Single scrotal incision orchiopexy - a systematic review

The undescended testis in children and adolescents part 2: evaluation and therapeutic approach

Undescended testis (UDT) is defined as failure of a testis to descend into the scrotum and it is a common reason for consultation in pediatric urology. As extensively discussed in "The undescended testis in children and adolescents: part 1", the failure of a testis to descend alters testicular germ-cells development, increasing the risk of infertility and testicular cancer in adulthood. Here, we present the second part of our review and analysis of this topic with the aim to propose an updated and well-informed approach to UDT together with a treatment flow chart that may be useful to guide pediatric surgeons and urologists in the care of these patients. The main goal of the management of patients with UDT is to diminish the risk of infertility and tumor development and is based on the clinical findings at the time of diagnosis.

The fat anchor orchiopexy technique: results and outcomes from 150 cases surgical experience

PURPOSE

The purpose of the study is to evaluate results and outcomes in a long-time follow-up period, by performing a novel testicular fixation procedure, known as "fat anchor orchidopexy" (FAO), for the treatment of palpable low inguinal undescended testis.

MATERIALS AND METHODS

We retrospectively reviewed all patients who underwent scrotal orchiopexy technique, from May 2013 to May 2019, at the Pediatric Surgery Division of Department of Surgical Pathology, University of Pisa (Italy). FAO (Spinelli's technique) consists in anchoring the testicles to sub-scrotal fat with a single trans-scrotal incision. All the patients enrolled had history of unilateral or bilateral undescended testis. Data collected included patient's age, operative times and complications.

RESULTS

A total of 150 children with cryptorchidism were treated using a single trans-scrotal orchiopexy. Of them, 130 patients (86.7%) had unilateral undescended testis and 20 (13.3%) bilateral cryptorchidism. Mean patient's age was 21 months (range: 14-28 months). All the procedures were planned in a day-surgery setting. Trans-scrotal orchiopexy was successful in all cases and no patients required an additional groin incision. No intraoperatively and postoperatively major complications were observed. Patients' post-operative pain was mild (mean pediatric visual analog scale = 2). In all cases, the healing process was rapid and no surgical wounds infections were reported during the post-operative period, referring excellent cosmesis results. During a mean 48-month follow-up period, no testicular retraction, recurrence or testis atrophy was reported.

CONCLUSION

The original Spinelli's technique (FAO) proves to be a safe and effective method for the treatment of palpable or distal-to-external-inguinal-ring testes. No immediate and delayed post-surgery complications were reported. In all cases, the anchored testicle remained in the scrotal position with normal vascularization. This novel surgical technique could give better options for scrotal fixation in case of low-lying cryptorchid testes.

Single Median Raphe Scrotal incision Orchiopexy: A safe & feasible approach for fixation of Palpable Undescended testes

Background:

We wish to share our outcome of single median raphe scrotal incision orchiopexy (SMRSO) regarding safety & feasibility of technique by evaluating ease of access, conversion rate, duration of surgery, success rate, complications, and the need for redo-surgery.

Methods:

We retrospectively analyzed data of 277 orchiopexies performed in our department on 224 patients operated on between June 2016 to June 2019. SMRSO was considered for palpable testes that can be brought to the upper limit of the scrotum under anesthesia. The conventional inguinoscrotal approach was used for high lying testes. A median raphe incision was made to access & mobilize the testis on either side, ligation of processus vaginalis performed, and the testes secured in the scrotal pouch. The approach was utilized for both unilateral and bilateral orchiopexies. Follow-up done at one week, one month & six months to evaluate the outcome.

Results:

A total of 277 orchiopexies were performed in 224 patients. 237 (86%) orchiopexies were via the median raphe scrotal approach in 184 patients. Out of these, 53 cases had bilateral orchiopexies. 30 (11%) performed via a conventional inguinoscrotal approach and 10 (4%) by laparoscopic approach. The mean duration of surgery for SMRSO was 24 minutes for unilateral and 42 minutes for bilateral cases. Immediate postoperative complications included scrotal hematoma in three (1.6%) cases, Hematoma of the abdominal wall in one case, and scrotal edema in 4 (2 %) patients. All complications were treated conservatively & resolved. No wound infection or testicular atrophy was reported. Long-term complications included testicular ascend in three cases [1.6%].

