases, ranging m age from five to tweIve years. These boys were otherwise apparentIy norma and exhibited no genera1 signs of glandular dystrophy except that they a11 showed undescent of one or both They were given injections of testes. anterior pituitary hormone in the form of antuitrin s (a dose of IOO rat units was used for each injection), and the resuIts were aImost unbelievabIe (resuIts to be pubIished in detail in a separate paper in the near future). In one case, a boy aged tweIve, within three hours after the first s, the injection of IOO units of antuitrin uniIatera1 undescended testicIe was seen to be aIready in the upper part of the scrotum. In each of the other cases, after the second or third injection spaced three days to a week apart, the ectopic testicIe had compIeteIy descended into the scrotum and remained there. In 2 cases, a boy of seven and an aduIt of thirty-eight with uniIatera1 undescent, no effect was obtained after repeated injections of autuitrin s. It wouId appear to foIIow from the foregoing resuIts that in cases of spontaneous descent and those produced by gIanduIar therapy, an endocrine factor aIone prevented norma descent, in contrast to the other type of case in which, as operation mechanica factors are IargeIy shows, responsibIe. Because of our present inadequate knowIedge on this subject, there is diffIcuIty in

FIG. 3. FIG. 2. usually seen at external ring Iying in superficial fat. Line of incision in external oblique is indicated. oblique divided, showing testicle enclosed in its sac in lower portion of inguinal canal and attached by its gubernaculum to superficial fat.

FIG. 2. Undescended FIG 3. External

testicle

FIG 4 FIG 4. Testick divided from its gubernacuIum FIG. 5. Cord being separated by sharp dissection

FIG. 5. and dissection of cord begun. from attached cremasteric fibers and fascial bands and accompanying hernial sac.

FIG. 7. FIG. 6. FIG. 6. Sac of hernia has been separated, opened, ligated and is ready to be transfixed under internal oblique, thus curing hernia. FIG. 7. Dissection of cord being carried upward and into retroperitoneal space. AI1 restraining fibers being sectioned, but extreme care taken not to injure spermatic vesseIs or vas deferens. Spermatic vesseIs are never sectioned in order to Iengthen cord.

FIG. 9. FIG. 8. FIG. 8. By sharp and bIunt dissection, using gentle traction on testicle to give exposure, cord is Iengthened to a point which aIIows testicle to lie opposite scrotum on thigh without undue tension. FIG. g. An obIique incision about 136 inches long is made into thigh at point where testes Iies without tension exposing fascia Iata, but not injuring saphenous vein. With finger in scrotum to stretch it an incision is made corresponding in Iength and direction with that of thigh incision and posterior lips of these two incisions are sutured together with chromic No. o catgut.

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determining whether a given case of cryptorchidism is caused by endocrine disturbance or by mechanica defects,

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Journal

of Surgery

451

with the resuhs of these operations. In this country, the operation which has had the greatest number of cases reported and

FIG. IO. FIG. I I. between posterior lips of scrotal and thigh incisions completed. Hemostat grasps testicIe at point where gubernacuIum was attached to it preparatory to bringing testicle to its new bed in fascia Iata through scrotum. FIG. I I. Testicle sutured to fascia lata of thigh with two to four interrupted No. o chromic sutures at point where it lies without tension.

FIG. IO. Anastomosis

hence earIy operation before the age of tweIve shouId not be advised. Exceptions to this, however, are cases of emergency which may arise from the coincidental hernia or torsion of the cord. The time for surgery is between the ages of tweIve and sixteen. In my own series, the average operative age was thirteen and a haIf years. In boys of this age, if descent has not occurred spontaneousIy or with the aid of specific gIanduIar therapy, we can be fairIy certain that the mechanica factor is preventing descent and onIy an operation can cure the condition. Does surgery offer an operation which gives satisfactory end-resuIts? Since I 820, when the first orchidopexy was performed by Rosenmerkel, there have been described over forty methods of bringing the testis into the scrotum. The fact that so many methods have been advocated indicates very definitely a genera1 dissatisfaction

which in the past has been generaIIy accepted as standard, is the Bevan procedure. The Iate resuIts of this operation, however, have been very unsatisfactory and it has the further objectionabIe feature of occasionahy necessitating the division of the spermatic vesseIs, which often Ieads to atrophy of the testicle. on the end-results CoIey* reporting of 415 cases of the Bevan’s operation concludes : UnfortunateIy in only a comparatively small number of cases did we find the testicle occupying the bottom of the scrotum in the cases observed several years after operation. The atrophied testicIe is generaIly found to have retracted to mid scrotum or in the region of the external ring end and is in a position somewhat less IiabIe to trauma than before operation. In 1926, Burdick and Coleyg reported on 537 orchidopexies performed in the Hos-