Conclusion:

Single-incision Median Raphe Scrotal orchiopexy is an attractive alternative to the standard inguinoscrotal orchiopexy for palpable low lying undescended testes with a better cosmetic outcome.

Comparison of Laparoscopic Orchiopexy and Traditional Inguinal Incision Orchiopexy for Palpable Undescended Testes in Cryptorchidism

Background: Laparoscopic orchiopexy (LO) has become a standard procedure for the treatment of nonpalpable undescended testes (UDT). LO for palpable UDT is still controversial. The aim of this study is to explore the method and effect of LO procedure for palpable UDT in children suffering from cryptorchidism. Methods: A retrospective study was performed for LO and traditional inguinal incision orchiopexy (TIO) for palpable UDT. A total of 291 children were enrolled, and they were aged 9-96 months with either left- or right-side palpable inguinal canalicular testes. Patients with testes that were nonpalpable, ectopic, and retractable were excluded. One hundred seventy patients received LO and 121 patients received TIO. Patient age, operative time, and clinical outcomes were reviewed. Independent t-test and Fisher's exact test were performed by SPSS 25.0 software. Results: The mean operative time (30.77 ± 6.02 minutes versus 44.76 ± 6.70 minutes) and postoperative normal activity time (1.25 ± 0.43 days versus 2.48 ± 0.68 days) of LO were significantly shorter than those of TIO group (P < .05). Forty-seven of 49 cases (95.9%) aged <1 year successfully achieved LO. Conclusion: LO is an appropriate choice for palpable UDT, especially in younger children aged <2 years. The success rate of LO decreased with age.

Quality improvement assessment of a bianchi-technique pediatric orchiopexy perioperative pain management pathway

BACKGROUND

Surgical correction of undescended testes is a common surgical procedure which can be performed via a two-incision technique or a single high scrotal incision (Bianchi technique). The Bianchi technique requires less surgical time and may be associated with less pain in the initial postoperative period, however it has been adopted slowly due to a lack of familiarity and perceived technical challenges of the technique. Traditionally postoperative orchiopexy pain is managed with a caudal or ilioinguinal/iliohypogastric nerve block. As urologists at our site adopted the Bianchi technique, the anesthesiologists stopped performing caudals or ilioinguinal/iliohypogastric nerve blocks as local infiltration appeared sufficient. Therefore, this quality improvement (QI) project endeavoured to assess Alberta Children's Hospital's care pathway in its effectiveness to control pain in the first 24 h following pediatric orchiopexy using the Bianchi technique.

METHODS

We completed a prospective QI project examining a care pathway for patients undergoing orchiopexy using the Bianchi technique. Eligible patients were healthy and aged 6 months to 12 years. A multimodal analgesic approach including local anesthetic surgical infiltration was used. Pain scores (FLACC) were recorded for up to 2 h postoperatively and a PPPM was completed at 24 h postoperatively.

RESULTS

Sixty-four patients were included in the final analysis. The median discharge FLACC score was 0 (range 0-2) (Table 2). Median intraoperative morphine administered was 0.09 mg/kg with no significant correlations between the amount of morphine administered and postoperative pain measures. Median PPPM scores were 4 and 3.5 for unilateral and bilateral procedures, respectively.

CONCLUSIONS

We have demonstrated that orchiopexies repaired using the Bianchi technique following the care pathway established at Alberta Children's Hospital are associated with minimal pain scores. Our QI project suggests that combining a Bianchi technique with a simple multimodal analgesic approach including local infiltration, negates the need for regional anesthesia techniques, yet still provides adequate analgesia.

Trans-scrotal Incision Approach versus Traditional Trans-scrotal Incision Orchiopexy in Children with Cryptorchidism: A Randomized Trial Study

Background:

Although undescended testis (UDT) is the most prevalent malformation in male neonates, the best mode of UDT treatment remains controversial. This study aimed to compare trans-scrotal incision approach with traditional trans-scrotal incision orchiopexy in children suffering from cryptorchidism.

Materials and Methods:

This single-blind randomized clinical trial was done on 100 children with UDT who needed surgery. The participants were alternately undergoing trans-scrotal incision orchiopexy (Group I) and traditional inguinal incision orchiopexy (Group II). The success rate and incidence of postoperative complications were evaluated 1 week and 1 month and 6 months after the operation in the two groups.

Results:

Both the groups were similar in baseline characteristics including age and laterality (P > 0.05). There was no significant difference between the two groups in terms of the incidence of wound infection, testicular atrophy, testicular hypotrophy, and relapse (P > 0.05). In addition, the success rates were 98% in Group I and 94% in Group II (P > 0.05).

Conclusion:

Both surgical methods have a high success rate, and there is no significant difference in the incidence of complications; however, in terms of beauty, satisfaction, and shortening the duration of surgery and the duration of hospitalization, trans-scrotal approach was more successful than the traditional method.

The impact of primary location and age at orchiopexy on testicular atrophy for congenital undescended testis

In this study, we investigated post-orchiopexy testicular growth of undescended testes (UDTs) at different primary locations and determined the risk factors for testicular atrophy (TA). We conducted a retrospective chart review of boys who had undergone orchiopexy for UDTs during January 2001–December 2013. Patient profile, age at operation, primary UDT location, and testicular volume were noted. TA was defined as ≥50% loss of volume after orchiopexy. The primary endpoints were testicular growth and TA after orchiopexy. The secondary endpoint was risk factors for TA. In total, 182 boys had undergone regular ultrasonography; the median follow-up period was 34 months. Among 230 UDTs, 18 (7.8%) atrophic testicles were identified within a median interval of 13 months after orchiopexy. TA rates were 3.3% (1/30), 6.9% (12/173), and 18.5% (5/27) in primary suprascrotal, canalicular, and above-inguinal UDTs, respectively. The survival probability of UDT was 91%, 92% and 100% when orchiopexy was performed in age ≤1 year, 1 < age ≤2 years, and 100% in age >2 years, respectively. Multivariate analysis revealed that inguinal and above-inguinal UDTs (hazard ratio [HR] 11.76, 95% confidence interval [CI] 1.55–89.33, p = 0.017) and genetic or endocrine disorders (HR 3.19, 95% CI 1.19–8.56, p = 0.021) were the risk factors for TA, but not age at operation, premature birth, and laterality. Thus, TA incidence was higher when patients had high primary testicular locations. Early orchiopexy before two years of age may be associated with higher TA risk, while most testicles have promising growth after orchiopexy.

A tailored surgical approach to the palpable undescended testis

INTRODUCTION

Orchiopexy for a palpable undescended testis can be approached through a traditional inguinal incision or trans-scrotally. Despite the possible advantages of the scrotal approach, including reduced postoperative pain and shorter recovery, it is not consistently advocated.

OBJECTIVE

The objective of this study was to present the experience with a tailored approach to orchiopexy based on physical findings.

STUDY DESIGN

This is an extended case series.

MATERIALS AND METHODS

The mobility of the testis as described at examination under anesthesia informs the choice of surgical approach. If a 'low' palpable testis (defined as testis that can be manipulated to the scrotum) was found, a scrotal approach was used. In cases of 'high' palpable testis (testis that cannot be manipulated to scrotum), the inguinal approach was used. Success was defined by location and size of the testis 3 months after surgery.

RESULTS

A total of 259 orchiopexies were performed in 181 boys (78 bilateral). Scrotal approach was used in 125 (48%) and inguinal in 134 (52%) orchiopexies. Operative time was significantly shorter for the scrotal approach, 25 min vs. 40 min for inguinal orchiopexy (P < 0.05). The overall success rate was 98% with no statistical difference between the groups. Three children from the inguinal group and two from the scrotal group required an additional procedure for persistent undescended testis. The rates of testicular atrophy and hypotrophic testis were higher in the inguinal group than the scrotal group (5/134 vs. 0/125; P < 0.05 and 17/134 vs. 6/126; P < 0.05, respectively).

DISCUSSION

The substantial cohort of patients selected for trans-scrotal orchiopexy experienced success rates and rates of atrophic and hypotrophic testis comparable with those found in the published literature. Furthermore, trans-scrotal operative times were significantly lower than those of inguinal procedures, and less patients required re-operation in the trans-scrotal group. Limitations of this study include significantly higher age at operation in trans-scrotal patients and a difficulty accurately classifying hypotrophic testes. Furthermore, the higher atrophic rate in the inguinal group vs. the scrotal group likely reflects the vulnerability of a testis that is located higher and not the superiority of the scrotal approach.