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pita1 for the Ruptured and CrippIed (I 8gra11 under seventeen 1924L on patients years of age. Most of these operations were

TesticIe

MARCH. ,935

and CoIey’O reported just recentIy, a cases, from the review of 137 compIeted HospitaI for the Ruptured and CrippIed,

FIG. 12. FIG. 13, FIG. 12. Anterior margins of thigh and scrotal wounds are sutured together over testicle with interrupted silk sutures. A strip of Vaseline gauze is passed through skin canal between scrotum and thigh which acts as dressing for posterior layer of sutures. Cord is seen in inguinal cana which is now cIosed by method of Bassini without, however, transplantation of cord. FIG. 13. CompIeted operation showing both inguina1 and thigh scrota1 wounds cIosed. VaseIine gauze strip used as dressing fo; skin canal.

by the Bevan method. The end-resuhs were so discouraging that they sought some better method of operating. In 1927, Meyer2 reported the resuIts of 64 cases operated by an origina two-stage procedure, devised by Franz Torek in 1909. The end-resuIts were IOO per cent satisfactory and seemed to prove concIusiveIy that one of the essentia1 principIes for a successfu1 end-resuIt in an orchidopexy is the deveIopment and stretching of the It is this factor which atrophic scrotum. had been overIooked in a11 of the previous orchidopexies and which explains why in many cases operated by the oIder methods despite suff&cient Iengthening of the cord, the testis frequentIy retracted or was pushed up to the externa1 ring by the atrophic scrotum. The Torek operation today is rapidIy becoming recognized as a soIution to the surgica1 probIem of orchidopexy. Burdick

and concIuded that, “The end resuIts in our hands are so far superior to those which we obtained by the former methods that we do not fee1 justified in using any other type of operation.” The Mayo CIinic as reported by WaItersl’ has Iikewise adopted this procedure for the surgica1 treatment of these cases. My own series consisting of 27 operated cases from 1926 to 1933, on which thirty operations were performed; 3 cases were biIatera1 and a11 have shown satisfactory end-resuIts. In no instance has the testicIe atrophied or retracted up against the pubic bone or come to Iie in the upper scrotum. Gangrene of the testicIe did not occur, and the testicIe in a11 of the cases Iies free in the bottom of the scrotum. The herniae have remained cured. The technique of this operation is shown by the accompanying iIIustrations. The advantages of the Torek method of orchidopexy are :

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I. The ectopic testicre is given every possible chance to develop and function as there is compIete preservation of its bIood

FIG. 14. 14. Second stage. Incision separating

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Amrrican Journal of Surgery

353

3. The testicIe of its own accord, without the use of a foreign body, becomes fixed in the bottom of the newly formed scrota1

FIG.

Is.

scrotum from its attachment

FIG.

16.

testicle preparatory to its return to scrotum. FIG. 13. Second stage. Releasing testis from its attachment to thigh after four to six months. Note number of blood vessels which have grown into testicle. Care must be taken at this stage not to injure testicle which is firmIy united to fascia Iata. FIG. 16. CompIeted second stage. Testicle in scrotum. Thigh and scrotal wounds are closed by interrupted black silk sutures. FIG.

supply; the spermatic artery and vein never being ligated, and in addition, the transplanted testis receives a new bIood suppIy during its few months domiciIe in the thigh. Because of this Iast reason, I strongly urge that the testicIe shouId be Ieft attached to the thigh for a period of at Ieast six months. I cannot agree with Walters and Love’l of the Mayo CIinic who advocate a second stage in three to six weeks. I have Ieft the testicIe attached to the thigh for as long as two years and many times the testis, which hardIy seemed worth saving, has deveIoped during its stay in the thigh, to two or three times its former size and approximates or is even Iarger than its feIlow. This condition is quite in contrast with that which so often foIIows the other type of operation. 2. A norma scrota1 sac is formed out of what is usually a small atrophic rudimentary scrotal pouch. Such a scrotum does not contract again and force the testicIe up against the pubic bone for its final position.