CONCLUSION

This tailored approach to a palpable undescended testis appears simple, safe, and effective, providing high success rate with marginal complications. It is considered a preference in cases of low undescended testis, whereas the standard two-incision inguinal orchiopexy may better serve those with high undescended testis.

Utilization of scrotal orchidopexy for palpable undescended testes among surgeons

Introduction:

Scrotal orchidopexy for palpable undescended testicle (UDT) has received attention in the last decade due to its lower morbidity. This study was conducted to determine the frequency and factors related to the use of the scrotal approach in the surgical treatment of palpable UDT among surgeons.

Methods:

An observational cross-sectional study was carried out using an online survey, which was sent to different pediatric urologists, pediatric surgeons, and urologists groups. The survey consisted of questions on demographics as well as surgeons opinions and experience toward scrotal orchidopexy.

Results:

Of 163 respondents, 57 (35.0%) were pediatric surgeons, 98 (60.1%) were pediatric urologists, and 8 (4.9%) were urologists. There were 86 respondents (52.8%) who used the scrotal orchidopexy approach for UDT at any time in their practice. Pediatric urologists tended to use the scrotal orchidopexy approach for UDT more significantly than others (P < 0.001). There were significantly more scrotal orchidopexies for UDT performed by the pediatric urologists throughout their practice and per year compared to others, respectively (P < 0.001). Fifty-two respondents (31.9%) claimed that scrotal orchidopexy is not a good option for their patients, while seven respondents (4.3%) claimed that the procedure was hard to perform.

Discussion:

Based on the results of this study, we believe that there is a discrepancy in the reported advantages and success rate of scrotal orchidopexy in the published literature and the utilization of such an approach among surgeons managing palpable UDT in children.

Conclusion:

Scrotal orchidopexy is an underutilized approach in the management of palpable UDT in children. Only 52.8% of our respondents used it for UDT. One of the main reasons why scrotal orchidopexy is underutilized is due to the surgeons’ perception that scrotal orchidopexy is not the procedure of choice for their patients and their unfamiliarity with the procedure.

Single-Port Laparoscopic Assisted Transcrotal Orchidopexy for Palpable Inguinal Canalicular Cryptorchidism Accompany With Indirect Inguinal Hernia

Purpose: To assess the outcomes of a novel laparoscopic assisted transcrotal orchidopexy (LATO) combined with percutaneous extraperitoneal closure (PEC) for palpable inguinal canalicular cryptorchidism accompany with indirect inguinal hernia, and evaluate its safety and efficiency. Materials and Methods: A retrospective cohort study for single-port LATO-PEC and traditional inguinal orchidopexy (TIO) was performed between 2011 and 2014. Totally 53 children with both palpable inguinal canalicular testes and indirect inguinal hernia were included. Median patient age was 15month (range, 6 months to 4 years). Of them, 35 patients underwent LATO-PEC procedure, utilizing an umbilical trocar for laparoscope, transcrotal dissection for orchidopexy, and an inner two-hooked cannula for ligation of the patent processus at the level of the internal ring. Three of them were bilateral, 12 on the left side and 20 on the right. Eighteen patients received TIO, seven of them on the left side and 11 on the right. Patient demographics, surgical technique, complications, and clinical outcomes were reviewed. Follow-up visits were performed to reassess position and size of the testes. Results: All 56 undescended testes were delivered into the scrotum successfully. In the LATO-PEC group, nine contralateral herniorrhaphy were accomplished simultaneously. Fifteen contralateral patent processus vaginalis (PPVs) in 32 unilateral undescended testis (UDT) were newly confirmed during the laparoscopy, while 6 of them received percutaneous extra-peritoneal herniorrhaphy for visible inguinal bubble in pneumoperitoneum condition. No additional port placement or conversion to open procedure was needed. Mean operative time for unilateral and bilateral LATO-PEC in this study was (37.81 ± 5.23) min and (53.33 ± 2.98) min, respectively. In TIO group, mean operative time was (41.11 ± 8.67) min. There was no statistical difference in operative time between the two approaches for unilateral UDTs (p = 0.098). Median follow-up interval was 24 months (range, 12-84 months). No operative complications were found in either group to date. Conclusions: Singe-port LATO-PEC is a safe, effective, and cosmetic choice for inguinal canalicular cryptorchidism accompany with indirect inguinal hernia, minimizing injuries to the vas deferens and testicular vessels. Laparoscopy can provide a diagnostic and therapeutic solution of contralateral PPV.