to thigh and exposing transplanted

sac. 4. The operation is thoroughIy surgical. No foreign body is necessary for traction on the testicle to keep it down, and a11 the wounds heal by primary union. No vital or important structure is injured or divided. 3. The operation is appIicabIe to biIateraI as we11 as uniIatera1 cases. In the biIatera1 cases the procedure is divided into three stages: at the first sitting, one testis is brought down, sutured to the thigh and the hernia repaired. About six months Iater this testicIe is separated, pIaced in the scrotum and the opposite one brought down to the thigh; the hernia on that side is repaired. In another six months, this side is separated from the thigh and the patient is Ieft with both testes hanging normaIIy in the bottom of the scrotum and with both herniae repaired. The operation is done in three stages as it is not advisabIe to attach the scrotum to both thighs at the same time, aIthough some operators at the Mayo CIinic have done so.

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There have been no serious compIications in my series of cases, using the Torek method. In a few patients there was a sIight deIay in heaIing at the angIes of the thigh-scrota1 wounds, due to fauIty approximation. No testicIe sIoughed. The patients have been perfectIy comfortabIe between the first and second stages. They can waIk, jump, swim, horseback ride and foIIow any activity that any other boy can do. The few bad resuIts reported by this method by other writers, were admittedIy due to technical errors, such as suturing the scrotum to the thigh with too much tension or insuffIcient lengthening of the cord. CONCLUSIONS I. EtioIogicaI factors preventing descent of a testicIe are either endocrine or mechanica1. 2. In the endocrine cases, surgery is never indicated as the testes wiI1 either descend spontaneousIy before puberty or wiI1 respond to specific injections of anterior pituitary hormone, known as antuitrin s. 3. The group of cases in which mechanica1 factors are at play in the etioIogy of this condition necessitate surgery, which shouId not be done before the age of twelve and preferabIy between the ages of tweIve and sixteen years. 4. The Torek two-stage orchidopexy appears to eIiminate the bad resuIts previously reported by former types of in thirty oroperations. Th e end-resuIts

MARCH,19s~

TesticIe

chidopexies performed on 27 patients further confirm the reported superior endresuIts of this procedure. FORTY-FIVE CASES OF UNDESCENDEDTESTICLES ‘926-1933 Uni-

Bi-

Ages lateral lateral Spontaneous descent. . , Descent foIIowing injections of antuitrin s. . . Operative cases.. . . . . . .

II

3-12

6

5

7 27

5-12 I I-19

5 24

3

2

REFERENCES I. WANGENSTEIN, 0. H. Surgery of the undescended testis. Surg. Gynec. O&t., 54: 2rg (Feb.) 1932. 2. MEYER, H. W. Undescended testicle. Surg. Gynec. Obst., 44: 53 (Jan.) 1927. 3. HIGGINS, C. C., and WELTI, H. SurgicaI treatment of undescended testicle. Surg. Gynec. Oh., 48: 536 (ApriI) 1929. 4. BEVAN, A. D. The operation for undescended testis. Ann. Surg., go: 847 (Nov.) rgzg. 5. CABOT, H. and NESBIT, R. M. Undescended testis. Arch. Surg., 22: 850 (May) 1931. 6. DRAKE, C. B. Spontaneous Iate descent of the testis. J. A. M. A., 102: 759 (March IO) 1934. 7. ENGEL, E. T. ExperimentaIIy induced descent of the testis in the maceus monkeys by hormones from anterior pituitary pregnancy urine; roIe of gonadokinetic hormones in pregnancy blood in norma descent of testes in man. Endocrinology, 16: 513 (Sept.) 1932. 8. COLEY, W. The treatment of undescended testicIe. Surg. Gyflec. Obs., 28: 452 (May) rgrg. g. BURDICK, C. G., and COLEY, B. L. AbnormaI descent of the testicle. Ann. Surg., 84: 867 (Dec.) 1926. IO. BURDICK, C. G., and COLEY, B. L. Undescended testicle. Ann. Surg., 98: 495 (Oct.) 1933. 11. WALTERS, W., and LOVE. Torek operation for cryptorchidism. Surg. Clin. N. America, 13: 941 (Aug.), ‘933.