Circumcision-incision orchidopexy: A novel technique for palpable, low inguinal undescended testis

Given that both orchidopexy and circumcision are commonly done in a single operative setting, we adopted a technique of combined orchidopexy and circumcision using a single circumcision incision. We applied this new technique to boys with palpable, low inguinal cryptorchidism. Here we describe a case series of 7 boys who underwent concurrent orchidopexy via the circumcision site. We present this novel technique and discuss our preliminary outcomes, including the anatomic basis and feasibility. The technique appears to be an alternative for concurrent circumcision and cryptorchid cases with palpable, low inguinal testes.

Canadian Urological Association-Pediatric Urologists of Canada (CUA-PUC) guideline for the diagnosis, management, and followup of cryptorchidism

Cryptorchidism is one of the most common congenital anomalies in males, characterized by inability to palpate the testicle in the expected normal anatomical position (i.e., within its respective hemi-scrotum). It represents an abnormality of testicular descent and development associated with long-term concerns, including infertility, hypogonadism, and development of neoplasms.

Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines

CONTEXT

Undescended testis is the most common endocrinological disease in the male newborn period. Incidence varies between 1.0% and 4.6% in full-term neonates, with rates as high as 45% in preterm neonates. Failure or delay of treatment can result in reduced fertility and/or increased testicular cancer risk in adulthood.

OBJECTIVE

To provide recommendations for the diagnosis and treatment of boys with undescended testes which reduce the risk of impaired fertility and testicular cancer in adulthood.

EVIDENCE ACQUISITION

Embase and Pubmed were searched for all relevant publications, from 1990 to 2015 limited to English language. Data were narratively synthesized in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed.

EVIDENCE SYNTHESIS

There is consensus that early treatment, by 18 months at the latest, for undescended testes is mandatory to avoid possible sequelae regarding fertility potential and cancer risk. The current standard therapy is orchidopexy, while hormonal therapy is still under debate. However, in some individuals the successful scrotal placement of previously undescended testes may not prevent potential negative long-term outcomes regarding fertility and testicular malignancy.

CONCLUSIONS

There is good evidence for early placement of undescended testes in the scrotal position to prevent potential impairment of fertility and reduce the risk of testicular malignancy. No consensus exists on the various forms of hormonal treatment, which are assessed on an individual basis.

The Safety and Efficacy of Laparoscopic Percutaneous Extraperitoneal Closure for Inguinal Hernia in Neonates and Infants Younger Than 1 Year of Age in Comparison to Older Patients

PURPOSE

Laparoscopic percutaneous extraperitoneal closure (LPEC) has been performed in Japan for the repair of the pediatric inguinal hernias for over a decade. However, the safety and efficacy of LPEC in neonates and infants under 1 year of age remain unknown. The aim of the present study is to elucidate the safety and efficacy of LPEC in the treatment of inguinal hernia in patients who are younger than 1 year of age.

PATIENTS AND METHODS

The medical records of the patients who underwent LPEC at Saga-Ken Medical Center Koseikan (Saga, Japan) between August 2007 and November 2012 were collected. The intraoperative findings and postoperative outcomes were retrospectively investigated. The data of the patients who were younger than 1 year of age (Group A) were compared with the data of patients who were older than 1 year of age (Group B).

RESULTS

During the study period, 150 LPEC procedures were performed in 112 Group A patients, whereas 607 LPEC procedures were performed in 456 Group B patients. There were no serious complications in either group. After a mean follow-up period of 50.4 ± 15.6 months (range, 28-91 months), there were no significant differences between the two groups in the operating time or the incidence of intraoperative or postoperative complications. Postoperative testicular ascent and recurrence were observed in some cases of each group.

CONCLUSIONS

LPEC is a safe and effective procedure for the repair of an inguinal hernia, even in neonatal and infant patients who are younger than 1 year of age.